How would you treat this patient?

[GM911 0]

Hey all, time for another exciting round of....

TREAT THE PATIENT!!!!

Today's victim: Eve S. Arration

MOI: Well, knife in back.

Keep in mind he needs to be immobilized... Would you remove the object to get him on a backboard? Backboard him prone? What if he needs to be bagged?? Looking forward to seeing you answers!!

[Guest]

Would lying him down face first and then securing and imobilizing the object from moving. then strappiing him in be the right thing. I would think leaving the object in would stop bleeding and clogging the whole until surgery to remove the object. I could be wrong. dont have to much knowledge in major wounds like this. Just a thought.

Edited May 7, 2008 by ccbub31

[Raz 14]

NEVER remove the object, it's helping to stem the bleeding and you could damage the spinal column (well, more) by pulling it out. Dress the wound and transport prone.

[helicopper 1,050]

Let me guess, he got home and asked his wife if dinner was ready yet before leaning into the refrigerator for a beer!

Raz is absolutely right, never remove an impaled object in the field!

[GM911 0]

agreed with the above statements, but what if he was having difficulty breathing? not only would i imagine being prone on a board would restrict chest rise, but i imagine jaw thrust/bvm on this patient would be extrememly difficult on this pt as well

[ny10570 745]

Stabilize the object and transport. Even if it was possible to effectively immobilize him, spinal immobilization wouldn't do much. The goal there is to prevent injury by providing stability so what ever damage done by the blade isn't going to be made worse so long as that blade stays exactly where it is. Besides the pain of a large knife in his back should be enough motivation for him to keep still. If he stops breathing bleeding and spinal injury become less important so feel free to play excaliber, pull the knife, flip him and begin airway management.

agreed with the above statements, but what if he was having difficulty breathing? not only would i imagine being prone on a board would restrict chest rise, but i imagine jaw thrust/bvm on this patient would be extrememly difficult on this pt as well

Difficulty breathing, sucks for him all you can really do is oxygen and an NRB. At some point if it becomes so compromised that he is no longer able to sustain life see above.

Edited May 7, 2008 by ny10570

[moggie6 54]

I wouldn't even worry about spinal immobilization. I would document in my PCR why I didn't apply a c-collar\b-board and take full spinal immobilization per cautions. I'd also call medical control to run it by them and see if they could offer any assitance and to cover my own rear.

[nycemt728 49]

I agree, spinal immobilization does not appear to be a priority in this instance...as always and has been said above, secure the knife and monitor life threatening conditions. Not sure about pulling the knife if breathing goes, perhaps if it's secure enough, shift him to the side and assist breathing from there? I like Moggie6's answer, if ever there was a time to break out that number for medical control, this would be a good one.

[Guest CRASH]

I agree, spinal immobilization does not appear to be a priority in this instance...as always and has been said above, secure the knife and monitor life threatening conditions. Not sure about pulling the knife if breathing goes, perhaps if it's secure enough, shift him to the side and assist breathing from there? I like Moggie6's answer, if ever there was a time to break out that number for medical control, this would be a good one.

.

.

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4 Words.

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.Call in the bird .

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I want the chopper if this guy spirals down I want a lil more than als care...

[GM911 0]

how about using the trusty trauma shears and cutting the blade so that you can lay him on the board??

[RescueKujo 130]

Hey, that guy used to work in my dispatch center! So him being stabbed in the back is true!!

In reality, transport prone. Any chance of him crashing, depending on distance to the trauma center, call the bird for sedation then intubation. Let them manage the airway their way....

Otherwise, double big bags with a 14 gauge in each a/c and haul a$$ for the big house...

[mvfire8989 22]

how about using the trusty trauma shears and cutting the blade so that you can lay him on the board??

I don't think shears would cut through a steel blade.

Edited May 8, 2008 by mvfire8989

[Guest]

If he needs to be tubed, it wouldn't be the most difficult situation I could think of. Scoot him up on the stretcher so his head is hanging off the end. Have your partner hold his head up. Squat down at the head of the bed. Tube him with the laryngoscope in your right hand.

There's a knife on my leatherman tool, maybe I could cut through the blade with that? Ya know, cut it precisely flush with the skin.

[calhobs 110]

This is 100 percent true.

Stabilize the object and transport. Even if it was possible to effectively immobilize him, spinal immobilization wouldn't do much. The goal there is to prevent injury by providing stability so what ever damage done by the blade isn't going to be made worse so long as that blade stays exactly where it is. Besides the pain of a large knife in his back should be enough motivation for him to keep still. If he stops breathing bleeding and spinal injury become less important so feel free to play excaliber, pull the knife, flip him and begin airway management.

First off the knife looks like it is going stright in and appears not to be in the pt that much,. So it is safe to say that there is no spinal injury even if there is like stated above not much we can do. Also since the knife does not appear to be in that far chances are likely that the lung was not hit. also if its is hit keeping the knife in place is doing more good there then pulling it out. Also if the lung was hit you most likely see nice frothy blood.

