View Full Version : Help, I Burnt my Arm
one of the guys on your team comes walking up to you holding his arm and tells you he just did this detonating explosives....
what are the steps you take to evaluate/treat.....
Sneaky SF Dude
9 July 2003, 18:34
.
I've hogged the last few. I'll sit back and let someone else treat this fella. It looks kind of gangrenous, in an unpleasant sort of way, that is.
If no one else steps up, Doc T, I'll take a try at it and be sure to try to make a few stupid mistakes that you and USSFPA can call me out on.:D
RsovRanger
9 July 2003, 19:45
move to a safe area
check for injuries other than that
nose hose to maintain airway make sure he's good there
burn pad to affected area
2 18g saline locks, if showing signs of shock push a 500ml bag of NS, elevate feet
2g cefoxitin followed by saline flush
phentanol lollypop 5 on 5 off 4 on 4 off down to 1 minute, combine with morphine if the phentanol isn't enough, titrate to
effect
make him comfortable as possible given the situation
call for casevac
fill out casualty card, going off of DIME he will probably be delayed, but would be priority evac otherwise if no other casualties.
Originally posted by RsovRanger
move to a safe area
check for injuries other than that
nose hose to maintain airway make sure he's good there
burn pad to affected area
2 18g saline locks, if showing signs of shock push a 500ml bag of NS, elevate feet
2g cefoxitin followed by saline flush
phentanol lollypop 5 on 5 off 4 on 4 off down to 1 minute, combine with morphine if the phentanol isn't enough, titrate to
effect
make him comfortable as possible given the situation
call for casevac
fill out casualty card, going off of DIME he will probably be delayed, but would be priority evac otherwise if no other casualties.
THANKS DOC T!!!
Good start...how about the evaluation basics???
Looks circumferential and full thickness...what kind of things would you start checking for in your PE???
What would your concerns be over the next 18-24 hours???
Casevac will say is not available and you are in your GP small BAS. Not a gangrenous photo...but an acute burn.
Please continue...
PRimum non Nocere
Originally posted by Sneaky SF Dude
.
are you left speechless?
Originally posted by RsovRanger
move to a safe area
check for injuries other than that
nose hose to maintain airway make sure he's good there
burn pad to affected area
2 18g saline locks, if showing signs of shock push a 500ml bag of NS, elevate feet
2g cefoxitin followed by saline flush
phentanol lollypop 5 on 5 off 4 on 4 off down to 1 minute, combine with morphine if the phentanol isn't enough, titrate to
effect
make him comfortable as possible given the situation
call for casevac
fill out casualty card, going off of DIME he will probably be delayed, but would be priority evac otherwise if no other casualties.
great start checking for other injuries...people tend to forget that burns are often also traumas and simply concentrate on the burn.... but i will tell you he has no other injuries besides the burnt arm.
ABCs are intact.
no fear of shock from isolated burn...what is the probable total body percentage for burning one forearm circumferencially?
what degree would you think this burn is...first, second, third?
how much pain would you expect?
are antibiotics needed? tetanus?
any immediate threats you can see from an injury like this one...?
what is DIME?
doc t.
RsovRanger
9 July 2003, 20:38
Good start...how about the evaluation basics???
Looks circumferential and full thickness...what kind of things would you start checking for in your PE???
What would your concerns be over the next 18-24 hours???
Casevac will say is not available and you are in your GP small BAS. Not a gangrenous photo...but an acute burn.
Please continue...
Nerve deficit distal to the injury, distal pulse. I'm willing to bet he's gonna be stumpy when he gets released from the hospital.
My concerns in the 18-24 hour period following injury would be temperature,pain management, and control of possibility of infection.. obviously he only has (if my conceptualization of the rule o 9s aint fucked) around a 5% total burn on his body but that fucker has to hurt. Even though supposedly you cant feel a 3rd degree burn there has to be live nerves somewhere that will hurt and pain management in a burn patient is a asset consuming proposition. he'll probably end up munching on alot of lollypops. Not sure how much of your body you need to fry to lose temperature control but I'd take care of that anyway, and keeping that area clean and dry would be important. I'd ask MY pa what the hell else to do.
and what's this casevac isn't available bullshit... :)
RsovRanger
9 July 2003, 20:52
great start checking for other injuries...people tend to forget that burns are often also traumas and simply concentrate on the burn.... but i will tell you he has no other injuries besides the burnt arm.
ABCs are intact.
no fear of shock from isolated burn...what is the probable total body percentage for burning one forearm circumferencially?
what degree would you think this burn is...first, second, third?
how much pain would you expect?
are antibiotics needed? tetanus?
any immediate threats you can see from an injury like this one...?
what is DIME?
I'd go with about 5%. He's got all three, rare medium and well done in the middle. Pain? Honestly have no experience, I'd just keep slowly feeding him more until he didn't hurt anymore, but keep track of his ABC's so I don't dope him up to the point of being mr veggie.
Antibiotics are part of my work protocol for any combat injury on a mission, either PO or IV/IM depending on the situation. Cipro PO or cefotitan (can't spell it for shit but know what vial it's in in the dark) IV/IM. protocol as well to get at least one saline lock on board, 2 if time permits. DOn't delay evac because you don't have an iv on board though. Immediate threats would be loss of limb. if that's a full thickness burn he's going to be stumpy, pure and simple.
RsovRanger
9 July 2003, 20:58
DIME
Delayed
Immediate
Minimal
Expectant
Delayed is those that need to get evac'ed but don't need to go on the first lift.
Immediate is mr spurting blood has a alien popping out of his chest and no legs, gots to go yesterday.
Minimal is shrapnel wounds, shit you can bandaid up and toss them on CCP security with someone who's good to keep checking on them while waiting for exfil.
Expectant... He may be concious, may not be. Chaplain's over with those guys taking care of them.
RIT_MEDIC
9 July 2003, 21:21
Originally posted by RsovRanger
DIME
Delayed
Immediate
Minimal
Expectant
Delayed is those that need to get evac'ed but don't need to go on the first lift.
Immediate is mr spurting blood has a alien popping out of his chest and no legs, gots to go yesterday.
Minimal is shrapnel wounds, shit you can bandaid up and toss them on CCP security with someone who's good to keep checking on them while waiting for exfil.
Expectant... He may be concious, may not be. Chaplain's over with those guys taking care of them.
Never heard triage quite that way before...then again I am not a military medic.
We use Priority 1-4 and include major area of injury and RTS, unless head injury and then add GCS. This is more for dispatch to relay PT(s) condition to awaiting trauma team, and/or medevac bird. I like the DIME thing though.
Now back to the subject at hand.
PE:
4.5-5% TBSA with partial and full thickness. PMS to the hand would also be a major consideration here.
I know DocT stated there was no other trauma, but I would definately check the eyes good...possible flash burn there too.
Tx:
POC(Pos of Comfort)
Dry dressing.
2 18 ga w/ LR
Morphine til the pain went bye-bye.
EVAC to Augusta or MUSC Burn CTR.
frogstyle
9 July 2003, 21:23
Win the gunfight...
Break contact..
Make COMMS enroute to extract
Consolidate ammo..
Then ............
frogstyle
9 July 2003, 21:27
I will be interested in seeing the variations between SOF and "regular" med protocol.
