# Did I provide sufficient EMT care? 7 y/o hit head on slide



## r4state (Jun 15, 2011)

Hi guys! I'm a newbie EMT-B, and I'm very paranoid about the quality of care I provided since it's my first call BY MYSELF. I would like comments/critiques, and feel free to be as harsh as you'd like. 

I was called to a water park because a 7 year old hit her head coming down a 20+ feet slide. Lifeguards back boarded her in the water and they brought her out for me to check. While someone held c-spine, i slipped on a c-collar and started talking to her, asking for her name, her age, what happened, and what hurts. She only said her head hurt, and I made sure she wasn't hurt anywhere else such as her back and neck. I did a quick pat down and found nothing unusual. She had a thumbnail sized scrape on her forehead. Her pupils were PERRL, HR 100. The only thing unusual was her skin, which was cold and clammy due to the fact that it was windy and the water was chilly. Even though we had a towel around her, she was still shivering like crazy, so I really wanted her to warm up. Since I found nothing else wrong, we got her off the backboard while she still had a c-collar on. I told her mom that an ambulance isn't necessary but she should still see a doctor just in case. Her mom took her to a clinic to get checked out. 

Thanks for your help! I've never worked alone before, so I felt paranoid that I might have missed something... not to mention this is my first job as an EMT.


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## MrBrown (Jun 15, 2011)

Brown is satisfied your care was appropriate.

Did you ask about loss of consciousness or any altered sensation at all? It's not the end of the world but Brown would ask


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## r4state (Jun 15, 2011)

I did not, and that's a very good idea. Thank you, I will remember that next time.


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## 18G (Jun 16, 2011)

Sounds like you made a good assessment of the situation and the right disposition. 

I would only add that you applied a cervical collar. Just curious what your suspicion or reasoning was for applying it only to later take it off? You justified putting it on, what was the justification for taking it off? What changed your mind? Again, just curious and make sure to always document why you "un-immobilize" someone. 

Agree with Brown... ask about loss of consciousness... but hey, none of us are perfect.


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## rmabrey (Jun 16, 2011)

r4state said:


> . I told her mom that an ambulance isn't necessary but she should still see a doctor just in case.



Im curious as to why you said this? In a RO we are told to inform the patient of all consequences up to and including death, however you've done virtually the opposite. I trust your assessment that she didn't need to go, purely curiosity.


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## JPINFV (Jun 16, 2011)

This is why amusement parks need their own first aid staff. 



rmabrey said:


> Im curious as to why you said this? In a RO we are told to inform the patient of all consequences up to and including death, however you've done virtually the opposite. I trust your assessment that she didn't need to go, purely curiosity.




...because you can't always play those cards. Did you ever visit the school nurse growing up? What would have happened if every time you visited the nurse it was, "Well, you should go to the hospital OR YOU COULD DIE!"? Some calls really are a, "You just have a bump, don't worry about it," and this is doubly true (however not the case here) if you have any sort of 'clinic' type job like running first aid at a water park.


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## Akulahawk (Jun 16, 2011)

Something to think about: sometimes people won't remember "blacking out" or "losing consciousness." A 7 year old probably won't understand that concept anyway. Try asking them if they remember waking up.


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## rmabrey (Jun 16, 2011)

JPINFV said:


> This is why amusement parks need their own first aid staff.
> 
> 
> 
> ...



Very good analogy. Simply curiosity, I know not all systems are the same, and not everyone needs a hospital. I just prefer to cover my butt.

I would have chosen to say something like "I recommend she go see a doctor to be checked out, would you like us to take her". If mom says no go through the steps of a refusal.


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## r4state (Jun 16, 2011)

18G said:


> Sounds like you made a good assessment of the situation and the right disposition.
> 
> I would only add that you applied a cervical collar. Just curious what your suspicion or reasoning was for applying it only to later take it off? You justified putting it on, what was the justification for taking it off? What changed your mind? Again, just curious and make sure to always document why you "un-immobilize" someone.
> 
> Agree with Brown... ask about loss of consciousness... but hey, none of us are perfect.



I never took off the c-collar.

And thank you everyone, all of your comments are extremely appreciated! I'm actually not with an ambulance, I'm more like a first-responder with an EMT-B certification that specifically goes to the waterpark for calls so that the team actually working with the ambulance will be available for more urgent calls.


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## JPINFV (Jun 16, 2011)

So, wait, do you work for the ambulance service or work for the water park?

