Rogue Medic is in a great mood as of late and this article about the complete joke that is Mechanism of Injury (MOI) hits the nail on the head.  I recently had to triage a car over a patient because of strict trauma guidelines, luckily finding the always available “Paramedic Judgement” to wiggle my way out of it.

 

The simple point is this: Mechanism needs to be a symbol on a map, not the destination.  With cars designed to crumple around our patients, what if it does take 30 minutes to get them out but they are unharmed?  And the pedestrian clipped by the mirror on the arm by a passing car at 40MPH?  Why are they on a board and in a collar?

 

Because 30 years ago when this Profession was still trying to figure itself out we bought into some crazy ideas, that’s why.  Now that we’re actually starting to study some of these ideas and finding them hurting more patients than they are supposed to help, we need to start revamping a number of our “standards of care” which actually should read “That’s what everyone else does…”

Whenever I have to document damage to a vehicle (mainly for my recollection of the run later on, just in case) I try to use some basic terms that at least remain consistent in my own description of vehicles.  Those are:

Light truck, truck, large truck, coupe, sedan, wagon, van and commercial vehicle.

Then I go and describe the damage using 3 terms, light, moderate and considerable.

Those are mine and can be widely interpreted.  Maybe I’ll get Motorcop to jump in on this but…A coupe hitting a brick wall at 40MPH will look differently than a van that hits another van at 25MPH.  One is a trauma, the other not by protocol, even though one may indeed have carried far more force.

And even if I do mention light damage to the front of the vehicle, what does that mean? What kind of car? What kind of impact? Against what? Did the vehicle’s protection systems discharge properly?  If the driver was able to self extricate and has no chief complaint, why am I chasing him down with a C-Collar? Because the folks who wrote the policy are in a committee long ago and far away.

MOI is important as far as it gives us an idea of POSSIBLE injuries to consider.  I consider it as a part of the Past Medical History and weigh it just as heavily.  If it does not apply to the patient’s presentation it will be considered, but not relied upon.

One rollover will have a 17 year old girl sitting on the curb completely unharmed while a minor damage collision could yield significant injuries to the passengers.  We won’t know until we assess them.

I remember long ago in far off new Mexico, some medics would launch the helicopter just based on dispatch information of the reported damage.  And we’re back to the telephone game of one person’s “Oh my God! They’re trapped!” and another’s “She’s just not getting out, but looks fine.”

Assess.  Use MOI as a tool, not a guide.  We always look inside the passenger compartment for deformity, blood, marks, bent steering column etc, but we should not be basing a transport on the vehicle.

 

Then again, try documenting that you let a driver refuse transport who had moderate damage after a head on collision into a guardrail, deploying front airbags with a non-complete recollection of events.

Now if I tell you they hit the guardrail head on after sideswiping another vehicle at 40MPH and spinning around, coming to rest in the slow lane and is avoiding telling the police they cut across 6 lanes of traffic to make an exit…now can I let them go home?  Or should I be chasing him down with a collar?  We all know the answer to that one.

 

Looking forward to more, Rogue!

It’s easy to see an accident and keep on walking, but something in some people kicks in to make them want to learn more. At a recent accident we’ve all seen on video by now a motorcyclist collided with a car and, surprisingly, they caught fire.
As random folks come to the car and look inside a woman in flip flops does what EVERY rescuer needs to do at EVERY roadway incident:

She looks under the car.

Seeing the unconscious body of the motorcycle rider she tries to lift the car off of him. Others seem interested and when she confirms again “there’s someone under there” the troops are flocking to the scene to lift the car.

You can give credit to the worker who pulled the rider out of harms way, the cops and their interesting fire attack or even the firefighters and paramedics who magically appear, but the real credit goes to flip flop lady and her desire to answer the burning question she had inside: “Where is the rider?”

From NPR: According to the Salt Lake Tribune, Wright suffered a “broken leg, a shattered pelvis, bruised lungs and burned skin,” when he and his motorcycle collided with a car. But, thankfully, he is “well on his way to recovery, his doctors said.”

