Category Archives: You Make the Call

You Make the Call – Handcuffed

Man it sure has been awhile since we fired up the ol’ You Make the Call Machine here at HMHQ, but I thought it’s finally time to get back on the posting circuit.

 

For you new people, I post a situation, you answer it based on your local policies.

 

Dispatched in the first response vehicle of choice for your agency, the local PD has detained a man who assaulted another person.  The other person is receiving care from your partner and is stable, bleeding controlled and has agreed to transport.  PD presents you to the window of the patrol car where you can see a superficial laceration to the forearm just distal to the left elbow.  There was a small drip of blood that appears to be dry, no other injuries are obvious through the window.

After repeated pleas the officer agrees to open the door and remove the patient but warns that he became violent when they took him into custody.  He stands and allows a brief primary and secondary exam and you note no other deformity or injury.  He is refusing vital signs, treatment and transport in colorful language, but denies alcohol or drug use.  When asked if he understands the risks of refusing assessment and treatment he replies in the affirmative and states his reason for assaulting the man and the police is his business, not yours.

 

Is he able to refuse service?  If so, who signs the form when PD tells you there’s no chance of him removing the cuffs to allow for a signature?

 

You Make the Call.

You Make the Call – Bit – Part II

Let’s recap:

We’re miles from the nearest ambulance, 35-45 minutes from the arrival of the first response unit and a now rapidly swelling index finger from a snake bite.

The Coleman Brand Snakebite kit is a small package of provodine, a scalpel and a little sucker tube.  More or less useless unless we were hours from help.  We’re far, but not nearly THAT far.

One of the moms has the rangers on the phone and they’re en route, advising us not to take any action.  They’ve got a small BLS bag and arrive soon after we heard them running sirens on the mountain road.

The Rangers gather their patient’s basics and make a decent attempt to take a blood pressure when I suggest ever so gently that perhaps time is of the essence and an intercept with the responding ambulance would be a good idea.

“We can’t transport him.”

No, you can, you just can’t bill for it, or call your vehicle an ambulance.

“Oh, OK” was what came out of my mouth.

A patient update has been sent and when I realized the decision that had been made only one thing crossed my mind:

I wish Rogue was here to see this.

The helicopter was already circling, less than 10 minutes since the gentleman wandered into camp and at the rate the edema was intensifying even a ground intercept was going to be cutting it close.  The initial edema didn’t seem so bad, but now you can almost see it creeping slowly past the second knuckle with no sign of slowing down.

All my breathing coaching is helping a bit, but I was later informed of the reason his pulse rate increased:

He has no insurance.

 

The landing was fast, they didn’t wait for an LZ to be set up, just picked an empty campsite around the corner and did their thing.  One of the rangers drove off to check on them, code 3 of course, and came back moments later.

“Get him in here I’ll drive him over to the chopper.”

Chopper?  Really?  Oh well.  Suddenly we CAN transport, and I remind the patient to stay calm and let the nurse and medic know about any dizzyness, numbness, trouble breathing, the big stuff and away he went.  Another few moments later we hear the helicopter throttle up and tilt the rotors and away they went.

Now imagine he hears the helicopter and tells you there’s no way he’s going with them and asks you to drive him to the ambulance.

What would you do? You Make the Call.

You Make the Call – Bit

This weekend was to be the first camping trip of the year.  Staying local, visiting a state park that we had never visited takes the strain of a few hours transit out.  On a clear day you can see most of our region, 60-70 miles in all directions.  Seemed like a fun spot and provisions were secured.

Universe Warning #1: No alcohol allowed in the park.

Now I know how CHL folks feel when they can’t take their weapon with them certain places.

Universe Warning #2: Extreme Fire Danger in effect. Only charcoal and gas stoves allowed, no open burning.

How am I supposed to do SMORES over a charcoal built in? We’ll make do.

 

And that was before we even packed the car.  Looking back, the Universe, God, Karma, something was trying to send me the signal NOT to go camping this weekend.  I wasn’t listening.

I’m getting to the You Make the Call…trust me.

Arriving at the park we picked out a shady site with a large enough spot for our tent and the girls to run around and exhaust themselves.

As I open the back of the van to get the gear I hear from commotion from the next site over, “Oh God he got bit by a rattlesnake!”

 

A 58 year old male walks in from the open space nearby holding his left hand.  He sits at a nearby bench, 1st finger with a single puncture wound, the bleeding has stopped but the site shows initial edema.  He is smacking his lips while speaking in full sentences and is in good spirits considering.

