Engine 1, an ALS engine company staffed with one paramedic and two EMTs, is dispatched to assist police with a welfare check. On arrival, the crew finds a small, one-story house with the doors locked.
After knocking on the door, a male voice is heard yelling for help. The door is immediately forced open and the crew finds a conscious obese male, lying supine on the floor, impaled by two wooden dowels of a magazine rack. The dowels are penetrating the posterior right buttock and continue through to his lower abdomen and pelvis.
The officer radios dispatch and requests Truck 1 and Rescue 1 be dispatched emergent to the scene because additional resources and manpower are needed. The extra crews arrive on scene simultaneously.
The patient is a 70-year-old male, 6-foot 6-inches, weighing approximately 400 pounds. He’s lying supine on the floor with both legs bent at the knees and folded underneath him, his skin is noted to be pale and dry, and his right lower leg presents with cyanosis, is cool to the touch, and distal pulses and sensation are absent. The patient denies any complaints other than “wanting to get up off the floor” and says he was ambulating when he slipped on a magazine and fell backward onto the magazine rack; he believes he’s been down between 12 and 24 hours.
Examination reveals a wooden magazine rack approximately two feet in length with 12″-long wooden dowels sticking up vertically at 3–4″ intervals. Two of the dowels have impaled the patient, the first entering approximately one inch to the left of his left testicle. The other entry wound isn’t visible due to the patient’s position, but the ends of both dowels are visible just under the skin of the patient’s pelvis and left lower quadrant. Blood loss is estimated at 200 cc with minimal active bleeding; there’s a large amount of fecal matter noted in and around the wound. The patient’s vital signs are as follows: blood pressure 98/42, pulse rate 100 bpm and irregular, respirations 20 and non–labored with an oxygen saturation of 91% on room air, blood glucose is 277 mg/dL. The cardiac monitor is applied and confirms atrial fibrillation. The patient reports a history of Type 2 diabetes, high cholesterol and hypertension, but has no previous cardiac history. Medications include amlodipine, simvastatin, metformin and lisinopril. Patient reports no known drug allergies.
Two large bore peripheral IVs are initiated–one with normal saline and one with lactated Ringer’s. The patient is also placed on oxygen via a non-rebreather mask at 15 Lpm. Contact is then made with medical control at a Level 2 trauma center located approximately one mile from the scene, but it’s decided to transfer the patient to a Level 1 trauma center 25 miles away after photos of the injuries are relayed.
Paramedics on scene request an order for 100 mEq sodium bicarbonate, but the request is denied. After consulting with medical control a combat application tourniquet is placed on the patient’s right leg just above the knee before carefully straightening both of the patient’s lower legs. The magazine rack is stabilized by securing it to the patient’s left leg with towels and ACE bandages.
The patient’s shoulders are gently lifted just off the floor and a bariatric soft stretcher is slid under his upper body with gentle seesaw-type movements. Four personnel are assigned to lift the patient’s lower extremities and the patient is then gently lifted just enough so a Stokes basket can be placed under him. His lower legs are secured to the outer edges of the Stokes basket for stabilization and pillows are placed around the patient for padding. Measurements are made and it’s determined he’ll fit through the doorway if the door is removed from its hinges.
The patient is carried outside, secured to the cot and loaded into the ambulance; a firefighter paramedic is requested to assist with patient care during the 25-minute transport. During transport the patient remains conscious, alert and oriented but begins to complain of mild pain in his lower abdomen. His blood pressure is 95/72 and a second 500 cc bolus is given. The patient remains in atrial fibrillation with his heart rate becoming slightly erratic, ranging from the 60s to the 130s with an increasing number of multifocal premature ventricular contractions (PVCs). Per medical control, 100 mEq of sodium bicarbonate is administered, which substantially decreases the PVCs and stabilizes the heart rate at 96. Blood pressure remains stable at 100/62.
Report is called to the Level 1 trauma center and a Level 1 trauma alert is initiated. The patient’s condition remains unchanged throughout the remainder of the transport.
On arrival at the ED the patient is taken to a trauma room where the staff is waiting. Report is given to the attending physicians and the patient is lifted from the Stokes basket to the exam table. He’s logrolled onto his right side for examination of the injury. An indwelling catheter is placed with a small return of brown urine. Labs are drawn and the patient’s blood pH is noted to be 7.1, creatinine is 31,000 (it peaked at 91,000 the next day). A Gigli saw (flexible wire saw) is used to separate the two dowels from the rack so the rack can be removed, and the patient is prepped and taken to the OR.
A rigid sigmoidoscopy is performed and no rectal injuries are found. A 17-cm incision is made between the path of the dowels and the dowels are removed. The wound is explored and there’s noted to be extensive dissection of subcutaneous fat, but there’s no evidence of penetration into the abdominal fascia or femoral vessels so the wound is packed with Kerlix and left open.
The surgeons turn their attention to the patient’s right lower leg. A four-compartment fasciotomy is performed. The patient is found to have a large amount of necrotic tissue, and an above-the-knee amputation is performed the following day.
Additional complications included renal failure due to rhabdomyolysis resulting from compartment syndrome, which requires hemodialysis three times a week.
There are times when a patient’s traumatic injuries can appear horrific, but it’s not in the patient’s best interest to “load and go.” Several considerations had to be taken into account before moving this patient:
- The close proximity of the impaled dowels to the patient’s left femoral artery– any movement might initiate catastrophic blood loss.
- The issue of the cyanotic, cool, right lower leg–it appeared the circulation had been cut off for some time, but the leg would have to be straightened to remove the patient from the residence. In doing so, the toxic byproducts of anaerobic metabolism would enter the bloodstream and could lead to serious complications from compartment syndrome.
- The size of the patient relative to the size of the doorway–the rescue company might need to enlarge the door opening to facilitate patient removal. It’s important to recognize the need for additional resources and call for them early.
Interestingly, the abdominal injuries appeared to be the most critical issue with this patient, but the right lower leg presented more issues and complications. Compartment syndrome and crush injuries aren’t things we tend to see often; it’s important to understand them nonetheless. Rhadbomyolysis may be minimized with fluids and keeping the urine pH as close to normal limits as possible. The amount of myoglobin precipitated in the urine is directly proportional to the pH. In other words, the more acidic the patient becomes, the more myoglobin stays in the kidneys plugging the tubules rather than being passed in the urine.
Don’t focus solely on the horrific injuries that first grab your attention–do a thorough assessment and consider the global picture so you don’t miss other critical factors. Recognize the need for and utilize all necessary resources early on in an incident. Implementing effective interagency communication provides for a meeting of the minds, which lends to the most promising outcomes for the people in the communities we are proud to serve.