BLS dispatched for man down no ALS assigned in initial dispatch.
AOS to a 72 y/o male on the ground. Upon initial patient contact patent is CA&Ox4 yet seems sluggish in answering questions. Patient relates he does not remember falling. RP on location said he witnessed the man walking down the street and collapses, by the time he made his way over to the patient is alert. Patient presents w/ minor abrasion above (L) eye & abrasion on (L) hand. ALS requested via protocol due to the LOC. Patient HX: Diabetes & HTN Unknown Meds NKDA. Loaded into truck & ALS AOS. BGL: 134 BP:122:84 Resp:16 SPO2:98 HR:70. Stroke scale preformed yielded bilaterally equal in all fields however could not assess speech due to heavy asian accent. Patient attempts to deny however we talk him into going to the closest facility (4 minutes away) which is non specialty. ALS does a 4 lead which is unremarkable, establishes IV access and transport is initiated. . . Find out on a later call patent was transported to a speciality hospital for a bleed...
My Clinical director flagged the chart for not providing spinal immobilization. They related although there was only minor trauma noted upon the assessment (2 small abrasions) that it'd be impossible to determine if the patient fell suffered the trauma & had the LOC or if the patient suffered a syncopal episode and then trauma. What are your thoughts on providing C-Spine to this patient whom denies Head/Neck/Back pain and only complaint is us talking him into going to the ED.
AOS to a 72 y/o male on the ground. Upon initial patient contact patent is CA&Ox4 yet seems sluggish in answering questions. Patient relates he does not remember falling. RP on location said he witnessed the man walking down the street and collapses, by the time he made his way over to the patient is alert. Patient presents w/ minor abrasion above (L) eye & abrasion on (L) hand. ALS requested via protocol due to the LOC. Patient HX: Diabetes & HTN Unknown Meds NKDA. Loaded into truck & ALS AOS. BGL: 134 BP:122:84 Resp:16 SPO2:98 HR:70. Stroke scale preformed yielded bilaterally equal in all fields however could not assess speech due to heavy asian accent. Patient attempts to deny however we talk him into going to the closest facility (4 minutes away) which is non specialty. ALS does a 4 lead which is unremarkable, establishes IV access and transport is initiated. . . Find out on a later call patent was transported to a speciality hospital for a bleed...
My Clinical director flagged the chart for not providing spinal immobilization. They related although there was only minor trauma noted upon the assessment (2 small abrasions) that it'd be impossible to determine if the patient fell suffered the trauma & had the LOC or if the patient suffered a syncopal episode and then trauma. What are your thoughts on providing C-Spine to this patient whom denies Head/Neck/Back pain and only complaint is us talking him into going to the ED.
