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18 year old John Thompson is home alone working on his family farm in the rural town of Minot, North Dakota. He is unloading a grain truck using a tractor with a spinning power shaft. His shirt tail gets wrapped up in the power shaft and when he tries to remove it both his arms are pulled into the spinning shaft and are both amputated below the shoulder.

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The spinning shaft has amputated both of Johns arms above the elbow. He is rapidly loosing blood and has no way to slow it down. He is not injured anywhere else so he is able to walk into his house and call for help on a telephone by dialing the number with a pencil which he holds with his teeth. He then sits in the bathtub to wait for the ambulance.

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Trinity Health general hospital is located in Minot, North Dakota. Close to where this incident happened. They are open 24 hours a day and are a trauma level II hospital. They have ground emergency transport as well as a helipad.

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Heart of America Medical Center is the next closest hospital in Rugby, ND. It is classified as a Level V trauma center. They have available trauma MDs and nurses on site and some diagnostic abilities. However for a trauma like this one, their main focus would be stabilization and then to transfer to a more equipped hospital

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Dispatched to a traumatic accident in a delta response. Dispatch notes provided that the patient had amputated both arms. A helicopter was called while in route for immediate transport for the patient since they were in a rural area. Upon arrival the patient is found inside their home in their bathtub. The patient was alert to painful stimuli and was not very reactive. Lots of blood was noted around the house and in the bathtub (approximately 2000cc’s). Immediate pressure was applied on both arms with large trauma pads while tourniquets were placed up by their shoulders. Immediate oxygen therapy via a BVM with assisted ventilations was administered as patient was GCS 10. Bleeding had been controlled and immediate IO access was placed for a fluid challenge. Vitals were obtained and were as follows (HR 140, BP unobtainable no pulse on patients feet, weak pulse in femoral, SP02 98%, RR 10 slow and shallow but being assisted with a BVM. Access was also located via IV in the patients foot. Fluid was administered to maintain an adequate femoral pulse. 2g of TXA was also administered in a bolus at a rate over 10 minutes. The patient was kept warm and intubation equipment was prepared for the patient if they continued to decline. Helicopter was able to land in the nearby field. Flight crew made contact and rapid sequence intubated the patient with ketamine and rocuronium. The patient was loaded into the Helicopter and they were taken to Trinity Health general hospital. A call was also given to the hospital letting them know of the incoming patient and interventions done.

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At the hospital a trauma room will be readied. The equipment gathered will include suction, IV supplies, intubation equipment, warmed IV fluid, O- blood. The personnel will include the ER provider, two RNs, the trauma specialist, and the trauma surgeon on stand by.

Some questions that I would ask would be what made them decide to intubate the patient? Did they give any additional medications? And if they patient has any family members on the way.

The mechanism of injury is traumatic amputation of a limb because of a shearing force.

Thank you for your response!

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At the scene

When the flight paramedic and flight nurse arrive to the scene, they will do a rapid primary survey focused on the ABC’s (Airway, Breathing, Circulation). As the team checks the airway and breathing, tourniquets should be applied to both patient’s arms to control the bleeding and trauma pads will be used to help stop the hemorrhaging. The team needs to work together to also assess the Disability (neurological status) and Exposure (checking for additional injuries) of the patient.

Large-bore IV access should be obtained likely as an IJ, or EJ (Internal Jugular/External Jugular vein), and IO access (intraosseous access) will be established if IV access can’t be gained quickly. The patient’s vital signs need to be closely monitored. The patient will likely need fluid resuscitation and possibly trauma blood transfusion in the field to maintain stability.

Intubation will likely be performed in the field to secure the airway and for pain management. Once the patient is stabilized, the amputated limbs should be carefully recovered. The limbs should be cleaned with sterile water or sterile saline, wrapped in saline soaked gauze, and placed in a cooling ice pack for possible reattachment.

