AnthonyM83

You notice blood trickling from his hairline, though exact source is obscured by his hair. His right lower leg seems to be at an awkward angle, but no blood at this time. These are the only deformities or wounds you see as you visually inspect him. Well, if I did all that you for you, there wouldn't be much of a scenario. The diagnosis of injuries isn't that complex, the purpose is to practice assessment skills of the things listed above. Right now, we've got scene-safe, BSI, c-spine, initial visual inspection for wounds. As far the side issue of holding cspine before asking for consent when there's a significant initial index of suspicion for cervical injury, all training's I've had here have told us to secure cspine before making verbal contact. I'm this varies by school....the explanation I was given was it's implied that if you might go paralyzed by moving your neck, you'd want EMS to immediately take measures to prevent it before asking for permission...especially if there's the possibility that you might be altered.

For this scenario, I would accept not securing the neck if one cited safety issues (though I personally think that's one of our job's risks when you come upon such a scene). I would not accept assault/battery defense, as (I think) it falls under implied consent and court would probably protect you. The patient says: "Yeah, it's fine." Anything you want to inspect, visualize etc must be stated specifically. Point is just to go over trauma procedures for practice...textbook way, but if it's a good textbook, it's also the street way (for the most part). I personally tell the patient not to move his neck, as I approach, then tell him I need to keep his neck still, as I apply manual stabilization. I don't technically ask, but if he's going to be combative I'm giving him a few seconds to react, say no, get verbally aggressive, give warning that I'm going to touch, before I actually touch...even if only a second or two, that's usually enough to see a reaction.

He turns to look at you to say "Thanks for stopping to help," but his his cervical spine lacerates his spinal cord and he becomes a quadrapalegic. Fortunately, this is only a scenario. Your game was saved at the last checkpoint (last post), try again.

As far as the guarantee issue, I think with smaller items it might the case, since few people ever get around to it. But with more expensive products (like in the thousands), I think people will remember that and go through the effort or sending it back. Then, again, even for cheap items, the manufacturer might genuinely believe it's a quality item, but knows he'll increase his sails even more if he adds in the guarantee. That'll help him convince the buyers were finance is more of an issue.

Thanks for the reply. So to keep track of blunt with penetrating and cervical with rest of the spine: When considering blunt trauma, localized force to the lower back would not usually be cause to immobilize cervical spine (except in with neuro deficit or extreme cases, such as the baseball bat to the back example), but obviously localized force to the cervical area would indicate c-spine immobilization despite lack of neuro deficit since damage could occur later? Or is pain complaint for A&O subject always there when there's damage. When considering penetrating trauma, localized penetrating force to the lower back would not indicate c-spine immobilization without neuro deficit since damage is caused immediately. I would imagine penetrating force to neck would have the same rules? Even if the penetrating trauma caused some injury from dissipating energy from the object (what I was referring to as blunt trauma from the bullet energy to surroundings), it would be localized to lower spine, thus no cervical spine immobilization. BUT if the bullet went through the neck, though it obviously missed the spine, there would be need for c-spine immobilization due to dissipation of force or cavitation? The last concern was bullet fragmentation, which would be treated exactly like the cavitation? Possible fragments from a GSW to the neck would make us immobilize cpsine, but possible fragments from a GSW to the lower back would not indicate cspine, because bullets don't fragment that powerfully. Is everything I wrote valid and what you were saying? I italicized parts I specifically wanted to confirm. Also, a follow-up: Why are we not as worried about injury to lower spinal cord? It could still cause paralysis from the fracture point down, right? (Though it's probably harder to injure) Do people immobilize only thoracic downward, ever? In a GSW to thorax, should we be doing thoracic immobilization?

The main PCR is done by the FD on-scene. They give us a yellow copy for us and a red copy for the receiving hospital. We fill out an additional continuation form which simply has a field for 3 VS & GCS, 3 fields for meds given, and a prompt that says similar to "Patient Condition During Transfer" and just lines. The county FD's PCR sheet aren't always the most...thorough...I've had one where the text box only said: "chief complaint: Elusive". That's it, then all the check boxes. Or sometimes they flat out lie "Panic Attack, No KO, No Sz activity" when I was there when entire family witnessed the 14yro have a full tonic-clonic seizure x2 minutes w/ hx of epilepsy and patient says she felt the seizure aura, then just waking up. So, when they BLS a patient with more complication issues than what they wrote down, I'll do a full narrative...but half the time it just gets thrown away. The better hospitals take the time to look at it, but the more overworked hospitals just leave it...I'll see it floating around hours later five runs after.

Apoptosis has been one of my favorite terms and words since 1997.

You try to throw away the Debbie Gibson paraphernalia, but your partner smacks you in the back of the head and asks what you're thinking. He stashes it away, saying that's for later. Tell me the methods you use to assess and I'll tell you what results you get after you "do" them. This way I can see if you skipped something. Asking it in series makes it so I have to assume they were done in the right order...but this scenario makes YOU decide that.

