# "Non-Injury" Traffic Accident



## Tigger (Jun 15, 2014)

Dispatched to a two car traffic accident on a state highway. One vehicle crossed over and sideswiped a compact hatchback all down the left side at approximately 50mph. Side curtain airbag deployment with pillar deformity but no intrusion into passenger compartment. Rear axle no longer substantively attached to vehicle.

Arrive on scene to find your 75 year old male patient ambulating around vehicle and talking to other driver. Initially he is has no complaints though after being asked the usual litany of questions he states some "very minor" L arm pain from the airbag deployment. 

At this point I am thinking about starting a refusal, in terms of history he says he has Afib and takes Pradaxa. 

So now what? Physical, mental status exam entirely unremarkable, as was a 12 point cranial nerve screening. No other complaints. 130/70, HR 60 regular, 93%RA sat. 

Transport? Refusal? POV transport? No ambulance needed?

My partner practices his own brand of medicine and as he is the medic, I often end up doing so as well, so I'd like to see what others would do.


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## DesertMedic66 (Jun 15, 2014)

With that, I would like to transport him but you can't force him to go.


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## TransportJockey (Jun 15, 2014)

Inform him of risks of refusal, do a full workup (if the patient allows), and then ask him again what he would like to do. If he still states that he doesn't want to go, get a refusal signed and witnessed (preferably by family and at least one LEO) and go back in service.


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## DesertMedic66 (Jun 15, 2014)

TransportJockey said:


> Inform him of risks of refusal, do a full workup (if the patient allows), and then ask him again what he would like to do. If he still states that he doesn't want to go, get a refusal signed and witnessed (preferably by family and at least one LEO) and go back in service.



Same as this if he refuses. This is a standard process out here.


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## Ewok Jerky (Jun 15, 2014)

Review the risks of anticoags with the old man. highlighting campartment syndrome and head bleeds. Hopefully transport, if not release AMA.

Even though I would like to transport this fellow, the ED isn't going to do much for him besides watch.  There is no "antidote" to reverse the effects of pradaxa in the setting of a bleed.


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## OnceAnEMT (Jun 15, 2014)

beano said:


> Review the risks of anticoags with the old man. highlighting campartment syndrome and head bleeds. Hopefully transport, if not release AMA.



This. Explain the worst case scenarios and encourage it like all else. I'd add a recommendation to call 911/go to the ED in the event that his s/s worsen over the next few days.


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## Gymratt (Jun 22, 2014)

I agree with the above posters and honestly I always encourage all of my patients at this point in my career to allow transport and if I'm dealing with someone that might be high risk such as age or history then I will even call med control and allow the med control doc to speak directly to the patient as well.


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## spnjsquad (Jun 23, 2014)

Agreed. Try and do a workup, and go over the RMA with him and how when he signs it we are not liable anymore. Be sure tell him the possible risks of not going to the hospital. If he can have someone else drive him, then I wouldn't think much of it. If he claims he wants a transport to x hospital, then I would but with no lights or sirens.


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## rails (Jul 13, 2014)

TransportJockey said:


> Inform him of risks of refusal, do a full workup (if the patient allows), and then ask him again what he would like to do. If he still states that he doesn't want to go, get a refusal signed and witnessed (preferably by family and at least one LEO) and go back in service.



I like your reply. Can you elaborate on what you personally would state as the risks of refusal in this instance, and what kind of workup you'd do?

Hope you don't mind my question.


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## EMT4EVA (Jul 18, 2014)

The way I would handle this would be to have him sign a refusal in the presence of one other witness.



Tigger said:


> Dispatched to a two car traffic accident on a state highway. One vehicle crossed over and sideswiped a compact hatchback all down the left side at approximately 50mph. Side curtain airbag deployment with pillar deformity but no intrusion into passenger compartment. Rear axle no longer substantively attached to vehicle.
> 
> Arrive on scene to find your 75 year old male patient ambulating around vehicle and talking to other driver. Initially he is has no complaints though after being asked the usual litany of questions he states some "very minor" L arm pain from the airbag deployment.
> 
> ...


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## Brandon O (Jul 18, 2014)

You did 12 cranial nerves?


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## Ewok Jerky (Jul 18, 2014)

Brandon O said:


> You did 12 cranial nerves?



Do you smell something?

"CN II-XII grossly intact" is a sufficent documentation of a cranial nerve exam.


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## Carlos Danger (Jul 18, 2014)

Brandon O said:


> You did 12 cranial nerves?



He's _that_ good.


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## medicaltransient (Nov 3, 2014)

If you are unsure you can elaborate your assessment. Give him you best impression of the risk and let him decide. Definitely not a no ambulance needed.


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## Pond Life (Nov 5, 2014)

Pre-crash phase (old, ?meds, ?underlying arthritic issues) - place him on a Vac Matt and get him cleared by someone with more medico-legal cover than me.


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## OnceAnEMT (Nov 5, 2014)

Pond Life said:


> Pre-crash phase (old, ?meds, ?underlying arthritic issues) - place him on a Vac Matt and get him cleared by someone with more medico-legal cover than me.



Interesting, self-lacking comment from someone practicing in a remote area.


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## TransportJockey (Nov 5, 2014)

Pond Life said:


> Pre-crash phase (old, ?meds, ?underlying arthritic issues) - place him on a Vac Matt and get him cleared by someone with more medico-legal cover than me.


