discerning Sprain vs. Broken vs. Dislocated

[Melclin]

The question still had not been answered... and I quote

My answer is: Generally as a field provider, you won't have to. With proper training and education, it is possible to learn how to do it quite accurately. I do know how to do it. In my own personal experience, many Physicians do not know how to do this well. As a Paramedic, I can't do the testing necessary to confirm my evaluation. If I take that particular hat "off" (as in off-duty)... then yes, I can, and have, done precisely that.

The question was answered. You didn't say anything new. Given that a simple question has been succinctly answered it's not at all unreasonable for the conversation to expand beyond the original strict parameters, to a related and important topic.

That said, I don't really understand what Vent is talking about with the difference between refusal and declination. I assume its some American hyper-litigious BS, that I don't have to worry about.

If a pt wants pain relief, then they'll get it, if they don't, then they won't (Assuming a legitimate cause of pain: clinical judgment and relevant documentation). The obvious extenuating circumstance being if their pain is so bad it's clouding their judgment. In which case I will relieve their pain enough to return them to what I judge, as a competent and well educated clinician, to be a state of sound mind. Document accordingly. What's the issue? Is it the difference between a pt asking for meds and you refusing, and you asking the pt if they want meds and them refusing?

 

[Akulahawk]

The question was answered. You didn't say anything new. Given that a simple question has been succinctly answered it's not at all unreasonable for the conversation to expand beyond the original strict parameters, to a related and important topic.

That said, I don't really understand what Vent is talking about with the difference between refusal and declination. I assume its some American hyper-litigious BS, that I don't have to worry about.

If a pt wants pain relief, then they'll get it, if they don't, then they won't (Assuming a legitimate cause of pain: clinical judgment and relevant documentation). The obvious extenuating circumstance being if their pain is so bad it's clouding their judgment. In which case I will relieve their pain enough to return them to what I judge, as a competent and well educated clinician, to be a state of sound mind. Document accordingly. What's the issue? Is it the difference between a pt asking for meds and you refusing, and you asking the pt if they want meds and them refusing?

I didn't get into the specific ways to evaluate whether someone has a sprain or Fx because I'd have to basically re-write "the book", there isn't adequate space to do it here, and as a field EMS provider, you don't have to worry about it. Even if you DO get the book, read it cover to cover, and even take a class specifically for it... you still will need to have a LOT of practical experience before you develop the feel necessary to accurately grade the level of injury. Of course that's even after you've had a good course in Anatomy.

The lack of hands-on experience is what makes most physicians very poor (in my experience) at evaluating these injuries clinically. Thus, they send the patient out for image studies such as x-ray or MRI.

Of course I didn't post anything "new"... I was learning to do this 18 years ago, and it was "old" news back then!

In GENERAL, though, it does involve palpation of specific structures and stress testing in a number of different ways. This skillset is like intubating... it doesn't take all that long to learn, it takes a long time to master, and it's perishable.

I also don't see any difference between a patient refusing or declining to take any pain meds... it's the same thing. The patient was offered pain control and the patient decided not to use it. Documentation of that is easy. If the patient declines and you give it anyway... or the patient asks for it and YOU withhold (and you could have given it)... Those are different matters entirely.

 

[VentMedic]

I also don't see any difference between a patient refusing or declining to take any pain meds... it's the same thing. The patient was offered pain control and the patient decided not to use it. Documentation of that is easy. If the patient declines and you give it anyway... or the patient asks for it and YOU withhold (and you could have given it)... Those are different matters entirely.

Negative documentation, patient rights and alternative options should have been covered in your paramedic class. Don't wait until an attorney rips you a new hole to learn the difference. If the patient is not fully aware that your protocols mandate that they must take what you are offering, it can not and should not be counted against them negatively.

 

[mycrofft]

Sorry been gone, like, at work.

We covered the question about sprain versus fx. Only wrinkle I can guess might arise is if a poorly written protocol says "If fracturd do this, if sprained do that" becuase that bases action on diagnosis instead of upon signs and symptoms.

