This Kind of Bothered Me

[Ezio]

I did a ride along last night (1500-2300) that was quit upsetting in some respects.

I was doing it with a different company then the one I was going to school and doing ride outs with (all I needed was one more trauma contact) and this station was known for a high volume of trauma patients.

The call was a pediatric patient who had jumped off a balcony (5ft off the ground) and had broken his arm. The kid was A&Ox4, BP 142/94 (understandable) and R was 22. What bothered me was that the medics (it was a two paramedic truck, I am a basic student) did not notice it was an open fracture until a nurse pointed it out at the hospital. The kid had been holding an ice pack over the broken skin. There was blood on his hand, the medics didn't even notice that.

I thought that during both assessments (primary or detailed) that someone would have taken a good look at the whole affected area (arm was deformed).

Am I making a mountain of a mole hill or is this really an issue?

 

[Porta]

I did a ride along last night (1500-2300) that was quit upsetting in some respects.

I was doing it with a different company then the one I was going to school and doing ride outs with (all I needed was one more trauma contact) and this station was known for a high volume of trauma patients.

The call was a pediatric patient who had jumped off a balcony (5ft off the ground) and had broken his arm. The kid was A&Ox4, BP 142/94 (understandable) and R was 22. What bothered me was that the medics (it was a two paramedic truck, I am a basic student) did not notice it was an open fracture until a nurse pointed it out at the hospital. The kid had been holding an ice pack over the broken skin. There was blood on his hand, the medics didn't even notice that.

I thought that during both assessments (primary or detailed) that someone would have taken a good look at the whole affected area (arm was deformed).

Am I making a mountain of a mole hill or is this really an issue?

Did you know the kid had an open fracture prior to the nurse pointing it out?

 

[Ezio]

Did you know the kid had an open fracture prior to the nurse pointing it out?

I saw the blood on his hand and pointed it out to them. We just thought the blood was from a cut (he played football so he had all sorts of abrasions on his arms). I was getting info from the uncle and a neighbor while they were working on him.

 

[Porta]

For you, use it as a learning experience. For the Medics, they were sloppy and should have removed the ice pack if there was obvious gross deformity.

How did they splint if the ice pack was still on his arm?

 

[Ezio]

For you, use it as a learning experience. For the Medics, they were sloppy and should have removed the ice pack if there was obvious gross deformity.

How did they splint if the ice pack was still on his arm?

They used an air splint and cravat, all over the ice pack.

There where other issues with this crew:
1. Their truck looked like a war zone. Trash all over the place, equipment not put away (gloucometer was left on the seat). Blood on the door. Only one box of gloves, with two pair left. No other boxes on the truck that I could see.
2. Before we left the scene they put in an IV line. First time they collapsed his vein and the when they finally got it in, more blood then I've ever seen came out (enough to make a half dollar sized pool on the floor).

I'm not really knowledgeable about IV's but that seemed a little off.

 

[Porta]

They used an air splint and cravat, all over the ice pack.

There where other issues with this crew:
1. Their truck looked like a war zone. Trash all over the place, equipment not put away (gloucometer was left on the seat). Blood on the door. Only one box of gloves, with two pair left. No other boxes on the truck that I could see.
2. Before we left the scene they put in an IV line. First time they collapsed his vein and the when they finally got it in, more blood then I've ever seen came out (enough to make a half dollar sized pool on the floor).

I'm not really knowledgeable about IV's but that seemed a little off.

Yes, totally use this as a learning experience. Good for you for realizing this wasn't a well handled call.

 

[Jon]

Well, I'm not sure how it works in your neck of the woods, but when students are riding with me, they preform their own assessments.

Sounds like you got a dunce crew, based on what you say.
I will say that sometimes you'll find great medics that are less than polished, and are working in what appears to be a mess - because it "works" for them. Much of the time, it just means the medic is lazy.

 

[Ezio]

Well, I'm not sure how it works in your neck of the woods, but when students are riding with me, they preform their own assessments.

Sounds like you got a dunce crew, based on what you say.
I will say that sometimes you'll find great medics that are less than polished, and are working in what appears to be a mess - because it "works" for them. Much of the time, it just means the medic is lazy.

Usually the let me once they confirm the patient is stable. But since I had never ridden with this company/crew before, I was unsure what they would allow me to do. At times it felt like they really didn't want me there. Asking questions was like pulling teeth.

 

[Veneficus]

Not defending the medics, but most providers do not know an open fx when they see one.

In most of the textbooks and on the internet, they usually picture the most extreme cases.

More commonly all it appears to be is a small cut. It is easy to overlook or misdiagnose to those not expert in trauma.

