Responded off duty... Looking for critique

[Mattyirie]

Hey all,

Responded to a patient this afternoon while going to class and i am looking for any critiques. I will try to be as descriptive as possible.

The scenario:
Walking on campus when i happened upon a young female lying left lateral on the pavement with about 5 bystanders. General impression from a distance was that no trained provider was on scene so i approached. Coming up i immediately asked if 911 had been called and identified myself to the patient as an emt. The patient and bystanders stated she had fallen off her bike and the patient was not wearing a helmet. I didnt see any life threats and noted that the patient was slightly tachypnic (splinting from ABD pain?), guarding her right costal margin and crying. No apparent cognitive deficits from her responses and she stated no neck or back pain upon inquery. After this i backed off and waited with her until ems arrived. I did not continue an assessment, i did not touch the patient and left her in her assumed position of comfort.

Personal commentary:
This didnt go 100% smoothly as i always get this catacholamine dump in "emergency" situations even if there really is no emergency which i attribute to being green and i tend to stumble a bit and not think as clearly as i do when reevaluating the scenario or what have you. Is this common? Does it reduce as more experience is gained in the field?

I chose not to move the patient because while she did sustain injury to her ribs, i have read articles discussing the position of comfort that patients can assume post injury and whether or not to move them. I thought this was appropriate here due to the absence of life threats demanding immediate intervention. I also felt it important to leave the patient and scene as i found it (in this case) so ems can get a full picture.

I did not thoroughly assess the patient because:
A: i had no tools to do so (except pulse and resp)
B: why do an assessment when ems is going to complete a thorough head to toe anyways? And when they move her it can be on a spine board or gurney and she can be transported.

So what else could/should i have done?

 

[abckidsmom]

If I came upon this girl, I would have helped her be still and wait for the help to get there, and doing what I could to help her calm down.

As a bystander, I do not switch into medic mode unless there are obvious life threats that I can help with without tools.

 

[Medic Tim]

you did more than most would have. I personally would not have identified myself as an EMT unless I had to. besides that anything you do will be to protect the pt or relay to the oncoming ambulance. gcs, meds, allergies, pmh, etc.

the more experience you get the less rushed you will feel.

 

[EpiEMS]

...and the patient was not wearing a helmet

I see this all the time on campus. I can't stand it. I guess it'll just take one TBI to change minds...?

 

[Mattyirie]

Thats a good point. It almost places both me and the patient in a different situation when i mention im an emt. The patient was fairly calm but i probably could have helped a bit more. What are your thoughts on this position of comfort idea? I have even read articles that say a case could be made for NOT moving the patient in suspected c spine injuries because they have assumed a position that gives them the most comfort and moving them may be more harmful, making a case for transporting the pt in that position where possible. A complex issue to say the least.

@Medic Tim:
What are your thoughts regarding these....thoughts?
I purposefully did not ask many questions because in this situation i felt it was better if working emts gathered that info first hand which i thought would decrease her work as she was already tachypnic and the emts could get right down to business. I could see though in a head injury, gathering that info asap would be pertinent.

 

[Medic Tim]

Thats a good point. It almost places both me and the patient in a different situation when i mention im an emt. The patient was fairly calm but i probably could have helped a bit more. What are your thoughts on this position of comfort idea? I have even read articles that say a case could be made for NOT moving the patient in suspected c spine injuries because they have assumed a position that gives them the most comfort and moving them may be more harmful, making a case for transporting the pt in that position where possible. A complex issue to say the least.

Pts will usually find a position of comfort or as close to it as they can. There are some areas using full body vacuum splints to immobilize pts in the position they are found in. A lot of services have spinal rule out as well making transport more comfortable for those that don't need a board.

 

[rwik123]

I'd only assess off duty if there a life threat or assume it's a more critical situation. You said she wasn't altered. Did you find out if she's CAO? Ask if she remembers falling, ever lost consciousness or knowingly hit her head. If she passes all those and has no head neck or back pain, just chat it up untill EMS arrives. PFA (psychological first aid) off duty is almost more important off duty because you lack resources.

