July 16, 2007
Posted by Jim Macdonald at 12:23 PM * 106 comments
Now it’s time to have our little chat about shock. Shock is what kills people. Shock, dear friends, is what will eventually kill you, personally. The only question will be how you got into shock to start with.
Shock is the simple word, hypoperfusion is the fancy word. That is hypo (low), perfusion (delivery of oxygen and nutrients to the cells throughout the body).
Some of those body cells are more sensitive to low perfusion than others. Brain cells, now, can go without oxygen for between four and six minutes. That’s why we’re checking Airway, Breathing, and Circulation every five minutes. Big chunks of emergency medicine, and all of CPR, is about getting oxygenated blood to the brain. Skin cells can go hours without oxygenated blood. Maybe days. Other tissues have other thresholds.
There are four main classes of shock:
- Hypovolemic (from hypo, low, and volemic, of or pertaining to volume). Bleeding is the most obvious way to get there, but dehydration from whatever cause (burns, diarrhea, etc.) will get you to the same place.
- Obstructive (something is stopping the blood from picking up oxygen) (examples: pulmonary embolism, tension pneumothorax, cardiac tamponade),
- Distributive (something is preventing the oxygenated blood/nutrients from reaching the cells), with its subcategories and
- Cardiogenic (the heart isn’t beating well enough to push the blood around).
But now for the good stuff: Hypovolemic shock.
Usually in trauma the kind of shock you see is Hypovolemic shock—there just isn’t enough blood to move oxygen around to everywhere, because that blood is now in a puddle on the ground. As the body loses blood, it compensates by shutting down peripheral circulation. Skin and muscle can go for a long time without nutrients and oxygen. Then the various internal organs get their blood supply shunted to the heart/lungs/brain area. And here is where the Golden Hour—the hour from when the trauma occurs to the moment the OR doors close behind the patient—comes from. Just as the brain lasts four to six minutes without oxygen, the kidneys last forty-five minutes to an hour and a quarter without oxygen. And if your kidneys die, you’re dead, and not in any kind of quick and pleasant way, either.
Your patient will complain of being thirsty. Don’t give him water. He’ll just vomit it up, because when he started going into shock one of the first systems to shut down was the digestive system. That gives you the added problems of ruining his blood pH by dumping stomach acid, and compromising his airway from aspirating the vomitus. Besides, who wants to get puked on?
The adult human body contains between four and six liters of blood. That isn’t a heck of a lot. Kids and babies have less.
A sign is something that you can see for yourself. A symptom is something that your patient tells you. The first symptom of going into shock is a feeling of anxiety. The patient is restless and apprehensive. As time goes on and shock progresses, the skin gets cool and pale as blood is shunted away from the skin and into the deeper organs. The heart rate goes up, to move what blood is still in the body around, the respiration rate increases to get more oxygen on the red cells that are left. The body releases adrenaline, which causes sweating. The body temperature goes down. The patient becomes listless, speech becomes confused, blood pressure plummets, the pupils get sluggish and dilate, breathing becomes slow and irregular. Then the patient dies.
This is all no fun for you, and less fun for the patient. The abbreviation for this is CTD, for Circling The Drain.
Even if you can’t see a pool of blood, the patient can be bleeding out internally. One of the tiny little costal arteries (the ones that run along the bottom edge of each rib) can bleed 50 mL per minute. The femoral arteries are as big around as your thumb: you can lose a lot of blood out of one of those puppies, very fast.
Less than 15% blood loss is referred to as Class I shock. The only thing you’ll see in Class I shock is that anxiety. The patient remains alert, the blood pressure, heart rate, and respiration rates stay within normal limits, and the skin’s temperature, color, and condition are unchanged.
For an adult with the average 5 liters of blood, that’s up to 750 mL. 750 mL is the amount in a wine bottle. For an adult bleeding internally with a torn costal artery, that’s fifteen minutes.
Next comes Class II shock. 15-30% blood volume loss. The patient is more anxious and restless. The skin gets pale, cool, and dry as blood is shunted to the vital organs. Blood pressure remains within normal limits, The heart rate increases to over 100 beats per minute, the respiration rate rises above 20 per minute. Capillary refill slows. (To check capillary refill, pinch the fingernail. It’ll blanch. Release pressure. The color returns. Normal is less than two seconds. (Not a reliable sign in adults.)) The pulse becomes thready (that is, hard to feel).
Class III shock is 30% to 40% blood volume loss. Up to two liters (a large plastic Coke bottle) in that average adult. The body’s compensatory mechanisms start to fail. The blood pressure plummets; you lose the radial pulse (in the wrist), then the femoral pulse (in the groin), then the carotid pulse (in the neck). Only now do you get the classic “signs of shock”: pale, cold, clammy skin; confused verbal responses, rapid heartrate, rapid respirations; cold extremities.
By the time you see the classic signs of shock you are on the edge of Too Friggin’ Late.
Next stage is Class IV shock. 40%+ blood loss. Forty minutes for that guy with the tiny little costal artery bleed The vasoconstriction from earlier, compensated, shock starts to be a complication itself. The heartrate continues to rise, then falls. Blood pressure continues to fall. Respiration rates rise further still, then fall sharply. The patient becomes incoherent, then unconscious. The pupils dilate. On a scale from good to bad, the needle is now pegged out on Bad.
What to do about this: Establish an IV (or two) and put in crystaloid (normal saline or Lactated Ringer’s) to a max of about two liters. You don’t want to raise the blood pressure too high, because that can blow off any newly-formed clots that are limiting bleeding. Take it up to about a systolic pressure of 90mm Hg (the point where you can first detect a radial pulse). Likewise it does you no good just to run water around in the patient’s veins. Without red cells (which are likewise lying in that pool on the ground) oxygen won’t be transported. This patient needs a nice blood transfusion, which you probably don’t have in the trunk of your car.
Another way we categorize shock progression is as:
- Compensated shock,
- Decompensated shock,
- Irreversible shock.
Friends, you don’t want to get to Irreversible shock.
Little kids are very good at compensating. They maintain their blood pressure, and they maintain their blood pressure, and they maintain their blood pressure … then they crash and there’s no coming back. Don’t look at blood pressure in kids. Look at heart rate.
Here’s something else you can do: take your Sharpie marker. Feel the kid’s arm. You’ll notice a place where the arm starts getting cold. Draw a line on his arm at that level. Do the same again a while later. If what you’re doing is working, the line between warm and cold will have moved down the arm. Keep doing it. If the line is moving up the arm, what you’re doing isn’t working. Find something else to do (or continue what you’re doing only more, and better).
The signs and symptoms for all varieties of shock are very similar, and the treatment for all of them is nearly identical in the field.
Some brief notes on some kinds of shock you might see on a trauma scene.
You can see Neurogenic shock and Obstructive shock in trauma cases. Distributive and Cardiogenic less often.
In Obstructive Shock the blood is prevented from picking up oxygen. Some examples of this include cardiac tamponade (the pericardial sac is filling with blood, preventing the heart from expanding and moving blood), tension pneumothorax (the chest is filling with air and is squeezing the lungs and heart), and pulmonary embolism (there’s a blockage in the pulmonary artery (blood clot, fat, marrow, air) that keeps blood from moving through the lungs to pick up oxygen.
Some of what I’m going to talk about is Black Belt EMS-fu. Don’t try this at home, kids. You need training, equipment you probably don’t have with you, and a license, to do it.
That being said: Cardiac tamponade. You’ll suspect cardiac tamponade when the patient’s pulse pressure is narrowing (the top and bottom numbers on the blood pressure are getting closer together), the heart sounds are muffled, the mechanism of injury suggests trauma to the mid-chest, and the guy is developing signs and symptoms of shock and you’ve already fixed everything else but it didn’t help. What’s going on: The heart is inside of a tough fibrous sac called the pericardium. If the heart is lacerated and is bleeding into that sac, eventually the pericardium will fill up with blood and the heart won’t have room to expand. No expansion, no blood being pumped, no oxygenated blood reaches the cells, the organs die, no fun for anyone.
What to do about it: Hook the guy up to an EKG. Get a big-ass needle attached to a syringe. Go in below the rib cage, angled slightly up. When you touch the heart you’ll seek EKG changes. Put the needle through the pericardial sac. Pull out the blood. It’ll be dark and very liquid. When you’ve done this, the guy should improve.
