# In trouble with the doc!! 1st time in 19 yrs



## kristendanielle (Mar 18, 2009)

I hope someone can make me feel better about my treatment of a pt. Please do not hold back if you guys think I did wrong PLZ tell me. I read alot on these boards and know that you guys can help me with my situation.

Ok got a call to a 4 year old child who had been ran over by a bicycle. When we arrive the mother was holding the child. As soon as we hit the door the child starts screaming and trying to climb behind the mother. I bend down as to try and calm the child. Child is just not having it. I palpate the leg the mother said was injured the best I could with pt all over the place. The child had long jeans on  I could feel some minor deformity to lower leg. I instructed the mother we needed to get the jeans off to see the injury. mother got the jeans off and I noticed minor visible swelling to left lower leg. We get pt to the unit and pt is fine as long as she is with mother. I got mother to place the leg on a pillow. I then got the splint out to place on pt and she starts trying to climb up mom just going crazy so I put the splint where she can not see it. She then calms back down and puts her leg on the pillow. She did allow mother to put an Ice pak wrapped in towel on the site. No crying, no moving around actually smiling at some points as long as I kept my distance. I then said well if she will be this still I will just keep her leg on the pillow and go from there. Pt had great distal pulses on scene, in rt to er, and on arrival to er. We take pt in with mother holding her and us supporting her leg. when we get in the er I tell them of my treatment. I get back to the station and get a call from the er doc asking what our policy is for splinting. I tell him the whole story again and why I did not splint. He advised me it was broken (Fib) and they had another dr to come in and if they found more damage it would be on me because I did not splint. He called my director that night and wants me to go thru a splinting class! I have been with my job 19 years and this is a first for me. I was trying to keep the child calm and not cause more damage to her leg. She was calm and happy with the support of the pillow. Was I wrong in my choice of treatment?? Sorry so long but it has really had me worried because I do like to do what is best for the pts.


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## medic417 (Mar 18, 2009)

Sometimes best treatment is no treatment.  I see your and their point.  Ask the director if they would prefer next time for you to sedate the patient and splint or do what you did allow patient to be calm and still?


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## Veneficus (Mar 18, 2009)

unless i am very much mistaken a pillow splint is an acceptable form of splinting particularly for lower legs.

I wouldn't get too worked up about it. There are a lot of not so smart doctors. You will never hear a public confession of that, but 1/2 through school there is already a list of people we hope never treat anyone we know.

Especially in US med schools, there is a lot of reliance on the latest greatest gadgets. It is entirely possible he had no idea you could use a soft splint. Of course the ER doc was going to call in another doc. It is orthopedic surgeons who fix bones, not EMs. 

As for splinting class, think of it as an opportunity. The splinting classes I teach in addition to the medical theory are all about plaster and it is a good time for all. (when in the last 19 years have you got to play in the mud with the goal of getting dirty?) I am sure whoever teaches splinting class at your local facility will be able to teach you some stuff you might never have seen or heard and you may become more knowledgable than some of your peers and even some docs.  

As for something wrong, If i wanted to nit pick, I would say the child should not have been carried in, but wheeled in with mom on the cot too if that's what it takes. Just to minimize movement of the leg, not because i thought it would prevent some catastrophic damage. Avasclar necrosis is not an uncommon long term complication of a fracture, so even if a few vessles were broken, no way to objectvely say it wasn't part of the initial injury. 

I am not disagreeing with medic417 as the above posted clinical judgement is very sound, but I would have made every effort to sedate the kid, mostly because I like to be proactive about pain and the child was probably sedated at the hospital anyway. 

I wasn't there, but it sounds like the EM definately over reacted from your side of the story. But as we know, there are 3 sides to every incident.


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## kristendanielle (Mar 18, 2009)

Thanks for all the replies. I would like to let everyone know this was a bls truck. No paramedic on duty so we could not give any drugs


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## rescuepoppy (Mar 18, 2009)

Being  a BLS truck you were limited as to what could be done. Sometimes in efforts to do something we can do more damage. Not being there I can not say for sure but it sounds like the child fighting to get away might have caused more injury to the leg than not doing anything would have. Again not to Monday morning quarterback One thing I would have done differently would have been to have the mother hold the child on the stretcher and wheel them both in. This is one example of why we can not use the cook book approach to emergency medicine. Sometimes we have to play things by ear and do what we feel is best for our patient.


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## medic417 (Mar 18, 2009)

Only thing different would be to have mom place child in care seat rather than letting her hold the kid.  This is a safety issue.


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## Veneficus (Mar 18, 2009)

medic417 said:


> Only thing different would be to have mom place child in care seat rather than letting her hold the kid.  This is a safety issue.




very good point


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## Aidey (Mar 18, 2009)

Could the leg have been splinted at all in a proper car seat? I guess a pillow/blanket base could have been built under the leg if the car seat wasn't too high. 

Sometimes the best thing you can do for a patient is stop fighting them. The more they move the more damage they are going to do. I've had to forgo back boarding a very combative (head injury) 9yo because she was moving more fighting us then when we just let her lie down on her own.


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## Veneficus (Mar 18, 2009)

Aidey said:


> Could the leg have been splinted at all in a proper car seat? I guess a pillow/blanket base could have been built under the leg if the car seat wasn't too high.
> 
> Sometimes the best thing you can do for a patient is stop fighting them. The more they move the more damage they are going to do. I've had to forgo back boarding a very combative (head injury) 9yo because she was moving more fighting us then when we just let her lie down on her own.



sounds like a smart 9 year old, I would put up quite a fight if you tried to board me.


