# Vehicle accident



## emergancyjunkie (Apr 27, 2012)

Ok you roll up on scene and find a car on its side with the occupants walking around your patient is a 19 year old female with slight bleeding on her hand from an abrasion was the front passenger of the airbags were deployed windshield was cracked but not evident of you patient hitting it with her head. She does not want to go to the hospital. Vital signs are 122/72 pulse of 152 and respriations of 22. What do you do


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## DesertMedic66 (Apr 27, 2012)

Put a little gauze pad on her hand and have her sign AMA.


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## beefaroni (Apr 27, 2012)

Get her number


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## emergancyjunkie (Apr 27, 2012)

Ok but your protocol state that Medical command for an ama has to be contacted due to vitals upon contact they state that you should try and convince her to go to the er and put a c collar on her if she goes due to the moi


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## emergancyjunkie (Apr 27, 2012)

Supertampon5 said:


> Get her number



Nice


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## Veneficus (Apr 27, 2012)

emergancyjunkie said:


> Ok but your protocol state that Medical command for an ama has to be contacted due to vitals upon contact they state that you should try and convince her to go to the er and put a c collar on her if she goes due to the moi



Many years ago I was made aware of an EM study that demonstrated patients refuse less often when they speak directly with online med control. 

So hand the phone to the girl and let the doc convince her himself. That way if she is not convinced, nobody can blame it on your effort.

If the med control line is recorded, more the better.


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## Remeber343 (Apr 27, 2012)

I would cardiovert.  Right after cut the roof and roll the dash.


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## NYMedic828 (Apr 27, 2012)

emergancyjunkie said:


> Ok but your protocol state that Medical command for an ama has to be contacted due to vitals upon contact they state that you should try and convince her to go to the er and put a c collar on her if she goes due to the moi



Idk how it is by you but over here mechanism of injury alone is not a ruling for spinal immobilization. 

Her vitals are fine...

Her respirations are a little elevated and her HR is up there but its not so high for a 19 year old girl who just rolled a car and is freaking out.

Would have stayed with her for a little while, bandaged her hand and if she doesn't wanna go tell her sign here.

The report should clearly state where she is signing that she has been told to go to the hospital and regardless of her best interests has decided not to.

If it bothers you that much to RMA her, call the doc. Then its off your shoulders.


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## Medic Tim (Apr 27, 2012)

Remeber343 said:


> I would cardiovert.  Right after cut the roof and roll the dash.



don't forget to call for a chopper


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## NYMedic828 (Apr 27, 2012)

http://www.youtube.com/watch?v=YzYxz_uvtSI


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## DesertMedic66 (Apr 27, 2012)

emergancyjunkie said:


> Ok but your protocol state that Medical command for an ama has to be contacted due to vitals upon contact they state that you should try and convince her to go to the er and put a c collar on her if she goes due to the moi



Then contact Medical Control. If she doesn't want to go then you can't force her to go. Try to talk her into going, if still no then have her sign AMA.


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## Remeber343 (Apr 27, 2012)

Moi shouldn't be a reason to use c spine. I'd throw her on the monitor after doing a physical exam.


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## Akulahawk (Apr 28, 2012)

emergancyjunkie said:


> Ok but your protocol state that Medical command for an ama has to be contacted due to vitals upon contact they state that you should try and convince her to go to the er and put a c collar on her if she goes due to the moi





firefite said:


> Then contact Medical Control. If she doesn't want to go then you can't force her to go. Try to talk her into going, if still no then have her sign AMA.


Contact Medical, get them to speak with her on a recorded line, if possible, if she still is refusing transport, she gets signed out AMA, witnessed if possible. Of course, there's a whole lot more... since she's allowed you to get vitals, is she coherent/alert & oriented? Repetitive questioning? Can she count backwards from 100 by 7's? Does she have a plan for self-care? Failure of some of these things make me think "concussion" and some make me think that she's flat-out altered mental status, in which she would be unable to refuse...

Know what criteria patients in your system must meet in order to be able to AMA.


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## exodus (Apr 28, 2012)

I cant even count backwards from 100 by 7 lol.


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## Aidey (Apr 28, 2012)

^^^ Same here. I must be permanently concussed. 100...93...86...ummm yeah.


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## CANDawg (Apr 28, 2012)

exodus said:


> I cant even count backwards from 100 by 7 lol.



1) Subtract 10.
2) Add 3. 
3) Repeat.
4) Look like a genius as you rattle it off while the pt is counting on their fingers.