Being the kind camper you are you approach and offer assistance.  A woman is tying a twine tourniquet on the finger which you quickly remove and they raise his hand which you quickly restore to it’s natural position and ask if anyone has called the Ranger Station.

Another woman has appeared (It was a Girl Scout outing, moms and girls) with a snake bite kit.

Your situation:

What might pass for a BLS camping kit plus a dose of epi 1:1000 back in your own camp.

New in package Coleman brand Snake Venom Removal Kit.

Campsite is 15 linear miles up a mountain, the drive took you 35 minutes avoiding bikers.

The Ranger Station is maybe 2 miles back down and just a few minutes ago had 2 Ranger vehicles parked there.

The man has no pertinent medical history, is alert and oriented and in the few moments it takes to assess the situation the edema has not changed.  His pulse rate is elevated, 130, but he is anxious as well.

 

What do you do?

You Make the Call

 

This will be a 2 part YMTC and will expand on what I did and what happened then.

You Make the Call – Still Hanging Around?

PD often asks us to preserve their crime scenes before we can get in and do our work, but this situation seems unique indeed.

 

While the particulars have been decently obscured, there was no hesitation on my part when faced with this situation.  We have a “reported” hanging and judging from the past medical experience of my callers it could actually be a car accident out on the lake.  We’re loading up the boat and making our way out there.

Until we can assess and determine a clinical plan other agencies will have to work with us, not delay us, in completing our task.  If we wait for PD dockside a viable patient could deteriorate making our interventions more complex and leading to a poor outcome.

 

So, on the boat we go.

10 minutes later, after listening to PD screaming for us to wait, we come around the bend in the lake to a cove where we see a small sailing boat with a person clearly hanging from the mast, motionless except for when the boat slowly rocks as our wake disrupts it.

His feet are about 6 feet off the deck and it’s been awhile since you were a Sea Scout but the rope tied around his neck does not appear to be there accidentally.  A jacket is hanging on the same mast and his shoes are neatly arranged below him on the deck.

 

Your primary assessment as the boat approaches includes the notation that the patient’s neck is deformed and elongated in such a manner that suggests internal decapitation.  The fingers are flexed into the palm and the arms appear rigid as the body slowly rocks on the boat.  The entire body moves as one.  Do to his dark skin color, no pooling of blood is noted, cyanosis and bruising are also difficult to distinguish.  Judging from the marks measuring the mast the length from his mandible to his clavicle is almost 12 inches with the possibly 3/8″ rope hidden withing the skin behind the mandible, taught.

 

The dock manager feels now is a good time to tell you that the person who found him was in a kayak and first noted him an hour ago.

PD seem to have been able to find another boat and have radioed for you to not enter the crime scene if the person is deceased.

 

Well, is he?

You make the call, based on your local protocols and policies.

You Make the Call – Hanging around

The title is a bad pun, but has a dual meaning, trust me.

You have been dispatched in your first response vehicle to a boat yard for a reported hanging. The location is about a 10 minute drive from your posting spot and no other rescuers are responding with you.

About half way there dispatch advises the reporting party states the victim is in a boat out on the lake and will take rescuers to it when they arrive. The local Sheriffs used to have a boat but budget cuts have it on a trailer in a parking lot.

Arriving at the scene, or at least the closest your rig can get, a man identifies himself as the boat yard manager and motions you to a well kept vessel dockside with 2 other men staffing it. It is larger than a house boat and has plenty of room for all your gear, even the gurney!

Local PD radios you and states they are 10 minutes out with a field investigator and camera and request you do not board the boat until they arrive.

The man on the boat is adamant that you hurry and come with him immediately. It is a 10-12 minute ride to the boat anchored around a corner.

 

What do you do?

You make the call.

Surprise You Make the Call – Prank

I read this story over at Curt Varone’s Fire law blog a few days ago but it’s really had me thinking.  Where does your prank end and vandalism against my property begin?

We’ve all done something funny at someone’s expense which they didn’t think was too funny at the time, but what about the situation in Curt’s story?  Comment here, there or both.

 

Was that example a prank or something else?

 

You make the call.

You Make the Call – Stove Fire

You are assigned to a three person engine company dispatched to a reported kitchen fire in a restaurant.  On arrival you have light smoke showing and a manager advises you a cutting board is on fire on the stove top and that all employees and patrons have exited and are accounted for.

