Trauma Scenario #1: "Mishap in the chuckwagon"

[El Solis]

So there you are, you just set up camp, cracked open a celebratory beverage to enjoy as you stare off into the majestic scenery surrounding you when all of sudden you hear "@$!#"!! It came from one of your travel partners who was cutting up limes for their drink. When you get over to them, they are holding their finger tightly and you can see that there is blood on their knife and their clothes and they look quite pale and sweaty. What do you do???? You are allowed to use anything that you already carry in your rig. (great time to see if you need to update your first aid kit)

(Here's a hint: step one, put your drink down!). I was trained that if you don't say it, it doesn't happen when I was taking all of my exams. It is a great way to not miss anything and to make sure you know what you need. Feel free to ask questions, I'll do my best to reply in a timely fashion.

 

[slomatt]

"Hold my beer..."

1. I'm #1
I would check to make sure that the scene is safe to approach, I don't want to become an additional victim. Based on the description of the scenario there is no obvious risk to others. If I was cooking, using a sharp edge, or moving a car I'd want to quickly make everything safe before helping my friend. If the victim is in a place that is unsafe for me I would not approach, and if they are in a place that is unsafe for them (ex. in a burning car) they should be moved, otherwise the victim should be kept in place.

2. What happened to you?
Assuming it is safe to approach then I would walk over and try to quickly determine what likely happened, both visually and by asking my friend what happened.

3. Keep that stuff off of me
Before making any physical contact I would ideally put on personal protective gear, in this case nitrile gloves (not latex due to possible allergic reactions) which are always the first thing you access in my first aid kits. This step can be a bit tricky because if there is catastrophic bleeding you might not want to take the time to run and get a kit and get out gloves. In that situation it may be better to immediately apply pressure to the wound(s). Human skin is a very good barrier, but there is some risk here. In this particular scenario the friend is already applying pressure to the wound, so I would take the time to put on gloves.

4. Are there any more?
Check the scene for additional victims, if there are we will need to triage. Based on the description I'm assuming just a single victim.

The above steps should take very little time. After that I would say something like "I'm trained in first aid, can I help you out?". The victim in this case is an adult and is conscious, so if they say "no" I am legally prevented from helping.

Since the victim is conscious and holding their finger I can quickly verify airway and breathing, and given that there is no description of major bleeding (just the finger) I'm assuming circulation is fine.

The above all falls under the first C of the CCC (check, call, care) procedure used by the Red Cross. If there was any immediate risk to life, (and there were resources available) I would call or send for help at this point. In this case I don't see any immediate risk and would move onto the "care" step.


Caring for the victim is going to largely depend on the results of step #2 above. To keep things straightforward I'm going to assume they told me that they cut their finger while cutting up limes.

There does not appear to be a mechanism of injury for neck or spine damage, so I would ask the victim to sit down. Some people don't like the sight of blood and could potentially faint and sustain further injury.

If the wound was still bleeding significantly I would get out gauze and have a bystander or the victim use it to hold pressure on the wound. I would then might do a quick head to toe assessment of the victim to identify if there are any other injuries, I'm assuming there are not. I would also attempt to quickly determine the mental state of the victim since there's a small chance they could be suffering from a stroke or something like that. I'm assuming they are normal (awake and orientated).


At this point I think we've ruled out any issues other than the finger, unless this is a trick question. :) So we can move forward with treatment.

The first step would be a visual inspection of the wound to see how deep it is. I would also check CSM (circulation, sensation, movement) of the finger tip to try to determine if there is nerve or tendon damage.

If the finger is severed I would wrap the separate part in damp gauze, put it in a plastic bag, and then use ice to keep it cool. The digit should stay with the victim, but ideally somewhere they can't see it. Yeah, this is a bit gross.

Assuming that the finger is not severed I would use a syringe and clean water to irrigate the wound. If the wound is minor I would apply a bandaid. If the wound is more severe I would use suture strips to close the wound and then wrap it in gauze covered with a pressure dressing. I don't personally carry a clotting agent, but that could be used as well.

Ideally I should do a full SAMPLE evaluation of the victim, but this post is already really long. If they have a preexisting condition such as trouble clotting then that changes the treatment plan.


What next?
If the wound is extremely deep or there is any indication of nerve or tendon damage then it is time to slowly evacuate the victim to get advanced help.

If we decide to stay and keep drinking beer then I would monitor the wound for infection and replace the bandages every day (or more often if needed). I would also apply an antibiotic cream such as Neosporin. The victim may want to take a pain medication such as aspirin or Tylenol (if they have no allergies).

In both cases I would monitor the victim for signs of them passing out or going into shock.


There is another post where I listed the contents of my first aid kit. In this scenario I potentially used the following:
- Nitrile gloves
- Syringe and clean water
- Bandaids
- Suture strips
- Gauze
- Pressure dressing or bandage
- Antibiotic ointment
- Aspirin or Tylenol


I think it is great that you are posting this scenarios, it really helps to get us all to think about possible issues that may arise while on the trail, in camp, or driving to the trail.

