# MVA With Injuries



## taylor24 (Jan 7, 2013)

I have a scenario for you! 

Skills practice for all of you, and answers and knowledge for me!  

I’m a writer, and part of my current plot involves a car crash. 

I’m a member of CERT response teams and have had some first aid training. I’ve also been a civilian role player for all sorts of different scenarios for my local first responders. This is one that we haven’t covered, though. Books and Google searches only provide so much info, not to mention that search queries like this might raise some eyebrows.  

So I need all of the details and information that you can possibly give me about your response to a scene like this. PLEASE!

Without further ado, here you go:

You are dispatched to the scene of an MVA. Upon arrival, you find two severely damaged vehicles and multiple injured victims.

*CAR ONE:* This vehicle contains only the driver.

*DRIVER:* The driver is a male in his early thirties. He is slumped forward in his seat, initially unresponsive, but rouses when you address him. There is a strong smell of alcohol on his breath, and although he is responsive, he is obviously intoxicated. He has a large bleeding laceration on his forehead and minor scrapes and bruises on his face from the impact of the crash, and bruising from his seatbelt. Aside from these, he is uninjured. Upon seeing the crash scene in front of him, he becomes upset, crying and saying things like, “Oh, my God”, “I didn’t mean to”, “My wife is going to kill me”, and “What have I done?”

*CAR TWO:* This vehicle contains a driver and two passengers.

*DRIVER:* The driver is a female, age 18. She has no detectable pulse or respirations. Deceased, killed on impact in the crash.

*PASSENGER ONE:* Female, age 17. Managed to free herself from the car after the crash, and is sitting in the grass a short distance away. She is slightly drowsy, but conscious and mostly responsive, and complains of a severe headache, nausea, and dizziness. Chest and neck are bruised from her seatbelt, and she has several other bruises and superficial bleeding cuts on her body. Her right arm is bruised, swollen, and oddly angled, and she is cradling it against her chest and complaining of pain. She is displaying signs of shock. Respirations are slightly shallow and rapid, skin is pale and clammy, and pulse and heart rate are elevated. 

*PASSENGER TWO:* Female, age 17. Pinned in her seat inside the car, unable to free herself. Conscious and responsive, but clearly very frightened, and displaying signs of shock. Chest and neck are bruised from her seatbelt, and she also has several bruises and cuts on her face, arms, and legs. You can see a large, deep bleeding laceration on her right lower leg. She is complaining of some pain in her neck, numbness and lack of sensation below the waist, and inability to feel or move her legs. 

.


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## DrParasite (Jan 7, 2013)

What's the question?  what should be done?

first, call for 3 ambulances, maybe even helicopters depending on where you are.

DOA driver is dead, that sucks.

Passenger 1 is a transport to the trauma center as a trauma patient.

Passenger 2 gets cut out of the car and then taken to the trauma center as a trauma patient.

Drunk driver gets taken to the trauma center as a patient, with PD, and is arrested for DUI.  He might even be made a trauma due to the bruising from the seatbelt.


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## taylor24 (Jan 8, 2013)

> Books and Google searches only provide so much info, not to mention that search queries like this might raise some eyebrows.  So I need all of the details and information that you can possibly give me about your response to a scene like this. PLEASE!



I'm unable to edit my original post now, so here's some clarification.

Yes, I'm asking what should be done in this scenario. My training is basic trauma first aid - so in a situation like this I would stop the bleeding, immobilize spinal injury patient somehow, keep concussion patient awake and as alert as possible, and hand them over to the EMS personnel ASAP. 

So, when you get that call from dispatch and arrive on this scene:
Triage, who would you treat first? 
How do you treat these patients? 
What medications would you give them? 
Etc etc.


.


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## DesertMedic66 (Jan 8, 2013)

Triage from the first patient you see then work your way to the last patient. 

Driver is DOA. She is left where she is. 

Drunk guy at a glance is stable. If the bleeding is bad then give him a couple of 4x4s and have him hold it to his head or just tape it on. That's about all that will happen when you are the only unit on scene. 

Have a partner calm down patient #1. More then likely she is hyperventilating (sp?). I wouldn't worry about splinting the arm right now. She is holding it against her chest which is acting as a crude splint. 

