Personal Responsibility and Patient Care.

[EMT Martin]

Greetings!

I come foward today to post a story that happened to me approximately a week ago, which is now making repercussions in my department. Of course, all names are withheld to protect the innocent, blah-blah-blah.

I happened to be in-quarters at my department when Fireboard set off our tones to notify us of a 70-ish year old female who'd attained injuries from a fall. There was no further information, as the caller was too hysterical to get past saying that there was some bleeding and that the subject couldn't move. I attended the call as a simple technician with one other EMT-B/IV Tech who was my crew chief and our driver.

Upon arriving at the scene, we found the female outside. She'd fallen from a standing position, less than four feet backwards. She was stating that she couldn't move because it hurt too much. My crew chief (recently promoted) simply took a knee beside the female and asked her what happened. She then listened to what the patient had to say...and pretty much did nothing else. This discouraged me, because I knew a rapid trauma assessment was needed, immediately. Therefore, I stepped up and stated to her "would you like me to start a rapid trauma assessment?" I was told not to. It wasn't severe enough. I didn't like that answer, so I stepped up again and took over patient care. I began asking the lady what was going on and found that she'd stated she was suffering from pains in her chest. I asked her to describe them, and feeling that it was a risky situation, dispatched for a medic.

It should be noted that our medic units are chase units; paramedics who board when called for, et cetera.

So our medic unit is responding, and our driver comes over with the stretcher, long spine board, headblocks, collar, et cetera. With still no idea how extensive the injuries are, I'm told to step aside and help log roll the patient. I figured during the roll, the 'chief' would finally take it upon herself to check the backside of the patient. She didn't. We roll the lady aboard, and by now I know we've broken a lot of protocol. The patient's loaded onto the cot and taken into the ambulance, where I begin to take vitals and assess her breathing.

Before I get a good set of vitals, the medic arrives. Unfortunately, she is by herself, and since my crew chief is younger than I am and has no license, I'm advised to drive the unit behind the ambulance until we get to the hospital. It was a largely uneventful trip for me from then on out, but I had advised the paramedic before she boarded that besdies chest pains, there was blood in the back of the woman's head.

Upon arrival to the hospital, I parked the medic unit and turned it off, meeting my crew and the medic inside. I hand her the keys, she thanks me, I wash my hands off after taking all BSI precautions, et cetera. Now I'm back in the unit and we're headed home. After the crew chief calls us back in service, I turned the command chair around to talk to her (both she and the driver are in the front, I'm the only one in the back of the 'box'). I asked her if they'd consulted with the online trauma centre, since there was at least a Category A and D consideration for this patient. She told me they did not.

A few days later, the driver approaches me and tells me that the hospital ended up transporting the elderly lady to the nearby shock/trauma centre and have kept her for a near week. Indeed, as I thought, the patient had fractured her skull. She also had a hip injury (a second category A consideration) that I couldn't have known about due to no rapid trauma assessment. Now...the call is under investigation.

So here's my question. What can I expect from this call? I did everything that my crew chief told me to, while being unable to do what I felt was necessary. Furthermore, a seasoned paramedic never initiated a call for fly-out (my area having only one hospital and being too far removed for ground transport to be effective). Should I make some sort of statement to my EMS Chief? I want to know what you guys think.

[HERBIE1]

Need more info. Vitals, mentation, anything on physical exam- even a cursory one.

But...

A simple quick exam may have revealed a hip fracture- shortening, rotation, etc. Maybe not. The fractured skull may or may not have presented with obvious signs or symptoms. Assuming vitals were stable, a fall from a standing position may or may not exhibit obvious injuries, but with an elderly patient, obviously you need a higher index of suspicion. I don't know what your local protocols are, but in this area, unless you had reason to suspect such injuries, it may not warrant a trauma center. It would depend highly on the capabilities of the local ER, distances to a trauma center, etc.

I once had a 60 year old guy who fractured C-2 with a small 1inch forehead lac as the only obvious injury when he tripped and fell backwards while walking, so anything's possible.

[ERDoc]

First off, welcome to the city. Since this was one of your first posts, you need to realize that you are dealing with an international audience here. Please avoid using local codes/signals. As for the care of this pt I think everything was done appropriately (though it is hard to judge fully since we do not know what happened during the transport). This was a fall from a standing position, definitely not something should be taken by helicopter or require a trauma activation. Yes, there was blood. The scalp is very vascular and will bleed, alot, if there is a wound. Think of a kid running into a table and cutting his scalp. There will be a lot of blood but not a very signifiacnt wound. A skull fracture by itself is not serious either. Many people with skull fxs will get sent home. What is concerning about this call is the fact that is sounds like it was an open skull fx. That is a little more concerning because you need to worry about infection. This still does not require a helicopter or trauma activation. The reason that the pt was probably transferred to the trauma center was because the needed services were not available at the local hospital such as neurosurgery and trauma. They may also not have orthopedics. A question I have is when did the pain in the chest start, before or after the fall? Was the cause of the chest pain what caused the pt to fall? If there was an arrhythmia this may also result in the pt going to a tertiary care facility.

