Vehicle accident

[Dwindlin]

I've never used serial 7's (nor have I seen any of the geriatricians/neurologists use it), I always have them spell world backwards. Way less thought involved on my part to make sure they are correct.

 

[Melclin]

Funny. I went to a very similar job just the other day.

19YOF rolled her car off a dirt road into a ditch. Self extricated through the smashed drivers side window. Ambulating normally O/A. Pt was shaken and largely uninjured with the exception of several small lacerations on her hands.

I dressed her hands and sent her home in the care of her father in law, with instructions about calling back/self presenting to hospital and some minor head injury advice just in case.

Difference was though that she had a HR 102 not 150 odd. I would be more concerned with that HR. My preference would be to see how it trended with some calming influences during my assessment. If it trended to almost normal in that space of time with some deep breathing and in a calm environment, I would be more happy to let her make her own choices about going home (my chick's HR went from 102 to 80 in the 10 or so minutes I was chatting to her). I'd have to say though, that my preference would be to transport your girl and just stick her in the hospital waiting room at the very least. In all honestly, probably just to cover my arse. I'd find it difficult to sit there are confidently argue that I was right to balance a persons life on the assertion that a HR of 150 after a serious crash was entirely anxiety related.

But as far as the refusal goes, its pretty simple. They refused. You can't kidnap them. Its their problem now. Just make sure its all documented properly.

I'd probably give a short radio report saying that the patient went AMA on account of them being recorded lines.

 

[phideux]

Had one not too long ago. 20yo girl says she saw "an animal" maybe a dog in the road, on a curve, alongside a marsh, 3am. She left the road, luckily at low tide, and her car ended up about 50ft into the marsh, on it's side. By the time we got there she was out of the car, back on the road, covered head to toe in "Pluff Mud". She was alert and oriented, the only mark on her was a couple of cuts on her leg from the oyster shells in the marsh. She was freaking a little, HR in the 140s, but she eventually calmed down. She signed a waiver.

 

[Melclin]

Idk how it is by you but over here mechanism of injury alone is not a ruling for spinal immobilization.

Her vitals are fine...

Her respirations are a little elevated and her HR is up there but its not so high for a 19 year old girl who just rolled a car and is freaking out.

Would have stayed with her for a little while, bandaged her hand and if she doesn't wanna go tell her sign here.

The report should clearly state where she is signing that she has been told to go to the hospital and regardless of her best interests has decided not to.

If it bothers you that much to RMA her, call the doc. Then its off your shoulders.

Moi shouldn't be a reason to use c spine. I'd throw her on the monitor after doing a physical exam.

The canadian c-spine rule recommends pts involved in high mechanism trauma be imaged (and I think we can assume we should be immobilising the same cohort of pts).

Also, in terms of reliability, I think a person involved in a seriously massive car accident may not really be reliable for exam in some cases (most of mine have been a little spacey at first), remembering that the NEXUS study was pretty anal about establishing reliability. I'm generally of the opinion that one should shoot first and ask questions later when it comes to at least begining the immobilisation process with these pts. You can always take a collar off when everything has calmed down a bit and your more satisfied with a thorough exam.

 

[Aidey]

The Canadian c-spine rule says consider imaging for high mechanism trauma, which it defines as auto vs ped, ejection, or high speed* rollover, none of which seem to be present here.

They define high speed as >60mph

 

[Tigger]

How is she altered? If she answers all my questions with no issue and I find her to be AOx4 then there is not much you can do. Have her talk to med control, try to talk her into going. If still no then have her sign AMA. Make sure you document the heck out of the call and make sure you advice the patient to go to the hospital by some other means since she doesn't want to go by ambulance.

If your patient is AOx4, not on a psych hold, not under police protective care, and is charge of their own care then it is kidnapping if you transport them against their will.

I guess the question is more along the lines of "if she has a concussion, is her mental status therefore altered making her unable to refuse, regardless of her answers to questions?"

 

[DesertMedic66]

I guess the question is more along the lines of "if she has a concussion, is her mental status therefore altered making her unable to refuse, regardless of her answers to questions?"

If she answers all the questions correctly and without trouble then she is not altered...

 

[Veneficus]

just out of curiosity...

was the pt belted?

 

[Melclin]

The Canadian c-spine rule says consider imaging for high mechanism trauma, which it defines as auto vs ped, ejection, or high speed* rollover, none of which seem to be present here.

They define high speed as >60mph

First, patients judged to be
at high risk due to age, dangerous
mechanism of injury, or paresthesias
must undergo radiography.

This is from the original paper and it sounds reasonably unambiguous to me. Maybe I've missed something?

I agree that none may have been present here. It was just a response to the idea the mechanism is completely irrelevant in the application of precautions.

 

[Aidey]

Hmmm, that is what I heard from a MD involved in PHTLS*. Maybe it is a difference between information in the abstract and the full text?


*Not directly, a rebuttal they wrote to something made its rounds via e-mail. I was CCd on the e-mail from a reliable source.

 

[Melclin]

Hmmm, that is what I heard from a MD involved in PHTLS*. Maybe it is a difference between information in the abstract and the full text?


*Not directly, a rebuttal they wrote to something made its rounds via e-mail. I was CCd on the e-mail from a reliable source.

The quote was from the full text. The following, from the abstract seem even more absolute. Not having a crack at you, its just that I've been pouring over the spinal literature RE my own recent conundrum (See the 'to collar or not to collar' thread), so I thought I'd just point out what I've read.

The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age 65 years, dangerous mechanism, or paresthesias in extremities)? (

Bold added.

 

[Aidey]

Interesting, I received a printed version of the e-mail, I will have to look around and see if I still have it. The reason I remember it is because 60mph seemed fast, in the past 45mph has seemed to be the cut off for high speed vs not.

 

[Melclin]

Interesting, I received a printed version of the e-mail, I will have to look around and see if I still have it. The reason I remember it is because 60mph seemed fast, in the past 45mph has seemed to be the cut off for high speed vs not.

I was a bit confuzulated by the 60mph thing. It does seem surprisingly high. 45mph or there abouts is considered a significant in our mechanism discussions too. It lists a surprisingly high speed for its MVA criteria but then next to it, the surprisingly ambiguous "rollover" (with no qualifying remarks, so, strictly interpreted, it could mean any rollover at all. It really could do with some sort of "serious rollover" or "rollover >45mph" etc). PM me if you don't have access too, but would like, the full text to have a bit of a squiz.

 

[emergancyjunkie]

just out of curiosity...

was the pt belted?

Yes the patient was belted