# I'm confused.



## med_gal (Apr 12, 2009)

I work for a transfer company so I'm not used to dealing with trauma. Just recently we got a call from a psych hospital. When we got there we had found that the pt jumped out of a two story window. It had happened two and a half hours before the hospital decided to call. They had moved the pt back upstairs and had him sitting on the floor. My partner was taking the call who decided to just load and go. I was uncomfortable with this so I stepped in and suggested a c-collar and backboard. The pt refused even after I told him the consequences that could occur. He was A&OX3, had a good pulse, good BP, and only complained of pain at a 5 on a scale of 1-10 coming from his L leg. He had schizophrenia. The pt only agreed to go to the hospital without the c-collar and backboard. My partner told me that we were going to load and go, so that is what we did. It has been bothering me ever since. Was that the right thing to do?


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## Mountain Res-Q (Apr 12, 2009)

A couple questions:

Your level of cert?
Your partners level of cert?
BLS transfer only?
Neck pain/deformity/etc?
Was it a "load and go" type of call?
Code 2 transfer?
Transfer to where?


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## amberdt03 (Apr 12, 2009)

honestly. i think he should have been backboarded and had cspine precautions handled. i don't know anyone personally that wouldn't have done at least that.


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## MMiz (Apr 12, 2009)

First, welcome to EMTLife!

I understand that when you do mostly transfers you sometimes miss the finer points of trauma, as has happened to me on occasion, but there are certain standards of care that should be met.  A patient that jumped out of a window is a clear candidate for head/neck/spinal trauma, and should have been at the very least c-collared and immobilized.

I've had calls at the local jail on occasion where a patient was in an accident, brought in, and then complained of pain, and even hours later they're collared and immobilized.  Sometimes they're compliant, and sometimes we need additional assistance from staff/PD, but it really all goes back to the basics.

A big piece of the puzzle is missing though, and we don't know the patient's condition.  What made this patient "load and go"?

This call serves as a great learning experience, and you may want to take a refresher course or review sections in your EMT-Basic textbook so you can get out of the "transfer-slump" and get back to seeing the bigger picture.


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## Sasha (Apr 12, 2009)

amberdt03 said:


> honestly. i think he should have been backboarded and had cspine precautions handled. i don't know anyone personally that wouldn't have done at least that.



How well would that have worked? I think forcing him down onto the backboard (if he didn't want it, I imagine he'd put up a fight when forced) may cause more trauma than transporting him sans backboard.

Did he have neck or back pain? Studies show that the instances of patients requiring immobilization without the presence of back or neck pain are few and far inbetween.

Let's move away from the Bake-A-Medic protocols and backboarding everyone. Just because it's trauma doesn't mean it's spinal trauma.


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## amberdt03 (Apr 12, 2009)

Sasha said:


> How well would that have worked? I think forcing him down onto the backboard (if he didn't want it, I imagine he'd put up a fight when forced) may cause more trauma than transporting him sans backboard.
> 
> Did he have neck or back pain? Studies show that the instances of patients requiring immobilization without the presence of back or neck pain are few and far inbetween.
> 
> Let's move away from the Bake-A-Medic protocols and backboarding everyone. Just because it's trauma doesn't mean it's spinal trauma.



true, but his leg pain could be classified as a distracting injury and he could be more focused on his leg, than any neck or back pain he might be having. i thought a 20ft fall is significant enough moi regardless of amount of time that has passed.


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## medicdan (Apr 12, 2009)

I agree, but I dont, and outside Maine and New Hampshire I dont think anyone has street spinal clearance protocols. I am more interested in whether the patient can refuse a treatment (immobilization). If he is in a psych facility, they often are not their own medical proxy. Is there a nurse of MD there who can sign for hte patient. I tend to like to adapt the RMA form for patients who refuse a specific treatment, especially boarding. 

Details re: physical exam? Type of psych facility? Was this a 911 or transfer call? What was teh receiving facility?


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## Sasha (Apr 12, 2009)

amberdt03 said:


> true, but his leg pain could be classified as a distracting injury and he could be more focused on his leg, than any neck or back pain he might be having. i thought a 20ft fall is significant enough moi regardless of amount of time that has passed.