Another cause of obstructive shock is tension pneumothorax. The chest is filling up with air, leaving no room for the lungs to expand and the heart to beat. You can get this from a ruptured lung or from a sucking chest wound.
Ruptured lungs. Gotta love ‘em. You see this with “paper bag syndrome.” The guy sees the tree approaching the nose of his car. He reflexively takes a deep breath and holds it—then his chest hits the steering wheel. Should have been wearing his seatbelt.
Tension pneumothorax is bad — you can tell you’ve got that because you have an injury to the chest, absent lung sounds on one side, diminishing lung sounds on the other, and the trachea moving (tracheal deviation — it isn’t just for breakfast any more!) away from the injured side toward the uninjured side. That’s happening because the contents of the chest are all moving over toward the uninjured side, smushing them, and the trachea is attached to the stuff that’s moving. Plus, the patient is CTD and you’ve already fixed everything else that you’ve found. Oh — and it’s getting increasingly difficult to ventilate the patient with a BVM. (BVM is not only the Blessed Virgin Mary. It’s also a Bag Valve Mask, used for artificial ventillation. Sometimes called an Ambu Bag because they’re made by the Ambu company.)
Tracheal deviation is a late sign. How to look for it: Put your thumb and forefinger on either side of the patient’s windpipe and trace it down. The trachea should be vertical. Shifting to right or left is bad. If the trachea shifts toward the injured side, it’s simple pneumothorax, which is merely bad. If the trachea is shifting away it’s tension pneumothorax, which is Bad.
One thing to do (and again, this is high-level EMS-fu, don’t try it at home): Needle decompression: Put a big-ass needle through the chest wall just above the third rib on the mid-clavicular line. Wait for a nice gush of air and the patient’s condition to improve. This is what we call “an invasive procedure.” If the guy didn’t have an open pneumothorax before he does now.
In practical terms, get a large-bore IV catheter. Snip the tip off one of your spare latex gloves. Shove the needle through the tip of that cut-off finger (this will form a one-way valve). Find the space between the second and third ribs. (Here’s how: Find the suprasternal notch (the little dished out bit at the top of the breastbone at the neck, centerline). Trace down to the Angle of Louis, which is the bump you feel as you run your finger down the sternum. That marks the gap between the 2nd and 3rd ribs. (You can’t count ribs directly because the clavicle overlies the first rib.) Now trace the space between the ribs at that level over toward the injured side to the mid-clavicular line (the vertical line that bisects the collarbone), and stick the needle with its little glove-tip through into the the chest. If everything is working right, you get a rush of air, and the patient improves. You want to go on the top of the rib rather than the bottom of the rib, because there’s a little costal artery and a nerve that run along the bottom edge and hitting them would be bad.
If you don’t have the needle, and the training (or better still, a chest tube), the quick hold-what-you’ve-got fix is to roll the guy onto his injured side and let gravity help keep the uninjured side open.
Another cause of Obstructive Shock is Pulmonary Embolism (PE).
For Pulmonary embolism check the ABCs: Adios, Buy Flowers, Call the Coroner.
Actually, seriously, a PE is a blockage in the pulmonary artery that is bringing blood through the lungs to pick up oxygen. Lots of things can block that blood vessel: a blood clot that’s broken loose (which is why DVT (Deep Vein Thrombosis) is so dangerous; that’s what kills people who’ve been sitting in one position for a long time (for example on a long air flight in a cramped position, or when attached to a cell wall with handcuffs at Abu Ghraib)—a clot forms due to sluggish circulation, then breaks free, travels through the Vena Cava (a big vein), through the right side of the heart (still large-bore) then into the pulmonary artery, where the diameter of the blood vessels get smaller and smaller until at some point it’s too small to pass the clot. Other things that might form emboli include fat, marrow from broken bones, air, and little bits of plastic from very bad technique when you’re starting your IVs.
With blood blocked from dumping carbon dioxide and picking up oxygen, bingo, there you are in hypoperfusion. Shock.
What to do about it? Provide oxygen so that if any part of the lungs is getting blood flow around the aveoli that it’s oxygen rich there, and get your patient to the hospital.
Now that we’ve lightly touched on Obstructive shock, time to move on to Distributive shock. Oxygen is getting to the blood, the heart is beating, but the oxygen isn’t getting distributed to the organs.
First up is Neurogenic shock.
As you know, Bob, the veins and arteries have layers of muscle that are under control of the autonomic nervous system, to change their diameters and thus control exactly where the blood goes. If the body loses that ability to constrict the blood vessels and they fully relax, there just isn’t enough blood to fill all those miles and miles of veins and arteries and venules and arterioles and capillaries and so on. You might as well have that pool of blood on the ground, because there isn’t enough fluid to move oxygen and nutrients to the vital organs. You get this if the spinal cord is disrupted, or in certain disease conditions.
You can tell you have neurogenic shock because the patient has the classic signs of shock (pale, sweaty, cold) above a horizontal line on his body, but below that line he’s all warm, pink, and dry. You’re also looking for mechanism of injury: did he get hit in the spine? Also, in males, he has a raging erection. This is the ever-popular priapism (named for King Priapus, who apparently had it), a Bad Sign. (The blood vessels below the injury have fully relaxed, and that’s blood pooling in those open veins and arteries.) This may be part of why the Marquis de Sade thought that hanging was the most sensual way to die. The trauma to the spine puts the person into neurogenic shock.
Very similar in most respects is Psychogenic shock. That’s when the Publisher’s Clearing House Prize Patrol arrives at your door, gives you a check for ten million dollars, and you faint. What’s happened there is again your nervous system not controlling the blood vessels, the vessels dilating, and oxygen no longer reaching your organs. The brain being most sensitive to lack of oxygen you pass out and down you go.
Psychogenic shock is self-limiting. Once you’re unconscious your autonomic nervous system checks back in and gets oxygen back to your brain.
At an accident scene you can’t tell if your patient is in psychogenic shock because his new Beemer is now junk, or he’s in hypovolemic shock because he’s bleeding out into his pelvis, so you treat ‘em the same.
You don’t generally see toxic shock (aka septic shock) or anaphylactic shock on trauma scenes, except maybe Granny fell down the stairs because that urinary tract infection got to her, or maybe the reason Fred crashed was because he was stung by a bee and he’s allergic. In both toxic and anaphylactic shock the root cause is the blood vessels getting porous and allowing fluid to dump into the intercellular space, not leaving sufficient to move the red cells around to perfuse the organs.
Similarly for cardiogenic shock — having a heart attack can make someone fall in the shower.
I haven’t touched on asphyxia (a kind of obstructive shock) or diabetic shock (distributive) or many other things. I did talk about diabetes in general elsewhere.
What to do about this?
First, assume that your patient is going to go into shock if he isn’t there already. Once the patient starts to slide it’s awfully hard to get back up the slope, so start treating for shock early, before any signs or symptoms develop.
To treat for shock, get the patient lying down. A person in shock can’t control body temperature well, so wrap the patient in a blanket (under them as well as over them). Raise the patient’s feet twelve to eighteen inches. Provide oxygen if you have it. Establish two large-bore IVs in the best, most proximal veins you can find. Stay with the patient, hold their hand, talk to them.
Do all of these things for any variety of shock and you will be doing well.
Trauma and You will return in Part Three: Sticks and Stones.
Copyright © 2007 by James D. Macdonald
I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.
(Attribution URL: http://nielsenhayden.com/makinglight/archives/009148.html)
Trauma and You, Part Two: Shock by
James D. Macdonald is licensed under a
Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.
Index to Medical Posts
So giving blood (1 pint) is Class II shock? I've never noticed the symptoms you describe. (Some weakness and lethargy, sometimes thirst.)
I think I might be still confused. It sounds like psychogenic shock is something that is most likely to hurt you by making you hit your head as you go down. Otherwise, no worries? The catch is that you can't trust that it is psychogenic shock, and anything else is fatal if untreated?
OK, but we can't start IVs or anything, since we won't have them. Unless I missed where you told how to make them out of drinking straws.
Seth @1:
Exactly.
There's a reason they have you sit down, drink something with sugar in it, and eat cookies after you've donated.
Then there are those of us who pass out whenever they donate a pint...
1 pint is approximately 500 mL. 500 mL != 750 mL
Donating blood is class I.
