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Between a Rock and a Hard Place

alexmiller4_2 — 2024-06-10 03:10:20 UTC

The Book Between a Rock and a Hard Place is an autobiography about Aaron Ralston. He was an avid rock climber and hiker. He decided to go hiking in a canyon where he didn't have cell service. Long story short, as he is scaling a rock that is wedged in one of the smaller canyons, the rock buckles and he falls. In the commotion of the fall he ends up getting his hand and arm pinned between the boulder and the canyon wall. The book describes how her survives for several days with his hand crushed. He ultimately realizes that he needs to cut his own arm off in order to get out of the canyon before he dies from dehydration.

His most apparent injury would be the self amputated arm. I would also suspect severe dehydration.

The incident took place in Bluejohn Canyon in Southeastern Utah. The Moab Regional Hospital and Blue Mountain Hospital would be the closest hospitals.

This is the movie adaptation of him amputating his arm

https://www.youtube.com/watch?v=nj_BZHReStY

Paramedic Scene Size up

2024-06-13 01:59:45 UTC

Dispatched to an unknown age male for a rock climbing accident. Scene appears to be safe. There is 1 patient, MOI is a rock climbing fall and entrapment, with a self inflicted below the elbow arm amputation, as well as a NOI of severe malnutrition and dehydration. Additional resources needed, search and rescue, with a high angle rescue team. There is a need for c-spine precautions.

Paramedic Primary Assessment

2024-06-13 02:18:57 UTC

Approaching on scene, and following extrication, presents a male, appearing to be in his mid 30's, lying supine, crying out in pain.

Airway is patent.

Breathing is tachypneic and labored, with obvious use of accessory mucsles.

Circulation, pulse is thready and rapid, patient is bleeding profusely from the amputated arm. Tourniquet applied to stop the bleeding. Skin is pale, cool, and clammy.

Patient is AxOx2, does not know time or place. GCS 13.

Patient's chief complaint is R arm below-the-elbow amputation, and severe malnutrition and dehydration.

Immediate transport an spinal precautions initiated. Since there are no trauma centers nearby, I would diapatch a helicoptor to airlift this patient to Dixie Regional Medical Center, which is a level II trauma center.

Paramedic History, Secondary Assessment, Treatment, and Transport

2024-06-13 02:32:43 UTC

Initial Set of Vitals

HR 134, thready and rapid

BP 86/64

RR 40 and labored

SPO2 86% on RA, 95% on 15L NRB

Temp 34.8

BGL 52

lung sounds clear and equal bilaterally

Pupils PERRLA

SAMPLE History

S-as previously noted

A-none

M-none

PPMH: knee replacement 6 years ago

L: 5 days ago

E: hiking in a canyon with no cell service, scaling a rock, falls and R arm gets wedged between boulder and the wall of the canyon.

Treatments

Place patient in spinal precautions, c-collar applied, and pt placed on backboard

Establish bilateral large bore IV's, administer a fluid bolus of 20mL/kg to titrate blood pressure to 90-100mmHG systolic, and 100mcg of fentanyl for pain

Placed pt on 15L via NRB to support oxygenation

Initiate shock protocol en route by activaly warming the patient

Secondary Assessment shows no further injuries.

I would place a hemostatic dressing on the pt's injured arm, as well as bandaging the exposed injury.

Report to Hospital

2024-06-13 02:36:10 UTC

En route to hospital, I would alert the trauma center of an incoming trauma patient with a CC of a rock climbing accident, as well as details of the extrication and initial assessment. I would inform the hospital of my interventions and vital signs, along with any acute changes that occurred throughout transport.

Arrival at Hospital

2024-06-21 17:09:43 UTC

Upon arrival, the patient will need to go directly to the operating room. A surgeon, OR nurse, anesthesiologist, and scrub tech will be needed for the immediate surgery to repair and reduce the damage to the right arm. The patient would likely need fluids and maybe even blood products given the blood loss.
I would ask the time frame from when the patient self amputated the arm.
This would be a penetrating injury, or traumatic amputation.
Thanks for adding to the post.

Question from instructor.

mitchellstanding — 2024-06-26 05:25:38 UTC

What is a high-angle rescue? And does that add any threat or complication that nurses should be aware of?

Instructor comments

mitchellstanding — 2024-06-26 05:31:04 UTC

Great work! Might be a good idea to have a rapid infuser and/or fluid warmer present.

It will be really interesting to see how severe dehydration effects the labs and outcome.

Questions for Radiology

alexmiller4_2 — 2024-08-02 05:16:11 UTC

What precautions would you take while getting imaging for a patient who has sustained as much physical trauma?

Does the dehydration and blood loss affect your ability to get clear imaging?

alexmiller4_2 — 2024-08-05 05:35:48 UTC

I don't see anything from the other disciplines