# Second guessing another BLS's assessment/treatment?



## Amycus (Oct 4, 2010)

Ok, this is going to seem kind of silly, maybe, but an incident kind of inspired it....an incident I'm still kicking myself over, but anyways...

In my area, most Firefighters are also EMT-Bs or higher, but are non-transporting. I work for a private EMS service that does transport. In the more rural areas, Fire can often get on scene faster than us and they usually have an assessment of some kind already in progress by the time we get there. 

In this incident, Fire said they had controlled a bleed prior to c-spining someone. I took it at face value since 4 of them were involved in the whole process. By the time we got on scene, they already had the PT rolled onto the board. We loaded and went. Did a rapid assessment en route, found nothing new of note. Turns out by the time we got to the hospital, after moving the PT off the stretcher still on the board, there was blood on the PT's posterior side, which dripped through parts of the board unseen by me (as they were covered by the PT). I can only think of two possibilities...either an undiscovered lac, or the bleeding *wasn't* controlled afterall (the head blocks on the board covered the gauze from the bleed), basically meaning I'd have had to compromise c-spine to have re-assessed it.

In any case- this bleed went undiscovered til arrival at the hospital, which made me look like a total idiot talking to the RN, because I had a legitimate "Where the heck did that come from?" look on my face. Luckily, the PT was stable the entire time, and that never changed.

Now, here's where my mental dilemma resides. I blame myself 110% for this. If I was more vigilant, I should have caught this bleed somehow. Perhaps I should have done a glove sweep anyways once I assumed PT care (I didn't think about it since I assumed the only bleed was controlled and wanted to catch whatever else might have been missed). Perhaps I should have risked the c-spine compromise to make sure the bleed really was controlled. In either case, I blame my failings on one key thing. I accepted the assessment of another at face value. 

How do you go about telling another provider, or multiple providers (in this case, the 4 on scene prior to me), that you want to check the PT out yourself AFTER they've already told you "what's going on"? In this case, the majority of the work was already done by the time I even arrived. Should I have told them to take the PT off the board and let me start from scratch? Was this just one of those ugly situations where I couldn't really do much because of the position I was in?

I'm obviously still new at the EMS thing, but scenarios like this bother me because I feel as though I would have caught this problem where it was missed by the others.

This is kind of a long ramble. I apologize. I feel like I learned a valuable lesson, which compromised PT care, but did not know how to handle the situation any other way without blatently insulting a colleague's skills. Obviously, I documented the hell out of what happened in my run report. Longest narrative I think I ever wrote...

Anyways, opinions, if any of this makes sense?


----------



## Shishkabob (Oct 4, 2010)

You're the transporting truck.  In the end, it's your call, regardless of what the first responders think (if you're all at the same level).  

Always do your own assessment, regardless of what the other providers tell you.  The new ones, or the egotistical ones, might take offense, but anyone worth a damn will understand (which is why once at the hospital, the nurses AND the doctors do their own exams).  





However, once a patient is on a backboard, I'd be hesitant at taking them off, especially just to check for other possible (probably non-life threatening) injuries.


----------



## JPINFV (Oct 4, 2010)

I agree. It's a cost vs benefit question when it comes to removing equipment including badges. One question sure is, would it have made any difference whether there's a piece of gauze between the back board and the injury? 

Also, you can always preface your report with, "I wasn't able to examine the back due to spinal immobilization prior to arriving, but I was told..."


----------



## 18G (Oct 4, 2010)

It may be a little awkward to repeat something that another provider already reported but it is necessary. Ultimately, if your the provider in charge on the transporting unit it's all on you. If the patient is stable... package them and do the full assessment in the unit.. then you won't have to worry about hurting anyone's feelings. 

Do your own assessment and do it the same as if you were the first person on-scene. If someone get's offended oh well. It's your job. I don't want to offend anybody but from my experiences most FD EMT's who are non-transporting have little clue about what is going on with the patient and they don't do the best assessments. 

Next time just be assertive and polite if anyone says anything while you do a repeat assessment. Your the primary care person.... they are there just to assist.


----------



## Aidey (Oct 4, 2010)

Wounds are a tough one, because you don't want to undo the dressing the first responders put on. I've run into the issue where the FR (EMT or Medic) describes the wound to me as being quite severe, and then we get to the hospital and it isn't, or vice versa. 

Sometimes no matter what you do blood is going to get around the bandages. This is especially true in head wounds on women with long hair (worse if curly or dark) that are back boarded. Its hard to find the edges of the wound, hard to see the bleeding, and hard to get pressure on the gauze over the right spot. Once they are on the back board it is hard to reassess. 

Like JP I usually say "The FFs had it bandaged before I got there, so I never saw it but they said..." 

Another thing is that if you re-assess a patient and feel an intervention is absolutely unnecessary you can undo it.


----------



## CAOX3 (Oct 4, 2010)

What was the complaint?

Superficial bleeding?  No.

Significant bleeding dripping through clothes and off a backboard?  Yup their coming off the board, I will be familiar with every hole and its severity not bestowed upon them by the good lord if I have to drag an entire engine company to the hospital to accomplish it.

