Harvest time

[Rivard17_343]

It's a warm sunny fall day and your taking a drive in the country. During your trip, you notice the local farmers combineing barley in the fields. When you get home, you sit on the couch to watch some TV when all of a sudden your pager tones go off:

" Attention (your FD name here), respond to 999350 Hillview road for a unknown agricultural accident called in by a family member, EMS unit en-route, ETA 30 minutes."

You jump into your car, plug in the dash light, and drive to the hall where you meet your fellow volunteer firefighters just pulling up.

You are a small volunteer fire department, with yourself and 6 other firefighters trained as first responders.

The Vehicles:

Pumper 10
firefighting equipment
basic hand tools
sawz all
basic first aid kit
back board

Rescue 12
Rescue equipment
SCBA's
oxygen bag (air ways, masks, O2 cylinder)
Trauma kit (assorted bandages, gauze pads, splints, C collars)
2 back boards

Other help
One paramedic crew (basic life support) (30 minutes away)
Air ambulance chopper (advanced life support) (60-75 minutes away)
Police
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When you arrive on scene which is 5 minutes from your hall, you see what looks to be a 45 year old man lying beside a running farm tractor with a 45' grain auger attached to it with the power take off shaft still running and a missing guard on the intake for the auger. ( see pic 1)

You get out of the rescue truck and go over to the man and his son who has a rag pressed against his fathers amputated left leg( pic 2). The son tells you that he came back with a wagon of barley and saw his dad lying unconcious on the ground beside the equipment, so he called 911 and started first aid. (direct pressure)

You assess the unresponsive man and see that he is not breathing and there is massive bleeding from the stump of the leg. As you look around you see the amputated part of the leg 4 feet away. Your work begins......

Pictures
1. 2.

http://images.google.ca/images?q=tbn:r1t2gTzWoHdGeM:http://www.grainaugers.com/graphics/MK_130.gifhttp://images.google.ca/images?q=tbn:WGrWG-Mu0gS8WM:http://www.wits.ac.za/trauma/images/Photos/Amputation.jpg

Questions

1. What Personal protection will you wear?
2. What are your main prioraties for the patient? for scene safety?
3. What would you do with the amputed leg?
4. Would you need to control the patients C-spine on this call?
5. How could this incident be prevented?

Bonus Questions

1. What major blood vessels run down the legs?
2. How do you shut down a power takeoff system on this type of equipment?
3. Would you use a tourniquet on this patient?
4. What hidden danger may be around grain bins?

After 20 minutes of patient care, you have successfully got the farmer breathing, slowed the major bleeding, taken care and packaged the amputated leg, and he is now responsive. The paramedics arrive and assume care of the patient. You pick up all of your gear and return to the hall.

Three weeks later the farmer comes to your training meeting and thanks all of you for a job well done.

[firefighter26]

Rivard17_343!!!!! GREAT Scenario! And I get to answer one that I didn't think up!!!! Ok, deep breath..... deep breath.... deep breath.....

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1. What Personal protection will you wear?
I don't get on the truck unless I have my turnout gear on, so I'll be wearing my PPE (minus the SCBA) when I step off the truck. Goves, of course; and if there is some good spray from the arterial bleed I'll grab that finicky mask/eye visor thingy out of my FR kit (you know, the one no one ever uses).

2. What are your main prioraties for the patient? for scene safety?
PT Priorities: Safety from the scene. IE, don't want him to be injuried again. After that, it pretty much goes into my primary actions. IE, control the bleeding (either by direct pressure or taking a pressure point), Airway (open and check, insert airway), Breathing (assist with BVM and O2 at 15lpm) and of course Circulation. IE, is this going to turn into CPR?
Scene safety: Make sure the tractor isn't going to injure myself, the PT, or any of my crew.

3. What would you do with the amputed leg?
I'll detail one of my firefighters to do this, but if it was me I would
- give the exposed end a quick spash of Saline to clean off any dirt, etc.
- wrap the exposed end in sterile guaze, perferabled the nonadhesive kind.
- put the entire thing into a sealed zip plastic bag.
- but that bag into another, larger, plastic bag with ice/water or in a pinch, cold packs and water.
- Transport with PT, making sure to mark the time it was bagged for the docs to have some kind of reference too.

4. Would you need to control the patients C-spine on this call?
This one is hard to answer. I am ruling out a fall and the fact that it is a lower extrimity ambutation, spinal probably wouldn't be high on my list (IE, it would be behind controling the bleeding). I would have to asses the scene and see if there was a fall or anything (doesn't appear to be from the scenario, but I don't know farm equipment that well), but who ever is at the head would probably take some kind of spinal control (I know I would, even if spinal wasn't a consideration)

5. How could this incident be prevented?
Sounds like there was a missing guard on the auger intake. Not operating the equipment until all its safety features are inplace would probably have been a good idea. OR, perhaps not going near the intake while the machine is running (sounds like he was complacent and got caught)

BONUS QUESTIONS

1. What major blood vessels run down the legs?
Without getting technical because I am still just a lowly first responder, I am going to say an artery.... no, not just any atery, THE artery, as in isn't going to take long to bleed out if things go wrong. (I know it is called the femoral artery further up in the thigh, but I think its technical name changes once it passes the knee....)

