ambulance or company vehicle

[JPINFV]

If the only thing I know is that the patient has a sore neck, but is actively refusing spinal immobilization AND is looking to get checked out in the ED, then, baring anything else, no probably doesn't. However, the information presented is limited AND certain non-verbal cues makes a big different when assessing patients. I do not think that everyone who suffers a traumatic incident either needs to go to the hospital, and those that do do not necessarily need an ambulance. There's a fine line between having an abundance of caution and crying wolf. Especially when it comes to lines like, "maybe you have something else that I can't detect." Ok, you can't detect it. What are you planning on doing about it? It's not like he's going home to sleep it off. He's going to the hospital. If the only realistic treatment option necessary is transport, does the form of transport really matter?

[PCP]

PCP, is this patient a technical boss over you in your medical office capacity?

I presume Canadian law to be on the same level as American law, that the medical person (you as the EMT or Paramedic on the scene) is medically in charge, until and/or unless there is a higher medical authority either on the scene, or in consult from the On Line Medical Control. This does not take into account a patient who signs the Refused Medical Assistance/Against Medical Advice paperwork, which is a different situation.

Is Entonox also known as "Nitronox", kind of a Nitrous Oxide/Oxygen anelgesic*, which is not (yet) in any New York State protocols, as far as I know?

Reviewing here: Took a nasty fall off a snowmobile, complains of head injuries, stiff neck, and tighness in the chest? I'm thinking possible C-Spine involvement, possible Traumatic Brain Injury, M I. Patient wants to RMA/AMA, instead of all spinal immobilization protocols being implimented (I trust you would have), O2 therapy, and patient monitoring enroute to the nearest ER. Seems like you did your best, at the time.

Just for information, you've mentioned an hour's travel time to the ER by private vehicle, and presume roughly the same with the on-site ambulance. While a critic of overuse of HEMS (Helicopter EMS), this qualifies, in my book, anyway, as a good time for the Medevac flight. How long to request the "bird", fly it in for pickup, and get to that ER?

If and when available, give us the followup prognosis.

Yes Entonox is Nitrous Oxide/Oxygen anelesic 50% oxygen and 50% Nitrous Oxide. Ya know, I did not feel this guy needed a chopper, plus it is snowing here like crazy so they would not have flowen in anyways. I spoke to the head of safety about that today. I am in charge while I am on duty as the first aid attendant, but when I do everything I can to try and talk the guy into going to the hospital and he refuses and I have no back up there is not much more I can. I phoned my boss today to let him know what happened today and he agreed that he should have been taken out by ambulance, but said I did evethying right by having him sign my refusal form.

It pisses me off when patients don't listen to me when I explain to them why I think they should be brought to the hospital fully packaged.

(*Possible misspelling, I can't get the spell check to work. subject for another string)

If the only thing I know is that the patient has a sore neck, but is actively refusing spinal immobilization AND is looking to get checked out in the ED, then, baring anything else, no probably doesn't. However, the information presented is limited AND certain non-verbal cues makes a big different when assessing patients. I do not think that everyone who suffers a traumatic incident either needs to go to the hospital, and those that do do not necessarily need an ambulance. There's a fine line between having an abundance of caution and crying wolf. Especially when it comes to lines like, "maybe you have something else that I can't detect." Ok, you can't detect it. What are you planning on doing about it? It's not like he's going home to sleep it off. He's going to the hospital. If the only realistic treatment option necessary is transport, does the form of transport really matter?

Okay, I see what your saying, I am trying not to put to much information on this website about my call as it is a site that is open for the genral public. My patient did have two 4 to 5 inch lacerations to the back of his head with moderate bleeding as well. I just feel when a patient complains of a sore neck that he should be put on a back board with a collar and transported by ambulance. I may not be able to detect a underlying injury, but at least I can monitor the ABC while enroute and I can fix those if needed, make sure the bleeding stays and make sure the bleeding is under control. I wish I had a X-Ray machine and was able to determine that he does not have a spinal fracture or any underlying injuries that would make my job sooo much easier.

I understand what you are saying about the non verbal clues as well and ya, this guy did not have any non verbal clues that I was concered about. I just would have felt better taking him in my self.

[Bieber]

I just don't see why not give a patient oxygen, sure they may not need it, but if it helps them feel comfortable, or help with nausea, bring there SPO2 stats up. I was taught that any trauma patient gets a non rebreather. So that is what I did, then I down graded to a nasal at 3 LPM.

Well, the only problem with that is that the science is saying that oxygen is NOT a benign drug and that in certain patients it actually CAN be detrimental to their long term mortality. I'm not saying to break protocol, and unfortunately my protocols force me to give oxygen to certain patients regardless of the science, their SpO2 or their presentation, but if you have the freedom to be a little more selective than I then I would strongly suggest you review some of the current literature. I agree with oxygen when in doubt, and that it does seem to help calm patients and relieve nausea to some degree, but don't be afraid to think outside of the textbook. A couples of liters by nasal cannula doesn't sound inappropriate to me in this scenario, especially if he wasn't presenting with any sort of respiratory distress.