Obviously, the shock my father went into when the sodium/potassium (and the jar of oil he was putting it in) blew up in his hand was psychogenic shock. [He ran into the kitchen - this happened in his shop at home, and it was no more than fifty feet away - put his hand under the faucet, turned the water on, then folded onto the floor (elapsed time: not much, actually). My mother took him to the hospital, and I cleaned up the floor.]
Xopher @3:
The First Aid course *used* to recommend giving the victim water with baking soda (1/4 t baking soda to 8 oz water) if they were able to drink.
I was never really sure what that accomplished. Jim, can you explain?
I don't know if anyone's mentioned it here, but if you're in NYC, the Office of Emergency Management trains Community Emergency Response Teams (CERT). If you have the time and inclination, I highly recommend it. It's a fairly intensive course (meetings are weekly 2-3 hour sessions for eleven weeks). And they want anyone. My class had retired firefighters, college students and three little old ladies.
Not everyone is going to be able to drag a large man away from a car that's about to explode, but even a little old lady can observe and keep track of anyone who is still in danger (and then inform the real pros when they arrive).
Another thing theses teams do is try to get to know their neighborhood in detail. It's helpful to be able to tell responding firefighters that there's a paraplegic living in apartment 3B. That's useful information.
There's a lot more that they do as well. If you're interested, their website is:
http://www.nyc.gov/html/oem/html/cert/cert.shtml
If you're not in NY, variations on the theme exist in a bunch of other cities.
Your description of Class I shock matches the anxiety attacks I get from time to time, which I suppose makes sense. I've never had that from donating blood, but then I meditate or trance to compensate for that, and they're always good - sometimes pushy - about the free tea & biscuits.
Speaking of which - tea with sugar in, sugary sweets, and so on. This is what I self-medicate with. Assuming they're conscious and able not to choke on it or throw it back up, is sugar good, bad, or pointless? Am I getting confused with hypoglycaemia?
Oh, by the way: thank you for posting these. I had occasion to use the ABC formula the other day, finding a woman asleep-or-unconscious at a night bus stop, obviously not deliberately sleeping rough. My girlfriend got a paramedic through 999, while I checked. Turned out she was drunk, not harmed, vocally uncooperative, and had done this quite often before, but as always - could've been serious.
Saw someone go into shock. Got out of the water, onto a boat, sat down, and collapsed.
The basics really count, lie them down, elevate their feet. As soon as the emt's showed up with oxygen, they regained some consciousness and got color back in their skin.
Getting the patient to lie down can be an amazing bit of help for how simple it is.
I think the rule is that unless the patient is suffereing from a heat-related thing (heat stroke, heat exhaustion), it's a safe bet to elevate their feet as if they might be going into shock.
If they're having heat stroke, the skin will be red, rather than pale, at which point, I think the rule was lie them down and elevate the head to keep the brain cooler, or something.
When red, lift the head. (heatstroke->red)
When pale, lift the tail. (shock->pale. tail->feet)
When in doubt, lift the feet. I don't think there's any harm in treating for shock when the patient isn't in shock. (other than heat stroke)
#1: Giving blood is Class I shock. One pint is about 475 mL. The most you should feel is anxiety -- but there aren't sharp lines differentiating the levels, and one person will react differently from another.
#2: Yep. In EMS you look for, assume, and treat, the worst first. If they guy was in psychogenic shock and you kept him warm and put his feet up, you haven't lost anything. If the guy's in hypovolemic shock and you don't treat it, you've lost quite a bit.
#3: You don't have to start IVs or give oxygen. I just include that so you know what'll be happening next, when the guys who have IV equipment with them arrive. For someone on the street, ensure the ABCs, put him on his back with his feet up, and cover him with blankets. Help is already rolling and the scene is safe by then, right?
OK, that makes sense. I got confused because it's all written as instruction. I have to look into that CERT training.
Xopher #12
I clicked on the link to your page and thought it was a little ironic to find this right away:
As you approach, you see
That it’s the bloody wound
Where my heart has been torn out.
What's the procedure for that?
I've passed out, oh, approximately 100% of the time I've given blood. I know it's coming, it doesn't concern me, but I always warn the nurse. I don't think it's the blood loss, though, because I also have passed out just having an IV run before surgery.
The doctor said at that point, that it's something like you're uptight about the needles, and you force yourself to relax, and overcompensate.
Nathan 14: Elevate the feet over the head. No, not mine, his.
[20 paragraphs of horrific information]...To treat for shock, get the patient lying down. A person in shock can’t control body temperature well, so wrap him in a blanket (under him as well as over him). Raise his feet twelve to eighteen inches. Provide oxygen if you have it. Establish two large-bore IVs in the best, most proximal veins you can find. Stay with him, hold his hand, talk to him.
James, this is the first post of yours that really upset me, in part due to its quite high danger to quite low potential assistance or response ratio. I'm not sure of what the value of spelling out this info when so few of us could have the tools to cope. It's not like your other amazing posts - this one is just a little too much like death-and-danger sadism to me. Maybe a little more on what to do?
Skip: passing out when you have blood drawn is not always a sign of shock. Bodies (and brains) vary. Some people get woozy at the sight of blood. It's an emotional response, and pretreating it by having them lie down wrapped in a blanket can help. I'm an oddity that passes out when I have blood drawn, and I'm quite calm if I'm bleeding from an accident. Someone *else* bleeding from an accident is likely to cause me to pass out. I don't do much first aid on wounds as a result. Not helpful to pass out while doing first aid. (hand me a cell phone, and let me call 911 with my head between my knees and the scene would stay much simpler for the EMTs)
Peter@17: Maybe a little more on what to do?
Don't underestimate the power of the dark side, er, I mean the simple treatment.
get them to lie down.
elevate their feet.
Really, that simple thing can make a fundamental, life-saving, difference.
The person I saw go down, the people were trying to help them sit up in their chair, while their lips had already gone grey. bad. bad. bad. Something as simple as pull them out of the chair, lie them down, lift their feet, can make a big difference.
I've only ever felt symptoms of shock when donating blood when I hadn't eaten for 7 hours beforehand -- or when I tried to climb 3+ flights of stairs immediately afterwards. I learned not to be stupid about blood loss from those experiences.
Otherwise I don't have any effects from it. I guess they preventively raise your feet and make you eat cookies and drink juice for a reason.
I did pass out once in college from something that was probably hypovolemic shock (they diagnosed me with a kidney infection afterwards, so it could've been infection or simply dehydration from kidneys not working right). It was very dramatic. I felt ill one morning when I woke up, headed to the bathroom expecting to throw up, rinse out my mouth, and feel better -- and collapsed unconscious in the hallway two steps outside my door.
In retrospect, no one called 911, including the girl who saw me fall while she was on the phone. She panicked, dropped the phone, and ran into her room screaming for her roommate to help her. Her roommate ran out and screamed my name (I was conscious enough to hear but not see or move by that point, so I remember that part), and then the guy down the hall came out, picked me up and carried me back into my room (I remember him asking the girls if I'd hit my head before he moved me). By then I'd fully come to, and when my roommate asked if she should call 911 I said no, I was fine. They shuttled me over to the student health center where I got IV fluids and a prescription for antibiotics.
Maybe I should send "Trauma and You" to the RD of that dorm for distribution to all residents, since now that I compare it to Mr. MacDonald's rundown, that reaction doesn't seem so useful (and I doubt I'd have done any better, had I been a witness instead of the patient). A college dorm seems like a place where you might run into this stuff more frequently -- people drink too much alcohol, people don't eat/sleep regularly enough, etc. Though it seems like it'd be good training for any office as well. We have mandatory online fire-safety modules; why not Trauma and You?
Skip @ #15 - how's your blood pressure? My sister passes out regularly because her blood pressure is too low; her doctor finally told her that if her lower number (systolic? Diastolic? I forget - whatever's on the other side of "over") is under 100 not to donate because she's more-or-less guaranteed to pass out.
IANAD, Take this comment with a grain of salt, and other appropriate acronyms and sayings.
I go shocky fairly easily without *physical* trauma. Part of it is wonky blood sugar, and part of it is the fact I've been working on turning my life upside down fairly seriously in the past 3 months. Class III symptoms in an instant, only without the fainting.
