Another head shaker

[NC-EMT]

I am standing at the grocery store today when an elderly man comes barreling towards me into the parking lot (MI?), taking out 3 barricades in his path. Airbags deploy, he hits a wall, tires still spinning. Can't tell if his head or the bag smashed the windshield. I call dispatch on my radio because I was off duty. Bystanders were screaming "take him out before the car explodes," (too many movies). I am trying to keep them back and tell them not to touch him. Bleeding from the nose, I assume head trauma. Three ambulance services arrive, AMR, Forsyth Rescue squad and Forsyth EMS. AMR does absolutely nothing to assist but instead decides to "assist" the PD in traffic by blocking the parking lot until County EMS arrives. I stand there and watch as F-EMS walks up to the gentleman and asks him if he feels any pain, he doesn't respond and gets agitated (that head trauma thing again hmm?), they tell him to move his head (!) he refuses to do so..the EMT-P has the nerve to push his head back (no collar) and forces him to get out of the car unassisted and walk to the ambulance. So much for protocol and professionalism.

[Les.H]

Oooppps.

It's times like these that a indepth debrief is required to identify any problems that may have arisen out of an incident. The problem is that the guilty normally don't want them because they think everything is great and there's nothing to fuss about.

How many personnel have heard someone say "Who needs training anyway, I know what I am doing".

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Kindest regards & keep safe,

Sprinkle (UK)

[NCRSQ751]

I was not present on this particular incident and I am not with FCEMS, so I can't say whether what was done was right or wrong.

I will say that you may or may not be aware that FCEMS has a new progressive protocol for clearing C-Spine in the field. They had special training on the subject and have strict protocol to follow and there is some kind of examination and manipulation of the neck involved (like you see the docs do in the ED). What you witnessed may have been that.

The only way to know is to have a critique as has been suggested. If you wish to do so, contact FCEMS administration directly (336)727-2404. You can request a review of the case with the crew and/or training officer.

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Susan Bednar
Captain - Forsyth Rescue
North Carolina Strike Force 1

[NC-EMT]

I was not aware of this procedure and was never taught that a patient with possible head/neck injury should be pushed around and forced out of the vehicle unassisted without some sort of immobilization, especially an older gentleman. I am curious about the benefits of this C/Spine technique and what advantages it has over a collar prior to extraction. What I saw did not look like any sort of field or clinical diagnostic of any sort, rather a crude push to the man's forehead when he refused to move it on his own. I am going to leave FC-EMS alone. No need to stir up anything. I am curious about your thoughts on our county EMS system. I am sure you heard AMR is out of here in a few months.
BTW Susan, keep up the good work, you guys at the rescue squad do a great job. http://www.firehouse.com/interactive/boards/smile.gif



[This message has been edited by NC-EMT (edited May 31, 2000).]

[This message has been edited by NC-EMT (edited May 31, 2000).]

[M G]

WOW, thats wild..we have x-ray vison in the field now!! What will they come up with next? Where can I get trained to use x-ray vision?

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The information presented herin is simply my opinion and does not represent the opinion or view of my employer(s) or any department/agency to which I belong.

[firejunkie99]

In regards to Susan's reply with all due regard; I am familiar with the c-spine rule out protocol she is talking about, because we have the same protocol in our EMS system.
But our protocol states, that if there is any trauma to the face/head/or neck, or the pt complains of pain, then the pt is to be immobilized on a LSB with cervical immobilization, fully packaged. The writer stated the pt did have trauma to the head, blood coming from the face, therefore this protocol was ruled out. There is no excuse for this kind of pt treatment. Why did the paramedic do this? Who knows. Maybe the crew is burned out on the job......

Kevin Pirtle
Paramedic
IN




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[medic320]

I can't understand why anyone would want to clear C-spine in the field. Since when did ambulances have X-ray capabilities? That's one heck of a risk I am not willing to take. The same kind of protocol has been rumored about in our area. However, no medic I have spoken with is willing to practice that kind of protocol. It is also not part of our protocol to have a patient walk to an ambulance, especially after an MVA. Unless a patient meets PHTLS criteria for rapid extrication, all patients are collared, immobilized with a KED, and then extricated to a board with CID.
Walking a patient to an ambulance is simply laziness, and lack of professionalism. Our medical director would pull our orders for such a blatant disregard for quality patient care in this situation.
You are right, this is a head shaker.

[EMT-P]

I feel your pain NC-EMT. Our EMS system does not clear C-Spine in the field, nor do I have a high desire to do so at this time. By the way, Is it true that you rely on the patients complaint to help you clear C-Spine? For example, Does this hurt sir when I push here or here or here? Good, no step offs, no crepitus, no echymosis, OK the C-Spine is clear. But do you really trust what a head injury patient tells you? How many times have you all been on calls to a MVA and the patient repeats himself or herself about 20 times before you reach the ER due to a concussion.

