Leg Lock

It’s early evening, and Attack One is requested for a “person injured in a work accident.” The address is a junk metal and automobile recycling facility in a rural area of the jurisdiction. This site has had a history of serious accidents, so the rescue crew in the same station informs the Attack One paramedic that they will follow them in “just in case.”

The response time is relatively long, so the EMT has time to prepare the trauma equipment.

The vehicle pulls into the industrial site, and there is no one to guide them to a victim. The dispatcher has no further information on location or the injury. Relying on experience, the crew drives to the area where scrap vehicles are loaded onto the conveyors. There they notice a worker at the top of a conveyor signaling to them frantically. The worker is about 40 feet off the ground, and he is pointing to a ladder where the crew can climb up to meet him. The site is noisy, and from the ground it is not possible to hear what he is yelling.

The paramedic begins a size-up. “Dispatch,” he reports, “we apparently have someone injured at the top of a piece of machinery. Please dispatch our heavy rescue, a ladder truck and a battalion chief as a rescue assignment to this call, until we have a better idea what our needs are.” He then goes on to give a better description of the location in the plant for the incoming crews.

The heavy-rescue team that had followed Attack One into the call arrives, and its officer jumps out to accompany the paramedic in a climb up to the victim. The EMTs will remain on the ground until the victim is located and his needs are determined.

The rescuers climb to the top of an elevated loader and find the worker who was signaling to them and the victim, a young man who has been partially pulled into a conveyor. He is partially wedged into a funnel-shaped portion. He is pale and complains of pain in his left leg, which is trapped in the conveyor. He has wrapped a belt as a tourniquet around his leg, and all the rescuers can see below the tourniquet is blood.

The Attack One paramedic asks a few quick questions while the rescue officer does a scene and extrication review with the uninjured coworker. “What happened, what is hurting, and how much blood have you lost?” the paramedic queries.

“My boot got pulled in, it snapped my leg, and I passed out,” the patient says. “I woke up and saw all this blood, then I yelled for help, and Rob came. He took his belt off, and I tied it as a tourniquet around my leg. Please make the pain stop.”

A few more questions, and the paramedic determines there are no other injuries in this otherwise-healthy 28-year-old. But his examination reveals the left leg is fractured and almost amputated just below the hip area. The man lost a lot of blood before the tourniquet was applied, and the leg remains trapped between the compressor belt and a piece of scrap metal. The victim’s pulse rate indicates he is in shock. It will not be possible to start IVs and give other treatment up on the platform, and the man is in tremendous pain.

The rescue officer has some good news: The coworker, who has been talking with a supervisor on the ground, can reverse the direction of the conveyor, and it is likely the leg will be immediately disentangled when that happens. The workers didn’t want to try it before the rescuers arrived because of the victim’s pain and profound blood loss, and in case anything went wrong.

The paramedic and rescue officer agree on a rapid incident action plan. The man’s treatment will consist of intranasal pain medication, a formal tourniquet when his leg is partially disentangled, and full assessment and intravenous fluids once they arrive on the ground. The rescue officer will be responsible for the work in reversing the conveyor and making sure the scrap metal doesn’t kick up and cause further injury. A ladder truck will raise an extrication basket to the platform, and the victim will be placed in it and lowered to the ground with the paramedic. A medical helicopter will be brought to the scene for transport to the trauma center, which is some distance away.

The battalion chief arrives and establishes command, the ladder truck is moved up to the base of the conveyor and stabilized, and a rescue basket is rapidly attached to the end of the ladder. The Attack One EMTs start shuttling supplies up to the platform, but only a limited number of people will be able to work at or near the top. It requires two doses of pain medication to get modest control of the leg pain so the victim can be extricated. The paramedic explains to the patient the procedures that will be used, and that the two of them will ride down in a basket to the ground. He further explains that a medical helicopter will then take the patient to the trauma center.

A landing zone for the helicopter is the responsibility of an engine crew, and they survey the plant site for a safe location. There are lots of overhead wires, loose, rusty gravel and piles of scrap that make the location decision difficult. That crew establishes radio contact with the helicopter when they mark en route to the scene, and they move their communications to the department’s tactical channel.

The safe placement of the basket on the end of the ladder is the most time-consuming portion of the operation, but it gives the rescue officer time to make sure the machinery will operate correctly when the conveyor is reversed, and that the operators have complete control of the speed at which this will occur. He constructs a set of pads that will make sure the metal cannot strike the patient and the victim’s leg won’t move too quickly and swing into the other side of the conveyor.