If you're working at the waterpark, then you need to get used to making an actual disposition for your patients. You're options are basically, the patient can stay, the patient needs to go home, the patient needs to go to an ED or urgent care via POV (preferably with a group/friend/family member), non-emergent ambulance, or emergency ambulance. Also, remember that you have the option of them calling their primary care physician to help determine where they need to go. Working at a waterpark is a clinic job where, unlike the ambulance, it is completely inappropriate to automatically default to a transport disposition.


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## r4state (Jun 16, 2011)

It's a bit confusing and weird... I work for the city, but don't get dispatched with the ambulance for 911 calls. Like I said, kind of like a first responder for those parks, where urgency is usually low, unless otherwise told so. So I guess you can say I work for waterparks and other areas prone to accidents. It's definitely one of those temporary jobs until a full-time EMT-B moves aside and I can take their spot. So this counts as a clinic job? 

*Anyway, I'm more concerned about my assesment and whether or not I covered enough details to make a sound judgement*... I know I need to cover by ***, which I believe I did fine when I told Mom she should have a doctor look at her daughter if she wasn't going to have her transported by EMS. PLUS She signed a refusal of care form that indicated she was going to get her daughter to a provider herself.


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## medichopeful (Jun 16, 2011)

You did very well!

One thing to keep in mind is that a c-collar does very little, if anything, to provide stabilization of someone's neck by itself.  If they want to move their head, they will.  So just make sure that next time if you decide to let somebody off a backboard, that you keep in mind that leaving the c-collar on won't do too much 

Very nicely done other than that!


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## medichopeful (Jun 16, 2011)

r4state said:


> *Anyway, I'm more concerned about my assesment and whether or not I covered enough details to make a sound judgement*



The one thing that you probably should have checked was the BP.  If you're familiar with Cushing's Triad, you'll know why.  I'm not saying that there was necessarily going to be anything in that regard to this patient, but just a good habit to get into with head injuries.  That and a BGL.

Hope that helps!


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## r4state (Jun 16, 2011)

> You did very well!
> 
> One thing to keep in mind is that a c-collar does very little, if anything, to provide stabilization of someone's neck by itself. If they want to move their head, they will. So just make sure that next time if you decide to let somebody off a backboard, that you keep in mind that leaving the c-collar on won't do too much
> 
> Very nicely done other than that!



Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.


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## Akulahawk (Jun 16, 2011)

r4state said:


> Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.


In the conscious patient that has good voluntary control over head movements, the c-collar serves as a reminder NOT to move the head around. Yes, it will provide _some_ control of movement, but nowhere nearly as good control as the patient can provide on their own...


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## r4state (Jun 16, 2011)

Yes. Thanks for the insight, I feel wiser already!


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## medicdan (Jun 16, 2011)

Did you get a signed refusal from the parent? Any vitals other than HR? Any neuro exam other than Pupils? Did you release the patient wearing the c-collar? 

If you're going to applying treatments (the removing them), you need to decide which authority you are going to stand under (the city 911 or the water park), and talk to your medical director (if you're functioning as an EMT you should have one) about their standards for these kinds of cases. Did you formally document the call anywhere? Why not ask colleagues about the local standard of care? QA/CQI person for your department?


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## 18G (Jun 16, 2011)

r4state said:


> I never took off the c-collar.



Ok. I misread or perhaps assumed when you said you had taken the patient off the backboard.

Again though... why take a patient off a backboard, leave a cervical collar on, and have the patient up walking around? What was your suspicion for leaving just the collar on? I have never heard of pre-hospital spinal immobilization of that type.

Around here anyway an EMS service or provider would be laughed at for sending a patient on her way with a cervical collar in place. I would never treat and release a diabetic with their IV still in place and send them on their way to the doctors office or ED. Kinda the same principle.



> PLUS She signed a refusal of care form that indicated she was going to get her daughter to a provider herself.



A signature alone on a refusal form does not constitute a valid refusal of services. So please do not let that fool you into a false sense of security. The refusal has to be informed - mom explained what her daughter's condition was, perceived risks involved with refusing immediate care, and provide options for seeking care outside of EMS, and specifically ask Mom if she has any questions  and document all of it. 

It sounds like the refusal was informed but just wanted to reinforce that.


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## mycrofft (Jun 16, 2011)

*Pretty good.*

"Since I found nothing else wrong, we got her off the backboard while she still had a c-collar on. I told her mom that an ambulance isn't necessary but she should still see a doctor just in case. Her mom took her to a clinic to get checked out".
1. Not to be snotty, but if a spineboard is not needed due to lack of spinal injury, then of what field-EMT-diagnostic level use is a C-collar alone? What was the presumed diagnosis necessitating the C-collar without board? How does delayed MD attention play into this? (NOTE: at Bedrock EMS, if the collar went on, the board  did also until radiologically cleared.
2. I'd have said much the same, with the spin towards go today/now, not tomorrow. 