 

[Handsome Robb]

So I'll play this from the other side.

If I were the patient I personally wouldn't want you moving me all around prior too arrival of EMS. That's just my opinion.

Now from your side, there's no reason to move her unless there's a immediate life threat. You cite c-spine precautions which is fair however she did deny head/neck/back pain per your OP and per NEXUS does not require spinal motion restriction. There's no reason to move her.

You did just fine. Like someone else said I personally wouldn't have ID'd myself as an EMT but that's your prerogative. You could have asked history, allergies, meds but like you said the arriving crew is probably going to ignore most of what you say unless they know you personally.

Responding off duty is a touchy subject so I'll leave my post short.

Side note: if she was hott you should have nabbed a phone number "to follow up and make sure she was ok" h34r:

 

[Mattyirie]

@rwik123:
I will admit here that i did not dive into the previous events deeply enough to completely rule out head injury. The bystanders had said that she had just fallen (within 5 minutes as witnessed by 2 of the bystanders) and did not mention that she had lost consciousness. From all cues i was picking up she wasnt groggy or confused and knew what happened so i assumed she remembered falling off of her bike. Without the helmet on, those would have been very pertinent questions to ask. Thanks!

 

[EFDUnit823]

As a disclaimer, (maybe different outside of Indiana) one cannot fully practice as an EMT without Medical Direction. Of course, members of voluntary organizations have a unique ability to activate their medical direction as long as they are within their area.

I have found in EMS, even though we swim in a world of protocols we generally work in the world of grey. You know, that spot in between black and white! As long as my actions were justified, use of more necessarily “advanced” interventions (Basic level of course) would not be frowned upon outside of medical direction. But, I stray from your post.

It is difficult to critique the situation without assessing the patient first hand. The first thing I thought of when reading your post was controlling C-Spine and any possible brain injuries e.g. coup contrecoup. I would like to note that I have witnessed a few expire from similar accidents, luck of the draw I guess. However, these experiences have conditioned me to not underestimate things I want to consider insignificant. Error on the side of caution, as it is always easier to explain why you over treated instead of under treated. With that said, there are several things you can do without the tools of the trade.

* Establish baselines for incoming EMS personnel. A/O, GCS, pulse, RR, pain scale, etc… This could be invaluable if there happens to be any significant changes between the time you established the baseline and the time EMS arrives on scene.

* Consider doing a SAMPLE. Let’s just say for a minute that you happen to be a [censored] magnate and instead of having a patient with minor injuries, they will soon crash due to some internal injury…leaving you the last person they spoke to. Allergies, last oral intake, Hx, etc… could be critical information to give a Paramedic who is about to assume care of an unresponsive patient.

* A little trick to establish PERRL during the day. Use your hands to shade the eyes. Remove one at a time to determine responsiveness.

Regardless of the level of EMT, patient assessment is the most fundamental skill we must master. You can do an almost complete assessment with nothing but your eyes, hands, and brain. Add a stethoscope, BP Cuff, trauma sheers, and a pin light then there really shouldn’t be any reason not to complete a trauma/medical assessment.

I found this website some time ago, and like to refer back to it time to time…mainly to break complacency. Hope it helps; http://www.emergencymedicaled.com/241Patient Assessment.htm

 

[ATrain]

EFD, off topic (my apologies to OP), but is that for Evansville Fire Department in your name?

 

[EFDUnit823]

EFD, off topic (my apologies to OP), but is that for Evansville Fire Department in your name?

Ellettsville Fire Department (http://www.ellettsvillefire.org/). But, I do have some friends on Evansville Fire Department

 

[Melclin]

I've often thought about stumbling upon pts off the job and often hope it doesn't happen. In keeping with my nerdiness, I have a plan, and I've used it a couple of times to good effect.

1. I watch from the side lines until I establish an actual threat to life or until I can bugger off in good conscience knowing the person is fine and is just having a whinge.

