Back Story: We were assured that no one ever went to this particular village without getting into a fight, so were determined to go and get our fair share that day. For hours and hours we maneuvered, repositioned, goaded them, and breeched homes we had intel on. After 4 hours of nothing, we were ready to call it a day and head out to another location to try our luck. Just then, my interpreter comes up and says "We have a casualty coming in". He doesn't know anything more. I don't know if the casualty has been shot, blown up, or even who the casualty is at this point. So up pulls a mid 1980's Toyota Corolla, and the driver quickly gets out, pops the trunk, and lifts a man out of it who is curled up in the fetal position. He carries him over to us, and sets him on the ground. What follows is a mix of what I did correctly, what I missed in my assessment, and some very serious lessons learned.
As he is being unloaded, I get the information that this was a local ALP (Afghan Local Police) member who had flipped his truck while patrolling nearby, and a local found him and hurried him over to us.
All medics are taught to anticipate what injuries to look for based on how the wounds happened, right? So now knowing that this was a MVA (motor vehicle accident), I had a picture in my mind what could be wrong, but still needed to follow the SMARCH-RV formula.
Presentation of patient: Semi-conscious, seemed to be having irregular respirations that almost appeared agonal while gasping for air.
Security--We pushed teams out to secure the high ground, but we generally assessed our location to be secure.
Massive Hemorrhage--No obvious bleeding, quick blood sweeps also turned up negative
Airway -- Nothing obvious. No facial deformity, teeth and tongue were intact with no blood or foreign bodies in the mouth.
Respirations -- Patient was struggling to breathe. He was gasping for air and would suddenly have moments of clarity where he would reach for myself or a nearby Afghan helper and grab them in a panicked way.
As his labored, gasping breathing was the only sign to that point of anything wrong, I handed off the further physical assessment to the 68W1 Civil Affairs medic we had with us that mission to conduct the remaining circulation sweep, including crepitus and grimace checks for broken bones. Concurrently, I did the following:
1) Cut off his uniform to expose his chest
2) Placed a pulse oximeter on his finger. It gave us 84% when initially placed, indicating a serious problem.
3) Laid him flat to see if there was bilateral rise and fall of the chest. There was. No unilateral rise and fall, and upon closer inspection of his now exposed chest, no penetrating wounds or anything to indicate a collapsed lung or damaged chest cavity by outward appearance.
While this is taking place, the patient is still drifting in and out of consciousness, struggling with us, and his breathing is not getting any more regular. He seems to be panicking that he can't breathe. After conducting a quick roll to assess downside injuries and finding none, the 68W1 told me that the remaining checks, including for spinal deformities and step-offs, are negative. no ocular indications of severe brain injury, and that there doesn't appear to be any outward signs to indicate a reasoning for his labored breathing. I'm thinking that maybe I should just needle decompress him anyway to be safe. I mark the spot on his chest, but decide not do it at this time. Vitals at this point are Pulse 120, Respirations 10 and highly irregular, temp wasn't taken. BP wasn't taken because pulse was strong.
At this point, I am thoroughly confused. I have found no physical indications as to why this patient is struggling to breathe, and as a medic, I am trained to find a problem and fix it....but I've been through all the steps and found nothing, while he still continues to gasp for air. At this point I'm thinking that I missed something.
My next thought is that I'm going to have to calm this guy down in order to control his airway. I get out my field intubation kit and prepared everything in case the guy goes unconscious on me. So me and my brilliance (sarcasm) decide that I should give this guy a Fentanyl Lollipop to suck on to calm him down so I can start an IV, or at least get him relaxed enough to potentially bag him. After letting him suck on it for a bit, ...he simply looks at me with a 'what else you got?' look.
I decide I've wasted enough time guessing, and take his arm to prep it for an IV...only to find strong evidence of heroin use. So much for pushing morphine, and also...no wonder he rolled his damn truck.
My 68W1 volunteers that he has Ketamine. We draw up 50mg and push it DM. Within 2-3 minutes the patient calms down, his pulse ox reading goes from mid-80% to low 90%, and his breathing becomes more regular. We package him up, and decide to evacuate him with us back to the base in our RG-33 and let our FST role 2 facility check him out. On the way back, thanks to my brilliant decision to use Fentanyl, he proceeds to vomit numerous times.
The FST checks him out, and finds evidence of a bad concussion, and slightly cracked ribs, but not much else. The guy essentially had a severe case of having the wind knocked out of him, and coupled with the bad concussion, had a bizarre presentation of symptoms. He was discharged after 2 days with no memory of the incident whatsoever, but was fired for heroin use. Semi-happy ending.
