It’s a cool, wintry day as last-minute Christmas shoppers make their way down an extremely congested highway leading into a local community of approximately 100,000 people. An EMT and a paramedic are sitting in their mobile intensive care unit (MICU) post midway between two districts when they’re dispatched to a reported motor vehicle collision about three miles from their location. The dispatcher seems extremely anxious as she reports a patient whose intestines are showing through an abdominal wound.
After a short drive, the ambulance crew arrives at the scene. The involved vehicle, a red minivan that appears to have moderate damage to the front end and passenger side, is positioned upright but off the roadway an estimated 50 yards away and within 20 yards of a large tree and a residential structure. As the ambulance pulls into an adjacent driveway, about a dozen bystanders converge with haste, reporting that the person in the vehicle is “about to die.”
The local volunteer fire department has not yet arrived. The crew proceeds to the patient with all of their standard trauma equipment, accompanied by the bystanders who help carry the equipment and clear a path by spreading a barbed wire fence and breaking off the shrubbery and underbrush surrounding the vehicle. Extreme caution is observed to ensure safety of the providers and the bystanders around the vehicle. The driver’s side door is open and a bystander is standing beside the patient.
The bystander states that he’s lent his phone to the patient to make what the patient believed to be his last call to his father.
A Gruesome Scene
The crew finds an obese male in his late 30s, weighing approximately 320 lbs., sitting angled in the blood-covered driver’s seat, leaning toward the center console. He is awake and alert. It’s apparent that he’s trapped by the dash and unable to be extricated without the assistance of responding rescue personnel.
The patient is holding a blood-soaked towel over his abdomen. It’s covering a large laceration to the patient’s abdomen and greater omentum—a large fold of visceral peritoneum that hangs down from the stomach—and what appears to be an eviscerated organ are laying between the dash, broken windshield and instrument panel.
Although the patient is weak, pale, cool and lethargic, he’s awake and repeating “I know I’m going to die.” He’s breathing adequately and able to move all extremities, although his lower extremities are trapped by the dash. He has a LEMON (look, evaluate using the 3-3-2 rule, Mallampati, obstruction, neck mobility) score of 6. (Read more about the LEMON score, an assessment tool that can reduce the chance of unexpectedly encountering a difficult airway, at www.jems.com/lemon-score.)
The crew identifies that the patient has an evisceration in the left upper quadrant of his abdomen that is approximately 2–4" in diameter. There is a positive loss of consciousness and the patient’s radial pulse is weak but, surprisingly, maintaining a rate of 70 bpm.
The patient is unsure of what happened, stating that he “blacked out” while driving. He complains of severe back pain and asks several times what is wrong with his back. While surveying extrication possibilities, the sliding door on the passenger side of the van is opened.
The crew observes blood-soaked Christmas presents in the back of the van and, upon closer inspection, finds a 4–5" hole in the seat in a location that would line up with the patient’s retroperitoneal region. With the significant blood loss observed, evisceration and extrication required, the crew requests a second MICU team in anticipation of traumatic cardiac arrest. Due to the severity of the patient’s injuries, they also call in a high-level trauma activation at the local Level II trauma center.
The hole in the seat and the patient’s confusion about what happened to him puzzled the EMS crew. Was there someone in the vehicle who shot him through the seat? Did something penetrate his retroperitoneal region causing him to “black out” and wreck, or was he penetrated by something else?
A police officer who arrives on scene dons personal protective equipment and climbs into the rear of the van and assists the crew by holding pressure with an abdominal dressing through the hole in the seat and against the patient’s back. The hole appears to be just lateral to the spine on the patient’s left, which the EMS personnel project to be the path of destruction in the patient’s abdomen.
They place a cervical collar on the patient along with oxygen via nonrebreather mask at 15 lpm as direct pressure is maintained on the patient’s abdominal dressing. Multiple IV attempts are unsuccessful in the patient’s left arm. His right arm and his legs are inaccessible. His peripheral pulses remain weak, and his blood pressure is palpated at 90. His blood glucose level is 120 mg/dL. A SAMPLE (signs/symptoms, allergies, medications, pertinent past history, last oral intake, events) history is obtained. The patient denies any pertinent history, medications or allergies.
