CASE REPORT – Management of the patient in an impervious environment by the emergency nurse
VOL.2 | ISSUE 02 | YEAR 2022
- Enrico Lucenti, Nurse UOC Local Emergency 118 and CTIU, Azienda USL of Piacenza. Professor of Nursing, University of Parma, Piacenza. Director of the Scientific Committee of SIIET
- Cristian Sorrentino, Nurse, First Aid Point and 118, Bobbio Community Hospital, Azienda USL Piacenza.
- Francesco Bez, Nurse Operations Center 118 of Venice, AULSS 3 Serenissima.
The assessment of the patient and the relative treatment carried out by the first medical crew that arrives at the scene of the event have an important impact on the clinical evolution and the outcome of the traumatized patient; in fact, it is necessary to apply a systematic approach to these situations guided by clear and simple recommendations that see the technical rescue interacting with the medical rescue.
It is well known that technical rescue is the responsibility of the National Fire Brigade Corps and the National Alpine and Speleological Rescue Corps (CNSAS). It is equally evident that in specific patients’ clinical conditions, even if the event is in an impervious environment, medical rescue cannot delay its essential intervention .
The duration and the exposure to environmental factors for the patient itself validate the importance of territorial emergency medical figures even in inaccessible places: the medical staff, in addition to having the necessary knowledge for life support, should have logistic and rescue operations skills .
The “Golden Hour,” a term coined as far back as 1961, is a concept well known to rescuers in the pre-hospital setting; subsequently, the term “Platinum Ten Minutes.” In both cases, shortening the time from the traumatic event to definitive care is paramount for a better patient outcome . There are also contrasting opinions expressed in the literature about the effectiveness of the same “Golden Hour”; however, if we consider those traumatized patients with evidently time-dependent pathologies (e.g., hemorrhagic shock)  , the importance of prompt treatment becomes very topical again .
This case report describes a rescue in an inaccessible environment where the territorial emergency nurse, when the first MSA (advanced rescue vehicle) arrived on-site and therefore the first health figure, reached the patient at the scene of the event in order to evaluate and treat him early, in full collaboration with the rescue technician who arrived on site.
Therefore, the objective is to remind the actors of the territorial emergency system of the importance of collaboration between different entities, health care, and non-healthcare technicians, clearly having as its ultimate goal an earlier and more effective treatment of the patient on-site to improve the outcome.
 Popa TO. Prehospital Emergency Care in Acute Trauma Conditions [Internet]. Available at: https://www.intechopen.com/chapters/67641 (Consulted: 6/10/2021).
 Dipartimento dei Vigili del fuoco, del Soccorso pubblico e della Difesa civile [Internet]. Available at: https://www.interno.gov.it/it/ministero/dipartimenti/dipartimento-dei-vigili-fuoco-soccorso-pubblico-e-difesa-civile (Accessed: 6/10/2021)
 Corpo Nazionale Soccorso Alpino e Speleologico [Internet]. https://www.cnsas.it/attivita/ (Accessed: 6/10/2021).
 Hearns S. The Scottish Mountain rescue casualty study. Emerg Med J. 2003 May;20(3):281-4. doi: 10.1136/emj.20.3.281.
 Strapazzon G, Reisten O, Argenone F, Zafren K, Zen-Ruffinen G, Larsen GL, Soteras I. International Commission for Mountain Emergency Medicine Consensus Guidelines for On-Site Management and Transport of Patients in Canyoning Incidents. Wilderness Environ Med. 2018 Jun;29(2):252-265.
 Soteras I, Subirats E, Strapazzon G. Epidemiological and medical aspects of canyoning rescue operations. Injury. 2015 Apr; 46(4):585-9.
 Ströhle M, Beeretz I, Rugg C, Woyke S, Rauch S, Paal P. Canyoning Accidents in Austria from 2005 to 2018. Int J Environ Res Public Health. 2019 Dec 22;17(1):102.
 Okada K, Matsumoto H, Saito N, Yagi T, Lee M. Revision of ‘golden hour’ for hemodynamically unstable trauma patients: an analysis of nationwide hospital-based registry in Japan. Trauma Surg Acute Care Open. 2020 Mar 10;5(1): e000405.
 Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J. Redefining the golden hour for severe head injury in an urban setting: the effect of prehospital arrival times on patient outcomes. Injury. 2013 May;44(5):606-10.
 Schroeder PH, Napoli NJ, Barnhardt WF, Barnes LE, Young JS. Relative Mortality Analysis of the “Golden Hour”: A Comprehensive Acuity Stratification Approach to Address Disagreement in Current Literature. Prehosp Emerg Care. 2019 May-Apr;23(2):254-262.
 Soudry E, Stein M. Prehospital management of uncontrolled bleeding in trauma patients: nearing the light at the end of the tunnel. Isr Med Assoc J. 2004 Aug;6(8):485-9.
 Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2021 May 1;90(5):901-907.
