Opinion Wanted

[Dustdevil]

Why shouldn't the patient have been packaged and ready to load upon ALS arrival?

I agree. This is simple BLS 101. The patient should have had a proper immobilisation and extrication done, utilising full technique, not rapid extrication. Whether or not that could have been achieved under the circumstances before ALS arrived is something I don't know. But I do know that, unless all of your personnel resources were exhausted (not sure if this was the case or not from your description), you should have at least been well into the process by then. Why wouldn't you be? Did you expect that the medics would be any better at working on a screaming, hysterical patient than you were? What, if anything did you do for her prior to ALS arrival?

Wendy, "rapid extrication" is for those patients who are so critical that the risk of improper immobilisation is overshadowed by the risk of not immediately managing the ABCs. Rapid extrication is not something you do to make up for dicking around on the scene for too long.

[EMS Solutions]

OK well, I'll meet you half way. If the ETA was 8-10min.Then after about 4 you could have started getting the pt out and onto a board. If you were unsure you may have asked for an updated ETA to better time the ALS arrival, thereby limiting her laying on the ground time.

In the meantime, was demographics obtained? Name, address, HX, meds etc. Or was it all in your head and rattled off to the medic upon arrival?

Personally I hate when I arrive on scene and see numerous responders all standing around with a patient sitting in a car, no patient information besides a 10 min old vital signs report. Then its a big rush to get em out of the car and into my ambulance.

Everyone wants to "get there". But when they do, its a lot of standing around flexing their turnout gear and bat belts.

Did you do anything wrong? Maybe not, I wasn't there. But had I rolled up and seen several responders with one guy holding neck stabilization, I prob. would have been irritated.

Let them scream - everyone needs a little drama in their life.

Plus the car must have been hot as mentioned before. I personally don't like running vehicles while I'm with a patient, the door open, damaged, fluids leaking, blah blah blah.

Safety First - People Always

Now if I was the medic and awaiting a BLS truck to transport. I would not have even done the collar. I mean come on - That's a BLS skill. My talents cannot be wasted on those tasks.

I look much cooler standing there talking to the cops. <<- Just kidding. :twisted:

[Dustdevil]

Everyone wants to "get there". But when they do, its a lot of standing around flexing their turnout gear and bat belts.

LMAO! That's beauty!

And, I can just picture those wankers -- having ditched class to respond -- going back to their high school the next morning and telling everybody about the lives they "saved."

[medic001918]

I'm going to go against the grain of many other's and say that if you had the resources (man power and equipment), then this patient should have been extricated and immobilized prior to ALS arrival, especially since there was an 8-10 minute response time for ALS.

While slightly uncomfortable for the patient, they can sit on a backboard for a few minutes. This will give you the opportunity to have a much better look at your patient and provide a better assessment to report to the ALS providers.

While other's may feel that you've done nothing wrong, nothing right has been done either. It's a neutral situation with minimal effort on your behalf to promote expedient transport of this patient. Putting the collar on saves 30 seconds. Everything else has still been left for someone else to do, and we've lost 8-10 minutes worth of time.

Patient care should come before patient comfort. This patient should have been packaged and ready to go by the time ALS arrived without a doubt.

After this call, I would have more than likely been wanting to talk to you and find out why the patient wasn't ready upon our arrival. Removing this patient would expedite transport, while allowing you to do your job better by performing a better assessment.

And finally...this quote...

The arriving medic comes across as a lazy sob that didnt want to do the work of the extrication. I think you did the right thing. You were looking after your patient.

Just out of curiosity, why is the medic a lazy sob for not being happy about doing something that should have been done before their arrival in the first place? Maybe the medic should call the provider a "lazy sob" for not having immobilized the patient? What's been accomplished in the way of patient care during the ALS response to this call? I'd love to hear your thoughts...

Shane

NREMT-P

[rocket]

When the crew finally performed the extrication was it a "rapid" type straight to the board or was the patient first put into a KED or short board, etc?

Based on the patient complaints and the way you describe the scene/wait time it sounds like a KED would be the best/right way to extricate this patient...but then I don't know what you had available to you or what your protocols dictate so I am not sure if that was an option for you.

Supposing the KED was available:

If I were arriving on scene and found the patient still in the vehicle but immobilized in KED and ready to come out nice and easy onto the long board (with the board right nearby and all set up for the transfer) I would have no problem at all with what I found. The KED would help keep the patient stabilized in the vehicle and also reduce the potential for injury when removing her from the vehicle. Your crew would probably have the extrication plan worked out prior to my arrival ("we're gonna bring her out feet first and these two firemen will help hold the board") so the transfer from car to board should take up a trivial amount of time.

-Trevor

[spenac]

Original poster should have applied KED. Then moved to back board and secured. Plenty of time to handle this call the right way. Rapid extrication would not be justified, if you felt it was ok to let her stay in the car plenty of time to do it right. Patient screams, say so sorry but we'll have you ready to get pain meds quicker if we get you ready for the next ambulance.