To give you an example: I worked at this sporting event one day as a paramedic. This guy fell from a balcony about 15 feet. We went to help like good medics and he was very abusive, meaning that he did not want help. Called us every name in the book. Why I really do not know. We explained to him that he needed to wear the C-Collar for his own protection. He refused of course and signed a medical release. Two days after the accident his neck was stiff. You guessed it he broke his damn neck. He inturn tried to sue our EMS dept. Stating that we did not give the best care that we could. Go figure. Thank GOD for good record keeping, makes a great CYA!!

Just food for thought.

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Life, Death, We are the difference.

[This message has been edited by EMT-P (edited May 31, 2000).]

[NCRSQ751]

My point was not to defend, but to not judge and to suggest that steps be taken to fix the situation (via a critique). If something innapropriate was done, we aren't going to fix it in this forum - the only way to do it is to address it directly.

The only people who truly know what happened are those who were there. Since I was not, I don't presume to judge the medics or the protocol they have to work under. I agree that what was written here sounds somewhat suspect - but again I do not presume to Monday morning quarterback without knowing all the facts and hearing both sides.

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Susan Bednar
Captain - Forsyth Rescue
North Carolina Strike Force 1

[NC-EMT]

Susan was trying to give a possible explanation for what might have occurred at the scene with the pt. I respect her for giving her input into the matter, and like a responsible team captain, she would need to know all the facts before passing judgment. This is someone that I would indeed enjoy working under if I had the chance to. I was also not trying to implicate the County EMS but rather raise questions as to why this procedure was performed on a pt. with 'obvious?' head trauma by this one particular EMT. All I know is that I would have handled it differently and I was actually very scary to see what took place. Again, I want to thank Susan for her input into the matter.

[bob1350]

I guess I have to put my two cents worth in. I cannot believe that the EMS crew can get away with this total disregard for a patient who through obvious MOE should have C-spine immobilization. In our EMS system, we would have an enormous amount of expaining to do if we did something like this. Every patient in an MVA gets immobilized, collered, and do you guys back on right coast always have competing ambulance services showing up at calls?

[Paramark14]

Cross table c-spine x-ray with ALL seven vertebra visible, so until they put a tech and x-ray on my truck I'll be immobilizing pts. if they've suffered signifacant trauma (ie; MVA, fall, GSW). Call me old fashion I guess.

Mark
NREMTP
Indiana

[tigger]

I agree with the majority. It is NOT our place to diagnose, we are there to treat the symptoms. If a pt. shows ANY sign of head trauma/spine injury, FULL c-spine precautions should take place. (I say should, because I have been on scene, and witness AMR Paramedic disregard that.) I would rather protect when not needed, than wish I had after the fact.
I have a high respect for Paramedics, I plan to be one some day, but you know what they say, "Paramedics save lives, EMT's save Paramedics". http://www.firehouse.com/interactive/boards/biggrin.gif
Take care & be safe! http://www.firehouse.com/interactive/boards/smile.gif
tigger

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Pull to the Right for Sirens & Lights! ;)

[firemedic28]

under our protocols, we as paramedics are allowed to clear c-spine in the field...but we have to meet very stringent requirements to do this, and it must be clearly documented on the run sheet. Or else! The patient must be a & o x4, no LOC, no neck or back pain...lots of stuff.
As for the incident the writer wrote about at the grocery store, I too have seen poor EMS care by others (in my case it was actually a paramedic instructor)....I watched her and her emt allow a patient who had been hit by a minivan walk to the ambulance and climb up in the back and lay down on the stretcher...it was only then that the emt asked the paramedic, don't you think we should have backboarded him? My sentiments exactly...but by that time it was too late...and they chose to bring the patient into the hospital that way. Fortunately he was not significantly injured, but I felt the MOI was severe enough that he should have gotten the "full meal deal"...also because the guy had some positive menory loss of the events. But what could I really do at the time...I probably should have said more but I do not think it would have changed anything...I was the lowly EMTP student and she was an instructor in the course I was currently attending. I just made a promise to myself to use it as a learning experience...and to use it to make me better at my job.

Just my thoughts...
everyone stay safe out there.

Polimedic

[Trauma_Dog]

I am not defending the call in question, however I am defending spinal clearance. The facts and studies show that now only a small amount of patents that are in full c-spine are sent for x-ray,so I dont buy the "We dont have x-ray vision line". We have implemented this policy and it has been effect for 2 years with over 300 clearances with a 100% audit out of those pt only one was sent to x-ray and their c-spine was cleared.

