How would you handle this?

[zzyzx]

Although it looks like you were wrong in disagreeing with the doc's treatment, it's nice that you followed up on your patient and cared about their pain managment.

[Asysin2leads]

I hate to disagree, but it to me it doesn't sound like a mid-shaft femur fracture, if anything, its a fracture of the femoral neck, the same type commonly seen in the elderly. If this was the case, a traction splint could have exacerbated the problem by putting pressure on the area of the injury.

As for the doctor, I don't know what to say, I don't have all the facts. I've seen it both ways, people feigning injury for pain meds, and asshole doctors not doing the right thing, it could go either way. If she walked out of the ER, then it was probably a good bet she didn't have a fracture, midshaft or otherwise.

Whether you did the right thing or not, I guess thats up to you. If you really didn't think the doctor was doing the right thing, then you did the right thing, and if there's retribution for it, then take it on the chin and be willing to do it again in a heartbeat.

[medic001918]

Even with a close proximity to the hospital, if you were so concerned with pain management and making sure that the patient received something for it you could have provided pain relief for your patient instead of trying four times for IV access as long as the patient had stable vitals. I believe you mentioned that you had pain control as a standing order. In doing this, you know that your concern has been addressed.

I also have to agree that with the shortening and rotation, I would be thinking femoral neck or hip fracture as opposed to midshaft femur fracture.

There are a few lessons to be learned here from this scenario. Taking those lessons and move on.

Shane

NREMT-P

[Just Plain Ruff]

I normally stop iv access attempts after 3 attempts. That's just me but I do believe if I felt the patient warranted it and I had standing orders for pain control I'd have dosed her up.

Just curious what are your standing orders for pain relief?

[Ridryder 911]

I am a patient advocate for pain control, however; the scenario as described, I would question true pain associated with fracture. I agree with Asysin2leads the description is of a hip fracture (surgical neck ) and definitely not a mid shaft, which traction splinting is only indicated for (even by manufacturers recommendations). Yes, trochanter and neck fractures pain can be increased with traction splinting.

I am wondering if the patients representation of pain, allergies might had clued the physician?

Now, lies the potential problem.. you have accused (falsely) the physician of disregarding the pain (appearantly, it was muscular-no fxr/x) and as well misrepresented a wrong diagnosis. This has potential back drafts of later patients you will bring in... and I am sure, he/she might be monitoring your actions as well. In this case, I would be very careful.. and as you described, ...."they do have more wealth of knowledge" .....

Yes, being a patient advocate is great.. however; pick your battle wisely and more so, be sure you are in the right, otherwise your fight has been reversed.

R/r 911

[VillageEMT]

"Approximately 2 hours later, we returned with a different patient, and decided to check up on the previous patient. Still in the ER, crying in pain, no x-rays, nauseous from pain, and still on a backboard."

I'm just curious about something that seems to have been overlooked in this discussion. When you returned to the ER 2 hours later the patient was still on the back board. In my area this would be extremely unusual, particularly considering that the doctor did not think there was a fracture. I can understand an honest disagreement about diagnosis, but to have a patient lay on a back board for 2 hours without a very pressing reason would, at the very least, be considered uncaring, if not downright abusive treatment.

[Ridryder 911]

It is appearant that yu do not work around ER's very much .. < 2 hours is pretty good, especially in busy ER's ... I have seen patients on LSB > 8 -10 hrs.. ER Doc's are getting better and recognizing the dangers as well and are removing them in a better timely manner; as well as some medics are beginning to finally truly assess if the patient has an isolated injury and really even needs a LSB.

R/r 911

[NREMT-Basic]

Unfortunately, once you place your patient in the hands of the ER staff, they are no longer yours. But, despite what alot of others say, I believe that what they physician did or didnt do violates standard of care. I would follow through, but do so through proper channels. Yes, the doctor may get his undies in a bunch, but you dont work for him.

Best of luck and good for you for looking after someone who needed it.

[VillageEMT]

It is appearant that yu do not work around ER's very much .. < 2 hours is pretty good, especially in busy ER's ... I have seen patients on LSB > 8 -10 hrs.. ER Doc's are getting better and recognizing the dangers as well and are removing them in a better timely manner; as well as some medics are beginning to finally truly assess if the patient has an isolated injury and really even needs a LSB.

R/r 911

I frequently take patients to an ER that is our Regional Trauma Center and Regional Cardiac/Stroke Center, and they frequently have patients coming out their ears. It is also the ER where most of our clinical training time is done, so we get to see how they work. I don't know the standard of care in OK, but in upstate NY 2 hours on a LB by a patient who has been diagnosed as having no spinal injury would raise a lot of questions. If they do have a spinal injury, why would it take that long to start treatment? Wouldn't delay lead to the risk of worsening the injury? (Note: The questions are retorical and the answers obvious.) A backboard is not intended for long term care. It is an expedient to get a pt to the ER. Busy or not, a reasonably good standard of care would be to get the patient off the back board as soon as practical.

Also the original poster stated that there were only a few non-critical pts in the ER in question, so patient load is not a factor here. This was, at best, sloppy care.

[Ridryder 911]

I agree that 2 hours is too long and preferred to be removed after initial exam or performance of x-rays. I was not referring to Oklahoma, but actually at a very large area with one of the largest Trauma Centers where I worked at. I believe, if you were to actually study and read LSB studies, that there really is not a "gold standard" and that is part of the debate. Furthermore, part of the problem is not the conscious patient that can shift, or move to displace pressure upon the tissues, rather the unconscious patients that are unable to do so causing neuropathy, pressure induce occlusions, and nerve damage. (http://www.merginet.com/index.cfm?searched=/clinical/trauma/ProlongedSpinalImmob.cfm ) Remember, if the patient is package appropriately, they can turned on their side, etc . to displace weight... no where, does one have to remain supine. That is why more and more educators are endorsing scoop in lieu of LSB ( http://www.merginet.com/index.cfm?pg=products&fn=scoop ) especially ones with isolated injuries. Most of the time I see the LSB abused by EMS personnel, using it to remove patients, rather than using blanket rolls or even previously discussed scoop that can be removed in ER immediately after ruling out spinal injuries.

How many times has one seen true spinal injury patients left on LSB and C-collar without Crutchfield tongs? If you can have a neurosurgeon to attend those with single spinal injuries from trauma in less than a few hours, you beat the national standards by far.

I suggest discussing this with the physician one on one first. I warn those with a few nights a week of training, and the most the see a hospital is to pick up and drop off patients, to pick their battles very wisely before confronting any physician or ER staff. Remember it is a two way street, and I can assure you all us make mistakes at times, and those with the letters M.D. after their names definitely have more weight.....than any ambulance personnel, that is if one values their career.

R/r 911

R/r 911