Reaper375
9 July 2003, 21:36
Look at it this way, he can wear any size watch he wants to now... all the way to the last hole. Lucky bastard.
Originally posted by RsovRanger
I'd go with about 5%. He's got all three, rare medium and well done in the middle. Pain? Honestly have no experience, I'd just keep slowly feeding him more until he didn't hurt anymore, but keep track of his ABC's so I don't dope him up to the point of being mr veggie.
Antibiotics are part of my work protocol for any combat injury on a mission, either PO or IV/IM depending on the situation. Cipro PO or cefotitan (can't spell it for shit but know what vial it's in in the dark) IV/IM. protocol as well to get at least one saline lock on board, 2 if time permits. DOn't delay evac because you don't have an iv on board though. Immediate threats would be loss of limb. if that's a full thickness burn he's going to be stumpy, pure and simple.
5% is an excellent choice... whole arm would be around 9 by rule of 9's... the burn appears to be third degree on the arm and possibly deep second degree on the hand... third degree burns look awful but don't hurt AT ALL... second degree is another story so pain meds would be indicated (am not trying to imply otherwise but have had 90%TBSA third degree during my training...no pain, wide awake....its an awful sight)...
abx are not actually indicated for acute burns although I don't think there would be a big problem with giving them...they are just considered clean unless obviously contaminated with dirt or the person was in water (ie. boat fire and jumped overboard...the ocean is teeming with bacteria).
you noted that immediate threat would be loss of limb...what if i told you he said he was numb in his entire hand... anything you'd want to do before sending him off somewhere... Hint...it involves a knife and doesn't hurt (i promise)
doc t.
RsovRanger
9 July 2003, 22:06
Capsulization or something like that. fluid buildup in tissue causes it to swell and you have to fillet it open to allow it to bleed so it can heal right vs popping.
way way way above my level of care. I'll let the trauma surgeon take care of that.
with the time elapse since your first post.. he'd have been evaced to a forward medical team... then probably already be on a bird to germany now.
Originally posted by RsovRanger
Capsulization or something like that. fluid buildup in tissue causes it to swell and you have to fillet it open to allow it to bleed so it can heal right vs popping.
way way way above my level of care. I'll let the trauma surgeon take care of that.
with the time elapse since your first post.. he'd have been evaced to a forward medical team... then probably already be on a bird to germany now.
I am not sure the level of training on the board... would assume (maybe incorrectly) that SF medics could do escharotomies....do they not? The eschar is the black or chalky white area you see almost immediately on a third degree burn...when circumferential it acts like a vise causing pressure to build and a decrease in blood flow to nerves, muscle, etc. An escharotomy (cutting seams {for lack of a better word} into the eschar ) is the kind of thing that needs to be done ASAP to alleviate the pressure and allow blood flow at a tissue level. The patient feels no pain and it doesn't bleed since its done in an area of third degree.
The risk in this case is only loss of limb but loss of life can be real for larger burns that involve the circumferential thorax as a patient can suffocate in minutes even if intubated if he cannot expand his chest...
Hmmm...will post a drawing of where you do them tomorrow if someone wants... otherwise, sorry if i took this too advanced.
doc t.
CPTAUSRET
9 July 2003, 22:28
Didn't want to hijack this thread, but Nancy did a study of burn patients around 1970, and she used that experience as the example when she wrote the definition of PTSD for DSM lll or IV:
Terry
Originally posted by CPTAUSRET
Didn't want to hijack this thread, but Nancy did a study of burn patients around 1970, and she used she used that experience as the example when she wrote the definition for PTSD for DSM lll or IV:
Terry
the burn unit where i am currently employed has their own clinical psychologist to help the patients deal with PTSD... we occasionally borrow him for our trauma patients...separate units, same problems.
CPTAUSRET
9 July 2003, 22:36
Originally posted by Doc T
the burn unit where i am currently employed has their own clinical psychologist to help the patients deal with PTSD... we occasionally borrow him for our trauma patients...separate units, same problems.
Nancy is a Psychiatrist and earns her living as a Neuroscientist, her descriptions of the suffering some of those people endured sometimes brings tears to my eyes:
We need to get together sometime when we are a little closer to your AO:
Hi to your XO:
Terry
Originally posted by Doc T
I am not sure the level of training on the board... would assume (maybe incorrectly) that SF medics could do escharotomies....do they not? The eschar is the black or chalky white area you see almost immediately on a third degree burn...when circumferential it acts like a vise causing pressure to build and a decrease in blood flow to nerves, muscle, etc. An escharotomy (cutting seams {for lack of a better word} into the eschar ) is the kind of thing that needs to be done ASAP to alleviate the pressure and allow blood flow at a tissue level. The patient feels no pain and it doesn't bleed since its done in an area of third degree.
The risk in this case is only loss of limb but loss of life can be real for larger burns that involve the circumferential thorax as a patient can suffocate in minutes even if intubated if he cannot expand his chest...
Hmmm...will post a drawing of where you do them tomorrow if someone wants... otherwise, sorry if i took this too advanced.
doc t.
DOC...You are indeed correct in that SF medics are trained in escharotomies...I do not think that RSOV has been to the long course though and no other's have stepped up.
Good time for him to LEARN!!! :D
Perhaps you can elaborate a bit on the compartment syndrome, as well as testing for deficits in ROM and nerve conduction. Allen's test, fluid resuscitation(sp) formula (Brooke's OK?), etc. Proper application of silvadene and debridement techniques.
Your expertise would be greatly appreciated.
Primum non Nocere
RsovRanger
9 July 2003, 22:49
to give you a better idea of my credentials, just a little FYI shit.
Primary Military Occupational Specialty: Infantryman, 11B
NREMT-B
PHTLS Instructor
BLS Instructor
Ranger First responder instructor
NBC casualty course
Combat Trauma Management course
I function STRICTLY within the limits set for Ranger medics, and if I have ANY doubts I ask before performing any procedure, via whatever means neccessary.
I would not feel comfortable doing a procedure like that without at least my PA present to make sure I do it right. I take "prevent further injury" to heart especially since my training isn't at the same level as the 91W's I work with.
He wouldn't get that at my level, even from one of the medics.. the pa or surg would do that. that's not within our scope of practice.
Originally posted by ussfpa
DOC...You are indeed correct in that SF medics are trained in escharotomies...I do not think that RSOV has been to the long course though and no other's have stepped up.
Good time for him to LEARN!!! :D
Perhaps you can elaborate a bit on the compartment syndrome, as well as testing for deficits in ROM and nerve conduction. Allen's test, fluid resuscitation(sp) formula (Brooke's OK?), etc. Proper application of silvadene and debridement techniques.
Your expertise would be greatly appreciated.
Primum non Nocere
Compartment syndrome occurs when pressure within a muscle compartment exceeds the perfusion pressure required by muscle and nerves. The cycle begins when tissue pressure exceeds pressure within veins causing them to collapse leading to poor blood outflow. Pressure continues to build until its high enough to compromise arterial flow causing a loss of pulses distally, hypoesthesia, and extremity paresis. Untreated, the muscles and nerve within the compartment undergo necrosis. The goal, obviously is not to let things get this far.
The patient may experience crescendo pain out of proportion to the original injury. Pain is deep and aching in nature and is worsened by passive stretch of the fingers. The patient may describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of CS. The forearm is tender and tense, and sensibility of the fingertips may be diminished.
