# scenario



## soon2bemt (Oct 9, 2006)

So last night my partner and I are dispatched to a 4-wheeler accident unknown injuries.  We go en route and about half way to the scene dispatch comes back and says there is a doctor on scene (turned out to be a nurse and happened in her driveway)-anyway-says our patient has a possible broken arm and leg and roadrash.  Well we get there and his :censored::censored::censored::censored:in right leg is rotated outward and shortened.  Foot was cold and a weak pedal pulse.  We get him fully spinal immobilized and put a pillow under his knee to help support the leg.  He couldn't straighten it out or move his whole foot but he could feel it.  Good pulses in the arm that was very swollen around the wrist-splinted it.  Our patient was A & Ox4 the whole time.  He remembers losing consciousness but remembers everything that happened up to him losing consciousness and after he woke up.  Bystanders state he was only out approx. 20-30 seconds.  Patients vitals are as follows.... BP 120/80, P 94, R 18, P-ox 97 on RA, pupils equal and reactive to light.  He was pretty stable.  But due to my partner and I being BLS we didn't feel comfortable waiting on scene for and ALS unit or a helo because of his leg.  Helo was at least 20 minutes out and ALS was at least 15-20 out.  Foot was getting colder and pulse was still weak.  We loaded and went.  En route to the ER my partner gives her report and the ER comes back and asks us if our patient needs a trauma center.  We don't know what to say so my partner again informs them that we are BLS and that our patient is basically stable.  We get him to the closest facility in about 8 minutes.  They send our patient to x-ray and CT and comes back with a concussion which I was kind of suspecting, broken left radius, broken right hip-which I was suspecting also, and a broken left scapula.  They end up flying him to a trauma center.  The doc comes over to our EMS "cubicle" and tells us that we wasted 1hr and 45 min by bringing him here.  We responded to that with a "our patient's leg needed to be stabilized."  Pulse was weak and foot was cold.  The doctor said Oh, well I got a good pulse in that foot.  Totally trying to make us look bad.  Anyway, would ya'll have done anything different.  My partner and I were worried about the leg.  When we got back to the station we told our lt. and her partner and the medic who was coming on to relieve me what happened and they all said they would have done the same thing in our situation and they will back us up 110%.  So, in ya'll's eyes-did we do anything wrong?


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## Summit (Oct 9, 2006)

My inclination would have been to send him straight to the trauma center though not by helicopter from the information provided for prehospital info (more vitals would have been nice to judge stability trend and continuing neuro exams). 

However, we never had that luxury where I worked. Our protocol said "always go to the nearest medical center unless you are flying." So we would have taken him to a level IV and he would have been flown from there from what you said.

If the patietn showed any sign of instability I wouldn't have hesitated to have called flights to meet us at the hospital.

Edit, on second thought, if I really though that circulation was significantly compromised in the broken leg, as you thought, I might have flown that due to the transport times in my area (1.5hr to a level I).


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## soon2bemt (Oct 9, 2006)

*2nd set of vitals*

The second set of vitals were if I remember correctly- BP 120/80, P 88, R 18, Pupils still equal and reactive, Pox 100% after we put him on 2L NC.


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## Chimpie (Oct 9, 2006)

What would have been the transport time to a trauma center?

If it's more than 30 minutes then I would have done exactly what you did, got him to the closest hospital to stabilize the leg/pt.  The hospital did exactly what they had to do:  They realized that injuries were at a point that he need a trauma center and flew him out.  Pretty basic to me.


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## soon2bemt (Oct 9, 2006)

*times*

From the time of call to dispatch for them to get us a helo to time the patient would have been at a trauma center would have been probably an hour.  The helo's around here usually have a 15-20 minute ETA and won't land until fire gets there and that would have been about 15 minutes.  Then once the helo's land they shut down (some protocol), load the patient and at least a 20-25 minute flight to the trauma center.


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## Epi-do (Oct 9, 2006)

In your situation I would have probably done the same thing you did - get the patient to the closest facility to be stabilized and then transfered.  At the BLS level, that is really all you can do.  Aren't we always told that if you can get to the hospital before ALS can get to you, that you are better off transporting?  You did recognize that the patient was going to need more care, but also did what was in the best interest of the patient by getting him someplace his leg could be stabilized before the longer transport to the trauma center.