I only asked a couple of things 1) look or ask the Doc how they clear c-spine, ask questions. 2) Sit down and take a look at spinal clearance protocols, they are not designed for the "slacker" to get away with not collar and boarding, they are designed for a specific target group of pts not those with a high index of trauma.

Spinal clearance has been around a long time overseas I has taken a while to get over here. I think if you sit down with the facts you just might change you mind a bit.

I am greatful that you have pride and concern for pt care, just want you to give spinal clearance a fair shake.

Just encase you were wondering, as you describe the pt, from the outset he would not have met the clearance policy, so backboard and c-collar were warrented.


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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[one_dm_gd_emt]

what kind of resource hospital allow there medics to clear c-spine in the field?! That is bizzarre and a lawsuit waiting to happen. I work for a private company once that a manager did that too, (they later did the c-spine protocol) and when he got to the hospital they found a fractured vert.! Hmm, couldnt you imaging what would happen if we all started doing that?! Needless to say i terminated my employment with that particular service following that incident and exposed them to the resource hospital, the owner of this service even tried to make the medics lie about the run report! In closing i dont feel that clearing the spine in the field is a good idea, this gentlemen had a fracture vert, and he walked alright, and could move his neck alright, what would happen if that would have caused the vert to go ahead and break?

[Sand Creek Lynn]

I'm not in the EMS portion of our department and have no medical training other than basic first aid. So I will not attempt to address the medical issue here.

But I do wonder about something. Given the possibility of this person having a spinal injury and the fact that NC-EMT was concerned enough to bring to this forum his doubts on the care provided why didn't you [NC-EMT] follow through the proper channels there at home before putting out in a public forum only one side of the facts.

And then write this in a later post:

"What I saw did not look like any sort of field or clinical diagnostic of any sort, rather a crude push to the man's forehead when he refused to move it on his own. I am going to What I saw did not look like any sort of field or clinical diagnostic of any sort, rather a crude push to the man's forehead when he refused to move it on his own. I am going to leave FC-EMS alone. No need to stir up anything."
Didn't you indeed risk "stirring up something" by putting this out to the public.

And why put it here and "leave FC-EMS alone."

If you had a concern take it to those involved before bringing it here.

I'm not trying to be hard on you but if I screwed up, AND I sure have, I'd like to have some one talk to me about it and get my side of the story before putting it on the net.

Food for thought.

I'd like to hear opinions.

Lynn

[JMP17]

I have a couple of comments, (1) Nc-EMT the picture you painted of this incident leaves me wondering. Do you have a DUTY TO ACT!! You wittnessed the mva and called it in on your radio to start EMS but stated nothing about performing any Pt. care. If you were so worried about Pt. care why did you not perform any. If nothing else you should have done an initial survey and been holding c-spine when EMS arrived and then turned your Pt. over to the responding R-2 . As for this field clearence of the c-spine depending on the MOI, Pt. assessment abilities of the tech.s this is questionable. I've seen volys do full c-spine on someone who hit a shopping cart in a parking lot( not to down volys, I'm one myself, But a creer NREMT with a paid service.) It comes down to experience and confidence in your assessment abilities. This only comes with many many many calls...

JMP17
Stay safe & take care of each other.
GOD hold our fallen HEROs

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Opinions expressed are mine and may not be those of my Dept.s

[This message has been edited by JMP17 (edited July 01, 2000).]

[E229Lt]

JMP17, I couldn't have said it better.

" I was off duty, so I called it in" end of incident.
You took no action ( other than a phone call) but critiqued the whole incident.

Worse yet, you post the identity of the units involved. In the future you should change the names to protect the " innocent until proven guilty"

Next time, provide !

[pyroknight]

I believe I remember reading a study in JEMS where the injury rate in one of the third world countries that didn't even know what a c-collar is was lower than in the industrialized world. I've heard (BELIEVE me, I'VE HEARD) the horror stories of the guy who was in the MVA and left AMA and 39.4 hours later turned his head to the right and dropped dead with a severed spinal cord, but COME ON PEOPLE. This is the EXCEPTION to the rule. These people almost always have mechanism. How many times have you strapped someone to a board that you KNEW deep in the innermost part of your little EMS soul couldn't POSSIBLY be injured? Didja like hearin' 'em whine all the way to the ER?
I'm not saying we shouldn't collar people, but do you really believe we should collar EVERYBODY? Apathetic burn-outs exist in every system and they won't do it right no matter how many protocols you write. I, for one, would just like to see those of us who take our profession seriously given all the tools we need to provide the highest level of patient care and patient comfort possible.
Life is a risk. Being in EMS is a risk. You'd take the risk to give a patient in pain a narcotic analgesic, right? (RISK) Why wouldn't you take the risk to forego the board for patient comfort?