From the sounds of things you are rather new to the field (I don't mean this as an insult in any way). We've all been there. Don't get caught up by the blood. Focus on your assessment and don't get distracted or you will miss something. I've seen providers who were so focused on a laceration or fracture and missed the fact the pt was hypotensive and circling the drain. Helicopter transport is dangerous and expensive, think about if your pt will benefit from the increased risk you are subjecting them to. As you gain experience you will get more comfortable with things like this and you will begin to realize that there are very few true emergencies and even fewer that require the helicopter.

[EMT Martin]

First off, welcome to the city. Since this was one of your first posts, you need to realize that you are dealing with an international audience here. Please avoid using local codes/signals. As for the care of this pt I think everything was done appropriately (though it is hard to judge fully since we do not know what happened during the transport). This was a fall from a standing position, definitely not something should be taken by helicopter or require a trauma activation. Yes, there was blood. The scalp is very vascular and will bleed, alot, if there is a wound. Think of a kid running into a table and cutting his scalp. There will be a lot of blood but not a very signifiacnt wound. A skull fracture by itself is not serious either. Many people with skull fxs will get sent home. What is concerning about this call is the fact that is sounds like it was an open skull fx. That is a little more concerning because you need to worry about infection. This still does not require a helicopter or trauma activation. The reason that the pt was probably transferred to the trauma center was because the needed services were not available at the local hospital such as neurosurgery and trauma. They may also not have orthopedics. A question I have is when did the pain in the chest start, before or after the fall? Was the cause of the chest pain what caused the pt to fall? If there was an arrhythmia this may also result in the pt going to a tertiary care facility.

From the sounds of things you are rather new to the field (I don't mean this as an insult in any way). We've all been there. Don't get caught up by the blood. Focus on your assessment and don't get distracted or you will miss something. I've seen providers who were so focused on a laceration or fracture and missed the fact the pt was hypotensive and circling the drain. Helicopter transport is dangerous and expensive, think about if your pt will benefit from the increased risk you are subjecting them to. As you gain experience you will get more comfortable with things like this and you will begin to realize that there are very few true emergencies and even fewer that require the helicopter.

Not insulted at all, I know that I've got a lot to learn, yet.

To attempt to give you a background, and at the same time avoid the confusion of local codes:

My state's requirements through trauma decision protocols state that "open or depressed skull fractures" be flown out. This is due, in no small part, to my unit and any unit in my vicinity being able to 'safely' transport a patient to the nearest trauma centre within the 'golden hour'. By default, that statute is considered "Category A" in a tree that decends in line to "Category D". Since this was on the highest point in the scale, it's considered an automatic flyout, as is any hip injury (the one I was unable to assess, due to being told not to).

For the chest pain: it began after the fall, from what I was informed. Our state does not have our EMTs question whether it could or couldn't be an MI, but rather, call the medic unit by default. From my anatomy classes as well, we were taught that falls, injuries from accidents, et cetera could all constitute a heart attack, due to it's anchoring in the spine. Ergo, since she fell backwards, I would've thought it a good call to make.

In all, my overall look at the situation was that it was multiple traumatic injuries; the focus on the head only made because it was the only injury site I was 'allowed' to palpate and physically see. Regardless, the hip and head both constituted a fly-out and high traumatic injuries, as far as my protocol states. This was why I felt the need to commit online consult with the local trauma centre, first and foremost. Further, considering that the patient was flown out hours after we dropped her off...I would've thought I was in the right on that call.

[Eydawn]

Why do you have a crew chief who is too young to drive? That's my first question. Just curious, but am I smelling some good 'ol boy "boss's daughter" stuff going on here?

My second question is why a crew chief thought it was appropriate to interfere with an EMT who wanted to do a rapid exam on a patient who obviously needed to be backboarded. A fall from standing in an elderly patient is a cat of a different color than a fall from standing for a younger or middle aged person... a simple fall can trigger a huge number of problems for someone who is elderly.

These would be the crux of the issue. If you're going to backboard someone you need to do a rapid exam first, so that you can document any changes that occur after backboarding. The problem now is to explore why this didn't happen, without casting "blame" or calling names. And chin up- you didn't withhold anything that resulted in patient death... so it could be very much worse.

Go talk this call out with your EMS chief. Explain your perspective, and try to figure out why your crew chief decided that examination was not necessary. Don't shred the chief, just analytically approach the situation and explain why you felt certain things were necessary and why you didn't agree with your crew chief. INVOLVE THE CREW CHIEF in the conversation!!

It's not a personal issue, it's an issue of call review to ensure that you are acting according to your protocols. You felt the call was not appropriately handled (PER PROTOCOL), and as a learning exercise for everyone it is important to make sure that you're all on the same page.

That would be my suggestion. Yes, you have a lot to learn, but so do all of us... and there's a reason you're taught to follow protocols. If this was indeed a protocol breach, it needs to be figured out.

Good luck to you!

Wendy

CO EMT-B

[aussiephil]

This is due, in no small part, to my unit and any unit in my vicinity being able to 'safely' transport a patient to the nearest trauma centre within the 'golden hour'.

Can I refer you to the following threads on this non subject & the farce called the golden hour.

