# Assault Victim



## RedAirplane (Dec 29, 2014)

(Hypothetical, inspired by a few calls on which I was an observer, want to hear your thoughts to better prepare myself for something like this if I need to respond to this sort of thing).

You are a BLS foot team dispatched for a reported assault victim. The scene appears safe, albeit pretty crowded considering the parade marching along. Event security officer is on scene, police enroute, delayed due to the traffic situation around the parade. You have minimal equipment (OPA, NPA, OTC meds, and some bandaging stuff). The transport unit is enroute, also delayed.

Initial assessment:
The patient is a middle aged female, conscious, seated on the sidewalk, screaming/crying.
Airway: some broken teeth and blood in the mouth, but pt is talking/breathing
Breathing: Patient keeps repeating "He took my money," so breathing is present.
Circulation: Blood on the face, unclear if it is from the mouth or another wound.

You ask a few questions to determine if the patient is oriented. She only gets one question right, but you're unsure if this is due to disorientation or just objession/screaming about the $50 she lost.

Witness comes up and advises that pt was kicked in the head. Would you treat the pt as a C-spine candidate?

As you move closer to the patient, the patient shuffles away, going to different locations and asking "where's my money" to herself, occasionally sitting, getting back up. She gets very agitated if you approach.

Do you let her shuffle around or forcibly keep her with you because she might injure herself further by moving? Do you bother to collect the belongings and teeth?

You finally manage to convince the patient to be calm enough for an assessment. You find some soft tissue injuries on the head and upper extremities. You find both feet swollen and painful on palpation. The patient then remembers that "the guy rolled it over my feet" with no further clarification on what "it" was. Patient does not seem to understand your questions in the SAMPLE history.

Now PD and your transport team arrive. How would you give your handoff report?

--

The thing that gets me so confused in this scenario is the number of things going on. In the event you want to protect the spine, she isn't necessarily oriented and understanding of the risks of not being treated, but you also don't want to batter her a second time in one day.

What do I do about the teeth? Remove the loose ones that are still in the mouth, or not mess with an airway that is working, at least for the moment? Assuming the parade will smash the teeth unless you collect them now, do you bother picking up teeth as you go along?

Another thing is communication. My strength is with patients who need someone to explain politely what is happening, what I'll do, and why. How do you "calm and reassure" the patient if you can't exactly communicate without scaring her away?


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## NomadicMedic (Dec 31, 2014)

Ishan said:


> Initial assessment:
> The patient is a middle aged female, conscious, seated on the sidewalk, screaming/crying.
> Airway: some broken teeth and blood in the mouth, but pt is talking/breathing
> Breathing: Patient keeps repeating "He took my money," so breathing is present.
> Circulation: Blood on the face, unclear if it is from the mouth or another wound.



Get a better assessment to determine where the blood is from



> Witness comes up and advises that pt was kicked in the head. Would you treat the pt as a C-spine candidate?



No.



> As you move closer to the patient, the patient shuffles away, going to different locations and asking "where's my money" to herself, occasionally sitting, getting back up. She gets very agitated if you approach.
> 
> Do you let her shuffle around or forcibly keep her with you because she might injure herself further by moving? Do you bother to collect the belongings and teeth?
> 
> ...



Hand off report: Hi guys. Bystanders relate this woman was assaulted and kicked in the head. Looks like some broken teeth and some soft tissue injuries. She's pretty agitated and somewhat altered and wouldn't answer my questions appropriately. You need any help getting her in your truck?" 
--



> The thing that gets me so confused in this scenario is the number of things going on. In the event you want to protect the spine, she isn't necessarily oriented and understanding of the risks of not being treated, but you also don't want to batter her a second time in one day.



She doesn't need C-spine protection.



> What do I do about the teeth? Remove the loose ones that are still in the mouth, or not mess with an airway that is working, at least for the moment? Assuming the parade will smash the teeth unless you collect them now, do you bother picking up teeth as you go along?