At a 5/10? I'd be hard pressed to believe that, but maybe, but going back to my first point. Do you think he'd sustain more damage wrestling him to the backboard and keeping him on the backboard than in a nice calm ride to the hospital?


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## MMiz (Apr 12, 2009)

Sasha said:


> At a 5/10? I'd be hard pressed to believe that, but maybe, but going back to my first point. Do you think he'd sustain more damage wrestling him to the backboard and keeping him on the backboard than in a nice calm ride to the hospital?


I'm not sure it matters what we think.  I have protocols to follow.


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## Sasha (Apr 12, 2009)

MMiz said:


> I'm not sure it matters what we think.  I have protocols to follow.



Down here we have an option of going outside of our protcols with med director approval, which is just a radio call away.


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## MMiz (Apr 12, 2009)

Sasha said:


> Down here we have an option of going outside of our protcols with med director approval, which is just a radio call away.


Do you really think any doctor is going to allow you, as an EMT-Basic, to clear c-spine precautions in the field?  I've called in for a lot of things, but this wouldn't be one of them.


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## Sasha (Apr 12, 2009)

MMiz said:


> Do you really think any doctor is going to allow you, as an EMT-Basic, to clear c-spine precautions in the field?  I've called in for a lot of things, but this wouldn't be one of them.



Do you really think a doctor would want you to put YOUR safety at risk by irritating a psych patient who has already proven by jumping out of a window that he has no qualms over dying?

Do you think a doctor would find it more prudent for you to wrestle a patient onto a backboard, causing more spinal trauma than a nice calm ride to the hospital would, being the patient is asymptomatic, complaining of a 5/10 leg pain but NO neck or back pain? 

As long as you can logically justify it, most doctors here will give you what you want, from my limited experience.


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## LucidResq (Apr 12, 2009)

I'm going to have to agree with Sasha on this one. If it was immediately after the incident, I would probably try to immobilize him, but if he struggled I probably would not continue. Not in the best interest of our safety or the best interest of the patient... unless he could somehow be safely sedated by the hospital staff. Would that be allowed? 

The first and foremost protocol for most, if not all, EMS agencies is to act in the best interest of the patient. Sometimes that means deviating somewhat from the other protocols. 

"Deviation from the protocols is occasionally necessary due to the vast array of complex clinical presentations. It should always be done with the patient’s best interest in mind and backed with documentable and defendable clinical reasoning and judgment." (from my protocols)

Noting this, perhaps in your situation, med_gal, it would have been best to immobilize. I'm kind of disappointed that your partner didn't at least consider following your notion to err on the side of caution. Unless you were completely off base, I would respect your intuition to take what may have been the more cautious route. If an attempt at boarding resulted in a thrashing, combative pt, however, I would likely abandon it.


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## amberdt03 (Apr 12, 2009)

Sasha said:


> At a 5/10? I'd be hard pressed to believe that, but maybe, but going back to my first point. Do you think he'd sustain more damage wrestling him to the backboard and keeping him on the backboard than in a nice calm ride to the hospital?



i know it is kinda far fetched but i was just trying to make a point. i agree that he would sustain more injury with us trying to struggle with him. i would probably try and compromise with him and at least get a collar on him and lay him flat on the cot, after talking with a doc at the trauma center to get an ok.


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## amberdt03 (Apr 12, 2009)

Sasha said:


> Do you think a doctor would find it more prudent for you to wrestle a patient onto a backboard, causing more spinal trauma than a nice calm ride to the hospital would, being the patient is asymptomatic, complaining of a 5/10 leg pain but NO neck or back pain?
> .



i've transported a patient from a hospital that said cspine was cleared to a level one trauma for a tibia fracture post motorcycle wreck. first thing they did after we transferred her to the bed was take cspine precautions even though she wasn't complaining of any neck or back pain.


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## RMSP05 (Apr 13, 2009)

MMiz said:


> Do you really think any doctor is going to allow you, as an EMT-Basic, to clear c-spine precautions in the field?  I've called in for a lot of things, but this wouldn't be one of them.



As a Basic EMT in Maine, we are allowed to use the spinal protocal provided that we have taken the class for it.  If the person can pass every test we don't have to imobilize them.  but ive imobilized before even when the person could pass just because of a gut feeling.  if there is any dought in someones mind, they should be imobillzed.  