I deal with a LOT of refusals. Hrer is how it was explained to me:
1. The pt refuses specific items. If you make the pt specify you may find out what their problem is and resolve it you may find that you will be able to go ahead with your course of action.
2. If other actions can and should be taken for the pt's safety and comfort, they should not be witheld if they can be safely accomplished without the refused items. (i.e., if the pt refuses vitals or an exam, you can withold certain drugs due to "I can't give you narcs because they might be contraindicated"; that will fly. Refusal of a history would not be grounds to withold or reverse application of a clinically obvious need for a traction splint if you could exam the pt enough to determine NEED and SAFETY.
3. The pt can change their mind.
4. The pt must understand.
5. Document their undestanding with a handwritten codacil to the standard form if it is inadequate, then have the pt sign the addendum.

 

[triemal04]

Negative documentation, patient rights and alternative options should have been covered in your paramedic class. Don't wait until an attorney rips you a new hole to learn the difference. If the patient is not fully aware that your protocols mandate that they must take what you are offering, it can not and should not be counted against them negatively.

You really haven't worked outside a hospital in a very long time, if ever, have you? Perhaps you should not comment on things that you no longer have any understanding of.

Not to speak for anyone else, but with an alert, informed pt who is capable of making informed decisions, I'm not "mandated" to give them anything; they can refuse whatever they want, whenever they want. (as an aside, I haven't seen any of the previous posters mention anything about them being REQUIRED to give pn meds to pt's, just that they can. chalk another one up for venty...:lol

 

[mycrofft]

Shin kicking again are we? Personally I'm switching to decaff.

The response was to show we can be liable if we spring a trap on the pt by denying or withdrawing care because the pt does not accept it initially, or does not accept certain portions of it; the pt needs to be aware, and capable of understanding consequences. I can't deny care if the pt refuses part of the package, but I will withold care ("Step 2", say, adminsiter a drug) which may LIKELY do harm if a preliminary part of the care ("Step 1", such as vital signs or a list of current meds or allergies) is not done.

My response earlier was to show we are ethically and morally deficient if we use the "take it all or leave it all " approach without regard to actual necessity of each and every measure.

Once we are engaged with the pt (and in some states driving by engages you), you are ethically, morally and often legally bound to help them and to do no harm nor cause unnecessary suffering. This is part of the price we pay for the privilige of being a care provider of some sort.

Just imagine you are the pt and you say NO to part of the EMTs' approach, then they pack it up and drive off, or turn off the O2, stop the IV, or refuse to give meds because you won't do everything they say, or you are a little dazed or obtunded.

 

[triemal04]

The response was to show you can be liable if you spring a trap on the pt by denying or withdrawing care because the pt does not accept it initially, or does not accept certain portions of it; the pt needs to be aware, and capable of understanding consequences. I can't deny care if the pt refuses part of the package, but I will withold care ("Step 2", say, adminsiter a drug) which may LIKELY do harm if a preliminary part of the care ("Step 1", such as vital signs or a list of current meds or allergies) is not done.

I don't disagree; that's where the "alert, informed pt who is capable of making informed decisions" comes into play. Usually it's more of an issue when it's not a drug given for pn, but it happens with them too. Regardless, if the pt is capable, it is still their decision. Of course they can change their decision at any time (and telling them that is part of making them an "informed" pt) and I'll abide by it.

But, for the given situation (which isn't that rare really), I'll explain to the pt what I can do for them for pn management, explain how rough a ride it may be, and that they may not be able to immediately get pn meds on arrival at the hospital, and, if they still refuse, that they can change their mind whenever they want. Some do, some don't. Sometimes I repeatedly offer, sometimes I don't. Any problem with that?

 

[mycrofft]

Problem immaterial. (Have none, anyway).


But back to the original post, was I the only one who thought about the Ottawa Rules? Or did I remember to mention them?
Ah, well, same field tx, but an interesting subject if you want to know more.