soooo there we were.....

[cookiexd40]

last night me and my partner were at a highschool rodeo standby and about 5 kids from the end of the rodeo a kid got stepped on by a bull and fx his femur. well as me and my partner and the cowboys and the kids mother (a nurse) were getting the traction splint on and him on a long spine board, c-collar, CID, the announcer started playing the top gun theme song quite loudly over the PA lol....as dumb or imature as it might sound i guess i thought it was kind of cool lol...anyways from the time i called dispatch and requested a back up ambulance to come standby while we transported to the time we went enroute to the er scene time was 14 mins...bilateral anticubital ivs 18g one NS and one LR both flowing tko after a 250cc bolus of LR, vitals and the packaging. 14 mins seems pretty good to me considering the situation. anyways...just thought id talk randomly for a bit.


and just for giggles

http://www.youtube.com/watch?v=f90YCdYIADQ

 

[8jimi8]

why did you bolus him?

 

[cookiexd40]

why not bolus him...250cc isnt going to do much one way or the other...severe trauma so i decided to fill him up just a little since we have to start 2 iv per protocol and we dont use hep-lok or saline loks here i jsut gave him a little fluid...intial BP was lik 110 palp so it wasnt gonna hurt

 

[EMSLaw]

I'm sorry... your local high school has a /rodeo/?

Things are just different in Texas.

 

[cookiexd40]

no it was a tri-state highschool rodeo assoc. rodeo finals lol

 

[Shishkabob]

why did you bolus him?

Femur fx... Lots of potential blood loss even if its closed.

 

[cookiexd40]

thanks linuss! 1000-1500 cc potentially in a closed femur fx ...250cc bolus was enough to help the situation in the 4 min transport time to the er

 

[exodus]

Can -i's do pain management?

 

[EMSLaw]

Can -i's do pain management?

Depends on state law and local protocol. It'd be nice with a femur fracture, but I think he said they were four minutes from the ER, so at least any suffering was minimized.

 

[reaper]

May be a dumb question, but why did you fully immobilize him, if he had his leg stepped on? Unless I missed something here.

Why give a bolus for the hell of it? Set to tko and have ready if needed. If the leg showed no signs of bleeding and BP was holding steady, why give fluids? You have to look at long term and compartment syndrome.

 

[cookiexd40]

no i's cant do pain manegment in tx....and it was just 250cc bolus...it was for the potential of inter-thigh bleeding. my protocol. and he was fully immobilized beacuse he was thrown not just bucked off he was thrown off a 2k lbs spinning bull and then stepped on and i dont have xray vision

 

[LucidResq]

May be a dumb question, but why did you fully immobilize him, if he had his leg stepped on? Unless I missed something here.

I'm guessing if his femur was stepped on, he was on the ground. Maybe he was riding said bull and was thrown or otherwise fell?

 

[reaper]

OK,

These kids are "thrown off" every time they ride. That does not mean they are backboarded everytime they get bucked off.

I rode for 20 years and could not stand having to stop EMS from back boarding every rider that hit hard. You have to use assessment and judgement here.

I am not picking on you, just saying that this is not something that falls under MOI. Their bodies take forces all the time, that most people would be crying over. They are used to it. If they are complaining of neck or back pain, then listen very carefully, that means there is something wrong.

You can use the LSB for transport to stretcher, but why make them more uncomfortable, when it is not needed.

Same for bolus. 250ml is not a lot, but why are we giving it for "just in case". Lets assess these pt's and treat off our assessments.

 

[cookiexd40]

reaper as far as im concerned yes you are correct they take a beating all the time but when they actually get hurt and they need transport then im going to do it the way i feel is best...i dont care if there is no head neck or back pain. im going to immobilize the pt if it can be done w/o making him unconfortable. a throw to the ground, no helmet, and then stepped on...that moi to means lsb,collar, cid, bilateral large bore ivs, a bolus then reduce to tko, and the traction splint for the obviously broken femur period....that is my protocol and that is what i feel is best in that particular instance and the difference between you and i is i watched it happen. and if you would have been there then decisons you made would be on the chopping block as are mine now. and if it happens again tomorrow or any other time im probably going to do the same. i dont not have xray vision, and im not a doctor. i am however confortable enough with my knownladge and abilities to challange some thing in the protocol but as far as this MOI is concerned i feel as if the protocol is correct.

 

[MrBrown]

... and there we were all in one place, a generation lost in space with no time left to start again oh so come on, Jack be nimble, Jack be quick ....

I would agree with both that a spine board and fluids were unnecessary.

Once agian, there is nothing magic about oxygen, IV fluid or a spine board and they are often used when not required or in quantities greater than what is prudent or required.