After Action Review:
Did well:
1) Focused on SMARCH-RV and didn't immediately go to the distractor wound (gasping for breath).
2) Allowed for my 68W1 to offer suggestions, and that he could see what I could not.
Did poorly: A lot.
1) Didn't allow myself to think big picture about what other things could cause such labored breathing.
2) The use of fentanyl was simply stupid. Not only is it probably the least effective narcotic to use on a population perpetually dehydrated (little absorption through membranes), but it is a respiratory depressant on a guy who was already struggling to breathe and had low O2 stats. Not to mention the fact he threw up, which only complicated his breathing efforts. Throw in the fact that he had a concussion, and needless to say I felt stupid for a long time after this one.
3) I laid him down numerous times to try and get a better idea of what could be going wrong with him. One of the things we also do as medics is allow the person who is having trouble breathing be in a position most comfortable for them. Because of his semi-conscious behavior, I didn't know if he was sitting up because he was scared or because he couldn't breathe, but I should have defaulted to allowing him to sit up after my initial inspection.
4) Not push Ketamine immediately. This was January/Feb of 2013, and I didn't feel as comfortable with Ketamine as I should have. From then on out I made sure it was my first-line drug.
5) Didn't push any antiemetics to compensate for fentanyl once stabilized.
What do you all think? Was there something I missed early that would have led you to diagnosis him quicker? Additional mistakes I made?
Have any of you been in similar circumstances that you can offer insight on?
Comments
What about using Narcan on the Pt after you discovered the possibility of heroin use? Don’t know if you carried Narcan. Might be something to seriously consider when operating in a known heroin growing/manufacturing/use area.
I’m a Construction Medic in Canada so I don’t have access to this type of training, however, I’ll take a shot at this.
I agree with not taking BP as he still had a radial pulse….loss of would indicate shock. What was his skin condition??? Shocky?
Re GCS Scale, you said ocular was OK, what about verbal and motor skills?
Any fluid coming out from the nose or ears?
I’ve had bad falls or accidents bruising or breaking ribs and it feels like someone has stuck an ice pick in my back or chest. Any discoloration or distention in the chest area?
Just thinking.
Thanks
While not a standard in battle assessment, if you found tracks, did you check pupils? Narcan is probably not part of kit, I assumed since you have fentanyl you may have that?
Though you didn’t mention it, I’m sure you checked for JVD and trachial deviation, which obviously would have been negative. Otherwise, I’d say you handle everything fairly well and in the end it was a hard case to figure out because we don’t run on very many heroin addicts involved in MVA’s who are being pussies. 🤷♂️
I would work off the assumption that he was unrestrained. That being said, I agree with the possible pulmonary contusion, but you can’t do anything but assist with a BVM if you have that kind of time and security. I drop an NPS if he’s borderline agonal and keep my airway kit close. Even though there was no obvious head injury indicated by the eyes, you can’t rule out concussion without imaging. I think that was the more likely cause of his vomiting. I agree Fentanyl was not the best course due to his SOB. Hypoxia due to poor excursion will cause that restlessness, but so will hypoxia due to pending shock due to a pelvic bleed. Simply because the pelvic doesn’t flex during inspection does not mean that it is not fractured. Any pain above the knee due to blunt trauma should get a binder. The JSOM had a good article on making them from combat trousers. Don’t beat yourself up over catching the heroin use indicators late. Its not priority at the time. I like that you used Ketamine to take the edge off to get him breathing slower. Considering that he had a chest wall injury, the pain will also hamper good chest movement, so again, good call on Ketamine. In retrospect, his poor SpO2 could have been due to the effects of the heroin induced respiratory depression. Position of comfort with difficulty breathing is always best. If he’s fighting you moving him to another position, that’s a red flag. Be careful attributing a problem or symptom to one thing and not considering other causes. He could easily have a head injury causing abnormal respirations also. I prefer to start an IV as soon as its practical to do so while the pt still had a decent pressure. (And provided they still have extremities) Its just preference on my part over an IO because I have had better luck securing the IV lines. Too much patient movement (transfers, arms moving, etc) in my experience risks losing the IO and access, but hey whatever works, works. Take it for what its worth, just some things I’ve learned through my own mistakes.
I thought collapsed lung also and possible pneumothorax occurring when I started reading. I think that’s an obvious differential. Did you auscultate to identify if the lobes were ventilating? I’m also wondering why his o2 sats were so low and think it may have been due to 1. Hyperventilating like you mentioned and 2. Pulmonary contusion due to blunt trauma. Either way interesting learning points and the humility you had is definitely a standard to pay attention to.