Patient with distracting injuries

[EMS Patient Care Advocate]

You are toned to meet a vehicle carrying a passenger involved in a vehicle fire in a POV now driving towards the hospital. Meet POV, man jumps out covered in approx 40% burns, majority 2nd degree and 3rd to hands, arms, shoulders, legs, arms and legs appear to be circumferential. All burned areas of skin peeling, some bleeding to left hand. The Airway is dry, white. All hair on head singed.

Pt states "I was coming down a hill, breaks went out and I crashed into trees. I was unable to get out of the vehicle immediately and it burst into flames"

Unable to stop him he gets into the ambulance and sits on edge of stretcher.
Pt refuses backboard, collar, or sitting back to be secured to transport. Pt is CAOx4 PPTE with 10/10 pain from burns-Id say this counts as distracting injury. Pt states he cannot/will not tolerate anything against his skin, stretcher/backboard/burn blanket. Pt has no midline neck or back pain. Distal Neurological exam somewhat unreliable due to severe burns to arms, legs and hands-However patient is able to move all extremities.

Would you use force and restrain?
Do you allow a patient who had no other contraindications to refusal of care other than a distracting injury? Then discuss this with doctor and document.
You are unable to obtain a BP, alternative placements also burned. All clinical signs of circulation, mentation and distal pulses intact.
No RSI available prehospital.

 

[the_negro_puppy]

You are toned to meet a vehicle carrying a passenger involved in a vehicle fire in a POV now driving towards the hospital. Meet POV, man jumps out covered in approx 40% burns, majority 2nd degree and 3rd to hands, arms, shoulders, legs, arms and legs appear to be circumferential. All burned areas of skin peeling, some bleeding to left hand. The Airway is dry, white. All hair on head singed.

Pt states "I was coming down a hill, breaks went out and I crashed into trees. I was unable to get out of the vehicle immediately and it burst into flames"

Unable to stop him he gets into the ambulance and sits on edge of stretcher.
Pt refuses backboard, collar, or sitting back to be secured to transport. Pt is CAOx4 PPTE with 10/10 pain from burns-Id say this counts as distracting injury. Pt states he cannot/will not tolerate anything against his skin, stretcher/backboard/burn blanket. Pt has no midline neck or back pain. Distal Neurological exam somewhat unreliable due to severe burns to arms, legs and hands-However patient is able to move all extremities.

Would you use force and restrain?
Do you allow a patient who had no other contraindications to refusal of care other than a distracting injury? Then discuss this with doctor and document.
You are unable to obtain a BP, alternative placements also burned. All clinical signs of circulation, mentation and distal pulses intact.
No RSI available prehospital.

If this patient is alert and orientated, of adult age, not intoxicated albeit influenced by pain with no mental illness or impairment using force and restraining him would constitute assault.

The best bet would be try and reason with him "Lie back so I can give you pain relief"

or give analgesia then see if we he comply with immobilisation.

This is a very strange question and it would be extremely unlikely to ever be encountered.

In regards to RSI. If you had serious suspicion of airway burns you should explain the procedure to the patient and why it is necessary. Once he is anaesthetised you could then take the necessary c-spine and other precautions. If he is mobile, with nil neuro deficits or neck the chance of c-spine injury is low. Obviously due to massive distracting injury and mechanism of injury one would no clear his c-spine in the field.

 

[EMS Patient Care Advocate]

If this patient is alert and orientated, of adult age, not intoxicated albeit influenced by pain with no mental illness or impairment using force and restraining him would constitute assault.

The best bet would be try and reason with him "Lie back so I can give you pain relief"

or give analgesia then see if we he comply with immobilisation.

This is a very strange question and it would be extremely unlikely to ever be encountered.

In regards to RSI. If you had serious suspicion of airway burns you should explain the procedure to the patient and why it is necessary. Once he is anaesthetised you could then take the necessary c-spine and other precautions. If he is mobile, with nil neuro deficits or neck the chance of c-spine injury is low. Obviously due to massive distracting injury and mechanism of injury one would no clear his c-spine in the field.

Patient did have distracting injury/Pain so you assault concern has a conflict. So if they have a distracting injury but everything else is in tact where do you stand?
This cant be that silly or unlikely, this was my patient last night. I can link the brief news article of the crash if needed.
Im saying RSI is not an option. You dont have protocols or medication available in this system.

 

[Aidey]

Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.

 

[NomadicMedic]

Agreed. This guy needs pain management and fluids. And a fast ride to a facility that can manage burns.


Sent from my iPhone.

 

[EMS Patient Care Advocate]

Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.

Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.

 

[EMS Patient Care Advocate]

Agreed. This guy needs pain management and fluids. And a fast ride to a facility that can manage burns.


Sent from my iPhone.

Fluid bolus in route. Do you worry about the parkland formula prehopital? 18g established in one area not burned, secured with gauze. Nearest facility provided RSI and air medical met us there to transport to proper facility.

 

[Aidey]

Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.

Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.

That includes anything resembling immobilization.

 

[fast65]

As others have already said, pain management is our priority at this point. This gentleman isn't going to let us do anything until we can manage his pain, at least a little bit. Once we get some morphine on board we can start trying to convince him to let us put him on a backboard. This goes without saying though, we need to start fluid replacement ASAP as well.

I would really like to RSI this guy, but, if you don't have that option, I suppose it's kind of irrelevant at this point.

 

[EMS Patient Care Advocate]

As others have already said, pain management is our priority at this point. This gentleman isn't going to let us do anything until we can manage his pain, at least a little bit. Once we get some morphine on board we can start trying to convince him to let us put him on a backboard. This goes without saying though, we need to start fluid replacement ASAP as well.

