Monday, March 2

You Make the Call...C-Spine Precautions...What Happened

Start by reading THIS if you don't know the setup.

I was perfectly content letting this fellow rest comfortably on the cot and get him to a physician, for no other reason than to have this whole gray area go away.

When we arrived at the County Hospital, his location of choice, which happens to be the regional trauma center (You know where this is going) we wheeled him in.

The triage nurse sees me, Happy, and blood in my patient's hair and doesn't make the connection that everything is OK. Before I can get a word out she's on the nifty little phones they have to communicate with the other staff 5 feet away.
"We have a no notification trauma at the door, activate Trauma 1."
"Wait a minute," I said, "This is not a trauma criteria patient, let me give a report and you can talk to him, he'll tell you what happened."
It was as soon as that thought passed through my brain stem and was transformed into the muscle movements that created the sounds that I knew exactly the words that would come out of his mouth.
"I got hit in the head by a baseball bat, I think, I can't remember."

Gads, don't say it like that.

The nurse proceeds to do the kind of panicky, disorganized shuffle that comes with too many long nights at the triage desk of the only county hospital.

They wrestle my patient into a C-Collar and Hospital security restrain his flexing and writhing body to a rigid wooden board. Nice "precautions," eh?
His shouts and protests draw the attention of our Medical Director, who happens to be on staff and on duty.
"No precautions in the field for a combative head injury guys? This is cut and dry protocols."
"He can't remember if he got hit by a bat or scraped his head against a wall running away, mainly because it happened so long ago Doctor. And he didn't become combative until people began fighting him to 'help' him. All CMS (sensory, motor, function) was intact before they jumped on him," I said suddenly realizing I was picking a fight with the one person who could END my career with the flick of his pen.

I followed up with our protocol officer, since I got a stern lecture from the attending physician, the medical directer, the charge nurse, the triage nurse and just about everyone from janitor to lab tech on how to C-spine patients, about what the discharge diagnosis was.

Superficial laceration.

In the end, our patient, who only went to the hospital in the ambulance to escape the awkward situation at a night club, was physically restrained, chemically restrained, treated and released with no injuries.

The best part of the whole story is that I was never given a chance to give my pre-hospital verbal report that summarized exactly what my written report did. I followed protocol to a point and make a judgment decision that his laceration was not related to his suspected, possible but not proven, mechanism of injury.

Soon after this call I was C-spining everyone with a pulse just to avoid confrontation at the ER when I realized that diagnosing in the field is not in my scope of practice and that mechanism of injury, as we are beginning to learn, is a poor indicator for treatment.
If all we used were protocol and mechanism, every Nascar driver, football player and olympic diver would meet trauma criteria just by doing what they always do.

Then again if I jump off the 18 meter platform, we have other problems.

If you said keep the pateint calm, comfortable and C-spine neutral, you made the right call.


firefighter / paramedic said...
This comment has been removed by the author.
firefighter / paramedic said...

Gotta love the nurse character. Nurse Crotchet usually cant wipe a runny nose without a doctor's order, yet is always ready to declare a trauma alert! All that power to get all those doctors running into the ER. Amazing.

Anonymous said...

I had a feeling this was where your story would end up HM. I could hear it coming like a freight car a ways off, but I heard it.
We had a nasty-nasty here about 2 years ago. You know that type that makes it hard to identify which car is which, how many patients even after 15 minutes on scene, and what to do first. The first flight medic on scene started making transport decisions, we had the third and fourth rigs on the scene and one of our rigs was directed to handle 2 patients, BLS, and the medivacs (2) were FULL and it was time to switch to 'what works'. When our crew got to the (community) hospital they got ripped to pieces for bringing in serious trauma patients while at the very same moment the extrication crew (30 miles away) was discovering another patient (deceased) they had been partly standing on while they pulled apart the wreckage in layers.
To try and make the E/D staff understand what was going on at the scene was impossible, they just don't get it. We don't have options on hospitals, we have 2 to choose. All the other patients went ALS to other trauma centers.
The re are times when I wish we could force these E/D personell to spend a few weeks on a rig so they could make some adjustments in their attitudes.
One hospital we run to has most of the E/D nurses who run with Volley sqauds in their 'free' time, they are MUCH easier to work with because they give us the benefit of the doubt until proven otherwise.
I too had a run-in with an MD who didn't like my attitude and I didn't like thata he took more time to bitch at me than he did caring for my seriously hemoraging patient. He said 'I want your name before you leave' and I said 'no sweat Doc, I'll write it all out for you and wait outside the door, just give me your Director's name so I know where to send my letter.' He never came out the door I was waiting at and I never heard another thing about it.
I THINK the protocols are changing from MOI to Assessment based, it will take a while, but someday we should be able to make the judgement calls and have them stand.
By the way, as long as I'm all worked up now: That VERY SAME E/D took an 8 Y/O Female I brought in with a head injury from a sledding accident, boarded and collared. In our turnover report we expressed concern about the pt.'s listlessness, spontaneity, motor and pupilary responses. We were really concerned about this little girl. The MOI was head first down a sled hill into a wall. They had her off the board before I had done my paperwork and I again expressed my concern. They discharged her in 2 hours. She saw a specialist the next day. She had a skull fracture, bone chips in the cranium, and some other problems. The specialist had a long talk with the E/D director. The little girl had a LOT of work and testing done and today she is doing just peachy. I saw her last week, she is gonna be a mna-killer some day.
SO head up HM! Someday they just might learn.
Capt. Tom

Anonymous said...

Been there done that!! More than a couple of times.
It's always more frustrating, as anonymous says, when it's the opposite way around and you are seen to have " over treated" the patient.
Luckily, my main and usual A&E have a great deal of respect for most of our decisions and as of yet ( luckily) I haven been caught out.
I'm sure it's only a matter if time though, but unless we collar and board all of our patients with even a hint of trauma then eventually one will slip through that will surprise everyone.