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Old 18-08-2011, 19:55   #1
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Challenge: Thinking Outside the Medical Box | Traumatic Shock

Shock can take many forms (no not the electric one) but the one we are most likely to see and have to deal with is acute shock from trauma. Other types of shock are more likely slower onset, and as such can be dealt with on shore. Yes I know Anaphylactic shock is rapid onset, but I gotta hold back some material for another edition

Traumatic shock is deadly! Per the NIH,
Quote:
Originally Posted by NIH
What is shock?

Shock often accompanies trauma. Also known as “circulatory collapse,” shock can occur when the blood pressure in a person’s arteries is too low to maintain an adequate supply of blood to organs and tissues.
So in laymen’s terms... there isn’t enough blood! It can be because there is too little blood (from hemorrhage) or the “container” has gotten too big for the normal quantity of blood. The first is pretty straightforward... STOP THE LEAK! The later is a bit more complicated. Our circulatory system is capable of compensating and adapting to the circulating volume of blood... to a point. There are muscles around out blood vessels that shrink or expand the system as necessary to maintain circulation and perfusion (oxygenation of tissues).

Shock comes about when the compensatory mechanisms become overwhelmed. Signs of shock include cold & clammy skin, weak and rapid pulse, irregular breathing, dry mouth, faintness, decreased urine output. Traumatic shock can progress very rapidly. There are stages of shock which are progressive (and beyond the scope of this thread) but the idea remains to recognize the symptoms and take steps to mitigate the progression as soon as possible..... before it is too late! It is an arguable point that people don’t bleed to death, because they die of shock first!

There are two types of bleeding: internal and external. In a boat at sea without advanced medical capabilities, there isn’t much you can do with internal bleeding other than supportive care, so we won’t go into that other than to say getting the patient to a physician’s care as soon as possible is the best treatment. External bleeding is best controlled with direct pressure. Make a compress out of absorbent material and use the heel of your hand to press it down directly over the wound. Failing that, on extremities, in spite of the bad press given tourniquets, a wide elastic applied just tight enough to stem the flow may save a life (we use SWAT-T). A narrow tourniquet may cause damage to underlying tissues and should be avoided. If you have a blood pressure cuff aboard, these are excellent!

There are also commercial coagulative agents available (we use TraumaDEX and Celox), but if you don’t have any, simple cornstarch or flour will help (remember we are thinking outside the box). They work be absorbing the liquid components of blood and allowing the solids to form a clot faster.

Without advanced life support, shock management is limited to elevating the feet, keeping the patient warm, oxygen if available, and rapid evacuation to medical care.

So here’s the Outside the Box section.....

This happened to me in Cozumel Mexico fifteen years ago:

A 25 year old male was in a skiff circling and jumping his own wake between the two piers to the island (yup before the cruise ship pier was built). He managed to loose his balance and fall overboard while his skiff continued to circle. I was on one of the piers filling my boat with diesel (from 5 gallon cans!); I heard the commotion just in time to see the poor guy run down by his own boat. There was so much blood, you could see it in the water. Literally dozens of men jumped in from shore to help, but the circling boat was keeping them at bay. A good samaritan in a sportfisherman saw what was going on and literally rammed the skiff with his boat sinking it. The shore rescuers towed the unconscious and bleeding man to shore..... THEN STOOD AROUND AND DID NOTHING TO STOP THE BLEEDING!

I took off down the pier (ignoring the objections of my now EX-wife). The crowd was so large by now that I had trouble getting to the patient “Yo soy paramedico” didn’t count for much. When I got to his side, I realized all I had to work with was...... NOTHING! I was wearing a pair of nylon running shorts, and a pair of topsiders. I asked a bystander for his guayabera shirt.. he was reluctant until I gestured at my shorts! I folded the shirt into a thick pad and applied it to the patient’s right shoulder. Blood turned the shirt crimson in seconds, and blood continued to flow............

What did I do next?
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Old 18-08-2011, 20:03   #2
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Re: Thinking Outside the Medical Box: Traumatic Shock

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S....

