Sunday, November 29, 2009

Hear Here!!!

I just finished reading an excellent piece over on the Rogue Medic that every EMT, RN, and ED Physician should study carefully. Such was the value of this piece that I wanted to run and scream it from the rooftops for everyone to hear. Unfortunately I live in the woods and nobody would get the message except for some random wildlife. So I am doing the next best thing and posting here to perhaps get some others to pay attention to this excellent and well written post.
For too long the protocol fairies have been out there second guessing those of us who deal with patients in their native environment and ‘as found’ condition. Spinal Immobilization is one of the worst problems we have to deal with as specified in our protocols. To ‘do no harm’ should be way up the ladder of commandments. Tim brings this point clearly to light with his ETOH patient and an equally unpleasant Medical Control physician.
We are taught to do things in a certain way, and we expect that this is what’s best for the patient. Once we learn, sometimes repeatedly, that this MAY NOT be what’s best, we are left without any alternatives. I have seen Medics and EMTs threaten patients with the fear of severe crippling injuries should they not submit to a backboard and collar for no better reason than ‘it’s protocol’.
Sometimes, the protocol is not always best for the patient in a given set of circumstances. I recently did a PED job where the child, less than a year old, had fallen about 4 feet and landed on her forehead. The child was reported to be dazed on impact but slowly came around and was alert and oriented on our arrival (6 minutes from dispatch). Head to toe and front to back exam revealed nothing, no sensitivities, no complaints (guarding, withdrawal, etc). PEARL was positive as was cap refill. The only thing we observed was a slight red mark over the left temple. The child was animated and followed colored toys with her eyes. When I took her from her Mom and laid her on the coach, she began to fuss during the physical exam. Putting her back in Mom’s arm calmed her right back down. In consultation with the ALS crew, we decided to do a BLS transport for a further exam and observation at the E/D. My partner said he'd go get a PED board and collar, but I told him to hold up a sec. I turned to the Medic and said “I’m thinking that tying this child to a board is gonna be scary and upsetting for her. Based on the way she fussed when we layed her down, I’m thinking we don’t want to do that again, what do you think?" The Medic looked at me, looked at the child, then looked back at me and said “Do no harm”, the she turned to the parents and asked if they had a car seat that fit this child properly. Yes, in fact they did. So we secured the car seat to the stretcher with the back fully raised on the stretcher and put the child in the seat, we didn’t even need a headroll, the seat already had one.
Is this the protocol? No. Was it the right thing to do? In my opinion, Yes and I would do it again.
Our State’s protocols demand that every suspected hip fracture be transported on a long board in the supine position. Have you ever tried to pull the overweight little old lady out of her bathroom at 2am and make her straighten that leg out? You can’t even ask her to roll on her back. If you try to make this happen she will probably grab your lower lip and pull it up over your eyes, at least I hope she does. Elderly hip patients are very delicate and need to be moved as little as possible. My weapon of choice is the scoop stretcher so that we can lift them while keeping them in whatever is the most comfortable position. Lots of pillow padding in the proper places and everybody is happy. Leave the scoop in place on the stretcher if it doesn’t cause discomfort and you have eased their transition to the hospital bed. But again, this is contrary to our protocol and another reason why this is an anonymous blog. I will not increase my patient's pain. If they fight to avoid a treatment, I get them to sign a refusal after I explain why I want to do the treatment. Informed consent works both ways.
Why is this so hard to get included in our protocols!?
So go read Tim’s article and spread the word. Maybe if enough of us keep talking about it, it will get fixed.

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