Monday, February 9, 2009

Trauma is Easy

People like to say that compared to complex medical calls, trauma is easy. Just backboard, Oxygen, and bang in an IV, they say. Still, it has been these trauma calls that have been tripping me up lately.

Its about scene control. These patients aren't supine in their nursing home beds with a neatly-printed medical history and medication lists at the ready. There are no nurses with the story, no recent diagnosis to help with the case. Instead we find these patients twisted up in their cars, drunken on the sidewalk or combative on the ground. Taking care of these people isn't simply about their medical problems, but also (sometimes even more so), about resolving the issue at hand. A combative, drunken man dressed in four snowcoats who needs to be exposed and backboarded provides a unique challenge, and I've found myself more than a few times at a loss what to do next.

A man drove through an intersection and T-boned another car at a high rate of speed. When we get there we notice immediately that both cars have significant damage, but only the occupants of the second car are on scene. They tell us that the man who hit them ran down the street, taking with him a small child who was also in the car. A few minutes later the police find the man, and call us over to evaluate him. He is about 30 years old, not making any sense, and gripping a two year old girl tightly to his chest. His left leg is severely deformed with an open tib-fib fracture. How he made it two blocks away from the accident on that leg, we may never know. We can't communicate with the guy. He is either altered, drunk, or doesn't speak english. ...Likely some combination of all three. He won't let go of the little girl, who is now screaming in terror and burying her face in the man's chest. This man's car is destroyed, with intrusion damage into the passenger compartment and windshield starring. We need him backboarded and to the trauma room, but he doesn't seem to understand and he won't let go of that child.

How long do we work with him? How hard do we try to coax the child away from his arms? Do we just pull the two apart and hold the man down as he struggles to get his child back? What is the best for both patients?

I wasn't sure.

13 comments:

medicblog999 said...

Nightmare job!
Don't think there will ever be a right or a wrong answer, just a judgement call by the medic on the scene.

On one side it's a hell of a call to make, on the other, these types of jobs are usually the reason why ultimately we do the job we do. I agree with you, there is a set order of interventions for a cardiac chest pain, an anaphylaxis, an LVF, but having to take a few seconds and take in a big trauma scene is something else!
How did you handle it in the end?

MedicMatto said...

I couldnt agree with you more when you say that trauma patients present with a whole array of different problems when compared to medical patients.

Im a new medic as well and find that on calls like the one you mention here, I give it my best shot with my personal skills and utilize the different personalities of my partners.

Its might not get any eazier, but were bound to get more comfortable doing these sort of things.

brendan said...

Ativan blowdarts.

PDXEMT said...

These can be tough calls indeed. The worst part is that you are there, in the middle of that chaotic scene, with no resources -- and your actions will be judged by the hospital staff, with bright lights and lots of hands, and QA, sitting behind a desk with all the time in the world to think about what the perfect solution is.

My advice is don't get trapped into one plan for how to run the call, be ready to re-evaluate and change direction if warranted, be assertive, and stand by your decisions after the fact. And don't be afraid to tell the Monday-morning QBs, "Eff off, you weren't there."

Anonymous said...

What a thought provoking and well written post. I always get so much out of the cases that you share here, I know you are fairly "new" but I really admire your assessment and thought process. I would understand if you opt not to discuss your choices and the outcomes but let me just say I'm really, really hoping you do. Given your track record here I'm sure your decisions were marked with good judgement and compassion, even if they weren't easy. Thanks again - great post.

fiznat said...

Anon and others,

Thank you so much for the nice comments!

I have to admit I didn't include the resolution to this story because it was a bit anticlimactic. Between fire, police, and EMS there were quite a few people on scene. We ended up pretty much taking turns with different people trying to coax the child from the man. The last person to try was a female firefighter who, I can only guess, had just the right disposition to make the man feel at ease handing the child off so that he could be treated.

I guess the lesson here is if at first you don't succeed, have someone else try! ;)

Mastabattas said...

This is something I've battled with too! I work incredibly remote and so it's me and my partner. When I feel it's important enough to ensure my patient gets to the hospital but they refuse to allow us to board them for whatever reason. It's a very tough call... I've had to make choices to achieve the end goal that I'm sure people would questions.

At the end of the day, it's all about documentation, documentation, documentation I guess. That and calling my medical control to show my efforts.

Hate it thought. We aren't as litigious a society up here, but these things can still come back and haunt us if something goes south.

I've always preferred medical calls. Trauma to me is infested with way more potential problems.

Cheating Death said...

The actual care of trauma patients is all the same.

Getting to the patient, controlling the scene, and extricating the patient are NOT the same.

Watching YOUR ass is a lot more difficult on a busy freeway than it is inside a house in the burbs. No questions.

Further, your adrenaline is much more likely to go through the roof on a trauma call, making it that much harder to control YOURSELF.

If you can get past that.... you're golden!

Around these parts, if we are in over our head, there is no shame in calling our docs for "orders". I suppose we are lucky compared to a busier system.

nhill said...

I am currently in school for my EMT I and just tonight we had exercises on critical thinking. We took apart scanerios similiar to this one. The whole purpose of these exercises were to think outside the box. You definately had to think through this one.

Ckemtp said...

Trauma *IS* easy.. if you find something really hard to be easy. Your statements are right. You've got a lot of decisions to make. Plus, you've still got to do a thorough primary and secondary assessment and get your mind past the obvious trauma to assess for any underlying medical cause. I can say that I've seen a handful of multisystem trauma patients from car accidents that just happened to have a glucose of 20...

Keep up the good work.

Anonymous said...

I'm an ER nurse for..ahem ...a few years. I would have been glad to see you stap him down with his child laying on top if it calmed both and provided necessary treatment. But, alas, I am not the norm. Like the others say...it's your call baby..do what ya gotta do.

Anonymous said...

Medicblog999 (A), Matto (A), Brendan (A+), PDX on M.M. QB (A+), LISTEN TO MATSA (A+) rural is an entire new breed of medic, that is why PRN at a rural post will buid scills FAST, get coffee and introduce yourself to medical control in the first hour of every shift. (A+), CheatingDeath hit it on the head with Adrenoline hitting your head (A), ANON "old-school nurse" (A+) (extra credit)(THINKING OUTSIDE THE BOX TO ACHIEVE C-SPINE). ANNOTATION: **AUDIT A.T.L.S. DO NOT ASK ANY QUESTIONS. AUDIT A.T.L.S. A SECOND TIME. THIS TIME INVITE AN ER DOC TO ALSO AUDIT THE CLASE AND THE BOTH OF YOU WORK OUT SCENARIOS OUTSIDE THE BOX. ASK 10 ATTENDINGS IF YOU HAVE TO. YOU WILL BE SURPRISED AT HOW MUCH THE OLD-SCHOOL, SEASONED DOCTORS CAN PICK APART THE "YOUNGSTERS" AND SHOW YOU SOME VERY, VERY CRITICAL THINKING. 4-MONTH GOAL-- FIND A RURAL POST WITHIN 60 MILES OF YOUR CITY, GET ON THE PRN LIST, AND GO TO EVERY SINGLE TRAINING EVEN THEY HAVE. IT WILL BE WORTH IT IN THE END. PUT THE IDEA OF MEDICAL SHOOL ON HOLD. YOU ARE NOT DONE WITH THIS CHAPTER OF LIFE YET.

EMT-I said...

In my system the people who tells you that trauma is easy are normally the ones that have less experience in this job and the ones that are worst in trauma.

Tough call you had to make there.

Regards from Mexico.