I work for a transfer company so I'm not used to dealing with trauma. Just recently we got a call from a psych hospital. When we got there we had found that the pt jumped out of a two story window. It had happened two and a half hours before the hospital decided to call. They had moved the pt back upstairs and had him sitting on the floor. My partner was taking the call who decided to just load and go. I was uncomfortable with this so I stepped in and suggested a c-collar and backboard. The pt refused even after I told him the consequences that could occur. He was A&OX3, had a good pulse, good BP, and only complained of pain at a 5 on a scale of 1-10 coming from his L leg. He had schizophrenia. The pt only agreed to go to the hospital without the c-collar and backboard. My partner told me that we were going to load and go, so that is what we did. It has been bothering me ever since. Was that the right thing to do?
I'm confused.
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Mountain Res-Q
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A couple questions:
Your level of cert?
Your partners level of cert?
BLS transfer only?
Neck pain/deformity/etc?
Was it a "load and go" type of call?
Code 2 transfer?
Transfer to where?
Your level of cert?
Your partners level of cert?
BLS transfer only?
Neck pain/deformity/etc?
Was it a "load and go" type of call?
Code 2 transfer?
Transfer to where?
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First, welcome to EMTLife!
I understand that when you do mostly transfers you sometimes miss the finer points of trauma, as has happened to me on occasion, but there are certain standards of care that should be met. A patient that jumped out of a window is a clear candidate for head/neck/spinal trauma, and should have been at the very least c-collared and immobilized.
I've had calls at the local jail on occasion where a patient was in an accident, brought in, and then complained of pain, and even hours later they're collared and immobilized. Sometimes they're compliant, and sometimes we need additional assistance from staff/PD, but it really all goes back to the basics.
A big piece of the puzzle is missing though, and we don't know the patient's condition. What made this patient "load and go"?
This call serves as a great learning experience, and you may want to take a refresher course or review sections in your EMT-Basic textbook so you can get out of the "transfer-slump" and get back to seeing the bigger picture.
I understand that when you do mostly transfers you sometimes miss the finer points of trauma, as has happened to me on occasion, but there are certain standards of care that should be met. A patient that jumped out of a window is a clear candidate for head/neck/spinal trauma, and should have been at the very least c-collared and immobilized.
I've had calls at the local jail on occasion where a patient was in an accident, brought in, and then complained of pain, and even hours later they're collared and immobilized. Sometimes they're compliant, and sometimes we need additional assistance from staff/PD, but it really all goes back to the basics.
A big piece of the puzzle is missing though, and we don't know the patient's condition. What made this patient "load and go"?
This call serves as a great learning experience, and you may want to take a refresher course or review sections in your EMT-Basic textbook so you can get out of the "transfer-slump" and get back to seeing the bigger picture.
Sasha
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How well would that have worked? I think forcing him down onto the backboard (if he didn't want it, I imagine he'd put up a fight when forced) may cause more trauma than transporting him sans backboard.
Did he have neck or back pain? Studies show that the instances of patients requiring immobilization without the presence of back or neck pain are few and far inbetween.
Let's move away from the Bake-A-Medic protocols and backboarding everyone. Just because it's trauma doesn't mean it's spinal trauma.
true, but his leg pain could be classified as a distracting injury and he could be more focused on his leg, than any neck or back pain he might be having. i thought a 20ft fall is significant enough moi regardless of amount of time that has passed.
I agree, but I dont, and outside Maine and New Hampshire I dont think anyone has street spinal clearance protocols. I am more interested in whether the patient can refuse a treatment (immobilization). If he is in a psych facility, they often are not their own medical proxy. Is there a nurse of MD there who can sign for hte patient. I tend to like to adapt the RMA form for patients who refuse a specific treatment, especially boarding.
Details re: physical exam? Type of psych facility? Was this a 911 or transfer call? What was teh receiving facility?
Details re: physical exam? Type of psych facility? Was this a 911 or transfer call? What was teh receiving facility?
Sasha
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At a 5/10? I'd be hard pressed to believe that, but maybe, but going back to my first point. Do you think he'd sustain more damage wrestling him to the backboard and keeping him on the backboard than in a nice calm ride to the hospital?
