I'm confused.

[amberdt03]

If it turns out he has a neck fracture and ends up paralyzed, he can also argue that you forced him down on the backboard, despite the fact he refused, and the wrestling him down further irritated his injury and may have caused the paralysis and sue you.

did you not read the first part of the message.

granted it would make his injury worse if you have to fight him

just like i said this is a case of you're d*mned if you do and you're d*mned if you don't.

 

[amberdt03]

The issue for me here is that they are a BLS level transfer ambulance, correct? They should never have taken the patient in the first place IMHO. In this case, why were we transfering from a psych facility? and where to? I assume that the patient was being taken to the hospital for injuries associated with the fall. It shouldn't have been treated like a transfer call.

it really isn't uncommon for there to be a bls transfer truck, at least not in my area.

And yes they should transfer him to a hospital. psych facilities aren't set up to deal with emergencies other than psychiatric. i'm pretty sure they are taking him to an emergency room to make sure he didn't break anything from the fall/jump. happens all the time in dallas(not the jumping, but the going to the er) and i agree that it shouldn't have been treated like a transfer call, but it was.

 

[Mountain Res-Q]

it really isn't uncommon for there to be a bls transfer truck, at least not in my area.

And yes they should transfer him to a hospital. psych facilities aren't set up to deal with emergencies other than psychiatric. i'm pretty sure they are taking him to an emergency room to make sure he didn't break anything from the fall/jump. happens all the time in dallas(not the jumping, but the going to the er) and i agree that it shouldn't have been treated like a transfer call, but it was.

In teh city I worked Ambulance we had 15-18 ALS 911 units on during the day and BLS 5-6 transfer units. The ALS guys didn't want to be bothered withe transfers so we often got calls from Doctor's Offices or Psych Facilites that IMO weren't BLS transfers. I got real use to saying, "No, call a medic unit to take this." Maybe I can take the call at a EMT/BLS level and be fine, but that isn't protocol, and bearing that in mind I prefer to CYA (something I didn't do once and got reamed for), especially when an ALS unit can be there in 2 minutes.

 

[NEMed2]

Obviously no one here can tell you the right thing to do since none of us were there. That being said: A facility waiting over 2 hours after a potentially significant injury to call for a transport is outrageous. (Not that it doesn't happen.) Why did they choose to call now? Was the pt decompensating from their injuries? Had something changed from the time of initial injury? You stated that the pt was A&Ox3, is that 3/3 or 3/4? Can they refuse treatment? I would have called a supervisor or medical control on back boarding the pt if they could not refuse the immobilization. Yes, it could potentially cause additional injuries/aggravate existing ones. Think of your safety first if the pt may become violent. Document document document. I agree with the general question regarding whether this pt was truly a "load & go", in which case ALS should have been notified anyway.

 

[Sasha]

Why did they choose to call now? Was the pt decompensating from their injuries?

Sometimes they have to wait for approval from the medical director of the facility, which can take a few hours to get if they are not onsite. At least that's why some nursing homes take a long time.

 

[NEMed2]

Sometimes they have to wait for approval from the medical director of the facility, which can take a few hours to get if they are not onsite. At least that's why some nursing homes take a long time.

I can understand that, and in non-emergent case, I have no concerns over taking a few hours for a routine transfer.

This situation involves a potentially life threatening injury and I cannot understand why anyone would take 2 hours to call 911 for this type of MOI, even if the director was informed that the pt only suffered a leg injury. A lay person should be able to understand someone can be hurt beyond what can be seen with a naked eye. Not that it should be on the head of a non-present director if they were not given all the information.

 

[Veneficus]

I'm just curious to know what an ALS unit would do for this patient that hasn't been done already or couldn't be done by BLS?

Clinical clearance of C-spine? A Psychiatrist, is a specialty of a physician. (if I am not mistaken the med director of Acadian is/was a psychiatrist) Is it possible that the patient was evaluated and needed transefer to cover him/her?

An IV for pain meds? In the length of time taken, PO sedation or medication could have been given.

A heart monitor? A patient has to be medically cleared to be admitted to a psych facility.

Advanced airway? For a talking "trauma" patient with leg pain?

As food for thought, the original traumatologists were orthopods. ~80% of all trauma is ortho in nature. The only recognized life threatening ortho injury is compartment syndrome. Unless a medic is planing on calling for orders to perform an emergent fasciotomy, (aka surgery), there is little a medic can do that BLS cannot. Infact I can't think of anything.

If by some irrational chance there was a compartment syndrome,the lactic acidosis would be released after the compartment is opened. Even if there was a slight increase in blood lactate, the bodies natural buffers and the heart and liver metabolizing lactate back to pyruvate, as well as NAD+ to NADH should be more than able to compensate for even moderate lactate levels.

as for the mechanism, vertical compression of the spine would cause a fx at the atlanto-occipital joint. (aka c-1) Which would very likely cause and immediate cord insult.

