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You are working as an industrial EMT in the oilsands for a large petroleum company. You are called to a truck-mounted rig where an 18-year-old male has been caught in the cable spool on a service truck. Your response time to the scene will be approximately 45 minutes. You are driving a 4x4 Mobile Treatment Centre and your paramedic partner will be bringing the ambulance from the base camp. Her response time will be at least 60 minutes. Your backup is limited and air ambulance is only an option with ideal flying weather, as well as availability of helicopters in the area.

It is a bright winter day and the temperature is –30ºC. You know you have limited daylight available. When you arrive on scene the casualty is still caught by his right forearm in the cable spool. His co-workers have been keeping him warm with blankets and keep replacing the blankets with new ones warmed by a heater. The work crew says they should be able to have him untangled from the cable in less than five minutes.
You see the man lying over the top of the cable spool with his right arm stretched out in front of him. His clothes have been partially pulled off of him. He is alert and oriented but having trouble breathing because of the way he is laying and may also have a chest injury. His right arm is obviously fractured because it is bent at an abnormal angle close to the mid-forearm with a thick cable entangled around his arm. The right radial pulse is absent and the distal end of that limb is cold. There was no loss of consciousness and no other obvious injuries.

His vitals signs are:

  • RR: 24
  • HR: 105
  • SPO2: NA
  • BP: 126/74
  • Temperature: 36°C
1. In addition to the cold temperature, what other hazards may be present on scene?
2. H2S gas may be present at which of these scenes?
3. The patient is lying in abnormal position. What is likely to be wrong with this man's respirations?
4. Initially, you have limited access to the patient. Your role as a first responder is restricted. What is the best first course of action?
5. What is the next step?
6. Before disentangling him from the spool it might be a good idea to:
7. His breathing is hampered because of his body's position. What else could be affecting his breathing?
8. What are we most concerned about with an entrapped limb that has impaired circulation?
9. Compartment syndrome starts to develop after six hours. Why might this patient be at risk after a much shorter period of time?
10. If the distal limb becomes detached during the extrication, how would you manage the amputated limb?
11. What secondary complication will we have difficulty dealing with while on scene in this situation?
12. If breathing fails to improve, what traumatic injury may have occurred?
13. Limbs with compromised circulation are more susceptible to frostbite.
14. Although it may not be immediately apparent, how might an EMT differentiate between deep and superficial frostbite?
15. What would you like to do for this patient now that you have him in the back of your ambulance?
16. After the patient has been freed from the cable spool and all BLS interventions have been completed, your paramedic partner finally arrives on scene to assist you. The patient is loaded into the ambulance on a stretcher. He is on O2 at 10 lpm via NRB. He has an 18 ga IV lock in his A/C so you can hook to the IV in the ambulance. His right arm is splinted in the position found with a tourniquet applied above the elbow. The injured limb is cold and pulseless but still attached. What would be an adequate IV solution for this patient?
17. The patient is having severe pain from his injured arm and sore chest. What medication would be appropriate for analgesia now?
18. The patient's respirations are slowly getting more laboured. This maybe a sign of:
19. There are no distal pulses to the damaged limb. You may attempt to:
20. He seems very upset about his injured hand. What medication is appropriate for sedation?
21. By the time the patient gets to the ambulance, his temperature is cold. For an accurate temperature it would be best to assess:
22. A core temperature consists of:
23. The 12-lead may show a sign of hypothermia. This would be a(n):
24. What are the true indications of a tension pneumothorax?
25. If you decide this patient requires an intubation in the event of a sudden deterioration of his breathing, can you use Anectine now?