2. How do you shut down a power takeoff system on this type of equipment?
Seeing as how we are only 5 minutes away, chances are someone on the crew will know. For me, I am just going to disengage it (assumung it is PT driven) or cut out the middle man and shut the engine off all together.

3. Would you use a tourniquet on this patient?
Direct Pressure first. If that doesn't work, a Pressure Point (along with direct pressure). If those don't work in conjuction, a tourniquet is about the only option left.

4. What hidden danger may be around grain bins?
Apart from silo gases blow up or something, the only thing I can think of is machenery with all sorts of spinning and chopping parts ;)

Great Scenario, Rivard17_343! Feel free to add some more!

[Scuba]

Good answers 26... Here's what I'd add.

1. Gloves - Double or triple bag'em... bones are sharp.. and there's gonna be LOTSA blood.

2. Scene Safety... Chock the wheels of both the auger, and the tractor. Disengage the PTO and IC gets the keys for the tractor...It's a powered machine that you're crews going to be working around - lock out and control is necessary... this is as good as it's gonna get interms of isolating who has control.

3.Permanant marker handy? Write his name on the pieces... Had an ER doc tell me that once (when they were threatening to cut my leg off.... ) and we were chatting about amputees... apparently there's a sizable portion of clients who's limbs get misplaced because they just don't know who they belong to.

4. He was caught by a PTO of a tractor most likely in the 70-100hp range moving at 540 or 1000RPM. I'd put money on it that he was probably tossed around like a rag doll at some point during his adventure. C-Spine would be a priority after plugging the leaks - and something to consider throughout my initial assessment.

Bonus

1. It's the Popliteal Artery. (http://en.wikipedia.org/wiki/Popliteal_artery)

2. See my other #2.

3. Direct pressure can only be applied to all the blood vessels in the leg by using a tourniquet imho... Being a farm I'd probably guess that they have those camstrap things... it'd work great. So as not to cause too much damage... I'd release the strap every few minutes untill blood flows through to the stump... not sure if it's right or not, but to me I woudl think this would help keep the tissue alive and well, as well help prevent bacteria from working it's way up the drained vessels... an hour is a pretty long time to be in this condition...

4. silo gasses = dust explosion btw, Herbacides/pestacides, mad cows and other assorted animals. After all it is a farm...

good scenerio Rivard...

[YammieR6_24]

I also agree with firefighter26 with a few small differences. The order of the inital response should be airway, rescue breathing then deal with the bleeding. We always stress in the 1st responder program not to get side tracked by the gross stuff and make sure you keepin order A B C. But if you have 6 firefighter standing around this can go on at the same time. 2 FF working on breathing, 2 on the amputation, 1 getting the defib ready just in case and 1 getting the amputated part. Also you need to worry about shock so getting blankets and elevating the lower limbs once he begins breathing again.
As for shutting down the machinery that seems to be a good job for the son to get him out of the way and give him something else to think about.

[dentedhead]

Great answers all round.

Quick A&P the femoral artery becomes the poplateil artery at about the anterior aspect of the knee it then bifurcates and becomes the dorsalis pedus at the ankle and the pedal artery on top of the foot.The big vein in the leg is called the greater saphonous(sp)

In extremme bleeds esp arterial, a quick and safe tornoquiet to use is a manual BP cuff.Place it 4-6 inches up from the bleed and inflate it slowly depending on the location usually 40-60mmHg will do it,best bet watch for the blood flow to stop.

And as yammie mentioned most importantly in any medical/trauma A-B-Cs
if any of those are not there thats priority one.

Dentedhead

[PEMS17]

Beat me to the punch DH.
Had an amputation like this in the spring. Did not bleed much at all due to the crushing force, didn't even get my gloves soaked. Ended up with a BKA at 26 years old.
FYI, due to the tissue depth that the popiteal artery is contained within, it often more effective to apply the touniquet above the knee for below the knee injuries. The arteries in the upper leg are easier to constrict even though they are larger. Great scenario

[Scuba]

What's a BKA?

[dentedhead]

Below the Knee Amputation.

Dentedhead

[PEMS17]

Sorry jude. My world is an acronym

[dentedhead]

Sorry jude. My world is an acronym

Sometimes I miss that,nmonics and acromyms, throw in a bit of shorthand you never have to worry bout spelling again.It makes it easy for the wife and I to leave notes though.

Dentedhead

[PEMS17]

Sometimes I miss that,nmonics and acromyms, throw in a bit of shorthand you never have to worry bout spelling again.It makes it easy for the wife and I to leave notes though.

