# trauma call, head and facial assault



## knxemt1983 (Aug 23, 2011)

So here's a scenario I ran into today and I would like some opinions on it. 

Responded to a 29 year old female, assault victim. Once there the pt is ambulatory, but with numerous abrasions and lac's on her head, face, and upper extremities. She does not remember the occurence, only that she was knocked down and when she came to she was on the ground with head and face pain. Bystanders said she was repeatedly punched, and kicked on the head. No neck or back pain. Obvious broken jaw and nose.
Pmh: asthma
Nkda
Only med is proventil prn, rarely used
V/s: 130/80, pulse 100, spo2 96%, rr 16
Alert and oriented appropriately
Immobilize or not?

My partner disagreed with my decision. I immobilized with the thinking that if enough force was transferred to the head to break her jaw and nose, with loss of consciousness then spinal immobilization was needed. I wouldn't second guess it except the physician at the ed immediately pulled it all off when we got there. By our protocol for immobilization I was right, but is there something I'm missing? Would you have immobilized or not? I know the usual lessons about following protocol, and I have read up on current research on how immobilization is not completely effective etc etc etc, but wonder what the "standard" would be


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## DesertMedic66 (Aug 23, 2011)

For that call I would have immobilized also. Broken jaw + LOC + numerous hits to the face + hitting the ground = C-spine IMO. 

And for alot of people you immobilize as soon as you get to the ER/ED they will remove then from C-spine (from what I have seen.)


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## truetiger (Aug 23, 2011)

You did right by your protocol. Just because an ED doc pulled it off immediately doesn't mean he was right. I would make a note of this to whoever does your training/QA/education so that they can follow up with the hospital and find out why. If immobilization was not indicated for this patient you'll get an answer why and if it was, the hospital can follow up with the doc for improperly removing it.


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## Melclin (Aug 23, 2011)

Doctors can pull all the c-collars off that they want, doesn't mean you shouldn't have put it on in the first place.

Take a job I went to a little while back. Assault, complaining of c-spine pain on palpation, altered numbness and tingling down the left side. I was pretty sure he didn't have a spinal injury and that the numbness and tingling was because he'd been laying on he left side on cold concrete for the past 25 mins. Still immobilised the kid. You have to. When we got to the ED all of a sudden the c-spine tenderness is gone and no more altered sensation. Doesn't mean it wasn't indicated half an hour ago. 

I'm the last person to immobilise people every idiot I come across and I hate immobilising people when I do, but the fact remains that it is still a standard of care with certain indications. Multiple kicks to the head with LOC and a distracting injury. How can you write that on your PCR and not have immobilised the person? I would have immobilised in the sense that I would have put a collar on and asked her to lay still and flat on the bed.


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## knxemt1983 (Aug 23, 2011)

truetiger said:


> You did right by your protocol. Just because an ED doc pulled it off immediately doesn't mean he was right. I would make a note of this to whoever does your training/QA/education so that they can follow up with the hospital and find out why. If immobilization was not indicated for this patient you'll get an answer why and if it was, the hospital can follow up with the doc for improperly removing it.



Yeah I filled out an incident report to our qa department and medical director as well as sent the epcr to them for review. I don't regret doing it but wanted to make sure I wasn't out of touch, the fire dept agreed with my partner so I was totally outnumbered. I nformed the pt of the risks of notdoing it and she agreed it was best. As for the doc, idk if he was right or wronghe did some neuro tests and cleared it, if he wants to take it off that's on him and he's not bouncing down the road in a work truck lol


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## truetiger (Aug 23, 2011)

Did he take her off the board or both the collar and the board?


