By Gary Ludwig
Here is the typical scenario that many firefighter/emergency medical technicians (EMTs) and paramedics face daily.
Scenario: You are working a 24-hour shift on a Friday night. The tones go off. You, your ambulance, and the engine company from your station are dispatched to a report of a shooting outside a bar in the downtown area. As the engine and ambulance leave the fire station, you are directed to a staging area until the scene has been secured.
The dispatcher reports that there is a large and unruly crowd on the scene. After arriving at your staging area and remaining for about five minutes, the dispatcher informs you that the scene is secured and you can report to the address. All firefighters on the engine and the ambulance have already donned their personal protective equipment (PPE) and are ready to approach the patient when they arrive on scene.
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You arrive at the address. The police have created a large swath around the scene with yellow crime scene tape, and the crowd has been pushed back beyond the tape. You can see from the engine and ambulance that a young male is lying on the sidewalk.
As the firefighters disembark from both apparatus, they grab trauma boxes and other equipment and approach the patient. The patient, a male in his 20s, is conscious, alert, and orientated. A large amount of blood is pooled on the front of his white t-shirt in the area of the mid-abdomen. The patient looks pale and is sweating profusely. He appears to be in moderate pain. His airway is clear. His respirations are shallow and rapid. A quick glance over his entire body reveals that there is a large amount of blood pooled on his right pants legs and some of the blood is pooling on the sidewalk. You ask the patient a quick assessment question, “Have you been shot?” He answers with a definitive “yes.”
Treatment. The six firefighters, two of whom are paramedics, begin immediate treatment with cervical spine stabilization. Another firefighter puts the patient on oxygen while another firefighter begins assembling IV fluids. You, as one of the firefighter/paramedics, begin to physically assess the patient by lifting the shirt and examining the wound. When you lift his shirt, you see there is a single gunshot wound just to the right of the navel area. You quickly dress the wound. Another firefighter begins cutting the patient’s pants legs, exposing another gunshot wound to the upper thigh. There does not appear to be any fracture. This wound is also bandaged with an occlusive dressing.
A quick check reveals the patient does have a pedal pulse on his right foot. An examination reveals no more gunshot wounds anywhere on the anterior side of the body. You roll the patient over to see if there any more gunshots wounds and any exit wounds. There are no gunshot or exit wounds on the patient’s posterior side. After he is rolled back over, a quick blood pressure check reveals the blood pressure at 100 over 60 and a pulse of 132. You palpate the abdomen; there appears to be some rigidity. The lungs are clear, and breath sounds are bilateral.
The other firefighter/paramedic has started an IV in the left arm; two other firefighters get a backboard and the stretcher from the ambulance. After the IV has been established, the patient is log-rolled onto the backboard, secured, and lifted to the stretcher. The stretcher is then rolled to the back of the ambulance and placed inside.
Once inside the back of the ambulance, both firefighter/paramedics continue to work to stabilize the patient. The patient is placed on a cardiac monitor, which shows Sinus Tachycardia at 136. A listen of the lungs in the relatively quiet ambulance confirms that lung sounds are clear and bilateral. Oxygen saturation is 90%. A double-check of the IV shows that it is running wide open. A blood pressure check reveals a B/P of 104 over 64. You start another IV in the other arm.
You signal that it is clear to begin transport to the closest Level 1 trauma center. A firefighter/EMT jumps into the driver seat while the two paramedics remain in the back. En route to the hospital, you radio the hospital and give a report with an estimated time of arrival of 10 minutes. The hospital responds that it is standing by and that you should bring the patient to Trauma Room #2.
Later, you find out that your patient was shot with a .22 caliber handgun and has a severe liver injury from the abdominal shot and a soft tissue injury from the leg shot. The patient lost approximately 1,500 cc of blood prior to arriving in the operating room. The patient survived five hours of surgery and now, two days later, is in the intensive care unit.
Penetrating Trauma
If we could only see what is going on below the surface of the skin of the abdomen and the leg. Unfortunately, that is not possible in the field. That is the reason penetrating trauma is such a challenge when performing emergency medical services in the field.
Most penetrating trauma that EMTs and paramedics contend with in the field comes in the form of gunshot wounds; stab wounds; falls onto objects; and other accidents involving darts, nails, and other objects capable of penetrating through skin. During my career, I have seen screwdrivers, car antennas, a nail from a nail gun, the bit of an electric drill, and the pipe from a cyclone fence penetrate the body. Basically, any object that pierces the skin and enters the body is considered penetrating trauma. If it severe enough, it penetrates the skin and then exits. This is known as perforating trauma.
The most common form of penetrating trauma in the United States is a gunshot wound. In 2013, there were 73,505 nonfatal firearm injuries (23.2 injuries per 100,000 U.S. citizens)1 and 33,636 deaths caused by “injury by firearms”” (10.6 deaths per 100,000 U.S. citizens).2 That equates to more than 100,000 people shot with a firearm in 2013.
Stabs/cuts with a knife is another common type of penetrating trauma.
Each form of penetration is unique and can involve the head, chest, abdomen, pelvis, or an extremity. The type of instrument used presents its own set of unique challenges.
References:
1. Priorities for Research to Reduce the Threat of Firearm-Related Violence. The National Academies Press. 2013.
2. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf Page 84, Table 18.
BIO
Gary Ludwig is the chief of the Champaign (IL) Fire Department. He also served in fire departments in St. Louis, Missouri, and Memphis, Tennessee. He has 40 years of fire, rescue, and EMS experience and has been a paramedic for more than 38 years. He has a master’s degree in business and management and is a licensed paramedic.