Caroline@21, that brings up a good point that I don't think Jim has mentioned. I learned it after a car accident in which I was passenger. The adrenaline had me pumped up, so I was doing jumping jacks by the side of the road when the EMTs arrived. They nearly fell over themselves running over to stop me. I got a firm lecture on internal bleeding and costal embolisms.
If you're the victim of trauma or any kind of problem that causes unconsciousness, *submit*. Even if you feel fine, there could be something wrong that hasn't presented itself yet. If they want to give you an IV or put you on a backboard, let them. Don't fight. If you lost consciousness briefly, go to the ER. Assume you're injured until someone knowledgeable checks you out.
Better to pay a few extra hundred dollars for quick medical care than to have the words, "...he seemed fine, until..." uttered at your funeral.
These entries are just plain awesome, Jim.
It makes that sexy EMT lifestyle seem so very tempting to me. It appeals to my interest and enthusiasm for working on things that are broken and sometimes fixing them.
Sadly, computers rarely exhibit arterial spray.
Sadly, computers rarely exhibit arterial spray.
...despite my best efforts. </tester>
Building water-cooled computers greatly increases the possibility.
Too many words...unpossible! More pictures! More pictures! We are simpletons!
Zak @27:
I've tested software on water-cooled computers, but never anything that would break one. Sadly. But then, I think they'd have taken me into indentured servitude to pay it off if I had.
Great post.
I had a PE. Really not fun.
I find it interesting that, just a couple of entries away from this on my LJ FList of syndications, Scientific American asks, "After a person's pulse and breathing stop, how much later does all cellular metabolism stop?"
Pretty morbid theme for the day, IMHO.
Regarding Nathan at # 8, yes, CERT is available nationwide in the USA, and I suspect that similar programs are available elsewhere. The content varies depending on where you are-- Californians will learn more about earthquakes, and Kansans will learn more about tornados. You learn about preparedness, disaster safety, first aid, triage, and basic search and rescue.
I took a class a while back, and it was excellent. And by the way, the little old ladies were capable of removing large men from a dangerous scene that could not be made safe. (Generally one should not move people around.) If you can get them on a blanket, you can drag even heavy people fairly easily. My 110 pound self dragged the 250 pound firefighter instructor across the classroom. Granted it was easier on a slick linoleum surface...
Rachel @ 32,
I was more or less just pointing out that the CERT teams are totally inclusive. Regardless of your abilities (physical or otherwise), they'll show you how you can be extremely useful in the absence of professionals. And yes, they do show you some awesome ways to improvise.
Jim,
Thanks for this - excellent as always. I really enjoy your trauma/first aid posts - always useful.
One very minor comment from someone who spends large parts of her life looking at stuff she's written and thinking "do I need to define that?" - "pulse in the wrist" and"radial pulse" have not been put together (I noticed 'cos you did define where the "femoral pulse" is).
Caroline, @ 21: In the UK, colleges/universities always have posters up about how to spot that your friend has meningitis and thereby save his/her life. Sounds like another one on "in an emergency, call 999/911/112, THEN: (use fire extinguisher, check the ABC, lay patient out flat and raise feet, etc., as appropriate)" would be useful.
I can't stress enough how much of a difference just staying calm, keeping them down and warm and TALKING to them can help an accident victim.
I was one of the first two people at a very nasty car VS tree accident. It was a rural road in the pre-cell phone days (1972, I think, based on who I was with and which car we were in).
We got out, took one look at the driver and my companion started making 'we have to get him out' noises. The next nearest house was at least five miles away.
I said 'Give me both beach towels. Now, get in the car and go call for help Right Now. Do NOT have an accident and leave me hanging out here with this guy and no help. Go.'
The driver was pretty well pinned and kind of sort of awake. Since he could respond to simple questions (name, any one else in the car, ect.) I took A&B for granted and started checking for C.
Oh, yeah. The worst visible damage was a wound to his thigh. So I folded one of the towels and got pressure going, and used the other hand to tuck the spare towel over his upper torso like a blanket. All of this, mind you, hitched up over the driver's side window opening with my feet about an inch off the ground. (I'm short. The door was folded beyond opening.)
The victim kept trying to either shove me away- well, I'm sure what I was doing hurt- or (and this is a quote) 'take a little nap'. I just kept talking, using his name constantly. I was focussed enough that I didn't hear the sirens until they were practically on top of us.
One of the EMTs told me I could come out of the car and I explained why I was keeping pressure on the leg. So they kicked a box under my feet (to my eternal gratitude) and came in the other window. By the way, even under the blanket, a windshield being taken out of the car is very loud and sort of scary.
Then while two of the crew took care of the guy in the car another checked ME for injuries (oh, look, I cut myself on the car frame) and shock. And he was very nice and understanding about me going all wobbly and didn't let me hit my head when I started to pass out.
Three days later I went to visit the victim at the hospital. The only part of the accident he remembered was me. And really, just my voice, and the way I kept telling him I was going to stay right there and asking what he described as 'goofy questions'. The ER staff apparently expected his wife to answer to Barbara because he kept asking where I was.
I don't make regular donations of blood anymore.
After a gallon of going into shock, I decided that (absent specific need) it was too much of a problem.
If the Red Cross had a ht/wt table, instead of a simple minimum weight, they'd refuse me (5'9" 116 lbs, today).
But twenty-thirty minutes of being pale, clammy and nauseated is more than I can do, every eight weeks.
Xopher: I don't know what they were thinking with the water/baking soda (perhaps to ease the nausea?), but presently the practice is nothing by mouth.
At an accident scene you can’t tell if your patient is in psychogenic shock because his new Beemer is now junk,
Or because their kid's lower face just had an encounter with the grill of an SUV and is a bloody mess.
Psychogenic shock is absolutely no fun. Things that generate psychogenic shock less so (absent the PCH showing up).
Blood loss trivia:
My dog is a blood donor. She gives 400ml every two months.
The vet who taps her mentioned something interesting. After a dog loses certain amount of blood, his spleen contracts sharply . . . probably a response evolved to prevent shock. She mentioned this sometimes makes donor dogs agitated partway into the donation. Presumably it feels really odd.
Terry 36: That was Lori responding to me, actually, but it's good to know. If someone after an accident said they were thirsty I'd've given them water, before reading this.
I don't know what they did when I had my stroke, but I assume it was something to get blood back to my brain. It was 1987 and I was already in the hospital with kidney failure and my blood pressure went up. The doctor ordered what any other doctor in that situation and time and up to about 1993 would have: nifedipine under the tongue*. It made my BP so low so fast that I didn't get enough blood and oxygen to my brain for a while. I was in a coma for six weeks and when I woke up, I couldn't remember names of people and things. That came back in about another six weeks and then I learned to read and walk and take care of myself again.
I'm partially paralyzed on my left side (when I get tired, stressed, or sicker than usual, my left hand doesn't work and my left foot drags), I have bad balance control, and I have dysphasia. In the last five years, I've been having what has recently been diagosed as brain seizures. They all have to do with words. I can't read, or have a marathon of not-remembering words, and once I couldn't speak coherently. We've been increasing phenobarbital to get to a functional level. Whenever I complain, the doctors remind me that everybody thought I would die from the kidney failure, much less the stroke, so I should cut it out.
So I assume I was in shock, but I don't remember a bit of it.
*In 1993, a study was done with matching patients and it showed that using nifedipine sublingually (to keep the patient from having a stroke) caused more strokes than using nothing. The patients that went untreated had fewer strokes.
This reminds me of a profoundly stupid moment after giving blood when I was in college. It seems to take me a few minutes longer than average to be able to stand up without being dizzy after giving blood. One of the volunteers was sort of hassling me, because there were a lot of people waiting, so I got up sooner than I should have and walked over to the juice table. Started getting really tunnel vision-y about 3/4 of the way there.
I sat down and as I put my head on the table I told the nice juice giver and the person I sat next to not to panic, so long as I could put my head down I'd be fine. And I was--fully conscious, just dizzy.
What came after was a bit of haggling with the juice giver and the volunteers who came running when they saw someone slumped at the juice table. They wanted me to stand up right then, walk around a bit to get some air, and they'd get me a cot to lie down on in a minute or two; even with minimal emergency training I could tell that was a bad idea, and argued from my folded-over position. (As a compromise I sat in a slouchy way that wouldn't freak out the people coming in but still kept my head low, while the volunteers waited on another cot to open up. By the time one had, I was fine to cross a room again. I'm more insistent about staying put, now.)
