Part I

[Skip to the quiz if you’d like]

On his way over to Charlie’s, Bill connected with Reggie Hammond, his neighbor from across the street. Reggie and his wife Felicia were in their front yard surveying the scene. They were both OK, and their house had minimal damage. There were some broken windows and missing roof shingles, but that looked to be about it. Reggie accompanied Bill to Charlie’s, as it looked like something bad happened.

A 70-foot poplar tree dissected Charlie’s house diagonally from the front yard to the back. It did not look good. The brick walls of the house looked like folded paper where the tree impacted it.

“Charlie, where are you guys?” Bill yelled to his friend.

“In the back.” Was the muffled reply from Charlie.

The two men snaked their way through a crevasse of brick, wood, and tree into Charlie’s house. They were in the living room and could see that the tree had crushed the wall between it and the family room in back. They saw Charlie with his back to them to their left, but could not see Charlie’s wife, Eileen.

“Charlie, Reggie Hammond and I are right behind you. Don’t turn around. Keep your head straight and keep looking forward.” Bill said.

“OK. I can’t get up. My leg is under the tree. Eileen isn’t talking. She won’t wake up. She’s breathing funny.” Charlie sounded panicked, frustrated and scared.

“OK Charlie, we’ll get to her in just a second.” Bill replied.

As he and Reggie climbed over the debris that was once a wall and into the family room, Bill deduced that Charlie and Eileen had been sitting on the couch that was against the wall that was now gone. It looked like the tree had fallen in between them, knocking Eileen across the room and pinning Charlie to the floor by his lower right leg.

“Reggie, can you look over Charlie while I go check on Eileen?” asked Bill.

“Sure thing.” Reggie said.

“What hurts Charlie?” Reggie asked.

“My damned leg, Reggie. I can’t get it out. I’m fine otherwise. Didn’t get knocked out. Didn’t hit my head. I’m fine. You’re better off helping out Eileen.” Said Charlie.

“OK Charlie, I understand. Let me check your pulses and get a good look at that leg. I just want to make sure you’re not bleeding out somewhere and we don’t know it.” Reggie said.

Charlie nodded impatiently and Reggie got about his work.

Bill stepped over the tree, took one look at Eileen, and swallowed hard. She was on her right side with a very large deformity to the left side of her head. As he got closer to her, he saw that her eyes did not register his presence. He shone his Surefire G2 flashlight in them and saw that her left pupil was totally dilated and her right pupil was on its way to the same. Neither of them constricted with the light. Eileen’s breathing was off. She would breath deeply for a few seconds, then stop completely for a few seconds, and repeat the cycle.

“Biot’s respirations.” Bill thought to himself. This breathing pattern can show up when a person has a brain injury or bleed severe enough to cause the brain to herniate through the large hole in the skull, the foramen magnum, where the brain and spinal cord connect and the cord is enveloped by the vertebrae. Bill started to suspect that the blunt trauma to the side of Eileen’s head caused a bad bleed inside of her skull.

He reached down to take Eileen’s radial pulse on her left wrist and noticed that her arms were extended out but her wrists were flexed. Then he noticed that her legs looked the same with the toes pointed down. He remembered it was called decerebrate posturing, and it was another sign of a very serious brain injury. As he felt her wrist, the pulses were very slow, but the strongest he ever felt. He pinched the web of flesh between her left thumb and index finger hard.

Nothing.

He pinched harder.

Still nothing.

Without immediate evacuation to surgical care, Eileen was dead. “Hang in there, Eileen. This is gonna be hard.” Bill whispered into his neighbor’s ear.

Bill stiffened his back and said slowly and loudly, “Charlie, Eileen is not well. She needs a lot of help right now. Are you OK if we get her out of here before you?”

“Oh God, please. Yes. I can’t lose her.” Charlie replied. His voice cracked.

“OK buddy. Let me see what I can do.” Said Bill.

Bill did not have any of the things he needed to help get Eileen prepared for transport. He did have a ventilator bag in his medical kit, but no supplemental oxygen. He could try hyperventilating her with room air to see if that helped the herniation. At this point, there wasn’t a whole lot he could do, but he had to try.

He called Reggie over to help. The fact that it was Reggie Hammond of all people was a stroke of very good luck. Reggie was a retired senior chief engineman from the Coast Guard and there was very little that would rattle him. He was kind and quiet, but was able to flip a switch and slip right into business mode when needed. When “The Senior” tapped you on the shoulder, you got into gear.

Bill looked at his neighbor and said, “Reggie, we need to try and help her breathe better. I’m going to need you to help me with this and then run the ventilator so I can get on the radio and see if we can get her out of here.”

