Narrative saved the day

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Jn1232th

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Sooo I had a patient few weeks ago, got tumbled by a wave and hit his head. He ended up walking back to his house, showered. And about hour later decided to call 911 to get checked out due to shoulder pain and some neck stiffness. Me and my partner first in scene (we're a bls source only btw). We do a assessment. C-collar placed. No aloc, csm all extremities, pupils are perl, v/s are wnl. Only c/c is shoulder pain and neck stiffness and bit of headache. Fire arrives and assesses, determines bls only.
Patient is now complaining of some naseau,
Still, they downgrade bls.
We transport to local er. en route v/s still wnl. Only complaint is still shoulder pain, neck stiffness, but of headache and naseau (I don't think that's spelt right haha). Arrive , transfer care and leave. Later, we find out that patient had a epidural hemmorage since he hit his head, was transported to local trauma center and later died.
Now question is....should als upgrade to trauma due to the nausea and headache???
We got the blame at first but my narrative backed me and my partner up on what happened.
 
What if anything would ALS have done differently for this patient?
 
Nothing as far as I know other than transfer to different hospital. The hospital says we should have recognized the signs of the bleed...with only sings being headache and nausea
 
A head injury with nausea and a headache is concerning enough to transport to a trauma center instead of a local ED if the difference in distance is reasonable. ALS vs. BLS is a fairly trivial difference on this call, as mentioned above.

We're looking at this with perfect hindsight though, so it's understandable that we all get caught making mistakes from time to time. What were the rest of his assessment findings? Signs of outward trauma, loss of consciousness during incident, declining mental status? How about some vitals? It's easy for the hospital to place blame once they know the final diagnosis and outcome, but I'd be curious if any of them were immediately jumping for a transfer or consult on this guy until they had the privilege of reviewing his CT results...
 
No obvious trauma. Vitals were normal. No blacking out when he hit his head either. Not sure about what happened at hospital but I'm sure they didn't know of bleed to ct scan.
 
Even with the presentation, I still think I would transport to the community ED if that's what the patient wanted (and where I am the difference is at least a 40 minute drive). The most common diagnosis following a blunt head injury resulting in nausea and headache is a concussion, and with no other abnormalities I don't see this to be an unreasonable differential. Yes, epidural bleeds often present with a lucid interval, but aside from that there is nothing there that really screams intracranial hemorrhage to me.

I look back on my time as a new EMT working for a D1 hockey team and watching my guys get crushed and business carrying along as usual. I was mortified.
 
The retrospectroscope is an amazing tool which, unfortunately, you don't carry on the ambulance. I don't see anything wrong with this scenario as far as EMS goes. What would an ALS bus have done differently? Given zofran? That wouldn't have changed the outcome. A community hospital should know how to work this guy up and the work up would be no different at the trauma center.
 
It's really too bad that he died. This is something that with prompt surgical intervention has close to a 100% survivability.

ER Doc: if you saw an epidural bleed on a CT, how long would it take for a neurosurgeon to arrive at your community hospital? Could a general surgeon do this procedure if need be?
 
justin1232 said:
Nothing as far as I know other than transfer to different hospital. The hospital says we should have recognized the signs of the bleed...with only sings being headache and nausea
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That is absurd. As described here, this was a BLS patient all day long.

If the presentation of a TBI was so obvious, why didn't the receiving ED immediately ship him out to a neurosurgeon? Obviously they didn't recognize it right away, either, despite having infinitely more diagnostic capability than a BLS ambulance crew.
 
zzyzx said:
ER Doc: if you saw an epidural bleed on a CT, how long would it take for a neurosurgeon to arrive at your community hospital? Could a general surgeon do this procedure if need be?
Click to expand...

I can't speak for ERDoc's facility obviously, but community hospitals don't typically offer neurosurgical services at all, and a general surgeon usually won't even be consulted on these, because in normal civilian life 95% of general surgeons aren't going to touch something like this in 95% of cases. Exception might be where a surgeon with a military background or training in trauma happens to be around when one of these rolls in and decides to makes a heroic effort in a case where there is just no other option.
 
I work at both a level I trauma center and a small community hospital. At the level I, this would be no big deal, call neurosurg, they take the pt to the OR. There is no neurosurg at the community hospital and a general surgeon won't touch this. Scan, diagnose and transfer. We can't provide every service at every hospital so the level of care you get depends on where you get hurt. Sometimes, you just aren't close enough to a trauma center to go there initially. It's just luck of the draw in life and just the way it is when you live out in rural areas. From an ER standpoint, I would be comfortable opening up the hematoma if I had neurosurg walking me through it as I am doing it (my heart rate would probably be the highest in the room), although I doubt any community hospital would have the tools easily accessible.
 
Just to expand, at my facility, the surgeons don't even touch anything that has an MOI of trauma (or pediatrics). Apparently, its for insurance reasons and they aren't insured to do those types of surgeries, but any patient that sustained a traumatic injury must be transferred to a trauma center for surgical intervention.
 
ERDoc said:
I work at both a level I trauma center and a small community hospital. At the level I, this would be no big deal, call neurosurg, they take the pt to the OR. There is no neurosurg at the community hospital and a general surgeon won't touch this. Scan, diagnose and transfer. We can't provide every service at every hospital so the level of care you get depends on where you get hurt. Sometimes, you just aren't close enough to a trauma center to go there initially. It's just luck of the draw in life and just the way it is when you live out in rural areas. From an ER standpoint, I would be comfortable opening up the hematoma if I had neurosurg walking me through it as I am doing it (my heart rate would probably be the highest in the room), although I doubt any community hospital would have the tools easily accessible.
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ERDoc, I see that so very often... where I work now, we're very good at doing exactly that. I'm just glad that Field EMS can fly traumas to the TC and not to us. I'm glad folks like you are able to see both ends of that, going from a TC to a Community Hospital.
 
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