Would you allow the kid to return into the pool?:huh:


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## medichopeful (Jun 16, 2011)

r4state said:


> Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.



Definitely better one than none.  As far as moving it side to side, it might prevent a little bit of that, but if they want to turn their head they will.  The same goes for moving their head forward and back: if they want to move it, they will.  Now granted, it will most likely prevent forward and back motion more than side to side motion, but remember that the neck and is a lot stronger than the thin piece of plastic that is a c-collar.

Next time you have a chance, grab a c-collar and have somebody put it on you (don't steal it though ).  Make sure it's fitted correctly, then try to move your head.  You'll be surprised how little effort it takes.

In EMT school, think about how you were taught to backboard or KED somebody.  Ignoring all the arguments and clinical data for or against spinal immobilization, remember that even after the c-collar was on, that you were still supposed to hold the patient's head.  If the c-collar provided sufficient stabilization, they might not have you do that!

Again, keep in mind that I'm not faulting you for your care, which seemed for the most part good!  I'm just trying to point out the misconception that a lot of people have (not just you) that a c-collar by itself prevents injury.

Hope this is helpful!
Eric


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## medichopeful (Jun 16, 2011)

r4state said:


> Yes. Thanks for the insight, I feel wiser already!



By the way, I commend you for seeking advice and looking to improve your care!


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## firetender (Jun 16, 2011)

*I have a couple of things*



r4state said:


> Hi guys! I'm a newbie EMT-B, and I'm very paranoid about the quality of care I provided since it's my first call BY MYSELF. I would like comments/critiques, and feel free to be as harsh as you'd like.


 
First, as a report to us, this was very incomplete. If you're going to ask us to make a call on your judgment, include all the information you would need to tell a Doctor at your receiving station. 



r4state said:


> I was called to a water park because a 7 year old hit her head coming down a 20+ feet slide. Lifeguards back boarded her in the water and they brought her out for me to check.


 
This is a HUGE gap. *Why* would the Lifeguards board her? My first impression is a loss of consciousness. It could have been as simple as her standing up in the water complaining of pain and holding her Owwiee though. That info is ESSENTIAL to the narrative.

What was the mechanism of injury? Did you ask the Lifeguards? We'd never know. Did she bump her head on the slide, the pool wall, another kids head?



r4state said:


> While someone held c-spine, i slipped on a c-collar and started talking to her, asking for her name, her age, what happened, and what hurts. She only said her head hurt, and I made sure she wasn't hurt anywhere else such as her back and neck. I did a quick pat down and found nothing unusual.


 
Sorry, Kiddo, if you're going to ask my opinion I want to know you did a *thorough head-to-toe exam*. If the kid's not directing you to areas of discomfort or injury, you best find them. "a quick pat down" is not enough for me in a report. I have NO idea of what you may have missed. How can I help you?

The fact that she came backboarded to you and THEN you directed someone else to support her neck while you applied a C-collar tells me you had to have had SOME suspicion of injury. Where did that come from?



r4state said:


> She had a thumbnail sized scrape on her forehead. Her pupils were PERRL, HR 100. The only thing unusual was her skin, which was cold and clammy due to the fact that it was windy and the water was chilly.


 
You are reporting, not determining. Though you're likely correct in your assumption you jumped to a conclusion. What I see is by bringing this up in the first place, you committed to giving me follow-up. Now, for this to be a complete report, I expect you to tell what happened after she was dried off and, say, fifteen minutes had passed. It's possible you noted this, but that info never came to me and if I'm gonna help, I need it.



r4state said:


> Even though we had a towel around her, she was still shivering like crazy, so I really wanted her to warm up. Since I found nothing else wrong, we got her off the backboard while she still had a c-collar on.


 
Again, it appears to me you did not put in adequate observation time to make this call...



r4state said:


> I told her mom that an ambulance isn't necessary but she should still see a doctor just in case.


 
I take it your job is to DECIDE whether an ambulance should be DISPATCHED to the scene. When do you make that determination?

HOW did that "call" come to you? "Girl down on waterslide"? "Possible drowning"? "Fall injury in water"?

What was your response time? Were I the PARK, my directive would be if an emergency call of any sort originates in my facility, an ambulance is dispatched and my In-house medic (YOU) responds immediately and then DECIDES whether the ambulance needs to be cancelled or stepped up.

Apparently you were empowered to make the determination to DISPATCH the ambulance. You don't tell me how long of a process that would be. I really need to know. 



r4state said:


> Her mom took her to a clinic to get checked out.


