You Make the Call – Kid in the Street – What Happened

This call was fabricated to see what different kinds of treatment options and requirements exist amongst my 4.75 readers.

 

The kid seems fine, but the language barrier puts us in a gray area and learning that he fell to the hood of the car with mom on top, then to the ground adds to the dreaded M word.

 

But in this situation, unfortunately, many systems’ hands are tied.  In some areas a new category has emerged called the “High Risk” population, commonly those under the age of 5 and over the age of 65.  Some protocols are requiring MANDATORY precautions for patients who meet criteria regardless of physical assessment or paramedic judgment.

I am against blanket policies that take my clinical judgment out of a decision matrix.  If this is the future of EMS, let me off the train, we need to rebuild the track.

 

My system has this group but luckily we are still clinging to a “paramedic judgment” line in our policy to let me use my skills to evaluate the patient, not the protocol.

There is always a debate as whether to “immobilize” this child or not, mainly because we all know attempting just such an intervention will cause more range of motion and trauma than letting him stand still.  I don’t need research to tell me that.

Spinal Immobilization is useless at restricting cervical movement,  a nice splint for other things, but until an agency is willing to admit the truth, we’re afraid some lawyer will bring up a 30 year paramedic who will testify that they used the board for 30 years and never had a problem.  Groan.  Defensive medicine.

Instead, they would rather us pull out the pediatric LSB, wrestle the kid into submission, twisting and contorting his little body far worse than anything he’s experienced already, then, because he doesn’t understand our requests to stop ripping the tape off his head, we have to restrain him.  Restrain a 2 year old based on someone’s warped definition of a “high risk” group.

In the end I have 2 options for this kid, neither of them appropriate for the situation.

First, full C-spine immobilization and trauma activation based on the “High Risk” matrix or convincing mom that further evaluation is warranted and she and the kiddo should come calmly in the ambulance, no lights, no sirens.

A refusal on this kid is going to be tricky and a tough sell to the Medical Control MD on the other end of the line.  If you tell the story wrong they might launch a helicopter (or 2).

 

This tale began as a near drowning in a pool to see who would board him, but after running a guy hit outside a crosswalk I decided to change it.

As always, regardless of how archaic our protocols may seem, follow yours.  If you don’t like them, get them changed. On scene is no place to challenge established policy.

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5 thoughts on “You Make the Call – Kid in the Street – What Happened”

  1. One system I work in is able to admit that the protocol is written for the weakest link.  They tried to seperate providers based on experience and past “mistakes” but was shut down by the state EMS.

  2. In my system there are a set of guidelines in addition to the “standard” trauma activations (alerts) that determine hospital destination. These additional guidelines route a group of “high risk” patients as described above to a trauma center rather than a “regular” ED. This does not require code 3 transports or any crazy treatments other than what the patient’s condition might indicate.

    So, with the above scenario here is what we would be required to do:

    -Age less than 5 yrs = spinal motion restriction.
    -Auto vs. Ped >10 MPH will go to a trauma center (does not meet trauma alert criteria, but does require transport to the trauma center).
    -Inability to communicate with the patient ie language barrier would also indicate spinal motion restriction, but since there is a native speaker/translator on scene this point does not come into play.

    Now, all of this is mute if the parent does not wish the child to be transported. The mother would be advised that the assessment and evaluation of their injuries or potential injuries is incomplete without the added resources of the emergency department and physician. We recommend that they be transported to the ED for further evaluation. There is a caveat, we are able to make decisions with regard to treatment that are in the best interest of the patient. If the child were to be extremely agitated and non-cooperative with spinal motion restriction, it would be reasonable and expected to do what is best for the patient, barring any concerns for closed head injury, to transport the patient to the hospital (trauma center) in a position of comfort and document your findings and concerns. Contacting medical control with these concerns, as well, in order to get a second set of ears and another “brain” in the mix, would also be indicated.

    The bottom line is, there are a set of guidelines and expectations for “all patients”, but each situation will demand an individualized assessment with these guidelines in mind. When in doubt, phone a friend (medical control).

  3. I don’t think I’d have a hard time clearing c-spine or AMA’ing this one. We have a translator, the mother is not injured and states her child is acting appropriately. We can do a rapid trauma assessment with her consent and clear c-spine. Next, we make base contact and “paint a picture” for the MD.

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