A 35-year-old crashes their car into metal railings at the side of the road. The railings collapse, leaving the top rail exposed. The top rail comes through the front of car and into the patient’s right chest, about two inches above the costal margin and three inches lateral to sternum. The rail, which is two inches wide and one inch thick, goes completely through patient and out the back of the seat for approximately 18 inches.
The patient is found pale but awake in the car, GCS 15. They’re in pain and struggling to breath, owing to the pain and reduced air entry on the right side. The crew is unable to percuss due to environmental noise. Blood can be seen oozing freely from around rail and lung tissue is visible on the pole behind the patient’s seat. The patient has an intermittent thread radial pulse and the crew is unable to get reliable blood pressure measurement. The patient’s saturations are 98% on oxygen but respiratory rate is 30.
Over an hour is spent getting tech rescue and preparing to free patient. Small aliquots of analgesia are given to facilitate the cutting of pole, both behind and in front of patient. The patient is finally released and extricated out of the car onto their right side with the 18 inches rail still through patient.
The patient is now on their side on trolley and the hospital is approximately 15 minutes away.
How would you have managed this patient before extrication?
How would you manage this patient now?