I guess I'm not as prepared as I thought for a traumatic injury

Was driving home last night and was the 6th vehicle to stop at the scene of a hit and run against a pedestrian. By the time I got to the victim with my "oh shit" bag, there were 5 or 6 other people fluttering around him doing nothing. EMS had already been summoned. He had a compound fracture of his left ankle and blood coming from his nose and mouth, but no obvious facial injuries. There were a number of large blood spots on the pavement, roughly 3" in diameter. I'm guessing he had internal injuries. He was in a lot of pain based on the amount of noise he was making. He was obviously conscious and breathing.

I stood there for a minute trying to figure out what to do. My limited training said to look for other hidden injuries, stabilize the fracture and control the bleeding. There was surprisingly little blood from his ankle, so that was likely a non-issue. Then treat for shock and wait for the cavalry. By the time I did my mental evaluation, someone had a blanket on him (it was cold on the road) and I could see EMS inbound about 1/2 mile out. I elected to step away and leave it to the pros. I was totally creeped out at the thought of trying to help this poor guy, especially moving that broken ankle. I think I'd have done what needed to be done if no help had been available, but I was absolutely thrilled to see EMS coming over the hill.

The whole episode made me realize how hard it will be if I'm ever called upon to provide care in a real deal emergency.

Anything wrong with my evaluation? What did I miss? To be honest, checking for hidden injuries didn't occur to me until after I was home.

I think you did well. Sometimes the best you can do is keep the patient calm, warm, and out of shock, especially when the pros are only a minute or so out...

Great eval. You did everything right. Its hard to push through the 'what the fuck' - to the actual doing something, especially when your just a bystander. Only other things that you didn't expressly say, but I am assuming you did as part of the checklist:

Airway - could he breath? You said he was making noise so I am assuming yes, but since you asked.
Shock - Keep him talking and get as much information as you can out of him. Name, where he lives, anyone else, whats his phone number, anything to keep him talking (and get info).
Stabilize - Keep them immobile unless there is some life threatening need to move them.

Otherwise - good job!

I've been taught that as long as the victim is breathing and has a pulse (even if they aren't conscious) there probably isn't much more you can do until trained professionals arrive on scene.

Although, if there is obvious major bleeding that you can safely deal with then that probably would have been OK. Assuming you had the proper protection to protect yourself from hepatitis and HIV.

Well............................ my Opinion ([panic]) is.................I applaud you for actually wanting to assist the injured party. How you did or didn't act / respond after that, not my call. Armchair QB'ing someone when i was not on scene, doesn't resolve what did or didn't happen.

I will say, i am as annoyed as you were that everyone else was standing there with their thumb up their anus. If anything that is one of the biggest pet peeves i have. There's been more than 1x i was involved while everyone else stood there like statues.

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Originally Posted by Great-Kazoo

Well............................ my Opinion ([panic]) is.................I applaud you for actually wanting to assist the injured party. How you did or didn't act / respond after that, not my call. Armchair QB'ing someone when i was not on scene, doesn't resolve what did or didn't happen.

I will say, i am as annoyed as you were that everyone else was standing there with their thumb up their anus. If anything that is one of the biggest pet peeves i have. There's been more than 1x i was involved while everyone else stood there like statues.

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Well at least they called 911 instead of just using their phones to video the guy dying.

I recently had a thing where I had to go get my blow out kit, and also didn't have to use it. Maybe we should start a thread specifically for arm chair quarterbacking, just because it's not something many of us deal with.

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Originally Posted by Irving

I recently had a thing where I had to go get my blow out kit, and also didn't have to use it. Maybe we should start a thread specifically for arm chair quarterbacking, just because it's not something many of us deal with.

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I don't see it as arm-chairing. Tim specifically asked for anything else he might have missed and was looking for other opinions. Evaluating yourself, and having others honestly do the same, for what you did and did not do is a great way of learning.

Arm-chairing, IMHO, is telling the guy he did it wrong and saying how the arm-chair QB would have done it better (which in Tim's case was not an issue).

I think we could have a thread for evaluating. That's what I meant.

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Originally Posted by Irving

I think we could have a thread for evaluating. That's what I meant.

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Sorry misread. Sounds good to me.

Without formal training the best thing you can do is stabilize until ems or someone trained gets there. As bad as it sounds if it's not a life or death situation immediately the less you do the better (there are exceptions of course). I think you did great just trying to help and going through his injuries mentally that quick. There is often more going on internally that you can't see so that why I say stabilize and wait if help is that close.

im im sure you had the gear for it but doing surgery on the side of the road probably wouldn't have been a good time for either party.

In trauma (penetrating or blunt) the best assessment is MARCH

Massive Hemorrhage
Airway
Respirations
Circulation
Hypothermia

For medical emergencies it is still your ABC's.