If i am able to get to patient #2 then calm her down and stop the bleeding by direct pressure or tourniquet if necessary. C-collar on her. Check blood pressure and determine if the patient is going into shock. If so then the patient will be getting 1-2 IVs and a bolus of saline to get blood pressure up (I've heard that some places are moving away from saline bolus). 

Patient #2 needs to get transported first however since she requires extrication (depending on how long extrication will take) patient #1 will more then likely be transported first. 

A little phone call to the trauma hospital to give then a heads up that you have a MVC with 3 patients and one DOA so they can't get ready. 

Once more medical personnel get on scene is when more treatment begins such as pain management for the first patient if vitals are stable and it's within protocol. Other then pain management I don't see any other meds being given aside from Zofran possibly given to patient #1 to counteract the nausea side effect that morphine can have.


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## mycrofft (Jan 8, 2013)

*Basic first aid or CERT or ??level ? Any assistance on hand?*

OK basic without help:

Make scene safe/safer against being stricken by other cars (position your car with four-way lights flashing, set out flares or reflectors as is safe; crashed cars may have flares or reflectors too, but even just strewing debris in the lane can help make drivers mindful. If necessary, try to point your headlights at the scene for illumination. Shut off the crashed cars' ignitions. 

During your survey, cut trapped woman loose and giver her a compress to hold on her cut leg, or whip one on "for now". Tell her to sit tight.

Call for help, describe the situation.

Go back and stop the bleeding, reassure her. If the walking pt is up and walking around, have her sit with the lac case for mutual reassurance and to tell you if things are not well with either. 

Re-check your lone driver. "Alcohol" might be ketones, but not important, you aren't treating his breath. Bruised head with seatbelt? Think steering wheel. Treat as needed, keep coming back to him, maybe even stay with him if other victims are taking care of each other.

Where are the airbags in this scenario?  Not medically important but you are writing a story, right?

Go from there.

As a CERT you would have had first responder training (skill maybe untested and unused) if you are level 3, but the first aid at basic level is not designed for civilian occurrences except where you are swamped and no help is coming; don't write off pt's so lightly. Your equipment will be light or none. CERT is not dispatched (nor intended for it by DHS) to such accidents.


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## Clare (Jan 8, 2013)

Driver of car 1:  Minor problem, not time critical or life threatening 

Driver of car 2: Deceased
Passenger 1: Moderate problem, urgent but not life threatening 
Passenger 2: Serious problem, urgent and potentially life threatening 

Driver of car 1 can get checked out and be given to the Police if he has no problems that require immediate referral to a Doctor or hospital.  If the Police want him taken to the hospital or seen by a Doctor they can call a Police Medical Officer.

Passenger 1 needs to have her fracture splinted and some pain relief but does not meet major trauma criteria

Passenger 2 needs the Fire Service to cut her out, c-collar and KED, scoop and transport; she meets major trauma criteria and if practical should be taken to a hospital that regularly receives major trauma.


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## Med Control (Jan 9, 2013)

BASIC response:

Arrive on scene, general impression of situation is you have a MVA with possible multiple traumas. Call for ALS.

Car one: Talk to driver, he is responsive to verbal and begins to talk, he has a patent airway, patient is breathing, patient has a pulse. Quick rapid trauma assesment, fix up a bandage for the laceration on his head, try to calm the patient down. Stabilize and transport BLS

Car two/ Driver: DOA

Car two/ pass 1: Talk to pass, she is alert and talking, she does have a patient airway, she is breathing shallow and rapid resp with fast pulse rate. Her skin is pale and clammy. Give her some 02 on a non re-breather, asses her arm/ splint if there is enough resources and time to do so on scene, if not then in the ambulance. Take care of all secondary injury's and minor bleeding. Transported BLS 

Car two/ pass 2: Talk to pass, she is alert and talking, she does have a patent airway, she is breathing. Hold manual stabilization of her head/ neck until more resources arrive (fire) for rapid retraction, place a c-collar in place, ked, and then stretcher. Transported ALS if arrived on scene


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## RustyShackleford (Jan 11, 2013)

I stopped reading at signs of shock, signs of shock to a lay person as compared to ems is a different beast.  More information would be nice.


