Railway Incident Scenario

Do you go up the grassy bank and start to find the patient so you can report your findings to incoming resources?

What should be your first priority?

You contact control and they advise they have updated network rail and are awaiting confirmation that it is safe to go onto the tracks. The person shouting down has stated he is the train driver and it should be safe to approach.

Do you proceed? 

You are cautious to proceed as you recall you shouldn’t unless you get confirmation from your control that it is safe or you have notification from the rail incident officer that may be on scene. What mnemonic can you use to help in the management of risk specifically in rail incidents?

You finally get confirmation that it is safe to approach the patient at the side of the track so climb up the grass verge. You find the patient is still alert, screaming in pain. Immediately you see major blood loss coming from the patients lower right leg. You cut the bottom of the trousers off to find an almost complete amputation halfway up the tibia/fibula. The limb is only connected by some loose skin and muscle tissue. It is still bleeding heavily. 

What is your first action? 

You have an area proximal to the injury on the tib/fib lower leg where you have room to apply a tourniquet. To try and save the most viable tissue, where should you place the tourniquet?

You place a tourniquet on the lower leg as priority to stop the bleeding. Your patient is still in agonising pain. What appropriate pain medication could you consider for quick relief?

The exposed are of the partial amputation is grossly contaminated, you should irrigate this to clear the contaminants?

This patient also requires high flow 02?

You now have stopped the bleeding, have the patient on high flow 02, given Methoxyflurane which seems to have the patient more settled and calmer, and have placed a blast bandage over the wound to stop any further contamination. Whilst you have done this, your crew mate has done a quick head to toe assessment to search for any other injuries. He discovers the patient has severe bruising on the left side of the pelvis. This corroborates with the patients story and how he was hit by the train. Your crew mate states this looks superficial so is not going to put a pelvic binder on, should you follow your crew mates suggestion?

You put a pelvic binder on due to the mechanism and the bruising. Your crew mate starts to do observations, what other treatment options should you be considering with this patients ongoing management?

You are confident you have stopped the bleeding with the application of the tourniquet therefore you may not need to administer TXA

Your crew mate has completed observations of 128 HR, 32 RR, 76/42 BP, 100% Sp02 on 02, 35.8 temp, so you also look to administer a fluid challenge. What systolic mmHg should you aim for in blunt or limb trauma?

What is the name of the triad of symptoms that you should be aware of when dealing with this kind of incident?

Your other resources have arrived and look to take over care of the patient with their enhanced critical care skills and extrication options. What handover algorithm would be more appropriate to hand over this patient?