# Linclon, Ky paramedics in trouble after flying two young girls against parents wishes



## exodus (Sep 18, 2013)

http://www.wkyt.com/home/headlines/...njuries-despite-parents-wishes-224175611.html

Article is hard to read. But from the sounds of it, it was nowhere near necessary to fly.


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## shfd739 (Sep 18, 2013)

Agreed. Double load both kids and go ground.


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## Epi-do (Sep 18, 2013)

Wow!  I don't even know what to say about that.  I wasn't there, and I know the media doesn't always have all the facts, but from the information presented, it sure does seem as if the medic made a bad call.


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## Tigger (Sep 18, 2013)

If the mother stated that she did not want her children to be flown and they were, wouldn't that violate the mother's right to provide consent for her children?


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## exodus (Sep 18, 2013)

Tigger said:


> If the mother stated that she did not want her children to be flown and they were, wouldn't that violate the mother's right to provide consent for her children?



Yup. It sounds like though, she didn't specifically say, no you can't fly them. Instead, she said, "I really don't want them to be flown."


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## Tigger (Sep 18, 2013)

exodus said:


> Yup. It sounds like though, she didn't specifically say, no you can't fly them. Instead, she said, "I really don't want them to be flown."



Which still means that both the ground and air crews went against her wishes.


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## RocketMedic (Sep 19, 2013)

*AirEvac for Boo-Boos*

http://www.wkyt.com/home/headlines/...njuries-despite-parents-wishes-224175611.html


Let's talk about assessment and consent here. I don't want to criticize Mr. Cain too harshly, but let's be completely honest- this was a financially-abusive, inappropriate and ignorance-driven request in the first place. The reason this was even started hinges on the trauma assessment- Mr. Cain clearly failed to identify basic anatomical landmarks and was unable to even locate a secondary injury. Yes, I understand that scalp wounds bleed more profusely than others- but there is no excuse for not being able to complete a focused assessment. Due to the extremely short stays in the emergency room, I feel it would be appropriate to point out that neither patient experienced any sort of traumatic brain injury or was ever even close to "life-threatening danger". We can start this Monday film session with a comfortable chair, a bottle of cold water and a recognition that this paramedic's bread-and-butter, fundamental assessment sucks great big rocks from the sea floor. "Four stitches" is not a life-threatening emergency. We have a knowledge deficit here. I'm sure that Mr. Cain has already identified that deficiency and is working hard to correct it.

Mr. Cain and his crew were sucked into a fantasy world of their own creation, which they then panicked in and called for a helicopter. This farce of a health-care experience then apparently spun completely out of control when the second patient was flown, on a second helicopter, for 'mechanism'. People who actually study know that mechanism is a poor indicator of injuries. (http://www.east.org/resources/treatment-guidelines/triage-of-the-trauma-patient). 

This gets even more farcical when the mother's understandable concern is factored in for the cost and need for service here. Something that literally could have been handled by a community paramedic and a suture kit or a local community urgent care was upgraded by ignorance and tunnel vision to a dual-level-one trauma with two c-spined little girls strapped to backboards for at least the better part of two hours, with bilateral IV's established in immobilized limbs, by hyperexcited and serious-faced "paramedics", firefighters (and a flight nurse, let's not leave anyone out here) hovering around over them, shouting questions and generally seriously overreacting. Add in a mother whose concern is building as her daughters are strapped down, cannulated and start complaining about headaches, neck pain, back pain and IV-site pain, all while words like "possible head bleeds" and quiet prayers are whispered. Perhaps there was even some sort of dramatic time-to-arrival resource when the almighty, all-knowing flight crew gravely announced that both girls were in serious, life-threatening danger.

I'm not surprised they didn't hear Mom withdrawing consent, over the sound of how awesome they were being. MCI scene, idling vehicles everywhere, busy-looking officers and all sorts of people wondering if those poor little girls are dead or something....yep, must have been something to see. Completely ignoring the resources wasted, calls potentially unanswered, safety issues with sending the girls out by helicopter as opposed to an appropriate nonemergent ambulance transport...it must have been something to see. Meanwhile Mom is seeing something that she remembers her own mother fixing with a short ride in a Buick and a few stitches that she lacks only the kit for turning into a disaster scene worthy of a Hollywood movie- on her dime.