Paraesthesia, or numbness, is an unreliable early complaint Two-point discrimination is a more reliable early test and can be helpful to make the diagnosis.
In this case it would be difficult at best to evaluate his clinical status and compartment pressures would need to be checked. Anything greater than 30mmHg is considered too high (as its a pressure high enough to occlude flow into nerves) and the compartment should be opened.
This case is a bit different. An escharatomy should be performed first and if the muscle compartments are involved then fasciotomies (these require anesthesia of some sort as they will be painful for the patient unlike an escharotomy.
[i]
I function STRICTLY within the limits set for Ranger medics, and if I have ANY doubts I ask before performing any procedure, via whatever means neccessary.
[/B]
as a civilian I really have no idea what limits are set for Rangers, SF, etc. While my husband is a BTDT, he was never a medic and can only give me an idea of what each of you do. I am not advocating doing something outside your standards, I just don't know what your standards are....I appreciate the post. Thank you.
doc t.
RsovRanger
9 July 2003, 23:56
It's cool... I've had a ton of great doctors and PA's and surgeons show me all kinds of crazy shit... I remember when DR Houghston from the houghston sports medicine hospital here in town came and gave all the EMT's a class/briefing on the types of injuries you'll see in combat and what you have to do to take care of them...
I figured I'd post what my medical credentials are just so you have an idea of what I've been school taught.. then there's what I know how to do and will do if I have to to save a live on a Ranger in combat... then there's what I will do at a car crash due to the legality issue...
I don't need some georgia gomer suing ME because he did a nosedive into his windshield and dash because he wasn't wearing a seatbelt.. then a month down the road he sues me because of the scar my cric left on his neck since he couldn't breathe through his mouth or nose.
I also don't want to undertake a procedure on one of my boys that I have seen or read about but have never done in a controlled environment to ensure that I can properly complete the procedure... it's like a JMPI (ask your hubby) I've jumped for over 5 years now and I could DO one, but I haven't taken the course so of course I'm not going to do it...
[i]
Perhaps you can elaborate a bit on fluid resuscitation(sp) formula (Brooke's OK?), etc. .
Primum non Nocere [/B]
Fluid resuscitation.... any burn of greater than 15% typically requires intravenous resusciation...less than that you can usually just watch urine output and let the patient resuscitate themselves with oral fluids (children being the exception).
What you give and how fast you give it is based on the extent of burn (% total body surface area), the size of the patient (in kgs) and the type of solution you use. Parkland formula is based off of Lactated Ringer resuscitation which has 130 meq of sodium per liter. The formula used is as follows:
24 hour volume infused = 4 x (% TBSA burn) x (body weight in kg)
the first half of the calculated volume is given to the patient over 8 hours with the rest given over the remaining 16 hours. It is thought that sodium and volume shifts are greater early on and therefore more of the volume should be given in that time frame.
as an example... a new patient is a 70 kg male in an explosion who suffered a 50%TBSA burn. His fluids would be calculated as follows:
4x50x70=14000cc
first 8 hours=7000cc therefore ivf rate = 875cc/hour
next 16 hours=7000 cc therefore rate = 437.5 cc/hour
in other words alot of volume.... but its something that can and should be started in the field based on calculations. This is only a guide...not an absolute. Typically you wind up bolusing these patients to maintain urine output despite the large IVF rates of above.
I should add that the sodium replacement is the driving force of the burn resuscitation. By using a solution with a higher sodium content you can drop the IVF rate. This is often done with the larger burns or circumferential burns where you need to be more concerned about the huge amounts being given, edema, etc....
ussfpa
10 July 2003, 02:45
Originally posted by RsovRanger
It's cool... I've had a ton of great doctors and PA's and surgeons show me all kinds of crazy shit... I remember when DR Houghston from the houghston sports medicine hospital here in town came and gave all the EMT's a class/briefing on the types of injuries you'll see in combat and what you have to do to take care of them...
I figured I'd post what my medical credentials are just so you have an idea of what I've been school taught.. then there's what I know how to do and will do if I have to to save a live on a Ranger in combat... then there's what I will do at a car crash due to the legality issue...
I don't need some georgia gomer suing ME because he did a nosedive into his windshield and dash because he wasn't wearing a seatbelt.. then a month down the road he sues me because of the scar my cric left on his neck since he couldn't breathe through his mouth or nose.
I also don't want to undertake a procedure on one of my boys that I have seen or read about but have never done in a controlled environment to ensure that I can properly complete the procedure... it's like a JMPI (ask your hubby) I've jumped for over 5 years now and I could DO one, but I haven't taken the course so of course I'm not going to do it...
RSOVRANGER...
Dude...you are doing great. Happy to see you had stepped up to take care of this guy.
If there is one thing that I can absolutely say is true about medicine...the more that I learn, the more I find out that I didn't know.
Sometimes, when it is only you, and it is only GONNA be you...you can fall back on something that you read or learned but have never done or thought you were able to do.
Keep up the good work bro, I try and learn something every day, and hope I never have to use it.
Primum non Nocere
RsovRanger
10 July 2003, 03:09
I still ain't gonna do no damn laproscopys!
[i]
I figured I'd post what my medical credentials are just so you have an idea of what I've been school taught.. then there's what I know how to do and will do if I have to to save a live on a Ranger in combat... then there's what I will do at a car crash due to the legality issue...
I also don't want to undertake a procedure on one of my boys that I have seen or read about but have never done in a controlled environment to ensure that I can properly complete the procedure... it's like a JMPI (ask your hubby) I've jumped for over 5 years now and I could DO one, but I haven't taken the course so of course I'm not going to do it... [/B]
as I said earlier, in the case of a burnt arm it is only a limb at stake....but lets put one of your guys in the field...same explosion but this time his burns total 40% and his whole thorax, front and back, is involved. You intubate him but find you cannot bag him at all because his eschar is acting as a vise as i described earlier... his sats are dropping....
if you had read about how to do an escharotomy and knew this to be a life saving procedure would you not try it? Believe me when I say the patient...your team member...would die without it done because hard as you try there is no other way to get someone like that to be able to move air...no drug would do it and when you try to bag him there would just be a ton of resistance.
I think sometimes you have to try things you have only read about or seen in pictures... because the alternative is the patient surely dying...at least you give them a chance.
again, just my two cents...
RsovRanger
10 July 2003, 10:03
LOL
Yes i'd try it if there were no other alternative.
Sneaky SF Dude
10 July 2003, 11:01
Originally posted by Doc T
are you left speechless?
LOL. Not at all. My personality leads me to dive in and take over. Just sharing the love and the training opportunities. That's a really good case, thanks. There have been cases similar in our work, arty simulators or bangers. Good TX from the posters as well IMHO.
RSOVRANGER - Word of caution, don't rely on having your PAs and Docs. One of the few casualties on the 6th Ranger POW raid in WWII Pacific Theater was the Battalion surgeon. He was wounded at the front gate by mortar fire and eventually succumbed to his wounds. In today's environment, YOU could become the PA if things go south. Also, don't count on medevac. The Reaper and I know of one case in Hondo where they couldn't or wouldn't get in. Two 18Ds worked for hours. Dude died. 1980's. Rare, but it happens. Of course all pilots ain't Terry or Tiger Hooters.
frogstyle
10 July 2003, 11:35
Sneaky is correct..
