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Patient Care

Man vs. Machine

      The Attack One crew has been extremely busy on this warm spring day, and has just cleared a call at the far end of its metropolitan area. With the next call, the dispatcher asks for the crew to immediately call the 9-1-1 office by cellular phone. He is very concerned about the victim, a man trapped by both legs in a piece of farm machinery out in a field.

   The man's wife had called it in from the field. She'd found her husband unconscious, with a large volume of blood loss obvious, and she has no idea how to operate the machine. The first-responding fire department is en route, as well as two pieces of heavy rescue equipment from the county fire department, along with a battalion chief and a safety officer. The wife reports the man is trapped almost up to his pelvis in the machine, and one arm is also in a set of rollers. He had been missing for several hours, and she suspects he has been trapped in the machine for that long a period of time. According to her, he is still breathing.

   The Attack One crew leader thinks quickly. "Dispatch, please get the regional air ambulance service en route," he requests, "and if they can, ask them to bring blood. We will contact medical control at the local trauma center by radio now, but will likely have to use cell phones for medical direction that far out in the country."

   The response seems to take forever, but they finally arrive at the farm, where local police point them out into the field. The first responder BLS crew wants the ALS resources of Attack One out with the victim as soon as possible, and the lighter-weight Attack One vehicle moves across the dry, flat terrain without a problem, led by a local farmer on a tractor.

   They arrive to find the scene as described by the dispatcher: The man was pulled by his legs into the large machine, and apparently stuck his left arm into the rollers to keep himself from being pulled in completely. He is unconscious but breathing, and is being supported in place by some simple bedsheets held by the first responders. The victim's right leg is pulled farther into the machinery, and he has an immediately obvious fracture of his right hip and pelvis area. There is a large amount of blood underneath him.

   The extrication equipment has just arrived, and the battalion chief is organizing the crews to begin opening the machinery. The machine is off, but unfortunately cannot be reversed to disentangle the victim. The battalion chief estimates it will take at least 90 minutes to free the man. He also advises the crew that he has asked some local farmers to stay close and assist him, and that there is a mechanic from the local farm implement company coming to the scene. He believes those experts will help facilitate the quickest and safest operation possible, and will also provide the best support to the victim's wife, who insists on staying at the scene. The Attack One crew will oversee all medical operations; they will be supported by an engine crew that will assist with any equipment.

   The Attack One paramedics have already begun to assess and stabilize what they can. The victim is completely unresponsive but breathing and warm; he has obviously lost a great deal of his blood volume. An open pelvis fracture on his right side continues to bleed, as does his crushed left hand. Crew members fashion a large dressing into the wound on his pelvis and apply compression until the obvious bleeding stops. They apply a tourniquet to his left forearm, marking it with the time. The man's legs are both severely crushed, and the right one is compressed to such a degree that they anticipate it has been amputated inside the machine.

   They quickly establish an airway with an endotracheal tube and assist the victim's breath with 100% oxygen. The only sites for intravenous access are the right arm and external jugular veins in the neck. The victim is trapped about three feet off the ground, supported at that level by the firefighters’ bedsheets. His head can be lowered by lowering the sheets, and doing so allows one paramedic to find the external jugular vein on the right side of his neck and place a larger IV line than he could in the arm. Once the airway is secured, the paramedics feel more comfortable lowering the patient without fear his stomach contents could be aspirated. With his head and neck lowered and the jugular visible, a large intravenous line is started, and a fluid bolus given. The fluid and patient's upper portion are kept as warm as possible.

   Everyone welcomes the arriving air ambulance, which places down in the secured landing zone. The extrication crews are now starting to move pieces of the machinery. The Attack One crew leader and nurse leader of the helicopter crew develop a strategy for using the helicopter's resources: They will utilize sedative medications to maintain the patient in an unconscious state, and start blood resuscitation due to his extreme blood loss and the need for prolonged extrication.

   A decision also must be made concerning the victim's right leg. Together, using a cell phone that works well in the field, the lead paramedic and nurse contact medical control and discuss the potential that the right leg is already amputated, or will have to be amputated to remove the victim from the machine. The extrication team leader says that may be necessary, although he believes the other extremities can be freed. The discussion is difficult, but medical control ultimately advises that if it will save the victim's life, complete the amputation to remove him from the machine.

   All visible bleeding has now stopped, but the patient's vital signs remain unstable, his skin is cold and pale, and his conjunctiva are very pale. After the first two liters of saline are infused through the first IV line, the flight nurses prepare red blood cells to administer through special intravenous tubing. The patient's pulse rate is now a little slower, and he now has a vein visible in his right arm. A second infusion is started. The blood will be given in the arm, with ongoing saline solution continuing through the external jugular catheter.