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## knxemt1983 (Aug 23, 2011)

Melclin said:


> Doctors can pull all the c-collars off that they want, doesn't mean you shouldn't have put it on in the first place.
> 
> Take a job I went to a little while back. Assault, complaining of c-spine pain on palpation, altered numbness and tingling down the left side. I was pretty sure he didn't have a spinal injury and that the numbness and tingling was because he'd been laying on he left side on cold concrete for the past 25 mins. Still immobilised the kid. You have to. When we got to the ED all of a sudden the c-spine tenderness is gone and no more altered sensation. Doesn't mean it wasn't indicated half an hour ago.
> 
> I'm the last person to immobilise people every idiot I come across and I hate immobilising people when I do, but the fact remains that it is still a standard of care with certain indications. Multiple kicks to the head with LOC and a distracting injury. How can you write that on your PCR and not have immobilised the person? I would have immobilised in the sense that I would have put a collar on and asked her to lay still and flat on the bed.



That would be an option I would be open to, however our protocols are basically all or none. I mean we could document a refusal of lsb if that was the case, but likely would be in the "principles office" to 'splain ourselves for it. Not that we would be in trouble but it would just be a very extraordinary scenario. That's not likely to change either since even as times change rapidly its rare for our protocols to change other than with acls/pals


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## shfd739 (Aug 23, 2011)

I'd agree and say you were right. Our protocols stipulate any injuries above the clavicle get immobilized so I would have and could have justified it to the FD. I dislike having to immobilize and can usually rule out alot of folks but my sucspision would be high for this patient. 

The ER docs can pull all the collars they want. Their initials mean more than mine. 


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- Sent from my electronic overbearing life controller


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## knxemt1983 (Aug 23, 2011)

truetiger said:


> Did he take her off the board or both the collar and the board?



The whole shebang.... he said just try not to move around much until we get some xrays and a ct. I wasn't exactly comfortable with it but he signed my pcr and I was leaving by then so it was outta my control and on his license, and livelyhood not mine


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## knxemt1983 (Aug 23, 2011)

shfd739 said:


> I'd agree and say you were right. Our protocols stipulate any injuries above the clavicle get immobilized so I would have and could have justified it to the FD. I dislike having to immobilize and can usually rule out alot of folks but my sucspision would be high for this patient.
> 
> The ER docs can pull all the collars they want. Their initials mean more than mine.
> 
> ...




Yeah I justified it to them but they never wanna listen, they just wanted to hurry outta there and get back to the recliner. They actually wanted to walk the pt to the truck and said "just leave the cot in and we'll bring the pt out to ya". The call even came out as assault with positive loc


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## truetiger (Aug 23, 2011)

Great job of advocating for your patient and not going with the group. Who cares what the fire dept thought. This is a good example of taking control of your patient's care.


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## knxemt1983 (Aug 23, 2011)

truetiger said:


> Great job of advocating for your patient and not going with the group. Who cares what the fire dept thought. This is a good example of taking control of your patient's care.



Thanls for the compliment. Its beenone of those nights of second guessing everything I do and I needed some reassurance.


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## truetiger (Aug 23, 2011)

That collar should of stayed on until she was cleared by the radiologist. You shouldn't of had to justify your decision to anyone. Unlike the other thread, this was your patient whom you were transporting and writing the pcr on. They didn't like your answer, tough luck.


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## Melclin (Aug 23, 2011)

knxemt1983 said:


> The whole shebang.... he said just try not to move around much until we get some xrays and a ct. I wasn't exactly comfortable with it but he signed my pcr and I was leaving by then so it was outta my control and on his license, and livelyhood not mine



Sounds like he might have been in the c-spine precautions do nothing camp. Its a good camp. I think there is a lot to be said for pain relief plus "lay still" 

There also may have been risk stratification algorithms in play that weren't immediately obvious to you. He/the hospital may feel that pt's in her demographic with her mechanism, with a normal neuro exam have a low enough likelihood of injury that they don't need to stay immobilised. Some institutions really don't like to leave c-spine precautions in place for too long. You should have had a chat to the doc about why. I know you work in a different system, but I've always found docs more than happy to chat if you ask nicely.

