Replies to This Discussion

Permalink Reply by Beth on February 2, 2008 at 1:00pm

Who cares about the money? This is about the parents and the pt. The parents didn't feel as if they could handle this and REQUESTED transport. It is not our job to question why. It is our job to provide the best service for the pt. and family. What if the site of blood made the parents sick and they passed out while driving then you would be dealing with 3+ pts. and not just the kid.

You did right by going to your officer. Just make sure you doccument everything to CYA. In VA you have 7 years to file a lawsuit.

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Permalink Reply by ILDisasterEMT on February 2, 2008 at 2:22pm

I'm sorry, unless I missed it, you werent in charge of the call either. Anyone who says that they would keep their mouth shut so nobody would drop a dime on them when they screwed up deserves not to be in EMS. Period. Its a wrong-headed philosophy and it gets people hurt.

Second, if you would like to start slinging around name calling when I wasnt even talking to you, thats fine and I would be happy to oblige but we can take it to PM.

Yes. Deterring someone from seeking medical attention or trying to get out of providing it yourself does make you reckless and lazy and derelict in your duties and very possibly negligent. Its not poor public relations, its simply poor medical judgment.

Now since you have decided that you would like to call names here, let me tell you about my medical background and why I made the call I did about this scenario. Before I became an EMT I spent a year studying anatomy and physiology and then I spent a year studying the physio-kinetics of traumatic injury (otherwise known as traumatology) at the graduate clinical level along with trauma diagnostics and assessment. So...that being said, I know I am just a dumb old EMT and you are a paragod, but lets examine this in the way you should have in the first couple weeks of paramedic school.

1. This child fell from a standing position onto a surface sufficiently rigid and unyielding enough to lacerate his chin. We don't know if the lac ended up requiring suturing, but if it did, that, by definition, indicates a significant MOI.

2. Last time I checked, the chin is part of the mandible which is attached to the rest of the skull by tendons and muscles at the point of the mandibular condyle. Which means that any kinetic force transmitted through the mandible will be transmitted to the maxillary skull, the zygomatic processes and the rest of the skull. I used to work with a lot of boxers and MMA fighters so I know that falling from a standing height and hitting your chin is roughly equivalent in force-pound ratio to getting punched on the chin with a relatively hefty blow, meaning that the force exerted is between 300 and 500 pounds.

3. Given that information, and the fact that it takes less than 10 pounds of force to the skull to create a shock wave which transmits to the cervical spine, we can also extrapolate that there was some shock to the cervical spine as well as to the dendrobian process (that nifty little spike of bone between C1 and C2 that keeps them in line and when broken or pulled out of alignment causes a hangman's fracture).

4. Since we dont have x-ray or other imagine equipment in the field, we must necessarily use our knowledge of anatomy and physiology as well as the kinetics of injury. Basically (in extremely simple terms) it means that a shot to the chin causes a shock to the skull which causes a shock to the spine.

5. Any EMT-B student on about his third day of class can tell you that a fall which causes shock to the head (ie the head is hit against a hard surface like concrete, the edge of a coffee table, etc) is considered a significant mechanism of injury. We also know that a significant mechanism involving the head, face and or neck brings in the protocol of placing the patient in head blocks, and appropriately fitted c-spine MRD (motion restriction device) all of which is placed with the patient on a rigid long board to which the patient is strapped with his forehead and chin being secured last in case of emesis, which is a distinct possibility with any blow to the head (or chin as certain paramedics see it). Remember, when you fall from a standing height and hit your chin, you cannot help but also hit your head creating the above described (and I think fairly clearly and simply described) shock to the c-spine.

6. In patients who strike their heads, it is extremely common for them to exhibit no symptomology whatsoever of a head or neck trauma for several hours or even up to 24 or 48 hours. So the question you have to ask yourself is, do you feel lucky. Well, do ya punk? (Sorry couldnt resist the Dirty Harry reference). Do you want to be lazy (and thats the only excuse) and not act with an abundance of caution which, after all is our job, and possible cause your patient much more serious injury ranging from a worsened contra coups injury (which he probably had in any case since most boxers who take it on the chin have some degree of contra coups trauma after every single fight...reference: Muhammed Ali who does not have Parkinson's Syndrome but rather Parkinsonian Syndrome from repeated blows to the head and the chin and face, which like in most people is connected to the head which also like most people is connected to the spine). Do you want to act out of that abundance of caution or do you want to just pawn you patient off on someone with no medical experience and hope for the best which is this case would be a child with no occult (ie hidden) injuries and you not getting dragged into court later for failing to do your job?