   The extrication is proceeding safely and smoothly, and teams of extrication workers are collaborating with the local farmers and the farm machinery expert. A local clergy member has arrived, and he and the wife take a moment with the patient to pray. The patient's pulse rate continues to decrease with the administration of blood and fluids, and after about 20 minutes of work, the perfusion in his right hand has improved to where the pulse oximeter can finally get a reading. After the third unit of packed red cells, the patient has a palpable radial pulse.

   The extrication is complete after about 60 minutes. The right leg was indeed amputated in the machine, so as the victim is removed, rescuers apply a tourniquet to his upper right leg. The crews quickly assess the entire patient for the first time. He has a severely crushed and pulseless left leg, and a crushed left hand and wrist. They find no other injuries. All equipment has been prepared for a rapid removal, and the patient is quickly loaded onto the air ambulance, which departs for the trauma center.

   The Attack One crew stays to assist in cleaning up the scene, and will secure the amputated leg once it is removed from the machine. Crew members talk to the wife before she leaves for the hospital, ensuring she has a safe driver and instructions to get there. They work with the battalion chief to talk with the neighbors, friends and others who contributed to the rescue. They thank everyone for the effort and, although no one at that point can predict the outcome for the victim, congratulate the combined work force on giving the victim his best chance for survival. Investigators continue to work the scene, and all recovered body parts are given to the Attack One crew to transport to the hospital.

   The man's condition does not change on the flight to the trauma center. He is taken directly to the operating room and undergoes hours of surgery resulting in the loss of both legs. His pelvis is saved, however, and at a later date doctors repair his crushed left hand. He has a long hospital course and period of rehabilitation, but ultimately returns to his home and to farming.

Case Discussion

   This case demonstrates the care of a major trauma patient who has lost most of his blood volume. Blood products are not generally available on standard EMS units. Under extenuating circumstances, blood from a hospital blood bank may be available through use of a hospital-based transportation system, most commonly an air ambulance. Long-distance fixed-wing transportation providers typically transport patients between facilities, and they may have blood products available to assist in managing those moving between hospitals. Blood products can only be given by qualified providers, usually nurses, using special filters, tubing and documentation systems mandated for the safety of the patient.

   Farm-related injuries can be devastating, and may involve complicated, time-consuming and dangerous extrications. Victims may require major resuscitative efforts, as this one did, using a variety of tools and techniques. Agricultural areas are often far from trauma centers, so victim care will require consideration of appropriate transportation. Victims of major trauma incidents will benefit if EMS agencies have excellent working relationships with regional air ambulance services. Strategic use of air transport can be valuable for both resources not generally available on ground-based vehicles (like blood) and rapid transport to trauma centers and other specialized facilities.

   In caring for victims of agricultural accidents, prioritize stabilization of airway, breathing and circulation; preventing or reversing shock; and rapid transport to the appropriate hospital. Where necessary, medical control may assist in making difficult decisions involving saving lives or limbs.

Initial Assessment

A 32-year-old male with multiple injuries, trapped in farm machinery. He has suffered significant blood loss.

Airway: Intact and uncompromised.

Breathing: Distress due to profound shock.

Circulation: Obvious large-volume blood loss. Both legs are crushed to the pelvis. Delayed capillary refill and mottled skin.

Disability: Unresponsive.

Exposure of Other Major Problems: Victim has near-amputations of both lower extremities, and an open injury to the right side of his pelvis that continues to bleed. He also has a crushed left hand.

Vital Signs

Time HR BP RR Pulse Ox.
1610 140 60/palp. 32 Not Detectable
1620 136 70/palp. 28 Not detectable
1630 120 80/palp. 28 78%
1645 110 80/palp. 20/bagged 95%
1720 100 80/palp. 30/bagged 99%

AMPLE Assessment

Allergies: None known.

Medications: None.

Past Medical History: No significant medical history.

Last Intake: Breakfast about 0630.

   Event: Major trauma from an incident involving a large piece of farming apparatus, with the victim suffering extensive lower-extremity injuries and major blood loss.

   Customer Service Opportunity

   Extrication from farm apparatus must involve persons who understand the machinery and are qualified to operate it. In agricultural communities, these are often coworkers, neighbors and/or friends of the victim. Blend these individuals into the rescue operation in a manner that is safe for all involved. Stress management will be provided before, and sometimes during, the extrication.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton and a clinical associate professor in the Department of Emergency Medicine at Wright State University. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

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