“Not a problem boss, let’s do this.” Reggie replied.

Bill placed a King LT-D airway. It is a blind insertion airway device that doesn’t require a laryngoscope and is ideal for people who don’t place advanced airways regularly. It is a supraglottic airway that uses two air bladders to seal off the esophagus and isolate the trachea as well as anchor itself in the oropharynx, allowing a patient to be ventilated with a bag-valve mask. Bill carried these in his kit because they had become standard equipment in prehospital medicine and were easy to use. He confirmed its placement by listening to Eileen’s lungs with his stethoscope while Reggie squeezed the ventilator. Reggie continued to ventilate and was helping Eileen breathe at twenty breaths per minute.

Bill switched over to the ARES frequency he was on earlier and stood by for almost a minute. The air was clear.

Bill opened. “This is KXXXX at station Patrick Henry with an emergency communication. Do you copy?”

The radio crackled back. “Receiving. What is your emergency? KXXXX?”

“I need immediate medical evacuation for one unresponsive patient with a severe head trauma.” Said Bill.

There was a pause for ten seconds. “Received. Stand by KXXXX.”

Bill waited. Almost two minutes went by. The radio came back to life.

“KXXXX. Ground transportation will not be available in your area for at least 48 hours. Air transportation will be online in two hours. The regional Level I trauma center is down. A mobile emergency department is being set up in the parking lot of the football stadium in Lumberton. We can only send helicopters by greatest need and greatest number. I need a census within two hours of total number of patients triaged in red, yellow, green, and black as well as missing. Stay on this frequency and report in at 1705 hours. Coordinator out.”

Bill signed off, “KXXXX at station Patrick Henry copies.” He hung his head, closed his eyes, and heaved a sigh.

Bill looked at Charlie. His eyes were locked onto the ceiling as they filled with tears and his chin trembled.

“Can you bring her over to me?” whispered Charlie.

“But Charlie, we…” Bill started to say.

“Dammit, just bring her over to me! And take that thing out of her mouth! I heard what the man said on the radio. I know what’s going on. Let me be with her. Let me hold her.”

Bill looked over to Reggie, who was still tending to Eileen. Reggie nodded, and Bill went into the other room and grabbed a sheet. Reggie stopped the ventilations and removed the airway. They got her on the sheet and laid her next to Charlie.

Charlie cradled her to his chest with his left arm and began to sob in anguish, his face contorted in pain, “It’s OK baby. It’s OK. I’m here. You’re OK now.”

“Charlie, we need to get you out…” said Bill

Charlie interrupted, “Just leave us! Please. Come back later.”

At this point, Bill looked up at Reggie, whose gaze was fixed onto him like a tiger about to jump onto a deer. Reggie made an infamous “knife hand” motion towards the hole they came in and punctuated it with a nod in the same direction without ever breaking eye contact.

The two men got outside of Charlie’s house and Reggie turned to Bill.

“Bill, I know Charlie is your friend. He is my neighbor, too. This is painful. This is horrible. This is almost unbelievable. But right now, he’s a yellow and Eileen is a black. That’s two that we know about.

“The reality is, we need to get him out of there. We need to get people going through this neighborhood and finding anyone else that needs help. We need to get people organized and moving to make this thing suck less than it already does. And that means you, me, and everyone else with a pair of stones needs to push that sadness back down and get on it, NOW.

“I’m going to go over there and I am going to get people organized for search and rescue. I will get some people to come over here and help you get Bill out and Eileen taken care of. I’ll go talk to Felicia and have her set up a treatment area in our garage, since our house is in good shape.

We need to get on this, because in two hours, we have an opportunity to let people who can help us know how much help we need. From what the man said on the radio, this is a no-shitter, and this is just beginning.

You’ve done good today. Your wife and family are safe. You’ve helped your friends. Now we need to prepare a whole bunch of people for something they’ve never experienced before, and we need to keep as many people alive as we can.”

With that, Reggie pulled a cigar case out of his front shirt pocket, took out a Romeo y Julieta Belicoso, jammed it into the right side of his mouth, bit down on it, and straightened his cap. He squared himself towards Bill, stuck his chest out, put a firm right hand on Bill’s left shoulder and gave it a good squeeze.

He looked Bill straight in the eye and winked while saying, “It’s time to go to work.”

With that, Reggie jogged off towards Felicia and started waving people in his direction.

Bill stared at the ground and thought of his friend with his dying wife inside the house. Bill thought of his own wife and he started to heave and sob. After a minute, he gritted his teeth and inhaled deeply.

“Keep going,” he said to himself, “you’ve got to keep going.”

