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Scenario: Fall from Height — Oil Field, Rural San Juan County

Difficulty: MODERATE Category: Trauma — Multi-system Generated: 2026-04-04

Dispatch

Unit 2, respond to an oil well pad on County Road 4900, northeast of Bloomfield. Caller reports a worker fell from a rig platform. Approximately 20-foot fall. Patient is conscious. Additional units and helicopter may be requested. Time out: 0832.

Scene Size-Up

Gravel road, 4 miles off NM-544. You arrive at a Permian Basin well pad with 5–6 workers standing around a male lying on the deck grating. Rig is still operating — site supervisor waves you in and says the rig is shut down. Slippery metal grating, narrow access, no space to land helicopter nearby. Approximately 1 patient. Significant MOI: 20-foot fall onto metal grating.

Patient Presentation

Chief complaint: "My back — I can't feel my legs."

Bystander info: Fell backward off a platform approximately 20 feet up. Did not land on his head. Coworkers held c-spine as soon as he went down — one is still holding it manually.

Physical exam: - AVPU: Alert, oriented × 4 - Age: ~35, male, safety harness partially on (failed to clip) - Airway: patent, speaking in full sentences - Breathing: 24/min, shallow, complaining of right chest pain with each breath - Circulation: HR 118, radial pulse weak. BP 90/64. Skin pale, cool. - Neuro: cannot move or feel bilateral lower extremities. Hand grip weaker on right. - Visible injuries: right chest wall bruising and tenderness (ribs 4–7), no tracheal deviation, no JVD noted. Pelvis stable on compression. No obvious long bone fractures. - SpO2: 91% on room air

Vitals: - BP: 90/64 - HR: 118, weak radial - RR: 24, shallow - SpO2: 91% - Skin: pale, cool, diaphoretic

Assessment Steps
  1. Scene size-up — BSI, scene safety (rig shut down, supervisor confirms), slippery terrain noted, 1 patient, significant MOI (20 ft fall). C-spine already held by bystander — thank them and take over or maintain.
  2. Primary assessment — Alert, airway patent. Breathing: 24/min, shallow, SpO2 91% → inadequate oxygenation, high-flow O2 now. Circulation: BP 90/64, HR 118, weak radial → hemorrhagic/neurogenic shock. Priority patient.
  3. Simultaneous — High-flow O2 via NRB. Manual c-spine. Call ALS + medical helicopter (tight access — coordinate landing zone with site supervisor away from rig).
  4. Rapid trauma assessment — Head-to-toe DCAP-BTLS. Right chest wall tenderness + bruising + SpO2 91% + shallow breathing → suspected rib fractures, possible pneumothorax or hemothorax. No tracheal deviation or JVD (tension pneumo less likely right now but watch).
  5. Neurological — Bilateral lower extremity paralysis + right hand weakness after fall = spinal cord injury until proven otherwise. Maintain strict spinal motion restriction.
  6. Reassessment — Vitals every 5 min. If SpO2 drops further or tracheal deviation appears → ALS for needle decompression.
Interventions
  1. Spinal motion restriction — Manual c-spine throughout. Apply correctly sized cervical collar. Move to long board via log roll with 4-person team (bystanders can assist if directed). Body straps before head. Reassess PMS after securing.
  2. High-flow oxygen — NRB at 15 LPM immediately. Target SpO2 ≥94%. Reassess continuously.
  3. Chest — monitor — Right chest tenderness + shallow breathing. Apply a 3-sided occlusive dressing if any open wound is found (none described, but examine carefully under clothing). Do NOT apply tight circumferential wrap (splinting ribs is outdated and worsens breathing).
  4. Shock management — Supine (already on board). Leg elevation contraindicated if spinal injury suspected (it may worsen spinal alignment). Keep supine, warm, priority transport. IV/IO en route (ALS scope).
  5. LZ coordination — Identify flat area ≥100 ft from rig. 100×100 ft minimum. No power lines. Brief helicopter crew on MOI on radio.
  6. Package rapidly — Scene time goal: under 10 minutes. Every minute of hypotension with a spinal cord injury worsens long-term neurological outcome.
Transport Decision

Priority — air transport if achievable without delay. Destination: UNM Hospital (Albuquerque) is the Level I Trauma Center for NM. SJRMC (Farmington) is the closest facility but is not a trauma center — it can stabilize, but this patient needs neurosurgery and thoracic surgery capability. Coordinate with medical direction on destination.

If helicopter is unavailable or LZ is not feasible: ground to SJRMC with ALS intercept, with request for inter-facility transfer to UNM or UNMH.

Key Takeaways

What this tests: Significant MOI trauma, multi-system injury (chest trauma + suspected spinal cord injury + shock), prioritization under difficult scene conditions.

Common mistakes: 1. Treating BP first before airway/breathing — SpO2 91% and RR 24 shallow is the immediate kill. Oxygen before worrying about the BP number. 2. Elevating legs for shock when spinal injury is suspected — do not. Keep supine flat. 3. Spending too long on scene — packaging + loading should be under 10 minutes. Definitive care for this patient is in an OR. 4. Skipping the LZ coordination — this is rural San Juan County. Air transport changes outcomes here. Get that call in early. 5. Missing the right chest injury — always examine under clothing.

NM protocol note: NM spinal injury protocol: patients should NOT be routinely transported on long boards for spine precautions alone. However, this patient has a significant MOI, active neurological symptoms (bilateral LE paralysis), and unstable vitals — full SMR on long board is appropriate.

chest-trauma | spinal-injury | shock | spinal-immobilization-supine | bleeding-control-shock | scene-size-up | secondary-assessment