Page 23 - JSOM Spring 2018

Benefit of Critical Care Flight Paramedic–Trained
Search and Rescue Corpsmen in Treatment of Severely Injured Aviators

Ryan W. Snow, MD *; Wayne Papalski, SMT, NRP, FP-C, TP-C ;
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John Siedler, SMT, NRP, FP-C ; Brendon Drew, DO ; Benjamin Walrath, MD, MPH 5

ABSTRACT
During routine aircraft start-up procedures at a US Naval Air 15 minutes after the accident and split into two teams, with
Station, an aviation mishap occurred, resulting in the pilot one SMT and one PJ per patient.
suffering a traumatic brain injury and the copilot acquiring
bilateral hemopneumothoraces, a ruptured diaphragm, and Point of Injury
hepatic and splenic contusions. The care of both patients, in- The first team found a mildly combative middle-aged man in
cluding at point of injury and en route to the closest trauma a cervical collar with the EMT performing bag-valve-mask–
center, is presented. This case demonstrates a benefit from ad- assisted respirations. Primary survey revealed (patient 1) bleed-
vanced life-saving interventions and critical care skills beyond ing from his right temporal region controlled with direct pres-
the required scope of practice of search and rescue medical sure. His airway was intact and he had equal but rapid breath
technicians as dictated by relevant instructions. sounds bilaterally. His radial pulse was present, his pelvis was
stable, and no other source of hemorrhage was identified. His
Keywords: en route care; MEDEVAC; military; traumatic brain eyes were closed, he was moaning incomprehensibly, and he
injury; pneumothorax; critical care localized movement to noxious stimuli (Glasgow Coma Scale
[GCS] score 8, E1V2M5). No gross deformities were identi-
fied. He was exposed to complete the examination and then
covered to prevent hypothermia. The SMT recognized the
Introduction
potentially severe head injury with altered mental status, re-
During routine aircraft start-up procedures at a US Naval Air spiratory distress, and poor airway protection and decided to
Station, an aircraft mishap occurred secondary to catastrophic intubate.
overpressurization of the cockpit and subsequent explosion of
the canopy subjecting the pilot and copilot to barotrauma and Intravenous (IV) access was established in the right antecubi-
penetrating injuries. The care provided for both patients at tal space with an 18-gauge angiocatheter. The patient was in-
the point of injury and en route to the nearest trauma center duced with 20mg of etomidate IV and paralyzed with 100mg
is presented. This case demonstrates a benefit from advanced of succinylcholine IV. Intubation via direct laryngoscopy was
life-saving interventions and critical care skills beyond the re- successfully performed with a 7.5mm endotracheal tube. Tube
quired scope of practice of search and rescue medical techni- placement was confirmed via end-tidal CO (ETco ) mea-
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cians as dictated by relevant instructions. 1,2 surement and auscultation of bilateral lung sounds with no
sounds over the epigastrium. The tube was secured at 22cm.
The patient was then hyperventilated for concern of increased
Case Presentation
intracranial pressure (ICP) to maintain ETco between 30 and
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Prologue 35mmHg. Vital signs showed a systolic blood pressure of 220,
The initial response to the flight line was made by Commander pulse of 126, and sinus tachycardia, with O saturation 95%
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Naval Installation Command Federal Fire Department emer- on 100% Fio . Secondary assessment revealed an injury just
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gency medical technicians (EMTs), and squadron maintenance above the right eye with visible bone but no gray matter and
personnel. At the time of the event, two search and rescue a second wound anterior to the right ear with bleeding con-
medical technicians (SMTs) from the Naval Air Station and trolled by direct pressure. The patient was packaged and pre-
two Air Force Pararescuemen (PJs) from a nearby unit were pared for transport. The SMT administered 10mg vecuronium
performing survival training approximately 10 miles from IV to maintain paralysis during flight.
the flight line. The first responders extricated the pilots and
moved them to two ambulances adjacent to the mishap lo- The second team approached the second patient, a middle-aged
cation. The SMTs and PJs arrived on scene approximately man who was alert and oriented, complaining of extreme chest
*Address correspondence to ryansnow1@hotmail.com
1 LCDR Snow is an emergency medicine resident at Naval Medical Center San Diego and previously served as an undersea medical officer. HMC
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Papalski is the leading chief petty officer and lead flight Paramedic at Naval Air Station Whidbey Island Search and Rescue and previously served
as a flight Paramedic with HSC-84 “Redwolves.” HM2 Siedler is the SAR medical and rescue technician standardization petty officer and flight
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Paramedic at Naval Air Station Whidbey Island Search and Rescue. CDR Drew is a staff emergency physician at Naval Medical Center San
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Diego, with eight deployments to Asia, Afghanistan, Iraq, and Africa. CDR Walrath is an EM/EMS board-certified physician currently deployed
as the team leader for a damage control surgery team and the regional EMS medical director for Navy Medicine West. He is stationed at Naval
Medical Center San Diego.
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