Only three rescuers can fit on the top of the conveyor, so it will be difficult to lift and place the victim and his injured leg onto a long backboard and into the basket. They use a simple sheet, placed underneath the victim, to make sure they can lift and hold him safely. Another sheet is available if needed to lift his leg.

The truck officer completes placement of the basket, and it is raised to the edge of the conveyor and swung into a position where they can transfer the patient quickly. When the paramedic feels confident the patient can tolerate movement of the leg, a formal tourniquet can be placed quickly, and the patient can be lifted onto a board along with his damaged leg, he signals command and the rescue officer. Command gives the signal, and the conveyor is activated.

The victim has been prepared for the first movement of the operation, but he still screams in pain. The conveyor lurches as it starts up but moves the leg and metal. The padding works effectively, and the leg is freed.

The paramedic reassures the patient: “Just like we talked about, your leg had to move a little for the metal to come off it. We can’t lift you alone, so you use your arms to push up out of the machine, and I will grab your leg while my partner slides this board under you. Then scoot yourself up, and we can all grab you.”

The paramedic strips the pants off the leg, cuts off the old belt, and wraps and secures a formal tourniquet in a matter of seconds. The mangled leg is now in full view of the paramedic but shielded from the view of the patient. The patient is loaded onto a backboard, secured with straps and placed in the basket. The paramedic is also secured, and the two are lowered rapidly and safely to the ground, where a stretcher awaits.

Secured on the stretcher, the patient is moved quickly to the back of the ambulance, where the paramedic has the first opportunity to completely examine the leg, which is kept from the patient’s view by a sheet. The caregivers find a mangled leg, fractured at the upper end, with torn muscles and blood vessels in the wound. The tourniquet is in good position, but a large amount of old and clotted blood is caked on the lower leg. The EMTs quickly finish exposing the patient, finding no other significant wounds. The paramedic places a large IV catheter, then administers a dose of intravenous pain medication and nausea medicine. The IV fluids are squeezed into the patient, who is now saying little and seems to be fading in and out of consciousness.

The helicopter has approached the scene, and the engine crew has found a site for landing it at the front of the facility. The space is of adequate size, well lit in the late evening and free of overhead wires. They position their apparatus and personnel to keep vehicles and other persons away. The victim has been moved in the ambulance to that side of the plant, and the crews are prepared to do a rapid load into the helicopter.

The helicopter circles the site, then begins to lower to the ground. But suddenly the engine officer waves it off and directs the helicopter abort the landing, and the helicopter roars as it rises again into the sky.

The officer had noticed that a lot of industrial debris and gravel was being picked up in the propeller wash and starting to pepper the apparatus and the bottom of the helicopter. That is way too dangerous; the landing site will need to be moved to a safer location. The officer contacts the pilot, and together they agree the only safe location is in the middle of the road near the driveway into the plant. That location is cleared, boundaries are established, and the helicopter lands safely. The pilot clears the staff to exchange the patient, and the helicopter lifts off with him on board.

Hospital Course

On arrival at the trauma center, the young man is in much less pain, and his perfusion status has improved after the intravenous fluids. He is taken to the operating room, where surgeons determine the leg is not salvageable, so the amputation is completed and the wound edges are cleaned up. The young man has no other significant injuries and is released for rehabilitation after a week in the hospital.  

Case Discussion

The Attack One crew members discuss the case in a debriefing session with the battalion chief. The chief begins by praising the crew on a timely operation and the good condition of the patient on turnover to the flight crew. He congratulates the paramedic and trains all of the rescuers present on the exceptionally well-organized trauma care delivered, recognizing that in critical trauma patients the treatment priorities are to:

• Assess and stabilize the airway;

• Assess and facilitate breathing;

• Apply direct pressure or a tourniquet for uncontrolled extremity hemorrhage;

• Identify the correct time and place for intravenous or intraosseous access for fluid resuscitation;

• Administer pain medication by an intravenous, intramuscular or intranasal route;

• Explain what you are doing to the patient and make them as comfortable as possible;

• Consider other needed treatment, like nausea medication.

This patient had intact airway and breathing, and using a tourniquet was the only way to control bleeding due to the nature of the trapped leg. The pain medication given in the nose allowed the difficult work of freeing the leg to take place without further compromising the patient, and allowed him to assist in his own rescue. An IV line could not be started until later, but once in place was used to resuscitate the patient and give further important medications.

The chief also recognizes the rapid and safe work of the rescue and ladder crews, who were able to carry out the movement of the patient with no delay or further danger. There was a thorough discussion about landing zone safety and the characteristics that make a landing zone site safe.

Industrial incidents can produce multiple casualties, severe injuries, and scene safety and security issues. They disproportionately produce injuries where tourniquets prove to be lifesaving.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.