While I was in BUDS we had a fatality. Not only was he the senior Medic. He was also a BUD/S instructor. He was worked on by E2 HM's, before the DMO could get there.
You never know who will get hit.
Our Docs always emphasized that YOU are the senior medic until a better qualified one arrives, irrespective of quals. Its an operators responsibility to KNOW trauma med. If you cant run a J tube or an EJ IV, what good are you? You gonna stuff Curlex and tell him "Youre gonna be fine"?
RIP Kiko
Here are the pics I promised last night. They are of where to put your escharotomy and a photo of one being done... note that you see fat thru the eschar not muscle fibers. An escharotomy is very different from a fasciotomy which takes more skill or more knowledge of anatomy.
and where to put them....
Originally posted by Doc T
and where to put them....
sorry...it hadn't attached the pic...or rather i guess i did something wrong...second try.
CPTAUSRET
10 July 2003, 12:27
Originally posted by Doc T
and where to put them....
Not an MD, but this procedure makes perfect sense to me, the ammount of constrictive pressure that was alleviated must be substantial indeed:
Gotta keep that blood flowing:
Terry
Sneaky SF Dude
10 July 2003, 12:43
There you go RSOVR, what are your questions? I'd be willing to bet all you have to do is lay the knife on it and it'll open right up, right Doc? See one, do one, teach one.
Originally posted by Sneaky SF Dude
There you go RSOVR, what are your questions? I'd be willing to bet all you have to do is lay the knife on it and it'll open right up, right Doc? See one, do one, teach one.
yes, you see it separate as you cut and realize just how much tension the eschar is causing... it is a VERY satisfying procedure as the benefit is seen even while you are still cutting....
got to like that....
i think in the case of escharotomy you don't even really have to see one which was my point above... you can just read about one, do one and then become an expert!
The cuts are on both sides of the extremities? Inside and outside of each arm and leg?
Also, how quickly after the injury will compartmentation develop?
Originally posted by Axe
The cuts are on both sides of the extremities? Inside and outside of each arm and leg?
Also, how quickly after the injury will compartmentation develop?
yes, cuts on both sides...
and it can occur very quickly after injury...we perform them in the trauma room/burn resuscitation room... so within the first hour.
ussfpa
10 July 2003, 14:32
This gives ABSOLUTE WOOD seeing all this learning / teaching / interacting going on...
Medicine ROCKS :D
Primum non Nocere
CPTAUSRET
10 July 2003, 14:43
Originally posted by ussfpa
This gives ABSOLUTE WOOD seeing all this learning / teaching / interacting going on...
Medicine ROCKS :D
Primum non Nocere
Agree completely:
Terry:)
I know that I am not a doctor. I know that I will not be willing to give the time and money commitment to be one. After spending the past three years in hospitals with sick family members and catching many mistakes in treatment, I realize that the one of the best things you can do for the people you care about is to know as much as possible about medicine.
I hope I never have to do some of these things. I may not have been formally trained in a lot of them, but as Doc T said, if it is life or death anyway, the patient has nothing to lose and neither do I. I can at least know that I gave everything I had.
Sneaky SF Dude
10 July 2003, 15:17
Originally posted by ussfpa
This gives ABSOLUTE WOOD seeing all this learning / teaching / interacting going on...
Medicine ROCKS :D
Primum non Nocere
Nice to see a man that enjoys his work:D
[i]If you cant run a J tube or an EJ IV, what good are you? You gonna stuff Curlex and tell him "Youre gonna be fine"?
RIP Kiko [/B]
what is a J tube?
Sneaky SF Dude
10 July 2003, 16:39
oropharyngeal airway.
RIT_MEDIC
10 July 2003, 21:12
Doc T:
How deep is the incision made?
Here in the civilian EMS world we do not get to see many done, as we fly burns straight to MUSC or Augusta Burn Ctr.
I wonder if we can work out something with the National Registry for CEU's...
This is great stuff.
James D
Originally posted by 2ndgener2b
Doc T:
How deep is the incision made?
Here in the civilian EMS world we do not get to see many done, as we fly burns straight to MUSC or Augusta Burn Ctr.
I wonder if we can work out something with the National Registry for CEU's...
This is great stuff.
James D
I used to transfer to augusta a bunch at my last job..we were a trauma center but not a burn center...
The incision is simply made through the eschar...no deeper...the eschar is the charred dermis/epidermis since its a full thickness injury. YOu wind up going down to fat when you incise it since that is what is below dermis and definitely not through fascia...again that is a whole other thing...fasciotomies.
The explosion coulnd't have been that bad, all the fingers are still there.
#1) For Gods sake make sure there won't be another explosion or flare up that will take more people out. How often this step is ignored always baffles me.
#2) If ABC's are good, chances are he'll be able to hear you when you tell him how stupid that was.
#3) Provide appropriate medical care if there is time
BTW, never heard an oral airway referred to as a J tube. Is this commonly used?
RIT_MEDIC
10 July 2003, 21:50
Originally posted by Doc T
I used to transfer to augusta a bunch at my last job..we were a trauma center but not a burn center...
Most of the ones here never see our Level 1. The medics on our birds bypass the ER and fly straight to the Burn Ctr.
To be honest most of the recent burns I have seen are on firefighters. I understand the need to have protocols and standings orders to work within, but if it was my certification or a fellow firefighter's life, I believe I would have to be a slick sleeve again. John Q Public would just have to meet his maker though. Just my .002.
Thanks DocT.
SHYTE:
J-tubes or OPA's are used quite often. They are a simply airway adjunct and are often used by EMT's whos medical control MD will not allow them to orally intubate, there is not time to orally intubate, or when you need a bite block if chemoparalysis is not an option.
James D.
EDITED for more detail.
frogstyle
10 July 2003, 22:02
To elaborate on the J Tube.
Its called J because its shaped exactly like a J.
Each shooter has one in his self preservation med kit already measured to fit. The J tube is a quick and EASY way to maintain an airway while moving at night while being chased. Flick it in, maybe tape and throw him over your shoulder. Intubating is only practical when you have TIME.
Im rapidly aproaching a grey area here regarding OPSEC, so thats all needs be said with relation to tactics.
ussfpa
10 July 2003, 22:02
Originally posted by SHYTE
The explosion coulnd't have been that bad, all the fingers are still there.
#1) For Gods sake make sure there won't be another explosion or flare up that will take more people out. How often this step is ignored always baffles me.
#2) If ABC's are good, chances are he'll be able to hear you when you tell him how stupid that was.
#3) Provide appropriate medical care if there is time
BTW, never heard an oral airway referred to as a J tube. Is this commonly used?
Dude...read the memo...this is not helpful to the thread...
Thanks.
Primum non Nocere
frogstyle
10 July 2003, 22:13
Question,
If in a very unsterile enviro would it be a bad idea to carry out this procedure? Meaning: How necessary is this to sustain life?
"Cover me while I intubate!" LoL
RIT_MEDIC
10 July 2003, 22:28
Originally posted by frogstyle
Question,
If in a very unsterile enviro would it be a bad idea to carry out this procedure? Meaning: How necessary is this to sustain life?