At my local Red Cross, I've seen them terminate a donation because someone started passing out. Perhaps things are different elsewhere.
My own body seems to treat the loss of 500 mL of blood as no big deal. Which is good when donating; I can imagine (after these posts, all too easily!) situations where it would have more of a downside.
Given that an adult has from four to six liters of blood, a donation of 475mL could be 8% to 12% of blood volume. 12% is getting close to that fuzzily-drawn line between Class I and Class II shock.
Alas, the American Red Cross no longer takes my blood, based on the amount of time I spent in Europe with Uncle Sam. I'd done gallons up to the time they changed their guidelines. If they've changed 'em back I haven't heard.
I used to be able to give blood no problem, but after nearly passing out each of the last three times, they asked me not to come back. The annoying thing is that I nearly manage to fill the bag, but they have to stop before I get there.
This is in the UK, where a pint is 568ml - very nearly an armful, as a wise man once said.
iain @ 44:
Having had it sucked out of my arm last Thursday, I can confirm that a UK unit is 470-475 ml, the same as a US unit...
Peter (17), I thought the point was that many things result in shock, but they're all treated pretty much the same way.
There's not a sadistic bone, ligament, or corpuscle in Jim's body.
Patch (28), I've looked at Jim's EMT textbook. You don't want to see the pictures. Trust me.
John,
That's interesting. I'd always heard it spoken of as a pint - as in the famous Hancock episode I quoted. I wonder whether that was always incorrect or whether there was a change at some point.
#7 Lori: The First Aid course *used* to recommend giving the victim water with baking soda (1/4 t baking soda to 8 oz water) if they were able to drink.
Trauma is only one of the possible causes of altered mental status (see the AVPU post).
Perhaps they were talking about hypovolemia from causes other than loss of blood? (Hemorrhagic shock is one of the sub-categories of hypovolemic shock.)
They might have been trying for an electrolyte solution (as mentioned in the flu pre-pack post here). (Y'all have set up your flu pre-packs, haven't you? Fall, and flu season, are coming.)
By the time you're actually in hypovolemic shock (from diarrhea or vomiting or sweating or urinating) you're still in major danger of vomiting and aspirating, and you're still in major danger of throwing your blood chemistry out of whack. For your patient in shock due to diarrhea, if you give oral fluids you'd have to be very careful, use small amounts, monitor the patient constantly, and probably be doing it in a hospital setting. In the field I'd still go with IV crystaloid.
"Blood chemistry out of whack" is really metabolic shock (a variety of distributive shock) which I didn't even mention above. The pH of blood is between 7.35 and 7.45. Outside of that range the oxygen doesn't hop on and off the hemoglobin. No oxygen to the cells = hypoperfusion = shock. Too much or too little potassium, calcium, or sodium in your bloodstream has other bad effects.
None of those will you likely see on a trauma scene (unless the trauma was caused by the patient going into shock and the altered mental status leading to an accident).
Up here "sody water" is a folk remedy. When I arrive on scene and hear that someone (particularly an elderly someone) is "feeling poorly" and "took some sody," my first thought is "myocardial infarction."
There isn't a darned thing that you can do about metabolic shock in the field other than keep the patient warm, elevate his feet, give oxygen, and replace fluid.
Low blood pressure means not enough blood to the brain means add fluid to get enough blood to the brain. The way to do this is first by the foot-raise, next intravenously: giving fluids by mouth has too great a risk of losing the airway and/or making the shock worse.
Of course, if the cause of the altered mental status is diabetic shock (a variety of metabolic shock) then you'd give sugar by mouth if the patient can still guard his airway. (On an accident scene with altered mental status I routinely test my patient with a glucometer after I've dealt with the more immediate life-threats.) I have found patients with hypoglycemia that way. Even so, particularly if my patient will be going into surgery soon (Golden Hour and all that), I'll correct the blood sugar problem with IV dextrose rather than oral glucose. Vomiting and aspirating are that major a concern.
(Aspirating, in case it isn't clear from context here, is sucking vomitus into the lungs. On a scale from good to bad, this is bad.)
Airway, airway, airway. If you don't have an airway you don't have anything.
So: Trauma = NPO. (That's the abbreviation for Nil Per Os, Latin, nothing through the mouth.)
Jim @48: Ok -- nothing by mouth.
My 1st First Aid course would have been 1966-67.
The "baking soda/water" step was not in the text book when I took the course in college in 1974.
When Jan took the "First Responder" course in 2001, I was able to walk her through some things because they hadn't changed.
I blush to admit that the last CPR course I took (198?) still had 'pre-cordial thump' (or as my Mom the RN termed it "jump start") as one of the steps to restart the heart. Considering my classmates' versions of this, I was praying that none of these folk would ever find me if I had a heart attack.
I have got to find the time and money to get recertified...
Maybe being fat can be an advantage for giving blood - higher blood volume, maybe? I've gotten dizzy after giving blood, but never anxious and I never passed out.
For that matter, I've never passed out at all from anything.
I didn't really understand the point about not giving an accident victim water. When Leslie's car was totaled in January, she had bumps and bruises (and, it turned out, a broken wrist), but was kept on a back board for over two hours and not allowed to drink anything. That puzzled me - the ER was pretty sure she wasn't seriously hurt (they left her alone for a long time), but still wouldn't give her a bottle of water?
If you need surgery, you can't have anything in your stomach - it can affect the anaesthetic. They may have left her for a while just to make sure that her condition wasn't going to deteriorate.
Laurie D. T. Mann @50:
If I read Jim correctly the reason for no water is:
Shock = Nausea, which can lead to vomiting, which can lead to aspiration of vomitus (i.e., the stuff comes up, then goes down the wrong pipe into the lungs). Not good.
So nothing by mouth, hydration is maintained by IV.
Jakob/Lori - I meant to say,
"Until I read Jim's piece on shock, I didn't understand..."
Oh well.
Amazing post and amazing, rich and diverse comment thread. Sometimes I feel everything I know, I learned at Making Light. Where else would I possibly learn about spleen shrinkage in donor dogs [Stefan (38)]?
Newsweek is running an article entitled Back from the Dead about new protocols for dealing with loss of oxygen to the brain -- it seems that it's not so much the oxygen going away that kills you as its restoration, and that cooling the body down helps, but no one knows why.
I hate when something like this happens:
You've got a person going in for what's supposed to be a laparoscopic cholecystecomy (removal of the gall bladder via a small incision visualized with a scope, which is preferred because it's less traumatic than an open procedure, where you make the big incision and lay it all out to look at).
So your person is under general anesthesia, and you've got your two surgeons, your anesthesiologist, your OR nurses. Everything is going well except at some mysterious point, a different movie gets spliced in. But nobody quite notices.
What's happened is that the lead surgeon has accidentally nicked the mesoenteric artery, and the patient is quietly bleeding out. The blood is pooling, unseen, in the abdominal cavity.
A few members of the team grow uncomfortable. Someone asks the anesthesiologist if everything's okay. He says, of course. A nurse mentions that the patient's hand seems awfully cold. The surgeon suggests that she get a warming towel for the patient's hand.
Now, having to convert a laparscopic procedure to an open procedure is not uncommon. What is uncommon is when no one recognizes the need, or doubts their own instincts because they don't want to upset the surgeons.
Finally, the hypovolemic shock causes the patient's heart to stop. Much rushing around ensues, including the desperate attempts of an on-duty ER doc to save the patient's life. But the patient is dead, and eventually the surgeons go out to the waiting room and regret to inform the waiting relatives that there was an unfortunate massive heart attack, which the patient didn't survive.
There were so many opportunities (granted, within a short period of time) to have turned this around. The anesthesiologist and the surgeons seemed to have been in different states of consciousness, and the support staff kind of froze. For all practical purposes, the patient died after a knife attack.
But once you piece together the medical records, it's totally a text-book case of hypovolemic shock.
Larkspur...jolly. And I'll try not to keep that in mind when I go under the knife for surgery in the next week or so... *sigh* Oh well, at least my papers are in order. (It shouldn't be a huge deal, it's for ovarian cysts, and I had a similar surgery about 30 years ago.)
speaking of changes in training, I saw something in the news that some study found that chest compressions alone, without breaths, was statistically as good as with breaths. Don't know if the training will change to follow that, but it was odd to see that.