[Eydawn]

So you put the KED on them to make it easier to transfer them to a board just prior to putting them in the arriving ambulance... equally valid. From how the scene was described, I don't envision a patient out on a board sitting for 10 minutes being safer or that being more beneficial to their well being as opposed to remaining in the shade of a vehicle with open doors.

I might also add that yes, rapid extrication is *best* utilized for those patients with critical injuries, life over limb... but a patient who is panicking as you're placing a KED is going to put themselves in danger as well. You removing them in a rapid, controlled fashion would seem preferable to me, because either way minimizing movement of the spine is our goal.

I guess I envisioned the scene as a hysterical woman with some painful injuries panicking and not necessarily being entirely cooperative with or receptive to the actions being taken by the responders... perhaps I didn't see it right. If so, mea culpa. If no, I still might have gone with this route... quicker and less conducive to further panicking the patient.

PS, dusty, of course you don't use it as a "whups, I've been on scene for..." technique. DURH.

Wendy

CO EMT-B

[James_ffemt]

These are the types of replies I hoped for. I was not sure I did the right or wrong thing by waiting on the truck to arrive. I will say that the 8-10 minute ETA for the second truck was established as soon as we arrived on scene. I helped my paramedic package the more critical patient first. (EMT-B/FF was with pt. who was still in car.) Once the critical pt. was in the ambulance I went to the pt. in the car and obtained baseline vital, SAMPLE, etc. I also placed the pt. on O2 while she was in the car. I have no idea how long all of this took, but I would say 6 min. or so.

KED would have been a great choice.

Once the other crew arrived, I gave a report to the medic and he released me to help my partner so that we could get to the LZ.

I think this scenario could have been handled many different way depending on many different things. That's why we are all here is to learn and ask questions, so that the next time we will have more knowledge to handle a similar situation differently.

Thanks for all the replies.

[spenac]

I applaud you for looking for ways to improve. I work in an area where mutual aid is 1 hour away. I have been on wrecks with more patients than we had back boards and c-collars for. But when mutual aid arrives all 4 of my backboards have patients properly packaged on them. If any kids they are are secured on pedi-board or even have used KED to immobilize them. Point is always be moving patients toward the hospital, if you can't transport them all yourself by getting them packaged you are getting them to the hospital that much quicker. As far as screams of pain, good thing, worry about the quite patients not the loud ones. Do what you can to minimize pain, and often immobilizing them is all a basic can do to help pain.

Bystanders are used to hold sheets for shade and in the 100 + temps we have here for 5 months that is a plus. Other calm bystanders will hold c-spine and talk with patients to help keep them calm. Anybody hanging around becomes your tool. Put them to holding pressure on a bleed, etc. Take charge and do the job.

In the end look to improve but don't beat yourself up when you realize something could have been different. At the moment you made the decision it was the best choice at that moment in your opinion. Next time something may motivate a different approach, maybe even some of the things that you read here.

[medic001918]

From how the scene was described, I don't envision a patient out on a board sitting for 10 minutes being safer or that being more beneficial to their well being as opposed to remaining in the shade of a vehicle with open doors.

I have a great reason to remove the patient from the safety of the vehicle. The first is in the interest of patient care. How thorough of an assessment can you do on this patient while they're sitting in their car? I can assure you that it's not as thorough as if you had removed the patient from the vehicle and had a good look at them from head to toe.

As far as shade goes, even a car with the doors open will increase heat significantly. Remove them, package them and transfer care to ALS. The few minutes that they might be sitting outside in the sun (assuming a 10 minute response minus a few minutes to pacakge them leaves just a few minutes), is not going to cause significant detriment to the patient if any at all.

Let's put another question out there...did the airbags go off? If not, that's a good reason not to have a patient sitting in front of the steering wheel while nothing is getting done for them. There are plenty of cases where airbags go off well after an accident.

I'm still siding with that by just sitting with this patient with them in the car, the only thing that has been advocated for successfully is a needlessly prolonged delivery time to the hospital. Remove the patient, package them and perform a correct and thorough assessment of this trauma patient. If another occupant of a vehicle was flown and is going to a trauma center, this patient could certainly benefit from a head to toe assessment. Especially since the patient is reported to be hysterical. Your best assessment tool in an uncooperative patient (for whatever reason) is your physical assessment. And a thorough physical assessment cannot be performed while the patient is sitting in the car.

If you're not doing someting to get this patient packaged when I arrive if I arrive 8-10 minutes after you and you're just standing with the patient holding c-spine with a collar...you've done a disservice to your patient, and to your service as that kind of treatment should not be tolerated. We've put a percieved patient comfort (the hot sun outside instead of the "shady" car) over patient care (a proper and thorough assessment). That equates to a loss of credibility as a provider in my opinion. That loss has been properly earned back in this case by making an honest attempt to learn from the situation. While his supervisor's may agree with him in this case, that doesn't make them right.

Let's not lose sight of our jobs as prehospital healthcare providers. That function is to transport the sick and injured to the hospital. Sitting with this patient in a car while the equipment and manpower is present to perform patient care shouldn't be tolerated.

Shane

NREMT-P