 Braverman MA, Smith A, Pokorny D, Axtman B, Shahan CP, Barry L, Corral H, Jonas RB, Shiels M, Schaefer R, Epley E, Winckler C, Waltman E, Eastridge BJ, Nicholson SE, Stewart RM, Jenkins DH. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021 Jul;61 Suppl 1: S15-S21.
 Tucker H, Avery P, Brohi K, Davenport R, Griggs J, Weaver A, Green L. Outcome measures used in clinical research evaluating pre-hospital blood component transfusion in traumatically injured bleeding patients: A systematic review. J Trauma Acute Care Surg. 2021 Jul 12.
 Pierrie SN, Seymour RB, Wally MK, Studnek J, Infinger A, Hsu JR; Evidence-based Musculoskeletal Injury and Trauma Collaborative (EMIT). Pilot randomized trial of pre-hospital advanced therapies for the control of hemorrhage (PATCH) using pelvic binders. Am J Emerg Med. 2021 Apr; 42:43-48.
 Ministero Della Salute. I mezzi di soccorso [Internet]. Available at: https://www.salute.gov.it/portale/temi/p2_6.jsp?id=1100&area=118%20Pronto%20Soccorso&menu=vuoto (Accessed: 6/10/2021).
A call was received from the 118 CO requesting the intervention of the India ambulance (a car with rescuer driver and nurse onboard) for an SC01R (code red – traumatic road accident) with the following description: the patient fell from a road infrastructure from a height of about 15 meters.
At the same time, an MSB ambulance (basic rescue vehicle) was located in a position at about 5 minutes from the place of the event, and at the same time, the Fire Brigade vehicles were activated.
The Indian crew arrived at the scene where two bystanders, who had previously been with the patient involved, signaled by cell phone lights to indicate the area of the event given the poor artificial lighting. The bystanders reported that the patient was walking along the roadside (river viaduct), when for unknown reasons, he fell below the road surface (a fall of about 15 meters), landing in a disjointed manner on the rocks below adjacent to the riverbed. The patient was in a sitting position, alert, agitated, and in severe pain. The CO 118 was immediately alerted about the immediate impossibility of reaching the victim; therefore, the intervention of the Fire Brigade was requested.
The technical service personnel arrived and began to evaluate the operational theater. In the meantime, the nurse contacted again the CO 118 to give information about the first and summary medical information regarding the patient involved, and it was decided, by common consent, to alert the helicopter rescue service (a helicopter equipped with a winch was chosen due to the particular complexity of the scenario).
Given the obvious impossibility of carrying out a quick recovery, together with the fire brigade foreman, it was decided to harness the 118 nurse and lower him employing a winch together with a member of the technical service to reach the injured person. The nurse took the rescue backpack and the cervical collar.
After rappelling, the 118 nurse reaches the victim, performs the assessment, and places the cervical collar. Since other immobilization devices are not available, the Rautek maneuver is performed by the firefighter. The patient is alert, agitated, but cooperative, GCS 15, airway clear. He presents subgaleal hematoma in the frontoparietal area, with various excoriations on the face. In addition, at the quick look, there is an exposed fracture of the right ulna, evident deformation of the humerus and ipsilateral shoulder. A saturation of 94%, a respiratory frequency of 22 breaths per minute with pain in the right hemithorax evoked by the respiratory acts themselves was found. The Israeli bandage is placed over the exposed fracture to stop bleeding and protect the lesion. Arterial pressure of 80/50 mmHg with a heart rate of 110 beats per minute, skin pallor, and capillary refill time close to 2 seconds are detected. The nurse places a 14-Gauge peripheral venous Canute on the right arm.
Through radio contact with the rest of the operators on the viaduct, a system of ropes is organized for the passage of the equipment, and the spinal stretcher with relative fixation and warm liquids are brought down. In the meantime, the nurse notes a reduced capture of respiratory sounds at the right apex with reduced expansion and sharp pain at the slightest palpation. In addition, there is pain on palpation in the right hypochondrium. Infusion therapy with 500 ml hot lactated Ringer’s is started.
The patient is placed on a spinal board. Given the extreme pain of the right upper limb (VNS 10/10), a nursing protocol of analgesia is implemented, and Perfalgan 1 gr EV is administered (morphine is not chosen because of hypotensive symptoms). A vacuum splint is applied to keep the arm in an antalgic position. In addition, evaluated the dynamics, in the suspicion of internal bleeding given the positivity of the shock index, the nurse administers two vials of Tranexamic Acid as per protocol. Thermal isolation is completed with metalline and a sheet.
After about an hour from the arrival on site of the rescue teams, the patient is alert but with a tendency to drowsiness, GCS 14, sometimes reiterating in speech, a slight improvement in pain symptoms (VNS 7/10), PA 100/60 after infusion of 1000 ml total of lactated Ringer’s, capillary refill time 1 sec, HR 94, O2 saturation 94%, FR 20.
The helicopter rescue service arrived at the event scene and disembarked the personnel on the road surface. In the meantime, the mountain rescue service has set up the descent system for the helicopter transported personnel that is lowered to reach the patient.