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## Shrimpfriedrice (Jan 25, 2013)

Clare said:


> Driver of car 1:  Minor problem, not time critical or life threatening
> 
> Driver of car 2: Deceased
> Passenger 1: Moderate problem, urgent but not life threatening
> ...



Psngr 1 DOES meet major trauma criteria based on death in same pt compartment just an fyi.


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## Veneficus (Jan 25, 2013)

Shrimpfriedrice said:


> Psngr 1 DOES meet major trauma criteria based on death in same pt compartment just an fyi.



Based only on outdated and disproven mechanism prediction.

Not based at all on patient assessment.


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## Shrimpfriedrice (Jan 25, 2013)

Veneficus said:


> Based only on outdated and disproven mechanism prediction.
> 
> Not based at all on patient assessment.



MOI is not supposed to be based on patient assessment, thats why its a MOI. She meets criteria period! Had the 2 other ppl died and she only sustained a minor sti with no complaints would u rma her?!


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## Veneficus (Jan 25, 2013)

Shrimpfriedrice said:


> MOI is not supposed to be based on patient assessment, thats why its a MOI. She meets criteria period! Had the 2 other ppl died and she only sustained a minor sti with no complaints would u rma her?!



Maybe, depends on what I found.


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## STXmedic (Jan 25, 2013)

Shrimpfriedrice said:


> MOI is not supposed to be based on patient assessment, thats why its a MOI. She meets criteria period! Had the 2 other ppl died and she only sustained a minor sti with no complaints would u rma her?!



Were the two that died unrestrained? And if they were, where was the damage to the car? what do you find to be the reason for the fatal injuries? Was the one without complaints restrained. Did the one without complaints have anything concerning on the physical exam? If not, then why not?


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## Shrimpfriedrice (Jan 25, 2013)

Veneficus said:


> Maybe, depends on what I found.



Then when she died a week later from an unchecked intracranial hemorrhage u'd show up in court when the family sues and say i pick and choose which protocols to follow because i THINK they're outdated? Have fun with that.


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## Gastudent (Jan 25, 2013)

Shrimpfriedrice said:


> Psngr 1 DOES meet major trauma criteria based on death in same pt compartment just an fyi.



I have to agree with this. You might say it's outdated, but Passenger 1 still has signs of shock. She also has an MOI that makes it very likely she has internal bleeding. So since we have to wait for passenger 2 to get extricated from the car as soon as another ambulance arrived passenger one would need to be transported. As for the driver I would say he could wait until the 2 passengers were taken care off. From what I am told in the scenario I don't think he will die any time soon.


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## DesertMedic66 (Jan 25, 2013)

Shrimpfriedrice said:


> Then when she died a week later from an unchecked intracranial hemorrhage u'd show up in court when the family sues and say i pick and choose which protocols to follow because i THINK they're outdated? Have fun with that.



Patient was alert and orientated x4. We could not force the patient to go to the hospital. Patient was advised of all the risks up to an including death. Patient was advised to 911 back if she needed to for any reason. Patient was advised to still seek medical attention at the ER. Patient signed releasing us from all liability.


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## STXmedic (Jan 25, 2013)

Shrimpfriedrice said:


> Then when she died a week later from an unchecked intracranial hemorrhage u'd show up in court when the family sues and say i pick and choose which protocols to follow because i THINK they're outdated? Have fun with that.



Does she haven an injury that has a high level of suspicion for an intracranial hemorrhage? Subdurals don't magically appear because you get refusals. Also, don't sip on so much of the "EMTs will always get sued for getting a refusal" legal koolaid. Do your job, be competent, and don't hide anything and you'll be fine.


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## Shrimpfriedrice (Jan 25, 2013)

Veneficus said:


> Maybe, depends on what I found.