The building is 3 story type 5 with the top 2 floors residential.

Conditions inside are smoky but the kitchen area is visible from outside and only 20 feet inside the front door. It is open to the dining area, only a half wall separates the kitchen from the rest of the area.  You observe flame across 8 burners climbing 2-3 feet towards the vent.

 

All utilities, ventilation, search and other concerns are being handled by other responders.

 

Your selection of suppression devices is as follows:

1)Water extinguisher

2)CO2 extinguisher

3)150′ 1 3/4″ preconnect

4)1″ booster reel

 

Which do you choose and why?  You Make the Call.

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.

You Make the Call – The Kid in the Street

Oh, I caught you off guard didn’t I?

For you new people, this is a situation I completely made up.  This did not happen.  Today I give you a situation, on Monday we discuss what I would have done.  Now that that is out of the way, let us begin the call.

 

You are dispatched to a reported motor vehicle versus pedestrian incident at an intersection well known for trouble.  You and your EMT partner arrive on scene before anyone else to find a car stopped BEFORE the crosswalk and a woman and a toddler nearby on the sidewalk.

As you approach the child, later you discover he is 2, he begins to do the usual “I’m afraid of the new people” dance behind mom’s legs.  He does it steadily, never off balance and if he’s hurt he isn’t showing it.

Mom is giving you the same impressions as you complete your primary assessment, finding nothing of note, except she does not speak English.  They’re from out of town but your partner speaks their native language, but the kiddo seems uninterested in answering questions.

No trauma, no pain, no complaint.  All she wants is the police to come and cite the driver.

 

A BLS crew arrives as you begin to head for the driver, just to be sure, when they wave you off.  They’re a strong crew and you trust their judgment.

That’s why you believe them when they tell you what the driver tells them:

“I came around the corner and the lady was in the street already.  I couldn’t have been doing much more than 10, when I hit her, she was carrying the kid and she flopped onto the hood.  Well, onto the kid on the hood at least.  They seemed fine, the kid didn’t cry or anything, but they hit the ground and got up no problem.  I backed up just to make sure they were OK.”

Per your own protocols and policies in your area, what do you do next?

You make the call.

You Make the Call – MotorDoc – What Happened

I was hoping the word kidnapping would come into play on THIS scenario from Friday.

 

The Doc doesn't want a trip to the trauma center, even though he meets the criteria that he helped create for us sad, lonely medics who can't use our own judgment.

He was separated from the bike after hitting the side of a truck somewhere a bit less than 30mph, or so he says, and there is no gray area on this one for my system.

He meets trauma criteria wether or not I think he should go.  Such is the state of EMS in my system at the present time.  Even though he presents alert and oriented, he himself would be the first one down our throats about how the clavicle is a distracting injury and hitting his flank could also have injured his pelvis and abdomen.

We could go on for years about wether he is or isn't injured, but there is no need.  There is also only one way I can transport him to another facility outside our protocols.

Direct Medical Control.

You see, regardless of where your patient WANTS to go, it is your responsibility to make every effort to take them where they NEED to go.  If Erma having the CVA demands a hospital without a scanner, call ahead and have them divert you.  Taking her to the wrong place based on her request is worse than "kidnapping" I'd argue it's downright neglectful.

Imagine we take Mr MotorDoc to Saint Farthest, per his request, documenting in quotations everything he says, heck, even get a photocopy of his ID for the report.  All those items will look really good blown up at the trial after his injuries turn out to be more than you thought and he cites you violated clear cut trauma protocols.

This is not a matter of Kaiser vs a Blue Shield participating Hospital, this is a matter of getting a patient to difinitive care.

 

So, back to MotorDoc.  A simple phone call to the attending Medical Control Physician explaining our situation got the intended response.  MotorDoc had to explain his injuries and his reasoning to the attending to get permission to deviate from protocol and be seen at Saint Farthest.  At that point it is the Physician's responsibility should the injuries turn out to be more than we thought.

And the best part of the story?  The attending wanted him to come into the trauma center and from what we could tell did everything we had already done to convince him to do so.

Destination protocols are a necessary tool to keep track of which hospitals in your area can be the best resource to your patients.  Keep in mind they may not know their requested hospital can not help them and it is your responsibility to make sure they get the care they need.

 

If you said kick the decision upstairs, you made my call.