I've given blood once, but I only filled part of a bag, which the staff said wasn't enough to be useful. It was a little embarrassing, really; I left feeling it was my fault somehow, though they didn't give me any clue about what I could have done about it.
Since then, I've had kidney stones, which led to an emergency visit, an overnight stay, and a few X-rays. These latter involved putting an x-ray opaque dye into me via a canula. On each occasion the staff had a bit of trouble getting the canula into my veins; on one occasion they stuck that damn needle into me four times before they got it. So I guess I just got thin veins in my arms. Maybe I ought to suggest a leg next time (if it happens again, touch wood).
Hmmm...the first time I broke an arm (wiping out on my bike), I got pretty shock-y - dizzy, tunnel vision, pale etc. The nurse at the hospital insisted I lie down, commenting that, 'You look about as pale as your friend there.' (I'm of South Asian descent, and he has blue eyes and is approximately the colour of a sheet of paper - I always seem to get the funny nurses).
I can't imagine that I was bleeding enough around the fracture site for this to be hypovolemic shock. Is going into shock as a result of a bad injury just a special case of psychogenic shock? I kind of thought it was more physiological than that.
Debcha: Broken bone = bleeding, lots. You went into shock, like people normally do when they break a bone (even a tiny one).
The bruising from when I broke a finger bone covered around 50% of my hand's surface (the swelling immediately after was... impressive). That was for a single simple fracture, on one of the smallest bones in my body. I'd presume an arm would have similar levels of bruising, but it would get covered by the cast for a simple break. Ditto the swelling.
You can actually bleed out and die from a mistreated broken bone that doesn't break the skin. This is why first aid manuals are so emphatic on correct treatment. The other half of why is it's *easy* to muck up a broken bone and break the skin, and that's just all kinds of fun to treat. I have no idea how much you'd bleed after that, and I don't want to find out either.
Peter @17: I've never had first aid training, yet I've read the phrase "treat the patient for shock" at least a hundred times. It's repeated in every first aid procedure, like a mantra. And the treatment is simple and easy to describe.
But the books I've read (e.g. The Boy Scout Handbook, long ago) never really said why. If they did, they didn't make it stick. (And now I know why they didn't - thinking too hard about the implications of shock is enough to send some people into shock.)
Unfortunately, if you don't know the nature, and the consequences, and the stages of shock, the textbook advice "always treat for shock" can become a boring stock phrase, like "wear sunblock to prevent skin cancer" and "eat five servings of vegetables" and "always wear your seatbelt". Once again, Jim has comprehensively solved the boredom problem.
JDM@43: the rules have definitely changed; e.g., a year or so ago they stopped asking for total time in the U.K. since 198x, instead asking for time between 198x and 1996(?). I'm reasonably sure the rules for Europe as a whole also changed (didn't pay much attention since I've spent 26 days on the continent in the last 42 years), but don't ask me how much; and I was tracking the rules for other parts of the world even less. It would be worthwhile asking IFF it doesn't interfere with your life, rescue work, etc. -- there are a lot more potential donors than qualified emergency providers. (They also changed the donations/yr from 5 to 6 when I wasn't paying attention, and now they say it was always 6. "Boston" center (now in Dedham) is losing its history -- they have only one person left who remembers when they had a major downtown operation.)
Greg@58: the Newsweek article mentioned above you talks about ~100/minute compression-only "CPR" as effective -- not to mention more likely to be administered, as people are more and more shy about mouth-to-mouth with someone they don't know. Obviously that's not a medical-class reference, but I'd hope they'd take \some/ care in what they put in a technical article.
Reading debcha @ #60, I'm reminded that I've been wondering if shock caused by pain is psychogenic. I'm thinking specifically of conditions where the cause of the pain isn't trauma and won't kill the patient (ie, menstrual cramps.) Or does this class of shock belong to a different category?
As always, great post.
I recently had to go to the hospital via a rig because I couldn't get myself to wake up much and was getting increasingly sweaty, dizzy and I suppose anxious (not sure if that's what I'd call it-I sure knew something was up and I was able to check my glucose which was ok). It turned out that my BP as very, very low and I was very, very dehydrated with an infection I was unaware of. I felt so stupid calling 911 (at my docs insistence) but in retrospect it was the right thing.
I do have a sort of related question. I'm on Cape Cod for the summer and one of our favorite beach areas had an accident recently where a young man dove into water too shallow and was stunned and then felt some paralysis. Folks who happened to be at the scene immobilized him in the water and wouldn't let anyone move him until the paramedics came and apparently they did the right thing. I'm not sure of the outcome, the injury was pretty serious. Wouldn't the water add to his problems? I was just curious.
I will say that as a result of your past writings when I bike, hike, canoe etc with the kids this summer I bring more emergency stuff than I use to. It's stood me in good stead when minor injury occurs and when my glucose suddenly crashes. I like dealing with stuff BEFORE it's an issue I need to bother a professional with!
Jim, #48, I've known people with diabetic children to keep frosting in a tube with them because a squeeze of it under the tongue is absorbed by the mucus membranes.
Laurie #57 - You'll be fine. The laparoscopic disaster I described was pretty egregious. Weird shit can happen in complicated stuff like surgery. The bizarre and tragic thing is that everyone in that particular OR was asleep at the wheel. I'm permanently astonished that none of the personnel raised an alarm. They're supposed to have each other's backs, you know? I'm afraid that several of the OR folks probably still have nightmares about that day.
Although I swear, if I ever need surgery I'm gonna quiz them all before they put me under: I'll put them through a field sobriety test, I'll ask them what type of surgery they think they're about to do, I'll make them tell me exactly where they intend to cut, I'll make them show me the chart to make sure it's my name, and damn, I'll ask the anesthesiologist to make totally sure that the tubes are connected to the correct gas dispenser thingies, and that all the meds are the right strength.... Jeebus, they'll probably knock me out as soon as they can just to shut me up. (But I'll have penned instructions and dire warnings near the surgical site.)
My blood donation days are over; my blood these days is an evil concoction of drugs that nobody wants second-hand. Back in the day, though, I found out the hard way that the Red Cross blood techs around here will terminate a donation if they see a problem. One time I got a little over-enthusiastic on pumping the blood out, going about half again as fast as I should have, and about half-way in I started to get really dizzy and my sight went into tunnel-vision. One of the techs walked by just as I started to sag back into the cot, turned off the valve to the bag, and made me stop and rest. It took a few minutes to convince everybody that I'd just been a little too gung-ho, but I did get a few extra cookies out of it.
larkspur @ 56
What is uncommon is when no one recognizes the need, or doubts their own instincts because they don't want to upset the surgeons.
This is a classic case of the kind of group dynamic that can cause planes to crash or no one to call 911. There's a group with a hierarchy in which the leader is focused on the task at hand, and none of the others in the group has enough confidence in their own judgment relative to the leader's to insist that there may be a problem outside the parameters of that task. I've read one case study of a commercial airliner that ran out of fuel short of landing because they were in a holding pattern waiting for other traffic to land and the pilot was busy keeping out of the way of other planes in the holding pattern. The copilot and engineer were too diffident to interrupt him with the news that the gauges read empty. In the investigation afterwards, the copilot said that he thought the pilot was aware of the situation and would deal with it.
There are training programs to teach flight crews to recognize and prevent this sort of situation; there probably should be such programs for surgical teams as well. I spent a few years running the instrumentation in a medical school surgical lab, and my experience is that the doctor / resident / intern /nurse hierarchy is ideally suited to creating these sorts of problems.
#66 ...a squeeze of it under the tongue is absorbed by the mucus membranes.
You can also go PR (per rectum -- a mucous membrane is a mucous membrane) with glucose. I'm still not going to fool around with possibly compromising the patient's airway, or ticking off the surgeon. On a trauma scene I already have a couple of large-bore IVs going anyway.
CHip@63: I started donating blood regularly (i.e., as often as possible, as opposed to once a year or so) in early 2002. Minimum spacing then as now was eight weeks...which translates to six donations in a year.
larkspur - And I know my doctor is extraordinarily cautious, so I expect that means she'd be really careful in surgery, too.
