Personal Responsibility and Patient Care.

[fiznat]

...we were taught that falls, injuries from accidents, et cetera could all constitute a heart attack, due to it's anchoring in the spine.

What?

[WolfmanHarris]

This is an issue I have with both a too many cooks situation and creating ranks and positions for the benefit of the person being promoted rather than the organization.

I don't care whether you call your supervisory and management staff, Superintendents, Chiefs, Lieutenants, Crew Chiefs or Grand Pubbahs, the initial questions needs to be what purpose does this position serve? Then, what are their duties going to be? Then, what qualifications, experience and education is required for this job? And finally to double check, do we need this?

How is it that you have an individual placed in a position of authority who is too young to complete the duties of those they are supervising? Age isn't the issue here, per se, but being fully qualified is.

I don't see you as an individual being liable in this circumstance, but I do see potential issues in your organization. Please understand that this is shooting from the hip based on the impression I've gained from your own description. How is a new, young provider already so complacent as to not to a proper assessment? This speaks to the senior personnel this individual is taking their cues from.

What?

Blunt force trauma leading to cardiac contusion? That's my best stretch from that. Honestly I have trouble wrapping my head around the way complex concepts are explained in EMT-B training. I ended up getting rid of my copy of "Emergency Care" during school as it wasn't even speaking the same language as the rest of my text books. (Still don't know why it's on the booklist for the SSFC PCP Program)

[scubanurse]

Being another product of the almighty MIEMMS organization... I think you are misinterpreting the Trauma decision tree. From what I gathered, the patient was just bleeding from the back of the head and had no obvious sings of a skull fracture. The hip injury is not a reason to fly out or even begin to call this a category A trauma. The protocol states 2 or more proximal long bone fractures. a Hip fracture you could argue is a long bone fracture but personally I would say that's stretching it, and since it was only affecting one side it doesn't meet the protocol regardless.

Like others have said, you need to bring this up with the crew chief and your ems duty officer/chief. I don't know what county you are in, but you should have an officer (Lt and above) who is in charge of EMS operations. Talk with them, you need to hear the crew chiefs side of the story and understand the reasoning behind her decision to not follow the protocol. In my book there is no excuse for not doing at least a rapid trauma. Even when I had a priority PIC in front of a Level 2 trauma center, I still did a rapid trauma. She could have missed a life threatening injury by not doing one.

Another question...not meant to intrude or anything, but why did you listen to her? If I were in that situation, and I can tend to be bullheaded and stubborn, I would have said, nope, I'm going to do an assessment and we can discuss this later. If I had been a supervisor on that call and witnessed you laying down in front of her and disregarding protocol yourself, I would have had issues with your behavior as well.

[fiznat]

Isn't it possible that the patient was alert and oriented, without obvious injury, warm/pink/dry, and appearing nervous? Sometimes it behooves us to TALK with our patients first before we go hands on and start cutting clothes. Yes, a trauma assessment needs to be done, but unless she fell off of a skyscraper or something I think we can spend 30 seconds introducing ourselves and making the patient comfortable with our assessment first, right? Maybe that is what he was doing?

[EMT Martin]

ERDoc:

Per new stipulation put out by the state medical director, units who's drive times are greater than thirty minutes to a trauma centre are not to leave their county/jurisidiction during consult. Ergo, since the nearest hospital is a basic level and has no ability to treat the trauma of this level, we're told to consult online with the local hospital and the trauma centre. Since the drive time to the latter is overwhelmingly long (2 1/2 hours one way, on a good day where I-95 isn't backed up), running it priority two with lights and sirens the entire way (in my opinion) puts as much risk to the patient as does flying them out.

Yes, we all still have the loss of Trooper 2 fresh in our memories when we fly anyone out.

But the bottom line is, the state's medical director basically tells us in the rural areas to expect flyouts from Cat A and B's. I'm really glad someone found the trauma decision tree, too; that's helpful in illustrating what I'm trying to say.

I personally see no problem in consulting with the trauma centre as a safety net, period. We're not doctors. Well...those of us who're EMTs, only. We're told to have a high index of suspicion, and that's what I was undertaking. But the fact that this young upstart (who is allowed to be a crew chief only because she's been with the squad for a year) didn't know what to do and I did illustrates only that my squad's inner-workings needs to be reconsidered. I think it's sad that I knew the protocol, knew the procedure, and this crew chief (should be noted, crew chief is in charge of care on the ambulance) didn't!

Bottomline, I sort of suspected it would be a penis-measuring contest...which is what I'm trying to avoid. As the new guy, my EMS-Peen doesn't measure up to theirs; and though I may be in the right, this doesn't necessarily mean that I'm going to be considered much in whatever preceedings come of this. I hate that. While the young gal simply shrugs off another suspension, I'm possibly going to get my first and put a permanent scar on the beginnings of my EMS career.