 
Based on what you presented, I would not allow the Mom to do anything *but* get the kid in for a thorough exam. You sound unsure enough (why would you ask?) at the time, so I think your best judgment would have been to get the ambulance in there for a Second Opinion. You really sound like you were in over your head. You release a kid to her mother when you're SURE!



r4state said:


> Thanks for your help! I've never worked alone before, so I felt paranoid that I might have missed something... not to mention this is my first job as an EMT.


 
Perhaps it's only by your presentation, but I don't hear paranoia, I hear doubt. I don't think YOU have clear enough of a picture of what and how it happened, let alone your role in the chain of emergency medical care, to even ask our opinion.

I'm not picking on you, please understand; but it IS your first job and, as you present it, you really need to get clear on what you're doing.


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## r4state (Jun 17, 2011)

thanks firetender, i _am _in over my head. I guess I never learned that a c-collar alone won't do anything. I'm pretty embarssed,  but I'm glad I know better now.


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## mycrofft (Jun 17, 2011)

*Hang tough there.*

Especially if you are new, it can be daunting to decide to board or not, especially with the current anti-spine boarding discussions going around. Your instructor should have made it clear, then it is up to you. It is usually not your call to roll back another responder's care (spineboard by lifeguards). It is not ok to split the difference between a full tx and a half one; I doubt that your protocols say you can put someone only in a cervical collar, and especially after they have already been boarded.
Go back to your books and your employee protocols. If your employee protocols are vague, look out!


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## medichopeful (Jun 17, 2011)

r4state said:


> thanks firetender, i _am _in over my head. I guess I never learned that a c-collar alone won't do anything. I'm pretty embarssed,  but I'm glad I know better now.



Don't be embarrassed my friend.  In all seriousness, there's a reason that they call what people do in the medical field "practice." 

You'll screw up.  EVERYBODY does.  It's what you take away from those errors that will make you a better provider!


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## JPINFV (Jun 17, 2011)

mycrofft said:


> It is usually not your call to roll back another responder's care (spineboard by lifeguards).



I would agree if this wasn't a first aid situation. It doesn't matter quite as much if the patient is going to be transported regardless of anything else. However part of a first aid EMT's job is to decide deposition. The only possible deposition for a patient who is backboarded is the hospital via 911 ambulance. So if the lifeguards are overzealous with their backboard, it is very much a valid argument to remove it if it is unnecessary.

This is also why I'm against fresh-grad EMTs from working first aid jobs solo. Waterpark first aid is a clinic, but EMTs are trained for transport.


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## r4state (Jun 17, 2011)

Thanks everyone for your support. I am a bit  frustrated. My orientation consisted only of filling out New hire paperwork and introductions. I plan on seeking out the protocols an more of what is expected of me. When I started this job, I was very uncomfortable with the minimal information my supervisors gave me. Maybe this is because my nature of work isn't so urgent?


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## JPINFV (Jun 17, 2011)

r4state said:


> Maybe this is because my nature of work isn't so urgent?



It's also because you have options that aren't normally available. The default mindset when working on an ambulance is every patient gets transported. So EMS can get away with stupid things like backboards for every trauma or non-rebreathers for every patient. That transport assumption is no longer valid. You have to make the decision now, "Can this patient go back to the park? Does this patient need an emergency department? How long am I willing to let the patient who hasn't been drinking enough water and is now light headed sit in first aid?" These aren't issues addressed in EMT training and you aren't going to find a protocol that will lay out who gets what when simply because it's not that simple.

...also for some background, I worked 2 summers during undergrad as an EMT at a water park.


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## medicdan (Jun 17, 2011)

JPINFV said:


> It's also because you have options that aren't normally available. The default mindset when working on an ambulance is every patient gets transported. So EMS can get away with stupid things like backboards for every trauma or non-rebreathers for every patient. That transport assumption is no longer valid. You have to make the decision now, "Can this patient go back to the park? Does this patient need an emergency department? How long am I willing to let the patient who hasn't been drinking enough water and is now light headed sit in first aid?" These aren't issues addressed in EMT training and you aren't going to find a protocol that will lay out who gets what when simply because it's not that simple.
> 
> ...also for some background, I worked 2 summers during undergrad as an EMT at a water park.



What he said ^. The only addition I would make is to emphasize the importance of providers having experience or observation with BLS, ALS and ED care-- so they can make more educated decisions, knowing what treatments to expect from each disposition option.


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## mycrofft (Jun 17, 2011)

*J'Accord.*

........


