Has this ever happened to you?

[SSaint]

Patty:

I suggest you re-read your Maryland Statewide Protocols. In fact, if you follow the trauma decision tree (it's page 128 in my copy), it says "CONSIDER helicopter transport". You are under no obligation what-so-ever to call for a helicopter simply based on MOI. Further, by stating that you had to call for it based on MOI tells me that not only are you unsure of the protocols, you didn't even really assess the patient or the situation appropriately.

OK, that makes more sense to me...

I'm glad someone mentioned (sorry, I forget who) that airbags can star a windshield. They can and they will do just that. From everything that has been posted it doesn't sound like the patient hit her head. It sounds like the airbag cracked the windshield. What you included here regarding your assessment should've led you down that line, too. You said she had no tenderness or lacerations on her head. Don't you think that hitting a windshield at the speeds you mentioned might have caused some damage? Don't you think that maybe her agitation might have something to do with being annoyed/scared/freaked out at having just been involved in an accident? Now, I'm not saying she didn't hit her head...simply that the information posted doesn't lead me to think that's what happened.

I forgot about the airbags... AND missed that post. :oops: :oops:

[kpeppermintpatty]

paramedicmike- I understand the windshield starring and would be thinking the same as you if it wasnt for the fact that the first thing the woman said to me was "I hit my head on the windshield." Being "shook-up" and being agitated boardering combative are 2 different things. When it comes to MVA's, I do stick to my protocols for the most part, as where I am located a majority of our calls are not trauma, but medical. My chiefs know this and were on-scene, any questions I had went straight to them.

As for the other stuff in your post, I agree that I stand corrected, my eyes skipped over the "consider", my apologies.

[Ace844]

"Pepper,"

Examples are as follows..

http://www.emtcity.com/phpBB2/viewtopic.php?t=2851

http://www.mass.gov/dph/oems/memos/treatrelease.pdf

http://www.emtcity.com/phpBB2/viewtopic.php?t=3560

http://www.emtcity.com/phpBB2/viewtopic.php?t=2342

http://www.emtcity.com/phpBB2/viewtopic.php?t=1871

http://www.emtcity.com/phpBB2/viewtopic.php?t=2910

http://www.emtcity.com/phpBB2/viewtopic.php?t=1533

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://www.jems.com/news/102474/

http://www.mass.gov/dph/oems/admin/ar_5_610.doc

http://www.semaems.com/Documents/SEMAEMS/Polices/Manual503.pdf”" data-cite="\"

http://www.semaems.com/Documents/SEMAEMS/Polices/Manual503.pdf”

">

4. Patients who, after EMS arrives at the dispatched location, refuse treatment and/or transport to the hospital.

a. For those patients who refuse transport to a medical facility, the provider will document that:

i. The person was informed of the need to go to the hospital

ii. The person indicated his/her understanding of the provider’s opinion that they should be transported, and

iii. That the individual refused care

b. The patient should also sign the patient refusal section of the form. If the patient refuses to sign, the reason for such refusal shall be documented in narrative section.

c. Providers should also sign the patient’s ability to sign (e.g. minors, persons who appear intoxicated, or patients unable to understand the possible consequences of their refusal) in deciding whether to attempt to contact responsible parties, involve police officials or seek the advice of medical control in the decision-making process.

d. At no point may an emergency ambulance service refuse transportation or discourage a patient from being evaluated at a medical care facility.

9.9.0

Patient Refusals and Sick Assists

To properly document a patient refusal, you must first understand what constitutes a patient refusal. Just as the consent to receive treatment must be informed, the refusal for treatment must also be informed. A sick assist is a similar situation that should involve similar documentation and patient interaction.

FOR THE PURPOSES OF DOCUMENTATION, A REFUSAL AND A SICK ASSIST SHOULD BE TREATED EXACTLY THE SAME WAY. BOTH OF THESE SITUATIONS REQUIRE THAT THE PATIENT BE EXAMINED AND SIGN THE PATIENT REFUSAL SECTION OF .

You must do an adequate examination of the patient. You cannot just take their word that they are fine. Often, the patient is the least qualified person to assess his or her own medical condition, and, if the patient's judgment proves to be wrong, you could be held liable. If the patient refuses to let you touch them, evaluate the patient as best you can visually and gather as much information as possible.

After completing the examination, clearly advise the patient of your findings and explain why you recommend that they be transported. Even when the medical problem is minor, your best protection is to recommend that the patient seek treatment.

ADVISE THE PATIENT OF THE POSSIBLE CONSEQUENCES OF NOT SEEKING MEDICAL ATTENTION. THESE CONSEQUENCES MAY INCLUDE DETERIORATION OF THEIR CONDITION OR DEATH.