In this case, i probably wouldn't have imobilized because if someone is trying to fight you they are going to cause more damage to themselves then if you can get them straped to the cot and keep them calm.


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## amberdt03 (Apr 13, 2009)

this is probably a case of you're d*mned if you do and you're d*mned if you don't. granted it would make his injury worse if you have to fight him, but you have to deal with a possibility of a fracture that can become worse and paralyze him. if that happens he'll sue you and even though you documented that he refused treatment, he'd probably win and you'd be out of a job.


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## Mountain Res-Q (Apr 13, 2009)

The issue for me here is that they are a BLS level transfer ambulance, correct?  They should never have taken the patient in the first place IMHO.  I'm drawing this conclusion becaseu when I started in Ambulance I was "forced" to do only BLS transfers for 6 months and then jump on ALS 911 calls.  At teh BLS level transfers indicated that a patient is stable and in need of a continuation of care to be provided at another facility.  I.E. granny breaks a hip, gets sx, and will now rehab at a SNF.  No emergency or new injuries, we are just assuming pateint care from teh hospital and transfering her into the care of the SNF nureses.  In this case, why were we trandfering from a psych facility?  and where to?  I assume that the patient was being taken to the hospitl for injuries associated with the fall.  It shouldn't have been treated like a transfer call.  Example:  We once had a transfer from a psych facility to a OB center for a woman that tried to commit suicide weeks earlier and was now in labor.  Labor is BLS, but this was not just a transfer of a phsych pateint to another facility that would continue the treatment/care for the existing problem.  A psych doctor, even being a doctor) isn;t really in a possition to diagnose a new set of injuries and order you to transfer.  They can try, but for use, we had no obligation to take any patient on a transfer if we didn't feel like this was a BLS trandfer call.

I would have called the shift supervisor, explained teh situation, and asked for his thoughts.  Knowing my supervisors, I would have been told to standby there and continue patient care, do not abandon the patient and wait for the ALS rig that would be there shortly.  If, by chance, Iwas told to transfer (reluctant) I would have strongly recommended the c-spine recautions, but wouldn't have pushed the issue (DOCUMENT, DOCUMENT, DOCUMENT).  Example:

We transfered a dialysis pateint from a SNF to get treatment in the am.  We went to pick him up and return him several hours latter.  However, this normally jovial man, was quiet and distant (major ALOC).  The nurse at dialysis said, "Oh he's been like that all day."  I checked a quick BP and it was like 80/40 (normal of 140/90) and he didn't seem to recognize me or what was going on.  The SNF is 2 blocks in one dirrection and the Hospital wa 1 block in teh opposite.  The nurse looked at the BP and said, "Maybe you should swing him by the ER."  What do you do?  We called dispatch and asked for an ALS rig.  One was at the hospital and showed up in 60 seconds.  Turns out his bood chem was all out of wack (no details were given to me).  Should we have transferred him anyway?  It was no longer a transfer call becaseu another condition existed seperate from the original call given me by dispatch.

Just my thoughts from a lowly EMT who ran a trasfer or two or a thousand.  And yes, we back board way to much to CYA.  Most don;t have the symptoms to warrent it and those that do usually don't have a thing wrong with them.


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## Sasha (Apr 13, 2009)

A huge pet peeve of mine.

How far away was this psych facility from a hospital? How far out would an ALS unit be? 

Would you, at a BLS level, be able to get this patient to definitive care significantly quicker than it would take for an ALS unit to get there and take them to definitive care?

From the information given (besides being crazy) this patient sounds stable.


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## Sasha (Apr 13, 2009)

> if that happens he'll sue you and even though you documented that he refused treatment, he'd probably win and you'd be out of a job.



If it turns out he has a neck fracture and ends up paralyzed, he can also argue that you forced him down on the backboard, despite the fact he refused, and the wrestling him down further irritated his injury and may have caused the paralysis and sue you.


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## amberdt03 (Apr 13, 2009)

Sasha said:


> If it turns out he has a neck fracture and ends up paralyzed, he can also argue that you forced him down on the backboard, despite the fact he refused, and the wrestling him down further irritated his injury and may have caused the paralysis and sue you.



did you not read the first part of the message.



> granted it would make his injury worse if you have to fight him



just like i said this is a case of you're d*mned if you do and you're d*mned if you don't.


