Did this provider mess up?

[JPINFV]

What makes you think that the personell from the FD who were dispatched by 911 are not qualified to take over?

[sarcasm]Emphasis added. What part of the bolded are we not understanding here?[/sarcasm]

 

[Jay]

[sarcasm]Emphasis added. What part of the bolded are we not understanding here?[/sarcasm]

LMAO... Good one, on a related note I was interviewing with a very large ambulance company in Philadelphia the other day (Yes! I got the job! Yay!) and he told me right from the start that he will not ask me any EMS or health related questions, he was more concerned about my social and customer service skills. Bottom line was if you have a cert than you get your foot in the door, if you don't know what your doing once your in training as a probie than your out anyhow which is a good point.

I find it interesting that a lot of 911/Fire/EMS personnel can be lacking in competency for one simple reason; the little kids are probies and lacking experience and the big kids are burnt out, of course this doesn't apply to everyone but it does happen so you really never know who you are transferring care over to. Is the guy (or gal) who is taking over within their 90 day probation period, suck at their job and going to be let go anyhow?

Feel free to correct me if I am wrong but I believe that Philadelphia City Paramedics are bonded after 5 years, of course they can't collect a pension after just 5 years but do begin to get bonded into the system at that point... Why? Because the burnout rate is so high that the city does not expect to get a lifetime out of them. Just an interesting segue while we are on that page.

 

[8jimi8]

We then proceeded to examine and question the patient, who said he was not sure if he was unconscious or not for a small period of time. The patient was alert and oriented to person, place, and time, but he was still a bit dazed.

No one considers a possible alteration of consciousness as possible evidence of significant MOI?

I am also inclined to attempt to clear c-spine, but not by just questioning the patient.

I'd like to see some neurological/musculoskeletal assessments before i tell someone to release c-spine, once it has been taken.

Anyone see any flaws in that logic?

 

[JPINFV]

No one considers a possible alteration of consciousness as possible evidence of significant MOI?

I have a problem with the word possible, and a bigger issue with two uses of possible in the same sentence. Yes, it's possible that he had a bout of loss of consciousness. Yes, a loss of consciousness could be evidence of a significant MOI. However, I'm much more concerned about what can be determined with 100% certainty, which is the physical exam information that you and I requested.

Edit:

Let's play out this scenario. The patient has a confirmed bout of 30 second LOC. He is now a little dazed, but A/Ox4, otherwise interacting appropriately, no tenderness or pain along the spine, and no focal deficits. Does the 30 seconds of LOC dictate cervical spine immobilization regardless of the rest of the patient presentation?

 

[8jimi8]

I have a problem with the word possible, and a bigger issue with two uses of possible in the same sentence. Yes, it's possible that he had a bout of loss of consciousness. Yes, a loss of consciousness could be evidence of a significant MOI. However, I'm much more concerned about what can be determined with 100% certainty, which is the physical exam information that you and I requested.

Edit:

Let's play out this scenario. The patient has a confirmed bout of 30 second LOC. He is now a little dazed, but A/Ox4, otherwise interacting appropriately, no tenderness or pain along the spine, and no focal deficits. Does the 30 seconds of LOC dictate cervical spine immobilization regardless of the rest of the patient presentation?

lol that's funny, i didnt even catch my double possibility...

in any case, i agree, it doesn't make me highly suspicious for a spinal injury, which is why i would attempt to clear it in the field. That being said, if he hit his head hard enough to damage his brain (albeit with reversible deficits) ... doesn't that warrant more caution than less?

***are you really serious about being 100% certain in the field...?

 

[Akulahawk]

Positive LOC, in a patient who is A&Ox4, with no spinal tenderness, crepitus, step-offs, or focal deficits, is not a MOI for an injury. Positive LOC indicates that something knocked the brain around.... that is potentially significant. Possible LOC for 30 seconds, a bit "hazy" on things, but A&Ox4 tells me this patient most likely has a grade 2 concussion, not a cervical injury. That makes me very suspicious that the patient has had a TBI worse than just a concussion, so I'd be on the lookout for that. In absence of the parents, I'm transporting... and given enough latitude in my protocols, I wouldn't put this patient on a board

Remember folks, people might not remember being knocked out... but they might just remember waking up! And don't forget to ask questions that the patient can't answer by looking around on scene. I've had the fortune to have evaluated more than a couple concussion patients over the years.