I was thinking mainly traffic collisions at high speed or even medium speed lateral impacts where the body might bend in an over-flexed sideways direction. Or am I still thinking too Los Angeles County? We only went over cavitation briefly, but the basic points were that energy is dissipated to areas surrounding the bullet's path. Sometimes it's temporary where tissue just bounces back, but permanent cavitation might actually cause some damage. It was mainly in regards to soft tissue...but one girl specifically later seemed upset that they spent time talking about fragmentation and cavitation and how there's more damage than the straighline path of the bullet, yet we don't worry about harm from shrapnel or energy dissipation effecting c-spine. Also, second part: if neuro deficit is a deciding factor, then why do doctors ask patients about pain when clearing cspine. Isn't that a strong indicator of spinal injury even in absence of neuro deficits? That's why drunks don't get cleared as quickly. Then, wouldn't the distracting injury (of a bullet hole in your chest) invalidate patient's response of no neck/back pain?

The question then arises, why do we cspine for blunt trauma without neuro deficit? In case spine is unstable and certain movements might injury the cord, right? But wouldn't the energy from a bullet with cavitation be similar to blunt trauma and the bullet fragmentation potentially lodge near cord where movement might cause fragments to shift causing injury? That's where it doesn't quite make sense to me...

There is one patient. You see a male in his 40's leaning his head and arms against the steering wheel, with a bit of moving and muttering. He is wearing a baseball cap, t-shirt, and jeans. The patient is accessible from driver and passenger side doors which are unlocked and open easily.

Ummm, I finish mine almost before we get to the hospital? But that's mainly for BLS runs where patient has a chronic 'stable' problem and I can write while we talk about their condition further. Otherwise, I spent the ride assessing further, even if not really needed, just for practice. Or if patient is worried, it's mainly comfort time. I used to wait until after, but partners get all huffy when I go back to the rig to write in comfort (and cleanliness), so just learned to do them quick. And honestly in the middle of the night, I want to get going back right away. We're supposed to finish at the ER, though, not at station.

You notify your dispatch who says they're calling PD. Street and area is relatively empty, occasional car passes by. No fluid leaks and smoke has dissipated, but still in the air, as if collision was recent. Your scene is safe. (And umm, yes, it was a telephone POLE...I have a bad habit of thinking too fast for my typing speed...odd things get left out)

They don't have hallway cots, just so we don't leave them there. A FEW have hallway chairs...some are even discharged from their chairs. But seriously, if they did that, you'd have the hallway PACKED. People wouldn't avoid the busy hospitals like the plague. The main problem, though, even if you only have a few patients in the hallway, is you don't have anyone to keep an eye on all of them. They use us as their techs even after we've given our report and supposedly transferred care. But if something were to happen to them, we'd still be liable I'm sure b/c we're supposed to be watching them...being on our gurneys and all.

edited. temporary post only.

Right, I can see how you end up turning into a First-Aid booth just because you're there. I think when you do standby you end up doing dual function unless they have a separate First Aid booth and have you guys in a separate area. But that's just like field EMS where patients call me because they have the infected toe or a cold (when I have full on flu)...but you're fully equipped to work a code and even call it in the field....

Yeah, seems strange to me. And it didn't sit well with a few people in class, though that's often the case when something new comes in where the studies are opposite of what one would think. Does anyone here teach PHTLS? I'm sitting in, so I didn't buy the book, so not sure what the details are or if it lists sources in the back.

Thought I'd give putting on a scenario a try. Because it's short and so that we can critique each step, only answer one procedure or one small grouping of assessment steps at a time. Wait until my reply, unless you'd like to do something different than what has already been done or you're at the same step. You just finished a run and are driving (your ambulance) back to the station at 1AM. You see a 1980's model smaller-sized pickup truck that has obviously collided with a telephone. It is partially up on the sidewalk and the front end isn't quite wrapped around the pole, but there's significant intrusion into the hood area by the pole. You're in a suburban environment. Do things by textbook, as if you're being graded. Go.

I'm helping as a role-player (and getting to sit in) for PHTLS, again. Apparently, PHTLS is saying that spinal immobilization is no longer indicated for penetrating injuries (including GSW's) to the thorax if patient is A&O without pain or neurological deficits (they had this whole little flow-chart). It seems really counter-intuitive considering concern about cavitation injuries from bullets, but apparently if patient has not had a neuro deficit by the time EMS arrives, then there isn't one (NOT to be confused with faulty thinking that patients with cspine indications can be walked to backboard if already ambulatory). Has anyone else been taught this? What do you think?

I know and I understand how it fits your definition, but just wondering why you chose that criteria.

That's a LARGE number of our patient population in certain areas where we're used as their primary care providers and taxis. Holding the walls at the hospital is one of the main things that wears us out. That and constantly driving from area to area to cover when coverage gets depleted. A 24 shift might only have 5 - 9 transports, but we might be running straight through the day and night. Makes it hard on the ambulance company too staffing that many units while not running that many calls.

Why does one need to provide treatment AND transport to be EMS? It's all part of the system and if you're part of the system, you're EMS. From dispatcher to ER personnel, right?

They wait in our hallway on our gurney until we can give the triage nurse a report. That's usually 1 minute to 1 hour. Then, we wait in the hallway with the patient, until they get a bed. That's usually 5 minutes to 3 hours. Sometimes 4. Occasionally 6 hours. Then we put them in bed and if their actual nurse is there, we give the report again, but depending on the hospital that might be only half the time.

WHAT!? They changed it!? I'm going to pretend like I never heard that....uhh unless I'm camping with a bunch of dudes.

That's what I was going to say. Only the leaders were allowed to use them, though. I would imagine the bite kit is better than no kit if it's a confirmed witnessed poisonous snake bite? Though, I personally, just suck the poison out and swallow it. Builds character. Then I bite the snake back. (Yes, I know that wouldn't work.)