Belly Full of Trouble

     It's a warm, sunny afternoon when Attack One responds to a mutual aid call for assistance in a neighboring jurisdiction. The crew rolls up on a severe head-on collision between a sports car and a small pickup truck. Crews from the neighboring EMS agency are working on the driver of the sports car, whose head is protruding through his windshield. Attack One is directed by Command to care for the single victim in the pickup truck.

     The driver is alone, still belted in. He's a healthy man in his 20s. A single member of the other EMS agency has placed a cervical collar and is attempting to control the bleeding from a large laceration on the man's forehead. The patient is helping himself by placing direct pressure. He is awake, alert, oriented and expressing concern about the other car's driver. He remembers rounding the curve, finding the other driver in his lane and being unable to turn away. He saw the other driver come through his windshield, and fears for the man's life.

     The Attack One paramedic does a rapid trauma assessment and finds the doors on the truck won't open. They will require a quick extrication, but nothing as time-consuming as will be required to remove the other driver. He places a pulse oximeter on the man's finger and finds oxygen saturation in the high 90% range, the pulse rate regular. There's a lot of blood down the man's face, chest and in his lap, but he has no obvious chest, abdominal or extremity trauma. The laceration on his forehead is the site of all the bleeding, and it continues, rapidly. Only firm pressure directly on the wound edges slows it.

     The Attack One crew uses a few tools to quickly force open the driver's side door. The crew leader talks with Command; it appears the extrication of the car's critically injured driver will take some time, and an air ambulance has been called to transport him once he's free. Command suggests the patient from the truck be removed immediately in the ambulance, to clear the scene before the helicopter has to land.

     The Attack One crew performs a rapid extrication, places the young man on the backboard and stretcher, and loads him into the ambulance. They will leave immediately for the trauma center. The patient is still talking with the crew, but they note his heart rate increasing and oxygen saturation decreasing. Direct pressure still controls most of the bleeding from his forehead.

     "Are you uncomfortable in any other way?" the medic asks.

     "My head hurts where you're pressing on it, and my belly feels a little tight," the man says. "Can you loosen my belt?"

     The paramedic finds this request odd. "Sir," he tells the patient, "you don't have a belt on. You're wearing gym shorts."

     He decides to examine the man's abdomen again. As he presses around, the patient complains of some tenderness. There are no signs of trauma, but a faint line is visible where the seat belt had been. That's where the abdomen is tender.

Initial Assessment

     A 24-year-old male, restrained driver in a head-on collision. No air bag. Profuse bleeding from large laceration on forehead.

     Airway: Intact and uncompromised.

     Breathing: No distress.

     Circulation: Normal capillary refill, pink skin, neck veins flat.

     Disability: No neurologic deficits. Awake and alert, complaining only of forehead pain.

     Exposure of Other Major Problems: Significant blood loss from forehead laceration; bleeding is difficult to control even with direct pressure.

     AMPLE Assessment

     Allergies: None.

     Medications: None.

     Past Medical History: No problems.

     Last Intake: Large lunch an hour prior to incident.

     Event: Severe trauma from MVA.

Prehospital Management