Blast lung injury in a 20-year-old man after a home explosion

A large family home exploded after a propane leak ignited. Initial reports from the scene noted that 11 people were injured, with many sustaining critical injuries. Immediately, multiple helicopter emergency medical services aircraft were dispatched to respond to the scene, and ground emergency medical services (EMS) providers were en route. Of the five aircraft requested, only two were available to respond; one aircraft was out for maintenance, and two others were committed to other missions.

Intractable seizures in a 4-month-old girl

A 4-month-old, 7-kg girl with a 3-day history of mild diarrhea was brought into a rural emergency department (ED) by private vehicle. The patient's parents reported that the child was in her usual state of health until the past several days, when she began having multiple loose stools. After an extensive interview, the family said she was born full term without any complications. She had never been hospitalized and was up to date on all of her immunizations. Family also stated emphatically that there was no alteration in her formula concentration and intake before her presentation. Approximately 30 minutes before her arrival, her parents noticed "shaking of the extremities" consistent with seizure activity. Concurrently, they noted she had irregular respirations and was not acting at her baseline.

Carbon monoxide poisoning in a 55-year-old man after a suicide attempt

A flight team was activated for a scene call in rural Vermont for a patient with apparent carbon monoxide (CO) poisoning. Per ground emergency medical services (EMS) personnel, this 55-year-old man with a history of coronary artery disease (CAD) was found unresponsive in his parked vehicle in his garage. "Dryer hose" tubing ran from the tailpipe into the rear window of his sedan. EMS providers also stated that a variety of unidentified pills were found on the floormat. There were no pill bottles in the vehicle or in the home to identify the medications. Whether the pills had been consumed was unclear. Ground EMS removed the patient from the vehicle and immediately placed the patient on high-flow oxygen. The duration of the exposure was unknown.

A 27-year-old man with multiple stab wounds to the chest

A 27-year-old man presented to a community emergency department (ED) after sustaining multiple stab wounds to the anterior and posterior chest and posterior neck after an altercation at a local bar. Shortly after arrival at the ED, the patient's mental status altered, and he increasingly became combative and confused. When the patient was assessed in the ED, staff found the patient hypoxic with oxygen saturations noted to be in the low 90s. He was tachypneic and tachycardic, although there was no evidence of hypotension. The ED staff quickly intubated him using standard weight-based dosing of succinylcholine and etomidate for airway protection. Once his airway was controlled, he was placed on propofol for sedation and was pharmacologically paralyzed with pancuronium. His initial chest x-ray demonstrated bilateral pneumothoraces. Bilateral chest tubes were placed and arrangements made for transport by helicopter emergency medical services (EMS) to the nearest level 1 trauma center for continued management (Figure 1).

A 12-year-old boy with gastrointestinal bleeding

A 12-year-old male patient presented to a local emergency department (ED) with approximately 12 hours of abdominal pain and multiple episodes of nausea and vomiting. When the emergency physician was eliciting the patient's medical history, the patient was discovered to have hemophilia A. His evaluation continued with a computed tomography (CT) scan of the abdomen and pelvis, which demonstrated several abnormalities, including a spontaneous transmural duodenal hematoma and retroperitoneal gastric obstruction.

Subarachnoid hemorrhage in a 13-year-old girl

At 5:20 pm, a local flight team was activated to respond for an interfacility transfer of a 13-year-old girl with a subarachnoid hemorrhage. In the history obtained, the patient's parents noted that she had not been feeling well for the past several days. She had been complaining of intermittent dizziness and a persistent headache. Until the onset of these prodromal events, she had been active with no medical history. That afternoon, the child was playing with her friends at the school playground. As the group was walking home, they noticed that the patient was not with them. They subsequently returned and found her lying face-down in the bushes, unresponsive, with agonal respirations.

Extensive burns in an elderly man found in a brush fire

This past spring, a flight team was activated by a rural advanced life support ground service for a scene call approximately 30 minutes from their base for an 80-year-old man found lying in the middle of a brush fire. The ground paramedics did not know how the patient came to this position. During the initial call to the flight service, ground emergency medical services (EMS) reported that the patient had 100% burns that varied in severity from superficial to full thickness. The intercept was requested for emergent transport to a burn center, analgesia, and advanced airway management. On arrival, the flight crew saw that a bag valve mask was being used to ventilate the patient. EMS had placed the patient on a spine board for extrication from the scene. His initial Glasgow Coma Score was noted to be 6 (E1, V1, M4). The flight team noted that the patient occasionally moved his upper extremities and his head. Immediately, there was concern for a compromised airway in the setting, with soot and edema noted in the nares and oropharynx. The ground EMS crew was able to ventilate the patient with difficulty. However, given the severity of the burns and noted trismus, an oral airway could not be placed. Stridor was noted, with obvious swelling of the neck.

Thoracic aortic dissection in a 38-year-old man

A few days before Christmas, a flight team was activated for an interfacility transfer of a 38-year-old man with a history of hypertension and spinal stenosis diagnosed with a thoracic aortic dissection. The patient was presented to a local community hospital complaining of nearly 5 days of left-sided rib pain. This afternoon when he stood up from a chair, he experienced a near-syncopal episode. Concurrently, he had an abrupt onset of a tearing sensation in his chest that radiated to thoracic spine in the region between his shoulder blades. Ground emergency medical services (EMS) was called, and the patient was transported to the community hospital. During the initial transport and evaluation by the emergency department (ED) staff, the patient was noted to be hypertensive, with a systolic blood pressure greater than 180 mmHg. In the ED, the patient received aspirin, morphine, and Lopressor. He underwent a chest x-ray (Figure 1) and computed tomography (CT) scan and was diagnosed with a type B thoracic aorta dissection, which was noted to start on the descending thoracic aorta distal to the left subclavian artery and extend to the level of the celiac trunk (Figure 2). Despite the initial beta blockade, the patient was noted to be profoundly hypertensive, with initial blood pressure greater than 190 mmHg systolic. The flight team was activated for hemodynamic management and rapid transport to a facility capable of vascular and cardiothoracic surgery.

Thoracic spine injury after a high-speed motor vehicle crash

In late October, a hospital-based flight team was activated at 9:30 pm for an approximately 30-year-old man involved in a high-speed motor vehicle crash into a tree. Per emergency medical services (EMS) documentation, flight service was requested for advanced airway management and rapid transport of the patient to a Level 1 trauma center. Ground transport was estimated at 60+ minutes, whereas actual flight time was less than 15 minutes. On the crew's arrival at the designated landing zone, they were escorted to an ambulance where a 100-kg man was immobilized on a stretcher. Because the landing area was at a remote location, the flight team did not witness the scene; however, the ground paramedic reported that the patient was the single-occupant driver of a small sedan. Given the extent of damage to the front and passenger side of the vehicle, it was determined that the patient was driving at a high rate of speed when he struck the tree. He required approximately 20 to 25 minutes of extrication. An empty bottle of zolpidem (Ambien) was found on the floor of the vehicle; the 30-day prescription had been filled approximately a week before the accident occurred.

Cold Hearts: a case study of therapeutic hypothermia in helicopter emergency medical services (HEMS)

A 36-year-old white man hit a home run in the seventh inning of a community baseball game. The patient ran the bases successfully and returned to home plate. As he was bending over to pick up the bat, he suddenly collapsed. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated, and defibrillation occurred within 5 minutes per the local emergency medical services (EMS) service. The automated external defibrillator (AED) shocked the patient a total of three times, and he was transported to a local hospital at the basic life support level. Helicopter emergency service (HEMS) was activated by local medical control, and LifeFlight of Maine responded to transfer this patient to a tertiary care center.