"Cover me while I intubate!" LoL
The purpose is to minimize compartmental syndrome in the extremity. In an extremity it would be to possibly save it. DocT elaborated on compartmental syndome earlier in same thread. If the burn was over the thorax it would be to allow for chest expansion during respiration or ventilation if intubated/cric'd as well which would make it a life sustaining procedure.
James D.
ussfpa
10 July 2003, 22:30
Originally posted by frogstyle
Question,
If in a very unsterile enviro would it be a bad idea to carry out this procedure? Meaning: How necessary is this to sustain life?
"Cover me while I intubate!" LoL
We actually have equipment now that allows completely blind intubation in about the same amount of time it takes to drop a J tube. Ranger medics are being intro to this equipment army wide. Better to do it and carry a patient, than not and carry a corpse ;)
Primum non Nocere
RIT_MEDIC
10 July 2003, 22:34
Originally posted by ussfpa
We actually have equipment now that allows completely blind intubation in about the same amount of time it takes to drop a J tube. Ranger medics are being intro to this equipment army wide. Better to do it and carry a patient, than not and carry a corpse ;)
Primum non Nocere
Can you spell LMA?
James D
frogstyle
10 July 2003, 22:37
Originally posted by ussfpa
We actually have equipment now that allows completely blind intubation in about the same amount of time it takes to drop a J tube. Ranger medics are being intro to this equipment army wide. Better to do it and carry a patient, than not and carry a corpse ;)
Primum non Nocere
Thats GREAT news. The advances in field trauma are incredible. Im sure you remember the days of stuffing curlex and whispering sweet nothings (Youre gonna be fine man".
Ive never seen ANY 3rd degree burn victim. Im curious. If you having a guy charred up that bad, are there any techniques specific to this situation that will aid in finding a good vein? It seems difficult from the pic.
I know my knowledge is dated and underpar, remeber I carried a radio and a 60. Thanks for be patient.
Originally posted by frogstyle
Question,
If in a very unsterile enviro would it be a bad idea to carry out this procedure? Meaning: How necessary is this to sustain life?
"Cover me while I intubate!" LoL
If they need to be intubated sterility isn't a huge issue..... you'd be amazed how endotracheal tubes are treated in the hospital before they go in... on all sorts of not so clean surfaces including the floor on occasion and a trauma room floor is just a bunch of grime mopped time after time. The pneumonia that occurs can be dealt with while the patient you don't have a tube in who needs one doesnt' stand a chance.
oral airways won't really take the place of intubation unless its simply a mechanical problem with the tongue...
doc t.
Originally posted by ussfpa
We actually have equipment now that allows completely blind intubation in about the same amount of time it takes to drop a J tube. Ranger medics are being intro to this equipment army wide. Better to do it and carry a patient, than not and carry a corpse ;)
Primum non Nocere
are you using the hook light? I can not remember the proper name but one of the nurse anesthetists I work with showed it to me the other day... he promises to teach me how to use it...
[i]
Ive never seen ANY 3rd degree burn victim. Im curious. If you having a guy charred up that bad, are there any techniques specific to this situation that will aid in finding a good vein? It seems difficult from the pic.
I know my knowledge is dated and underpar, remeber I carried a radio and a 60. Thanks for be patient. [/B]
don't think your knowledge is dated... its just not something you do everyday... good question about access as its almost as important as airway...
typically you place IV's outside of the areas of burn if any area is available but you can blindly try to place them thru burn where you think they should be (you cannot feel a thing)... if that cannot be accomplished (takes lots of time and swearing) then you simply switch to a central line (subclavian or internal jugular) since they are typically blind procedures anyway that you use anatomic landmarks for success.
Which groups of medics take ATLS (advanced trauma life support)...i believe we teach central lines as part of the course.
RIT_MEDIC
10 July 2003, 23:17
Originally posted by Doc T
...typically you place IV's outside of the areas of burn if any area is available but you can blindly try to place them thru burn where you think they should be (you cannot feel a thing)... if that cannot be accomplished (takes lots of time and swearing) then you simply switch to a central line (subclavian or internal jugular) since they are typically blind procedures anyway that you use anatomic landmarks for success.
Which groups of medics take ATLS (advanced trauma life support)...i believe we teach central lines as part of the course.
Central lines...now there is a skill I wish we could do here in the street...well in the Bus anyway.
I am only a street medic but I have had ATLS, but only on an audit level while I worked in the Trauma Center here in Greenville. Now I take it every year. Very good material, but a bit out of my scope of practice. Still, I love to learn.
James D
frogstyle
10 July 2003, 23:21
I have a cool pic of myself drinking a Corona with an Internal J line in. In fact a member og SOCNET did the stick. ANd the pic is sentimental as Matt Bourgious is in it..
RsovRanger
10 July 2003, 23:58
forget where it was in the thread... you referring to the combitube, LMA, nasal intubation, or what? We don't use J tubes a whole lot however we carry them. Easier to jam a nose hose in, and it'll stay put if he gets concious. If he was burned to the point where I couldn't see landmarks, I'd bust out my FAST-1 intraosseous infusion pain machine. Either that or using the incision lines for the escharotomy, I'd use the same incision area to do a veinous cutdown and tie in a line that way.
We do PHTLS because it's significantly more applicable to what I do than ATLS, simply because ATLS is more geared towards a semi-sterile environment... a trauma center, what have you. PHTLS is more geared towards the first responder.
We do PHTLS because it's significantly more applicable to what I do than ATLS, simply because ATLS is more geared towards a semi-sterile environment... a trauma center, what have you. PHTLS is more geared towards the first responder. [/B]
PHTLS may be geared more to the first responder but it sounds like, at times, you are the only responders for what could be more than a few minutes. ATLS is not designed so much for a semi-sterile environment but rather its designed to give guidelines for diagnosis and management of the trauma patient. It is designed to teach those who don't do trauma everyday how to do it when you have to... namely to stabilize someone or at least temporize their condition until you can transfer to a level of higher care.
the history of the course revolves around an orthopedic surgeon who crashed his plane in the middle of nowhere and he and his family were taken to a local hospital where he felt he, as an ortho guy, knew more than the ER doc about taking care of trauma patients. The ortho doc found this unacceptable and pushed for some kind of course to teach ER docs and others basic trauma care.
it may be that both would benefit your training...PHTLS and ATLS.
RIT_MEDIC
11 July 2003, 00:58
Originally posted by RsovRanger
...I'd bust out my FAST-1 intraosseous infusion pain machine.
Have you had the opportunity to use one yet? My only experience with it has been on cardiac arrests, other than the usual pediatric pt's.
We do PHTLS because it's significantly more applicable to what I do than ATLS, simply because ATLS is more geared towards a semi-sterile environment... a trauma center, what have you. PHTLS is more geared toforget where it was in the thread... you referring to the combitube, LMA, nasal intubation, or what? We don't use J tubes a whole lot however we carry them. Easier to jam a nose hose in, and it'll stay put if he gets concious. If he was burned to the point where I couldn't see landmarkswards the first responder.
If you have the opportunity, and are so inclined, ATLS is a very good class to audit. I was the only paramedic in the first class I took and I only know of 2 others that have sat thru it. Much of the materail is out of our scope of practice, but the information is invaluable.
And having worked a few years in a Level 1 Trauma Ctr...I would hardly call that sterile, very clean at times...and damned hot...but not sterile. "James, could you hand me that thorocotomy tube I just dropped by my foot?" "You mean this nasty thing?" "Its okay...thats what the Abx are for in Trauma ICU." Just my .002.