I would really like to RSI this guy, but, if you don't have that option, I suppose it's kind of irrelevant at this point.

If only RSI ! Yeah needless to say the report to the truama center included the statement- "Well he walked out of the ambulance"
I hope I get an A on my documentation-ick:wacko:

 

[Tigger]

I'm confused as to why this patient would be a candidate for c-spine precautions. Maybe the MOI has you suspecting a c-spine compromise, but he did after all drive to your location and then walk into your ambulance. It seems highly unlikely to me that someone who has already done all this (including escaping a burning car), would be able to provide the force to change a stable c-spine injury to a deficit causing one in the back of the ambulance.

I understand that you can't actually clear c-spine because of the distracting injuries, but were there any other aspects of the assessment that pointed you towards c-spine precautions?

In this case, I can't see how a backboard is going to provide any benefit to the patient, and I am not going to implement an intervention based on what protocol says. If it is going to put the patient in severe pain and there is nothing screaming c-spine injury besides MOI, I don't I'll bother with a board. I will document heavily, however.

 

[EMS Patient Care Advocate]

I'm confused as to why this patient would be a candidate for c-spine precautions. Maybe the MOI has you suspecting a c-spine compromise, but he did after all drive to your location and then walk into your ambulance. It seems highly unlikely to me that someone who has already done all this (including escaping a burning car), would be able to provide the force to change a stable c-spine injury to a deficit causing one in the back of the ambulance.

I understand that you can't actually clear c-spine because of the distracting injuries, but were there any other aspects of the assessment that pointed you towards c-spine precautions?

In this case, I can't see how a backboard is going to provide any benefit to the patient, and I am not going to implement an intervention based on what protocol says. If it is going to put the patient in severe pain and there is nothing screaming c-spine injury besides MOI, I don't I'll bother with a board. I will document heavily, however.

I Agree
I think a stable fracture may be made worse if moved the correct way- that would then cause neuro deficit and cause a problem beyond just a spinal FX if it impedes on the nerves.-Not the case I hope for this patient. Also He wasn’t exactly doing jumping jacks :rofl:
I did palpate and assess spine- distal motor and sensory very unreliable-though moved everything well, he did tell me his back was fine. I was hoping this would stir some conflict as I have c-spine/backboard debates a lot. I did document very heavily.

 

[Slinky]

Would you use force and restrain?
Do you allow a patient who had no other contraindications to refusal of care other than a distracting injury? Then discuss this with doctor and document.
You are unable to obtain a BP, alternative placements also burned. All clinical signs of circulation, mentation and distal pulses intact.
No RSI available prehospital.

I'm confused as to why you would even think about forcing an alert and oriented adult into spinal immobilization. A distracting injury is a contraindication to clearing c-spine, not overriding a patient's right to refuse any treatment. If you feel c-spine precautions are necessary, strongly recommend it and if the pt refuses, simply document it and let the receiving hospital staff know. Competent adults get to make the decisions about their care, even if it is not in their best interest.

 

[epipusher]

I agree with with strongly suggesting the c-spine precautions. Maybe suggest once more after pain meds. Document accordingly.

 

[Aidey]

Anyone trying to do anything to this patient besides provide pain relief would be locked out of my ambulance.

Without hesitation! All clinical signs of proper perfusion intact, no reason to withold. Fentanyl was the drug chosen for analgesia. There was no reliable way of monitoring a BP at this time.

That includes anything resembling immobilization.

Let me rephrase again. Anyone who even thinks the words "backboard" or "c-collar" is getting locked out of my ambulance.

 

[EMS Patient Care Advocate]

Let me rephrase again. Anyone who even thinks the words "backboard" or "c-collar" is getting locked out of my ambulance.

I guess Ill drive :sad:

 

[EMS Patient Care Advocate]

I'm confused as to why you would even think about forcing an alert and oriented adult into spinal immobilization. A distracting injury is a contraindication to clearing c-spine, not overriding a patient's right to refuse any treatment. If you feel c-spine precautions are necessary, strongly recommend it and if the pt refuses, simply document it and let the receiving hospital staff know. Competent adults get to make the decisions about their care, even if it is not in their best interest.

I didnt think of it until I asked the doctor after he stated to the truama center that the pt walked out of the ambulance. My question to the doctor was " Is there something you suggest I could have done more?" His actual answer was "other than using brute force-no, document document document."
I would never ever do this to my patient- I was seeing in there were emt's out there convinced backboards need to "always" be used when the possibility of needing one is there.
Plus I like talking about this stuff. Am I innapropriate?

 

[EMS Patient Care Advocate]

I agree with with strongly suggesting the c-spine precautions. Maybe suggest once more after pain meds. Document accordingly.

yes, and again after the hospital provided RSI. It was implied at that point for transfer

 

[usafmedic45]

Patient did have distracting injury/Pain so you assault concern has a conflict.

Being distracted doesn't excuse the legal right to self-determination. Just chart it and deal with it as best you can. Keep in mind that forcibly restraining someone is more likely to displace an otherwise stable spinal fracture than letting the person just sit there. I say stable because if it weren't stable, the patient would likely know about it already and/or be dead because of it.

 

[usafmedic45]

His actual answer was "other than using brute force-no, document document document."
I would never ever do this to my patient- I was seeing in there were emt's out there convinced backboards need to "always" be used when the possibility of needing one is there.
Plus I like talking about this stuff. Am I innapropriate?

It's not inappropriate per se, but it does get kind of tiresome when we have debates over rather simplistic things.