 

[darjo242]

Assess sensation in injured extremity. apply a pressure dressing. Advise them to keep their hand elevated above their heart. Lay them down and elevate their feet while I prep for the trek out to the nearest ER

 

[systemdelete]

Walk over and assess the situation, tell them to keep pressure on the laceration and return to my truck and grab my trauma first aid kit. Head back over, glove up, irrigate the wound with sterile saline and assess the damage. If treatable in the field explain the options to the patient/friend to allow them to choose from care here on site or in the nearest ED. If damage is bad, stabilize, plan, and begin mobilization to get them to an ED. Begin notation of times, meds given, vitals and care given for ED staff.

If not bad and they choose option “a” select a suitable suture and administer a local anesthetic and a local antibiotic. Then proceed with stitching them up. Laugh about it in a few hours as they admire their new stitches.(chicks dig scars) Follow up with them in the following days keeping a keen eye out for signs of infection until the stitches come out.

I do prefer steri-strips these days on most cuts but they just don’t bond on fingers and other wiggily bits very well.

 

[Winterpeg]

Some pretty thorough responses already. Reminds me of the responses from first aid classes/courses.

I'll just emphasize pressure on a bleed... crazy glue is also a good way to seal up a cut if you have it.

Sounds like that person would need to sit down pretty soon too as they seem to freak out at the sight of their own blood.

If the tip is going to fall off I would take them to the hospital.... otherwise I would bandage them up and finish making their drink for them. They're on their own for their next drink though.

 

[PandaMonium 428]

Slow motion run from across the camp with either Baywatch or rocky theme music playing.

Assess the mortal wound.

If its omg bad i cant even. Apply bandage and tell them to suck it up.

If its actually bad. Bandage er up, grab vitals and head to nearest ED.

Its its super bad and we’re nowhere near help within a reasonable time, Some form or tourniquet applied above the injury, lidocaine nerve block and suture it up as best i can. I don’t carry a pharmacy with me so we’re probably going to have to head back to a town and get you into an urgent care/ED for some nice antibiotics.

 

[RXH]

"Hold my beer..."

1. I'm #1
I would check to make sure that the scene is safe to approach, I don't want to become an additional victim. Based on the description of the scenario there is no obvious risk to others. If I was cooking, using a sharp edge, or moving a car I'd want to quickly make everything safe before helping my friend. If the victim is in a place that is unsafe for me I would not approach, and if they are in a place that is unsafe for them (ex. in a burning car) they should be moved, otherwise the victim should be kept in place.

2. What happened to you?
Assuming it is safe to approach then I would walk over and try to quickly determine what likely happened, both visually and by asking my friend what happened.

3. Keep that stuff off of me
Before making any physical contact I would ideally put on personal protective gear, in this case nitrile gloves (not latex due to possible allergic reactions) which are always the first thing you access in my first aid kits. This step can be a bit tricky because if there is catastrophic bleeding you might not want to take the time to run and get a kit and get out gloves. In that situation it may be better to immediately apply pressure to the wound(s). Human skin is a very good barrier, but there is some risk here. In this particular scenario the friend is already applying pressure to the wound, so I would take the time to put on gloves.

4. Are there any more?
Check the scene for additional victims, if there are we will need to triage. Based on the description I'm assuming just a single victim.

The above steps should take very little time. After that I would say something like "I'm trained in first aid, can I help you out?". The victim in this case is an adult and is conscious, so if they say "no" I am legally prevented from helping.

Since the victim is conscious and holding their finger I can quickly verify airway and breathing, and given that there is no description of major bleeding (just the finger) I'm assuming circulation is fine.

The above all falls under the first C of the CCC (check, call, care) procedure used by the Red Cross. If there was any immediate risk to life, (and there were resources available) I would call or send for help at this point. In this case I don't see any immediate risk and would move onto the "care" step.


Caring for the victim is going to largely depend on the results of step #2 above. To keep things straightforward I'm going to assume they told me that they cut their finger while cutting up limes.

There does not appear to be a mechanism of injury for neck or spine damage, so I would ask the victim to sit down. Some people don't like the sight of blood and could potentially faint and sustain further injury.

If the wound was still bleeding significantly I would get out gauze and have a bystander or the victim use it to hold pressure on the wound. I would then might do a quick head to toe assessment of the victim to identify if there are any other injuries, I'm assuming there are not. I would also attempt to quickly determine the mental state of the victim since there's a small chance they could be suffering from a stroke or something like that. I'm assuming they are normal (awake and orientated).


At this point I think we've ruled out any issues other than the finger, unless this is a trick question. :) So we can move forward with treatment.

The first step would be a visual inspection of the wound to see how deep it is. I would also check CSM (circulation, sensation, movement) of the finger tip to try to determine if there is nerve or tendon damage.

If the finger is severed I would wrap the separate part in damp gauze, put it in a plastic bag, and then use ice to keep it cool. The digit should stay with the victim, but ideally somewhere they can't see it. Yeah, this is a bit gross.