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## amberdt03 (Apr 13, 2009)

Mountain Res-Q said:


> The issue for me here is that they are a BLS level transfer ambulance, correct?  They should never have taken the patient in the first place IMHO. In this case, why were we transfering from a psych facility?  and where to?  I assume that the patient was being taken to the hospital for injuries associated with the fall.  It shouldn't have been treated like a transfer call.


 
it really isn't uncommon for there to be a bls transfer truck, at least not in my area.

And yes they should transfer him to a hospital. psych facilities aren't set up to deal with emergencies other than psychiatric. i'm pretty sure they are taking him to an emergency room to make sure he didn't break anything from the fall/jump. happens all the time in dallas(not the jumping, but the going to the er) and i agree that it shouldn't have been treated like a transfer call, but it was.


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## Mountain Res-Q (Apr 13, 2009)

amberdt03 said:


> it really isn't uncommon for there to be a bls transfer truck, at least not in my area.
> 
> And yes they should transfer him to a hospital. psych facilities aren't set up to deal with emergencies other than psychiatric. i'm pretty sure they are taking him to an emergency room to make sure he didn't break anything from the fall/jump. happens all the time in dallas(not the jumping, but the going to the er) and i agree that it shouldn't have been treated like a transfer call, but it was.



In teh city I worked Ambulance we had 15-18 ALS 911 units on during the day and BLS 5-6 transfer units.  The ALS guys didn't want to be bothered withe transfers so we often got calls from Doctor's Offices or Psych Facilites that IMO weren't BLS transfers.  I got real use to saying, "No, call a medic unit to take this."  Maybe I can take the call at a EMT/BLS level and be fine, but that isn't protocol, and bearing that in mind I prefer to CYA (something I didn't do once and got reamed for), especially when an ALS unit can be there in 2 minutes.


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## NEMed2 (Apr 13, 2009)

Obviously no one here can tell you the right thing to do since none of us were there. That being said:  A facility waiting over 2 hours after a potentially significant injury to call for a transport is outrageous.  (Not that it doesn't happen.) Why did they choose to call now? Was the pt decompensating from their injuries? Had something changed from the time of initial injury? You stated that the pt was A&Ox3, is that 3/3 or 3/4? Can they refuse treatment?  I would have called a supervisor or medical control on back boarding the pt if they could not refuse the immobilization.  Yes, it could potentially cause additional injuries/aggravate existing ones.  Think of your safety first if the pt may become violent.  Document document document.  I agree with the general question regarding whether this pt was truly a "load & go", in which case ALS should have been notified anyway.


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## Sasha (Apr 13, 2009)

> Why did they choose to call now? Was the pt decompensating from their injuries?



Sometimes they have to wait for approval from the medical director of the facility, which can take a few hours to get if they are not onsite. At least that's why some nursing homes take a long time.


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## NEMed2 (Apr 13, 2009)

Sasha said:


> Sometimes they have to wait for approval from the medical director of the facility, which can take a few hours to get if they are not onsite. At least that's why some nursing homes take a long time.



I can understand that, and in non-emergent case, I have no concerns over taking a few hours for a routine transfer.  

This situation involves a potentially life threatening injury and I cannot understand why anyone would take 2 hours to call 911 for this type of MOI, even if the director was informed that the pt only suffered a leg injury.  A lay person should be able to understand someone can be hurt beyond what can be seen with a naked eye.  Not that it should be on the head of a non-present director if they were not given all the information.


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## Veneficus (Apr 13, 2009)

I'm just curious to know what an ALS unit would do for this patient that hasn't been done already or couldn't be done by BLS?

Clinical clearance of C-spine? A Psychiatrist, is a specialty of a physician. (if I am not mistaken the med director of Acadian is/was a psychiatrist) Is it possible that the patient was evaluated and needed transefer to cover him/her?

An IV for pain meds? In the length of time taken, PO sedation or medication could have been given.

A heart monitor? A patient has to be medically cleared to be admitted to a psych facility.

Advanced airway? For a talking "trauma" patient with leg pain?

As food for thought, the original traumatologists were orthopods. ~80% of all trauma is ortho in nature. The only recognized life threatening ortho injury is compartment syndrome. Unless a medic is planing on calling for orders to perform an emergent fasciotomy, (aka surgery), there is little a medic can do that BLS cannot. Infact I can't think of anything. 