I took off down the pier (ignoring the objections of my now EX-wife). The crowd was so large by now that I had trouble getting to the patient “Yo soy paramedico” didn’t count for much. When I got to his side, I realized all I had to work with was...... NOTHING! I was wearing a pair of nylon running shorts, and a pair of topsiders. I asked a bystander for his guayabera shirt.. he was reluctant until I gestured at my shorts! I folded the shirt into a thick pad and applied it to the patient’s right shoulder. Blood turned the shirt crimson in seconds, and blood continued to flow............

What did I do next?
Artery or vein bleeding?
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Old 18-08-2011, 20:15   #3
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Re: Thinking Outside the Medical Box: Traumatic Shock

Bright red and pulsing.....
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Old 18-08-2011, 20:30   #4
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Re: Thinking Outside the Medical Box: Traumatic Shock

artery,,,,,,tourniquet if possible, if not the patient will go into shock and die from loss of blood. You might have to clamp the artery if you can get to it, (lots of pain) blood loss must be stopped immediately.
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Old 18-08-2011, 20:34   #5
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Re: Thinking Outside the Medical Box: Traumatic Shock

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Bright red and pulsing.....
Remember, I'm lay.

You have an artery broken. Elevate victim so wound is higher then heart. Keep pressure on wound.

I wish I could remember my pressure points, but I don't, as that would slow the bleeding.
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Old 18-08-2011, 20:37   #6
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Re: Thinking Outside the Medical Box: Traumatic Shock

Ah! Pressure points are a good suggestion... but THIS laceration was AT the pressure point (Brachial Artery)......
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Old 18-08-2011, 21:05   #7
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Re: Thinking Outside the Medical Box: Traumatic Shock

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Ah! Pressure points are a good suggestion... but THIS laceration was AT the pressure point (Brachial Artery)......
Zeeeeeeeeeeee... HELP!!!

Flying by the seat of my pants, you had very few tools with you. Hopefully you sent someone to get help, seeing you had a large crowd.

You had shoelaces available. Was the laceration such that you could use them as a makeshift tourniquet?
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Old 19-08-2011, 03:31   #8
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Re: Thinking Outside the Medical Box: Traumatic Shock

uhm, how high on that arm/shoulder? if pressure near collarbone is out direct pressure on wound (possibly enough to break collarbone) and elevating legs is just about only way I can think on to keep him alive until plasma can be given, possibly not even then.
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Old 19-08-2011, 22:07   #9
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Re: Thinking Outside the Medical Box: Traumatic Shock

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Ah! Pressure points are a good suggestion... but THIS laceration was AT the pressure point (Brachial Artery)......
First thing is to check that you are applying pressure directly on the bleading wound (think "direct pressure"). This may require briefly re-exposing the wound. Locate the source of bleeding exactly, then press down hard with your compress and hold pressure. Elevate the wound to the extent possible, but maintain pressure at all costs.

If this fails, your next option is to improvise a tourniquet. (Since you said it was at the brachial pressure point, I'm assuming there is enough arm proximal to the wound to apply the tourniquet If need be, get someones belt. Tighten until the bleeding stops.

Bottom line is you must stop the arterial bleeding, and you must stop it right now.
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Old 20-08-2011, 02:32   #10
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Re: Challenge: Thinking Outside the Medical Box / Traumatic Shock

Knock him out with a sharp blow to the chin to allow his body to relax and ignore the pain of your fingers probing to find, and tie off, the damaged artery. He'll be no worse off unconcious but the crowd maybe a problem.
Shouting 'Doctor' very loudly may help. Off duty doctors are cautious of law suits if they don't get things right. It may also convince the crowd that you know exactly what you are doing. Even if it's just the immediate ring around you.