Of course, I am totally spoiled here because we have two level 1 trauma centers in downtown Indy and I can have a patient to either one of them in about 15 minutes or 2 other ERs that I can be to even quicker.  I can't imagine having to take into consideration that the closest trauma center would be a 20-25 minute flight away.


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## Jon (Oct 9, 2006)

Ok... sounds like you made the right call. If aeromedical could have been there quickly, then that would be good... since it wasn't then the closest ED was appropriate, at least to see if they could try to stabalize the leg better.


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## wolfwyndd (Oct 11, 2006)

Eeehhh.  Judgement call, I think.  Six of one, half dozen of another.  Due to the nature and method of injury he could have gone either way.  I wouldn't loose any sleep over it.  Although on the report to the hospital, I WOULD have said that the patient needed a trauma center.


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## FF894 (Oct 12, 2006)

soon2bemt said:


> From the time of call to dispatch for them to get us a helo to time the patient would have been at a trauma center would have been probably an hour.  The helo's around here usually have a 15-20 minute ETA and won't land until fire gets there and that would have been about 15 minutes.  Then once the helo's land they shut down (some protocol), load the patient and at least a 20-25 minute flight to the trauma center.



Where are you that it takes 15 min for fire to get there and secure the LZ!?


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## oldschoolmedic (Oct 12, 2006)

The patient is hemodynamically stable based upon the set of vitals you have given us, but I am more concerned with the moi and the age of the patient.

The patient experienced a transient loss of consciousness which suggests a pretty good shot to the melon. Was the patient wearing a helmet? How fast was he going when the crash occurred? What did he hit?

You have a shortened, rotated limb, probably swollen, point tenderness, loss of mobility. This is indicative of a fracture. So we already have a possible long bone fracture. On top of that there may have been circulatory compromise. The patient needed a trauma center.

Now we add in a shortened, swollen arm on the same side as the leg/hip. So we have at least two long bones, if not three, involved already. Multitrauma, the patient needed a trauma center.

Then we have a fractured scapula. Does anyone know how hard it is to actually fracture a flat bone? The force required is very significant, because the bone is irregular and flat, making it very hard to get a hard shot on it.

The patient needed a trauma center. Now that the crabby part is out of the way...

You did the right thing. If you are unsure of something turn it over to the people with more letters after their name. They want to spend all of that money becoming doctors, let them earn it back working. The doc in question was wrong to do what he did. There was no need to belittle you guys. 

His problem falls under COBRA and EMTALA. See now that the patient is on his doorstep, he has to evaluate and stabilize the patient. Only then can he ship them out to where he wanted them to go. Legally, he doesn't have a leg to stand on, because his was the closest facility. If he had diverted you he would have had to notify the receiving hospital and gotten an accepting physician for the patient. Now do you see why he has his knickers in a twist? Had you diverted around his little island of false hope, the problem would never have come to him. Ignore him and drive on.

Next time he says something smarmy to you, look him straight in the eye and sat, "I didn't know this ER was invitation only, sorry." It will be worth the day off, trust me.


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## soon2bemt (Oct 13, 2006)

oldschoolmedic said:


> The patient is hemodynamically stable based upon the set of vitals you have given us, but I am more concerned with the moi and the age of the patient.
> 
> The patient experienced a transient loss of consciousness which suggests a pretty good shot to the melon. Was the patient wearing a helmet? How fast was he going when the crash occurred? What did he hit?
> 
> ...



Patient was 21 years old, not wearing a helmet and he and bystanders said he was going about 20 mph around a gravel curve when he lost control and flipped.

Our patient was not complaining of any shoulder/back pain and upon examination in rta and oa nothing was noted.  No indication to us of a scapula fx.