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I'm not sure it matters what we think. I have protocols to follow.
Sasha
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Down here we have an option of going outside of our protcols with med director approval, which is just a radio call away.
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Do you really think any doctor is going to allow you, as an EMT-Basic, to clear c-spine precautions in the field? I've called in for a lot of things, but this wouldn't be one of them.
Sasha
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Do you really think a doctor would want you to put YOUR safety at risk by irritating a psych patient who has already proven by jumping out of a window that he has no qualms over dying?
Do you think a doctor would find it more prudent for you to wrestle a patient onto a backboard, causing more spinal trauma than a nice calm ride to the hospital would, being the patient is asymptomatic, complaining of a 5/10 leg pain but NO neck or back pain?
As long as you can logically justify it, most doctors here will give you what you want, from my limited experience.
LucidResq
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I'm going to have to agree with Sasha on this one. If it was immediately after the incident, I would probably try to immobilize him, but if he struggled I probably would not continue. Not in the best interest of our safety or the best interest of the patient... unless he could somehow be safely sedated by the hospital staff. Would that be allowed?
The first and foremost protocol for most, if not all, EMS agencies is to act in the best interest of the patient. Sometimes that means deviating somewhat from the other protocols.
"Deviation from the protocols is occasionally necessary due to the vast array of complex clinical presentations. It should always be done with the patient’s best interest in mind and backed with documentable and defendable clinical reasoning and judgment." (from my protocols)
Noting this, perhaps in your situation, med_gal, it would have been best to immobilize. I'm kind of disappointed that your partner didn't at least consider following your notion to err on the side of caution. Unless you were completely off base, I would respect your intuition to take what may have been the more cautious route. If an attempt at boarding resulted in a thrashing, combative pt, however, I would likely abandon it.
The first and foremost protocol for most, if not all, EMS agencies is to act in the best interest of the patient. Sometimes that means deviating somewhat from the other protocols.
"Deviation from the protocols is occasionally necessary due to the vast array of complex clinical presentations. It should always be done with the patient’s best interest in mind and backed with documentable and defendable clinical reasoning and judgment." (from my protocols)
Noting this, perhaps in your situation, med_gal, it would have been best to immobilize. I'm kind of disappointed that your partner didn't at least consider following your notion to err on the side of caution. Unless you were completely off base, I would respect your intuition to take what may have been the more cautious route. If an attempt at boarding resulted in a thrashing, combative pt, however, I would likely abandon it.
i know it is kinda far fetched but i was just trying to make a point. i agree that he would sustain more injury with us trying to struggle with him. i would probably try and compromise with him and at least get a collar on him and lay him flat on the cot, after talking with a doc at the trauma center to get an ok.
i've transported a patient from a hospital that said cspine was cleared to a level one trauma for a tibia fracture post motorcycle wreck. first thing they did after we transferred her to the bed was take cspine precautions even though she wasn't complaining of any neck or back pain.
As a Basic EMT in Maine, we are allowed to use the spinal protocal provided that we have taken the class for it. If the person can pass every test we don't have to imobilize them. but ive imobilized before even when the person could pass just because of a gut feeling. if there is any dought in someones mind, they should be imobillzed.
In this case, i probably wouldn't have imobilized because if someone is trying to fight you they are going to cause more damage to themselves then if you can get them straped to the cot and keep them calm.
this is probably a case of you're d*mned if you do and you're d*mned if you don't. granted it would make his injury worse if you have to fight him, but you have to deal with a possibility of a fracture that can become worse and paralyze him. if that happens he'll sue you and even though you documented that he refused treatment, he'd probably win and you'd be out of a job.
