Off-roading accident in a rural emergency room

Living in an apartment above Kremmling Memorial Hospital (KMH), just shy of 30 miles away from where I'm working this month, did have its silver linings. I met several doctors who rotate through KMH; they alternate covering emergency room shifts and making rounds on the long-term-care patients. All of them were very nice, talked a lot about their experiences as rural physicians, and asked me if I wanted to be called if an interesting case came in downstairs. Yes, of course!

This only happened a few times. The most exciting case was a young guy who had an accident while off-roading. He caught some air when going over the top of a hill, landed the wrong way, and was thrown from his vehicle with it rolling over him.

He had hit his head but was helmeted and never lost consciousness. There were no signs of head trauma, and there were no neurological deficits. He denied neck pain and was taken out of the C-collar after physical exam and x-rays showed no damage to his cervical spine. He was taken off the backboard after physical exam showed no injury to the rest of his spine.

He denied any shortness of breath and lung sounds were normal. He did not have any abdominal complaints, and abdominal exam was normal. Interestingly, an ultrasound FAST exam was not done because KMH does not have a portable ultrasound machine.

The major problem was a deep wound in the medial aspect of his right lower leg that extended down to the tibia. He was able to wiggle his toes but could not plantarflex (like stepping on the gas pedal). The wound was full of dirt and gravel. We were able to stop the bleeding with gauze and pressure. X-ray showed that the bone was not broken. He was given Dilaudid to manage the pain of his leg injury and clavicle fracture.

The doctor explained to me that he had to assess whether there was tendon involvement because that would dictate whether he should send this patient to a higher level of care or just close the wound. We numbed the wound with injections of lidocaine/epinephrine and cleaned it thoroughly. The whole time, his off-roading buddies were taking pictures and video on their iPhones. With the wound all numbed and cleaned out, I could see his extensor digitorum longus tendon move back and forth when he wiggled his toes.

The doctor decided that it would be best to send this patient to a higher level of care because the patient still could not plantarflex. The two options for higher-level care from Kremmling are Steamboat Springs and Denver.

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This case was interesting to me for two main reasons, aside from the excitement of trauma. First, this trauma was the result of an off-roading accident, something that I would be much less likely to see in the city. Second, I got to see how this rural doctor, covering the emergency department of a small hospital, first assessed the seriousness of the injury and then negotiated the system in order to figure out the appropriate transfer of care. Events would have unfolded slightly differently if this were at University Hospital Emergency Department.