 

[lightsandsirens5]

... and there we were all in one place, a generation lost in space with no time left to start again oh so come on, Jack be nimble, Jack be quick ....

I would agree with both that a spine board and fluids were unnecessary.

Once agian, there is nothing magic about oxygen, IV fluid or a spine board and they are often used when not required or in quantities greater than what is prudent or required.

Yes! Another Don McLean fan.

I would agree that the LSB was a slight overkill. But I would be running fluids as well. With the potential for a loss of 1000-1500 ml per fx femur in an adult pt, why let him slide into shock and then try to bring him back out. Besides, being young, he will probably compensate until he crashes, then where are you? Up Salt Creek with no paddle. I would definately run fluids until we transferred care to the ER. Then they can do whatever they want.

 

[JPINFV]

im going to immobilize the pt if it can be done w/o making him unconfortable.

I'm sure you didn't mean it this way, but that's the most ironic and humorous statement I've ever seen... I'm not sure there's any way to comfortable strap someone down to a long hard board.

i am however confortable enough with my knownladge and abilities to challange some thing in the protocol but as far as this MOI is concerned i feel as if the protocol is correct.

Ok... justify the bolus besides "it's protocol" and "it doesn't hurt."

 

[Epi-do]

OK,

These kids are "thrown off" every time they ride. That does not mean they are backboarded everytime they get bucked off.

I rode for 20 years and could not stand having to stop EMS from back boarding every rider that hit hard. You have to use assessment and judgement here.

I am not picking on you, just saying that this is not something that falls under MOI. Their bodies take forces all the time, that most people would be crying over. They are used to it. If they are complaining of neck or back pain, then listen very carefully, that means there is something wrong.

You can use the LSB for transport to stretcher, but why make them more uncomfortable, when it is not needed.

Same for bolus. 250ml is not a lot, but why are we giving it for "just in case". Lets assess these pt's and treat off our assessments.

But couldn't a femur fx be considered a distracting injury? I'm not saying that the kid wouldn't feel any other pain at all, but could it be possible that the femur hurt bad enough that he is focused on that and not mentioning any other pains that he has? Just a thought - I know our protocol for selective c-spine states that if there is anything that could be considered a "distracting injury" we can't use the protocol.

I am all for not boarding a patient when they do not need it , but some medical directors are more conservative than others. I know the new MD we have is alot more conservative than the one we used to have and he would fully expect this patient to be boarded. (Of course, the new one doesn't work at a Level I trauma center and the old one did. Think that may have anything to do with it?)

 

[Mountain Res-Q]

OK,

These kids are "thrown off" every time they ride. That does not mean they are backboarded everytime they get bucked off.

I rode for 20 years and could not stand having to stop EMS from back boarding every rider that hit hard. You have to use assessment and judgement here.

I am not picking on you, just saying that this is not something that falls under MOI. Their bodies take forces all the time, that most people would be crying over. They are used to it. If they are complaining of neck or back pain, then listen very carefully, that means there is something wrong.

You can use the LSB for transport to stretcher, but why make them more uncomfortable, when it is not needed.

Same for bolus. 250ml is not a lot, but why are we giving it for "just in case". Lets assess these pt's and treat off our assessments.

Protocol based treatment that sets everything into nice clean packages... see MOI X... provide Treatment Y... One day we might actually get to the point where we treat patients and not MOI's... I too would have left the backboard out of the picture until my assessment determined if it was needed.

If the OP felt medically that his actions were correct, fine he was there, we were not... but never use the "I followed protocol" argument to justify actions.

 

[MrBrown]

Yes! Another Don McLean fan.

LOL, American Pie was the first song I learnt the words to.

With the potential for a loss of 1000-1500 ml per fx femur in an adult pt, why let him slide into shock and then try to bring him back out. Besides, being young, he will probably compensate until he crashes, then where are you? Up Salt Creek with no paddle.

Hmmm I sort of see what you are saying. However, there is always "potential" for everything and to be overly blanket with our approach is considered poor practice.

Starting an IV to give access for pain relief is OK (I bet this guy is going to need a good amount of morphine and probably some ketamine) and it will also give us the ability to infuse should it become necessary.

Let us not forget that the evidence seems to be moving towards permissive hypotension for hypovolaemic shock.

Is 250cc the end of the world? No and I don't want to make a mountain out of a mole hill but we should not be dishing out fluids willy nilly.

But couldn't a femur fx be considered a distracting injury? I'm not saying that the kid wouldn't feel any other pain at all, but could it be possible that the femur hurt bad enough that he is focused on that and not mentioning any other pains that he has? Just a thought - I know our protocol for selective c-spine states that if there is anything that could be considered a "distracting injury" we can't use the protocol.

Good point, I did not think of that and our guideline is the same.