As far as calling in the bird I think you will do more damage then good the vibrtations from the chopper alone will have that knife moving like a tuneing fork.

I use to get stabings like this all the time back in the day its really no big deal.

Edited May 8, 2008 by calhobs

[ems731 0]

i would immobilize the knife to keep it from moving, i can't tell how long that knife is and i would much rather wait for the dr to tell me at the hospital cause removing it onscene could cause much more damage. once the knife is secure i would transport as fast as possible to the nearest trauma center.

[helicopper 1,050]

This is 100 percent true.

First off the knife looks like it is going stright in and appears not to be in the pt that much,. So it is safe to say that there is no spinal injury even if there is like stated above not much we can do. Also since the knife does not appear to be in that far chances are likely that the lung was not hit. also if its is hit keeping the knife in place is doing more good there then pulling it out. Also if the lung was hit you most likely see nice frothy blood.

As far as calling in the bird I think you will do more damage then good the vibrtations from the chopper alone will have that knife moving like a tuneing fork.

I use to get stabings like this all the time back in the day its really no big deal.

So you have x-ray vision now?

There's no way of knowing the length of the blade or what it damaged. It could have been manipulated by the stabber or the stabee if he tried to pull it out himself or fell down. Frothy blood in the airway is a good indicator but is not present 100% of the time.

Agreed, air transport sounds great but would likely do more harm than good (especially waiting for it).

As for cutting the blade, WHY? It's not a fence post, you can move him as is so move him to a hospital where he belongs! Cutting it will only move it more and could make the surgery more difficult if its suddenly flush with the skin. Stabilize it in place and transport.

[irishfire2491 24]

CALL A MEDIC and let them DECIDE lol

but i would lay him prone with head blocks.

Leaving enought room for beathing

If need to be bagged i would lay him prone

extend over the back board have some hold

C SPINE druring transport use BVM Upside down

Would need a lot of people for that one or even

use a Short board if it does not reach down to the

knife and leave him prone. But it would have to be a

Call it as you see it kind of thing.

Last time I looked I was not a Doctor so I would

Leave the knife and pad the area around it.

[Guest feraldan]

Notice the MD's in the background with their hands in their pockets?

[Guest alsfirefighter]

I want the chopper if this guy spirals down I want a lil more than als care...

CRASH...not sure what you mean by a lil more than als care...but what would he get in a helicopter? A flight medic and/or flight nurse...he's not getting anything above als care that he would receive on the ground except for a heftier bill and a little faster travel time ONCE they are in the air. Not to mention the crew would have to watch for any baro issues depending on altitude. There isn't all that much space to be able to do much inside the bird and they are an "air" ambulance.

I had a very similiar patient to this about a year or so ago...4" serrated steak knife about 2" left of the spinal column to about the mid point of the scapula, blade was at a downward angle and buried deep with no handle being it fell off. Patient was laid prone, object was stabilized, NRB, 2 large bore IV's, constant vital/lung sound checks and clothing was stripped. All dude wanted was the knife out and he didn't like that we couldn't...quite beligerant would be a good description especially with the IV's and his clothes being cut off. I tried to explain to him why things are the way they were and he still liked his profanity laiden tirade so I simple told him to wait until he gets to the trauma center and see what they say and even more so what they will do in addition to what I did. Needless to say he never developed SOB or any significant changes in L/S while in my care, but he certainly didn't like the chest tube he got anyway and he then stopped his profanity and said to me "you weren't lying bro I should've listened and been nicer to you." The trauma surgeon couldn't pull it out with his hands it was so buried into his scapula, they had to find pliers being there was no handle to get leverage.

Advanced airway if needed....combitube. Easy to insert at any position. Pneumothorax develops...roll him/her into a recumbant position, perform the needle decompression and use sheets blankets to keep him off of the device you used to perform it. Also every ounce of clothing goes to get a detailed head to toe trauma assessment looking for more holes! Check the clothing quickly as well for holes which can assist in finding any penetrating trauma not felt due to the flight or fight response. Try not to cut through the holes or tear the clothing like on TV being most PD agencies will take the clothing as part of the investigation.

Chris brings up an important point...you never can tell how far a object is or has been inserted. I had a BLS crew cancel me a a couple years back while responding to a stabbing call. The reason, the patient was hemodynamically stable on scene and he was stabbed with a short paring knife just below his navel. The problem was the 1" knife was just long enough to knick his intestine and he was internally bleeding and should have been sent to a trauma facility. Never assume with penetrating trauma.