PoeticInjustice said:


> Does she haven an injury that has a high level of suspicion for an intracranial hemorrhage? Subdurals don't magically appear because you get refusals. Also, don't sip on so much of the "EMTs will always get sued for getting a refusal" legal koolaid. Do your job, be competent, and don't hide anything and you'll be fine.



i get what an rma is, we're just goin off on a tangent. To bring it all back, the scenario said nothing of an rma. It only came to that because someone alluded that patient assessment is what mattered and not MOI..ppl sustain head trauma that they think is nothing that can become life threatening. In the end thats the protocol that what u go by!


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## usalsfyre (Jan 25, 2013)

Shrimpfriedrice said:


> Then when she died a week later from an unchecked intracranial hemorrhage u'd show up in court when the family sues and say i pick and choose which protocols to follow because i THINK they're outdated? Have fun with that.



:rofl: :rofl: :rofl:

You really, really need to lay off whatever Kool-aid you've gotten into. MOI is intended to be an ADJUNCT to assessment, not THE assessment. Relying on "Major Trauma Criteria" is outdated at best and negligent at worst. Make your decisions based of patient condition, not the condition of the scene. Occult injuries are really fairly rare.

So lets flip it around and say you force an uninjured patient to go by HEMS because they meet "criteria" and the helicopter crashes enroute to the hospital. Now who's negligent? Good luck using the magical protocol shield...


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## Veneficus (Jan 25, 2013)

Shrimpfriedrice said:


> Then when she died a week later from an unchecked intracranial hemorrhage u'd show up in court when the family sues and say i pick and choose which protocols to follow because i THINK they're outdated? Have fun with that.



Firstly, I don't think they are out dated, I know they are, right down to the history of why they were initially penned.

A week later of an intracranial hemorrhage. After a week, most likely a subdural specifically. Which may or may not have shown up on an emergent CT.

We are then to assume she was not discharged after a day or two of watchful waiting in the hospital? 

We would also assume she did not have progressive or constant symptoms which she did not seek medical attention for? (like a seizure)

Based on the meager assessment given here, I agree with Clare, this person does need to get checked out, it is not at this point urgent.

If she wanted to go to the hospital with a friend or family, fine. She is not going to die at this moment and unless her symptoms worsen, most certainly can wait an hour or so.

If she was hell bent on RMA, and capable of making a competent decision, or convincing her parents to permit refusal, then she does with instructions to get checked out or call for help if anything changes.

But if I may?

The death in the same compartment mechanism was written back in the days of steel cars without the impact absorbtion and isolation safety measures today. Additionally, off center impacts usually produce extreme injury in one front seat passenger and lower injuries in the opposite side. (physics)


http://www.ncbi.nlm.nih.gov/pubmed/18271994

"CONCLUSION: 

This study identified only five articles on the predictability of the mechanism of injury criteria alone. *All studies stated that the mechanism of injury criteria alone are not good predictors of major trauma or the need for trauma team activation.* This study was the precursor of a Victorian prehospital study to determine the predictability of the mechanism of injury alone criteria for trauma patients in the Australian context."


Another one for peds!

http://www.ncbi.nlm.nih.gov/pubmed/23188240



"CONCLUSION: 

For pediatric trauma patients, *the emphasis on APB triage criteria and de-emphasis on MOI results in selection of higher-acuity patients for major activation while maintaining acceptable undertriage and overtriage rates overall.* This improved accuracy of major activation results in a more cost-efficient resource use and fewer unnecessary disruptions for the surgeon, operating room, and other staff while maintaining appropriate capture and evaluation of trauma patients. The low sensitivity noted in both the MOI and APB groups is largely caused by the broad definition of HR patients used in this study. We recommend the use of APB criteria for pediatric trauma triage."


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## Shrimpfriedrice (Jan 25, 2013)

usalsfyre said:


> :rofl: :rofl: :rofl:
> 
> You really, really need to lay off whatever Kool-aid you've gotten into. MOI is intended to be an ADJUNCT to assessment, not THE assessment. Relying on "Major Trauma Criteria" is outdated at best and negligent at worst. Make your decisions based of patient condition, not the condition of the scene. Occult injuries are really fairly rare.
> 
> So lets flip it around and say you force an uninjured patient to go by HEMS because they meet "criteria" and the helicopter crashes enroute to the hospital. Now who's negligent? Good luck using the magical protocol shield...