Being another product of the almighty MIEMMS organization... I think you are misinterpreting the Trauma decision tree. From what I gathered, the patient was just bleeding from the back of the head and had no obvious sings of a skull fracture. The hip injury is not a reason to fly out or even begin to call this a category A trauma. The protocol states 2 or more proximal long bone fractures. a Hip fracture you could argue is a long bone fracture but personally I would say that's stretching it, and since it was only affecting one side it doesn't meet the protocol regardless.

Yay! Another MIEMSS-y.

Actually, I'm not referring to long bone fractures. Nothing in the leg at all. Rather, pelvic fracture. From what I was told on the follow-up, there was a good fracture in/near the Illiac Crest or something of the nature. Sadly, our driver that day was not an EMT, so he doesn't understand anatomy as well; he just understood that the woman was flown out of the hospital we took her to, due to skull fracture and pelvic injury.

Like others have said, you need to bring this up with the crew chief and your ems duty officer/chief. I don't know what county you are in, but you should have an officer (Lt and above) who is in charge of EMS operations. Talk with them, you need to hear the crew chiefs side of the story and understand the reasoning behind her decision to not follow the protocol. In my book there is no excuse for not doing at least a rapid trauma. Even when I had a priority PIC in front of a Level 2 trauma center, I still did a rapid trauma. She could have missed a life threatening injury by not doing one.

I have since brought it up with one of our two captains. Her outlook on the situation is more that I need to 'step up' more and that weather may not have allowed the chopper to take off anyway.

Like you, I feel that if trauma has occurred, a RTA is absolutely necessary. As you said, I could easily miss something life-threatening. This is why it's on our practicals, afterall. It's a necessary step in patient care; period. Why this crew chief couldn't understand that...is beyond me.

Another question...not meant to intrude or anything, but why did you listen to her? If I were in that situation, and I can tend to be bullheaded and stubborn, I would have said, nope, I'm going to do an assessment and we can discuss this later. If I had been a supervisor on that call and witnessed you laying down in front of her and disregarding protocol yourself, I would have had issues with your behavior as well.

I tend to discredit my methods and not question the 'authority' until after the situations. Bad, I know. But my thoughts are that I'm still too young to understand all the reasoning, and I tend to get overlapped by other EMTs. Nice guys finish last, et cetera. I'm working on improving that, as best as I can.

[cosgrojo]

Martin - It sounds like you have a department with a median age of 17. The crew chief is too young to drive, you are too young to feel confident... what is going on in Maryland? I know that EMS is tending to skew young these days... but this is ridiculous.

The solutions to your issues are knowledge and confidence. If you know what needs to be done because of your studying and protocol review, you must have the confidence in that knowledge to make the right decision. If you go into a call review situation armed with all the proper information and can tell everyone there all the mistakes that everyone else made... the question becomes, why did you let it happen? I would rather be charged with stepping on the toes of my 16 y/o crew chief then negligent patient care. If you noticed things going the wrong way on the call, you are just as guilty as everyone else is if you don't do something about it.

I'm not trying to dump on you... I've been in similar situations, and made similar mistakes. Learn from your mistakes as well as the mistakes of others. I think it is important and healthy to judge your own actions as well as everyone else's. Anything that went wrong on that call was a product of every person on that scene. Nobody deserves all the blame, and everyone deserves a little.

[HERBIE1]

Maybe this is an issue of proprietary terms and local vernacular, but one thing that keeps sticking in my head is "rapid trauma assessment". What was this patient's presentation that deemed such an assessment necessary? Doc alluded to it-was it the blood? Copious amounts of blood from the scalp- or anywhere for that matter- can be distracting, but you need to look past that. Like Doc said, a scalp bleed could look horrible but is actually not necessarily clinically significant. Think of a heavily bleeding but nontraumatic epistaxis in a normotensive and otherwise healthy patient- the scene and the patient can look like a horror movie, but people don't generally bleed out from their nose, and any ER could handle such an issue.

To me, when someone needs a rapid assessment- medical or trauma, that means they are unstable in some way- airway issues, multiple obvious and potentially life threatening injuries like a GSW to the chest or back, CSF or grey matter visible, etc. Then you do your ABC's and see what level of care the patient would need. It appears that in this case, the mechanism of injury was known, so it was not a fall from a height, struck by a car, or other high speed impact, so a thorough evaluation of the patient's condition AND their complaints is not only warranted, but mandatory. The index of suspicion for an internal injury would not be high(except for a potential closed head injury) from a fall from a standing position. Take your time to do a thorough exam- especially if it means deciding how and where the patient will be transported, whether to mobilize an ALS unit, or a chopper evac.

Let the patient's condition dictate the proper route to take.

