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NCHammerhead
12-11-2010, 11:08 PM
Good afternoon. I am impressed with the wide diversity of knowledge available in this forum. So impressed, in fact, that I am figure I should try to take advantage of it. J

I am looking for someone with a medical background (doctor / EMT / Army field medic, etc) to let me know what steps would be taken in the following situation.

Kidnap victim (female/22). She has been abducted for one week, with minimal food and water provided. She has been restrained for the past two days (following an unsuccessful escape attempt). She has suffered repeated physical and sexual abuse. Psychologically, she has given up and is no longer fighting back, she is simply waiting for death. A group of volunteers has found her, one of the volunteers is a doctor.

The scene ends with the girl drifting into unconsciousness, and the doctor announcing that he has to get her to a hospital immediately, there is nothing else he can do for her here.

*Upon finding the kidnapping victim, what would the doctor do? What vital signs would he check? What assessments would he make? What would he do to prepare his patient to be moved to a hospital? What should be done while they are waiting for an ambulance to arrive? What might be the key symptoms that he looks for when doing an initial and cursory exam?

Any info is helpful. Iím hoping this forum works, otherwise I have to ask my primary care doctor some strange questions at my annual physical next week, and he already thinks Iím strange enough. J

Thanks
Mike

GeorgeK
12-11-2010, 11:47 PM
ABC's...Airway, Breathing Circulation and always in that order. I'm assuming the volunteers don't have any medical equipment. Listen to her breathing (If she's talking, she's breathing). Count respirations per minute and check pulse, then look at her mouth to see how dehydrated she is. Try to find some water for her to drink and cut any bindings.

Is she able to talk? You'd want to probably elevate her legs to shunt blood to the heart and brain, but before any attempt to move her you'd want to try and see if she's neurologically intact. You don't want to move anyone with a potential fractured neck or spine until you have a backboard and preferably a few extra experienced hands. Check to see if she can move herself and wiggle fingers and toes. If she's conversant and neurologically intact, have her roll on her back and elevate her legs onto some pillows or folded up coats etc. She's also going to need to conserve body heat, so get a blanket over her.

I'd be nice to put in an IV, but in a dehydrated patient, your average Dr is going to have trouble getting a line in unless their a specialist that puts in a lot of lines, like an anaesthesiologist. The paramedics are going to be much more used to getting in an IV in someone who is volume contracted (dehydrated).

Kitti
12-12-2010, 12:29 AM
What equipment do they have and where/how do they find her? This is almost more important for determining how a doctor would react than knowing what has happened to her.

Step one: Check out the location. Is it safe? Secure? Are they in any danger? Does the patient have to be moved for her own safety and the safety of her rescuers?

Step two: Ascertain if the patient is breathing (which obviously she is, which also means her heart is beating - check!) and/or has any major injuries (like bleeding profusely) that must be dealt with right away. Also make sure she doesn't have any medical alert jewelry on, so you know if she has any underlying conditions to be worried about.

Step three: From what you said above I'm inferring that she's pretty non-responsive to her rescuers? Especially if there were signs of physical abuse, I'd worry about internal bleeding and shock. That's where the elevating her legs comes into play (and other stuff that GeorgeK is talking about above).

leahzero
12-12-2010, 03:53 AM
As to what Kitti said above, another consideration: do they find her at the crime scene itself? If so, smart rescuers are going to know not to disturb things. Her body itself may also have traces of DNA and other material that can be used in the criminal investigation, so I'd think they'd handle her very carefully.

jclarkdawe
12-12-2010, 10:10 PM
First thing to understand with any search and rescue, there will probably be a dedicated ambulance. Very rarely are you going to have a rescue where an ambulance crew isn't available, both for the victim, and also because of the number of injuries that happen to the rescuers. Even on a recovery mission, you usually have a dedicated ambulance.

So you should have an ambulance on scene, with a pretty good supply of medical supplies.

Second thing is that a search and rescue mission, medical personal over and above the ambulance crew are scattered throughout the rescuers. Most will carry backpacks will their chosen weapons (varies from person to person). In addition, the medical personal will be supplied with radios, as much as possible.

As soon as the person is found, a notice is broadcast over the radio, including the location and the approximate medical status. Ambulance starts approaching as near as it can to the location, and medical personal in the area start converging. Realize that a doctor at an emergency scene does not outrank the EMTs. We will work with a good doctor, ignore a middling doctor, and have the police remove a doctor who's a nuisance.

In your situation, the medical personal would be reminded prior to going out that this will be a crime scene. Rape protocols will be in place, and patient needs have to be balanced with the police needs. A hostage/victim counselor would ideally be available.