I wouldn't fret too much about what the hospital ended up doing vs what you did. There are many different factors in play. Pts report different things at different times, different institutions are willing to except different levels of risk and hospitals have ideal environments and plenty of time in which to do assessments.   

Taking a pt sitting on the side of road upset, crying, cold, covered in blood and in pain, making quick decision about transport and treatment and getting it done with only one other person to help often involves challenges and compromises that hospitals often don't have to deal with. Its much easier to take a pt who has had time to calm down, has some pain relief on board, had been cleaned up warmed up and reassured, and _thoroughly assessed_ then wander over and do a 5 minute neuro exam.  

You shouldn't take what the hospital did later, to be the gold standard of what you should have done. Sometimes its because they have more time, more help, greater scope, more equipment, etc and other times they're just wrong. Take what they have to say into account, but ultimately its only ever expert opinion and hopefully you know where that sits on the hierarchy of evidence.


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## knxemt1983 (Aug 23, 2011)

Melclin said:


> Sounds like he might have been in the c-spine precautions do nothing camp. Its a good camp. I think there is a lot to be said for pain relief plus "lay still"
> 
> There also may have been risk stratification algorithms in play that weren't immediately obvious to you. He/the hospital may feel that pt's in her demographic with her mechanism, with a normal neuro exam have a low enough likelihood of injury that they don't need to stay immobilised. Some institutions really don't like to leave c-spine precautions in place for too long. You should have had a chat to the doc about why. I know you work in a different system, but I've always found docs more than happy to chat if you ask nicely.
> 
> ...



All that sounds true, I plan to talk it over with our medical director (who happens to be this hospitals director also) tomorrow. We got sucked out of there for another call before I could chat with him, and he was new so idk who he was or if I'll even run into him again. We have a lot of team health docs move in and out all the time


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## Handsome Robb (Aug 23, 2011)

firefite said:


> For that call I would have immobilized also. Broken jaw + LOC + numerous hits to the face + hitting the ground = C-spine IMO.
> /QUOTE]
> 
> I'll second this. The one question I have and I may have missed it is how were was her neuro exam? The way we are taught is that the mechanism is there and she has a distracting injury. Even if her CSM was intact I would still have put her in full spinal restriction unless she refused after being properly informed of the risks. We don't have imaging in the field to rule out a possible cervical injury. Sure you could go with the opinion of everyone else on scene but when it comes down to it, it's YOUR *** on the line.
> ...


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## usalsfyre (Aug 23, 2011)

To play devil's advocate....

Did she have a distracting injury? Unless a patient is unable to calmly participate in my exam due to pain from another injury, I don't automatically assume "distracting" injury. Meaning just because she had a broken jaw doesn't mean it was "distracting" from a neck injury.

I don't know whether I would have c-spined or not. My hunch is no, but without seeing her I can't say. You didn't do wrong by doing so though, it's one of those grey areas in medicine.


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## Smash (Aug 23, 2011)

Further to usalsfyre's comments, the incidence of spinal cord injury as a result of assault and blunt trauma is actually very low. Can't remember exact numbers off top of my head, but not much at all.


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## 8jimi8 (Aug 23, 2011)

follow your protocols.

here's some food for thought.  Not the article i was looking for but pretty sure the article i was looking for is referenced here.

http://www.scahec.net/prepares/summit/ppt/c_spinal.pdf


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## HMartinho (Aug 23, 2011)

Obviously you should immobilize the victim. Here in Portugal is also very common in the triage nurses remove the immobilization equipment from patients, but it is their responsibility. From the moment that we deliver the patient in triage nurse, it is no longer our responsibility, but if we do not the immobilize the patient and follow the protocols, and the patient develops some complication, then it will be our responsibility, and we will have to answer for it!