This is not patient advocacy. This is not providing community service or health care. This is throwing resources at problems that do not need those resources thrown at them, and then shrugging when our patients are billed for those services and falling back on ignorance and stupidity as our justification. This is why we, as a profession, are not trusted with important decisions and have permission to perform dangerous interventions stripped from us. This is why those doctors whose voices actually matter are sitting down when a paramedics asks for orders- they don't want to fall too far laughing when we ask them for a surgical crike or a nonstandard drug administration or permission to deviate from lowest-common-denominator protocols. How can they trust you to make doctor-level decisions when a paramedic cannot even appropriately triage Level-4, 'meh' patients, and when your overreaction is so severe as to bring in AirEvac?

Yes, this is Monday-morning quarterbacking. I wasn't there, I didn't see these horrific scalp wounds resolved by a few stitches. I don't know the precise MoI, and I don't know Mr. Cain or his fire department's usual performance. I really hope that this is an outlier, and I hope that the department uses this as a positive training tool for the improvement and prevention of future mistakes. I don't wish any disciplinary action on good people that can learn from their mistakes- but I do want it made clear that there were mistakes made that we can all learn from. At the end of the day, this is not a Lincoln County, Kentucky issue. This is not a fire-paramedic or flight issue. This is an issue that concerns all of us, ranging from my big-city private company to the most rural volunteer EMT/FF. Would your community trust you if your sole function in their eyes was to send boo-boos to the big city trauma center by helicopter? They reckon you break out the transporter beam when you have a real mess! 

Monday morning is when coaching staffs go over films and decide who plays, who sits and who walks, and professional teams are better for it. Let's see who we can retrain before our communities decide who walks.


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## Tigger (Sep 19, 2013)

Threads merged.


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## RocketMedic (Sep 19, 2013)

Thank you!


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## Tigger (Sep 19, 2013)

Also just an aside but the responding paramedic was from West Lincoln EMS, which would appear to be a third service. I get that it wouldn't be a fire-medic issue if he were one (and I agree), just thought I'd point that out. 

Also serves as a good reminder that even government third service EMS providers make serious mistakes. I think most people on this board are well aware of that, but it seems like half the people I talk to that judge every other model of EMS delivery as inadequate also seem to think that third service medics walk on water. "If they weren't on the fire truck/private ambulance, they would stop making medication errors." Yea no.


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## triemal04 (Sep 20, 2013)

Stop with your inane gibberish.

If you are going to write a diatribe about an inability to properly assess a situation or patient, knowledge deficits, and people panicking and overreacting, then you first need to be sure you aren't guilty of doing exactly the same thing.  As it stands all you have done is jump to conclusions out of ignorance and helped to perpetuate the very things that you are concerned about.  If you really want to be taken seriously as a writer, then you need to be very clear about the topic you choose to write about, accurate in your presentation of the facts, and clear in what you mean without contradicting yourself.  In all of these posts you are clearly lacking in one, or all of these things.

I would strongly suggest that you either take several classes on writing, or find an editor (at least a proofreader) who will go over what you write well before you even consider publicly presenting it.



RocketMedic said:


> Yes, I understand that scalp wounds bleed more profusely than others- but there is no excuse for not being able to complete a focused assessment.


There is no mention of any blood loss or concern for it, and nothing to indicate that this played any part in the incomplete assessment or decision process.


> I feel it would be appropriate to point out that neither patient experienced any sort of traumatic brain injury or was ever even close to "life-threatening danger".


This is nothing more than a lowblow from the cheap seats well after the fact.  While the decision to fly seems inappropriate with the given information, to use the lack of poor outcome to prove that something wrong was done is not always advisable, or accurate.


> Mr. Cain and his crew were sucked into a fantasy world of their own creation, which they then panicked in and called for a helicopter.


That is a large assumption on your part. If it actually took over 20 minutes for the helicopter to be requested that sounds less like panic, and more like ignorance.