The Golden Hour/Platinum Ten

The Golden Hour - is it a real principal for EMS

[CBEMT]

Wait- ANY hip injury is a fly-out?

Oh boy....

Moving on.

This discouraged me, because I knew a rapid trauma assessment was needed, immediately. Therefore, I stepped up and stated to her "would you like me to start a rapid trauma assessment?" I was told not to. It wasn't severe enough.

This right here tells me she has zero business being a crew chief, preceptor, whatever. If the new kid wants to do a rapid trauma, whether the patient "needs" it or not, let him do the rapid trauma! It doesn't cost anything for cryin out loud. You needed the experience, and she denied it to you. Fail.

I began asking the lady what was going on and found that she'd stated she was suffering from pains in her chest. I asked her to describe them, and feeling that it was a risky situation, dispatched for a medic.

Again with her failure to lead. If she's the crew chief, and she's making patient care decisions, why is she letting you request additional resources? It doesn't matter, technically, that it was the right call to make for the situation. If she's in charge of the truck, and is taking charge of patient care, she shouldn't be letting the new guy call for help. Either be in charge, or don't be. Fail.

That said, it doesn't sound like things improved a whole lot once the medic showed up, which is always unfortunate. Bad BLS followed by bad ALS does not typically result in positive patient outcomes, except by dumb luck.

[Dustdevil]

Remember, folks, this is Maryland EMS we're talking about, so don't be expecting 21st century operations.

I agree that I would probably have been more concerned about the medical aspects of this patient than the trauma. And simply needing orthopaedic surgery doesn't constitute a "golden hour" trauma emergency in the real world. I too have to question what role the chest pain played in the overall event. Although, I don't quite get the spine-heart connexion you are making. If there is one key pearl that I make sure my students take from EMT school, it's that WHY the patient fell is every bit as important as the injuries suffered in the fall.

As for what to expect from the investigation, it's hard to say. Depends on who is investigating and why, and what their agenda is. More than once I've pushed for an investigation on something, only for them to turn it around on me to make me wish I hadn't, and vice versa. I don't personally see any liability on your part from the limited info you have given us. You weren't in charge. However, if someone determines that she received sub-standard care, then yes, they are likely to hold you complicit with that responsibility. Especially if the "crew chief" (whatever that is) is their golden child. And after all, it's supposed to be a team effort when you're both of the same level of training.

Of course, you're damned if you do and damned if you don't. If you debate patient care with the crew chief, you're insubordinate. If you do what he says and it's wrong, you're incompetent. You can't win. Either way, your partner can make or break you. Sorry that's not more comforting, but the bottom line is that the chips may fall anywhere, including on top of you, regardless of what you do.

What sounds like should come from all this is some serious changes within the organisational structure of the agency, especially in the way "crew chiefs" are trained, evaluated, and appointed. Rarely is an organisation objectively introspective enough to achieve this though. Usually, they just find a scapegoat to blame for anything embarrassing, then continue to encourage the same Gong Show operation down the line.

[CBEMT]

Remember, folks, this is Maryland EMS we're talking about, so don't be expecting 21st century operations.

Dude! I hadn't even looked at his personal info, but reading through the post I was thinking, "Where the hell is this? Maryland? Pennsylvania?" I almost asked in my post too.

[ERDoc]

Yup, missed the Maryland thing too. I am going to assume that you are a volley. Looking at your trauma protocols, I guess you could say that the person meets that criteria based on Cat A. There is no way to tell at the scene that this pt had a skull fx though. I highly doubt the intent of your protocols was to fly out some little old lady who fell and bumped her head. It also says that you should consider helicopter txp, it does not say it is required. Again, calling a helicopter should not be taken lightly and I would think anyone in Maryland would know that, especially after the loss of the state helicopter. You should ask yourself, "Is the lives of those three people on the helicopter worth any benefit the pt may get from the transport?" Would you be comfortable with the deaths of those three people, and possibly your pt, if you called the helicopter? You also say that a hip injury constitutes a fly out. I don't see that in your protocols (at least at the state level). I do see a problem with the other person not checking the back when you were rolling the pt on to the longboard. How do they know the lady didn't fall on a knife and that is what is causing her chest pain? Passing the buck on to the medic by saying, "Our state does not have our EMTs question whether it could or couldn't be an MI, but rather, call the medic unit by default." is just poor medicine. If you are treating the pt, it is up to you to figure out what happened. The workup for someone who fell and then had chest pain is a lot different than someone who had chest pain and then fell. No one is asking you to diagnose an MI, but there are a lot more causes of chest pain than MIs. It is up to you, the provider to do a full assessment, including finding out about the chest pain. It is the thing that you ignore that will kill the pt (Murphy will make sure of that). As you gain experience you will see what I mean. Don't get discouraged by this call. Use it as motivation to improve you knowledge and become a better provider.

As Dust said, as far as the investigation, it all depends on who is involved. If you are riding with a volley squad it is no more than politics and who has a bigger penis. Without knowing the workings of the social crowds at your company there is no way for us to predict what will happen. I do have an issue with someone who is not even old enough to drive being old enough to be a crew chief. Does anyone else see a problem there?