I work in the city, at best my trauma hospitals are 15mins from each other i wont be using any helicopter  and EXACTLy i mever said otherwise; u probably need to read on how this whole conversation went


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## usalsfyre (Jan 25, 2013)

Shrimpfriedrice said:


> I work in the city, at best my trauma hospitals are 15mins from each other i wont be using any helicopter  and EXACTLy i mever said otherwise; u probably need to read on how this whole conversation went



I really don't think you grasp what was said.....

Strike "helicopter" insert "transport code 3". You can't justify doing either one. The just following orders excuse doesn't work well.


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## Shrimpfriedrice (Jan 25, 2013)

usalsfyre said:


> I really don't think you grasp what was said.....



Lol i did i was just tryna lighten the mood..relax everyone we made our points..


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## Veneficus (Jan 25, 2013)

Gastudent said:


> I have to agree with this. You might say it's outdated, but Passenger 1 still has signs of shock. *She also has an MOI that makes it very likely she has internal bleeding*.



I'll bite.

Bleeding from where?

What class of shock is she in? (hint: 1,2,3,or 4)

How would you be able to tell?

Does she have mechanism for an aortic tear? How long after insult are those usually repaired? DO they have to be repaired surgically?

What other organs might she be bleeding from? What artery? How would you assess for it?

Perhpas her bleeding is from her longbone injury? Is it life threatening? LImb threatening? What would be the finding that would tell you?

What else do you think is important to check for in her?


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## STXmedic (Jan 25, 2013)

Shrimpfriedrice said:


> I work in the city, at best my trauma hospitals are 15mins from each other i wont be using any helicopter  and EXACTLy i mever said otherwise; u probably need to read on how this whole conversation went



Well assuming you're like 90% of the city medics I know, with similar mindsets, and you're transporting this patient to a Lv 1 as a trauma alert based off of MOI, you will be transporting with lights and sirens. Now, I don't recall the exact numbers on increased likelihood of getting in a wreck while driving emergent, but 23 times more likely rings a bell. Could be wrong on the exact number, but it's in the ball-park  So lets change the scenario from HEMS getting in a wreck, to you getting in a wreck. Better now?


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## Veneficus (Jan 25, 2013)

PoeticInjustice said:


> Well assuming you're like 90% of the city medics I know, with similar mindsets, and you're transporting this patient to a Lv 1 as a trauma alert based off of MOI, you will be transporting with lights and sirens. Now, I don't recall the exact numbers on increased likelihood of getting in a wreck while driving emergent, but 23 times more likely rings a bell.



In 2003 the Insurance Institute of America said it was 300x more likely to be in an accident and they didn't have numbers on wake effect accidents caused.

I know the number because I was researching whether or not code 3 driving should be discontinued by the service.

The conclusion then was it certanly should be, but because of public expectation it would continue. 

I doubt it is much different if not increased today.


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## Shrimpfriedrice (Jan 25, 2013)

PoeticInjustice said:


> Well assuming you're like 90% of the city medics I know, with similar mindsets, and you're transporting this patient to a Lv 1 as a trauma alert based off of MOI, you will be transporting with lights and sirens. Now, I don't recall the exact numbers on increased likelihood of getting in a wreck while driving emergent, but 23 times more likely rings a bell. Could be wrong on the exact number, but it's in the ball-park  So lets change the scenario from HEMS getting in a wreck, to you getting in a wreck. Better now?



*<moderator snip>*..I wasnt the one going off an MOI i said along with a patient assessment that need to be included..like Protocols sts! Read the entire convo before u comment and this whole thing was done 30mins ago.


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## STXmedic (Jan 25, 2013)

Shrimpfriedrice said:


> *<moderator edit>*


You* 



Shrimpfriedrice said:


> I wasnt the one going off an MOI i said along with a patient assessment that need to be included..like Protocols sts!


I know what you said. That's not what you said.



Shrimpfriedrice said:


> MOI is not supposed to be based on patient assessment, thats why its a MOI. She meets criteria period! Had the 2 other ppl died and she only sustained a minor sti with no complaints would u rma her?!