> ...with two c-spined little girls strapped to backboards for at least the better part of two hours, with bilateral IV's established in immobilized limbs, by hyperexcited and serious-faced "paramedics", firefighters (and a flight nurse, let's not leave anyone out here) hovering around over them, shouting questions and generally seriously overreacting


This is plain ignorance, overreaction and hyperbole on your part.  To make an assumption this large about the treatment and demeanor of all those involved should make you feel extremely embarrassed.  You have no basis to make any claim about how anyone on scene was acting other than your own personal angst and belief.


> ...her daughters are strapped down, cannulated and start complaining about headaches, neck pain, back pain and IV-site pain, all while words like "possible head bleeds" and quiet prayers are whispered.


This is no different than the above, and nothing more than a blatant play on emotion with no basis in reality.


> ...MCI scene, idling vehicles everywhere, busy-looking officers and all sorts of people wondering if those poor little girls are dead or something....yep, must have been something to see.


I'm sure it would have been...if that was what happened.  You must have some type of inside information on what happened.  Would you like to share it to support your claims, or is this just more hyperbole and ignorant exaggeration?


> a disaster scene worthy of a Hollywood movie


More embellishment and exaggeration.


> This is why we, as a profession, are not trusted with important decisions and have permission to perform dangerous interventions stripped from us.


And this type of reaction from a paramedic does not help things either.  When the people trying to speak out against ignorance make a farce of it that is detrimental to the cause they allege to support.  Though as a profession we have yet to have "dangerous interventions stripped from us" it may happen, and rightfully so if this type of ignorance continues to be perpetuated.


> How can they trust you to make doctor-level decisions...when your overreaction is so severe as to bring in AirEvac?


And when your overreaction is so severe that you would write something like this and think it would be taken seriously?  Something that is so filled with exaggeration, hype, and perhaps not even based in reality?


> I don't know Mr. Cain or his fire department's usual performance.


Mr. Cain does not appear to work for the local fire department.  If this was written due to a personal bias, then you should be sure that you know who works for who.  If it wasn't, then you still need to have all your facts straight.

Emotion filled distortions of reality make for great, flashy reading.  But they don't serve any real purpose, cause people to latch onto the flash and miss the point, and all to often will make the people who should be listening ignore the entire article.  If you want real change to occur, or to have people actually think about a problem then you need to do a far, far better job at making these posts coherent and convincing.


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## DrParasite (Sep 20, 2013)

Comment from one of the commenters:





> The whole key to all of this was the "mechanism of injury". If someone has an injury like that child (blunt force trauma) to the head you get that child to a trauma center. It doesn't matter if there is an open or closed wound but since there was an open wound it was obvious that the blow was a pretty good one. Brain injuries do not always show symptoms immediately so whether the child was awake and walking means nothing. If the brain is swelling and bleeding slowly, the child would seem to be okay. But, what if it wasn't? What if, there was bleeding inside the brain and the child died? Paramedics do not carry MRI's with them so you have to look at the mechanism of injury and know what injuries that can cause. This paramedic followed protocols that are already in place. How upset would the mother have been if her child had died because it was taken to a regional hospital instead of a trauma center? Then we would be hearing a distraught mother who lost her child and would be blaming the paramedic. Then when she sued, she would have discovered the protocols and would have gone ballistic because those protocols were not followed. Without tests being done at a trauma center there is no way to know that the only damage is a laceration. If it was my child, fly it out. Even without insurance, I would rather pay that bill and have my child at home instead of a casket. The "backseat driving" comments on this are unbelievable.


pretty much well said.  any uneducated assessment (the non-medical fire chief, parents, etc), are crap (well, it didn't look bad to me).  And the outcome being minor is also crap, because hindsight is always 20/20. 

I wasn't there, so I won't say this paramedic screwed up but I will ask this question: If the kids had been diagnosed with a skull Fx at the trauma center as a result of the incident, would the medic be hailed as a hero for making the right call?


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## johnrsemt (Sep 23, 2013)

Open wound to head indicates serious injury due to the force it takes to do that?