Up to you. Unless they're knocked out with the roots included, they won't get re-implanted. If she's got blood and debris in her mouth, have her lean forward and spit. If she can't clear or maintain her own airway, then suction and manage it. 



> Another thing is communication. My strength is with patients who need someone to explain politely what is happening, what I'll do, and why. How do you "calm and reassure" the patient if you can't exactly communicate without scaring her away?



Keep trying.


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## medicaltransient (Jan 2, 2015)

Yes I would treat this as a c-spine Pt. Unless I were able to assess her mental status accurately and assess her spine I would board her. Clear that mouth as soon as you note the blood and teeth, don't waist any more time once you see debris in the airway.


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## Underoath87 (Jan 3, 2015)

I wouldn't attempt to forcefully restrain a confused patient in the name of C-spine precautions. 
But once you get her calmed down and oriented (or at least non-combative), a C-collar wouldn't hurt.


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## DesertMedic66 (Jan 3, 2015)

Underoath87 said:


> I wouldn't attempt to forcefully restrain a confused patient in the name of C-spine precautions.
> But once you get her calmed down and oriented (or at least non-combative), a C-collar wouldn't hurt.


Patients who are already calm tend to freak out when a c-collar is placed. So mix in a patient who is already confused/scared/freaked out with a c-collar and you may get some harm done.


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## Joey DeMartino (Jan 25, 2015)

More pressing issues to prioritize .   This a crime scene. Render your care as such.
    #1 nature, extent of blood production. (of course this includes examination of the airway).  Treat- 
   #2 obvious concussion (based on injuries, repetitious nature of communication and singular focus of the 50 dollars not the actual assault, as well as the witness account) possibly causing combative response. Accept and do not abandon this patient. A middle age woman will rarely handle a kick to the head as well as a 20 year old kick boxer.      #3  Damage to the feet may not be life threats but if caused by a vehicle, there may be other unseen chest and/ or thoracic injuries from a mirror, door, etc.  Quick scan.- 
    #4 C-spine. Difficult to address at this time but the patient seems to be calming down. Work towards it. - 
   #5 gather and secure lost teeth bystanders may be of assistance here. (photograph location if possible). - 
   #6 leave other evidence alone if possible,  Otherwise photograph location of other evidence and secure using gloved hands and parer or plastic bags.   Keep talking to her and see if the LOC changes up or down-manage accordingly.   This is a parade with many people who would be willing and able to render assistance.  Utilize them.


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## Tigger (Jan 25, 2015)

Keep the patient from swallowing blood. Try to calm her down to have a productive discussion about being transported to the hospital. Continue to have said discussion until patient either gets in the ambulance or proves herself to have the capacity to refuse further care and transport. If the patient is walking around without deficit, I don't think I would be too concerned about c-spine issues. Perhaps a c-collar to keep the ED placated.


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## Carlos Danger (Jan 26, 2015)

Joey DeMartino said:


> More pressing issues to prioritize .   *This a crime scene. Render your care as such.*
> #1 nature, extent of blood production. (of course this includes examination of the airway).  Treat-
> #2 obvious concussion (based on injuries, repetitious nature of communication and singular focus of the 50 dollars not the actual assault, as well as the witness account) possibly causing combative response. Accept and do not abandon this patient. A middle age woman will rarely handle a kick to the head as well as a 20 year old kick boxer.      #3  Damage to the feet may not be life threats but if caused by a vehicle, there may be other unseen chest and/ or thoracic injuries from a mirror, door, etc.  Quick scan.-
> #4 C-spine. Difficult to address at this time but the patient seems to be calming down. Work towards it. -
> ...



Could not disagree more. Your job is to assess, manage, and transport the patient. The fact that a crime scene may or may not exist does not affect assessment or management one bit.

Plus, while I'm no detective, I'm pretty sure no on is going to dispatch CSI to the scene of a mugging, especially when it's already been thoroughly trampled.