They love me. :lol:

And I dont go with the firefighter did it, my names on the report no theirs.


----------



## LonghornMedic (Oct 4, 2010)

A little more info would be helpful. What kind of call was this? Fall? MVA? Assault?

Always, always, always do another primary assessment. Never, ever trust what you have been told by the medical personnel on scene. This includes ER nurses, CNA's, Doctors, FF medics, volly EMT's, etc. Whether you are picking up someone on a IFT call from a retirement home, home health care, urgent care or on a 911 call, always do a full assessment just as if you were first on scene. Ask all the same questions you would if you got there first. I will do this once we are in the back of the ambulance so as not to step on anyone's toes. But I've been hosed by FF Paramedics on a couple occasions. One of which was a stabbing where the FF insisted that they checked the patients back for wounds and said there were none. He was c-collared(wounds to the neck) and on a board when we got there. So I took their word for it. We get to the trauma canter and guess what? There's 3 stab wounds to his back. Talk about looking like :censored::censored::censored::censored:. Getting dressed down by trauma docs isn't fun.


----------



## Veneficus (Oct 4, 2010)

LonghornMedic said:


> There's 3 stab wounds to his back. Talk about looking like :censored::censored::censored::censored:. Getting dressed down by trauma docs isn't fun.



Was it Dr. Mattox out of curiosity?

Really though, for the OP. 

No provider should ever be upset that you did your own assessment. Nobody is so good they never over look something. A finding you notice could give a very subtle clue that radically changes the treatment. 

Especially in field conditions the more eyes, the better. 

Some pathologies develop over time. For example a pneumothorax or a Cullins or Grey-Turner sign. When the previous provider checked there might not have been any abnormal findings.

Imitation is the best form of flattery. If you notice when you go into an ED, the ED doc may assess a patient. Call for a consult, who does their own assessment from the top. (except for ortho it seems like) With each assessment  you do, your next one gets better. Never cheat yourself out of becomming better. 

When you first start out you hope for a good job. When you are good, jobs hope for you.

Most providers go through a phase where they feel like they are not being trusted or their skills respected when they first start out. You may have to explain it once or twice to them. eventually they will catch on and start doing it too.

If not, they will burn out quick and will move on anyway.


----------



## Amycus (Oct 4, 2010)

Longhorn, it was a fall, with the PT's head striking an object on the fall.

Everyone else- Thanks for the information. I hate stepping on toes, and I know I made a mistake, and the advice I'm getting will help me improve in the future. Thanks =)


----------



## Bullets (Oct 4, 2010)

Amycus said:


> Longhorn, it was a fall, with the PT's head striking an object on the fall.
> 
> Everyone else- Thanks for the information. I hate stepping on toes, and I know I made a mistake, and the advice I'm getting will help me improve in the future. Thanks =)



If you dont like stepping on toes, then you need to find something else to do. If you work in a system where there is a heavy FR presence, be it FD or volly the you are going to get all kinds of opinions on patient care. Ignore most of them, trust those you know as far as you can throw them, and always do your full assessment.

Ultimately, your are transporting, and if the PT dies enroute, YOU get sued, YOU lose your cert, and YOU go to jail.

Plus, despite that fact that it is protocol, once the pt is on a LSB, odd are the C-spine has been compromised at that point to some degree. It would be best to do you RTA while you have the FD manpower then alone in the box. And if you dont feel comfortable doing that, make the FF who did the initial assessment come with you. As the say in communist russia, Tough poopskis


----------



## Shishkabob (Oct 4, 2010)

Wait, we get sued, stripped of our cert and thrown in jail every time a patient dies?



Crap... I hope the family of the guy I transported in June doesn't find out who I am, even though he's the one that killed himself.  Otherwise I'm screwed!


----------



## Bullets (Oct 4, 2010)

Linuss said:


> Wait, we get sued, stripped of our cert and thrown in jail every time a patient dies?
> 
> 
> 
> Crap... I hope the family of the guy I transported in June doesn't find out who I am, even though he's the one that killed himself.  Otherwise I'm screwed!


Not every time a patient dies, but if you do a poor assessment and your actions, or lack of, cause the patients death, then yes.

In the case OP presented, everything was ok. But what if it wasnt? what if that bleed was from an penetrating wound that punctured the pt's liver? i think we all know how quickly things can go south in this job. 

My point is that if something happens, as the transporting EMT care and outcome of the patient is ultimately going to fall on your shoulders even if werent the first on scene.


----------



## JPINFV (Oct 4, 2010)

Bullets said:


> In the case OP presented, everything was ok. But what if it wasnt? what if that bleed was from an penetrating wound that punctured the pt's liver? i think we all know how quickly things can go south in this job.



Ok, the liver is punctured. Are you going to open up a MASH unit and operate in the field or something? Give blood products? ...or slap a 4x4 over the wound and roll the patient back onto the backboard and transport?


----------



## TransportJockey (Oct 4, 2010)

If at all possible I always reassess when getting a patient from another provider (medic, RN, EMT, etc. Hell, I even did my own re-assessed a patient given to me by an ED director. No one has ever complained to me face about it). Now, undressing a wound or taking them off a backboard is a little bit sticky, but like was said, if blood is leaking off the sides of the board, or just pouring through a dressing, I'm damned sure going to take a look and see why it either isn't controlled or wasn't dealt with properly.