I was getting something off the counter and home, and turned and moved 3" from where I was standing and took 4 sutures in the forehead due to running into the corner of an open cabinet door.     Went to Urgent Care, they refused to suture a head wound (could see my skull underneath the blood)  called an ambulance to send me to ED;  I refused patient contact with EMS; and drove my self to the doctor who sutured it and you can't even see the scar anymore   (about 10 years ago)


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## Tigger (Sep 23, 2013)

DrParasite said:


> Comment from one of the commentersretty much well said.  any uneducated assessment (the non-medical fire chief, parents, etc), are crap (well, it didn't look bad to me).  And the outcome being minor is also crap, because hindsight is always 20/20.
> 
> I wasn't there, so I won't say this paramedic screwed up but I will ask this question: If the kids had been diagnosed with a skull Fx at the trauma center as a result of the incident, would the medic be hailed as a hero for making the right call?



No, not in this situation. If he sold it well enough and got the mother to change her mind that would be one thing, but going directly against the wishes of the family is inexcusable. Not to mention that the commenter's post is about as useful as most bottom of article comments (it's not in the slightest), we have known for a long time that mechanism of injury *is not a good predictor of injury*.



johnrsemt said:


> Open wound to head indicates serious injury due to the force it takes to do that?
> 
> I was getting something off the counter and home, and turned and moved 3" from where I was standing and took 4 sutures in the forehead due to running into the corner of an open cabinet door.     Went to Urgent Care, they refused to suture a head wound (could see my skull underneath the blood)  called an ambulance to send me to ED;  I refused patient contact with EMS; and drove my self to the doctor who sutured it and you can't even see the scar anymore   (about 10 years ago)



Exactly, as I said above, mechanism does not predict injury. That alone should never be why the helicopter is called. If the patient presents with a head injury then fine, but if not start transporting. If the crew on scene was really so worried about a head injury manifesting itself later then why would they spend so long on scene waiting for the helicopter? Put them in the ambulance and start driving towards the hospital and meet the helicopter somewhere if you're so concerned.


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## Carlos Danger (Sep 23, 2013)

DrParasite said:


> > *The whole key to all of this was the "mechanism of injury". If someone has an injury like that child (blunt force trauma) to the head you get that child to a trauma center*. It doesn't matter if there is an open or closed wound but since there was an open wound it was obvious that the blow was a pretty good one. Brain injuries do not always show symptoms immediately so whether the child was awake and walking means nothing. If the brain is swelling and bleeding slowly, the child would seem to be okay. *But, what if* it wasn't? *What if*, there was bleeding inside the brain and the child died? *Paramedics do not carry MRI's with them* so you have to look at *the mechanism of injury* and know what injuries that can cause. This paramedic followed protocols that are already in place. How upset would the mother have been if her child had died because it was taken to a regional hospital instead of a trauma center? Then we would be hearing a distraught mother who lost her child and would be blaming the paramedic. Then when she sued, she would have discovered the protocols and would have gone ballistic because those protocols were not followed. Without tests being done at a trauma center there is no way to know that the only damage is a laceration. If it was my child, fly it out. Even without insurance, I would rather pay that bill and have my child at home instead of a casket. The "backseat driving" comments on this are unbelievable.
> 
> 
> 
> ...



This is just the the same tired, old argument for making decisions based on MOI, this time served on a platter of "hindsight is always 20/20" with a side of "appeal to emotion", and some delicious "we don't have x-ray vision" for dessert. 

The "Golden Hour" is a myth, pressure infusing liters and liters of IVF to maintain a "normal" BP is a bad idea, 15 ml/kg tidal volume is way too much, backboards are rarely needed, and everyone who injures themselves does not need a helicopter. That's what the last 20 years of data has taught us about prehospital trauma care.

MOI alone as an indicator of the need for transport to a trauma center has been thoroughly disproven in the literature. Progressive and honest HEMS programs are now teaching their requestors to use physiologic signs as the primary indicator for whether HEMS utilization is necessary. Basically, if there is no indicator of severe injury (unresponsiveness, severe blood loss, hypotension, pneumothorax, etc.) then there is no need for a trauma center, and definitely no need for a helicopter.

Of course there are grey areas, and judgement calls, and everyone would agree that a little over-triage is better than under-triage. But the "what if?" approach laid out in the comment above results in a lot more than "a little" over-triage.