With an Auto-Ped you are dealing with blunt force trauma and most injuries will be internal. You will not have much time with the patient to get down to figuring out what all is wrong with them, EMS rarely does as well. There is very little a bystander can do for blunt force trauma. Massive hemorrhage may not be seen quickly, it may be all internal. Ensure an open airway and adequate respirations best thing is keep the patient warm and treat for shock.

As as far as your reaction it is quite normal, the only reason EMS seems calm is it is their job, not their emergency. They are comfortable in those situations, but I promise you every EMT's first couple good trauma calls, they were reacting the same way you did.

Don't beat yourself up, it's difficult, do you best within your Knowledge, Skills, Abilities and Attitude and you will be fine.

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Originally Posted by cmailliard

In trauma (penetrating or blunt) the best assessment is MARCH

Massive Hemorrhage
Airway
Respirations
Circulation
Hypothermia

For medical emergencies it is still your ABC's.

With an Auto-Ped you are dealing with blunt force trauma and most injuries will be internal. You will not have much time with the patient to get down to figuring out what all is wrong with them, EMS rarely does as well. There is very little a bystander can do for blunt force trauma. Massive hemorrhage may not be seen quickly, it may be all internal. Ensure an open airway and adequate respirations best thing is keep the patient warm and treat for shock.

As as far as your reaction it is quite normal, the only reason EMS seems calm is it is their job, not their emergency. They are comfortable in those situations, but I promise you every EMT's first couple good trauma calls, they were reacting the same way you did.

Don't beat yourself up, it's difficult, do you best within your Knowledge, Skills, Abilities and Attitude and you will be fine.

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If somebody has internal bleeding, is there anything that can be done for them outside an operating room?

I think you did well.

http://griddownmed.com/ has some good info, but they have not posted anything new in a while.

Like cmailliard said. ABC's.
As a first responder, your main job is to get advanced medical care for your patient.
That means get the EMT & Paramedics to you.
It is probably good not to move them because if possible spinal injury, unless your trained to do it, or EMS needs your help with the patient.
Do your best, try to get vitals if possible while waiting for EMS. (pulse/respirations/mental state)

Cheers, you did good. Most people would just keep driving.

Only thing that hasn't been mentioned so far is spinal stabilization. If you had proper PPE (gloves definitely, mask preferred given the facial bleeding and coughing) you could have gently stabilized his head and gently prevented him from moving his head/neck around too much. That gives the added benefit of putting you in position to monitor the airway.

There's little else you could have done. Even EMTs have very few interventions available to them... oxygen and an oropharyngeal airway (or King/Laryngeal mask in more enlightened jurisdictions). That's pretty much it. Paramedics can intubate and push resuscitative fluids, but again, that's only a stopgap measure.

Trauma is a sickness and the only cure is the knife. Surgery or death.

Good insight on the neck stabilization. I'll file that away.

The take-away I have on this, is to make sure i have a blanket in the car for something like this.

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Originally Posted by HoneyBadger

If somebody has internal bleeding, is there anything that can be done for them outside an operating room?

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Not a lot but it depends on the injury. There are some injuries an OR can't even save. The hardest part is time, in most blunt force injuries it takes time for a sign (something you can see, like a bruise) to appear to help point you in a direction. Without diagnostic equipment it is very difficult to determine quickly.

Example - I was dispatched to Abdominal Pain. On arrival I went to the patient as I was the lead medic. I had my partner and the tailboarder helping me. My Lt. was talking to the family upstairs and my Engineer was working on patient movement. Patient had a pulse of 110, BP of 86/54 and respirations in mid 20's. He had shitty skin color and just looked weak. No obvious sign of trauma and patient denied any recent trauma. Belly was tender but not rigid. No real good history from him, but he was a poor historian. Overall on a Sick/Not Sick basis, he was sick. My Lt. came down stairs and informed me of some history and we both looked at each after comparing notes (history and Physical Exam) and knew. We carefully put him in a stairchair, moved him upstairs to the stretcher and went emergent to St. Anthony's. Enroute I called with my report and his pulse was up to the 120's and BP was falling. I called and told them what I had and asked for T10 (T10 is the emergent surgical suite at Holy Tony's). We took the patient up to T10, the trauma surgeon had his team going pretty good and had to calm them down, I remember him saying "calm down everyone, he still has a pressure of 80". He died 25 minutes later on the table.

What was wrong with him? He had an Abdominal Aortic Aneurysm (AAA). He had been seen for a small one a week or so earlier, well it had now increased in size. It had been bleeding into his belly faster and he just lost too much blood. Medicine is a lot about ruling things out and leaving a couple possible options. In this case we could rule a lot out but with the history we could zero in on a more than likely culprit. EMS also has the ability to discuss with ED Docs, the ED could have said no to my request for T10, but based on the info I gave and the trust there, the ED Doc agreed T10 was a good option.