As a general rule, EMS doesn't know $**t about trauma.

It is perhaps one ofthe most complex topics in medicine and to make it easy and managable, medics are taught about 1/3 of 1/2. Usually not in a very organized way because EMS involvement is a rather small part.

 

[mycrofft]

V beat me to it. An open fracture will sometimes retract back into the wound, especially sub-ungual ones.
PLUS, securing on ice with a bandage is asking for trouble. Especially a little kid. Hope ther was no freezing going on.

Thatw as a tiny amount of blood versus some I've seen.

 

[Chimpie]

V beat me to it. An open fracture will sometimes retract back into the wound, especially sub-ungual ones.

Yep. My sister in law broke both her radius and ulna. Both punctured the skin and retracted. She's got skills.

 

[EMSrush]

Is it possible that the fx was a closed fx initially, and became an open fx at some point during treatment or transport?

 

[TransportJockey]

Not defending the medics, but most providers do not know an open fx when they see one.

In most of the textbooks and on the internet, they usually picture the most extreme cases.

More commonly all it appears to be is a small cut. It is easy to overlook or misdiagnose to those not expert in trauma.

As a general rule, EMS doesn't know $**t about trauma.

It is perhaps one ofthe most complex topics in medicine and to make it easy and managable, medics are taught about 1/3 of 1/2. Usually not in a very organized way because EMS involvement is a rather small part.

This. I've always been taught, by ER RNs and MDs BTW, that if there is broken skin on an extremity with deformity, it's treated as an open fx until proven otherwise. Hasn't steered me wrong yet.

 

[Ezio]

Is it possible that the fx was a closed fx initially, and became an open fx at some point during treatment or transport?

I don't think so. There was a small amount of blood on the kids hand when we got there and the medic never removed the ice pack the kid was holding against his arm.

I talked to our program coordinator about this and she said it is normal to see problems like this with this particular company.

 

[Handsome Robb]

2. Before we left the scene they put in an IV line. First time they collapsed his vein and the when they finally got it in, more blood then I've ever seen came out (enough to make a half dollar sized pool on the floor).

I'll let you in on a little secret. Even us paragods miss IVs or botch tamponade from time to time. Especially on a little tyke considering it's not something all that common.

A half dollar pool of blood? Call the blood bank! alright I'm done being an ***.

Sounds like you had a bad experience with a questionable crew (from teh info provided). At least you got your trauma contact.

 

[epipusher]

give it time, you'll have worse things to worry about.

 

[med109]

I would say use it as a learning experience. I bet everytime you have a possible fracture you make sure to check each and every one of them because of this call. Your also sure to do a more thorough assessment on all your patients because of this call. You recognized alot of issues with organization, supplies, and the lack of a clean patient area. Use those things to keep your areas clean and organized.

Making a big stink about it really isn't going to accomplish anything. You may get a medic in trouble who may have been simply having an off day. Other than that not much will happen. That medic isn't going to call you on the phone and say "thanks for pointing out that fracture to my boss, I learned alot from you doing that!" The nurse pointed it out, and chances are the medic is kicking himself for it, we are always the hardest on ourselves. All you would accomplish is everyone thinking you are a know it all newbie that tattles on his crew members, (I am not saying you are that, I am simply pointing out how alot of people react to things like this). Then you lose the trust of anyone you work with.

As far as the blood goes, that really isn't that big of a deal. I have seen ALOT more blood then that spilled during an IV, and I have spilled alot more then that myself. I have had nurses spill alot more then that starting a line on me. Remember blood spreads, so a little bit of spilled blood can look like alot really darn quick. Chances are you will see a shocking amount of blood spilled during an IV very soon, and that dollar sized amount will be small potatoes.

 

[Handsome Robb]

Remember blood spreads, so a little bit of spilled blood can look like alot really darn quick.

Good post all around but this is a good thing for newbies to learn. Next time you get a chance squirt a 10cc flush out on a table or hard floor and see how big of a puddle it makes.

 

[mycrofft]

Is it possible that the fx was a closed fx initially, and became an open fx at some point during treatment or transport?

Unlikely. This was brought up recently, and if I remember my response, it was that broken bone isn't like a busted ash broomstick that becomes a needle-sharp hard lance. If the bone ends are right under the skin and the pt is severely manhandled, then maybe, but not likely.

Riddle me this: enough force is initially suffered that skin and muscle etc are opened by the external force, but the the bone is fractured but never erupted. Or, say, it didn't fracture but was exposed. (Seen it on biceps/humeri of the occupants of cars hit from the same side as the injured occupant). Treat as open or closed? Are your protocols different?