Mountain Res-Q
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The issue for me here is that they are a BLS level transfer ambulance, correct? They should never have taken the patient in the first place IMHO. I'm drawing this conclusion becaseu when I started in Ambulance I was "forced" to do only BLS transfers for 6 months and then jump on ALS 911 calls. At teh BLS level transfers indicated that a patient is stable and in need of a continuation of care to be provided at another facility. I.E. granny breaks a hip, gets sx, and will now rehab at a SNF. No emergency or new injuries, we are just assuming pateint care from teh hospital and transfering her into the care of the SNF nureses. In this case, why were we trandfering from a psych facility? and where to? I assume that the patient was being taken to the hospitl for injuries associated with the fall. It shouldn't have been treated like a transfer call. Example: We once had a transfer from a psych facility to a OB center for a woman that tried to commit suicide weeks earlier and was now in labor. Labor is BLS, but this was not just a transfer of a phsych pateint to another facility that would continue the treatment/care for the existing problem. A psych doctor, even being a doctor) isn;t really in a possition to diagnose a new set of injuries and order you to transfer. They can try, but for use, we had no obligation to take any patient on a transfer if we didn't feel like this was a BLS trandfer call.
I would have called the shift supervisor, explained teh situation, and asked for his thoughts. Knowing my supervisors, I would have been told to standby there and continue patient care, do not abandon the patient and wait for the ALS rig that would be there shortly. If, by chance, Iwas told to transfer (reluctant) I would have strongly recommended the c-spine recautions, but wouldn't have pushed the issue (DOCUMENT, DOCUMENT, DOCUMENT). Example:
We transfered a dialysis pateint from a SNF to get treatment in the am. We went to pick him up and return him several hours latter. However, this normally jovial man, was quiet and distant (major ALOC). The nurse at dialysis said, "Oh he's been like that all day." I checked a quick BP and it was like 80/40 (normal of 140/90) and he didn't seem to recognize me or what was going on. The SNF is 2 blocks in one dirrection and the Hospital wa 1 block in teh opposite. The nurse looked at the BP and said, "Maybe you should swing him by the ER." What do you do? We called dispatch and asked for an ALS rig. One was at the hospital and showed up in 60 seconds. Turns out his bood chem was all out of wack (no details were given to me). Should we have transferred him anyway? It was no longer a transfer call becaseu another condition existed seperate from the original call given me by dispatch.
Just my thoughts from a lowly EMT who ran a trasfer or two or a thousand. And yes, we back board way to much to CYA. Most don;t have the symptoms to warrent it and those that do usually don't have a thing wrong with them.
I would have called the shift supervisor, explained teh situation, and asked for his thoughts. Knowing my supervisors, I would have been told to standby there and continue patient care, do not abandon the patient and wait for the ALS rig that would be there shortly. If, by chance, Iwas told to transfer (reluctant) I would have strongly recommended the c-spine recautions, but wouldn't have pushed the issue (DOCUMENT, DOCUMENT, DOCUMENT). Example:
We transfered a dialysis pateint from a SNF to get treatment in the am. We went to pick him up and return him several hours latter. However, this normally jovial man, was quiet and distant (major ALOC). The nurse at dialysis said, "Oh he's been like that all day." I checked a quick BP and it was like 80/40 (normal of 140/90) and he didn't seem to recognize me or what was going on. The SNF is 2 blocks in one dirrection and the Hospital wa 1 block in teh opposite. The nurse looked at the BP and said, "Maybe you should swing him by the ER." What do you do? We called dispatch and asked for an ALS rig. One was at the hospital and showed up in 60 seconds. Turns out his bood chem was all out of wack (no details were given to me). Should we have transferred him anyway? It was no longer a transfer call becaseu another condition existed seperate from the original call given me by dispatch.
Just my thoughts from a lowly EMT who ran a trasfer or two or a thousand. And yes, we back board way to much to CYA. Most don;t have the symptoms to warrent it and those that do usually don't have a thing wrong with them.
Sasha
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A huge pet peeve of mine.
How far away was this psych facility from a hospital? How far out would an ALS unit be?
Would you, at a BLS level, be able to get this patient to definitive care significantly quicker than it would take for an ALS unit to get there and take them to definitive care?
From the information given (besides being crazy) this patient sounds stable.
How far away was this psych facility from a hospital? How far out would an ALS unit be?
Would you, at a BLS level, be able to get this patient to definitive care significantly quicker than it would take for an ALS unit to get there and take them to definitive care?
From the information given (besides being crazy) this patient sounds stable.
Sasha
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If it turns out he has a neck fracture and ends up paralyzed, he can also argue that you forced him down on the backboard, despite the fact he refused, and the wrestling him down further irritated his injury and may have caused the paralysis and sue you.