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In the previous post, we knocked out the first part of the rapid trauma assessment that allowed us to establish a patient treatment priority. Buckle your seatbelts, because the rest of the assessment is long, but fast. If you were fast with the first part of the assessment, you have eight and one half minutes left. If you were slow, you have seven minutes left.

We’re going to do a more detailed assessment if we have the time and the patient is stable enough. The rough analog to this in TCCC would be the Tactical Field Care phase or the CASEVAC phase depending on the situation. We want to get a better – still rapid – look at the patient and find more things to fix if they are life threats. Key point here – TAKE HIS CLOTHES OFF. Seriously. If you can’t see it, you can’t find it, and you won’t fix it. I usually keep my patient’s underoos on if they are 100% conscious, alert, and oriented and inspect “down there” with their permission after a description of what I need to look for and why. If their mentation is altered, the underoos are coming off so I can check the genitalia and rectum for bleeding if there is any thoracic /abdominal trauma or pain in any area that indicates thoracic /abdominal injury.

Head, eyes, ears, nose, and throat (HEENT)

Start at the head and work your way down. Inspect and palpate – which means feel around in vulgar terms – the head and neck. Remember the DCAP-BTLS mnemonic. Key to look out for is fluid coming out of the ears or nose, as it could be cerebral spinal fluid (CSF), which indicates a skull fracture of some kind or disruption of the blood / brain barrier. If you see it, dab it with a gauze 2×2 or 4×4. If it looks like a pink blood spot with a halo around it, that’s CSF.

If you feel bones grinding around – known as crepitus – this is bad, too, as it also indicates skull fracture. Check the pupils and eyeballs. Are they equal, round, and responsive to light? Great. If one or both are dilated and your patient has an altered mental status, you are in deep because your patient probably has a bleed going in his brain. The contents of the skull are roughly 80% brain, 10% CSF, and 10% blood. Since the skull is a fixed volume, if anything new shows up in there or the amount of blood shoots way up, all sorts of issues with cerebral perfusion pressure (CPP) will occur because of increased intracranial pressure (ICP) [Recommended: Look up the Monroe-Kellie hypothesis and autoregulation.] If you are out in the middle of nowhere without rapid evacuation to an OR, this is most likely fatal, as was Eileen’s case above.

Clinical note: Another thing about Eileen’s case. A head injury with brain herniation will most likely present with projectile vomiting as the herniation progresses. I didn’t put that in the scenario because I’m lazy, but it’s a good bet that someone in her condition would be vomiting, thus complicating the situation even more. Eileen is presenting with irregular respirations (Cheyne-Stokes, Biot’s, ataxic, etc.) and implied severe hypertension (systolic greater than 180mmHg and diastolic greater than 120mmHg) and bradycardia (heart rate less than 60 beats per minute) from Bill’s radial pulse check, which are known clinically as Cushing’s Triad in patients suspected of increased intracranial pressure or brain injury.

Look for anything in the mouth that can result in an airway threat and take steps to mitigate. Teeth, Copenhagen, soft tissue, etc. The tongue is the most common airway obstruction, and if you hear snoring noises from your patient, most likely his tongue is in the back of his throat. Try basic airway maneuvers to open the airway like the head-tilt chin lift or modified jaw thrust first, and an oropharyngeal airway (OPA) adjunct if the patient has no gag reflex, and a nasopharyngeal airway adjunct (NPA) if he does have a gag reflex. Here’s a nice instructional video for measuring and placing OPAs and NPAs.

If cervical spine injury is suspected, stabilize c-spine and apply a c-collar if available. Inspect and palpate the back of the neck for crepitus or deformity before applying the c-collar. If you don’t have one, use a SAM splint, towels, clothing, and tape to create a hasty c-collar. The goal is to prevent the head from moving around and exacerbating a cervical vertebrae fracture that could slice into the spinal cord. Make sure you’re not restricting circulation in the neck or breathing with the hasty c-collar.

Neck

Inspect and palpate the neck. Look for any bruising or open wounds on the neck. If there is a wound near the jugular vein or carotid artery, apply an occlusive dressing like Vaseline gauze, or plastic wrap (a section of MRE rapper, etc.) to prevent air from going into the wound and causing an air embolus in the circulatory system. You may need to position the patient on his left side to mitigate the air embolus from entering the heart. Keep c-spine precautions in place if you do.

If the jugular veins are distended (bulging out), this could be a sign of circulatory compromise, with the right side of the heart failing to move blood adequately. This could be from a pericardial tamponade, which can only be fixed in the hospital, a tension pneumothorax or even a severe hemothorax.