On the aeromedical point......closest helicopter IF available would have been 15 minutes away if needed.  Around here they don't like to land if fire isn't on scene.  We were about 7-8 miles out of the city limits which would put county fire on for our call for an LZ which means they have to respond from their home to the station-wait for enough crew to show up and then go en route taking about 15 minutes to get to where we were.  The helo has to shut down-depending on which service we got which probably would have been Staff for Life and they shut down on scenes.  They would have had to get an IV in the back of our truck since we were BLS and couldn't get one and then load, start up, and flight time would have been about 20 minutes or so depending on which hospital they went to.  I'm in the middle of Missouri so they either would have gone to Kansas City to Research Hospital-which is where he went when the helo came for him at the hospital-or to Columbia University Medical Center.  Either way would have been a long transport to even a hospital if we didn't take him to the closest facility for stabilization.


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## Airwaygoddess (Oct 17, 2006)

Was the 4 wheeler still at the scene? (How tore up was that 4 wheeler?) and how fast was the patient going in the 4 wheeler and what did they hit? I think your course of treatment was on the money.  That right leg was unstable and did need to be assessed by the M.D.


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## kevinemt662c (Oct 17, 2006)

Sounds good to me.  Docs can be like that.  I feel your frustration!


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## soon2bemt (Oct 17, 2006)

Patient stated he was going approx. 20-30 mph around a gravel curve and lost control.  The 4-wheeler didn't look too bad.....handle bars were messed up a bit.  The only thing the patient hit was the hard ground.


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## TheDoll (Oct 18, 2006)

Epi-do said:


> In your situation I would have probably done the same thing you did - get the patient to the closest facility to be stabilized and then transfered.  At the BLS level, that is really all you can do.  Aren't we always told that if you can get to the hospital before ALS can get to you, that you are better off transporting?  You did recognize that the patient was going to need more care, but also did what was in the best interest of the patient by getting him someplace his leg could be stabilized before the longer transport to the trauma center.
> 
> Of course, I am totally spoiled here because we have two level 1 trauma centers in downtown Indy and I can have a patient to either one of them in about 15 minutes or 2 other ERs that I can be to even quicker.  I can't imagine having to take into consideration that the closest trauma center would be a 20-25 minute flight away.



hey, i'm in indy, too! for some reason i don't see the private message symbol
<---feeling especially stooopeeed today
sorry to threadjack, but where are you in these parts?


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## ffemt8978 (Oct 18, 2006)

TheDoll said:


> hey, i'm in indy, too! for some reason i don't see the private message symbol
> <---feeling especially stooopeeed today
> sorry to threadjack, but where are you in these parts?



The Private Message option is available by clicking on that person's screen name.  The second option down should allow you to send a PM to that person.


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## wolfwyndd (Oct 18, 2006)

FF894 said:


> Where are you that it takes 15 min for fire to get there and secure the LZ!?


Yeah, out here in the rural areas it can take that long.  I'm about 20 miles, as the crow flies, outside Dayton, OH and our EMS squad covers 48 square miles.  If we needed to fly someone we'd have to have one of our three local fire companies dispatched for a LZ too and it would not be unheard of for the helicopter to be circling for a few minutes while the FF's finished setting up the LZ.  Point is, 15 minutes is commom for us.


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## TheDoll (Oct 19, 2006)

ffemt8978 said:


> The Private Message option is available by clicking on that person's screen name.  The second option down should allow you to send a PM to that person.


thank you and sorry for being such a spaz. it was late. i looked for the button after clicking on the avatar but didn't see it. thanks for clueing me in:blush: 
<--needs to be handed her clues once in awile


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## brentoli (Oct 19, 2006)

I aggree with what you did to a point. Here in my part of Indiana, out side of indy... we can request PHI or Lifeline to the hospital. They still go in, get checked out, but the flight crew is waiting right there in the ER so when the doc is done the pt is out.
Secondly, why were there no fire units on the scene already? It is SOP here for any vehicle accident with injuries for fire units to respond. Yes that includes 4-wheelers. Just because you heard the report from the nurse on the scene doesnt mean the dude still isnt trapped under the 4-wheeler. 
Here... on any accident that sounds trauma... the first unit enroute puts PHI on standby or even starts them to the scene. And yes, thats BLS units. 
Ask anyone, execpt those at the anal hospital next county over, and they will tell you, it is better to have the bird lift off and start to you before you need it then call it 15 min later. 
Don't get me wrong, we dont start PHI on EVERY crash... anything on the interstate... reported entrapment, ejection, those types...


Did this make sense? I didnt sleep much last night.h34r:


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