Assuming that the finger is not severed I would use a syringe and clean water to irrigate the wound. If the wound is minor I would apply a bandaid. If the wound is more severe I would use suture strips to close the wound and then wrap it in gauze covered with a pressure dressing. I don't personally carry a clotting agent, but that could be used as well.

Ideally I should do a full SAMPLE evaluation of the victim, but this post is already really long. If they have a preexisting condition such as trouble clotting then that changes the treatment plan.


What next?
If the wound is extremely deep or there is any indication of nerve or tendon damage then it is time to slowly evacuate the victim to get advanced help.

If we decide to stay and keep drinking beer then I would monitor the wound for infection and replace the bandages every day (or more often if needed). I would also apply an antibiotic cream such as Neosporin. The victim may want to take a pain medication such as aspirin or Tylenol (if they have no allergies).

In both cases I would monitor the victim for signs of them passing out or going into shock.


There is another post where I listed the contents of my first aid kit. In this scenario I potentially used the following:
- Nitrile gloves
- Syringe and clean water
- Bandaids
- Suture strips
- Gauze
- Pressure dressing or bandage
- Antibiotic ointment
- Aspirin or Tylenol


I think it is great that you are posting this scenarios, it really helps to get us all to think about possible issues that may arise while on the trail, in camp, or driving to the trail.

Very detailed response. The chances of any kind of meaningful amputation is highly unlikely considering the MOI. Only thing to add would be on initial response would be to raise the injured arm, apply brachial compression and asses the wound. Never apply direct pressure on digit wounds... If you are holding the wound and the patient feels pain, they jerk and you risk the chance of further tissue damage, like legs, simple elevation and local pressure application will suffice. If the patient is conscious, they can apply the pressure themselves. Im a HUGE fan of keeping patients busy and involving them in their own treatment.

As for the pale and sweaty...Im assuming the OP is leading the scenario to possible shock. However, the amount of blood loss/time would not lead to shock at this stage and the patient would be pale and clammy, not sweaty...very distinct. Therefore, I might consider the patient is a Diabetic> Hypoglycemia protocol.

Good call on the Stroke as this would affect a lot of treatment options. Dont forget aneurysm, TIA etc.

 

[madcratebuilder]

If everyone is drinking red beer it's fine.

 

[slomatt]

Very detailed response. The chances of any kind of meaningful amputation is highly unlikely considering the MOI. Only thing to add would be on initial response would be to raise the injured arm, apply brachial compression and asses the wound. Never apply direct pressure on digit wounds... If you are holding the wound and the patient feels pain, they jerk and you risk the chance of further tissue damage, like legs, simple elevation and local pressure application will suffice. If the patient is conscious, they can apply the pressure themselves. Im a HUGE fan of keeping patients busy and involving them in their own treatment.

As for the pale and sweaty...Im assuming the OP is leading the scenario to possible shock. However, the amount of blood loss/time would not lead to shock at this stage and the patient would be pale and clammy, not sweaty...very distinct. Therefore, I might consider the patient is a Diabetic> Hypoglycemia protocol.

Good call on the Stroke as this would affect a lot of treatment options. Dont forget aneurysm, TIA etc.

Given the (likely intentional) lack of detail in the original post I tried to think a bit out side of the box and not just assume a simple cut on the finger, and that led to a much longer post than I initially meant to write.

I had not heard that recommendation against applying direct pressure on digit wounds before, that is great advice. Thanks. My somewhat limited first aid training did not delve deeply into the various pressure points and recommended direct pressure in most cases. I should probably do some additional reading to get more familiar with the "upstream" pressure points in the arms and legs.

 

[El Solis]

@RXH
I’m going to have to respectfully disagree with your advice to not put pressure directly on a wound to a finger/digit. Although what you describe may occur, it would be rare and the most beneficial location to apply pressure is directly at the source of bleeding. Putting pressure higher up reduces/stops blood flow to the entire limb distal to your pressure point which is unnecessary for a cut to the finger. Direct pressure on the cut is best.

 

[RXH]

@RXH
I’m going to have to respectfully disagree with your advice to not put pressure directly on a wound to a finger/digit. Although what you describe may occur, it would be rare and the most beneficial location to apply pressure is directly at the source of bleeding. Putting pressure higher up reduces/stops blood flow to the entire limb distal to your pressure point which is unnecessary for a cut to the finger. Direct pressure on the cut is best.

I agree, direct pressure on any bleeding is preferable. However, on digits, I always recommend the patient apply the pressure so as to ensure no further damage is done. The point of raising the arm and a little brachial is to have a quick way of stopping the bleeding to asses the wound, this is not meant as a long term solution, just a quick inspection aid.

 

[El Solis]

Just to close the loop on this one, slomat knocked it out of the park. Assessing the scene, following a simple, standard approach to assessing the patient, and then treating as able and evacuate as needed. These scenarios are to get you thinking about what you would do when you don't know what it wrong, not focused on getting the right answer to the specific injury. To allow you to assess your skills, your kit, and your comfort level with realistic situations and to give you something to think about while driving along enjoying the scenery.

 

[PandaMonium 428]

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