James D.
Sneaky SF Dude
11 July 2003, 10:07
Originally posted by frogstyle
Thats GREAT news. The advances in field trauma are incredible. Im sure you remember the days of stuffing curlex and whispering sweet nothings (Youre gonna be fine man".
Ive never seen ANY 3rd degree burn victim. Im curious. If you having a guy charred up that bad, are there any techniques specific to this situation that will aid in finding a good vein? It seems difficult from the pic.
I know my knowledge is dated and underpar, remeber I carried a radio and a 60. Thanks for be patient.
I agree with the Docs, I would go to an unburned area or do a cut down. I've never done a central line or a FAST. I would like to see the FAST, I've heard good things about it. I've done a cut down - they're cool.
Froggy, in your situation, I would probably try to run to cover before doing too much. Doesn't do the patient any good for the medic to be shot.
Shyte - reference your post on stupity - when you play with big boy toys like demo, shit happens. Doesn't mean they were stupid, most times it means they were pushing the envelope. That's one of the reasons there are medics and corpsmen on Spec Ops Teams. My breacher used to get pissed at me if my clothes weren't on fire - said I didn't trust him. Firefighters get burned all the time, occupational hazard when saving someone's life.
RsovRanger
11 July 2003, 16:25
cutdowns are fun.... and I learned how to do them quick as hell too... and the FAST-1 is cash money, really easy to use.. we had one pilot volunteer to get one as part of a training class to show exactly how to do it..
aint really pretty sounding or looking when you do it though...
push.. push harder... push harder yet... CHACHUNK.. money.. aspirate marrow, flush, and push your fluids.
RsovRanger
11 July 2003, 16:46
Regarding ATLS VS PHTLS:
A lot of research went into the choice between the two courses as to what would better benifit us as a community. The powers that be chose PHTLS, and I believe I was part of one of the first courses that was given to 3/75. We even got explained why they were teaching this to us vs atls. reasons included scope of practice, applicability to our environment and operations.
PHTLS more enables you to predict and have an increased index of suspicion regarding an individuals injuries so you know what you have just by looking, and what you might have that you can't see. example... you don't need C-spine stabilization on a GSW. I forget what the actual % is, but its like 5% of GSW's that have any CNS damage... shit like that... what to think might be injured due to the trauma involved.. and primarily I deal in trauma, much moreso than the "medical" side, ie: joes got green stuff coming out of his wang... I hand that off to the PA LOL.. Here you are sir!
exit, stage right!
Sneaky SF Dude
11 July 2003, 16:53
PHTLS -Did I miss where you said what the acronym stands for? If so, please tell me again anyway.
I went to ATLS - it was ok, but the one I went to was like "Have your nurse draw blood gases at this point." I'm WTF? We gonna get nurses 'cause we graduated this course? Cool! Never happened though. Drove from Ft Bragg to Mobile in a CUCV with no rear windor for that.
RIT_MEDIC
11 July 2003, 17:12
Originally posted by Sneaky SF Dude
PHTLS -Did I miss where you said what the acronym stands for? If so, please tell me again anyway....
Pre
Hospital
Trauma
Life
Support
...I went to ATLS - it was ok, but the one I went to was like "Have your nurse draw blood gases at this point." ...
Nurses drawing blood gas huh. Seems like I recall DocT drawing quite a few from the Femoral Artery when the Resp Techs could not manage to find the Radial nor Ulnar Artery. A needle that big, that close to the groin area gives me the shivers.
James D.
Originally posted by Sneaky SF Dude
PHTLS -Did I miss where you said what the acronym stands for? If so, please tell me again anyway.
I went to ATLS - it was ok, but the one I went to was like "Have your nurse draw blood gases at this point." I'm WTF? We gonna get nurses 'cause we graduated this course? Cool! Never happened though. Drove from Ft Bragg to Mobile in a CUCV with no rear windor for that.
yes, most ATLS scenerios give you a nurse and a resp tech but only to get the student to move along. Think the benefit of ATLS for medics in the field would be furhter learning in the ABCs, treatment protocols for the first hour or so and procedures like chest tubes, pericardiocentesis, crics, etc. Typically in my courses we let the auditors do most of the procedures...didnt' have them doing diagnostic lavages since I figured no one out in the field would have a need.
sorry you drove to bragg... you should have come to my course.:)
Originally posted by RsovRanger
Regarding ATLS VS PHTLS:
A lot of research went into the choice between the two courses as to what would better benifit us as a community. The powers that be chose PHTLS, and I believe I was part of one of the first courses that was given to 3/75. We even got explained why they were teaching this to us vs atls. reasons included scope of practice, applicability to our environment and operations.
PHTLS more enables you to predict and have an increased index of suspicion regarding an individuals injuries so you know what you have just by looking, and what you might have that you can't see. example... you don't need C-spine stabilization on a GSW. I forget what the actual % is, but its like 5% of GSW's that have any CNS damage... shit like that... what to think might be injured due to the trauma involved.. and primarily I deal in trauma, much moreso than the "medical" side, ie: joes got green stuff coming out of his wang... I hand that off to the PA LOL.. Here you are sir!
exit, stage right!
i do not know anything about PHTLS since i have never seen the course book or talked to any instructors but as a course director and instructor of ATLS I can assure you that ATLS teaches recognition of injury as well as initial treatment. It deals only with trauma, hence the name Advanced Trauma Life Support, and does not teach any of the medical things that paramedics/EMTs get called to like chest pain, shortness of breath, etc unless as it relates to trauma.
But again, not arguing that PHTLS isn't a good fit for you...I truely have no idea...just suggesting that ATLS can be additive.
doc t.
mac3982
11 July 2003, 17:47
i've taken atls and phatls in an urban enviormant the best course of action is get to the er but in the field phatls should help depending on the individuals skill level........or how they are as a medic......if a person can get all the knowledge they can gather and put it to practical use......i'm not sure if they still do it, they did take doctors and medics and a few nurses and "let" them do ride alongs in the "inner city" to get the "trama" experience... they still do it in my city.... get guys from the near by base and others.....
wolfhoundcowboy
11 July 2003, 17:57
I have a question regarding the fluids this guy needs. You said that the Parkland formula is only for greater than 15%. Why wouldn't you use it for all burns that are severe? Granted, this guy only needs about 1400mL of fluid in 24 hours, but he still needs that, right?
I'm just curious because in the school house they teach us that fluids are the single most important thing when working with burns. (After ABC's of course.)
Sneaky SF Dude
11 July 2003, 17:58
Is that it for this patient? If so, I suggest those that wish to continue to discuss the merits of ATLS vs PHTLS start a thread to discuss it. We haven't kept to USSFPA's memo very well on this one, and yes I'm guilty of it too.
Sneaky SF Dude
11 July 2003, 18:01
Originally posted by wolfhoundcowboy
I have a question regarding the fluids this guy needs. You said that the Parkland formula is only for greater than 15%. Why wouldn't you use it for all burns that are severe? Granted, this guy only needs about 1400mL of fluid in 24 hours, but he still needs that, right?
I'm just curious because in the school house they teach us that fluids are the single most important thing when working with burns. (After ABC's of course.)