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## Joey DeMartino (Jan 26, 2015)

Thanks Remi- so then we are actually in agreement.    Every point I make is IS  about patient assessment and management.  I was answering specific issues brought up by the writer. We just can't transport yet because the parade is cutting off the PD and probably any responding medical unit for now. 

  Since the writer asked specific questions regarding salvaging the knocked out teeth "before the parade smashes them"  I offered  a little more to address that but also include the caveat of  "if possible".

  CSI?  I don't remember that acronym in my text but if it was referencing taking pictures "if possible" you might be  over exaggerating a bit in order to make an ill premised point.  As I stated "It is a crime scene" and a few pics  "if possible" might just help the good guys nail the bad guys.  Or even accompany us if we get called in to court because we failed to secure property or parts  that someone claims we should have.  Strange what people sue over these days.  
  You fail to rationally and logically explain how a few extra cautious steps has altered my treatment and care "because it's a crime scene".  I am open to learn.   Are you?


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## Carlos Danger (Jan 26, 2015)

Joey DeMartino said:


> Thanks Remi- *so then we are actually in agreement.*    Every point I make is IS  about patient assessment and management.  I was answering specific issues brought up by the writer. We just can't transport yet because the parade is cutting off the PD and probably any responding medical unit for now.



No, we are not in agreement at all.

You specifically detailed making concessions for a possible crime scene.

I very clearly said that you should *not* consider preservation of evidence as any type of priority when you have a patient in need of care.

You are making a simple situation unnecessarily and unrealistically complicated. Probably from watching too many network crime dramas. 

Your job is to take care of the patient. Period. Full stop. The end.


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## Carlos Danger (Jan 26, 2015)

double post


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## Joey DeMartino (Jan 27, 2015)

Another poor assumption of yours.    Actually- I don't watch idiotic unrealistic television programs. I don't watch tv at all.   Experience my friend- a far wiser instructor. 
  Just to make it reeeal simple in order-just for you. As I wrote and paraphrase:
#1 Examine and treat blood in the mouth (obviously airway)
#2 Possible concussion (duhhh no brainer. Kick in head-teeth fall down-older woman)
#3 Thoracic and feet injuries (from a single kick? Possibly fell into the parade route getting nailed by a vehicle?  teeth in the road- you gettin' a little better pic here?)
#4 C-spine Difficult patient- do it if possible. Just as I stated
#5 Gather lost teeth if possible use bystanders. The writer indicated they could pick them up BEFORE the parade destroys them. (You can direct them while tending to your patient)
#6 Gather personal effects "if possible" use volunteers. (you can instruct them while you and your partner tend the patient)
   See Mr. Remi,  all the pictures and offensive material have been omitted. To me and my Medic-it sure seems like this patients' care wasn't compromised.  And she kept two of the teeth the bystanders salvaged as well as her belongings that other volunteers gathered.  It takes a village.  Not your unrealistic TV trash.  It was only hypothetical-calm down.
   This is the order my opinion was written in.  Very sorry if it was difficult to follow.  I learned. Did you?

PS  What idiot could  just leave this pt. to the PD without hanging around long enough to see if her LOC and general demeanor changes?  If so- stay out of my jurisdiction. We honor those who provide patient CARE.


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## DesertMedic66 (Jan 27, 2015)

Joey DeMartino said:


> Another poor assumption of yours.    Actually- I don't watch idiotic unrealistic television programs. I don't watch tv at all.   Experience my friend- a far wiser instructor.
> Just to make it reeeal simple in order-just for you. As I wrote and paraphrase:
> #1 Examine and treat blood in the mouth (obviously airway)
> #2 Possible concussion (duhhh no brainer. Kick in head-teeth fall down-older woman)
> ...


How long do you want a crew to hang around to see if her LOC changes? The several hours it could take for a bleed to build up pressure? I would love to see any crew who is able to stay with a patient that long.


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## Joey DeMartino (Jan 27, 2015)

DesertEMT66 said:


> How long do you want a crew to hang around to see if her LOC changes? The several hours it could take for a bleed to build up pressure? I would love to see any crew who is able to stay with a patient that long.