 

Each year I choose 1 story to share in an effort to keep alive the memory of those who died. Buying a sticker or a T-shirt that says “Never Forget” isn’t enough, heck it’s nothing. Learning about the lives of those who went into that morning not knowing if they would be coming out and sharing their stories with others is the only way to remember and keep them alive in our hearts.
I used to think the ancient Egyptians were foolish for claiming they were going to live forever, yet we still speak their names and honor their traditions in our museums and textbooks. They truly did accomplish living forever and if we want these men to be remembered in the same way we must continue to share their stories and speak their names aloud.
In my search for a story to share about those who died on September 11th, I kept coming back to a number: 10.  10 years, 10 Engine, Ladder 10…10 House…

A firehouse is much like a family and when a member of a family dies it can have an impact on the survivors. But what if more than 1 dies? Or 2. What about 6?

This year I share the memories of 10 House and the day she lost 6 of her children.

 

10 House is the quarters of Engine 10 and Ladder 10 who, in 1984, adopted the logo of a firefighter straddling the tops of the twin towers on fire reading “First due at the big one.” And they were.  Reports from survivors say that even as they rolled out the door there were already bodies in the street.
The firehouse is on Liberty Street directly across the street from the World Trade Center. The house survived the collapse and was re-opened after getting fixed up, but her family is still healing.
Both companies were established in 1865, later moving to the same house.  It is one of the few houses where the engine and ladder companies happen to have the same numbers. For almost 150 years she saw only 3 deaths in the line of duty, on that September morning the number would triple.

Lt. Gregg Arthur Atlas – Aged 44 years, Lieutenant Engine 10

Firefighter Paul Pansini – Father of 3 children, Firefighter Engine 10

Lt. Stephen Gary Harrell – Age 44, Member of 10 House assigned to Battalion 7

Sean Patrick Tallon – 26, Marine Reservist and only weeks away from completing Probationary status on Ladder 10.

Jeffrey James Olsen – Age 31, Firefighter Ladder 10

James J. Corrigan – Retired Captain from 10 House, oversaw Fire and Safety Operation for the WTC complex

 

The house was a gathering point for those wishing to visit the FDNY to offer their condolences.  Like many houses it was covered with patches and shirts from visiting firefighters, letting the members know they were in others’ thoughts.  A beautiful memorial was erected inside dedicated to the 6 members who died and included was a newer plaque honoring the 3 that had fallen between 1867 and 2000.

10 House became the site of a 56 foot bronze relief sculpture donated by Holland & Knight , a Law Office, who lost  employee Glenn J. Winuk, also a volunteer firefighter, when 10 House lost her children.  The relief was dedicated in 2006 and is the only 9/11 related site on my list of things to see when I visit New York later in the month.

I don’t want to see where 10 House lost, I want to see where she lives on.

You can learn more about 10 House on their excellent website.

2009′s memory

2010′s memory

When people call 911 for an intoxicated person, which amazes me to begin with, I have to wonder why the badges start to bump into each other.

“Code 3 for the PD request” is a call classification I hate hearing because it means the call taker has not completed a triage of the call.  There is a glitch (yes, I’ll call it a glitch because if this is done purposely I need to fix it) that allows PD to bypass call triage and get an amulance immediately.

There is no reverse for this system.  When I request PD code 3 I get barraged with questions.  And when I’m fighting someone no less.  When I get on scene to the PD request, they are most often standing, looking at someone.  Not providing care (which they usually don’t need to and are not trained to do), so why not take the time to classify their call too?

Who knows.

The reason this is fresh in my mind is because on a recent run with our boys in blue I was told “We’re not arresting him, it’s too much paper work and too expensive for the department to hold him until he sobers up.”

I stood up and cocked my head aside.

I responded that our paperwork is just as burdensome and the cost was exponentially more to the same city for what he was requesting.

