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View Full Version : Strangling, Swelling, Intubation, and a Broken Nose



thethinker42
01-10-2010, 10:32 AM
I'm still working on giving one of my characters a really, really bad day, so...here goes. Of course I'm doing some legwork on Google and at the library, but figured I'd throw it out here.

Here's how much I've thrown his way so far:
1. His nose is broken. Not severely, but it's bleeding like a mofo.
2. He's been nearly strangled using a metal bar, and now the soft tissue is swelling because it's not too happy about this circumstance.
3. He's got a wicked concussion (knocked him cold, now he's come around, but he's still disoriented)

So now the medics are there, he can barely breathe (getting worse), but there's a possibility of a neck injury.

Would the medics intubate him? If he's still conscious or semi-conscious? Are EMTs or paramedics able to moderately sedate someone for something like this? (Yeah, I'm clueless, I know...)

I've found some conflicting info so far, everything from "it's virtually impossibly to put an endotracheal tube in a conscious patient without causing more problems" to a doctor who intubated himself just to see if it could be done (and he succeeded). So I'm just not sure how this would work in an emergency situation, what would be believable, etc.

Any thoughts? Experience? "Why the fuck do you do this to yourself?"

Thanks in advance.

jclarkdawe
01-10-2010, 04:31 PM
Most people have a gag reflex. Some people do not or have learned how to suppress it. Sword swallowers are an example.

Conscious patient with a working airway? Most I'd think of trying would be a nose hose (a tube that goes down the nose) that many conscious patients will tolerate (not happily). But unless the risks of losing any airway during transport are very high, I'd probably dump it on the ER. They have the drugs to make this happen.

Remember that once the person loses his/her airway, then consciousness is going to go soon anyway. I'd have everything prepared, but probably wait.

Possibility of a neck injury makes this even more unlikely.

Best of luck,

Jim Clark-Dawe

thethinker42
01-10-2010, 04:38 PM
The only problem with the tube through the nose is the broken nose. I'm not sure how well that would work.

jclarkdawe
01-10-2010, 05:10 PM
It probably would give new meaning to the word pain. Nose hose isn't an exciting choice, but I'm going to guess there's nothing solid that would be obstructing it. But most likely, I'd just wait.

For some reason, even without a broken nose, people don't like nose hoses. Just can't understand why. It's for their own good, after all.

Best of luck,

Jim Clark-Dawe

thethinker42
01-10-2010, 05:15 PM
Hahaha, well yeah, he's going to be in a hell of a lot of pain anyway, so I don't expect this to add any measure of pleasantness to the experienced. He's not going to like me by the time that chapter is over.

Thanks for the info.

ColoradoGuy
01-11-2010, 03:16 AM
First, an awake intubation is difficult to do unless you numb the back of the throat with anesthetic spray.

More generally, your scenario is actually a quite complicated one from a management perspective. As a general rule, if someone has progressive neck swelling that could compress the airway we intubate sooner rather that later, because if the swelling becomes severe it may be impossible to get the endotracheal tube into the trachea. If that happens, a full tracheostomy or at least sticking a needle into the trachea from the outside to buy time, is needed.

So a lot depends on the details. If the paramedics think your character has impending closure of his airway from progressinve neck swelling, they will intubate him, probably with drugs to sedate and paralyze him first. BUT -- this can also be very risky if they give the drugs and are then are unable to get the tube in. It can be a very tricky decision to make and can result in a feared, nightmare scenario -- "cannot intubate, cannot ventilate."

Bottom line -- you've picked a scenario that is a tough one to give you a simple answer.

(I do this sort of thing as my day job)

thethinker42
01-11-2010, 04:26 AM
Bottom line -- you've picked a scenario that is a tough one to give you a simple answer.

(I do this sort of thing as my day job)

Yeah, I figured it was pretty complicated. The upshot is, I don't have to run through every thought, factor, scenario, etc., in the scene, because it's in the POV of my not-quite-with-it victim.