   The EMTs are on foot patrol as it is- assigned to the event so here's my thought.  PD is going to have to question her anyway.  I don't know what their ETA is- I based total time before LEO involvement around 20 min+/-.
    We don't have a hypothetical on where her head is when they arrive but the time elapsed should give us a fair indication.  If she can be talked into a transport, I already have one en-route. Especially if any of the recovered teeth were possibly salvageable or LOC deterioration is noted. I feel the injuries warrant it- just my opinion on what I pictured.
    Once LEO gets involved people tend to gain a little more focus.  A chat with PD- thanks guys, waddaya' think (informal chat not medical opinions).  It'll shake out pretty quickly where she's headed and being an assault- helping PD load her if they decide to transport is fine.  Sure the answer can be nit-picked. Private Service vs. Metro all comes into play.
   Pretty common scenario.     What do you think? Too protective? Critique it.


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## Joey DeMartino (Jan 27, 2015)

DesertEMT66 said:


> How long do you want a crew to hang around to see if her LOC changes? The several hours it could take for a bleed to build up pressure? I would love to see any crew who is able to stay with a patient that long.


   I do realize how long bleeders can take. I also realize how quickly they can show.  If we want we can blast everything on that premise but that will only stalemate and polarize the purpose behind this question.  I'm here to learn and share - not attempt to be the most brilliant bulb in the chandelier.


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## Carlos Danger (Jan 27, 2015)

Joey DeMartino said:


> Another poor assumption of yours.    Actually- I don't watch idiotic unrealistic television programs. I don't watch tv at all.   Experience my friend- a far wiser instructor.
> Just to make it reeeal simple in order-just for you. As I wrote and paraphrase:
> #1 Examine and treat blood in the mouth (obviously airway)
> #2 Possible concussion (duhhh no brainer. Kick in head-teeth fall down-older woman)
> ...



I don't know what you are talking about, if that diatribe is directed towards me.

My response was directed specifically at your suggestion that the scene should be treated differently because it was a "crime scene", and that "evidence should be photographed".

Photographing evidence is not your job as an EMT. You are neither trained for it nor tasked with it, and you have more pressing priorities.



Joey DeMartino said:


> I do realize how long bleeders can take. I also realize how quickly they can show.  If we want we can blast everything on that premise but that will only stalemate and polarize the purpose behind this question.  I'm here to learn and share - not attempt to be the most brilliant bulb in the chandelier.



Considering that a serious bleed can easily take several hours for signs of increased ICP to develop, waiting on scene to observe mental status changes makes exactly zero sense.

What if you are there for 30 minutes, and no mental status changes occur? Have you ruled out a bleed, or even reduced the likelihood of it? No, not even a little bit.

What if you are there for 30 minutes, and mental status changes DO occur? Then guess what, you just delayed transport to definitive care by half an hour, quite possibly negatively affecting the patient's chance of recovery.

If you are concerned for a serious head injury, you transport ASAP.


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## Joey DeMartino (Jan 27, 2015)

