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.

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.

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 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.

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.

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.

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.

In the midst of potty training our youngest I’ve found myself saying some interesting things that, taken out of context, would sound disgusting.  Then I went to work and found myself saying some of the exact same things to grown adults in the midst of an “emergency.”

So let’s have a little challenge here and see if you can correctly guess which of the following statements were uttered by me to my 2 and 4 year olds or to a grown adult, or which was said by a 2 or 4 year old or grown adult.  Results soon!

Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment. Sorry, there are no polls available at the moment.

Dispatch has rung you out for a reported sick/altered mental status at a local hotel.  No, not the one all the addicts live in when they cash their checks, the one where all the conferences are held.  Confidence is high that this might actually be a call for a sick person.

Halfway to the scene you hear another rig toned out for the same complaint at the same hotel, different room.  Double checking your screen you are going to a Mr Brown in Room 403, Medic 88 is responding for a Mrs Gutierrez in room 503.

Arriving at the scene you are met by the manager who asks you to park around back so as not to frighten the patrons.  Ignoring him you take the elevator up to 403 and find Mr Brown doubled over the toilet, vomiting.  It is then the door to room 405, the room next door, opens and a young woman asks you to take a look at her mother, who is dizzy and vomiting.

Something is bothering you about this, but you agree to stop in after checking on Mr Brown.  Mr Brown’s wife is also feeling dizzy and complaining of nausea.

From upstairs Medic 88 is asking radio for a full hazmat response and to shelter the hotel immediately, then goes off air.

What is your reaction?

You make the call.

This situation happened to, yes you guessed it, me when I was in the Officer’s seat for a few hours and we went shopping. We were so close to this alarm that we were on scene and in pump before the dispatch was completed.

On the surface we have a 3 story type 5 (Balloon frame ordinary construction) with similar buildings on both sides, 1/8″ apart not allowing for the “hot lap” so sought after in classes.

Soon after my firefighter shut down the power to the buzzing elevator box, my immediate concern was for what was behind the wall the box was bolted to and where the elevator motor room was.

As the balance of the box alarm assignment began to arrive I updated the Battalion Chief that we had no fire so far, but were checking for extension of an electrical box to an elevator control. Our truck companies carry Thermal Imaging Cameras (TIC) and we certainly needed one since this box turned out to be mounted on an exterior wall, meaning the only access was through the interior wall of the building next door.

Until we could confirm there was no extension, this situation gets the bulk of the resources assigned to it.

Behind all the clothes and storage was the elevator motor room, which was indeed charged with smoke, almost hiding the burnt out motor and smoldering wires. The electrical conduit served as a tiny chimney for the small motor room and was the reason the garage smoke seemed so light. The motor had faulted, causing the electrical box to trip. It was warm, but not hot, but the conduit fastened to the outside of the wall was hotter and was a bright white on the TIC.

If you said continue the assignment until confirmation of conditions, you made the right call.