Drunk is not an emergency, nor is it necessarily an arrestable offense, so what do we do?  If a person is unable to refuse transport (meaning unable to sign, not that they don’t need an ambulance, which they don’t) we’re trapped in a way.  We HAVE to take them and the ER HAS to accept them, meaning the actaul patient we bring in later has no room and has to be diverted.  This is not an argument to have on scene. When on a run THAT patient is your concern, not the next one.  Let me worry about the next one.

This is an opportunity for a third service to step in and handle intoxicated individuals.  We do have “sobering centers” although I’d reclassify them as ambulance drop-in and pick-up zones with a 2 hour waiting period.  We take people there in an ALS ambulance, then when they awake and vomit, the center calls us back code 3 for the “unconscious.”

Public intoxication is more common in my area than sudden cardiac arrest, yet there is no tool in my kit or on my radio to help.  The van service for shelter and detox requires a person to be ambulatory and climb in the van unassisted.  Most folks that meet that metric wander away when they hear us coming.

So why not let them sleep it off in the holding cell at the local PD?  I’m sure there’s a person there to monitor them and it is remarkably less expensive than an ALS transport and hospitalization.

But that’s not where they belong.  That is not the right place for them.

But the hospital is the more inappropriate place for them.  Why not check them out in the field, clear them of life threats (which the triage nurse will do from 100 yards) and let them sleep it off somewhere less expensive than an ER?

Motorcop?  Trauma Pig?

Turfing them to me is easy for you, but not for us, nor for the citizen.

Fodder for a Crossover indeed!

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.

Michael Morse is hiring for The EMS.

 

I don’t swear often, but when I do, I say:

“Michael, Hells yeah I’m in!”

No, this isn’t a post about the Golden Gate Bridge.

Although it could be.

More a comment a bout blind allegiance without question.

I think everyone’s mother at one time uttered the phrase “If all your friends were jumping off a bridge would you do that too?” when our defense of a choice was “But all my friends are doing it!”

I was wondering recently why so many systems are running full speed towards certain treatments that have a great effect, but not necessarily pre-hospital.  If the beneficial time of application is within 3 hours of illness or injury and my average time from patient contact to hospital is 30 minutes, is that worth the investment for the system?

What if the time of application is 6 hours?

If studies show that applying treatments within 6 hours is beneficial, is that a good investment for my system?

So many systems are running towards therapeutic htpothermia and judging by the studies it is a beneficial treatment.  But do we need to be starting it immediately?  From what I can tell systems with prolonged transport times, only Intermediate Life Support, most rural areas, could see a great improvement in patient outcomes.

But in the urban settings, when even the ER could wait to apply it, is it something we need on the rigs, in our continuing education, and yes I’ll go there, additional opportunity for misapplication (liability)?

When does the risk/cost outweigh the benefit?

I think it is similar to the decisions I make in starting an IV pre-hospital.  We have nifty little saline locks attached to tubing for “gaining access.”  With the risk of infection in the back of my rig, or worse yet in the street, I will only take that risk if the benefit is there.  Why am I breaking the skin simply to attach tubing?  If I am not anticipating the administration of life saving fluid or medication, then why even do it?

When these pricey little guys arrived in our bags there was a training session and now 4 saline tubes and tubing are in my overflowing 40 pound bag.  In the early days someone (I don’t know who…) put a little paper in the baggie with the saline lock that read:  “Peripheral venous puncture is not a benign procedure.  If you do not anticipate the administration of life saving fluid or medication, does the benefit of administration outweigh the risk of infection?”

I still don’t use them and am quite within policy, protocol and the one that should be first on the list, the patient’s best interests.

BUT, on the other side of the bridge jumping argument, I like to think I surround myself with people who are like minded, forward thinking individuals.  If Ted Setla, Radom Ward, Chris Montera and Jeremiah Bush jumped off a bridge I would have to ask some serious questions as to why.  Or trust my friends.

I have made some blind leaps in the past that I now find foolish, probably still a few left in my future, but a blind allegiance is the thing I want to bring to your attention.  It is said that the most dangerous person is the true believer and someone who will blindly jump off that bridge with their friends no questions asked is the same in my mind.  However, a constant doubter, someone who refuses to jump or stay, but wants to see what the majority of folks do first is equally as foolish.