You are correct, I was not in charge of the call. But being as this is an open forum and the call was referenced and last time I checked we still have freedom of speech (thanks to the fact that old "W" cant run for a third term) I am free to comment as I see fit. Its not that its not a good idea to talk a patient or the person responsible for the patient out of transport, it is that its unethical. See, where i was trained, we dont just care for patients when it is convenient and we feel like driving across town to the ER, we care for them all the time. And we dont just care for them, we advocate for them which includes advocating to the best of our ability that they be turned over to a higher standard of care.

As for your experience that a fall from a standing height means a whack on the chin which you were apparently taught was not connected to the skull means only a chin laceration, let me relate a similar experience. In fact it was the very first trauma I worked as an EMT. 87 y/o female falls from a standing height at the bottom of a short flight of concrete stairs when exiting her home. As a result she had upon initial examination on scene (I was in the ER) a rather large LAC on her left cheek, possibly a slight zygomatic/orbital fracture and a laceration to the lateral corner of her left eye causing bleeding into the eye. She was fine for about 30 minutes. She then began to decompensate and her daughter called 911. The woman was rushed to the hospital code 3 due to the development of slurred speech and was determined to have a basilar skull fracture and 9 centimeter paronchimal brain bleed. After 5 hours in the trauma center, she died 8 hours later in intensive care. And all from a simple laceration on the cheek secondary to falling from a standing height.

And any patient who contacts 911 warrants a trip to the hospital. See, I dont believe in BS calls. Its not part of my medical or EMS vocabulary. Im guessing you do. So yeah, if it means advocating for patient care, Im willing to be a jerk, but from your attitude, Im guessing I wouldnt be the only one.

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Permalink Reply by Art "ChiefReason" Goodrich on February 2, 2008 at 7:59pm

Can anyone who are now at each other's throat over this verify the "factual" content of the original post?
No; I'm not saying that they aren't true, nor am I believing that they are.
We now have people who don't know each other slugging it out over what sounds to me like someone stirring the pot.
These types of issues should be submitted to us in the "hypothetical" for a couple of reasons: 1) It keeps the poster from answering to another member of their service for "airing dirty laundry" and happens to see it here and 2) You will hopefully get an answer to your problem without exposing you or your service to undue public ridicule or even legal action.
What I have found when someone doesn't exhaust all of their internal steps for resolution, they go on a discussion board because they want that ONE person who agrees with them. And often, they will fashion the post to elicit the response that they are looking for.
So, before you people become "mortal enemies", make sure that you aren't being sucked in by someone that you only think you know from their post.
Now; I'll butt out.
Resume play.
TCSS.
Art

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Permalink Reply by JASON WURSTER on February 2, 2008 at 8:14pm

well it seems like you did the right steps to begin with. you notified your supervisor and told the other paramedic that you felt he was wrong. i would then write a completed incident report(make copies and label them)and send them to the education or human resources department of your squad and advise them of your situation. if that doesn't work then go and have a meeting with ems director and the county oes coordinator . and if always that doesn't work go to the state office of ems and make a formal complaint. but the one major thing is to have it all down in documentation. good luck

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Permalink Reply by Art "ChiefReason" Goodrich on February 2, 2008 at 8:47pm

And you are a reasonable person, Tom.
All I was saying was that this should have been one of those "I have a 'friend' who has this problem..."
Funny thing is that I recall a couple of times over at another website where someone aired their department's dirty laundry, not realizing that other members of their department was reading it and they had a very short but colorful stint in the forums.
Many use that "the opinions expressed are mine" disclaimer and I agree with that. But THAT all changes when you go public with an alleged transgression committed by someone on your fire department or ambulance squad and wish to share it with the rest of the fire community. I have certainly lobbied for others' opinions on a range of topics, but I would never-repeat; NEVER-go on a public forum with internal fire department business. How can you even use it as a learning tool?
The ONLY thing this discussion has taught me AGAIN is that it isn't wise to raise key, internal department business in a public forum.
But then, we wouldn't have all of this pithy commentary, would we?
Tuck and roll.

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Permalink Reply by Capkurt on February 2, 2008 at 9:47pm

What ever happened to common sense and using our heads instead of dogmatic rules like "Every head injury gets a c-collar and longboard". Doesn't anyone treat the patient anymore? It sounds like all this was a taxi ride since the Pt. was walking out to the ambulance on his own power.