Giving blood -- oh yes, I know that fun, fun combination of hypovolemic and psychogenic shock well. And under relatively silly circumstances too: I was doing your basic blood-typing Bio lab, and had to use the finger-punching thing on myself to get the blood. Well, at the time, I was severely phobic of needles (less so now), and I kept jerking away.
I finally managed to break the skin, but couldn't get enough blood out. The professor running the lab was ever-so-helpful, and squeezed my arm to get the blood going to my hand. I got enough blood in the pipette, and about thirty seconds later I started feeling really clammy and nauseated. As my vision tunneled out, I wobbled over to the man and tugged weakly on his sleeve. He realized immediately what was going on, walked me out into the hall and sat me down on a chair with my head between my legs.
Renee @ #64: I've been wondering if shock caused by pain is psychogenic. [...] (ie, menstrual cramps.)
You know, it never occured to me until now that getting pale, weak, cold, and sweaty when I'm in a lot of pain is shock. Huh.
Amysue @65:
Actually, keeping the victim in the water was the best thing they could have done. Attempting to remove him from the water (if they had no backboard available) might have severed the spinal cord if he had any cervical fractures.
If he had a concussion rather than a cervical fracture, moving him might have induced vomiting leading to aspiration, which is bad too...
A dive into shallow waters almost always results in a concussion or cervical fracture (or both), so immobilizing the patient immediately is likely to produce the best outcome.
I've been lurking around here for a while, and I am really enjoying this topic/discussion. I just wanted to point out to Kate@74 (and other commenters) that severe pain will indeed cause shock. For many people that will be mostly psychogenic shock, but sudden severe pain can cause a drop in blood pressure which then mimics hypovolemic shock. Since you haven't actually lost blood, you can recover from that. This is, of course, not the same thing as severe trauma with blood loss causing hypovolemic shock.
Hypoglycemia (or low blood glucose) will cause weakness, nausea and light-headedness, which can be perceived as shock, but it is just similar to the sensations that occur with shock.
Just so you know that I have some experience with this topic, I am a veterinarian. Animals have the same signs (but no symptoms) for the same reasons, so we have a lot of overlap -- it's just a little harder to communicate with a non-human species. ;-)
My father was an EMT in my home town, as well, and I read his training manuals when I was a kid. I've also experienced the symptoms of shock following blood donation, minor surgery, and dehydration (not all at the same time).
Lori @ 75
One of my professors did that as a teenager. He said that he knew something was wrong almost immediately. Ended up spending a year in the San Diego naval hospital, what with rehab and learning to deal with only partial use of his hands and arms - but most of the stuff they told him he'd never be able to do, he does.
(He wrote a book on Ada the language, just to connect another thread.)
larkspur @67
Re 'Although I swear, if I ever need surgery..'
I second that. I'm a (newly qualified) vet, which involves doing a damn sight more surgery that doctors of a similiar age.*
Since graduating I have given some thought to the criteria of choosing my own surgeon. I'd want at least five years' experience in the procedure, sobriety test, written diagrams, possibly 'THIS LIMB HERE' tattoos in red ink in the case of amputations. Surgeons are people too, and people do some pretty damn stupid things. Especially if they're short-staffed, or tired, or hungover, or stressed out, or...
And, for the record, the sight of excessive blood pooling up in an op site is a really nasty feeling.
*Removed 75cm of small intestine from a dog on Monday, solo. He's doing well.
Kate @ 78
Then there's the sinking feeling when you're newly qualified (first couple of weeks!) and doing "routine" surgery like a cat spay and you've been promised there's an experienced veterinarian in the next room in case you need an assist for anything and your fourth ligature still hasn't stopped the bleeding from the ovarian stump and you can't see where it's coming from exactly (due to the blood) and the "vet in the next room" turns out to have gone off to get lunch...
Well done on the gut resection.
P J Evans @77:
I've heard that several times in these types of accidents; the victims who remain concious are immediately aware there's a proglem. I think Christopher Reeve said the same thing about the riding accident (similar injury).
Glad to hear that he made a pretty good recovery.
Kate @ #78: when I had my breast biopsy (benign, thank God) they gave me temporary tattoos reading "YES" and "NO" to put onto the correct and incorrect breasts respectively before they put me under.
Kate @ #78 & Lila @ #81: JCAHO* issued a Universal Protocol to prevent wrong site, wrong procedure, wrong person events. The hospital where I work (I'm completely non-clinical), the patients are supposed to mark on themselves where the surgery is going to happen, if possible/reasonable.
They have a patient info blurb here.
The last surgery I had, the doctor and I chatted while he doodled all over the spots where he was going to cut. We were confirming what was going to happen, and why. About 10 minutes later the drugs were administered and I was out like a light.
But, even knowing all that, I'm right with you. I'd be using the markers that don't come off with soap/alcohol/betadine to write "YES" and "NO" where appropriate.
*Joint Commission on Accreditation of Healthcare Organizations
Terry @ 36:
Have you considered apheresis? You don't lose nearly as much blood volume for the simple reason that the vampires put most of it back. It also takes a couple of hours, so you need to make sure that you've got the time available. Basically, they take your blood, centrifuge it to remove certain fractions (I've always donated platelets), and put the rest back. Much easier on the donor, and you can donate every two weeks. Also, at our local donor center, they have video monitors that you can watch a movie on. The last time I looked they were still using VHS players, but they may have upgraded since then.
Okay, they'll probably want you to donate whole blood first and then wait the requisite 8 weeks. Making sure you've eaten not too long ago, and drunk sufficient fluids before donation helps.
I'm prone to low blood pressure (been bounced at least once for that), but the only time I really felt sick after donating: I a) was in the middle of my period, b) Had eaten only one package of ramen soup with some added protein, and c) IIRC, had gotten a hepatitis B vaccine the day before (recently at any rate). They probably should have bounced me for the vaccine, and I made a point of asking about it. I wound up in a back room with an emesis basin. Other than that, I think I felt a bit woozy after the first time I donated, but I may also have been unduly paranoid about potential ill effect.
Amysue @ 65: I assume that the beach is on the Bay Side of Cape Cod. I'd get the patient out of the water fast on the Ocean Side. Ocean Side beaches routinely have breakers coming in that I think would aggravate any spinal injuries. Bay Side beaches are much calmer, and it makes sense to stabilize the patient in the water under those circumstances.
Last week, my husband had some minor surgery - it was done in the hospital on an outpatient basis, but with general anesthesia. When he first went into the prep room, the nurse came in and asked "so what are we doing on you today?" and wouldn't do anything until my husband identified what was being done and to which side of his body. Obviously the medical record did say, but he wanted un-prompted confirmation of the details. When the anesthetist and then the surgeon came in (separately) later, they again asked him to state what was being done before doing anything else. And then the surgeon marked the site before any medications were given, so again my husband could agree that that was the right place.
It all went well, and he's healing fine.
Minor apheresis notes:
* You still have to be eligible to give whole blood, in case something goes wrong and they can't give you the rest back.
* If you give platelets, you'll probably have needles in both arms (they can do it single-arm, but it takes longer and I believe is otherwise suboptimal).
* A citrate anticoagulant is used which pulls calcium out of the blood, so drink a milkshake ahead of time and don't be afraid to ask for Tums if you start feeling tingly or numb. And if you start feeling *really* tingly and nauseous, congratulations, you and I are the very rare people who are sensitive as hell to the stuff, and it's probably whole blood or nothing for us.
Surgical site location is handled with care these days, as several examples above show. But it was not always thus. In the late '80s I went in to have some varicose veins stripped from the back of my right leg. At the time of admission, and when I was being prepped, and mind you this was in a good hospital, with a really conscientious staff, I had to argue with the nurse that despite what the paperwork said, I did not want my left leg operated on. Everyone got a good laugh out of it, largely because it would probably have been a self-correcting problem, since it's easy to see a varicose vein before opening the patient up. But the nurses and the surgeon were a little uncomfortable when I said I was glad it wasn't an amputation.
dcb @ 79: I'm starting to get flashbacks even as we speak. Was it a flank cat spay? You just can't se anything on those. My sympathies.
Dog's still doing well:, but this is off-topic enough...
Kate @ 85: I have lousy veins. They always ran the platelet donation on the one-arm machine because they simply couldn't get a decent stick in my right arm. Then I got bounced for medical in 1996. Between then and the time they decided they could reinstate me as a donor because they have better tests now, they added the Mad Cow disqualification to the pre-screening. Guess who spent approximately 3.5 months in the UK in 1980-81. Yep, so I still can't donate. Meh.