You must determine whether the patient has the capacity to refuse treatment. The patient's competency to refuse treatment should be questioned if head trauma, alcohol, or drugs could be affecting the patient's mental status. The questionable mental capacity of a patient to refuse treatment is the biggest reason why, when you are in doubt, to decide in favor of treatment and transport.

In sick assist situations, try to evaluate the situation to feel comfortable that the patient will be able to care for him or herself after you have assisted them and you have departed. We have seen instances where a patient has been assisted into a chair only to return the next day to find them in the same chair from the night before. You must carefully evaluate the patient and the patient's surroundings in an effort to prevent this scenario.

Once you are satisfied that the patient's mental capacity is not impaired, ensure that their understanding of the refusal is clear and absolute. If you believe the patient could change their mind, you should continue to urge the patient to consent to transport. Seek the assistance of others present to encourage the patient to consent. Many patients will refuse at first and then consent to treatment. When this occurs, document it.

You must document the names of witnesses for all patient refusals and sick assists. The witness should be an independent third party, preferably a friend or relative, who has witnessed your attempts to obtain consent and the patient's subsequent refusal. You should request an available witness to sign the trip report. This witness can be a police officer or a firefighter. If the person is a minor (anyone under the age of eighteen), enter the name of the parent/legal guardian who is signing under the "Comments" section. If no parent/legal guardian is present, and the minor has a complaint of pain or illness, you are required to transport that person to the hospital under the implied consent rule, as a minor is unable to make decisions himself. Implied consent does not apply to any individual who has no complaint of injury or illness. You must request assistance from dispatch or a supervisor if you are unsure of this procedure.

When you have exhausted all possibilities of performing a patient transport, you need to document the refusal in TabletPCR with a complete, detailed narrative. Enter the date, time and incident location. You are documenting this incident the same way you would document an actual transport. Explain to the person that this form is to document their refusal of treatment and transport and they will not be billed. Furthermore, inform the patient that if they change their mind after they sign the refusal, you will gladly take them to the hospital.

If the person required ALS treatment such as D50 and subsequently refuses transport, medical control must be contacted to document the refusal.

Again, it cannot be stressed enough that you must document everything that you have said and done. Clearly explain what you found in your assessment, what you told the patient, and the patient's response. Remember, if you do not properly document the steps you went through for the refusal, it could be embarrassing trying to remember the call in a court of law three years later.

For those of you who are in this profession you have a RESPONSIBILITY to EDUCATE yourself further and do all you can to become a better CLINICIAN. This whining about how "Oh, I only had 120 hrs...My class didn't help me learn..." Is a complete cop out, and B$!! Oh, Booie for you, now MAN UP and FIX IT!!!Fact of the matter is, you are in an autonomous field, with ALOT MORE RESPONSIBILITY THAN YOU WERE LED TO BELIEVE IN CLASS!!!

Furthermore, your an adult, or at least pretending to be one. So why should the rest of us hold your hand and give you an excuse to blame your lack of motivation, education, intelligence, understanding, or abilities on others. IT'S YOUR ISSUE, YOUR RESPONSIBILITY, SO DO SOMETHING ABOUT IT!!! Are there ways to do this, yes; and are there people here who are willing to help? Absolutely!!! There are many of us here who try to teach, and help you guys be better providers, and clinicians! If you have no interest in any of the things I mentioned. Go work in an industry where your lack of 'motivation' and complacency won't cause harm to someones family members and friends. WHAT WE DO EFFECTS LIVES IN A REAL WAY!!! THERE ARE MORE THAN A FEW INSTANCES WHERE WE MAKE LIFE, AND DEATH DECISIONS AND EFFECT OUTCOMES IN REAL AND OFTEN PERMENANT WAYS FOR SOMEONE WHO OFTEN WE HAVE JUST MET!!!

Think about it.... people.....

{climbs off his soapbox and relequishes the mic for a short time}

[itku2er]

Wait.. My Spidey sense tells me we can all expect an non-effective version of this type of defense from the man himself JOHHNY COCHRANE!!! Sadly though I suspect "peppermint," needs more services than "Johnny," could provide. Still ladies and gentlement of the EMTCITY AUdience.. Lets hear soem of the magic he could bring to her defense...

[stream:bbe5ee3dd0]http://images.southparkstudios.com/media/sounds/214/214_chewbacca.wav[/stream:bbe5ee3dd0]

Hey It worked for OJ... :roll: :shock:

ACE844

WOW ACE ..........wonder if Johnny could help me?..........will call him and see?