Bi peds are specifaclly built to reduce such compression forces. If the impact wasn't significant enough to even fx his femoral neck, it is not even reasonable to think there is an occult c-1 fx.

Obviously I wasn't there, but it sounds like the pt was being routinely transferred for another medical clearence so he could be turned around and shipped back to the facility. Dramatic though the story sounds.

Based on the OP desription, i think asking the pt to sit quietly on the cot, put on the seat belts, a splint and some ice (coldpack) would be the treatment of the trip.

In the long term, if nothing is broken but there is a joint insult. he will probably get a plaster or other formed splint, told to keep it on for 2 weeks, heat and ice as required, and told to take some ibuprofin for pain.

If there is a fx, he'll get the same with an ortho follow up for a full cast after he gets out of the psych facility as they usually don't allow full casts in psych or prisons because they can be used as a weapon.

Also remember that a physician to physician report is given between the transferring and receiving doc. If there was a strong suspicion of occult injury it likely would have been brought up on that call.

 

[Mountain Res-Q]

I'm just curious to know what an ALS unit would do for this patient that hasn't been done already or couldn't be done by BLS?

Clinical clearance of C-spine? A Psychiatrist, is a specialty of a physician. (if I am not mistaken the med director of Acadian is/was a psychiatrist) Is it possible that the patient was evaluated and needed transefer to cover him/her?

An IV for pain meds? In the length of time taken, PO sedation or medication could have been given.

A heart monitor? A patient has to be medically cleared to be admitted to a psych facility.

Advanced airway? For a talking "trauma" patient with leg pain?

As food for thought, the original traumatologists were orthopods. ~80% of all trauma is ortho in nature. The only recognized life threatening ortho injury is compartment syndrome. Unless a medic is planing on calling for orders to perform an emergent fasciotomy, (aka surgery), there is little a medic can do that BLS cannot. Infact I can't think of anything.

The lactic acidosis would be released after the compartment is opened. Even if there was a slight increase in blood lactate, the bodies natural buffers and the heart and liver metabolizing lactate back to pyruvate, as well as NAD+ to NADH should be more than able to compensate for even moderate lactate levels.

as for the mechanism, vertical compression of the spine would cause a fx at the atlanto-occipital joint. (aka c-1) Which would very likely cause and immediate cord insult.

Bi peds are specifaclly built to reduce such compression forces. If the impact wasn't significant enough to even fx his femoral neck, it is not even reasonable to think there is an occult c-1 fx.

Obviously I wasn't there, but it sounds like the pt was being routinely transferred for another medical clearence so he could be turned around and shipped back to the facility. Dramatic though the story sounds.

Based on the OP desription, i think asking the pt to sit quietly on the cot, put on the seat belts, a splint and some ice (coldpack) would be the treatment of the trip.

In the long term, if nothing is broken but there is a joint insult. he will probably get a plaster or other formed splint, told to keep it on for 2 weeks, heat and ice as required, and told to take some ibuprofin for pain.

If there is a fx, he'll get the same with an ortho follow up for a full cast after he gets out of the psych facility as they usually don't allow full casts in psych or prisons because they can be used as a weapon.

Still, while there is little that a Medic could do that an EMT couldn't, from a BLS TRANSFER standpoint, this is a gray area that should have been referred to a supervisor and be addressed in company/county protocol. they weren;t asking for the transfer of a psych patient, they were asking for the transfer of a pysch patient that had injuries that should have been handled by a 911 unit. Maybe protocol differs where you are, but my protocls would have suggested a Medic Unit. Not saying I couldn't handle this, but protocol is protocol until you violate it and are forced to work at McDonalds. This person works for a TRANSFER COMPANY, probably without a contract to handle transports of acute injury patients to Emergency Rooms.

 

[Sasha]

Still, while there is little that a Medic could do that an EMT couldn't, from a BLS TRANSFER standpoint, this is a gray area that should have been referred to a supervisor and be addressed in company/county protocol. they weren;t asking for the transfer of a psych patient, they were asking for the transfer of a pysch patient that had injuries that should have been handled by a 911 unit. Maybe protocol differs where you are, but my protocls would have suggested a Medic Unit. Not saying I couldn't handle this, but protocol is protocol until you violate it and are forced to work at McDonalds. This person works for a TRANSFER COMPANY, probably without a contract to handle transports of acute injury patients to Emergency Rooms.

And the patient, who based on the information given, appears to be in no major distress, was being TRASNFERred from one facility to another.