A citrate anticoagulant is used which pulls calcium out of the blood, so drink a milkshake ahead of time and don't be afraid to ask for Tums if you start feeling tingly or numb.
Oh, is that why they keep the Tums handy? I knew it had something to do with the anticoagulant, but I didn't know anything about the mechanism. The worst it ever did to me was make me feel slightly chilled, and that only the first time I did it. I think I took ONE Tums.
Slightly OT: Kitty triage.
David@71: 8-week spacing translates to \more/ than 6 times in some calendar years; it's not clear to me they now allow this. They certainly used to cap it at 5/yr -- but I've been giving regularly since 1971 (missing a few times, so I'm at only 19 gallons now); for all I know it was changed many years ago and I didn't notice.
I can't donate, but I did get 11 tubes of blood drawn today. My record is 16.
Thanks, Jim, for the Trauma write-up. Having something as simple, thorough, and practical as that would've been a great comfort when I was an Army Combat/Aid-Station Medic (in Korea, c. 1952). When Drafted, I was assigned to a Medical Company mostly of the basis of having had a year's course in Anatomy & Physiology in Highschool -- but it wasn't a _practical_ course. The Army's training was overwhelmingly oriented towards making me into a Soldier (which certainly failed, utterly) and it's pure luck that I didn't have to deal, unaided, with any serious trauma cases, so I didn't kill anyone unintentionally. When On The Line, there's no 911 to call.
As I understand it (& hope), modern Service Medics have much better training, and at least they have access to ParaMedic Training Manuals (& distillations like yours here) that are vastly better than anything available a half-century ago.
Jim,
I also really like what you're doing on these discussions. I've had a CPR course, but seeing the why makes it a lot easier for me to remember what to do. And going back and reading your earlier writeup about cardiac stuff motivated me to go to my doctor about those probably-indigestion chest pains. (Apparently they are probably indigestion, after an EKG and some poking and prodding, but this isn't a great thing to ignore.)
Kate @87 [Apologies for the delay in replying - been busy and not keeping up reading all the threads]. Yes, flank spay - the only cat spay I had trouble with, during my short time in small animal practice. I did finally get a ligature on which stopped the bleeding - my so-called backup walking in a few minutes later and commented, on hearing - well, you didn't need me, did you? Grr. Okay, the cat was fine, but my nerves were not.
Glad to hear the dog's okay.
Kate #74
It's possible that you're going into shock from pain (Lord knows, people do). It's also possible that you're experiencing an adrenaline (fight or flight) reaction, which is what causes those same signs and symptoms in shock.
In either case, wrapping up in a blanket and lying down with your feet elevated won't hurt and might help, so might as well do it.
Interesting stuff, as always. It explains a lot about something that I intellectually know and yet still get surprised about--I have food allergies, and I've been taken ahead of a gunshot wound for a severe allergic reaction at the ER.
Thanks, Jim!
I am sure I've mentioned before that your series has given me a lot to think about (including getting off my bottom and finding a first aid class). I was pleased to see that your words did stick - I read this today and knew what he meant:
"maybe I can move from A to B"
http://traumaqueen.blogspot.com/2007/08/you-are-no3.html
i got a case am looking at, preparing for a discussion, and my patient is a 22 year old man who was driving drunk and without his seatbelt fastened, when he was involved in a single-vehicle automobile accident, whne attended to by EMT techniian personnel, no information wa available aboutthe time of accident, he was found agitated and complaining of abdominal pain.his airway was patent, at the scene, he was breathing at 20 per minute, with B.P of 90/60,pulse of 130. he was placed ina hard cervical colar and on a back board and transported to emergency room. upon arrival, his vital signs are the same, witha temperature of 36degees celcius. his abdomenis markedly distended, his hands and feet are cold, his legs mottled. a nasogastric tube reveals a green liquid. a urinary catheter reveals dark yeallo urine, his hemoglobin is 7, his abdodminal lavage reveals gross blood.
which kindof shock does this patient exhibit?
i am thinking, first alcohol could possibly have an effect on the patient's heart beat and blood pressure, since its a vasodilator. could have abdominal pains as a result of damae caused to important organs9liver, spleen, kidney...) as a result of no seat belt.and also, in relation to thier anatomical location, usu most probable organ to be damaged is the spleen,and he's got primary signs of shock( pulse rate, breathing, B.P)hes got internal bleeding too( from abdominal lavage)the dark concetrated urine revealed by the catheter could indicate kidney function problems, even water-salt balance as a result of compensatory mechanism by the body...
is it possible to have "traumatic shock"?
am thinking we could have : traumatic shock, neurogenic shock, anemic shock( loss of blodd through internal bleeding), infection shock is probable too(how??)
please correct me where am wrong. is this in the right direction?
Rose @ 97, 98: Think hypovolemic shock, from blood loss -- it's not just loss of RBCs but also blood volume, so the BP drops. (Blood pressure can also drop secondary to pain, but that's not the primary cause in this patient.) This patient is bleeding out into his abdomen and is extremely unstable. Scoop and run, with direct admission to the OR is the best way to go. On the way, you need to place two large-bore catheters and start replacing the blood volumes with fluids -- the exact treatment will depend on your local ED's current SOPs, as there is currently some controversy over the "right" method of treatment.
Your post saved my girlfriends life today.
Specifically the part that reads "Your patient will complain of being thirsty. Don’t give him water. He’ll just vomit it up, because when he started going into shock one of the first systems to shut down was the digestive system. That gives you the added problems of ruining his blood pH by dumping stomach acid, and compromising his airway from aspirating the vomitus. Besides, who wants to get puked on?"
After several weeks of gradual blood loss through menorrhagia, a common occurrence which none of her doctors can explain, her rate of blood loss accelerated in single 24 hour period. We had been there before, fluids+electrolytes/iron/b-vit --the bleeding stops and she starts to improve. And for the first few hours that evening it was working, the bleeding slowed she felt better, although tired. But the next morning she woke with nausea, and after 3 weeks of this we were both worried and started to talk about going to. While she was in the bathroom throwing up, I was reading the first few paragraphs of this post, and I told her that we had to go immediately. But she felt better after vomiting and lay back down, so I checked her pulse, which was hard to find- again over 100 -, mildly cold and slightly damp skin, there was no capillary response in her fingers because there was no visible blood there, and noticed her pupils were dilated... I got her into the car in less than a minute and sped off to the hospital. We were there in fewer than 10 minutes.
Had I had time to read further I would have insisted she lay down in the back at the very least, or more intelligently, called and waited for an ambulance. But she was seated upright and as it happened, she started shaking half-way there and more violently as I wheeled her into the emergency room. She was barely able to breathe, no color in her skin, incoherent speech and went right into the ER...where things got worse before they got better.
Over 12 hours and 4 pints of blood later, she has her mental faculties back, her skin color, and most importantly to me, she is alive.
Thank you for this post.
Many many thanks
DSP, what a truly frightening experience that must have been. Thank goodness you read this post in the nick of time, and thank goodness JMD wrote it.
I hope the doctors find out what's behind your girlfriend's menorrhagia soon.
if the lower abdoman is bleeding internally and is in early stage of shock what pre hospital care is the patient
A} Semi Fowler's and direct pressure over injury
B} Oxygen therapy and rapid transport to hospital
C} "Shock" position administration of water by mouth
D} Oxygen therapy and warm packs to the abdoman
Greatly delayed answer to Crystal (hope it wasn't for a homework assignment):
B: High volume oxygen and transport.
At the Basic level, "High volume oxygen and transport" is the right answer to nearly every question.
That's also the only answer which makes any sense.
A -- for abdominal bleeding, you don't necessarily know where the injury is, so you can't put direct pressure on it.
C-- administer water by mouth to a shocky patient with internal bleeding? I think not.
D -- warm packs to the abdomen make no sense at all.
DSP, it's taken far too long to notice your comment. You're welcome. My god, are you welcome. And you've made Jim Macdonald very happy.
I've had a chance to try out a Hartwell Emergency Isothermal Blanket, and boy-howdy does it work as advertised.
If you're in a situation where carrying a disposable blanket makes sense, think about this one. Field tested by me.
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