If by some irrational chance there was a compartment syndrome,the lactic acidosis would be released after the compartment is opened. Even if there was a slight increase in blood lactate, the bodies natural buffers and the heart and liver metabolizing lactate back to pyruvate, as well as NAD+ to NADH should be more than able to compensate for even moderate lactate levels.

as for the mechanism, vertical compression of the spine would cause a fx at the atlanto-occipital joint. (aka c-1) Which would very likely cause and immediate cord insult.

Bi peds are specifaclly built to reduce such compression forces. If the impact wasn't significant enough to even fx his femoral neck, it is not even reasonable to think there is an occult c-1 fx. 

Obviously I wasn't there, but it sounds like the pt was being routinely transferred for another medical clearence so he could be turned around and shipped back to the facility. Dramatic though the story sounds. 

Based on the OP desription, i think asking the pt to sit quietly on the cot, put on the seat belts, a splint and some ice (coldpack) would be the treatment of the trip.

In the long term, if nothing is broken but there is a joint insult. he will probably get a plaster or other formed splint, told to keep it on for 2 weeks, heat and ice as required, and told to take some ibuprofin for pain.

If there is a fx, he'll get the same with an ortho follow up for a full cast after he gets out of the psych facility as they usually don't allow full casts in psych or prisons because they can be used as a weapon.

Also remember that a physician to physician report is given between the transferring and receiving doc. If there was a strong suspicion of occult injury it likely would have been brought up on that call.


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## Mountain Res-Q (Apr 13, 2009)

Veneficus said:


> I'm just curious to know what an ALS unit would do for this patient that hasn't been done already or couldn't be done by BLS?
> 
> Clinical clearance of C-spine? A Psychiatrist, is a specialty of a physician. (if I am not mistaken the med director of Acadian is/was a psychiatrist) Is it possible that the patient was evaluated and needed transefer to cover him/her?
> 
> ...



Still, while there is little that a Medic could do that an EMT couldn't, from a BLS TRANSFER standpoint, this is a gray area that should have been referred to a supervisor and be addressed in company/county protocol.  they weren;t asking for the transfer of a psych patient, they were asking for the transfer of a pysch patient that had injuries that should have been handled by a 911 unit.  Maybe protocol differs where you are, but my protocls would have suggested a Medic Unit.  Not saying I couldn't handle this, but protocol is protocol until you violate it and are forced to work at McDonalds.  This person works for a TRANSFER COMPANY, probably without a contract to handle transports of acute injury patients to Emergency Rooms.


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## Sasha (Apr 13, 2009)

Mountain Res-Q said:


> Still, while there is little that a Medic could do that an EMT couldn't, from a BLS TRANSFER standpoint, this is a gray area that should have been referred to a supervisor and be addressed in company/county protocol.  they weren;t asking for the transfer of a psych patient, they were asking for the transfer of a pysch patient that had injuries that should have been handled by a 911 unit.  Maybe protocol differs where you are, but my protocls would have suggested a Medic Unit.  Not saying I couldn't handle this, but protocol is protocol until you violate it and are forced to work at McDonalds.  This person works for a TRANSFER COMPANY, probably without a contract to handle transports of acute injury patients to Emergency Rooms.



And the patient, who based on the information given, appears to be in no major distress, was being TRASNFERred from one facility to another.


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## Mountain Res-Q (Apr 13, 2009)

Sasha said:


> And the patient, who based on the information given, appears to be in no major distress, was being TRASNFERred from one facility to another.



I'm just saying that protocol differs one place from another.  In this case, a question like this should have been dirrected to a Supervicor or might be addressed on County Protocol.  We can all say what we would have done based on our experience in the systems we work in, but are in no position to say what should have been done in the system they work in.  That said, any time the workds "load and go" are used, should we be talking about a BLS transfer?


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## Veneficus (Apr 13, 2009)

I think "load and go" might have been an overreaction from the lack of trauma experience from a normally transport crew.