The point is with internal problems it takes time and information to come an answer for what is going on. With internal injures from blunt force trauma your differential diagnosis list (things that it can be) is pretty big without X-Ray, MRI, CT, Ultrasound, etc. The ability for a quality assessment is a big thing in EMS, especially with Paramedics. It is all about the Differential Diagnosis and working the worst one in that list. Coming up with that list quickly is what takes practice (practicing medicine) and seeing as many patients as you can.

In every case you do the best you can with what you have (KSAA). Remember it's not your emergency, you doing your best to help. If you help within your KSAA nobody can ask more of you.

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Originally Posted by cmailliard

Not a lot but it depends on the injury. There are some injuries an OR can't even save. The hardest part is time, in most blunt force injuries it takes time for a sign (something you can see, like a bruise) to appear to help point you in a direction. Without diagnostic equipment it is very difficult to determine quickly.

Example - I was dispatched to Abdominal Pain. On arrival I went to the patient as I was the lead medic. I had my partner and the tailboarder helping me. My Lt. was talking to the family upstairs and my Engineer was working on patient movement. Patient had a pulse of 110, BP of 86/54 and respirations in mid 20's. He had shitty skin color and just looked weak. No obvious sign of trauma and patient denied any recent trauma. Belly was tender but not rigid. No real good history from him, but he was a poor historian. Overall on a Sick/Not Sick basis, he was sick. My Lt. came down stairs and informed me of some history and we both looked at each after comparing notes (history and Physical Exam) and knew. We carefully put him in a stairchair, moved him upstairs to the stretcher and went emergent to St. Anthony's. Enroute I called with my report and his pulse was up to the 120's and BP was falling. I called and told them what I had and asked for T10 (T10 is the emergent surgical suite at Holy Tony's). We took the patient up to T10, the trauma surgeon had his team going pretty good and had to calm them down, I remember him saying "calm down everyone, he still has a pressure of 80". He died 25 minutes later on the table.

What was wrong with him? He had an Abdominal Aortic Aneurysm (AAA). He had been seen for a small one a week or so earlier, well it had now increased in size. It had been bleeding into his belly faster and he just lost too much blood. Medicine is a lot about ruling things out and leaving a couple possible options. In this case we could rule a lot out but with the history we could zero in on a more than likely culprit. EMS also has the ability to discuss with ED Docs, the ED could have said no to my request for T10, but based on the info I gave and the trust there, the ED Doc agreed T10 was a good option.

The point is with internal problems it takes time and information to come an answer for what is going on. With internal injures from blunt force trauma your differential diagnosis list (things that it can be) is pretty big without X-Ray, MRI, CT, Ultrasound, etc. The ability for a quality assessment is a big thing in EMS, especially with Paramedics. It is all about the Differential Diagnosis and working the worst one in that list. Coming up with that list quickly is what takes practice (practicing medicine) and seeing as many patients as you can.

In every case you do the best you can with what you have (KSAA). Remember it's not your emergency, you doing your best to help. If you help within your KSAA nobody can ask more of you.

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One more reason i cannot say enough about this mans courses. For those who have not attended one, by all means put it on your TO DO List.

Would love to have a course down here once in a while down in Colorado Springs area for us southerners...

I think you did good Tim.

Hell, if it was me, I probably would have took his wallet and ran.

I couldn't find his wallet.

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Originally Posted by Tim K

I couldn't find his wallet.

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Just choked on my drink. Thanks for making my day.

Seems like you did what you could in the sitch. This is a reminder to update my bag with more med equipment. I've been meaning to do that for a while. A blanket is a good call. Never really thought of that except for personal use if stranded, etc.

Don't forget, extra gear is useless if you don't know how to use it.

Biggest thing I remember from my last Red Cross class is "be damned careful to NOT do anything you could get sued for, because no matter what you do for them, people can and do sue those who are trying to help them". He made us ask our "victims" for explicit permission to help them. That stuck with me.

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Originally Posted by rondog

Biggest thing I remember from my last Red Cross class is "be damned careful to NOT do anything you could get sued for, because no matter what you do for them, people can and do sue those who are trying to help them". He made us ask our "victims" for explicit permission to help them. That stuck with me.

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Must have been a long time ago, or the instructor didn't know what they were talking about. There are laws on the books protecting first responders from suit, provided they were given consent (implied or otherwise), and the responder wasn't negligent with their actions.

HERE is a decent resource for some law and definitions.

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Originally Posted by hurley842002

Must have been a long time ago, or the instructor didn't know what they were talking about. There are laws on the books protecting first responders from suit, provided they were given consent (implied or otherwise), and the responder wasn't negligent with their actions.

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It also varies greatly by state. Context

Great job, only basic thing I can add is check skin color and temp with the back of your hand. Ex: cool, dry, warm, pale, damp.....
Great job and as others stated, glad you stopped and provided comfort and it was a wonderful call on the blanket.