So when Mom asks  ”If all your friends jumped off a bridge, would you jump too?”

I’ll answer:

“Well…is there a train coming?”

Our engine boss is cramming for the Captain’s exam when the bells ring for a call at the golf course.  A HazMat at the golf course.  This could be interesting…

THE EMERGENCY

Multiple calls for multiple sick persons, unknown cause.

 

THE ACTION

There are a few things we look for on the way to these types of calls, right?  There was no smoke, or cloud, and we approach from upwind, despite the requests from local law enforcement to pull up to the main entrance with him.  However, his skin remained intact and he was conscious, so our trusty litmus officer was helping in an odd way.

There were, however, 2 things that had me curious on our approach.  First, the ambulance had arrived before us and was staged across the street.  Second, there was a line of cars exiting the parking lot in a hurry.

Something was up.

 

We parked upwind at a hydrant so we could hook in and mass decon if needed.  Airpacks went on and the triage kit came out of the side compartment.  I was having trouble resetting my mind from being the EMS supervisor the day before, to being part of the engine company today.  Part of me wanted to establish the warm zone and set up the decon corridor while also designing ambulance ingress and egress.

Instead I had to find out what on earth spooked an entire golf course to run like hell on a beautiful California afternoon.

The remaining people near the clubhouse are pointing and giggling at the firemen approaching taking full precautions as we’re shouting for them to remain still and tell us wha on earth is going on.

As with most emergencies of this nature, their first action was to come towards us.  Great.

“In the kitchen,” a man with a name tag tells us, “Pepper spray.”

Huh?

Around the side of the building is a person with a wet towel on their face and a group of white shirt, checkered pants clad folks, clearly the kitchen staff.

Someone thought it would be funny to release some pepper spray into the kitchen during the lunch rush.

When the entire staff ran out of the kitchen screaming and rubbing heir eyes, the patrons thought the worst and did the exact wrong thing.

They dispersed themselves across the City and the region before we had identified what had happened.  Perhaps they understood it was pepper spray, but none of the non-kitchen staffers were able to tell us what had happened, so I doubt that.

Now imagine it was somehow something more sinister and all 300 people escaped without being decontaminated.  There you are in your district running a general sick call.  She mentions being in San Francisco a few hours ago on a golf weekend that went sour.  Then the husband vomits and passes out.

Worst case scenario sure, but we deal in those sometimes.

Any ideas on how to stop those evacuating?  And don’t say PD, because remember, he’s already in the hot zone.

EMS1.com is reporting a Florida man who was transported after a loss of consciousness may sue the agency that transported him.

According to the report, the patient suffered a loss of consciousness and was assisted by neighbors to his home and someone other than the patient dialed 911.

After an assessment, according to the patient, the paramedics determined he was “at risk for a stroke” and needed transport.

Kenneth Rothwell, the patient, states he was told, “It was either go, or you’re going to be handcuffed and we’re going to take you.”

Hang on here a minute folks.

The story does not elaborate WHO said anything about the handcuffs, but a deputy and EMT were at the scene.  Now we have reports of 3 rescuers (“Paramedic” “deputy” and “EMT”).  I wonder which one brought up the idea of handcuffs?

 

We have safeguards in place for this kind of situation by way of direct Medical Control.  Whenever I have a high index of suspicion of illness or injury and a patient refuses, I do my best to convince them of what I think is in their best interests.  If that fails I fall back on direct Medical Control to talk to the patient.  If that fails, most times, the MD will instruct me to explain the dangers of staying home to the patient and…wait for it…leave them there.

There is never a threat of “being handcuffed and we’re going to take you.”  That should NEVER be an option.  The urban myth that is patient kidnapping is being supported by poor decision making based on false presumptions.  I can only imagine that the deputy who made the hand cuff comments (unconfirmed) had no intention of placing Mr Rothwell under arrest for passing out.  I’ll have to confirm with Motorcop that is not an arrestable offense.