I don't think anyone is saying that if you hit your head hard and are bleeding from the scalp, that you shouldn't seek medical attention. But to argue that anytime someone strikes their head they need to go by helicopter to a trauma center is exactly why the HEMS industry is in the shambles it is in now. 





triemal04 said:


> > I feel it would be appropriate to point out that neither patient experienced any sort of traumatic brain injury or was ever even close to "life-threatening danger".
> 
> 
> 
> *This is nothing more than a lowblow* from the cheap seats well after the fact.  While the decision to fly seems inappropriate with the given information, *to use the lack of poor outcome to prove that something wrong was done *is not always advisable, or accurate.



How is expecting a highly trained, professional paramedic to make accurate triage decisions "a low blow"?

Lack of poor outcome is actually a key QI measure tracked by air medical programs, and they are expected to have systems in place to prevent this type of gross-overutilization. Stats on things like ISS, TSI, discharge from the ED, and whether the patient required surgical or other interventions are actually tracked closely and requesting agencies should be held accountable for them.

As for the rest of Rocket's vision of what the scene might have looked like, he's probably not far off. I've been on more than a few of these and sometimes it does go down pretty much exactly how he describes it.


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## Summit (Sep 23, 2013)

RocketMedic said:


> http://www.wkyt.com/home/headlines/...njuries-despite-parents-wishes-224175611.html
> 
> 
> Let's talk about assessment and consent here. I don't want to criticize Mr. Cain too harshly, but let's be completely honest- this was a financially-abusive, inappropriate and ignorance-driven request in the first place. The reason this was even started hinges on the trauma assessment- Mr. Cain clearly failed to identify basic anatomical landmarks and was unable to even locate a secondary injury. Yes, I understand that scalp wounds bleed more profusely than others- but there is no excuse for not being able to complete a focused assessment. Due to the extremely short stays in the emergency room, I feel it would be appropriate to point out that neither patient experienced any sort of traumatic brain injury or was ever even close to "life-threatening danger". We can start this Monday film session with a comfortable chair, a bottle of cold water and a recognition that this paramedic's bread-and-butter, fundamental assessment sucks great big rocks from the sea floor. "Four stitches" is not a life-threatening emergency. We have a knowledge deficit here. I'm sure that Mr. Cain has already identified that deficiency and is working hard to correct it.
> ...



Wow... 10/10


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## Christopher (Sep 23, 2013)

triemal04 said:


> This is nothing more than a lowblow from the cheap seats well after the fact.  While the decision to fly seems inappropriate with the given information, to use the lack of poor outcome to prove that something wrong was done is not always advisable, or accurate.



I think you're absolutely right, we lack even the basic education required to make a decent triage decision in this case. We're strung along with war stories packed with Fear, Uncertainty, and Doubt (FUD for the non-tech savvy).

However, excessive overtriage *IS* an accurate indicator of a poor EMS/trauma system.


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## triemal04 (Sep 23, 2013)

Halothane said:


> Lack of poor outcome is actually a key QI measure tracked by air medical programs, and they are expected to have systems in place to prevent this type of gross-overutilization. Stats on things like ISS, TSI, discharge from the ED, and whether the patient required surgical or other interventions are actually tracked closely and requesting agencies should be held accountable for them.


As should happen.  But generally speaking, when data like that is collected by the better institutions it involves more than just looking at the raw numbers/data.

You know as well as I or anyone that at all levels of medical practice there are times that, for a given situation with incomplete information, a treatment will be given, a procedure performed, or a decision made that, in hindsight and with the benefit of all information including the final outcome, is determined to have not been needed or to have not changed the outcome.  Does that simple fact mean that, at the time it was done and in that particular setting it was innapropriate?  Not neccasarily.

Granted, that may not be applicable to the situation here.  Personally I think everything done was done out of ignorance and 911 probably never even needed to be called, but regardless, the statement I responded to, taken at face value, wasn't the best.


Christopher said:


> I think you're absolutely right, we lack even the basic education required to make a decent triage decision in this case. We're strung along with war stories packed with Fear, Uncertainty, and Doubt (FUD for the non-tech savvy).


Wow...guess you want to take this to a whole other level of discourse, huh?


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