This, to me, is saying that her assessment doesn't matter. This is saying that even if she is completely without injury or complaint, she needs to be transported to a trauma center, based SOLELY off of MOI. F*** the patient assessment. This is saying you're going off an MOI. That is what this is saying. 

Either take the time to post what you mean in coherent, thought out posts, or don't cry when people take your post as it is and call you out on it.


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## Veneficus (Jan 25, 2013)

*and now...*

back to our regularly scheduled program...

Cmon guys, there is sort of a good discussion here.


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## Gastudent (Jan 25, 2013)

Veneficus said:


> I'll bite.
> 
> Bleeding from where?
> 
> ...



I am just a student so I wont be able to get into as advance as you do, but the point I was making is that internal bleeding is a possible cause of the signs of shock, because of her MOI. As from where she was bleeding cant really say. It is going to be hard for anyone to tell for sure in the field, and I don't know if the limb has distal circulation so I cant really say if it is in danger. Like I say am just a student not trying to say I know more than anyone because I don't. Just giving my opinion on the scenario.


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## Shrimpfriedrice (Jan 25, 2013)

PoeticInjustice said:


> You*
> 
> I know what you said. That's not what you said.
> 
> ...



At the end of the day a MOI is a MOi and a patient assessment is just that. Earlier it was stated that this pt did not meet major trauma criteria. That was incorrect due to death in same compartment thats all. Follow protocol or dont treat asthma with glucose if u like ur perrogative

An assessment allows us to make a decision whether trauma or not just like MOI


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## STXmedic (Jan 25, 2013)

Shrimpfriedrice said:


> At the end of the day a MOI is a MOi and a patient assessment is just that. Earlier it was stated that this pt did not meet major trauma criteria. That was incorrect due to death in same compartment thats all.


That, I'll buy. As flawed as MOI injury predictability is, that patient could meet trauma criteria if you were hell-bent on taking that patient to a trauma center.


Shrimpfriedrice said:


> Follow protocol or dont treat asthma with glucose if u like ur perrogative


How is that relative or comparable in any way to the current discussion. Not following protocol =/= incorrect treatments. I'm not even sure how I was able to discern what you were trying to get across... :unsure: Oh, and prerogative*.



Shrimpfriedrice said:


> An assessment allows us to make a decision whether trauma or not just like MOI


Uhh... What? Again with being incoherent. Please try and make some form of sense on your next reply. It's really difficult to form an adequate rebuttal when I can't understand what the hell you're trying to say.


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## Chimpie (Jan 25, 2013)

*Keep it polite and on topic please.*


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## usalsfyre (Jan 25, 2013)

Shrimpfriedrice said:


> ..I wasnt the one going off an MOI i said along with a patient assessment that need to be included..like Protocols sts! Read the entire convo before u comment and this whole thing was done 30mins ago.



Lol wut?


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## Veneficus (Jan 25, 2013)

Veneficus said:


> I'll bite.
> 
> Bleeding from where? *Most likely her long bone injury.*
> 
> ...



Normally I charge about $200 for an hour of lecture...


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## Veneficus (Jan 25, 2013)

PoeticInjustice said:


> That, I'll buy. As flawed as MOI injury predictability is, that patient could meet trauma criteria if you were hell-bent on taking that patient to a trauma center.



Only if your outdated EMS system still has that in the protocols.

But it definately will not win you any friends on the trauma team.


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## Melclin (Jan 31, 2013)

Shrimpfriedrice said:


> That was incorrect due to death in same compartment thats all. Follow protocol or dont treat asthma with glucose if u like ur perrogative



I just finished posting some thoughts directed at you in another thread, but I respectfully suggest that the same idea may apply here. 

I assume that the reason you came to a forum like this was to expand your knowledge beyond your protocols say. 

One thing that is a constant theme in these discussions are the differences in guidelines and protocols. There are some extensive regional differences in accepted practice even when the practice is based on the same evidence. That you might do something in a particular way doesn't mean that everybody else in the world does or should do it that way. In the same vein, "Death in the vehicle" is no longer accepted as an MOI predictive of serious occult injury by many providers. While this may be different to you practice, education or protocols, that doesn't necessarily make it wrong.


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