Anyway, in the end, you did all you could and that's that. I don't know if you read my post about a month back about my little ethical dilema regarding a patient that we transferred from the hospital back to his home when they weren't able to adequately care for themselves, but believe me when I say I know that it's hard to see a patient make the wrong choice. Ultimately, we can only do so much. My preceptors were very big about "after the call's over, the call is OVER". Be done with it and move on to the next call.

Take care, I'm glad to hear everything worked out all right with that guy. Just don't let this hardship come back tenfold when you have a patient that refuses treatment and really suffers for it.

[Chief1C]

I have a last ditch excuse, that I have used to get people to go to "A" hospital, when they really needed to... But didn't want to. Keep in mind, none were out of control of their faculties, none were mentally ill. One thing is true of each and every person on the face of this Earth. They're going to die, eventually. So, you can sometimes use the excuse, "you really need to get in the ambulance and let us help you, or you could die". I know that sounds cliche, and dramatic.

But if they're badly, badly injured. It's possibly true, and just may convince them to get in the fricken ambulance. Don't do it too often, or on minor cases. But sometimes you just have to be bluntly honest. This may have not been a case I'd use it on.

Edited February 17, 2011 by 4c6

[usalsfyre]

A couple of thoughts here....

There's no point in trying to force a patient into a particular mode of transport (or for that matter transport at all) if they are in full control of their faculties and refusing. Just make sure they are VERY well informed of the risk and possibly consequences of doing so. Everyone has the right to self determination, even if the determination means they're probably gonna die (not this case specifically, but on occasion you'll see it).

Raising oxyhemoglobin levels (SPO2 saturations) is not a reason to apply oxygen. Increasing oxygenation and reversing hypoxia is. If the patient is not "hypoxicly hypoxic" than O2 is going to be pretty well useless.

Plain film x-ray is pretty notoriously unreliable at detecting c-spine fx (more unreliable in fact, than physical exam). Spiral CT is the standard.

[PCP]

Hey guys, thanks for all your comments and suggestions. I am going to do a little reading today on Oxygen, as I feel after reading some of your posts, I did not get a full understanding of the effects of Oxygen and its use. I did feel this patient could benefit from some oxygen, as he had just suffered a event that caused a few injuries, as well as having to climb up a side of a bank roughly 60 feet up in the snow. As mentioned I am going to do some reading today about Oxygen and its use.

I am still going to stick to my guns and say that my patient would have been better off by being transported by our ambulance with me in the back. I received a phone call from the person who transported my patient to the hospital and told me that when they explained to the nurse what happened, she asked " how come he does not have a hard collar on and why is he not on a back board?" As well as the Dr. questioned them as well and attempted to put a collar on him, but he refused again at the hospital.

Makes me feel good that, at least I was not the only one who could not put a collar on this guy and that I was correct, by wanting to board this guy and put a collar on him as well. He is back to work today, so I will be popping over to his office and checking in him to find out the final outcome.

Thanks again for all your suggestions, questions, and comments.

Brian

[island emt]

PCP: based on the presentation given, the correct thought process and care rendered would be to collar ,board and transport by ambulance,

That said , you cannot win the minds of idiots over to thinking this way. You can't cure Stupid and there are no laws against a competent pt making possibly stupid decisions.

You did what you could and it would seem that the hospital staff felt the same way.

[Richard B the EMT]

Just a thought, here, but anytime anyone signs an RMA/AMA when you as the EMT or Paramedic feel they really should have gone in the ambulance to an ER, follow the old mantra of "document, Document, DOCUMENT"!

I have heard of litigation where EMSers were sued because they accepted the RMA/AMA, when what the EMSers warned the patients could happen if they didn't go with them, happened. Admittedly, the lawsuits were unsuccessful, but time was lost, reputations were damaged.

[PCP]

Just a thought, here, but anytime anyone signs an RMA/AMA when you as the EMT or Paramedic feel they really should have gone in the ambulance to an ER, follow the old mantra of "document, Document, DOCUMENT"!

I have heard of litigation where EMSers were sued because they accepted the RMA/AMA, when what the EMSers warned the patients could happen if they didn't go with them, happened. Admittedly, the lawsuits were unsuccessful, but time was lost, reputations were damaged.

Any time I have to code X a call or while on duty as a first aid attendant and my patient refuses treatment I Document everything. I tend to do more writting on my PCR when the patient refuses to go with me then when I do a regular call where we end up transporting the patient.

[Richard B the EMT]

I tend to do more writting on my PCR when the patient refuses to go with me then when I do a regular call where we end up transporting the patient.

As we ALL should.