Edited May 8, 2008 by alsfirefighter

[Guest]

CALL A MEDIC and let them DECIDE lol...but i would lay him prone with head blocks...C SPINE during transport

why?

you don't need a medic if he is breathing and awake

c-collar, head blocks and back board are designed to immobilize a patient laying on their back

think about why we immobilize patients...it is to minimize movement in case there is some sort of unstable spine fracture or dislocation that could move and damage the spinal cord. A knife will not cause a spine fracture or dislocation, generally only blunt trauma will do this. So if the patient is not having any deficits or tingling, etc... then the spinal cord has not been stabbed and you don't really have to worry about spinal cord injury (as long as you don't start moving the knife!) Same goes for gunshot wounds, unless the patient is showing signs of a spinal injury or is unconscious (and cannot tell you about feeling/not feeling his legs), you are really just wasting time on scene

[crcocr1 8]

I agree wholeheartedly with alsfirefighter but am worried about some BLS members in this forum being reluctant to provide care prior to ALS arrival. Remember, whether paid of volunteer, the public views you as professionals, as does the courts.

Regretfully, NYS has not adopted the National protocol regarding backboarding. Therefore, BLS wise, I agree with c-collar and backboard, possibly with a shortboard, being mindful of airway access at all times. If it still is achievable in the prone position, then backboard in the prone position. If it isn't achievable, BLS providers ATTEMPT med control but if it fails, AIRWAY AIRWAY AIRWAY is the most important part of patient care. Without airway access, a pneumothorax cannot be treated b/c the utility of a chest tube is futile. There is no pressure to relieve when there is no air flowing through the body. Similarly, spinal immobilization is useless when the patient cannot be salvaged. Transport to a Trauma Center in accordance with state and local protocol accordingly.

ALS wise, I think the comments above are sufficient.

Edited May 8, 2008 by crcocr1

[Raz 14]

Cutting or breaking off the blade? I think some of you guys have been getting your BLS tips from watching Braveheart.

[Guest paramedico987]

Stable patient... well duh, same thing everybody else has said.

Unstable patient requiring airway management...

I'd see if the blade could be cut with bolt cutters or something like that from a rescue so that it wouldn't be so long. And either way turn the pt on his/her side so at lease we could make some kind of effort at bagging them.

Cardiac Arrest... all bets are off and that blade's coming out!

[ny10570 745]

First off, where are you putting the second headblock? C-collars are all (as far as I know) designed to fit a neck in which the head is facing forward and at least close to mid line. I suggest you guys try applying a collar to someone who's head is turned. One last thing about the collar, its to protect the cervical spine. Alone it doesn't do anything for an injury to the thoracic vertibra. Don't just be robots and do it because the book says so. Think about what the end goal of your interventions is and if they aren't going to help and especially if they may hurt your patient don't do them.

Yeah, it is possible to intubate this guy without removing the blade, I was thinking more along the lines of while transporting if he turns south there won't be enough room to position him where you want to.

He doesn't need to be flown or rushed anywhere. So long as he remains stable with good lung sounds he needs a calm easy ride to the Trauma center. One bad bump or too many little bumps could do some damage. I also would refrain from cutting it so long as he can fit into the bus. Shortening it isn't going to change your treatment and tampering risks making it worse.

EMT's enjoy this job, its all about BLS as long as his airway remains stable. Stabilize the blade and assess thoroughly and often.

[Guest mediconpatrol]

why wouldnt anyone transport in a side lying position...

[Guest alsfirefighter]

I'm not sure who you mean "anyone" wouldn't transport with the patient lying on their side...but in my post I mentioned about lying them in the recumbent position. I can tell you though, that most will not want to and will want to lay prone to limit movement of their body and the object.

[Guest mediconpatrol]

I'm not sure who you mean "anyone" wouldn't transport with the patient lying on their side...but post I in my mentioned about lying them in the recumbent position. I can tell you though, that most will not want to and will want to lay prone to limit movement of their body and the object.

I am sorry alsfirefighter, I did see that you wrote the "recumbent" position but I didn't know you meant "lateral recumbent" as opposed to "horizontal recumbent"

[Oswegowind 17]

First, have him walk to the ambulance...j/k

Slide him prone onto the board, strap him down, transport him to the hospital, collar and blocks will do him no good in this case. Control bleeding as necessary, affix the knife in its position using tape and gauze, vitals enroute, notify for or case, take to trauma center, not local yocal ER. Get back in service quick for the next one, and brag about job to friends and family!

[ckroll 101]

Interesting. In both BLS and ALS capacities I've 'stabilized' patients in position found. If the patient is neurologically intact I think it a fine idea to leave them as you find them, pad the voids and if the ER wants them supine, then let them do it where it is warm and dry and there are many hands to help.

I believe I'd lift the patient up and inch in line, slide a board in and manage from there, or scoop. The scoop is fabulous and under used. the absolute LEAST movement of patient or object should be the goal.

If she is neurologically intact and the airway is patent, there is not not much to improve pre surgery and some huge down sides. Great quote attributed either to Chinese tradition or Bugs Bunny... " Don't just do something, stand there." If there is already spinal or airway compromise, then it is a different scenario.

[Guest alsfirefighter]

No need to apologize brother, that's what I get for being a bit lazy and not typing in lateral as well. I just figured it would be known.

Oswego..mine did in a way he was standing leaning over a car trunk when I got there and the ambulance arrived a few mins. later.