 

[Mountain Res-Q]

And the patient, who based on the information given, appears to be in no major distress, was being TRASNFERred from one facility to another.

I'm just saying that protocol differs one place from another. In this case, a question like this should have been dirrected to a Supervicor or might be addressed on County Protocol. We can all say what we would have done based on our experience in the systems we work in, but are in no position to say what should have been done in the system they work in. That said, any time the workds "load and go" are used, should we be talking about a BLS transfer?

 

[Veneficus]

I think "load and go" might have been an overreaction from the lack of trauma experience from a normally transport crew.

 

[Sasha]

I'm just saying that protocol differs one place from another. In this case, a question like this should have been dirrected to a Supervicor or might be addressed on County Protocol. We can all say what we would have done based on our experience in the systems we work in, but are in no position to say what should have been done in the system they work in. That said, any time the workds "load and go" are used, should we be talking about a BLS transfer?

Well considering it's a BLS transfer service who is unfamiliar and probably uncomfortable with trauma, they may have "Loaded and gone" based soley on the MOI without assesing a patient because they were moving into unfamiliar territory, getting them to the hospital as soon as possible because they simply don't know what to do.

If you don't deal with something on a regular basis you tend to forget about it. That's why we have Broselow tape for peds!

 

[Shishkabob]

While doing triage at Cooks childrens, I had a 16/f come in cc of back pain 1/10 only very mild discomfort. She had blood and CSF coming out her ears. Her mvc was 3 hours before and refused treatment until the pain, no matter how mild, didn't go away.

We did a standing immobization with full precautions. Had 1 fx in her back. Lucky as hell to walk around for three hours.

WhY I'm getting at is people have different toldrences of pain, so just because he was a 5/10 doesn't mean it's less likely something is wrong.

 

[daedalus]

true, but his leg pain could be classified as a distracting injury and he could be more focused on his leg, than any neck or back pain he might be having. i thought a 20ft fall is significant enough moi regardless of amount of time that has passed.

Good point! The leg could have defiantly caused a distracting injury. What about the OP patient's focal neurological status, and how about the results of a detailed trauma exam, which should have been preformed.

 

[Mountain Res-Q]

I think "load and go" might have been an overreaction from the lack of trauma experience from a normally transport crew.

Isn't that the point? In light of this reaction shouldn't a BLS TRANSPORT ONLY CREW called in an ALS 911 Crew? Eapecially, as some have suggested, underlying problems could be present, however unlikely? Isn't that psych patient entitled to a higher level of care in a situation that requires more experience than that had by a crew accustomed to the transport of stable patients that have been diagnosed by and treated by a physician trained to deal with the type of injury sustained?

 

[Veneficus]

Isn't that the point? In light of this reaction shouldn't a BLS TRANSPORT ONLY CREW called in an ALS 911 Crew? Eapecially, as some have suggested, underlying problems could be present, however unlikely? Isn't that psych patient entitled to a higher level of care in a situation that requires more experience than that had by a crew accustomed to the transport of stable patients that have been diagnosed by and treated by a physician trained to deal with the type of injury sustained?

Have you ever gone to a doctors office on a call when and all they needed was something you had on the truck or a transfer to the hospital as a direct admit?

This seems a similar type of situation to me. There was not an emergency, but the impression of one.

I agree that the pt deserves to be treated by a specialist, but that specialist in this case is an orthopaedic surgeon not an EM doc. Once a formed splint is put in place,(usually in the ED) in the absence of gross deformity the xrays and consult can wait for days.

 

[ffmedic08]

hmm

Being a schizo pt, kinda gives you a different feel on things. If you are a BLS crew and have no way of chemically restraining him if things really go south - I'd probably have to determine his LOC, A&Ox4?? Compliant with meds? Idk if I'd push him to full c-spin immobilization if I didn't absolutely have to. Granted, protocols say BACKBOARD BACKBOARD BACKBOARD!!! However, each situation is different. Risk vs Benefit on this one. Granted if you backboarded him you could count that as restraint, I suppose. But if you completely restrain his arms, etc- then I am sure the pt is smart enough to realize what you are doing, if not freak out because he has absolutely NO control and nothing free. If you want a pt to trust you, you have got to show you trust him. (thats what I've learned in my experience).

I honestly can't say what I'd do. You gotta prevent further c-spine if there is any, but if you back board him adn he freaks- he's going to cause even more harm than if you would have just taken a nice easy ride to the ED....


hhmm....

 

[Lifeguards For Life]

Aren't suicidal patients classified as non competent adults and therefore can not refuse treatment? Would it be within procedure to get a LEO who can issue a 32? Though I guess if the patient is a combative schizophrenic a Baker Act would help very little.