`ANY POSITION YOU PLEASE`

     Attack One crew members have just started their shift on a nice Sunday morning. They are completing their vehicle inventory when they're dispatched for a "woman shot." Beautiful Sunday mornings should not have these incidents, and the crew is hoping for a false alarm, but while they're en route, the dispatcher asks the unit to "Stand by, as the perpetrator is still in the area, and law enforcement has not cleared it for approach by EMS." Further information reveals there's been a gunshot wound to the face.

     At the scene, law enforcement responders are working to secure the area; they ask that EMS approach quickly. At the house they find a young woman on her hands and knees in the front hallway, blood dripping from her face and neck. Law enforcement personnel are holding remnants of a glass-paneled screen door, and multiple bullet wounds are visible in the door, door frame and walls. The police ask that the crew try not to disturb the doorway.

     In many circumstances, this victim would be removed to another area to begin evaluation and treatment while the police continued their work. But that option is not available here. The woman, around 20, has been shot through the door with a shotgun, and the pellets and pieces of the door have made hundreds of holes in her face, head, neck and upper chest. The shooter, per the cops, was an ex-boyfriend. The victim had somehow managed to shut and lock the main door to keep him from finishing her off. Her child had called 9-1-1.

     The victim can't speak, but makes contact with her eyes. She has wounds across all surfaces of her face and part of her neck, scalp and the front of her chest. Somehow, her eyes have been spared. She'd fallen forward onto her hands and knees and maintained her airway in that position. She is in no respiratory distress, but has blood exiting her mouth and neck. She shakes her head yes or no in response to questions. Her neck doesn't hurt. She is on no medicines, has no allergies or medical problems, and does not believe she's pregnant. That's plenty of information for emergency care, and once the crew notes that more blood drains when she moves her head, they ask her to not move her head and neck anymore.

     The Attack One crew is familiar with unusual airway presentations, and this is one. This young lady would not be able to support an airway in any position besides on all fours. She has many wounds throughout the face and neck, but somehow her airway has been preserved. It would be prudent to leave her in that position for transport. The patient is asked about her ability to maintain her position for transport to the hospital, and she supports that plan. She will have an IV started and be infused with fluids, and given supplemental oxygen.

     The crew arranges a hand signal system by which the patient can notify them if she feels her airway is becoming compromised or becomes lightheaded. Transport time to the regional trauma center will be about 10 minutes, and the emergency department there is alerted to the patient presentation and the need to address her airway on arrival. Once she is placed in the medic unit, she's given a Yankauer suction catheter and asked to use it if it makes her more comfortable.

     The patient is advised that she's in control of her position and the speed of the medic unit. The crew has little ability to control bleeding, since any direct pressure will compress her airway or divert blood into it. A Chux pad is placed underneath her, and warm IV fluids infused to support perfusion.

Hospital Course
     The patient is still responsive as the crew pulls into the ED. The trauma team is waiting on the ramp, and the Attack One crew gives its report. The trauma team tells the patient they'll need to secure her airway, then control the bleeding and evaluate her for other injuries. The blood loss is reaching a critical point, and it will be necessary to get a tube placed quickly, then take her to the operating room to stop the hemorrhage.

     A three-option plan is devised: The patient will be prepared for an intubation through her mouth, using a laryngoscope or digital intubation by the emergency physician. Her neck will also be prepared for surgical cricothyrotomy if the intubation is not successful. For either of these, the patient will need to be sedated, and perhaps put under anesthesia. It will require all hands to safely sedate the patient and roll her to get the airway placed. A second IV is started, and she is prepared to receive blood transfusions in the OR.

     The surgery team cleans her neck and marks a site for a surgical airway. The emergency nurses administer medications to quickly put the young lady asleep, and the Attack One crew assists in rolling her onto her side to do the oral intubation. Several suction devices have been prepared, but as she's rolled, her airway quickly fills with blood. The surgeons make a quick incision in her neck and place a tracheostomy tube through the cricoid membrane. The patient can now be more completely assessed. Damage consists of hundreds of holes with shotgun pellets, pieces of glass and screen material embedded in them. She is moved to the OR for hours of surgery.

     After weeks of treatment, multiple operations and skin grafts, and rehabilitation, the young lady is able to leave the hospital. She soon visits the Attack One crew, whom she credits with saving her life.

Medical Decision-Making
     Penetrating wounds to the face create immediate and profound airway problems. Where possible, the preferred method of management should be a cooperative patient controlling his or her own airway. Spine immobilization should be dictated by mechanism of injury and evidence of trauma to the spine. Many of these patients can be managed without immobilizing the spine, which may simplify airway management. The Yankauer suction tube may be a valuable tool for the patient to use by him- or herself.

     EMS providers should be experienced in working with local hospitals and trauma centers, and able to call ahead when a crisis case is en route that will best be managed at the ED.

Critical Decisions
     What other clues from the scene or patient presentation could have helped diagnosis? The history and rapid evaluation contained all the elements necessary for care.

     Was this the only treatment path for an airway crisis? The best management path was rapid assessment, appropriate packaging and rapid movement of the patient to a trauma center prepared to do an immediate surgical airway should intubation not be successful. In some circumstances with facial injuries, before bleeding and swelling progress, the EMT can perform an oral or digital intubation to secure the airway. In some cases, the patient will need a needle or surgical cricothyrotomy, which can be performed by paramedics in some systems. The EMT in all situations can perform these better with the cooperation of the patient, and through having several options at his disposal.

     What communications are critical for the patient? The most important is the relationship with the patient: establishing a method to communicate and allowing her to control her own airway. Necessary communication was made with medical control about the critical condition of the airway in this patient and the need for emergency department preparation.

     How would this case study be different with a longer travel time to the hospital? Were an uncontrolled attempt made to flip her over and immobilize her on a backboard, this patient would have died. Many systems have access to air ambulances whose providers may bring more skills and tools for airway management. Crews managing critical airways across long prehospital care timelines must be prepared with a number of options for airway management.

     Would different equipment or medication have helped? There are a number of tools for doing airway management through the neck. These should be discussed with EMS system leaders and medical directors.

     Learning Point: Crisis intervention with atypical positioning to maintain the airway following a major gunshot wound to the face and neck.

Case Discussion
     Critical airway problems are best managed with a controlled approach by EMTs and the cooperation of the patient. Certain patients should have their problems deferred for management in the emergency department or operating room. This patient would have been very difficult to manage if the crew had attempted to roll her onto her side or back and intubate her in the field; she likely would have died. Temporizing patient care by allowing her to control her position kept a crisis from occurring. At the hospital there were more people, equipment and options for airway control. Good communication from the field to the trauma center allowed the trauma team to be prepared and the airway to be captured quickly.

     This incident also points out the need for cooperation with law enforcement. Ordinarily, patient care can be moved away from the active crime scene, so police can accomplish their duties. But this patient could not be moved out of the doorway for fear of compromising her life, so the police assisted in her rapid movement to the medic unit. This incident also had a nervous law enforcement group because the shooter could not be located, and they feared he would return to try to complete his murder attempt. The police provided support for the medic unit en route to the hospital, to prevent an attack on the street or at the ED. The shooter was captured later that day when he was, in fact, attempting to find the woman again and murder her.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.