 

[Aidey]

You also have to distinguish between the patients who truly lost consciousness and the "It happened so fast I don't remember what happened" patients.

 

[8jimi8]

You also have to distinguish between the patients who truly lost consciousness and the "It happened so fast I don't remember what happened" patients.

Aidey, i definitely agree with the distinction, but

Waking up fuzzy indicates to me that he lost consciousness.

again, i'm not advocating spinal immobilization, but AH elucidated what I was inferring.

 

[JPINFV]

in any case, i agree, it doesn't make me highly suspicious for a spinal injury, which is why i would attempt to clear it in the field. That being said, if he hit his head hard enough to damage his brain (albeit with reversible deficits) ... doesn't that warrant more caution than less?

Where does the caution end, though? Either an intervention is indicated or it isn't and we shouldn't be engaging in interventions not indicated 'out of an abundance of caution.' Look at the big up-to-do last year over the potential of brain injuries in football players. That right there is good evidence that you can have brain injury without spinal cord injury.

***are you really serious about being 100% certain in the field...?

In the sense that I mean it, absolutely D)! Either the patient has a neuro deficit or the patient doesn't. Either the patient has a distracting injury or he doesn't. Either the patient is currently complaining of pain/tenderness, or he isn't. That's vastly different than having the patient try to recall if he has missing time (LOC) at the time of injury or not.

 

[8jimi8]

Where does the caution end, though? Either an intervention is indicated or it isn't and we shouldn't be engaging in interventions not indicated 'out of an abundance of caution.' Look at the big up-to-do last year over the potential of brain injuries in football players. That right there is good evidence that you can have brain injury without spinal cord injury.


In the sense that I mean it, absolutely D)! Either the patient has a neuro deficit or the patient doesn't. Either the patient has a distracting injury or he doesn't. Either the patient is currently complaining of pain/tenderness, or he isn't. That's vastly different than having the patient try to recall if he has missing time (LOC) at the time of injury or not.

I getcha. My point of divergence is that the person assuming command of the scene was a little less cautious than I would have been. I guess we all end at the same place. Transport /s spinal precautions. To answer your question, my extra caution would not be so extreme that I delay tx or transport and as you said i was 100% certain that spinal immobilization was unnecessary.

 

[Aidey]

Define fuzzy though? That is a description that has a wide variety of presentations depending on who is using it.

To use myself as an example, a while ago I took a flying lesson in the back of the ambulance. I flew forward and hit the edge of the built in cabinets most ambulances have next to the airway seat, and I ended up on the floor. I remember standing up and listening to lung sounds. I remember lying on the floor, but the heck if I remember actually being airborne, it just happened too fast. I was lying there, and I could hear the driver asking if I was ok and I was having a little conversation with myself, "Hmmm. I'm on the floor. Why am I on the floor? Ohhhh right....brakes....I should answer him, hang on...that is a good question, am I ok?" Finally it occurred to me to SAY something out loud, which was the brilliant statement "I'm on the floor".

Was I fuzzy? Like an electrocuted kitten.
Did I have LOC? Nope, I just needed a minute for my brain to process WTF had just happened. Once it caught up I was fine (well, except for the broken rib).

So, is the kid sitting there going, "Hey, why am I on the ground with 20 people standing here and some guy holding onto my head?" or is he going "Where am I? Why is it night time? Why do I have my back pack?". Both could be described as "fuzzy", but the latter is a lot more concerning than the former.

 

[8jimi8]

Define fuzzy though? That is a description that has a wide variety of presentations depending on who is using it.