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## Aidey (Mar 18, 2009)

She had a bad concussion. She actually gave an EMT a black eye fighting him off as he tried to hold c-spine from behind. She went from AOx4 immediately after the accident to puking and responsive to pain by the time we got her to the hospital about 15 minutes later. 

That isn't the say that the EMT didn't deserve the black eye though.....*ahem*


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## exodus (Mar 18, 2009)

Veneficus said:


> sounds like a smart 9 year old, I would put up quite a fight if you tried to board me.



He spelled it correct  

Like others said, just move on with it, explain to the MD your approach, and why you did what you did. Then TAKE THE CLASS.  Good continuing education credits   And quick question, you have been doing this for 19 years and are a basic still?


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## PapaBear434 (Mar 18, 2009)

A pillow splint with a couple of cravats tied around isn't ideal but adequate for a lower leg fracture.  Why the Docs are giving you a hard time is simply CYA.  If mother decided to sue because the kid hurt their leg even more flailing about without a splint on, the hospital and medical director can toss it on you and say that you were properly re-instructed and dealt with.


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## VentMedic (Mar 18, 2009)

Veneficus said:


> I wouldn't get too worked up about it. There are a lot of not so smart doctors. You will never hear a public confession of that, but 1/2 through school there is already a list of people we hope never treat anyone we know.
> 
> Especially in US med schools, there is a lot of reliance on the latest greatest gadgets. It is entirely possible he had no idea you could use a soft splint. Of course the ER doc was going to call in another doc. It is orthopedic surgeons who fix bones, not EMs.


 
It is also not fair to criticize the doctor since none of us responding to the OP were there to see how this child presented. 

A splinting class might not be a bad idea since it could provide some pointers to something new or refresh on something forgotten. EMT(P)s may not get the chance to work with many different partners or other professionals to see if there is a better way to do something. Some may also take the easiest route for CEUs and don't always stay current or as skilled as they should be. Being an EMT for 19 years could give one a false sense of security of believing they know everything in their level especially if no one has ever criticized them before. Maybe it is time to see if new tricks can be learned or old ones remembered.


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## Veneficus (Mar 18, 2009)

VentMedic said:


> It is also not fair to criticize the doctor since none of us responding to the OP were there to see how this child presented..



I mentioned that at the bottom, 3 sides to a story. But I was trying to illustrate that just because somebody is a doctor doesn't make them all knowing and all powerful. 

Would be nice though.


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## benkfd (Mar 18, 2009)

kristen,
  YOU DIDN'T DO ANYTHING WRONG!!!!!!!!!!!I would have done the same things that you did. Keep the pt. as calm as you can through BLS means!!!!!!! Sounds like the Doc needs to ride on the streets for a while.  See if he/she could get the pt. to settle down.  Anyway,  I think you did the right thing.


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## mycrofft (Mar 18, 2009)

*The acceptable approach used to be to swoop on the kid and hogtie 'em.*

I see two questions: was the treatment correct and was the MD in the right?

1. If the MD tracked you down to try to beat you up by offering splinting classes care of you, he was off base. He should have lodged a complaint with your employer. Even if you had taken an O2 cylnder and beaten the kid to a pulp, trying to bully you around was not professional.

2. You could have ambushed the kid by having tape or some such under the pillow to secure it around the limb, then you could fasten a stiffener to the pillow. Mom didn't help??

Managing the people in EMS situations is harder than treating them. Live and learn but go to your boss about this doc.


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## curt (Mar 26, 2009)

I think I would've done the same as you. If she was constantly strugling and squirming around to not have the splint put on her, it probably would've resulted in her causing further harm to herself with that broken bone anyway- probably a lot more than just not splinting that leg. If someone's got obvious spinal trauma, but they're getting ready to really struggle to avoid getting collared, you're probably better off just having someone maintain manual control throughout, unless you plan on sedating him. I think you're covered under the primary rule of EMS, and, indeed, medicine: Do no further harm. 

 Also, as someone else said, specialty classe don't have to be a bad thing- you might learn something new and useful that you didn't get to learn from your classes or an associate in the field- especially since it's a class devoted to one thing and one thing alone.


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## VentMedic (Mar 26, 2009)

Welcome to being a medical professional. You are accountable for whatever decisions you make and whatever actions you take. If you can not adequately explain yourself with a logical reason then you may have a problem. It doesn't matter if every member on all the EMS forums agree with you. We don't know all the facts and cannot fight your battles for you.  Some may be agreeing with you but only from the picture you have painted.  Take the opportunity to review and refresh your skills.


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## 46Young (May 10, 2009)

How was your narrative written? Was it thorough enough to support your actions?


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## Dominion (May 11, 2009)

The only thing I would have done differently and this is something that's been hammered into my head is to have contact medical control.  In this situation I would have contacted an online doc and said "4yo pt with visible defomity and swelling in lower extremity (location), attempted to splint but pt is being difficult to work with, patient is calm with leg supported on pillow and in no visible distress.  <give vitals> Ok to continue transport with patients leg supported and immobilized on pillows?" then follow what the doc says.  if doc says to splint I'd try my best to get it splinted before arrival, if not possible then document document document document.


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## 2easy4u (May 11, 2009)

*Doc liability*

From your description, it sounds like the Doc was concerned about liability. Especially since this was a child,and the liability will be for many years. 
I have had several combative patients,and I have found that unless you can sedate or RSI the patient, your better off limiting your fight with them. In other words I don't think you did the wrong thing for your patient. The Doc got twisted up about it but he will get over that. And the child will have a better outcome because you did the right thing. Perhaps that Doc needs to ride along for a bit. So that he can become more comfortable with treating emergency patients.


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