If the patient’s windpipe – i.e. trachea – is deviating to one side, this is an ominous sign of a late stage tension pneumothorax, also known as a collapsed lung.

You may need to needle decompress the affected lung, but you’ll need to assess the chest to make the call.

Chest

Check the upper chest for little bumps. If you can push down on them and they pop like Rice Krispies, this is probably subcutaneous emphysema, and is a sign that the patient’s  airway has been compromised. The larynx, trachea or bronchi may have been damaged and air leaking air into the chest cavity. Look for this sign in pneumothorax as well. Personally, I have never seen this in the field, but Doc Grouch has seen it in his work, and in his words “It is unmistakable, if you have felt it once, you never forget, and really you can’t miss it.”

The other critical findings for a tension pneumo are low blood pressure, tachycardia (pulse > 100 bpm), a narrow pulse pressure (this is the difference between the systolic and diastolic pressures. A normal pulse pressure is 120/80. A narrow pulse pressure with hypotension is 70/60), absent lung sounds on the affected side, fast, shallow breathing, and low O2 saturation. The trachea will deviate AWAY from the side of the collapsed lung. NOTE: Tracheal deviation is a LATE sign in a tension pneumo. Look for the other signs and symptoms first. If you wait for tracheal deviation to show up, you’ve probably killed your patient.

You’ll need a 3.25” 14 gauge need and catheter for decompression. Insert the needle in the second intercostal space just above the third rib at the midclavicular line (in line with the middle of the collar bone) of the affected side. Press hard and remove the needle, and if you do it correctly, you’ll hear a flood of air come out of the catheter. Create a flutter valve with a spare glove fingertip and place it over the top of the catheter. Some of the newer catheters have a one-way valve built in, so what you have already may be adequate.

The 3.25″ needle is preferred, because most likely your tribe is full of studmuffins with 50″ chests who all bench 550lbs easily. The other guys have all the fat dudes with man tits. In either case, that’s a lot of material between the skin and the chest cavity full of air. The shorter needles may not make it all the way through, so keep that in mind.

TCCC Note: The threshold for chest decompression is much lower in TCCC. If your patient has a chest injury and is having trouble breathing, you decompress him. Why? Because if there are bullets flying and decompressing his chest allows you to put an M4 back in his hands and fire back, then you do it. Please DO NOT use the TCCC threshold in a non bullets flying scenario. If you have time, use it and be sure in your diagnosis before performing an advanced procedure.

Press on the clavicles for crepitus. If it is present, note it but keep going. Unless the clavicle is so screwed up that it looks like it is stabbing the the lungs, or you see sign of massive hemorrhage from a nick of subclavian artery and/or vein, it is probably not a life threat.

Press down on the ribs and feel for crepitus. Notice the patient’s work of breathing. Are both sides of his chest rising and falling in unison? That’s good. If you feel crepitus and see a portion of the ribs moving collapsing while the rest of the ribs expand and vice versa, your patient may have a flail segment, which is a section of ribs that have broken completely away from the rib cage. This is a serious sign and should be fixed when found. You want to tape down a folded shirt, saline bag, or bulky dressing over the wound site. Tape it down tightly, because you’re trying to prevent the flail segment for engaging in the paradoxical movement that can compromise breathing. Be highly suspect of a pneumothorax / hemothorax if you see this. This video shows it pretty well. Look how much effort this guy is putting into breathing. If he doesn’t get help soon, he’s going to tire out, crap out, and you’re going to need resources to breathe for him.

If you find puncture wounds over the chest, then cover them with occlusive dressings like Vaseline gauze, plastic wrap, or some of the fancy chest seals like the Asherman, Halo, Hyfin, and Bolin. If you are using Vaseline gauze or plastic wrap, tape it down on three sides only and leave one side open to allow for burping the wound.

Clinical note: I list Vaseline Gauze as a cheap alternative to the fancier chest seals. Honestly, the best thing to do with it is to open the mylar wrapper carefully, pull out the gauze, use it for kindling or something, and use the wrapper as the chest seal. Personally, I like the Hyfins, they’re big.

If the wound is gurgling, then you very likely have a pneumo / hemothorax to deal with. Make sure to count all of the puncture wounds and their locations. If you can, roll the patient on his side and assess the back for wounds and injuries. If there are more holes in the chest / thorax area, count them, note their locations, and get occlusive dressings on them. Don’t worry about exit or entry classifications. What matters is the number of holes in your patient’s body and what the implications are for what’s happening inside where you can’t see.

A quick talk about hemothorax and fluid in the lungs. A hemothorax is blood filling up the space in the chest that once was filled by your now collapsing lung. The space in your chest is big enough to hold 25-40% of your blood supply. Remember the shock table.

