When “Everything Hurts”

When you ask the question, “So what’s going on that made you call 9-1-1?” the words you hear next can represent an almost endless array of possibilities.

Without question, depending on what those words are (the patient’s chief complaint), the call immediately becomes either more or less challenging. If the words you hear are “crushing chest pain,” the patient care response will almost certainly follow the path of the national guidelines for emergency cardiac care. But if you hear, “I don’t know…I’m just not feeling right,” you’d best fetch your detective hat as you work to identify what is making your patient “not feel right.”

This month we are going to look at some of the most unique of the many possible responses—those that deliver a simple message but a complex patient care challenge, such as: “Everything hurts.” A few calls I’ve worked that all kicked off with that magical response include:

1. A 27-year-old male rappeller whose top belay was improperly fixed, resulting in a 30-foot free fall, with an additional 100 feet of rolling/tumbling down a rocky/gravelly embankment.

2. A 19-year-old crack dealer who was pushed out the side door of a car doing roughly 35 mph.

3. Three boys aged 21, 20 and 18, all unbelted with varying alcohol levels, who corkscrewed their Pontiac no less than three times in a muddy ditch.

A complaint that comprises total body involvement may appear to be overwhelming when it’s really not. What needs to happen involves a rapid trek down the decision-making tree in order to expedite and deliver quality care. In the three cases above, you have first a significant free fall, followed by the impossible-to-predict-injury potential of a tumble down a long stretch of hostile surface embankment; then a crack dealer acting like tumbleweed over one lane of very abrasive asphalt at a pretty significant speed before hitting the curb; and finally the boys in the car who were just human ping pong balls, bouncing around a relatively hostile automotive interior (head rests, dashboard, seat backs and other tumbling human beings). The significance of the mechanisms in these cases alone dictates spinal motion restriction steps must be employed immediately.

The next step involves a wide-angle scan of your patient, looking for any life threats or significant structural defects. Open chest wounds must be sealed immediately. Significant bleeding must be controlled with a clotting agent or tourniquet. Misshapen or malpositioned extremities need to be quickly identified as dislocations, fractures or both. Open book pelvic fractures require extraordinary splinting and pain management skills to avoid a catastrophic outcome. Even with great care a bad outcome is common, as this particular pathophysiology is almost without fail the result of a very significant mechanism of injury that has produced additional collateral injuries.

Once the find-and-fix life threat phase is complete it’s time to package and go, the goal being the reduction of time between significant traumatic event and the definitive problem-solving care provided in the surgical suite.

When you are challenged with doing all subsequent assessments and management in a rolling rig, a focused and circular—rather than linear—approach to medicine is required. As the catecholamines and endorphins start to wear off, “new” aches and pains may manifest, pointing in a new direction (e.g., “You know, my neck is really starting to hurt.”).

Woven into the care process, you must know with absolute certainty that the airway remains patent, breathing adequate and circulation uncompromised, or you must take whatever steps are necessary to make them so. This equates into the practical requirements of having suction always at the ready; cycling through breath sound reassessments every few minutes, or sooner if a change in patient status occurs; monitoring capnography readings and waveforms, as well as oximetry readings; and remembering to look up and see what the last NIBP reading was to provide some insight into trending. Keep a close eye on your diagnostics so you don’t miss important items like progressive tachycardias, rising CO₂ levels/poor waveforms or falling oxygen saturations, all of which can be predictors of impending doom.