The fire department arrives and begins extrication. During the fire department’s scene survey for hazards, the cause of the hole in the seat and trauma to the patient is uncovered along the car’s path down the embankment and shrubbery. It is a 3–4" diameter metal pole, approximately 10–15' long with what appears to be the remnant of an unidentifiable body organ attached to the end of it. It appears from the glass and debris on it that the pole entered the windshield, went through the patient and seat and was then somehow pulled back out of the patient before his vehicle finally came to rest.
There’s an increased sense of urgency to have the patient rapidly extricated and transported to the trauma center. The same crew was on duty a week earlier and had a patient who was awake, alert and trapped but perished before the extrication was completed. The crew doesn’t want to repeat that experience again here so they request that the rescue officer in charge expedite the patient’s extrication.
The closest trauma center is nine miles away and ready to receive and treat the patient. The additional MICU unit arrives just as the fire department announces they have cleared good access to the patient.
With the passenger door and seat removed, the EMS crew now has good access to the patient. He’s still conscious and talking. The dash is pushed up and, with the help of the fire-rescue personnel, police officers, four ambulance crew members and a few bystanders, the patient is moved onto a long backboard and away from the vehicle.
Secondary assessment reveals no gross deformity of the spine, and also continued bleeding from the entrance and exit wounds. Additional abdominal dressings are placed on the large wounds as the patient is secured to the board. Other than superficial lacerations and abrasions, the extremities are unremarkable, with movement and sensation throughout. Additional bystanders come to the aid of the emergency personnel, cutting the barbed wire fence, and assist in moving the stretcher up the incline and toward the ambulance.
They begin immediate transport. The patient’s airway is reassessed and found to be without obstruction, and the patient is at 100% saturation on a nonrebreather. The total scene time is just 20 minutes and a transport to the trauma center is 12 minutes.
There’s symmetrical chest wall movement and clear breath sounds bilaterally. The abdomen is distended with diffuse abdominal pain and continued bleeding. Intraosseous access is achieved in the left tibia while en route to the hospital with local anesthetics administered, and IV fluids are run wide open with a pressure infusion bag attached. A final report is given to the trauma center via radio.
The patient’s blood pressure appears to respond transiently to the IV fluid administration. Direct pressure to the anterior injury site is continued. The patient’s weight also provides pressure against the trauma dressing on the posterior injury site.
The bleeding appears to slow but his mental status begins to decline. One liter of normal saline is administered, and the patient’s blood pressure remains 90 systolic. His skin is starting to mottle, remaining cool and clammy.
Trauma Center Care
A team of emergency physicians, nurses and a trauma surgeon are waiting for the patient upon arrival. He is moved immediately to a trauma bay and is rapidly assessed. His skin is significantly mottled, and he is becoming increasingly hypotensive. A subclavian line is placed by the trauma team and he's intubated and moved into a surgical suite.
A laparotomy is performed, and the patient is found to have a lacerated diaphragm, small pneumothorax on the left, pancreatic injury, bowel injury, renal injury and the most disturbing: no spleen. The pole apparently severed the spleen and separated it from the patient when it was retreated out of the patient during the collision. It was later recovered and disposed of appropriately.
The spleen, which sits under the left rib cage near the stomach, is a vascular organ containing special white blood cells that destroy bacteria and helps the body fight infection. It is an important part of the body's immune system, but may be removed partially or entirely if ruptured or severely infected.
The patient’s injuries are repaired and he's moved to the trauma ICU in critical condition. He responds well and recovers after additional surgery. He remains hospitalized for approximately two weeks and is discharged without any sort of incapacitation.
The fates of most trauma patients rely heavily on critical decisions made by the crew before arrival and during care. Prior to arrival, appropriate resources, including flight resources, should be requested and confirmed. If extrication isn’t possible without assistance, it’s important to remember to treat your patient’s immediate life threats where they lie.
In this case, the early hemorrhage control by bystanders and the rapid assessment, trauma center notification, extrication and transport by providers, with appropriate treatment throughout helped sustain the patient’s vital signs until he could be turned over to the trauma team. The crews agreed that the discovery of the spleen on the pole assisted them in the determination of the cause and location of the injury.