Did I provide sufficient EMT care? 7 y/o hit head on slide

[r4state]

Hi guys! I'm a newbie EMT-B, and I'm very paranoid about the quality of care I provided since it's my first call BY MYSELF. I would like comments/critiques, and feel free to be as harsh as you'd like.

I was called to a water park because a 7 year old hit her head coming down a 20+ feet slide. Lifeguards back boarded her in the water and they brought her out for me to check. While someone held c-spine, i slipped on a c-collar and started talking to her, asking for her name, her age, what happened, and what hurts. She only said her head hurt, and I made sure she wasn't hurt anywhere else such as her back and neck. I did a quick pat down and found nothing unusual. She had a thumbnail sized scrape on her forehead. Her pupils were PERRL, HR 100. The only thing unusual was her skin, which was cold and clammy due to the fact that it was windy and the water was chilly. Even though we had a towel around her, she was still shivering like crazy, so I really wanted her to warm up. Since I found nothing else wrong, we got her off the backboard while she still had a c-collar on. I told her mom that an ambulance isn't necessary but she should still see a doctor just in case. Her mom took her to a clinic to get checked out.

Thanks for your help! I've never worked alone before, so I felt paranoid that I might have missed something... not to mention this is my first job as an EMT.

 

[MrBrown]

Brown is satisfied your care was appropriate.

Did you ask about loss of consciousness or any altered sensation at all? It's not the end of the world but Brown would ask

 

[r4state]

I did not, and that's a very good idea. Thank you, I will remember that next time.

 

[18G]

Sounds like you made a good assessment of the situation and the right disposition.

I would only add that you applied a cervical collar. Just curious what your suspicion or reasoning was for applying it only to later take it off? You justified putting it on, what was the justification for taking it off? What changed your mind? Again, just curious and make sure to always document why you "un-immobilize" someone.

Agree with Brown... ask about loss of consciousness... but hey, none of us are perfect.

 

[rmabrey]

. I told her mom that an ambulance isn't necessary but she should still see a doctor just in case.

Im curious as to why you said this? In a RO we are told to inform the patient of all consequences up to and including death, however you've done virtually the opposite. I trust your assessment that she didn't need to go, purely curiosity.

 

[JPINFV]

This is why amusement parks need their own first aid staff.

Im curious as to why you said this? In a RO we are told to inform the patient of all consequences up to and including death, however you've done virtually the opposite. I trust your assessment that she didn't need to go, purely curiosity.

...because you can't always play those cards. Did you ever visit the school nurse growing up? What would have happened if every time you visited the nurse it was, "Well, you should go to the hospital OR YOU COULD DIE!"? Some calls really are a, "You just have a bump, don't worry about it," and this is doubly true (however not the case here) if you have any sort of 'clinic' type job like running first aid at a water park.

 

[Akulahawk]

Something to think about: sometimes people won't remember "blacking out" or "losing consciousness." A 7 year old probably won't understand that concept anyway. Try asking them if they remember waking up.

 

[rmabrey]

This is why amusement parks need their own first aid staff.




...because you can't always play those cards. Did you ever visit the school nurse growing up? What would have happened if every time you visited the nurse it was, "Well, you should go to the hospital OR YOU COULD DIE!"? Some calls really are a, "You just have a bump, don't worry about it," and this is doubly true (however not the case here) if you have any sort of 'clinic' type job like running first aid at a water park.

Very good analogy. Simply curiosity, I know not all systems are the same, and not everyone needs a hospital. I just prefer to cover my butt.

I would have chosen to say something like "I recommend she go see a doctor to be checked out, would you like us to take her". If mom says no go through the steps of a refusal.

 

[r4state]

Sounds like you made a good assessment of the situation and the right disposition.

I would only add that you applied a cervical collar. Just curious what your suspicion or reasoning was for applying it only to later take it off? You justified putting it on, what was the justification for taking it off? What changed your mind? Again, just curious and make sure to always document why you "un-immobilize" someone.

Agree with Brown... ask about loss of consciousness... but hey, none of us are perfect.

I never took off the c-collar.

And thank you everyone, all of your comments are extremely appreciated! I'm actually not with an ambulance, I'm more like a first-responder with an EMT-B certification that specifically goes to the waterpark for calls so that the team actually working with the ambulance will be available for more urgent calls.

 

[JPINFV]

So, wait, do you work for the ambulance service or work for the water park?

If you're working at the waterpark, then you need to get used to making an actual disposition for your patients. You're options are basically, the patient can stay, the patient needs to go home, the patient needs to go to an ED or urgent care via POV (preferably with a group/friend/family member), non-emergent ambulance, or emergency ambulance. Also, remember that you have the option of them calling their primary care physician to help determine where they need to go. Working at a waterpark is a clinic job where, unlike the ambulance, it is completely inappropriate to automatically default to a transport disposition.

 

[r4state]

It's a bit confusing and weird... I work for the city, but don't get dispatched with the ambulance for 911 calls. Like I said, kind of like a first responder for those parks, where urgency is usually low, unless otherwise told so. So I guess you can say I work for waterparks and other areas prone to accidents. It's definitely one of those temporary jobs until a full-time EMT-B moves aside and I can take their spot. So this counts as a clinic job?