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## Aidey (Apr 28, 2012)

dbo789 said:


> 1) Subtract 10.
> 2) Add 3.
> 3) Repeat.
> 4) Look like a genius as you rattle it off while the pt is counting on their fingers.



Showoff :glare:


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## Tigger (Apr 28, 2012)

dbo789 said:


> 1) Subtract 10.
> 2) Add 3.
> 3) Repeat.
> 4) Look like a genius as you rattle it off while the pt is counting on their fingers.



I will remember this for the next time I get drilled in the back of the head with a hockey puck at work. I couldn't get past 93 and the "real" post-injury concussion tests went just as poorly. 



Akulahawk said:


> Contact Medical, get them to speak with her on a recorded line, if possible, if she still is refusing transport, she gets signed out AMA, witnessed if possible. Of course, there's a whole lot more... since she's allowed you to get vitals, is she coherent/alert & oriented? Repetitive questioning? Can she count backwards from 100 by 7's? Does she have a plan for self-care? Failure of some of these things make me think "concussion" and some make me think that she's flat-out altered mental status, in which she would be unable to refuse...
> 
> Know what criteria patients in your system must meet in order to be able to AMA.



So let's say that you do suspect that the patient has a concussion. It's likely though that she will still think that she is perfectly rational and just has a headache or something. How are you going to get this patient, who really, really does not want to go to the hospital, to go? Yes she's altered, but in such a way that she can argue back.


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## DesertMedic66 (Apr 28, 2012)

Tigger said:


> I will remember this for the next time I get drilled in the back of the head with a hockey puck at work. I couldn't get past 93 and the "real" post-injury concussion tests went just as poorly.
> 
> 
> 
> So let's say that you do suspect that the patient has a concussion. It's likely though that she will still think that she is perfectly rational and just has a headache or something. How are you going to get this patient, who really, really does not want to go to the hospital, to go? Yes she's altered, but in such a way that she can argue back.



How is she altered? If she answers all my questions with no issue and I find her to be AOx4 then there is not much you can do. Have her talk to med control, try to talk her into going. If still no then have her sign AMA. Make sure you document the heck out of the call and make sure you advice the patient to go to the hospital by some other means since she doesn't want to go by ambulance. 

If your patient is AOx4, not on a psych hold, not under police protective care, and is charge of their own care then it is kidnapping if you transport them against their will.


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## Aidey (Apr 28, 2012)

Also, what 19 year old has a plan for the next day let alone self care? lol


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## Dwindlin (Apr 28, 2012)

I've never used serial 7's (nor have I seen any of the geriatricians/neurologists use it), I always have them spell world backwards.  Way less thought involved on my part to make sure they are correct.


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## Melclin (Apr 29, 2012)

Funny. I went to a very similar job just the other day.

19YOF rolled her car off a dirt road into a ditch. Self extricated through the smashed drivers side window. Ambulating normally O/A. Pt was shaken and largely uninjured with the exception of several small lacerations on her hands. 

I dressed her hands and sent her home in the care of her father in law, with instructions about calling back/self presenting to hospital and some minor head injury advice just in case. 

Difference was though that she had a HR 102 not 150 odd. I would be more concerned with that HR. My preference would be to see how it trended with some calming influences during my assessment. If it trended to almost normal in that space of time with some deep breathing and in a calm environment, I would be more happy to let her make her own choices about going home (my chick's HR went from 102 to 80 in the 10 or so minutes I was chatting to her). I'd have to say though, that my preference would be to transport your girl and just stick her in the hospital waiting room at the very least. In all honestly, probably just to cover my arse. I'd find it difficult to sit there are confidently argue that I was right to balance a persons life on the assertion that a HR of 150 after a serious crash was entirely anxiety related.

But as far as the refusal goes, its pretty simple. They refused. You can't kidnap them. Its their problem now. Just make sure its all documented properly. 

I'd probably give a short radio report saying that the patient went AMA on account of them being recorded lines.


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## phideux (Apr 29, 2012)

Had one not too long ago. 20yo girl says she saw "an animal" maybe a dog in the road, on a curve, alongside a marsh, 3am. She left the road, luckily at low tide, and her car ended up about 50ft into the marsh, on it's side. By the time we got there she was out of the car, back on the road, covered head to toe in "Pluff Mud". She was alert and oriented, the only mark on her was a couple of cuts on her leg from the oyster shells in the marsh. She was freaking a little, HR in the 140s, but she eventually calmed down. She signed a waiver.


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## Melclin (Apr 29, 2012)

NYMedic828 said:


> Idk how it is by you but over here mechanism of injury alone is not a ruling for spinal immobilization.
> 
> Her vitals are fine...
> 
> ...