Just a wild guess but I'm not one to watch and see what happens.
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Old 20-08-2011, 05:17   #11
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Re: Challenge: Thinking Outside the Medical Box / Traumatic Shock

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Knock him out with a sharp blow to the chin to allow his body to relax and ignore the pain of your fingers probing to find, and tie off, the damaged artery. He'll be no worse off unconcious but the crowd maybe a problem.
Shouting 'Doctor' very loudly may help. Off duty doctors are cautious of law suits if they don't get things right. It may also convince the crowd that you know exactly what you are doing. Even if it's just the immediate ring around you.

Just a wild guess but I'm not one to watch and see what happens.
Very good! Well except for the knocking out part LOL! The brachial artery was nicked way up; a tourniquet was out of the question. "Tying" off an primary artery is not a good idea....

I did remove the compress and was able to visualize the nick in the artery.... Never an easy thing to find in the field with all of the "other" bleeding from the smaller vessels. I was able to tamponade the leak with my index finger and thumb.

I heard a siren, and saw an ambulance arrive....that said "Miami-Dade Fire Rescue" (remember we were in Mexico!). The doors opened and the entire interior was EMPTY! even the stretcher had no pad.. Only plywood!

The Bomberos (firefighters) insisted in spite of my protest that I go with the patient to the clinic. Once there with the patient transferred to the doc, I had to figure out how to get a half-naked, blood covered, gringo who had no cash or ID back to the other side of the island!
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Old 20-08-2011, 08:51   #12
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Re: Challenge: Thinking Outside the Medical Box | Traumatic Shock

A good conclusion, even though you were left high and dry.
One of the big problems of field medicine must be the lack of calming/pain relieving medicines. Too dangerous for the uninitiated, and a shame that such medicines are just not available in the UK to 'commoners'.
Life is very precious to most folk, it would be a shame to let it slip away from fear of making things worse. The problem is identifying!!
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Old 20-08-2011, 11:05   #13
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Re: Challenge: Thinking Outside the Medical Box | Traumatic Shock

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.....One of the big problems of field medicine must be the lack of calming/pain relieving medicines. Too dangerous for the uninitiated, and a shame that such medicines are just not available in the UK to 'commoners'.....
As others have noted, many meds that are 'prescirption only' in many develped countries may be available over the counter in less highly developed (and regulated) countries.

Another option is to find a physician sympathetic to your needs, and get them to write you prescriptions. Find a doctor who has some experience as an expedition climber, long distance cruiser, or treker. Explain what you want and why you want it....that you are planning a long trip where you will be days from medical help, and that the meds are for you and your families use only, and then only in dire circumstances. In Alaska, quite a few people planning climbing expiditions and other trips to remote areas do this.

The advantage of this approach is that the doctor can give you good instructions about when, and also importantly when not to use those drugs. Getting some training in wilderness medicine, and signing up for one of the services which give medical advice via radio or sat phone might also help convince your physician to help you obtain meds.
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Old 20-08-2011, 11:18   #14
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Re: Challenge: Thinking Outside the Medical Box | Traumatic Shock

many prescription meds in mexico are sold over the counter in small quantities. you definitely need an md for any significant quantity of prescription/relaxing agents.
pressure on an arterial nick is similar to closing an arterial puncture for angiography(heart cath), as long as nick is smallish..put good pressure on the site, allowing for enough flow to continue to have a pulse and color to distal extremity for at least 30 mins-- hour is often needed. walk home is not always an option-- sometimes have to be inventive as to transportation in mexico...sounds like the on scene gringo using pressure of the shirt to wound did a good job.
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Old 20-08-2011, 11:55   #15
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Re: Challenge: Thinking Outside the Medical Box | Traumatic Shock

Its been a busy shift at work, sorry!
Now for the rest of the story........ Is seems the victim was the fiance’ of the only daughter of the Fire Chief on the island, who also moonlighted as a taxi cab driver. I got the girl on the desk at the clinic call me up a taxi, and I my halting Spanish I attempted to explain that I would pay him when I got back to my boat. Well word travels fast on the island and to this day Los Bombero de Florida still enjoys free taxi rides in Cozumel!
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