Well good morning MR.Remi.    I have already addressed the "time to wait issue" as well as the " ICP issue" in responding to DesertEmts' questions /comments.  I also have a unit on the way- read my reply to DesertEMT- but unfortunately it is stuck in traffic- just as the PD unit is.   Read the original scenario for verification. 
  The "diatribe" was written for you since you persist with ill informed assertions about the lack of patient care due to my  efforts to salvage body parts-the condition of which the "writer" was not specific, yet, he indicates a possibility by the nature of the question posed "what about the teeth?" ( a previous poster was astute enough to recognize this possibility- but he did set sound parameters regarding this issue).    Read the original post and you may pick this point up.
   You remain fixated on a single point "The EVIL Crime Scene statement"  that blinded you from the facts of my attention to the patients' most life threatening issues.   Therefore my "diatribe" was the exact- step by step- priority list of the issues presented.  The categorical/prioritized scenario I originally posted.  This time without the pictures and an attempt to recover the patients' belongings.  Proper training will teach you that a priority list is nothing more than a comprehensive list of ALL factors presented.  The first being the most important the last being the least. Your goal is to address every issue presented IF POSSIBLE. 
   You also missed the fact that there were contingencies and the possibility that bystanders would be of assistance.      Even simple minded EMTs can multi-task and have willing volunteers assist in helping out this ASSAULT VICTIM.
    You may not have the ability and training to handle multifaceted incidents but many of us do so it is wise not to make assertions about others' training and abilities when making ill premised arguments.   You claim to be a paramedic-I respect you immensely for that- if in fact this is the case.    But this does not explain your unwillingness to listen and learn from those who would rather explore options and learn BEFORE an incident occurs.  Or does it?  This was a scenario.  This was an assault.  We are servants.  I CARE for my patients.
   I will maintain the fullest and most comprehensive patient CARE despite your protests. 
   I  have learned a great deal here- have you?
   This AAR is complete.  Enjoy your day.



  th at seemed to have launched you into quite the little dark place.  It's OK. My training has enabled me to adjust to such occurrences.
,  I have -indeed- made patient care my number one issue.  In order to provide you with a simpler   


 of based on the contextual  nature of his offering a possibility that the teeth were -in fact - were still salvageable) .  w redoing the scenario based on your input that you aren't trained to take pictures (you have no idea what the magnitude or extent of my training is).  Please understand Mr.Remi- I never said that the patient was to be treated differently due to the nature of the scene. I only


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## Carlos Danger (Jan 27, 2015)

I don't know your background, but you sound very new to EMS. 

Some folks just have to learn the hard way.


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## gotbeerz001 (Jan 27, 2015)

Joey DeMartino said:


> Well good morning MR.Remi.    I have already addressed the "time to wait issue" as well as the " ICP issue" in responding to DesertEmts' questions /comments.  I also have a unit on the way- read my reply to DesertEMT- but unfortunately it is stuck in traffic- just as the PD unit is.   Read the original scenario for verification.
> The "diatribe" was written for you since you persist with ill informed assertions about the lack of patient care due to my  efforts to salvage body parts-the condition of which the "writer" was not specific, yet, he indicates a possibility by the nature of the question posed "what about the teeth?" ( a previous poster was astute enough to recognize this possibility- but he did set sound parameters regarding this issue).    Read the original post and you may pick this point up.
> You remain fixated on a single point "The EVIL Crime Scene statement"  that blinded you from the facts of my attention to the patients' most life threatening issues.   Therefore my "diatribe" was the exact- step by step- priority list of the issues presented.  The categorical/prioritized scenario I originally posted.  This time without the pictures and an attempt to recover the patients' belongings.  Proper training will teach you that a priority list is nothing more than a comprehensive list of ALL factors presented.  The first being the most important the last being the least. Your goal is to address every issue presented IF POSSIBLE.
> You also missed the fact that there were contingencies and the possibility that bystanders would be of assistance.      Even simple minded EMTs can multi-task and have willing volunteers assist in helping out this ASSAULT VICTIM.
> ...


Standard assault call:
- Stage until scene is secure
- Assess and treat appropriately
- Determine destination based on findings. 
- PD meets you at hospital to get their report if necessary

Done.


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## Chimpie (Jan 27, 2015)

Let's make sure we stay on topic and have an open discussion, and not attack individuals.


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## Joey DeMartino (Jan 27, 2015)

gotshirtz001 said:


> Standard assault call:
> - Stage until scene is secure
> - Assess and treat appropriately
> - Determine destination based on findings.
> ...





Remi said:


> I don't know your background, but you sound very new to EMS.
> 
> Some folks just have to learn the hard way.


Started in '82. Thank you for the fuel for thought. Great scenario. I have a much better understanding. Very sorry if you felt offended- none intended.


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