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Permalink Reply by Joe Stoltz on February 2, 2008 at 10:30pm

Common sense is what the parents should have used. Assuming that the story was factual, the parents missed the opportunity to just take the kid to the ER themselves or maybe call the doctor. Which is what my parents would have done when I was young.

Once they called 911, the EMS crew has to come and apply the "dogmatic rules", a.k.a. protocols and treat the patient accordingly. New York State protocols dictate spinal immobilization for head injuries; if the person is erect and walking around a standing take-down onto a backboard is used.

The medic in the story used common sense, but using protocol would have covered his ass if things went wrong with the patient. Following the protocol would have been the best way to treat the patient, IMHO.

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Permalink Reply by Dan Hoey on February 2, 2008 at 11:41pm

I spent 14 yrs working in one of the poorest cities in the country and we did get abused by taxi seekers who needed a ride I cant tell you how many times I watched people get off my stretcher and walk out the other door to go to a clinic appt that they needed a ride to, with that said I would never refuse to transport thats a bad habit looking for refusals This will get you one day in the end.
The next part is your partner, well its so important to have trust, this is a two way street yes you should report anything you feel was dangerous and unsafe for you or your patient but also you need to make sure they have trust in you to not go running to some one for every little thing. Trying to talk to them was great first step and I would have told them straight out next time they go or I go take your pick but they tell you in school to report everything and trust me this will make you have a short career or make you a supervisor..lol..remember you need to earn trust and faith you did the right thing you reported up the chain the next step is theirs let them do it.

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Permalink Reply by ILDisasterEMT on February 3, 2008 at 12:49am

I was simply going to add in regard to the idea that an MOI of smacking ones head must necessarily make us suspect of cervical spine trauma and that I have seen one physician come in, touch the patients chest, the sides of their neck and their throat and say "does that hurt" and take the collar off. Another physician comes in, orders a study and finds a fracture. There is one and only one way (unless you have xray vision) to rule out spinal injury and that is with imaging, preferably and MRI since most folks in an ER couldnt take a decent xray to save their souls. Point tenderness of a lack of neuropathy or diminished sensation Also, vertebral hairline fractures are often missed on standard film xrays. One of the first thing taught in traumatology and trauma diagnostics is that a person who comes in with a collar gets to take that collar off and keep it off when and only when they have been studying by imaging. Simply because many doctors cant be bothered, doesnt mean its not the case. And after all, thats what the original post was about. Someone not wanting to be bothered. A paramedic or EMT with two active brain cells doesnt pawn the transport of their patient off on a civilian. This is what we try to talk them out of one we are on scene.

My general rule when someone says we can rule out that injury is to ask how? Sure, you can say someone may or may not have spinal cord injury by using the Dolls Eye test, buts its not definitive.

Back to your regularly scheduled program: we DONT talk people out of ambulance transport and it has nothing to do with money because studies show that in excess of 50% of people dont pay their little ambulance bills anyway. That being said...if the child had cut his hand on a broken glass and the lac were on his palm, who really cares who transports him though its still unethical to pawn it off on the parents. But when the lac is maxillo-facial, the possibility of head and spinal injury exists and one would think that this non-transporting medic would have taken this into account.

Just out of curiosity, if the same child had fallen from a standing height and hit the back of his head on the pavement causing a lac, would that, in your judgement, warrant collar and board.

As for the Indonesia, there are also parts of that country that use their hands as toilet paper. Neither practice is medically sound. I wasnt aware that the most medically advanced country in the world now based its protocols on third world Asian countries.

No harm no foul.

YMMV.

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Permalink Reply by Art "ChiefReason" Goodrich on February 3, 2008 at 12:25pm

Tom:
I can tell that one of the reasons we have lost our reasonableness is because of "potential" litigation.
I go to a FD trustees seminar every year and every year, we have an attorney there that tells us that everything that we do has the potential for lawsuit. Everything. Do we just pack up and stay home? NO! We go about our business, use our training, make our best decisions, hope for the best outcome based on our interventions and leave the rest to the sh*thouse lawyers in our communities and the real ones who chase the ambulance.
As a trustee, I am NOT going to be paralyzed by the fear that we may be sued. If or when that happens, it will only be for one reason and one reason only: money. Oh; the litigant will tell you it isn't about the money, but if it isn't then they are doing it during that "anger" part of their grieving process. THEY expect us to be super human with X-ray vision. There are no expectations of them. Just ask them.
Keep in mind, this is just my opinion.
TCSS.
Art

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