Posted by: medicblog999 | June 20, 2009

What would you have done?

x-ray_20cerv_20lat_20djd2I was working on the rapid response car, and was called to tend to a young adult male, collapse? cause.

On arriving at the scene it became apparent that this was much more than a collapse ? cause. There were 4 police cars, 2 police vans and alot of commotion going on in the street. Working on the car, we do not normally get sent to assaults, as it is deemed to high a risk of a job for a solo paramedic to attend to. However in this case, I was already on scene and there was a whole load of police around me, so I felt fairly safe!

I asked the closest police officer, who my patient was? I was directed to a 26 yr old male who was very angry and upset. He was being physically held back by the police to stop him from going after the men who had attacked him.

On approach I made the following visual observations:

  • Obviously fully conscious, alert and orientated.
  • Good colour, normal breathing – A, B, C, D all normal.
  • Did not appear intoxicated or under the influence of recreational drugs
  • Was moving without any apparent discomfort or significant injury
  • Was uncomplaining of any pain.
  • Had a small amount of dried blood from the corner of his eye, down his face.

Once I got him calmed down and moved to the car, I finished my examination. All of his observations were entirely normal. I asked if he had any pain anywhere and he said, No. He had two very small wounds to his face, one at the corner of his eye and one on his nose, neither of which were now bleeding.

On further questioning, he said that he had been hit in the head with a bottle which had smashed, he stated that he had been knocked out and fell to the floor and he thought that his assailants had stamped on his head. Whilst palpating his C-spine for tenderness he told me that he had some pain down the centre of his C-Spine (even though he stated he was pain free before). Despite the alledged pain, it was impossible to keep him still and from moving his head in all directions. I asked if it hurt his neck when he was moving like that, again he said no, but when I rechecked his C-Spine, he again stated that it hurt on palpation.

I love my job (as I keep saying), so as far as I was concerned (even though I wasn’t entirely convinced) there was a significant mechanism of injury – hit over the head with a bottle, loss of consciousness, and possibly stamped on whilst unconscious. To me, that means he has to be collared and transported by ambulance on a spinal board, but I know that at that particular time of night, I will have to wait longer than normal for my back up crew as the service in our area was extremely busy at that moment in time.

The question is, do you follow protocol to the word, or do you decide that the physical presentation of symptoms does not tally up with the patients descriptions, and transport him to the hospital in the car, thereby leaving other valuable resources free to deal with other emergencies and ultimately becoming available yourself quicker than if you had to wait for the ambulance to arrive to take him on the spinal board.

Your decision, what would you do?

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Responses

  1. Here in the US, we wouldn’t have had the option. The ambulance is our only means of transport and therefore: C-collar, LSB, cot, and to the ER for x-rays to rule out the occult fracture.

    The hit to the face could be a “distracting injury”, so could the fact that the guy was really ticked off. In the US, this incident would cause the guy to lawyer up, so defensive medicine is in order. He also would be sore as heck once he calmed down, and would probably call again.

    Or be paralyzed, one of the two.

  2. 999,
    I had a similar situation a while back:
    http://yourhappymedic.blogspot.com/2009/02/you-make-callc-spine-precautions.html

    I am a firm believer in position of comfort or anatomical correctness as opposed to a curved spine on a flat board when mechanism is the only qualifier.

    But you’re cheating in asking if I should take him in the car. I have no car so I say no.
    If I had that resource, however, I think with the pain on palpation is a red flag in my book.

    Mechanism is such a gray area in the protocols, I think this fellow needs to keep that part of his body as still as possible. Tackling him into C-spine precautions will do more harm than good, but I think this question will never be answered “correctly” in the eyes of the lawyers, doctors and the folks actually making the decisions, us.

    I’m talking him into the following in this order:
    Long board and collar OR
    collar OR
    hold still.

    He’s alert and allowed by law to refuse elements of his care, it is ala cart after all.

  3. Follow protocol, particularly as he is complaining of c-spine pain on palpation, also being strapped to the board for a while might calm him down

  4. As its spinal wait for the ambulance not worth the risk, then again ive seen fighters with more mechanism walk out without even being checked by the team medic. Always best to play it safe and cover your own backside.

  5. My first opinion (as lay St John Ambulance crew) is collar and long board – I would also happily retreat from this position if a Paramedic said it was OK.

    On second reading I wonder whether there is a real risk of your shiny RRV becoming a convertible to make this happen?

    Perhaps a KED?

    Nick.

  6. collar and longboard and wait for ambulance! or if you have them vacuum mattress – they are more comfortable for pt and at least they mould to the patient!!!

  7. I would do what wouldn’t get me put in a disciplinary hearing if things went wrong.

    Gut instinct as a first aider says c-spine collar and board. If his injury was somehow aggravated during transport and resulted in paralysis or death, and/or the FRU roof being cut off, I’m quite sure it wouldn’t go down well with your managers.

    Is there not a chance the level of aggression could be altered as a result of the head injury as well?

  8. Can’t imagine a situation where I’d transport anybody to the hospital in a car, much less one with midline spinal tenderness on palpation.

    At that point, what I think of the “mechanism” doesn’t really matter- even if I considered him a good historian, which I don’t.

  9. The US is still pretty big on the whole “Board everybody and ask questions later” kick that we got stuck on in the early days. It’s annoying. Fortunately, we have been progressing and I know of a great many services that have addressed the issue with (what we call) “Selective spinal immobilization”.

    Our criteria is this:

    1. The patient must be CAOx3 (Conscious, alert, and oriented to Person, Place, and Time – No intoxicants on board (that you can notice), no Altered Level of Consciousness, and no loss of consciousness during the incident.

    2. The patient must not have any “Distracting injuries” defined as grotesque and/or very painful injuries that could cause them to be ignoring subtle pain in their spinal area.

    3. Good neurological function all around. Good motor/sensation distally.

    4. No pain to palpation or slow movement to the c-spine. Palpate all of the vertebral heads if possible.

    5. If in doubt, even a little, board em and let an x-ray sort em out.

  10. Heres the predicament. There is a good chance that he may have already worsened his injury prior to you even arriving on scene. So my opinion would be to board him just to cover your ass. However i agree with HM on the doing more harm than good with regards to using c-spine precautions for this fellow.

  11. I would send him by Ambo, and preferably on a LBB in full c-spine.

    The fact that I am not to sure I should be buying his story in this case is a bit irrelevant. If something were to be wrong w/ his spine, it’ now my arse (Ooooo, a British word), and he isn’t getting all my stuff.

    As HM has already covered though, he can refuse any and all of his treatment (he will be signing for any and all refusals though).

  12. […] would you have done – The conclusion If you haven’t already done so, click here to read the start of this […]


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