Sorry wolfhoundcowboy, we must have been posting at the same time. Good question.
Originally posted by wolfhoundcowboy
I have a question regarding the fluids this guy needs. You said that the Parkland formula is only for greater than 15%. Why wouldn't you use it for all burns that are severe? Granted, this guy only needs about 1400mL of fluid in 24 hours, but he still needs that, right?
I'm just curious because in the school house they teach us that fluids are the single most important thing when working with burns. (After ABC's of course.)
the reason you don't need to calculate parkland here is that the ivf needed for his maintanence is more than he'd need for his burns. Take the same guy... 70 kg man..5%TBSA burn... He'd get, as you said 1400cc in 24 hours which is only 87.5 cc/hr for the first 8 hours and 43.75 cc/hr for the next 16. His maintanence based on body surface area would be 2250 cc/24 hours or about 95cc/hr so you just go with maintenance here and avoid any busy calculations...
15 % is about the cutoff where burn will beat normal maintanence over 24 hours.
so fluid are important... less than 15% you can decide IV versus po as your route but you'd never want to give someone less than maintanence.
RsovRanger
11 July 2003, 18:25
Because you can do the fluid resus for that small of a bolus with PO fluids.
Besides.. I know how to do a chest tube, cric, don't do pericardialcentisis, but I know how to do a needle thoracentisis.
USSFPA,
Sorry about that. I somehow missed the memo post (and I once scored a 94% for obvervation and recall skills-guess I need to be tested again). Don't mean to fuck up the board for others.
2ndgener2b,
I know what a J tube is, just never heard the term used. It just took me a while to clue in because of the uncommon term. We use oral and nasal airways on my truck, no ET's, they are very handy and quick. Thanks though.
frogstyle,
That must be quite a picture, sentimental to say the least.
mac3982
13 July 2003, 23:05
sorry sir.....for the pt... fluid res...pain control....complete ips....first and sec.....
ussfpa
13 July 2003, 23:11
QUIT FETCHIN APOLOGIZING ALREADY!!!
You are all doing a wonderful job...(insert group hug here)...this is turning out great...
Primum non Nocere
mac3982
13 July 2003, 23:12
sorry i scrolled backin the thread and read up i've seen third degree.... on live and fatal.. for the record i believe their is not much direct pain because of the nerve damage.....and lost of tissue... the docs i work with went into great detail which i can't type good enough to put down...
Teutates
14 July 2003, 10:04
Originally posted by mac3982
sorry i scrolled backin the thread and read up i've seen third degree.... on live and fatal.. for the record i believe their is not much direct pain because of the nerve damage.....and lost of tissue... the docs i work with went into great detail which i can't type good enough to put down...
I've been burnt almost like the aformentioned picture, all second degree, was very lucky. There was not much pain. (My skin was charred black and my hand curled shut, I was well done.)
The debriedment was another story....
USSFPA, Stop! You are hugging too hard!! Wait, what is that poking me, AAAAUUUGGHGGHHHHHH!!!!!!!!!!!
mac3982
15 July 2003, 14:34
axe was wonderin why both hands were on your shoulders... one question ...would you be concerned with hypothermia....or not....
ussfpa
15 July 2003, 14:46
Originally posted by mac3982
.would you be concerned with hypothermia....or not....
Loss of bodily fluids to third space and the inability to sweat / evaporate can play serious havoc on the temperature regulatory system of the body.
Add to that the probablility of MASSIVE amounts of fluid with a significant BSA burn...these fluids are often around 70-75 degrees farenheight so proper temperature management of the patient is very important, yes.
I am certain there are many more technical explainations...but your short answer is yes to hypothermia concerns.
Primum non Nocere
Originally posted by ussfpa
Loss of bodily fluids to third space and the inability to sweat / evaporate can play serious havoc on the temperature regulatory system of the body.
Add to that the probablility of MASSIVE amounts of fluid with a significant BSA burn...these fluids are often around 70-75 degrees farenheight so proper temperature management of the patient is very important, yes.
I am certain there are many more technical explainations...but your short answer is yes to hypothermia concerns.
great answer... the large resuscitation with room air temperature fluids does havoc with a patients ability to maintain temperature. If you figure your whole intravascular volume is about 5 liters and patients often get many more times that in volume you can see the problems more clearly.
plus, with large burns patients tend to leak fluids onto the dressings, bedlinens, etc causing them to sit/lie in a wet environment that leads to further loss of temperature.
burn rooms are kept very warm... ninety degrees and such for the OR and resus rooms, fluids are warmed and we do what we can overall to keep their wounds covered and their environment as warm as possible.
doc t.
mac3982
16 July 2003, 01:26
thanks for the direction... no one had asked........about it.....
Reaper375
16 July 2003, 21:53
Guys, just so y'all know (and I know I've told some of you)...
Mac3982 is my Brother. He's a Detroit Fire Fighter now, and still does his time as a Paramedic in the ER of Henry Ford Hospital. He's one knowledgeable sucka, even though he can't spell "kat".
He's also a former Jarhead who thought "Recon kicked butt".
He is very very knowledgeable on the subject of medicine though. Don't let the bad typing fool you.
mac3982
17 July 2003, 15:08
ahhh ... the little bro makes an apperence.... thank you but not needed........they will keep me in line i'm sure.......i'm gettin learned alot....not to often i get to read about this kind of stuff.....
Sneaky SF Dude
17 July 2003, 15:37
Hey Mac, Reaper 3/75 told me you guys have done the push up contest 3 times and he's whipped you like a rented mule all three times.
mac3982
17 July 2003, 18:29
hold on... i almost pissd myself for that one.. the last time reaper375 did anything pt. like was a good growler in the shitter... and at that he almost passed out from exertion....the only exercise he gets is pushin himself away from the dinner table......but, he is a high speed chair born.. a real badd ass tecno winnie..............he knows the pain that can be brought to bear on him self.... he won't play anymore...........but, he is fun to watch with others........ask him about the skin head gang.......
troy2k
18 July 2003, 17:52
Doc T,
Am I right in thinking that fasciotomies are the manual seperation of muscle groups to alleviate pressure in the intramuscular compartments, specifically Gastrocnemius related? Would this have an application to the original pictured injury; I was under the impression these compartments existed in gastrocs but not radial-ulnar?
By the by, if I remember correctly, ATLS is currently off limits to SOF medics. And all you folks are making me feel the pressing need to bury my head in a Merck manual. Team Daddy may not see me for a while... where's SOFMSSP when you need it?
RsovRanger
18 July 2003, 18:26
ATLS isn't off limits, it has just about no use for what we do. plain and simple.
Originally posted by troy2k
Doc T,
Am I right in thinking that fasciotomies are the manual seperation of muscle groups to alleviate pressure in the intramuscular compartments, specifically Gastrocnemius related? Would this have an application to the original pictured injury; I was under the impression these compartments existed in gastrocs but not radial-ulnar?
By the by, if I remember correctly, ATLS is currently off limits to SOF medics. And all you folks are making me feel the pressing need to bury my head in a Merck manual. Team Daddy may not see me for a while... where's SOFMSSP when you need it?
fasciotomies involve opening up fascial planes to release the muscle compartment whether in the arm or leg. Compartment syndrome is seen most frequently in the lower extremities but does occur in the upper ones too. The pics i showed have no bearing on fasciotomies...totally different procedure although you can use the escharotomy incisions as a starting point to locate the fascial planes you need to open.