DentedheadAmen, my misses is a pharmacy tech. Somehow it just doesn't have the same jist or romance when you say that you want "it" bid hs qd:D

[Brian911FD]

Amen, my misses is a pharmacy tech. Somehow it just doesn't have the same jist or romance when you say that you want "it" bid hs qd:D
Suppose the question then becomes do you get "it" bid hs qd? And if so, it doesn't matter how it sounds with the acronyms ..... *wink*

[Rivard17_343]

Thanks guys! I was a little worried about how my scenario would go over with you all, but I am very pleased and learned a little too. I'll try to think up some more scenarios (that FF26 didn't cover yet! lol) soon.

Good awnsers so far! very indepth.

[firefighter26]

You are more than welcome to keep adding them!

I enjoyed responding to one I didn't create and it gave me a reason to go back over my textbooks and re-read a few chapters for my own clarity/knowledge.... And that is what it is all about; IE, getting people to think and encouraging a good, healthy conversation!

I got a couple in the works right now, just havn't had the time to finish them!

[fire16]

Sorry jude. My world is an acronym

The EMS and Fire people that are separate entities but work together at incidents should have non emerg. get togethers. Just to remind each other that one entity doesnt always understand what the other is trying to convey.
For the most part, I expect the rural vol. fire person, has no ideal what a BKA is. Prolly best to talk to each other in "long hand". Have had to ask lots of times what the HE double L are you Ems people trying to ask or convey to me. I dont know , nor should I be expected to know all your "shorthands". Same as any EMS who is not "Fire Smart" , might not understand some/any fire "shorthand".

[firefighter26]

I ran into this problem a few years ago with a new firefighter who thought they where gods gift to the first responder program.... during a practice night I took over spinal during the mock MVA so she could assess the PT (as the interior responder) and started rattling off all the 400 point scrabble words from some anatomy book she purchased on Ebay or something.... needless to say when she was done, I looked at her asked for it "in english this time" because I didn't have a clue what she was talking about.

Vice versa, most paramedics or police officers don't understand the standard run of the mill FD jargon we often throw at each other on scene.

This where interagency interaction is worth its weight in gold. My suggestion has always been to attempt to invite EVERYONE to practice. Next time you put together a huge extrication scenario, invite the local RCMP or Ambulance crew to attend. I doubt they'd send whoever was on duty, but you might be lucky enough and find that some of them are willing to come down while off duty!

[mutts252]

3. Direct pressure can only be applied to all the blood vessels in the leg by using a tourniquet imho... Being a farm I'd probably guess that they have those camstrap things... it'd work great. So as not to cause too much damage... I'd release the strap every few minutes untill blood flows through to the stump... not sure if it's right or not, but to me I woudl think this would help keep the tissue alive and well, as well help prevent bacteria from working it's way up the drained vessels... an hour is a pretty long time to be in this condition...

i dunno if i'm off-base on this one or not...

but i have always been taught that once a tourniquet is applied, it is NEVER released / loosened except by a doctor etc in a hospital (or maybe paramedics)... but we are never to release it, as doing so can essentially counteract all the good we may have done by applying it in the first place.

DH or someone else who has more med-related experience.... comment?

[dentedhead]

i dunno if i'm off-base on this one or not...

but i have always been taught that once a tourniquet is applied, it is NEVER released / loosened except by a doctor etc in a hospital (or maybe paramedics)... but we are never to release it, as doing so can essentially counteract all the good we may have done by applying it in the first place.

DH or someone else who has more med-related experience.... comment?

If I remember that day in school correctly,(I was drunk alot in collegeBTW)When a tourniquet is applied it should be loosened slightly q5 to allow some circulation to the tissues below the constriction.

You just loosen it enough and slowly to allow the blood to flow.Leave it loose for appox 30-45 seconds dependent on blood loss and pt condition.

Im sure someone else will also be able to expand on this.I have learned a few things from some of the western folks,im sure they will weigh in for us.

Dentedhead

[mutts252]

thanks DH... i just dug out my SJA booklet, too, and here's a bit from it:

"If medical help will be available within one hour, do not loosen it [the tourniquet]. If medical help is delayed more than one hour, loosen the tourniquet each hour to assess the bleeding. If bleeding has stopped, leave the loosened tourniquet in place so that it can be tightened quickly if bleeding starts again."

so there's one tidbit... anyone else more on the med side of things to weigh in on this one?

[PEMS17]

The Manitoba Emergency Treatment Guidelines can be found here:
http://www.gov.mb.ca/health/ems/guidelines/index.html
The guideline specific to external bleeding can be found here:
http://www.gov.mb.ca/health/ems/guidelines/T2.pdf
On the third page there is info specific to tourniquets

These guidelines form our "bible" to which we are accountable. Being guidelines we can alter our approach, but need to stay pretty close. Hope that helps. EMR's by the way are expected to perform to this level as well as everyone trained above them.