Pre-Arrival to the Hospital

The hospital needs to be notified of the incoming trauma patient, and the appropriate trauma level should be activated. Orthopedic and trauma surgeons should be notified to stand by for the patient’s arrival, and the surgery team should be alerted and prepped. Additionally, laboratory, radiology, trauma team, anesthesiology, and other relevant departments should be notified according to hospital protocols to prepare for the patient’s arrival.

Arrival to the Hospital

Once the patient arrives at the hospital, the flight paramedic and nurse should give a detailed handover report to the trauma team, including the ABCDE’s (Airway, Breathing, Circulation, Disability, Exposure). The trauma team will then reassess the patient, following the same ABCDE process.

Radiology will perform x-rays on the injured and amputated arms, as well as checking for possible spinal or head injuries. Radiology will also confirm the placement of the endotracheal tube.

Laboratory will draw blood for crossmatching, coagulation panel, ABG (arterial blood gas), CBC (complete blood count), and CMP (comprehensive metabolic panel).

The emergency physician will lead the team in coordination with the trauma surgeon and orthopedic surgeon until the patient is stable enough to proceed to surgery. The trauma team nurse will prepare the patient for rapid blood transfusions, especially if the patient is showing signs of hemorrhagic shock. The tourniquets applied in the field will be reassessed and either readjusted or removed, depending on the control of bleeding.

Pre-Surgery

The anesthesiologist will manage the administration of general anesthesia and monitor the patient’s vital signs during surgery. This will likely be a long surgical procedure, so the anesthesiology team will be responsible for ensuring the patient is stable and pain-free throughout the entire surgery.

Surgery

The surgery will likely involve a trauma surgeon, orthopedic surgeon, and vascular surgeon all working together to attempt limb reattachment. They will focus on repairing any damaged tissues, blood vessels, and bones. The surgical team will work to restore functionality to the limbs or prepare the limb stumps for possible future prosthetics depending on the outcome of the replantation efforts.

Additional Information to Consider:

Amputation Details: Were the amputations clean or complex? Are there fractures in the remaining limb stumps or surrounding bones that need to be addressed?

Mechanism of Injury: Was there any other trauma that could affect internal organs or other structures, such as crushing injuries from the spinning shaft?

Pain and Sedation: Has adequate pain control been established? What is the patient’s current pain level?

Timeframe of Injury: How long has it been since the injury occurred? This will influence the success rate of the replantation efforts.

Psychosocial Considerations: How is the patient handling this traumatic injury? Psychological support may be necessary given the severity of the incident and potential long-term disability.

Resources (Equipment and Personnel) to Prepare in Advance:

Trauma Equipment:

Tourniquets and trauma pads for hemorrhage control.

Airway management supplies: Intubation kit, BVM (bag-valve-mask), oxygen, suction devices.

IV and IO access supplies: Large-bore IV catheters, IO devices, and fluids for resuscitation (normal saline, blood products).

Trauma and orthopedic kits for limb reattachment (sterile dressings, sterile water, ice packs, etc.).

Medications: Analgesics, sedatives, paralytics, TXA (tranexamic acid) for hemorrhage control, and general anesthesia agents.

Monitoring equipment: Cardiac monitoring devices, blood pressure cuffs, pulse oximeter, and capnography.

Personnel:

Flight paramedic and nurse for transport and stabilization.

Trauma surgeons (including orthopedic and vascular specialists).

Anesthesiologist for managing anesthesia during surgery.

Trauma team nurses for assisting with assessments, IV access, transfusions, and medications.

Radiology tech for imaging and confirming tube placement.

Laboratory personnel for blood work (crossmatch, coagulation panel, etc.).

By preparing all these resources in advance, the trauma team can respond effectively to stabilize the patient and improve the chances of a successful outcome. Ensuring timely intervention and careful coordination throughout the care process is essential in cases of severe trauma like this one.

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The decision to intubate was based on the preface that the patient was GCS 10 (and declining) and wasn't able to maintain their own airway. a definitive airway was going to be needed. 2 grams of TXA was administered along with ketamine and rocuronium for the intubation.

Police on scene stated that a wife of the patient would meet them on scene.