BTW, I apologize for any mistake, I still have to improve my English


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## knxemt1983 (Aug 23, 2011)

HMartinho said:


> Obviously you should immobilize the victim. Here in Portugal is also very common in the triage nurses remove the immobilization equipment from patients, but it is their responsibility. From the moment that we deliver the patient in triage nurse, it is no longer our responsibility, but if we do not the immobilize the patient and follow the protocols, and the patient develops some complication, then it will be our responsibility, and we will have to answer for it!
> 
> BTW, I apologize for any mistake, I still have to improve my English




That's kinda my thought, error to the side of caution. 

Not bad on the English, better than some of us native to it lol


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## Lady_EMT (Aug 23, 2011)

There was an issue once with a department in my area. EMTs took all c-spine precautions after an elderly gentleman fell. Got him to the hospital, the ER thought the crew was being over-zealous, and took off all the precautions without any x-rays or scans, and sent him home. Guy ended up back at the hospital a while later, complaining if extreme pain. Turns out he had a couple broken vertebra. 

Too long dont read:: do what your protocols tell you. You aren't in the ER, and your protocols are there for a reason. 


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## usalsfyre (Aug 23, 2011)

Lady_EMT said:


> There was an issue once with a department in my area. EMTs took all c-spine precautions after an elderly gentleman fell. Got him to the hospital, the ER thought the crew was being over-zealous, and took off all the precautions without any x-rays or scans, and sent him home. Guy ended up back at the hospital a while later, complaining if extreme pain. Turns out he had a couple broken vertebra.
> 
> Too long dont read:: do what your protocols tell you. You aren't in the ER, and your protocols are there for a reason.
> 
> ...



However, he was able to ambulate around for a few hours without doing any damage. Stable fractures of the vertebrae are rarely life threatening.

Protocols don't cover every situation. NEXUS proved physical exam is better at finding c-spine injury than plain films anyway.


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## Lady_EMT (Aug 23, 2011)

usalsfyre said:


> However, he was able to ambulate around for a few hours without doing any damage. Stable fractures of the vertebrae are rarely life threatening.
> 
> Protocols don't cover every situation. NEXUS proved physical exam is better at finding c-spine injury than plain films anyway.



Yes, but it still would have been the crews *** in the line if they hadn't taken all the precautions. And I'm sure this 90 year old man, who from the story is bed-bound, would hardly be moving around enough to easily unstabilize it. 

And what I'm getting at is hospitals sometimes overlook things, or get lazy. It's no excuse not to backboard/collar a patient even though your protocols tell you to. 


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## usalsfyre (Aug 23, 2011)

Lady_EMT said:


> Yes, but it still would have been the crews *** in the line if they hadn't taken all the precautions. And I'm sure this 90 year old man, who from the story is bed-bound, would hardly be moving around enough to easily unstabilize it.
> 
> And what I'm getting at is hospitals sometimes overlook things, or get lazy. It's no excuse not to backboard/collar a patient even though your protocols tell you to.
> 
> ...



I've yet to come across a convincing reason TO c-collar and backboard a patient, I only do it as it is required by protocol. Find me evidence it improves outcomes in any way and I'll consider changing my mind.


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## Smash (Aug 23, 2011)

usalsfyre said:


> I've yet to come across a convincing reason TO c-collar and backboard a patient, I only do it as it is required by protocol. Find me evidence it improves outcomes in any way and I'll consider changing my mind.



Amen to that!


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## DESERTDOC (Aug 23, 2011)

I think you did a good job and looked out for your patient.  Given the damage done to them, broken jaw, I would have done the same thing.  Just because the physician removed all of your work before evaluating his patient fully, does not mean you did anything wrong.

There is no way in hell he can tell if there is spinal column damage without a film.  Now, he may have guessed right, but what a gamble on his part.

Also, spinal column vice spinal cord.  One is a neuro exam the other ortho.

Good choice on yours.


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## MrBrown (Aug 23, 2011)

*throws hands in air to testify with Smash as Father usalsfyre preaches


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