New EMT Unsure About Recent "Headache" Call

[NUEMT]

Early teens. Pulse 100. Did you retake it later? Is that normal for that person. Caused by anxiety? Just because it is WNL doesn't mean that it's normal...or it might be entirely normal for that patient, or the anxiety level of anyone who has a bunch of EMS suddenly in their home. I would've retaken pulse 10-15 min later.

I would be perfectly fine recommending aspirin or anything similar. Ibuprofen, Aleve...

What was the kid's intake for the last 24 hours. Early teens: is it possible that he stayed up all night with friends eating pizza and mixing various types of sodas, skipped breakfast, ate a huge lunch and then went skiing and now has a headache? I would vomit without a head injury if I did that to my body. In the other hand, it could be a head injury, however, there don't appear to be any abnormal symptoms other than the vomiting and pulse. I'd re check pulse advise over the counter pain meds and recommend they call again if his condition changes.

That is a lot to assume on intake. Who cares what he ate? He fell and hit his unprotected noggin on snow hard enough to ski on. He then vomited. They felt it necessary to call. Points to subacute/developing symptoms to me. No aspirin. No advice regarding what to take. I would never advise not taking in POV. You have basically given that parent cause not to treat. And based on what...our mobile CT? lol.

 

[SpecialK]

He fell and hit his unprotected noggin on snow hard enough to ski on. He then vomited. They felt it necessary to call. Points to subacute/developing symptoms to me. No aspirin. No advice regarding what to take. I would never advise not taking in POV. You have basically given that parent cause not to treat. And based on what...our mobile CT? lol.

It is eight hours post injury and he has no clinically obvious signs of expanding cerebral haematoma or severe traumatic brain injury. What he does have a history, signs and symptoms consistent with minor traumatic brain injury (concussion).

What he needs is observation. In reality, he is probably better to be observed at home where mum can keep a close eye on him than in a busy emergency department where he is going to be checked by the nurse once an hour.

As for not treating him, not all patients are going to require treatment. What they do require is a careful history taken and assessment performed, a reasonable diagnosis made (or in the absence of ability to make a clear diagnosis, a reasonable clinical impression formed) and a reasonable recommendation regarding referral and transport conveyed noting not all patients will require a recommendation for immediate referral elsewhere and if they do, not all will require ambulance transport.

I would be quite happy to give him some oral paracetamol and ibuprofen for his pain, oral ondansetron for his nausea, give his mum advice regarding signs and symptoms to watch for and what to do if he doesn't get better or is they become more concerned.

 

[COmedic17]

That is a lot to assume on intake. Who cares what he ate? He fell and hit his unprotected noggin on snow hard enough to ski on. He then vomited. They felt it necessary to call. Points to subacute/developing symptoms to me. No aspirin. No advice regarding what to take. I would never advise not taking in POV. You have basically given that parent cause not to treat. And based on what...our mobile CT? lol.

8 hours after the fact leads me to believe it's not a major bleed. Vomiting is also a sign of a concussion. There is literally nothing a ambulance is going to do. IF patient is stable AND aox4, I don't see a problem with mom transporting to the hospital or making the decision to monitor the patient herself.

 

[EMS2PA]

If you look at the PECARN study, this kid fits into the CT vs Observation arm with a 0.9% chance of having a clinically important TBI. Given the fact that he has continuing symptoms this far out, I would CT scan him. It's most likely a concussion, which doesn't need an ER. I would never recommend aspirin for kids. I'd go with tylenol until there is a negative head CT.

This is exactly what I was going to say. In my ED, if this patient came in, he'd buy himself a CT. The one thing we cannot rule out at this point, even though unlikely, is a subarachnoid hemorrhage. I've unfortunately seen the waxing and waning mental status present very subtlely , and family only really picked up on it after repeat questioning.
This kid likely has a concussion, but in my EMS days I had no clue how to do a full neurological exam (and I'll admit, even as an ED provider, my neurological exam is still very basic, though much more thorough than when I was in EMS). While aspirin and NSAIDs are ok in a concussion, kids should not be given aspirin, and I'd be leery recommending NSAIDs if there was any concern for a bleed. In general, patients with a head injury that I send home, I recommend acetaminophen for the first 24-48h then NSAIDs after that. If they are having persistent headaches they need follow up.

 

[Gurby]

This kid likely has a concussion, but in my EMS days I had no clue how to do a full neurological exam (and I'll admit, even as an ED provider, my neurological exam is still very basic, though much more thorough than when I was in EMS).

This is why I'm wary of us, as EMS providers, "recommending" anything but a trip to the hospital. Our training focuses entirely on how to keep people alive in the short-term and get them quickly to definitive care. When it comes to more subtle things like this, we don't know what we don't know. I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital."

This might not apply in other countries where the barrier to entry is a 4-year degree, and/or where you're less likely to get sued into oblivion for making a mistake.

 

[conemt]

I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital.

I was taught this same way in my EMT class. If a patient goes AMA, before we leave, we have to tell them what could possibly go wrong without listening to our advice.

 

[Tigger]

This is why I'm wary of us, as EMS providers, "recommending" anything but a trip to the hospital. Our training focuses entirely on how to keep people alive in the short-term and get them quickly to definitive care. When it comes to more subtle things like this, we don't know what we don't know. I'll always give patients my honest opinion if they are thinking about refusing transport, but I always preface with "professionally, I have to recommend that you let us take you to the hospital."

This might not apply in other countries where the barrier to entry is a 4-year degree, and/or where you're less likely to get sued into oblivion for making a mistake.

There's the issue.

I figure that our taxpayers support us and call us when they don't know what to do. We owe it to them to be honest with them and not just bully people into transport because we're afraid of liability.