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## Sasha (Apr 13, 2009)

Mountain Res-Q said:


> I'm just saying that protocol differs one place from another.  In this case, a question like this should have been dirrected to a Supervicor or might be addressed on County Protocol.  We can all say what we would have done based on our experience in the systems we work in, but are in no position to say what should have been done in the system they work in.  That said, any time the workds "load and go" are used, should we be talking about a BLS transfer?



Well considering it's a BLS transfer service who is unfamiliar and probably uncomfortable with trauma, they may have "Loaded and gone" based soley on the MOI without assesing a patient because they were moving into unfamiliar territory, getting them to the hospital as soon as possible because they simply don't know what to do.

If you don't deal with something on a regular basis you tend to forget about it. That's why we have Broselow tape for peds!


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## Shishkabob (Apr 13, 2009)

While doing triage at Cooks childrens, I had a 16/f come in cc of back pain 1/10 only very mild discomfort. She had blood and CSF coming out her ears. Her mvc was 3 hours before and refused treatment until the pain, no matter how mild, didn't go away. 

We did a standing immobization with full precautions.  Had 1 fx in her back. Lucky as hell to walk around for three hours.  

WhY I'm getting at is people have different toldrences of pain, so just because he was a 5/10 doesn't mean it's less likely something is wrong.


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## daedalus (Apr 13, 2009)

amberdt03 said:


> true, but his leg pain could be classified as a distracting injury and he could be more focused on his leg, than any neck or back pain he might be having. i thought a 20ft fall is significant enough moi regardless of amount of time that has passed.



Good point! The leg could have defiantly caused a distracting injury. What about the OP patient's focal neurological status, and how about the results of a *detailed* trauma exam, which should have been preformed.


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## Mountain Res-Q (Apr 13, 2009)

Veneficus said:


> I think "load and go" might have been an overreaction from the lack of trauma experience from a normally transport crew.



Isn't that the point?  In light of this reaction shouldn't a BLS TRANSPORT ONLY CREW called in an ALS 911 Crew?  Eapecially, as some have suggested, underlying problems could be present, however unlikely?  Isn't that psych patient entitled to a higher level of care in a situation that requires more experience than that had by a crew accustomed to the transport of stable patients that have been diagnosed by and treated by a physician trained to deal with the type of injury sustained?


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## Veneficus (Apr 13, 2009)

Mountain Res-Q said:


> Isn't that the point?  In light of this reaction shouldn't a BLS TRANSPORT ONLY CREW called in an ALS 911 Crew?  Eapecially, as some have suggested, underlying problems could be present, however unlikely?  Isn't that psych patient entitled to a higher level of care in a situation that requires more experience than that had by a crew accustomed to the transport of stable patients that have been diagnosed by and treated by a physician trained to deal with the type of injury sustained?



Have you ever gone to a doctors office on a call when and all they needed was something you had on the truck or a transfer to the hospital as a direct admit?

This seems a similar type of situation to me. There was not an emergency, but the impression of one. 

I agree that the pt deserves to be treated by a specialist, but that specialist in this case is an orthopaedic surgeon not an EM doc. Once a formed splint is put in place,(usually in the ED) in the absence of gross deformity the xrays and consult can wait for days.


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## ffmedic08 (Apr 19, 2009)

*hmm*

Being a schizo pt, kinda gives you a different feel on things. If you are a BLS crew and have no way of chemically restraining him if things really go south - I'd probably have to determine his LOC, A&Ox4?? Compliant with meds? Idk if I'd push him to full c-spin immobilization if I didn't absolutely have to. Granted, protocols say BACKBOARD BACKBOARD BACKBOARD!!! However, each situation is different. Risk vs Benefit on this one. Granted if you backboarded him you could count that as restraint, I suppose. But if you completely restrain his arms, etc- then I am sure the pt is smart enough to realize what you are doing, if not freak out because he has absolutely NO control and nothing free. If you want a pt to trust you, you have got to show you trust him. (thats what I've learned in my experience). 

I honestly can't say what I'd do. You gotta prevent further c-spine if there is any, but if you back board him adn he freaks- he's going to cause even more harm than if you would have just taken a nice easy ride to the ED....


hhmm....


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## Lifeguards For Life (May 22, 2009)

Aren't suicidal patients classified as non competent adults and therefore can not refuse treatment? Would it be within procedure to get a LEO who can issue a 32? Though I guess if the patient is a combative schizophrenic a Baker Act would help very little.


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