As for the age of the crew chief- that would scare the hell out of me too.

[EMT Martin]

The median range of age in the department as a whole is roughly 32. That's taking into consideration fire side, which has no interaction with EMS, usually.

If we take EMS, the median age goes up to 47. Myself at 23, that crew chief at 19, and one other EMT at 17 are the youngest EMTs. Myself and the 17 year old are not in a crew chief position, and thusly, can't even run a call without one even if challenged by Fireboard dispatch (IE- "Any response out of Company 6 for the ambulance?"). It's as if the state recognises me as being an EMT...but my department does not.

I agree, wholeheartedly, that I should've done more. I really look back and kick myself in the ass for it. I knew the procedures but didn't do them because someone who has a title and a few more months experience told me not to. I shouldn't have allowed for that.

As for the reason I wanted to do a rapid trauma assessment: The patient fell backwards from a small stoop, thus increasing the height at which she fell (hence why I noted it was a fall from roughly four feet). Further, our classes are taught that all trauma situations should call for a rapid trauma assessment, if but to catch internal injuries we may pass up. Afterall, nothing like feeling crepitation or hearing it to illcit a response. This isn't, by far, my first trauma call. Though I may still be a bit new in the field, I have docked up around 120 calls; which, for my area, is astounding. I've seen first hand what passing up the smallest things can do to a patient.

The bottomline is this. I thank you guys for showing me the ways in which the call was handled incorrectly. I apologise for not having a full detail of everything in the original post, as I didn't complete the report for that particular run. I can only tell you that the baseline vitals I personally assessed on the scene were a BP of 135/92, pulse thready at 67, Oxygen stat of 85%, and that her CAP refill rate was less than two seconds. This was all I got before I made the decision to step on the crew chief's toes and make her call the medic for chest pains, then package the patient.

I just wanted to get it off my chest before I go getting whacked on the head for not stepping up when someone's in charge and I'm not.

[HERBIE1]

The median range of age in the department as a whole is roughly 32. That's taking into consideration fire side, which has no interaction with EMS, usually.

If we take EMS, the median age goes up to 47. Myself at 23, that crew chief at 19, and one other EMT at 17 are the youngest EMTs. Myself and the 17 year old are not in a crew chief position, and thusly, can't even run a call without one even if challenged by Fireboard dispatch (IE- "Any response out of Company 6 for the ambulance?"). It's as if the state recognises me as being an EMT...but my department does not.

I agree, wholeheartedly, that I should've done more. I really look back and kick myself in the ass for it. I knew the procedures but didn't do them because someone who has a title and a few more months experience told me not to. I shouldn't have allowed for that.

As for the reason I wanted to do a rapid trauma assessment: The patient fell backwards from a small stoop, thus increasing the height at which she fell (hence why I noted it was a fall from roughly four feet). Further, our classes are taught that all trauma situations should call for a rapid trauma assessment, if but to catch internal injuries we may pass up. Afterall, nothing like feeling crepitation or hearing it to illcit a response. This isn't, by far, my first trauma call. Though I may still be a bit new in the field, I have docked up around 120 calls; which, for my area, is astounding. I've seen first hand what passing up the smallest things can do to a patient.

The bottomline is this. I thank you guys for showing me the ways in which the call was handled incorrectly. I apologise for not having a full detail of everything in the original post, as I didn't complete the report for that particular run. I can only tell you that the baseline vitals I personally assessed on the scene were a BP of 135/92, pulse thready at 67, Oxygen stat of 85%, and that her CAP refill rate was less than two seconds. This was all I got before I made the decision to step on the crew chief's toes and make her call the medic for chest pains, then package the patient.

I just wanted to get it off my chest before I go getting whacked on the head for not stepping up when someone's in charge and I'm not.

New or not to the business, you already have the right attitude. NOBODY is too old to learn, and the only way you do learn is by asking questions when you don't know something. It's much better to say "I' don't know", than to do something wrong because you are too proud to ask a question. QA- and any post call analysis- is crucial-even on an informal basis. Obviously you need to be up to speed on your basic knowledge and skills but as you will soon learn, if you already haven't, as soon as you think you've seen it all, something throws you for a loop.

Good luck.

[EMT Martin]

New or not to the business, you already have the right attitude. NOBODY is too old to learn, and the only way you do learn is by asking questions when you don't know something. It's much better to say "I' don't know", than to do something wrong because you are too proud to ask a question. QA- and any post call analysis- is crucial-even on an informal basis. Obviously you need to be up to speed on your basic knowledge and skills but as you will soon learn, if you already haven't, as soon as you think you've seen it all, something throws you for a loop.

Good luck.

Many thanks.

And something did throw me for a loop today: a call to the nearby airbase for the pilot ejection from a crashing plane. Never seen that before...