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## jccilm (Jun 17, 2011)

I'm paranoid 

If the patient was presented to me on a back board and my suspicion was to c-collar and the patient was cool and clammy I wouldn't have taken her off board, moved her to a relatively sheltered location to see if the environment was the issue (provided additional blankets, etc.) and waited on an ALS/BLS unit to come and confirm or reject my impressions. I agree there needs to be more history here and that's a good thing to get into while the other unit is incoming.

Yes, I would definitely talk it over with my supervisor and get a copy of protocols.

That said I don't know if I could have done much better or definitely would have done different than you as I wasn't on the scene and didn't see what you saw.


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## r4state (Jun 17, 2011)

jccilm said:


> I'm paranoid
> 
> If the patient was presented to me on a back board and my suspicion was to c-collar and the patient was cool and clammy I wouldn't have taken her off board, moved her to a relatively sheltered location to see if the environment was the issue (provided additional blankets, etc.) and waited on an ALS/BLS unit to come and confirm or reject my impressions. I agree there needs to be more history here and that's a good thing to get into while the other unit is incoming.
> 
> ...



i'm glad i'm not the only one!


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## ic2283 (Jun 20, 2011)

For my company any pt we find immobilized we have to ask MD to remove c spine precaution after report of a complete head to toe with vital signs.  

practice makes perfect on your pt assessment.  doesn't matter if it's a full code, anaphylaxis, or a scratch on the head.

for all refusals assess thoroughly! explain risks and document it like your life depends on it because you don't know if that priority 3 will come back to bite you in the (__!__)


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## MrBrown (Jun 20, 2011)

What exactly did this kid hit her head on?  It's not like it was a 20ft "fall from height", she was going down the slide and what, bumped her head?

Brown has fallen out of two trees, fallen onto concrete and ran into a beam as a youngin, all of which resulted in Brown being knocked unconscious for a period of time.  Say, that might explain a lot 

The point is all but one of these happened at school and Brown just shook it off and the teacher said Brown go home and let Mum know if Brown got worse to go to the Doctor.

Unless this kid showed some sort of gross neurogenic deficit or abnormality she needs to go home and be observed for several hours to make sure there is no deterioration warranting further investigation.

No back boards, cervical collars, tens of thousand of dollars worth of CT machines or trips to hospital are necessary.


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## JPINFV (Jun 20, 2011)

One thing to consider, also (and this goes back to my earlier posts) is that releasing a patient from your care and the patient leaving AMA is not the same thing.


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## MrBrown (Jun 20, 2011)

True, now this is where it gets confusing.  

Ambulance Officers here have no legal obligation to treat or transport anybody; there is a requirement to offer treatment or transport if it is thought medically necessary.  

In this scenario, if it is thought in the professional judgement of the attending Ambulance crew that no treatment or transport is required, then so be it, we can grab our Thomas Pack and drive off into the sunset.

At no time are we bound by any provision to transport that patient unless we have provided "significant intervention".

Brown gathers the same is not true across the Pacific?


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## medichopeful (Jun 20, 2011)

MrBrown said:


> No back boards, cervical collars, tens of thousand of dollars worth of CT machines or trips to hospital are necessary.



Not always, but sometimes tests are definitely necessary. 

http://en.wikipedia.org/wiki/Natasha_Richardson


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## JPINFV (Jun 20, 2011)

MrBrown said:


> True, now this is where it gets confusing.
> 
> Ambulance Officers here have no legal obligation to treat or transport anybody; there is a requirement to offer treatment or transport if it is thought medically necessary.
> 
> ...



Oh course here's the wrinkle. What if there is no ambulance crew since you're providing first aid services, not transport services?


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## MrBrown (Jun 20, 2011)

JPINFV said:


> Oh course here's the wrinkle. What if there is no ambulance crew since you're providing first aid services, not transport services?



"First aid" is different, somebody with a Red Cross first aid certificate is not legally responsible for anything.

We provide private-hire of our Ambulance Officers for sporting events and such like, and the same rule applies as if we were working on an Ambulance even if we are not.  If Nana is found collapsed at the supermarket and we identify ourselves as an AO then the same rule applies.


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## JPINFV (Jun 20, 2011)

MrBrown said:


> "First aid" is different, somebody with a Red Cross first aid certificate is not legally responsible for anything.
> 
> We provide private-hire of our Ambulance Officers for sporting events and such like, and the same rule applies as if we were working on an Ambulance even if we are not.  If Nana is found collapsed at the supermarket and we identify ourselves as an AO then the same rule applies.




...then it's more like event standby than first aid. What I was told when I was working at a water park in California was that the park was required to have an EMT on site during operating hours by state law. Also, unlike New Zealand, EMS providers in the US operate under the assumption and training that all patients are going to be transported, which is not a proper assumption for standby work.


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