----------



## Bullets (Oct 4, 2010)

probably more like a 8x10 trauma dressing. 

But if its just a fall from standing height with associated lacerations around the head, i would take c-spine precations as per protocol, apply bandages and bleeding control, and provided no LOC, transport BLS to the closest facility

If there was a serious penetration to the back and liver AS AN EXAMPLE, perhaps im requesting, or keeping(depending on dispatch) ALS response for fluids and the like. 

im just advocating for doing your own full assesment whenever you make contact with a potential pt. You guys want to take everything i say literally and nit pick the minutiae and miss the overall point

Dont be afraid to step on toes in EMS when it comes to assuming Pt care


----------



## Veneficus (Oct 4, 2010)

Bullets said:


> what if that bleed was from an penetrating wound that punctured the pt's liver? i think we all know how quickly things can go south in this job.



Before I offer a comment, could I ask you to clarify this statement?

As I understand the OP was concerned about a posterior bleed.

Are you suggesting a scenario in where the Liver was penetrated from a posterior low velocity wound?


----------



## Amycus (Oct 4, 2010)

jtpaintball70 said:


> If at all possible I always reassess when getting a patient from another provider (medic, RN, EMT, etc. Hell, I even did my own re-assessed a patient given to me by an ED director. No one has ever complained to me face about it). Now, undressing a wound or taking them off a backboard is a little bit sticky, but like was said, if blood is leaking off the sides of the board, or just pouring through a dressing, I'm damned sure going to take a look and see why it either isn't controlled or wasn't dealt with properly.



I suppose I should clarify, boards we use have a small circular hole up near where the head is, the blood was going through that hole. The head completely covers the hole once the PT is secured on.

Edit:

I understand the point Bullets is getting at. I hopefully want to avoid people getting snippy at each other in this thread =P As I always say (and the real reason behind the "stepping on toes" comment), we're all on the same team, regardless of level of care or organization =P No sense biting each others heads off


----------



## sir.shocksalot (Oct 4, 2010)

This sounds like a case of the magical blood-letting backboard. As soon as you put anyone with a cut on the back of their head on a backboard it will immediately start to bleed profusely, regardless of size of the wound or how well it's bandaged. It's freaking magical, the backboard just laughs all the way to the hospital as it leaks the pt all over the pram and all over the floor. :lol:

But in all seriousness, always do your own assessment in the back of the bus, no one would blame you. In fact if I handed off a pt to the hospital and the doc didn't do his own assessment, I'd be concerned. This also sounds like one of those sneaky bleeders, sometimes you can do a good assessment, find no bleeding, and the pt will still spring a leak on you enroute that you wont notice, as before mentioned, cuts on the back of backboarded pt's heads are the biggest culprits.


----------



## CAOX3 (Oct 4, 2010)

Whether you can treat it is irreverent, its about recognition. Noting injuries and there severity can remove the possibility that this guy doesn't bleed out in a hallway because the provider didn't recognize or was even aware of severity of the injury.


----------



## JPINFV (Oct 4, 2010)

If, all things else being equal, the patient is stable enough to go lay in a hallway, then he most likely doesn't need to be spinal immobilized, which of course removes the condrum of the fact that the patient is on a board (of course now we get into the issue of over-immobilization of patients). Even still, he should at minimum, be removed from the backboard on arrivial regardless of being cleared or not (actually, step 1 of management according to one of the ortho docs at my school is removal of the backboard), at which time the back would be checked. Finally, continously monitoring the patinet, including looking for any unexpected blood and changes in vital signs, should clue into any unseen injuries.

It's not that I don't think that everyone assuming care shouldn't do their own assessment to cofirm what has been found, it's that I think there should be caution involved when that exam requires removing medical devices and/or temporarily discontinuing treatments in order to accomplish it.


----------



## Aidey (Oct 4, 2010)

^^^ That is very true. You can reassess the patient piece by piece if necessary. Instead of totally taking them off the back board remove one head block at a time. Or loosen the straps and do the flat hand blood sweep from day 2 of your EMT class. 

Following what JP said, it is infrequent I see a patient left on a back board. More commonly I see the c-collar left on and the back board removed.


----------



## Bullets (Oct 4, 2010)

Veneficus said:


> Before I offer a comment, could I ask you to clarify this statement?
> 
> As I understand the OP was concerned about a posterior bleed.
> 
> Are you suggesting a scenario in where the Liver was penetrated from a posterior low velocity wound?



yeah, before OP clarified, she just said it was some form of posterior bleed, i was merely providing an example of an injury that might look minor at first, especially compared to the level of bleed a head injury usually entail. but could have a profound impact on patient care if not managed.

Also, while we all work together, i dont begin to tell them how to fight a fire when i am working as an EMT, i appreciate the help, but i will do my own assessment, taking everything the FD said into consideration as long as it flies. If you explain yourself to them, im sure they will understand and appreciate your thoroughness


----------