To use myself as an example, a while ago I took a flying lesson in the back of the ambulance. I flew forward and hit the edge of the built in cabinets most ambulances have next to the airway seat, and I ended up on the floor. I remember standing up and listening to lung sounds. I remember lying on the floor, but the heck if I remember actually being airborne, it just happened too fast. I was lying there, and I could hear the driver asking if I was ok and I was having a little conversation with myself, "Hmmm. I'm on the floor. Why am I on the floor? Ohhhh right....brakes....I should answer him, hang on...that is a good question, am I ok?" Finally it occurred to me to SAY something out loud, which was the brilliant statement "I'm on the floor".

Was I fuzzy? Like an electrocuted kitten.
Did I have LOC? Nope, I just needed a minute for my brain to process WTF had just happened. Once it caught up I was fine (well, except for the broken rib).

So, is the kid sitting there going, "Hey, why am I on the ground with 20 people standing here and some guy holding onto my head?" or is he going "Where am I? Why is it night time? Why do I have my back pack?". Both could be described as "fuzzy", but the latter is a lot more concerning than the former.

Thanks for that. I've never hit my head that hard before. I definitely see your point.

 

[Aidey]

As far as I know (judging from the bumps, bruises and sore spots) I never did hit my head. I broke a posterior rib from hitting the corner of the cabinets, so it was a pretty focused impact.

Back on topic, people I work with have laughed at me because of my penchant for the use of medical terms when it comes to my reports. I know medical jargon can be bad, but at the same time, I have a thing for using the most proper term possible to describe something. I try and avoid ever using vague terms like "fuzzy" or "cloudy" because 10 different people are going to come up with 10 different definitions for what it means.

 

[8jimi8]

As far as I know (judging from the bumps, bruises and sore spots) I never did hit my head. I broke a posterior rib from hitting the corner of the cabinets, so it was a pretty focused impact.

Back on topic, people I work with have laughed at me because of my penchant for the use of medical terms when it comes to my reports. I know medical jargon can be bad, but at the same time, I have a thing for using the most proper term possible to describe something. I try and avoid ever using vague terms like "fuzzy" or "cloudy" because 10 different people are going to come up with 10 different definitions for what it means.

Dude you should see my computer charting. (what the MD sees IF they look)

Integument:
Color appropriate for ethnicity, Pt has generalized irregular <= 0.5 cm sanguineous crusts /c generalized serous secretions and a 7cm x 1cm well-approximated, dry, non-contiguous linear laceration to the superior, anterolateral aspect of the lower right extremity. No s/s of integumentary infection, or dependent edema. Turgor is brisk.

report on said patient to oncoming RN,

scabs everywhere on his skin, most are weeping, large healing lac to the right thigh, no edema, erythema, of purulence noted.

Same nurse writes on her report sheet

"Skin: Nasty"

 

[Aidey]

That sounds about right. If I ever end up in court I will have to spend an hour translating, but I would rather do that than explain some vague description of a condition.

I do admit that I once wrote "bad" under lung sounds on the non-official paper PCR (we do ePCRs, but have paper ones as scratch paper).

 

[Old Road Dog and Sidekick]

aside from your obvious concern over your patient, which is what he was if you are certified, not on duty, and decide which way you'll go on the good samaritan clause..you got the info you could, called for treatment and tx if deemed, and handed the care over to an equal or higher trained personnel.
what they did after that is on them. so we're talking scope of practice/local protocols, and liability. sounds like you did just fine. him being a minor, he had to go in. many teenagers we'd transport were leaving the ER before we did.

ps: not having a lab, xray machine, surgeon or ct scan on-scene has always been a hindrance..
*smile*

 

[Jon]

I could go either way.

if it seems like there really wasn't a LOC, and the Pt. only has localized pain where he struck his head, NOT back/neck pain, then I don't see a need to immobilize.

As for the forearm - if it wasn't deformed and had decent range of motion - why splint it?

 

[Akulahawk]

Wrist pain? Given my druthers... whether or not I splint the wrist would depend upon the findings on exam, IF I am allowed to evaluate it to the limit of my abilities, which I can when not on duty as a Paramedic.

 

[Shishkabob]

It might just be me, but...


I actually prefer when a lower credentialed provider who has yet to continue on in their education DOESN'T challenge my patient care decisions unless it's grossly negligent...



PS-- JPIN can question me any day... except Tuesdays.