[Ace844]

WOW ACE ..........wonder if Johnny could help me?..........will call him and see? : :shock: 8) D

Somehow I suspect you would be the one providing help TO HIM... :shock: 8) D

ace844

[paramedicmike]

paramedicmike- I understand the windshield starring and would be thinking the same as you if it wasnt for the fact that the first thing the woman said to me was "I hit my head on the windshield."

Fair enough. But how many patients can realistically remember the split second events of an accident even though they don't lose consciousness? Ever been in an accident yourself? I have. Didn't lose consciousness either. But I had the cops looking for a third vehicle involved because I swore up and down there was a third vehicle. This is where a thorough, complete and detailed assessment of not only the patient but the vehicles and the situation would come into play. This will be developed over time as you work the street. See my comments about getting your officers to partner you with someone very senior/experienced to help guide you in the right direction.

(Again, not saying she didn't hit her head. Just that an assessment and the info posted here don't indicated as much.)

Being "shook-up" and being agitated boardering combative are 2 different things.

Again, ever been in an accident? Ever been so freaked out that you don't want people to touch you? To the point that you'll forcefully pull away? (I have. Left some pretty nasty bruises on the people who didn't listen to me, too. But I was hardly combative.) If you haven't, you'll see this type behaviour in some patients. More experience will help you differentiate true combativeness versus scared $hitless.

When it comes to MVA's, I do stick to my protocols for the most part, as where I am located a majority of our calls are not trauma, but medical. My chiefs know this and were on-scene, any questions I had went straight to them.

As for the other stuff in your post, I agree that I stand corrected, my eyes skipped over the "consider", my apologies.

So you called for a helicopter and your chief was ok with this? Sounds like he could use more experience, too.

Tell you what, where's the closest MSP aviation unit to you? This might be a great opportunity for you to set up a con-ed program. Get them to fly out to you and help you with a presentation on trauma. Then you could also tie in the fire side by having a presentation on LZ safety, security, hazards etc.... Invite neighboring squads. Turn it into a weekend event! Have a barbecue, inter-squad competitions (e.g. tug of war etc...). Because it sounds increasingly like very few people in your area know when it's appropriate to call MSP (crass sweeping generalization, I know. Only going on what's here.).

Again, find a seasoned partner who can help mold you into a better street provider. You'll be better off in the long run.

-be safe.

[Ace844]

http://www.emedicine.com/emerg/topic717.htm

http://www.umassmed.edu/emed/lifeflight/transport.cfm ]Criteria for transport

Helicopter transport of critically ill or injured patients can mean the difference between life and death in many cases. In order to ensure appropriate use of the helicopter service, guidelines have been established for all emergency care personnel who are in a position to request the service on behalf of a patient.

Three general criteria should be considered before requesting a Life Flight mission:

would the amount of time needed to transport a patient by ground transportation to an appropriate facility pose a threat to the patient's survival and recovery?

would weather, road conditions, or other factors affecting the use of ground transportation seriously delay the patient's access to advanced life support care?

does the available ambulance unit have the clinical skills and equipment needed to care for the patient during transport?

In general, Priority 1 and 2 trauma patients are candidates for airmedical evacuation to a trauma center. In determining the need for a Life Flight mission, pre-hospital and/or hospital personnel should take into consideration the mechanism of injury, the patient's medical assessment, need for skilled medical care during transport, need for immediate intervention by a trauma team, and the need for rapid transportation of that patient to a trauma center.

The following are some examples of situations in which air medical transport would be appropriate:

penetrating injury of head, chest, or abdomen

fall from a height over 15 feet

pedestrian struck by a vehicle

motor vehicle accident with:

- extrication time greater than 15 minutes

- patient ejected from vehicle

- associated fatalities

any trauma victim under 14 years or over 55 years with associated chronic

trauma score less than 12

In addition to trauma patients, there are other types of patients with time-sensitive medical or surgical problems which may also be appropriate for interhospital transfer by helicopter transport. These may include patients with severe burns, as well as medical, surgical, and /or neonatal emergencies.

While each patient must be considered on an individual basis, the following guidelines are offered to further clarify the types of illnesses or injuries which might be appropriately considered for Life Flight transfer from a referral hospital or for evacuation from the scene of an accident.

patients further than 15 minutes from a hospital or ALS care with:

chest pain, signs of MI

progressive decreased level of consciousness

coma or GCS less than 10

potential airway obstruction/severe shortness of breath

progressive paralysis

signs of shock

severe burns

[FormerEMSLT297]

Hmmm ,,,, let me see,, whose side do i take on this one?...