 

Point is that Mr Rothwell has a very good argument against whoever told him he “had” to go, either willingly or in cuffs.  THAT is the part that bothers me about all this.  That and the fact Mr Rothwell is required to make health care decisions based on out of pocket expenses, but that’s another issue entirely.

 

Comments will surface soon about foolish EMTs or that this is a good reason EMTs and Paramedics should not be making refusal referrals pre-hospital, but this is EXACTLY what Mr Rothwell needed.  BLS before ALS failed Mr Rothwell.  A well trained Paramedic could have offered Mr Rothwell a calm comfortable ride in his first response vehicle, or even to follow him to the local ER if he likes.  Maybe even make an appointment to call or drop by later in the day to check in on him, but we are locked into a 40 year old model that scares our people into transporting every scratch and scrape, tummy and head ache so we don’t get sued.

And this is where it gets us.

At the very least, the agency who mislead Mr Rothwell using intimidation in order to remove him from his home against his will is at risk for setting an industry wide precedent and prove the urban myth a reality.

 

Your training exercise for the day:

Was Mr Rothwell, based on the EMS1.com story facts as reported, kidnapped?

We have all come to be familiar with the black, red, yellow and green triage tags and train repeatedly on thier application.  Whether it's a neumonic a 5th grader can follow or based on common sense assessment, we know the green are slightly injured and the black tagged folks are dead.  The red and yellow cover everything else from a respiratory rate of 31 to myself, with a natural cap refill of 3-5 seconds.

We are trained to assess, tag and go to the next person.

The system works great on table top scenarios, in drills and even in the field at mass casualty incidents, but I was inspired recently to introduce a new color/tag/classification to the triage kit.

I know, exactly what we need, right? Another confusing category.

 

Well, this one makes it even easier, believe it or not.

White.

I am officially adding WHITE to the triage category here at HMHQ.

When triaging you will no doubt come across persons with no injury, illness or complaint, but see the opportunity to become part of what they believe will be a chance to make a few bucks.  This is not uncommon in my area during bus incidents.  A bus will have a minor collision or hard stop and call for help.  Before help arrives, people will climb on the bus and create injuries inconsistent with the collision or direction of hard stop.

These people will fall into the NEW classification of WHITE or "I surrender."

When in a triage situation, if I encounter someone who is uninjured and ambulatory, they are not "walking wounded" but simply "walking."  Last I checked we can do very little for the "walking" other than sitting them down, tagging them green and wasting what few resources we have on them.

Same goes for persons displaced after a fire in their building or adjoining buildings.  They should be triaged WHITE and told to wait nearby for information from the Red Cross or other agency who can help them.  If there is no injury, a green tag seems wasteful, does it not?

Have you ever encountered an MCI with a crowd?  How do you know who is hurt and who is not?  By asking?  Great assessment skills there, Sparky.  Don't let your mind get lost in the sea of "Oh my God there's 10 of them!" and remember that you are doing triage based on your agency's instructions.  Chances are you're using the START Triage system, which assumes by the time you arrive and assess that life threats will be already changing mentation, respirations and perfusion.  Keep in mind that an ambulatory person missing an arm, breathing 22 times a minute with good cap refill on the remaining arm is a green under this system.

But let's get back to the lady wandering the triage area asking who to talk to about suing the building owner/bus company, or who states they were hit by debris but show no signs?  Are they GREEN or are they something less?

Currently the system does not let you make that determination.  After all, what do you know anyway.  Just tag them and deal with it later.  And by later, I mean let treatment sort it out, right?  While it does take a short amount of time to properly tag a person with name, age, allergies, medications, pulse, respiration and mentation status, we could be helping the next person who actually needs us.

Getting to them later is not a liability, spending time confirming they are uninjured is the liability.

So why does the system not account for the liability of the "walking?"

 

Because until now there was no WHITE category.

To be tagged WHITE in an MCI a person (they are not injured so are not a patient) must:

1) Be ambulatory

2) Have no sign or symptom of illness or injury

 

There, wasn't that easy?  I just saved you 8 backboards and 3 ambulances at your MCI.