Please please tell me you're joking


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## Akulahawk (Nov 5, 2014)

Something I was thinking about generally from the title... and sparked a memory from about 1999 or 2000. If you seen an accident and you can't stop, don't call it in as a "non-injury" accident. I was on-duty one day and heard a competitor's ambulance crew do exactly that. They didn't stop, called it in as a non-injury, and kept going. A few minutes later, a 911 crew arrived and found that not only was that not the case, at least one of  the patients had to be transported emergently to a trauma center for care. I heard the county dispatchers confirm that the crew stated that it was a non-injury... and a few minutes later, asked for their cert numbers over the air. It wasn't a "report to quarters" or "report to EMS office" but "We need your cert numbers, NOW."

It's my understanding that both were disciplined, probably by having their certs yanked for a while, if not permanently. 

In this particular instance, I may have ultimately found "no medical need" and therefore "no patient identified" but if that's the case, I would have also advised him about head-injury issues. I would have probably done a very thorough exam to be certain that the L arm pain is more likely musculoskeletal than cardiac in origin.


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## Ewok Jerky (Nov 5, 2014)

To call in an on view accident as "non injury" without actually is assinine and they deserve whatever consequences became of it, up to and including pulling their certs.


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## DesertMedic66 (Nov 5, 2014)

beano said:


> To call in an on view accident as "non injury" without actually is assinine and they deserve whatever consequences became of it, up to and including pulling their certs.


Saying an accident is non-injury without fully assessing a patient is asinine? 

I've had several traffic collisions where we get on scene and see there is very little damage to the cars, talk to the parties involved and see if they want medical attention. If they say no then it's just a matter of making sure they are not altered and then "dispatch Medic 310 is clear, non-injury TC."


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## Ewok Jerky (Nov 5, 2014)

Whoops. Looks like I missed a word in there.  I meant to say without stopping.

Inspecting the cars and talking to parties involved can simply be a "person not a patient" scenerio. That is due diligence. But calling it in without even stopping?


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## DesertMedic66 (Nov 5, 2014)

If it looks BS or we were just driving and we saw it we will normally stop and roll down a window and ask, unless we need to do traffic control.


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## Tigger (Nov 6, 2014)

I forgot I posted this oops. In any case I posted this after getting into discussion with my partner about how I would have been comfortable writing a refusal on this patient after a quality assessment and some time discussing the advantages of being transported. My partner was absolutely adamant that this patient had to be transported. He was also pissy that I didn't start an IV "since you know the hospital is going to call a trauma alert." I figure it's not my issue that our less than adequate facility is going to call a team on this guy with no complaints, so I am not going to go looking for them. 



Brandon O said:


> You did 12 cranial nerves?



12 (well technically 11) point cranial nerve exams are very popular round these part. One AMR CES employee got people to start doing them and kaboom, now everyone in the region does them. There's no rhyme or reason as to when or why, just a "hey why don't you do one on him." Sometimes I just do as I am told.


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## Pond Life (Nov 6, 2014)

75 year old male - am I joking about him possibly having arthritis - no. Am I joking about him possibly being on meds and so on which may mask alterations in his vital sign, nope again.

End of this year we in the UK will be adopting new criteria beyond CCSR and Nexus to allow us to ask patients to self mobilise onto stretchers from RTCs (MVAs) even if they have bony tenderness (as long as there are no red flags elsewhere). With this scope of practice comes an increased responsibility to look beyond the obvious which I think you are missing.

Insight into pre crash phase has been around for donkeys years and is applicable now as ever.

75 year olds are prone to fractures and if you believe this not to be the case I suggest you have a chat with your medical director and see have s/he thinks.


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## Ewok Jerky (Nov 6, 2014)

...except this patient isnt presenting with any signs of acute fracture, spinal injury, or hemorrhage.  Arthritis is not an acute condition requiring any special imobalizaton after a MVA or during transport.  

The biggest concern for this fellow is some sort of hemorrhage, most likely in his arm, leading to compartment syndrome.  What is the ED going to do? Nothing that he can't do at home with some proper education.

I would have to look back but I don't think anyone is saying absolutely no reason not to transport, but if this guy wants to AMA I wouldn't fight him hard on it, provided he is aware of the risks of pradaxa.


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## Pond Life (Nov 6, 2014)

apologies, got the wrong end of the tread in that case.
Agreed if the patient has capacity and demonstrates such then it's his right to decline ED AMA. In fact to force him is assault/battery, certainly in the UK and I'm sure it's the same across the pond.
again - apologies


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## TransportJockey (Nov 6, 2014)

Pond Life said:


> apologies, got the wrong end of the tread in that case.
> Agreed if the patient has capacity and demonstrates such then it's his right to decline ED AMA. In fact to force him is assault/battery, certainly in the UK and I'm sure it's the same across the pond.
> again - apologies


No worries. I can see now why you posted what you did, since you read the beginning and didn't quite make it to the end lol. You're very right that we do not force patients who can decide for themselves into a treatment modality.


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## Brandon O (Nov 10, 2014)

beano said:


> ...except this patient isnt presenting with any signs of acute fracture, spinal injury, or hemorrhage.  Arthritis is not an acute condition requiring any special imobalizaton after a MVA or during transport.



Ankylosing spondylitis might be!


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## ERDoc (Nov 12, 2014)

As others have said, if you properly assess the patient and explain your findings with him and he refuses, as long as he has the capacity, you can't make him go.  I would agree that he probably needs to be checked out in the ER but you can't force him.  OP, it sounds like your partner made the decision to force the pt to go but you were the one in the back.  If your partner was so adamant about it, why didn't he run the call?


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## Tigger (Nov 12, 2014)

He had somewhere to and it was a late call. Normally I make him take the patient in these sorts of situations.


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## ERDoc (Nov 16, 2014)

No offense, but it sounds like you need a better partner.


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