Originally posted by RsovRanger
ATLS isn't off limits, it has just about no use for what we do. plain and simple.
i do not recall...have you taken the course or read the manual?
Sneaky SF Dude
18 July 2003, 19:25
Originally posted by Doc T
read the manual?
Doc, don't make him feel bad.
Oh wait, I forgot :D
RsovRanger
18 July 2003, 20:32
Never taken the course, but I tend to listen to majors, ltc's, and full bird surgeons that tell me that I'm better off doing the PHTLS that we offer our guys than taking ATLS, given my level of patient care combined with my surroundings and equipment at hand.
Originally posted by RsovRanger
Never taken the course, but I tend to listen to majors, ltc's, and full bird surgeons that tell me that I'm better off doing the PHTLS that we offer our guys than taking ATLS, given my level of patient care combined with my surroundings and equipment at hand.
not to beat a dead horse BUT
there is a difference between saying you are better off doing one course than in saying another course is no use to what you do, plain and simple".... time and money constraints may make them chose one over allowing you to do both....
my point, as made earlier, is that if you are the first responder and responsible for a patient for more than the first hour or so due to difficulties beyond your control knowing more than prehospital stuff can be useful. If you learn to do chesttubes, pericardiocentesis and basic ABC techniques in other courses so be it but in my mind the more you go over such things the better...making the course more than useless. I doubt you often have to do such procedures in the field (at least i hope not) so any practice seems like a good idea for when its needed.
RsovRanger
18 July 2003, 20:52
Guess that's why we have a human patient simulator, medic validations yearly, multiple rotations to trauma facilities, various other things. :)
Originally posted by RsovRanger
Guess that's why we have a human patient simulator, medic validations yearly, multiple rotations to trauma facilities, various other things. :)
i am done beating a dead horse...you have obviously learned all you need to know so anything else would be a waste of time...sorry.
Doc T,
I still want my dead horse beaten!! Keep it coming, please!! I am learning a lot here.
Doc T,
There are many guys on this board that know their stuff. I haven't been posting here a long time but long enugh to know that fact. Certain courses are designed for very specific emergency medical personnel. The training many of these medics and corpsmen have gone through has obviously been effective because they accompany their best soldiers into the worst conditions. I don't personally know many military medics but the few that i have met I'd gladly serve with.
In my studies of medicine I have learned something very important: the more I learn, the more I realize is that there is so much more that I don't know. Some of these guys know a lot of good stuff. If you don't agree with it you don't have to.
Originally posted by SHYTE
Doc T
In my studies of medicine I have learned something very important: the more I learn, the more I realize is that there is so much more that I don't know. Some of these guys know a lot of good stuff. If you don't agree with it you don't have to.
that was exactly my point.... that there is always something more out there to learn and that someone should not say a course is a "waste of time" if he has never taken it or been a part of it. Time and financial constraints make choices for us...but you should always be looking for ways to learn more....
so i do agree with your statement as it is exactly what i was advocating the entire time. I never said or implyed that the people on this board do not know a lot of good stuff... quite the contrary...
Purple36
27 July 2003, 20:06
First, hats off to USSFPA for starting these threads, interesting stuff. I had to take care of my husband after he was burned in a similiar fashion. For what it's worth, Thai burn cream smells remarkably similar to peanut sauce! Go figure.
Tuetates, yes the debriedment (sp?) must have been the worse. He wouldn't let me do it for him, he just took that evil scrubby brush to himself, ugh!
Regarding ATLS, I'm confused. Maybe it's changed recently, but I seem to recall my husband (18D) going through ATLS on an almost yearly basis. I'll double check those facts when I get a chance to ask him.
TacMedic105
28 July 2003, 02:00
Joining the thread late, but a couple of things.
1. Our team?s SOP?s are similar to what Frogstyle mentioned with regards to using the OPA (oropharyngeal airway). In a hot zone, or when we?re taking fire, our care is limited to basic adjuncts (throw in an OPA, throw on a dressing), and evac. Once the threat has been neutralized, or we've moved to a warm or cold zone would an ETT or IV placement be considered.
2. Although probably not an issue with this particular patient, remember to be on the lookout for inhalational or airway burns. If they are present, securing the airway early may make the difference between an ETT and a surgical airway. RSI (sedatives and paralytics) or pharmacologically assisted intubation (sedatives only) would be necessary here.
3. As a PHTLS instructor, I highly recommend both PHTLS and ATLS. They more or less teach the same background material regarding injury patterns, etc but they complement each other very nicely, and ATLS covers many other treatment modalities.
4. Just to illustrate the potency of the edema from a burn and the need for an escharotomoy, I had a patient about 3 years ago that had a pretty nasty electrical burn. He took 12,000 volts in through his forehead, and exited via his buttocks. 2nd and 3rd degree burns everywhere in between. The only IV sites I could find were his hands due to the fact that he was wearing heavy gloves at the time, rendering his hands unburned. I started a 14g line in each hand, but could only get about 1 drop every 10-12 seconds out of them due to the massive amount of pressure the edema was putting on the vasculature in his arms. Pretty nasty.
Great discussion everybody!
Andy
mac3982
28 July 2003, 11:07
:eek:
ussfpa
28 July 2003, 13:03
Originally posted by Purple36
Regarding ATLS, I'm confused. Maybe it's changed recently, but I seem to recall my husband (18D) going through ATLS on an almost yearly basis. I'll double check those facts when I get a chance to ask him.
P36...as an 18D we used to ""Audit" the course as part of our yearly team certification process. JP Sanford (the guy who put out the SANFORD GUIDE to ANTIMICROBIAL MEdicine before he died) would typically travel with an MTT to the groups and give us our tropical medicine review in association with the ATLS class.
Though we received the class, we were not able to receive credit because we were not liscenced providers. But dentists could. Go figure.
Primum non Nocere
RsovRanger
28 July 2003, 13:23
Long story short on ranger IV's.. AC, AC, EJ, EJ, FAST1 to the chest.
Don't delay transport just because you don't have iv access.
Circumstances dictate what you have to do to get iv access however... like I mentioned before, it might just be easier depending on the severity of the burn, thickness of the burn, etc to possibly do a veinous cutdown in the same incision area that you do that escharotomy that doc T described. I'm not sure if it'd be the right thing to do, but if it's what you have at hand, then I'd personally go for it if it's all you have. probably not the preferred method however.
RIT_MEDIC
28 July 2003, 15:03
Originally posted by ussfpa
...Though we received the class, we were not able to receive credit because we were not liscenced providers. But dentists could. Go figure.
Primum non Nocere
WTF?
As I remember, in my first class there were a shit load of RN's, a handful of MD's and then there were 2 paramedics, myself included. Seems as though the Medics became the punch line for most of the jokes by the RN's...like they have a clue.
DocT taught a couple of the ATLS classes I took. I always come away with a renewed wealth of knowledge. I say renewed, because we all know, if you dont use it, you lose it.
With every class I take, albeit ACLS(damn case studies); PALS; PEMSTEP; ATLS; PHTLS; BLS; etc, there is one common thing I bring away from them all. An understanding that the more I learn, the more I have yet to learn.
Continuing Education.
James D.
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