2. I correct problems with their ABCs.

3. I may then, if drawn into the situation try and write down some clerical details to make life easier for the attending ambos who turn up while I have a chat to the idiot involved.

I've never moved beyond step one, which to my mind makes it a pretty good plan.

Stay out of the way as much as possible I reckon. Baring a direct threat to life and assuming nobody else is addressing those issues, I will work for free. Otherwise, there really isn't any reason for me to get involved other than to make myself look good, in which case I have a b**chen new pair of chinos that achieves that without my having to get involved with sick people I stumble across on my morning coffee run.

 

[Martyn]

you did more than most would have. I personally would not have identified myself as an EMT unless I had to. besides that anything you do will be to protect the pt or relay to the oncoming ambulance. gcs, meds, allergies, pmh, etc.

the more experience you get the less rushed you will feel.

Along these lines...I agree with what Tim says, you say you were on campus going to class, is that an EMT class? Are you actually an EMT? Sorry but no where in your profile does it say if you are actually qualified. If you are not then you should not have stated that you are an EMT. That is just like saying to a bank robber 'Put the gun down I am a deputy sherriff!!!' On the other hand, sounds like you did the right thing. Most of the in street/off duty incidents I have come across there is nothing to do except keep the person calm and wait 911 to arrive.

 

[Akulahawk]

My thinking on this goes a couple of different ways.These are not mutually exclusive, in my opinion. On the one hand if you have your five basic senses and a well-informed brain, you can pretty much do a full assessment on the patient without needing very many extra tools, if any. As ABC kids mom says, add a pen light, blood pressure cuff, and a stethoscope, and I too do not see how a full trauma assessment could not be completed, absent some imaging. The other thing that I see is that I really won't get too involved in emergencies that do not involve family. There are times that I do get involved, but when I do I want to function at the highest level I possibly can. Off duty, this means blending my knowledge, skills and abilities from two separate or three separate disciplines of patient care, the full scope of all of them is not available to me at the same time while I'm working on the job, only one at a time.

In this particular instance, I think I would most likely attempt to keep the patient/victim in a relatively still position, allowing the patient to remain in their position of comfort. I would try to gather as much information as possible so that I can pass that information on to the responding crew simply because if the patient becomes unconscious, the patient will not be able to participate in their care.

To the 0P, there is a lot that needs to be learned and refined when it comes to the subtleties of patient assessments. These days, unless I am doing a full assessment because I am directed to, I find that my assessments are much more focused in on figuring out what broke so that I can fix it, try to fix it, or get the patient to someone who can.

When it comes to jumping in and helping out in potential emergent situations, my advice is to tread very lightly, and do what is only absolutely necessary, and then fade into the woodwork. By restricting yourself to what is absolutely necessary, you avoid having further issues farther on down the line, even though you may have civil immunity through Good Samaritan laws.

 

[the_negro_puppy]

You did fine, but as others said I probably wouldnt have announced yourself as an EMT.

I'm yet to come across anything, but i'd only intervene in a life threatening situation i.e CPR, serious car accident (if safe) etc.

If an adult falls of a bike and breaks their wrist, they dont need my help.

 

[bstone]

I see this all the time on campus. I can't stand it. I guess it'll just take one TBI to change minds...?

A local guy was knocked off his bike and died of a head injury about a month ago. No helmet. Doesn't seem to encourage people to ride with a helmet. I ride every day and don't go a single inch without a helmet.

 

[mycrofft]

Sounds perfect to me.

Helmet sidebar: responded to a guy hit a bakery truck on his moped w/o helmet, leaked CSF onto the tarmac street. I took a running class next semester and ran over that stain for about ten weeks before it became indistinguishable.

 

[samiam]

That was a very descriptive/ legit vocabulary of that incident...Just wait until you have been working for a few years and it changes to... FDGB, Breathin Heavy and Didnt do :censored::censored::censored::censored:..

 

[tnoye1337]

Side note: if she was hott you should have nabbed a phone number "to follow up and make sure she was ok" h34r:

Slick