ORV accident

[ffemt8978]

You are dispatched to an ORV accident involving a preteen child. Upon arrival, pt. was alert but did not remember the accident. Bystanders state that patient had a LOC but weren't sure how long it would take. Pt. c/o pain in LLQ but denies head/neck/back pain. Pt. is very repetitive but has no obvious injuries.

Vitals: WNL
Lungs clear bilat
Abd. soft and tender in LLQ to palp.
Pupils PERLA
CMSx4

Parents are not on scene, but you have phone contact with them. They're in a town with a Level 4 trauma center. Transport time to a Level 3 Peds Trauma center is about the same amount of time.

Parents initially wanted to refuse transport, but then wanted transport the the Level 4.

What would you do?

 

[Sasha]

Initially I want to say you have to listen to the parents, so transport to the level 4, but the patient could recieve better care which may or may not make a difference on their prognosis at the level 3, so Id call medical direction and leave it up to them.

 

[akflightmedic]

First, I never would have had the parents on the phone at this point based on patient presentation.

Second, if I did contact them, I would have informed them enough to let them know their child is not dying at this very moment and then I would tell them their child is being transported to XYZ Pediatric hospital. I would make no mention of a different hospital even as an option.


You have to be a patient advocate and in this case, since the distances are the same, then go with the one that would best serve the patient.

 

[karaya]

Yeah, I agree with akf. The LOC alone would be enough for our non pediatric hospitals to force a divert to a ped trauma center.

 

[ffemt8978]

I forgot to mention that you're covered by a state law that says you MUST transport to the most appropriate facility if they meet certain criteria, which LOC is part of. :blush:

 

[marineman]

Between the LOC and the Tender LL abd I'd very politely let them know that while their child does not have any obvious life threatening injuries my protocols require that I go to the level 3.

Talk to the parents like adults, let them know their child probably won't die because of this but you have orders to follow and they don't necessarily have a say in the matter at this point.

On a side note does anyone know for sure if parents being on the phone can make choices regarding medical care for a child or would we treat it the same as no parents unless they're physically on scene? Did that even make any sense?

 

[AnthonyM83]

While not always the case, when you properly and very seriously explain the necessity of a specialty hospital to a family member, they rarely continue to refuse. Worry them just enough to allow the transport.

Let them know that if their child needs certain life-saving procedures, their hospital of choice will not be able to provide them (despite having a better reputation...if that's what they're basing their decision on) and may not be able to "get him back to normal" (referring to mental status).

As far as what I'd do on-scene. He's a priority load & go patient due to the abdominal pain, repetitive questioning, and mechanism of injury...so get him going. Keep reassessing VS/perfusion.

 

[mycrofft]

Tenterhooks; duty (to pt ) versus law (parent's permission)

You mght try to find out why they want the lower rated facility, maybe the kid is under treatment there for some other complicating condition. Or Aunt Clarisse works in the billing dept.

Once you contact the parents they can state their preferences, but if it is not based on complete and completely understood data it is not informed consent. If they purposefully or ignorantly direct a harmful course of action you have a duty to correct that because your duty to the patient supersedes that (if any) to the parents and your employer. You will have to make the call and pray you make it right, and document the excremento out of it. Anything happens to a kid (or hands or eyes) and the jury will award to the plaintiff, and the company will toss you first thing; however you may have saved a kid's life.

I once had a parent ask her eight year old if he wanted to go to the hospital after he had a hyperextension injury (football scrimmage) of the lower back with pain and c/o left thigh paresthesia. We called for the ambulance then and there, no problem once it arrived.
(I use the term "parent" loosely here).

 

[YouthCorps1]

whatever the parents say...you do it! if the parents were not in contact...THEN go ahead and use implied consent. check for MOI...how fast was he going? how much damage to the quad? all vitals normal...abd pain calls for internal bleeding. start patient on o2 in a nasal cannula on 2-lpm. if poss, get ready to est fluids and have a mask ready incase he has a syncopal episode...throw him on a backboard anyway...transport and do a trauma check...reassess vitals every 15 or so

 

[ffemt8978]

whatever the parents say...you do it! if the parents were not in contact...THEN go ahead and use implied consent. check for MOI...how fast was he going? how much damage to the quad? all vitals normal...abd pain calls for internal bleeding. start patient on o2 in a nasal cannula on 2-lpm. if poss, get ready to est fluids and have a mask ready incase he has a syncopal episode...throw him on a backboard anyway...transport and do a trauma check...reassess vitals every 15 or so

No, you don't always do what the parents say. State law trumps the parents around here, and the law says you transport to the closet appropriate facility.

 

[flhtci01]

Once you contact the parents they can state their preferences, but if it is not based on complete and completely understood data it is not informed consent. If they purposefully or ignorantly direct a harmful course of action you have a duty to correct that because your duty to the patient supersedes that (if any) to the parents and your employer. You will have to make the call and pray you make it right, and document the excremento out of it. Anything happens to a kid (or hands or eyes) and the jury will award to the plaintiff, and the company will toss you first thing; however you may have saved a kid's life.

I agree. Once had a kid with altered LOC secondary to a probable concussion. Talked to mom on the phone, she was adamant that I should send him home (a couple hours away) with a friend (another minor). He ended up getting packaged and a ride to a facility in the direction of home. Documented the excrement out of it. Never heard anything more.

 

[BossyCow]

whatever the parents say...you do it! if the parents were not in contact...THEN go ahead and use implied consent. check for MOI...how fast was he going? how much damage to the quad? all vitals normal...abd pain calls for internal bleeding. start patient on o2 in a nasal cannula on 2-lpm. if poss, get ready to est fluids and have a mask ready incase he has a syncopal episode...throw him on a backboard anyway...transport and do a trauma check...reassess vitals every 15 or so

Sweetie, aren't you tired of being wrong yet?

 

[mycrofft]

Youthcorps, stick around and read some.


Three rules we all need in all important pursuits*:
1. Calm down.
2. Step up.
3. Do what's correct and best (for the pt).

If the pt's parents (or anyone) dictate a lethal measure and you do it, you are wrong. If you do the right thing but they sue you, you are still right, even if you lose. This is not to suggest we pursue our own course of action in abeyance of competent authority, such as your protocols, but not to let exterior pressure or internal excitement cause you to do wrong, or fail to do at all.
It's OK to be "uber-technical" to begin with, that's why rookies got old fogies around, to temper their enthusiasms.

*not involving romance, dancing, or other means of decompression.