Case Study – December 2019 Newsletter
Beam Me Out of Here, Scotty – You are up at one of the 10th Mountain Division Huts on a December ski trip, tired after a great day of shredding some sweet powder. The hut is pretty full, maybe 20 people. You are ready to throw out a group of four twenty-something year olds, or sleep in the outhouse, due to their loud partying, fueled by a couple bottles of Jim Beam. They start trying to do hand stands and you watch in horror as one of the young women crashes into, through, and halfway out a window. Her buddies laughingly haul her back in and then someone screams; they drop her on the floor. You grab the hut first aid kit and throw on some gloves. She has cuts on her scalp that are bleeding badly, but what is scary is a huge laceration on her thigh that is spurting blood. A large pool of blood collects on the floor around her.
Scene and Primary Assessment: There are large shards of glass across the hut floor and all around the patient. One of the patient’s buddies continues to scream. You skip asking for permission to treat and get the spurting stopped with a couple of towels and two handed direct pressure.
Secondary Physical: Upon examination you find cuts on the scalp that continue to bleed, but they appear only skin deep. Besides the scalp lacs and the arm, you find no other injuries. You re-examine the thigh and see the pressure dressing is not working. Blood has soaked the towels; it continues to pour to the ground.
SAMPLE: Symptoms as described. The patient is agitated and too out of it to answer questions about her history. Her girlfriend who is a bit drunk but trying to help tells you that the patient’s name is Sam. Sam is 24 but the friend doesn’t know about any allergies and only that she is on some kind of birth control. No relevant history. They skied in today and Sam didn’t eat much for dinner—she was having too much fun with her new best friend, Jim.
Vitals: Round 1 – HR 104, RR 28, V on AVPU , skin pale. Round 2 – HR 124, RR 32, P on AVPU, skin cyanotic.
Setting: You’re at ~10,000 feet at one of the 10th Mountain Huts. It’s 8 pm, ~20 degrees F., calm, and clear sky, with a full moon casting a silvery light over a powdery snow pack. No one has a sat phone and there is no cell phone service at the hut, but someone says there is up on the hill about 45 minutes away. Someone else says they have an old SPOT transponder but they’ve never used it. Like all the huts there is a rescue sled down in the wood shed. It is about 5 miles and 1500 feet down to the trailhead. Snow conditions are great.
What else do you do? What is your Assessment? What are your Anticipated Problems? What is your plan? What are you really worrying about?
What else do you do?
Make sure no one else is cut by the glass – scene safety! Immediately throw a tourniquet on Sam’s leg, two to three inches proximal to the wound. Stop the scalp laceration wounds with direct pressure. If you have hemostatic dressings and the scalp wounds are bad, use them there, otherwise use them deep in the thigh wound, once the bleeding significantly slows. Keep Sam horizontal and warm, and her legs elevated. Make sure the Jim Beam is capped and no more is consumed. Reassure and calm down Sam’s friends.
What is your Assessment?
Sam, a 24 year old female went through a plate glass window after consuming large quantities of alcohol. Concerned about shock due to significant loss of blood from very serious spurting thigh, along with scalp lacerations. Tourniquet placed on thigh at (time applied) and dressings applied to scalp and arm. Patient placed in sleeping bag and legs elevated.
What are your Anticipated Problems?
For Sam altitude, hypoglycemia, dehydration (?), sobriety, loss of limb, if she is A,V, or P dealing with pain. For Sam’s friends possibly the same (other than laceration issues) and emotional issues. For you and your friends possibly the same, with hopefully the exception of sobriety. Evacuation.
What is your plan?
It would depend on Sam’s status, the capacity of the group at the hut, distance/trail conditions to trailhead, and phone coverage. The big question is whether you need to risk trying to get Sam out that night. Is there so much blood loss that she might not make it through the night? If that is the case do you have the people power (numbers, ability, energy, etc.) and the gear (sled) to safely descend to the road? Either way, do you have enough people that a few could be sent out with a copy of the SOAP note to request assistance (night time evac, first daylight rescue launch, ambulance or chopper at trailhead)? If sufficient people power try to fix window.
What are you really worrying about?
Death from shock. Loss of limb. Inebriated friends.