"Flights" - A Lonely Road

Welcome to the first case in our Air Care and Mobile Care Flight Orientation Curriculum for 2016! 

Throughout the winter, spring and early summer, there will be a series of posts and cases published to help spur some thought and discussion on the management of the critically ill patients we take care of in the pre-hospital environment.  These virtual flights will be used to highlight some key considerations in the management of blunt poly-trauma, severe TBI, penetrating trauma, STEMI, Acute neurologic emergencies, and several other common disease processes seen on Air Care.

Comments will be open for 2-3 weeks after which time, a post containing expert commentary and curated commentary from the community will be published to reinforce the key learning points brought up in discussion.

It is mid July and your first shift as the coveted H2 Doc at Air Care 2 is finally upon you.  It has been an especially warm and beautiful Saturday and you ponder the possible flights for the evening as you take the scenic drive to Butler County Regional Airport. 

You finish checking the aircraft with the flight nurse and sit down to begin the 20:30 brief with the flight crew when the tones drop and you are dispatched for your first flight of the evening, a scene flight to Franklin County, Indiana for an “un-helmeted motorcyclist”. You grab the blood cooler, perform a safety walk-around the aircraft and strap yourself in back. The clouds are flush with pink hues as the sun begins to set over the rural forested knolls of southeastern Indiana. While you scan the horizon looking for aviation hazards you ponder the pathology that you may encounter on the ground. You land in a grassy field besides a large red barn, unstrap yourself, and head towards your patient who is apparently inside of a BLS squad located on the nearby farm-road. The flight nurse heads to the back with the stretcher as you open the side door of the ambulance and head to the head of the bed with the black bag to assess your patient...

Your patient is a 56 year-old male with unknown medical history who was an un-helmeted motorcyclist found in a ditch roughly 40 feet from his motorcycle which was discovered in the middle of the road by a passing motorist. The accident was un-witnessed, but the bike was found just beyond a sharp downhill curve in the rural farm road. EMS has BLS capabilities only and they have placed the patient on a backboard and loaded him into the unit.

Physical Exam

  • Vitals: P: 122, BP: 84/52, RR: 24, O2 Sat: 84%, ventilations being assisted with a BVM

  • General: Patient is in acute distress, multiple abrasions and contusions throughout with diffuse anterior body road rash. The ambulance smells like emesis.

  • HEENT: Mid-face grossly stable, although face covered in abrasions. Large boggy area to the R anterior/superior temple with a large laceration that is actively bleeding.

  • Cardiovascular: Tachycardic

  • Pulmonary: Decreased BS on the Left, crepitus palpable over the left chest wall with some subtle paradoxical movements

  • Abdomen: Abdomen rigid.

  • Musculoskeletal: Shortened and internally rotated left leg, left arm obviously fractured at the mid-humerusand appears to be closed, pelvis without clear instability

  • Neurologic: With deep painful stimuli, will grunt, open the L eye, and withdraw all four extremities to pain.

Interventions PTA

  • Patient back-boarded and C-collared

  • Ventilations being assisted with BVM on 25 LPM O2

Q1: Walk through your initial assessment of this patient. What are your priorities with this patient? Discuss the pathology/pathologies that you are worried about in this patient. What are the critical actions/interventions that we can take that can improve this patient’s chances of both survival and meaningful survival.

Q2: What are the actions that you wish to take first and in what order? How do you hope to accomplish these actions and how can you use the resources at your disposal in the back of this ambulance and in the aircraft to accomplish these things rapidly to best serve your patient? Are there procedures need to be performed on this patient and if so, in what order and where (squad/aircraft/receiving hospital)?  

Q3: Are there medications that we can/should administer to this patient? Blood products? If so, what kind and in what order? Is there a role for vasoactive agents (epi/norepi/phenylephrine) in any form at any time in this patient?

Q4: Now, what if your patient is a 7 year-old that was tossed off of an ATV that then rolled over him causing similar injuries. How does this change your management if any?

Q5: Back to your initial patient (the 56 year-old male). What if the patient loses pulses as you prepare to transfer him to your cot? How would you manage this situation? How does the rhythm on the monitor change your management (if any?). Does this change your transport destination / modality? What if you get ROSC after several minutes of resuscitative measures? Does that change your management?