A decision is made to retrieve the patient by winch. The resuscitating physician administers a vial of Fentanyl for adequate analgesia, and we proceed to the harness on a specific device for aerial extraction. It is decided not to drain the PNX given the hemodynamic and respiratory stability (maintains spontaneous breathing).
The rescue operations are concluded with the helicopter’s departure for resuscitation to the HUB center of the reference region.
The case described above occurs in an inaccessible place, and the patient is obviously in such a condition that it is difficult to reach him immediately. As can be deduced from the timeline reported, from the arrival of the rescue teams to the moment the patient takes off for the reference Hub center, approximately 2 hours elapse; to these hours must be added the flight time. The patient immediately presented a significant dynamic polytrauma with evident signs of instability.
Early recognition of clinical instability can be complex, especially in settings such as the one described above, and it is known that a delay in detecting worsening symptoms correlates with a delay in activating a higher level of care. Nurses are among the professionals with the appropriate skills to detect early signs of clinical instability .
Applying the “Modified Early Warning Score” (MEWS)  with the parameters measured to the patient, at 5:15 am, at the first parametric evaluation by the nurse, a score of 5 is obtained (without adding the numerical value attributed by the measurement of body temperature). It is good to remember that through the MEWS, the patient is defined as critical and therefore unstable with a score of 4 or more. The choice of lowering the MEWS (half nurse) has allowed having a global and early framing about the potential evolutionary risk of the patient. After stabilization of the patient and treatment as far as possible, the MEWS score dropped to 2. Also, in this case, the summation of the value attributed by the detection of body temperature is missing; however, we wanted to report the data in any case to evaluate the downward trend (indexes hemodynamic stabilization).
Using the well-known shock index in the first evaluation, the patient presents a value of 1.37, then, in the second evaluation, after having had the opportunity to receive treatment, the patient presents a shock index equal to 0.94, thus showing a possible improvement from the point of view of hemodynamic stability. In this regard, it is worth remembering that a shock index > 0.7 is already predictive of an increased mortality rate even if the index itself should never be used alone  but in correlation with other vital parameters, the objective examination, dynamics, and kinematics of trauma.
In dealing with such a case, it must be determined that the safety of the operators must be paramount in the choice of the rescue operation itself. Reaching the patient in unsafe conditions would have been neither desirable nor ethically correct. Allowing the ambulance nurse to descend to the scene of the event and reach the patient early represents a well-considered choice but, above all, a choice made between professionals belonging to different professional profiles but all having in common the ultimate goal: to bring help to the victim.
 Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Ann R Coll Surg Engl. 2006 Oct;88(6):571-5.
 Dalton M, Harrison J, Malin A, Leavey C. Factors that influence nurses’ assessment of patient acuity and response to acute deterioration. Br J Nurs. 2018 Feb 22;27(4):212-218.
 Jackson S, Penprase B, Grobbel C. Factors Influencing Registered Nurses’ Decision to Activate an Adult Rapid Response Team in a Community Hospital. Dimens Crit Care Nurs. 2016 Mar-Apr;35(2):99-107.
 Liaw SY, Scherpbier A, Klainin-Yobas P, Rethans JJ. A review of educational strategies to improve nurses’ roles in recognizing and responding to deteriorating patients. Int Nurs Rev. 2011 Sep;58(3):296-303.
 Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. QJM. 2001 Oct;94(10):521-6.
 Beretta M, Popolla A, Subbe CP, Cornelli S, Bolzoni M, Grossi CF, Capelli P, Lucenti E, Guasconi M, Granata C. “Modified Early Warning Score” (MEWS) per il riconoscimento precoce dell’instabilità clinica. Scenario 2021; 38 (3): 5-9 IN PRESS.
 Koch E, Lovett S, Nghiem T, Riggs RA, Rech MA. Shock index in the emergency department: utility and limitations. Open Access Emerg Med. 2019 Aug 14; 11:179-199.
 Birkhahn RH, Gaeta TJ, Terry D, Bove JJ, Tloczkowski J. Shock index in diagnosing early acute hypovolemia. Am J Emerg Med. 2005 May;23(3):323-6.
In some circumstances, it is not always possible to give the first essential care to the critical patient, especially if the patient is inaccessible, difficult to reach immediately by the rescuers. Those who work in the territory must know their region and the peculiarities of the rescue that are created depending on the environmental variable. However, in the context of time-dependent pathologies and the severity of the trauma, the sooner the patient is given help, the better the outcome will be. It is even better if the assistance provided in the field, in addition to basic assistance, includes advanced assessment and management. This is where the figure of the territorial emergency system nurse comes in. Duly trained and in collaboration with the professional figures in charge of managing the scenario in safety, they are able to bring advanced skills to support the patient even in difficult environmental situations. A healthcare resource present at the event scene cannot just stand by and watch but must be one of the key players to get into the field early. This case highlights the improvement of the patient treated early due to the rappelling of the 118-nurse close to the victim. However, it is desirable to have a broader collaboration at the level of educational planning between different agencies but united by a single factor: the human factor, that is, the patient to be rescued.