25% of blood volume and above is Stage III and Stage IV hemorrhages. Like a pneumothorax, the blood in the chest cavity prevents the lung from fully inflating, but is less likely to result in the same amount of tension as a tension pneumothorax. Needle decompression will not be an effective treatment for a hemothorax. A chest tube placed on the midaxillary line (think inline with your armpit) in the fifth intercostal space in the ribcage is going to be a better solution in getting the blood out. This is not something that you see done in a prehospital setting very often, but if you have the training and equipment to do it, knock yourself out. If you know you have a hemothorax in the field and your patient is dying from it, you may need to place your decompression needle in the fifth intercostal while the patient is supine and try to get some of the blood out. If you are having to do this, your day is very, very bad. Groovy video of chest tube insertion below. Watch the whole thing if you have time. Skip to 6:20 if you don’t.

Fluid in the lungs is just that. It can be water, blood, vomit, beer, you name it. The fluid fills the alveoli and prevents O2 and CO2 from exchanging at the capillary membrane. Get enough fluid in your lungs and you will not be able to exchange enough gas to stay alive and will die quickly. The alveoli lose their surfactant and collapse, making it impossible for them to continue to hold and exchange air. This condition is called atelectasis and it is very bad. People who survive drownings can have this happen to them days after they are rescued.

DISTURBING CONTENT WARNING. A MAN DIES IN THIS VIDEO
The video below shows a scumbag who got shot for trying to steal. It looks like the guy who blasted him got a good lung shot and hit some blood vessels. Notice the frothy, bright consistency of the blood and how quickly the guy deteriorates once he starts coughing it up. Most likely he aspirated his blood into both of his lungs and ultimately drowned in his own fluids. Not pretty. Fixing this guy would require lots of suction, positive pressure ventilations, endo tracheal intubation, lots of diesel fuel or helicopter fuel to get him to the trauma OR ASAP to get the vessels spewing into his lungs closed. Lesson? Armed robber is a poor career choice.
http://www.liveleak.com/ll_embed?f=02b855f52d8b

Abdomen

Inspect and palpate the abdomen. If your patient reports pain anywhere in the abdomen, palpate that area LAST. You are feeling for rigidity and abdominal guarding, where the patient flexes the abdominal muscles when your palpating causes pain over an inflamed or injured organ. Also look for rebound tenderness, which is pain AFTER you take your hands off the abdomen and the abdominal wall returns to its normal position. This could be a sign of something – like blood – irritating the peritoneum, which is the lining of the abdominal cavity. Look for signs of ecchymosis on the skin of the abdomen. It can indicate severe blunt force trauma to the abdomen or bleeding somewhere else that is pooling in the abdomen.

If you see something pulsating in the patient’s abdomen, DON’T PALPATE IT. It could very well be an abdominal aortic aneurysm, which means their descending aorta may burst open at any minute. Find out what this patient wants to say as last words to anyone he cares about, because this finding in the field is very grim. Very carefully load him into a stretcher and take a nice gingerly trip to a vascular surgeon to try and fix it.

Trauma to the patient’s upper right abdomen should make you highly suspicious for a liver laceration or injury. The liver is very vascular and can bleed profusely. Keep a keen eye out for shock in these patients. The same thing holds true for the upper left side of the abdomen with the spleen. Watch for distension in the abdomen and signs of shock, indicating an internal bleed.

If the patient has an evisceration, which is where the intestines herniate through the abdominal wall and the skin, soak a dressing in sterile water or saline and place it over the intestine. Cover that with plastic and tape it down. You want to keep the tissue moist. DON’T shove the intestine back in the hole. It’s already been exposed to germs and dirt on the outside and you can make any rupture of the small bowel worse by spilling gastric contents into the abdomen, thus making a bad situation worse. This is not necessarily a life threatening condition, and you may be able to skip over it to continue your assessment. Let the patient’s condition guide you on this.

If your patient has been shot in the abdomen, any and all of the above injuries can occur simultaneously. Count the holes, note their positions, and place absorbent dressings over everything to help with bleeding. If you can roll the patient on his side to look for wounds on his back and treat them, do it. DON’T pour hemostatic agents into the wounds. If an evisceration is present, follow the above treatment. Allow your patient to bend his knees when laying supine when he has an abdominal injury. This alleviates some of the pull on the abdominal muscles and wall and alleviates some pain.

The abdomen is a magical, mysterious place where a lot of stuff can go wrong. You have to suspect a lot of different injuries in any kind of trauma because you have different kinds of organs and organ systems all in one compact area. Repeated patient assessments are key with abdominal wounds.