Anyway, I'm more concerned about my assesment and whether or not I covered enough details to make a sound judgement... I know I need to cover by ***, which I believe I did fine when I told Mom she should have a doctor look at her daughter if she wasn't going to have her transported by EMS. PLUS She signed a refusal of care form that indicated she was going to get her daughter to a provider herself.

 

[medichopeful]

You did very well!

One thing to keep in mind is that a c-collar does very little, if anything, to provide stabilization of someone's neck by itself. If they want to move their head, they will. So just make sure that next time if you decide to let somebody off a backboard, that you keep in mind that leaving the c-collar on won't do too much

Very nicely done other than that!

 

[medichopeful]

Anyway, I'm more concerned about my assesment and whether or not I covered enough details to make a sound judgement

The one thing that you probably should have checked was the BP. If you're familiar with Cushing's Triad, you'll know why. I'm not saying that there was necessarily going to be anything in that regard to this patient, but just a good habit to get into with head injuries. That and a BGL.

Hope that helps!

 

[r4state]

You did very well!

One thing to keep in mind is that a c-collar does very little, if anything, to provide stabilization of someone's neck by itself. If they want to move their head, they will. So just make sure that next time if you decide to let somebody off a backboard, that you keep in mind that leaving the c-collar on won't do too much

Very nicely done other than that!

Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.

 

[Akulahawk]

Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.

In the conscious patient that has good voluntary control over head movements, the c-collar serves as a reminder NOT to move the head around. Yes, it will provide some control of movement, but nowhere nearly as good control as the patient can provide on their own...

 

[r4state]

Yes. Thanks for the insight, I feel wiser already!

 

[medicdan]

Did you get a signed refusal from the parent? Any vitals other than HR? Any neuro exam other than Pupils? Did you release the patient wearing the c-collar?

If you're going to applying treatments (the removing them), you need to decide which authority you are going to stand under (the city 911 or the water park), and talk to your medical director (if you're functioning as an EMT you should have one) about their standards for these kinds of cases. Did you formally document the call anywhere? Why not ask colleagues about the local standard of care? QA/CQI person for your department?

 

[18G]

I never took off the c-collar.

Ok. I misread or perhaps assumed when you said you had taken the patient off the backboard.

Again though... why take a patient off a backboard, leave a cervical collar on, and have the patient up walking around? What was your suspicion for leaving just the collar on? I have never heard of pre-hospital spinal immobilization of that type.

Around here anyway an EMS service or provider would be laughed at for sending a patient on her way with a cervical collar in place. I would never treat and release a diabetic with their IV still in place and send them on their way to the doctors office or ED. Kinda the same principle.

PLUS She signed a refusal of care form that indicated she was going to get her daughter to a provider herself.

A signature alone on a refusal form does not constitute a valid refusal of services. So please do not let that fool you into a false sense of security. The refusal has to be informed - mom explained what her daughter's condition was, perceived risks involved with refusing immediate care, and provide options for seeking care outside of EMS, and specifically ask Mom if she has any questions and document all of it.

It sounds like the refusal was informed but just wanted to reinforce that.

 

[mycrofft]

Pretty good.

"Since I found nothing else wrong, we got her off the backboard while she still had a c-collar on. I told her mom that an ambulance isn't necessary but she should still see a doctor just in case. Her mom took her to a clinic to get checked out".
1. Not to be snotty, but if a spineboard is not needed due to lack of spinal injury, then of what field-EMT-diagnostic level use is a C-collar alone? What was the presumed diagnosis necessitating the C-collar without board? How does delayed MD attention play into this? (NOTE: at Bedrock EMS, if the collar went on, the board did also until radiologically cleared.
2. I'd have said much the same, with the spin towards go today/now, not tomorrow.

Would you allow the kid to return into the pool?:huh:

 

[medichopeful]

Really? I thought it would keep her from bobbing her head forward and back or moving it side to side too briskly... better one than none?? Had it been a more serious injury where spinal trauma was in the least bit suspected, I wouldn't have taken her off the backboard. She didn't hit the bottom of the pool and it was more like a hard wack on the head and a splash into the pool.

Definitely better one than none. As far as moving it side to side, it might prevent a little bit of that, but if they want to turn their head they will. The same goes for moving their head forward and back: if they want to move it, they will. Now granted, it will most likely prevent forward and back motion more than side to side motion, but remember that the neck and is a lot stronger than the thin piece of plastic that is a c-collar.

Next time you have a chance, grab a c-collar and have somebody put it on you (don't steal it though ). Make sure it's fitted correctly, then try to move your head. You'll be surprised how little effort it takes.

In EMT school, think about how you were taught to backboard or KED somebody. Ignoring all the arguments and clinical data for or against spinal immobilization, remember that even after the c-collar was on, that you were still supposed to hold the patient's head. If the c-collar provided sufficient stabilization, they might not have you do that!

Again, keep in mind that I'm not faulting you for your care, which seemed for the most part good! I'm just trying to point out the misconception that a lot of people have (not just you) that a c-collar by itself prevents injury.

Hope this is helpful!
Eric