[Trauma_Dog]

Amen brother, in five years from now it will all seem trivial. By the way, they thought the same thing when defibrilation was first used in EMS.

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Kent Simon
Paramedic Incharge
MCHD EMS,
Montgomery Co.,TX

[Libra]

Even here where I live, where we are aware that the training is very superficial, we do that, I think that in the field we must think the worst and act in consecuence, even if the "experience" or the new protocols say that it`s no necesary, anyway if we do our job rigth we can`t hurt the pt more. sometimes we forget that our job is protect the patient and don`t make the wounds worst, probably a few minutes uncomfortable but safe.

[JMP17]

This is getting a little nuts! OK of course we've all B&C'd someone we knew would be off the thing before we left the ED but are you willing to look your Medcontrol in the face and explain why you brought someone into the ED on a stretcher on whom rad. found a c-3 fx. Come on stop crying and do the job, if you want to be the MD go back to school.
PS Ive heard of Lead paramedics But, nothing personal but I think this whole Paramedic Incharge thing pumps your nads a little, just a thought Trauma-dog

Stay safe & DO NO HARM!!!!!
JMP17

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Opinions expressed are mine and may not be those of my Dept.s

[This message has been edited by JMP17 (edited July 07, 2000).]

[medic3401]

I am right there with pyroknight. I think alot of systems need to come to the 21st century and start giving patients the care and comfort they deserve. It is just plain nuts to use collars and boards on everyone involved in a mva.

By listening to lung sounds, percussing the chest and taking into consideration the MOI, I can "diagnose" a tension pneumo and in-turn treat it with needle decompression. In some parts of the country medics are taking an alive and breathing patient and using meds to paralyze every muscle in their body in order to secure an airway! There is a far greater chance of killing a live person with RSI than there is of killing someone by not boarding and collaring them. Why should I not be able to do a thorough neuro exam and clear someone's c-spine?

I feel it is a skill that should be performed by ALS providers, just the same as manual defib, IVs, Cricothyrotomies, etc. With the proper training, any medic in the country should be able to clear a c-spine, AND YOU DON'T NEED AN X-RAY MACHINE TO DO IT!!!!!!! I believe it is a collosal waste of time to c-spine someone who was involved in a MINOR mva with no neck/back pain and no other signs of central nervous system involvement.

I also think the personal attacks are not necessary. This is a forum to discuss ISSUES dealing with EMS, not to bash someone because of something they wrote under their name.


Matt Sulentic, EMT-P

[JMP17]

You know Matt, I do agree with you some what. No there's no need to c&b all Pt.s in a minor fender bender but where do you set the limits for judging MOI? Have you ever seen someone brought to the ED that you thought did'nt need the c&b to find the pictures showed a FX of the c-spine? I've been on this job long enough to have confidence in my ability to assess the Pt. but I'm not lazy enough to to put someones mobility or life on the line to save 2-3 minutes it might take to c&b them.
And I don't think the comments were so much
attacks as they were reminders of a duty to act in a given situation.
Stay safe & take care of each other!!!
JMP17
Jim Preston FF/NREMT-B

[medic3401]

I didn't feel your comments on the subject of immobilization were attacks at all. It was the comment about what Traumadog has written under his name that I thought was the attack.

You make it sound like a provider who doesn't board and collar someone is lazy, and that's just not the case. I do what is necessary in a given situation, and immobilizing someone isn't always necessary. That doesn't make me or anyone else who is allowed to make that decision lazy. The issue is not about work ethic.

If you or anyone else is more comfortable immobilizing every patient involved in a mva, then that is your prerogative and I wouldn't fault you for doing it. Just don't call those of us who wouldn't lazy.

[JMP17]

Once again I think you misunderstood where I was comming from. If you read my reply you'll see I stated of course all Pt.s do not require C&Bing But there are those (and don't act like you've never seen them) that would rather just say "can you walk over to the stretcher?" Like I said it all depends on MOI, Vehicle damage, Other inuries in the same car amongst other things. I in no way meant to insult anyone. You seem to have been around a while and you probably have the skills and confidence to make these dicisions my problem here is if we start letting every swinging *#@k on the job walk a Pt out of an MVA sooner or later the Pt.s going to turn their head to look at you (or who ever) to answer a question and say they can't feel there legs! Or maybe move their arms or even worse yet, stop Breathing! That'll tune a probie up for a great career.
Like I said I'm not here to affend anyone, if you got the skills more power to you, but you better have the ^$s to back it up.
Stay safe & take care of each other!!!
JMP17
(O.K. maybe the medic in charge thing was a dig, Sorry!)
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Opinions expressed are mine and may not be those of my Dept.s

[This message has been edited by JMP17 (edited July 25, 2000).]