So with that in mind, what I mostly want to know is this: If I had the medics drug him and intubate him, would someone "in the know" reading my book throw it down and exclaim "that wouldn't happen, you idiot!"

jclarkdawe
01-11-2010, 08:05 AM
So with that in mind, what I mostly want to know is this: If I had the medics drug him and intubate him, would someone "in the know" reading my book throw it down and exclaim "that wouldn't happen, you idiot!"

If they do, it's because their protocols don't allow it, not because it's not reasonable. Each medical control issues protocols as to what emergency workers can and cannot do. These vary within a state, never mind from state to state.

For example, the hospital I used to deal with has changed its protocols so that an auto accident victim who's up and walking and not complaining of back pain, but has other injuries, doesn't need a neck brace and backboard. The hospital to the south of us says backboard all auto accident victims.

Anybody who's been in this business for a while knows that local practices vary. A lot. Equipment, drug lists, and training requirements vary. One of the factors in this scenario is transport time. Can you wait until you can get to the hospital? That's going to be the ultimate question. If you can't, you do what you can. If you can get there, then probably you wait. But it's all a judgment call.

Best of luck,

Jim Clark-Dawe

thethinker42
01-11-2010, 08:08 AM
Anybody who's been in this business for a while knows that local practices vary. A lot. Equipment, drug lists, and training requirements vary. One of the factors in this scenario is transport time. Can you wait until you can get to the hospital? That's going to be the ultimate question. If you can't, you do what you can. If you can get there, then probably you wait. But it's all a judgment call.

Fair enough. Just wanted to make sure it was within the realms of possibility...not something that would get a medic in deep shit for even attempting, that kind of thing.

Good to know. Thanks for the info! :)

ColoradoGuy
01-11-2010, 09:41 AM
So with that in mind, what I mostly want to know is this: If I had the medics drug him and intubate him, would someone "in the know" reading my book throw it down and exclaim "that wouldn't happen, you idiot!"
No, that is a reasonable thing to do, especially if the character had increasing signs of breathing troubles -- difficulty getting air in, often manifested by what is called stridor, the high pitched sound of air sucking in under high velocity. You also may see retractions -- the upper chest wall moving inward rather than outward with each respiratory effort.

Tsu Dho Nimh
01-11-2010, 09:07 PM
Emergency care steps = ABC (airway, bleeding, circulation)

1. His nose is broken. Not severely, but it's bleeding like a mofo. This has to be stopped, probably with direct pressure to the nostrils. Just squeeze. And it's gonna hurt.

2. He's been nearly strangled using a metal bar, and now the soft tissue is swelling because it's not too happy about this circumstance. This is the one that can kill him, so the breathing would be monitored closely.

Our protocol would be to give O2 at high volume through a mask, to make up for the impaired breathing. With a broken nose, mask might not be possible, but putting one of the little 2-pronged nasal tubes on the upper lip, pointing down, is better than nothing.

3. He's got a wicked concussion (knocked him cold, now he's come around, but he's still disoriented) At least he's conscious for now.

So now the medics are there, he can barely breathe (getting worse), but there's a possibility of a neck injury. OH CRAP! That means they have to immobilize his neck to minimize possible damage if there is a spinal injury, but he has that injury problem ... they'll have to wing it by blocking his head on either side on the backboard instead of using the collar.

BUT, he has to be upright or on his side to keep the blood from flowing into his throat and getting aspirated into his lungs ... you see how conflicts happen. If the ambulance has one of those 1/2 backboards, it's pretty easy to have a sitting and secured patient.

Any thoughts? Experience?

It depends on the area's protocol. My house-mate was astonished when he stopped at a car accident in another state and found that the EMTs weren't allowed to do things that our ski patrol takes for granted we all know how to do, like insert airways.

The last tree strike we shipped out was semi-conscious with mashed face, possible spine injury (we always assume it's possible), possible broken ribs (we don't have x-ray vision, but it's always assumed in a tree strike) and multiple serious lacerations. After the hill guys got the bleeding stopped and brought him down (on a backboard, with O2), he was sedated and intubated (orally) by the paramedic who happened to be patrolling that day.

Perhaps because it's a large rural area, with easily an hour or more to the nearest hospital, the medical "control" lets non-physicians do things that other areas don't. It's us or the Grim Reaper.