1. First let me say that if she is in southern MD, the nearest trauma center is Prince George's Hospital center.. which may be 45-60 minutes drive time from the scene... maybe even more depending on the time of day, traffic etc.

2. It's not necessarily wrong to eye ball a patient and then start a helo,, you can always cancel it or turn it around, but if the initial impression is that the patient should go to a Trauma center then cant hurt to start, depending on how far away you are.....

3. Having been in a Medic for 20 years, and also in Law enforcement, there is a BIG BIG difference between SNOT SLINGING DRUNK can't make a rational decision about informed consent and maybe just "a little ETOH".

Now my question is did the cops do a roadside breath test,,,, i might have tried that... cause if you get a very high reading then you have a suspect you can place under arrest, or at least have ammo to back up forcing the patient to go under emergency orders. If you get a BrAC of .02 or .04.. then you can reasonably determine that the person is able to make an informed consent. (I didn't make this up this was a judges ruling about "emergency orders" the .02-.04 thing)

Now having said all that I might have suggested in the strongest terms possible that the patient needs to go

and if the cops know haw to talk to the patient they may have helped you to convince the pt. to go.

But keep in mind that Law Enforcement "emergency orders." in Maryland and most elsewhere specify that the person must be a danger to themselves or others, i.e. suicidal ideations... to be taken into protective custody.

Now I have been to hundreds if not thousands of calls involving law enforcement and protective custody emergency orders, etc,,, and I can tell you that the advice the police are getting from their legal teams is that "UNLESS THE PERSON PRESENTS AN IMMINENT DANGER TO THEMSELVES OR THE COMMUNITIES" be very careful and selective about who you FORCE TO GO.

What can I say,, we live in a VERY LITIGIOUS Society....

Stay safe

[Imagine89]

I absolutely and 100% agree with ACE and DustDevil.

Firstly, this call, based on what i've heard doesn't call for air flight, in my honest opinion. She was walking around complaining she hit her head. Her condition seemed relatively stable, at least enough so to go by ground with ALS on board.

Also. From the second I read your first post, I thought, "there is no way this patient should be allowed to refuse". Ace has this one nailed. She was not in a normal state of mind, despite the fact that she was alert and oriented. The simple line of questioning to determine the level of conscienceness is not the be all end all of "is my patient competent enough to make the decision that she normally would?" The police will have to comply with you, due to the fact that it's your patient, and they aren't qualified to make a medical decision. Inform them that letting this pt go is against the law. It's unnacceptable to let a patient like this go on a refusal because the officers were too lazy, you need to make sure they know of your legal obligation to decide whether or not teh pt is working in a logical state of mind. ETOH is jsut MORE of a reason, even if it was just a small amount. As far as I'm concerned, the state of mind that gels with running around frantically and screaming is not one that complies with making a very important decision.

[hfdff422]

pepper

This is part of one of Ace's posts that I felt was perfect-

You must determine whether the patient has the capacity to refuse treatment. The patient's competency to refuse treatment should be questioned if head trauma, alcohol, or drugs could be affecting the patient's mental status. The questionable mental capacity of a patient to refuse treatment is the biggest reason why, when you are in doubt, to decide in favor of treatment and transport.

The fact is, it is easier to prove negligence or abondonment than it would be to prosecute you criminally for "kidnapping" (which is likely to be called criminal confinement or something like that). Your documentation of her mental status is the determining factor in whether she would be considered competent to refuse. Her inability to calm down would be an issue for me. ALOC can present itself in many different ways. If she was competent to refuse, you should have been able to calm her at least somewhat in the process of being an effective EMS provider.

As for a helicopter- Protocols are great in the cover your butt situations, but if you are unwilling to force her to go, don't wake up the flight crew. I am all about starting a helicopter based on MOI- car vs. semi in a confirmed PI= helicopter before I am out of the station, entrapment with car on fire= helicopter before I assess the patient, but I use common sense when it comes to that. The last person we flew out was inaccessible for 15 minutes while trying to extricate him and had a compromised airway most of that time- he was in arrest when extrication was complete, but was rescusitated.

As for your age and being the in-charge EMT, I sure hope that was a precept situation. I don't have a problem with minors assisting or observing on the scene, that is how people learn. But I think your age may have been a factor in her agitation- depending on how old you look and how you conduct yourself. It is reassuring when someone is "in control" of the situation. A calm voice, strong posture, empathetic ear, and a few choice words will put a patient at ease and you in control.

As for Ace- he is right, so even if you don't like him take what he says into consideration.