Reader BG Miller left the following comment on my post about how a seemingly NBD (No Bog Deal) chart could be the most important one we write:

Okay, question from one of the non-EMS readers…
One of the injuries being listed for Zimmerman is having his head bounced off the concrete one or more times.  So you have a patient with a possible head injury who is experiencing great emotional stress and possibly shock, (unless he is a complete psycho, but that’s another argument) is he capable of signing a refusal?

Of course he is.

“Having his head bounced off the concrete” is not an injury, but a…wait for it…mechanism of injury, meaning he experienced an event that could have led to an injury.  Similar to saying “He got stabbed.”  Well, where, how deep, with what?  All those questions have to be asked to establish the extent of a possible injury.  So if I was told that at the scene we would transition, in my opinion based on little else, that this would shift from a refusal to an AMA consult with online medical control.  He’d also get a full work up in my office, not in the squad car.  Depending on the discoloration, shape, sound and feel of his injury (yes, I said sound) refusal may be out of the question.  Certain injuries can indicate that a significant amount of force caused it and remembering that the brain inside the skull can be injured just as badly, if not worse in some cases, can lead us to determine appropriateness for transport.

In my system, if a person exhibits trauma above the clavicles, they are candidates for full C-spine precautions.

Being capable of signing the refusal is an easy determination to make, it is when he should be evaluated and refuses is when it gets sticky.  This kind of scenario is when the lie of kidnapping gets added and we all panic and say we won’t kidnap the person who needs further assessment and just walk away.


Under ordinary circumstances getting his head smacked might leave him a bit dizzy but aware enough to decide on his own treatment.  Under ordinary circumstances a fight/shooting might put him under emotional stress but able to understand the medics treating him.  But what about when those two are combined?  Does that change your interaction with him as a patient?

As I mentioned above, if you as a witness tell me those things happened I need to better assess for an injury.  That is when we move to the ambulance, doors closed, lights turned up, so we can see everything the cops and their flashlights missed.  Funny thing  about cops, they are trained to look for weapons, drugs, offensive motions etc, but few of them have any clue how to assess for an injury. “He ain’t bleedin’ ” tells my nothing Serpico.  Bleeding is the least of my concerns.  From the cot inside the rig we can assess and if indicated initiate transport after convincing the patient it is warranted. “Look, you’re already in here, we could be there in 10 minutes and it’s done.” “You don’t need it? Well, you might be right, but let’s make sure, wadda ya say?”  If he needs to go, we can convince him it was his idea in the first place if we do it right.

Emotional stress accounts for most of my calls.  I often joke that we spot you 20 points on your blood pressure because of all the sirens.  If I had just shot someone I would be…well…I don’t know.  I would have to assume I’m jittery from the adrenaline of nearly being killed, killing someone, and now being assessed for an injury.  However, the down from that high could also be intense.  we all handle stress differently and can’t draw any conclusions from a person’s demeanor or level of calmness at the scene.


Also, having read a few cop’s take on self-defense shootings, it seems common that the problem the police face isn’t getting the shooter to talk to them but getting the shooter to shut up long enough to be mirandized.  Like someone that’s been through anything traumatic they tend to babble a bit.  So as a medic do you note what they are saying in your report?  “Came out of nowhere,” being mumbled will have a different spin in court than, “I shot him.”

I too have seen a tendency of purposeful shooters to not stop talking, mostly of the walk by and drive by variety, boasting of their accuracy or the severity of the wounds of their target.  When it comes to documenting their responses or comments, I stick to what is medically pertinent.  In this case, since the patient was involved in a violent action I will have PD in the ambulance with me and searched prior to being placed in the ambulance.  If he mumbles something it is the officer that needs that information, not me.  I could not care less why he did what he did, I care about his injuries.  If he mentions “Dude had a baseball bat and then everything went dark…” I note the bat because it directly impacts my impression of the injury.  Other details we’re better off pretending we didn’t hear and let the police handle it.


Thanks for a great question.  What about you fellow EMSers?

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