Remeber343 said:


> Moi shouldn't be a reason to use c spine. I'd throw her on the monitor after doing a physical exam.



The canadian c-spine rule recommends pts involved in high mechanism trauma be imaged (and I think we can assume we should be immobilising the same cohort of pts). 

Also, in terms of reliability, I think a person involved in a seriously massive car accident may not really be reliable for exam in some cases (most of mine have been a little spacey at first), remembering that the NEXUS study was pretty anal about establishing reliability. I'm generally of the opinion that one should shoot first and ask questions later when it comes to at least begining the immobilisation process with these pts. You can always take a collar off when everything has calmed down a bit and your more satisfied with a thorough exam.


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## Aidey (Apr 29, 2012)

The Canadian c-spine rule says _consider _imaging for high mechanism trauma, which it defines as auto vs ped, ejection, or high speed* rollover, none of which seem to be present here. 

They define high speed as >60mph


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## Tigger (Apr 29, 2012)

firefite said:


> How is she altered? If she answers all my questions with no issue and I find her to be AOx4 then there is not much you can do. Have her talk to med control, try to talk her into going. If still no then have her sign AMA. Make sure you document the heck out of the call and make sure you advice the patient to go to the hospital by some other means since she doesn't want to go by ambulance.
> 
> If your patient is AOx4, not on a psych hold, not under police protective care, and is charge of their own care then it is kidnapping if you transport them against their will.



I guess the question is more along the lines of "if she has a concussion, is her mental status therefore altered making her unable to refuse, regardless of her answers to questions?"


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## DesertMedic66 (Apr 29, 2012)

Tigger said:


> I guess the question is more along the lines of "if she has a concussion, is her mental status therefore altered making her unable to refuse, regardless of her answers to questions?"



If she answers all the questions correctly and without trouble then she is not altered...


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## Veneficus (Apr 29, 2012)

just out of curiosity...

was the pt belted?


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## Melclin (Apr 29, 2012)

Aidey said:


> The Canadian c-spine rule says _consider _imaging for high mechanism trauma, which it defines as auto vs ped, ejection, or high speed* rollover, none of which seem to be present here.
> 
> They define high speed as >60mph





> First, patients judged to be
> at high risk due to age, dangerous
> mechanism of injury, or paresthesias
> must undergo radiography.



This is from the original paper and it sounds reasonably unambiguous to me. Maybe I've missed something?

I agree that none may have been present here. It was just a response to the idea the mechanism is completely irrelevant in the application of precautions.


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## Aidey (Apr 29, 2012)

Hmmm, that is what I heard from a MD involved in PHTLS*. Maybe it is a difference between information in the abstract and the full text? 


*Not directly, a rebuttal they wrote to something made its rounds via e-mail. I was CCd on the e-mail from a reliable source.


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## Melclin (Apr 29, 2012)

Aidey said:


> Hmmm, that is what I heard from a MD involved in PHTLS*. Maybe it is a difference between information in the abstract and the full text?
> 
> 
> *Not directly, a rebuttal they wrote to something made its rounds via e-mail. I was CCd on the e-mail from a reliable source.



The quote was from the full text. The following, from the abstract seem even more absolute. Not having a crack at you, its just that I've been pouring over the spinal literature RE my own recent conundrum (See the 'to collar or not to collar' thread), so I thought I'd just point out what I've read. 



> The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that *mandates* radiography (ie, age 65 years, dangerous mechanism, or paresthesias in extremities)? (



Bold added.


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## Aidey (Apr 29, 2012)

Interesting, I received a printed version of the e-mail, I will have to look around and see if I still have it. The reason I remember it is because 60mph seemed fast, in the past 45mph has seemed to be the cut off for high speed vs not.


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## Melclin (Apr 29, 2012)

Aidey said:


> Interesting, I received a printed version of the e-mail, I will have to look around and see if I still have it. The reason I remember it is because 60mph seemed fast, in the past 45mph has seemed to be the cut off for high speed vs not.



I was a bit confuzulated by the 60mph thing. It does seem surprisingly high. 45mph or there abouts is considered a significant in our mechanism discussions too. It lists a surprisingly high speed for its MVA criteria but then next to it, the surprisingly ambiguous "rollover" (with no qualifying remarks, so, strictly interpreted, it could mean any rollover at all. It really could do with some sort of "serious rollover" or "rollover >45mph" etc). PM me if you don't have access too, but would like, the full text to have a bit of a squiz.


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## emergancyjunkie (May 2, 2012)

Veneficus said:


> just out of curiosity...
> 
> was the pt belted?



Yes the patient was belted


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