Gross physical exam would be done immediately. This would include airway, pulse, and gross bleeding. Patient would be reassured everything was okay, with numerous repeats of the information. Photos would be taken and any clothing removed (actually, anything removed) would be bagged and tagged for evidence.

Blood pressure, pulse, respirations, skin temperature and condition, deformities, CSMs (do the toes and fingers have feeling and are able to move), pupil reaction and movement, reflexes, and a physical exam with clothes on would be done. Patient would be placed in a position of comfort, preferably with legs up. I'd cautiously administer small amounts of water. If I had it, I'd probably set up an IV and O2.

Meanwhile, the ambulance would have arrived at the nearest point it can get. A stokes basket would be carried in, which would have an IV and O2, as well as a monitor. Once the stokes arrives, IV and O2 would be set up, and a strip for the heart run on the monitor. As soon as that is finished, unless there are conditions that could be treated, you start moving.

In your case, you're describing a patient who's crashing from shock. Other than an IV and O2, there isn't much you can do for them in the field, other than keeping them warm.

Once at the ambulance, you load the person. Depending upon the temperature, it will either have the heat or the AC running full blast. We're now in a position where we can start controlling the environment. More photos are taken, and the ambulance crew and a police officer get in the back.

Depending upon where the patient is at, you sit for a few minutes or do your exam on the road. In your case, you'd probably start driving immediately. Preferably you can have a female in the ambulance. Clothes would be cut off and removed, being bagged and tagged. Any injuries would be examined and treated. More photos of each. Any material used for cleaning will be bagged and tagged. Let the police decide what they need.

Ideally, someone would be talking to the patient throughout, explaining what is happening and reassuring her. Even when she loses consciousness. One of the main things is going to be to reassure the patient that everything is okay. Even if it isn't.

Being a doctor in this sort of situation is not always as big a help as you'd think. Emergency medicine is a specialty, and many doctors can focus on the wrong thing. In your case, for example, a broken bone is not as important as the dehydration, core temperature, and shock. But the broken bone is more obvious and exciting, so sometimes a doctor will fixate on this if they haven't done emergency medicine.

In your scenario, speed matters more than screwing around at the scene. You need to start getting the patient hydrated and her temperature under control. You may have internal injuries, but that would be a secondary concern. The extremities might have nerve damage from the bondage, but again, this is a secondary concern.

Signs I'd expect are slow pulse, blood pressure in the toilet or approaching there, respirations slow and possibly diminished, skin remaining tented when pinched, cold skin temperature, bruising over extensive areas of her body, swelling in the extremities, skin color pale. The doctor should be able to identify that she needs immediate transport as soon as he arrives on the scene. Her lethergy, pale skin, and breathing are all signs you assess as you approach the patient. Core temperature would depend upon the temperature of the room, and again, is assessed as you approach the patient. Easy case to decide that immediate transport is necessary.

Best of luck,

Jim Clark-Dawe

shaldna
12-13-2010, 02:57 AM
It might not help much, but sometimes IV's have to go into weird places. In babies here it's common to see IV's go in through the forehead when they can't get a vein anywhere else, it;s a bit traumatic for people to see, but when needs must...

NCHammerhead
12-14-2010, 03:58 AM
thanks everyone, outstanding information plus some extra thoughts for me to consider.. now that I have a better knowledge of what would likely take place, I'm ready to start a very rough draft of this particular scene...

Thanks!

Tsu Dho Nimh
12-15-2010, 12:35 AM
I think Jim does it for a living and I do it for a hobby: emergencies. Believe him instead of me if we differ.

Jim said: "Preferably you can have a female in the ambulance. " And they can draft one of the rescuers to be the female if need be. Pick a calm one with some grey in her hair and say, "you - keep her calm".

Being a doctor in this sort of situation is not always as big a help as you'd think. Emergency medicine is a specialty, and many doctors can focus on the wrong thing. Definitely! We did a car crash training scene and the docs (2 of 2) fixated on the guy with the crushed chest that we had no way of helping when there was a bleeder who needed immediate attention and another car to check out.

Nurses can be about as bad. I was holding C-spine on a guy, waiting for the EMTs and keeping his airway clear when a nurse came up shrieking about the bleeding that needed to be stopped and tried to yank me away so she could get to a fairly small trickle of blood from a head wound. I cussed at her until she gave up.

What Jim says is what I would expect to see here at a hiking or other "exposure" rescue. Evaluate, start body temp control, rehydration IVs, head for the hospital. Aside from splinting a busted bone, and in the absence of bleeding to stop, there's not much else to do in the field.

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Realize that a doctor at an emergency scene does not outrank the EMTs. We will work with a good doctor, ignore a middling doctor, and have the police remove a doctor who's a nuisance. I always wondered about that.