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A different scenario to discuss, Head injury

post #1 of 15
Thread Starter 
Based on an incident recently at my area.

We are called to the bottom of a lift. Geust has snowboarded down to the bottom and is sitting at a picnic table. His friends say he fell hard, hit his head and is acting different. No helmet.

When the incident occured further up the hill, the friends say he was out of it, couldn't remember place or events at first. After a few minutes he could recall place but events were hazy. They made their way to the bottom to regroup and upon further consideration ask for a patrolman.

The patroller responds and does a quick survey. No point tenderness in the spine but his head still hurts. Patroller takes the head as a precaution and requests additional help and a backboard, sled & O2.

The guest was out partying hard last nite and is somewhat in a hangover state, symptoms include some nausea, headache etc.

When I arrive the patroller have C-spine immobilized and the guest has agreed to be placed on a backboad but is very reluctant to accept an ambulance ride.

Friends say he is acting more normal but again say for a time he was pretty out of it.

Patient and patrol decide to transport to out F.A.R. for further evaluation.

At F.A.R. I discuss his past history. 1 Concussion maybe 8-10 years prior. Patient is still reluctant to have a Cat-Scan at local hospital. His vitals remain within normal limits, he is now AO- 4x4. But getting cranky.

Is it the head injury? Hangover? Prospect of being taken to the hospital against his wishes? The large ambulance bill for the ride? (he has no health insurance)

Further discussion and we call our local Vol. Fire Dept. and request an EMT-P to help.

Local Fire Dept. arrives and after much discussion, EMT-P has the guest sign off and takes off spinal precautions. After a while and further coaching his friends on signs and symptoms of closed head injuris the guests leave F.A.R.

Please begin discussion.
Thanks
post #2 of 15
I think the exchange between the EMT-P and the patient qualifies as passing off to the next level of care-so you're in the clear there.

Sounds like you educated the patient and friends on potential risks-you got all pertinent info from the patient and by-standers. All on hill/ patrol care was good.

If he were my friend I'd have pushed him to go get checked immediately--It sounds like you tried to impress upon him/ them the potential severity of the situation-but People have the right to make dumb choices.

Sounds like you did everything right-and the patient made his own choice.
post #3 of 15
I agree with Liam, once the EMT-P arrived on scene, it was his call.
post #4 of 15
Recently I told a story of a teensy weensy incident with my husband, during which he was put on a back board and collar. My husband refused to be transported by the ambulance, so they let him go. According to one of the patrollers, once he was in the collar they would not remove it until in the care of the ambulance personel.
I don't know if this is the policy of the resort, or if it's a policy industry wide.


I can attest to the fact that we had to sign a lot of paper work for the ambulance and the patrollers stating that "we" understood the risk and released them of any liability.


IMO you handled this incident with this kid very well, considering the fact that his buddies were concerned enough to bring your attent to it and will likely follow up with their friends health in mind. I hope!
post #5 of 15

health insurance and precautionary care...

This might be the subject of a new thread, but I believe that this brings up a very real issue... how hard should first responders push for aggressive treatment and evaluation of a potential concussion when the patient is uninsured and could wind up owing thousands of dollars that they can't afford. I have health coverage but I can easily see how someone without coverage would be afraid to let themselves be the subject of costly ambulance rides, CAT scans and other ER proceedures when they aren't convinced that there is anything really wrong with them.

Conversely, is there a major liability issue for the first responder if they simply let the person walk away with only a caution to seek medical care if they start to feel woozy?
post #6 of 15
As long as the patient, or guardian, if the patient is a minor is told the consequences of refusing treatment and they are lucid enough to understand the decision and they sign off as such, then no one can force them to undergo treatment.

Those are the rules when we have personal freedoms and responsibilities. If someone is lucid and accepts the risks and get paralyzed when released from the backboard because thats what they chose, well, I'll certainly feel bad and probably hang up first aid, but I know I will have done all I could to help them.

It really is NOT the first aiders call. Obviously if I decided to back board someone, I would be really, really cautious about releasing them. Once a higher level of care arrives and I transfer care it is no longer my patient.
post #7 of 15
Thread Starter 
Thanks Stan.
To all others, I was certain our course of action was the correct one. But thanks for the comments etc.

What Stan pointed out was the direction I was hoping for.

If there are further thoughts and comments in this direction, lets keep in going on this thread.
post #8 of 15
I think you did perfectly. Our protocol would be to try very hard to get permission for the patient to be properly stabilized (backboard, c-coller, etc) for a trip to the aid room. We would also call ALS (EMT-P) for almost any sort of potentially serious head injury. At the aid room, we would explain to the patient what is going on, what their options and choices are, then basically turn them over to the paramedic. If they decline any further treatment, they must sign a release.

If they decline packaging, they must sign a release. And this would always be witnessed if they refuse to sign.
post #9 of 15
Quote:
Originally Posted by bunion View Post
Thanks Stan.
To all others, I was certain our course of action was the correct one. But thanks for the comments etc.

What Stan pointed out was the direction I was hoping for.

If there are further thoughts and comments in this direction, lets keep in going on this thread.
You took all the precautions on the hill, you gave him the options and handed him off to ALS who then released him. Why are you second guessing yourself? I'm assuming since he was drinking the night before, he was of legal age. You did all you could, and he was clearing up, so he's probably fine, but even if not, you did all you could.
I've seen full on amnesia getting released to family, and I've seen minor road rash to the spleen area with no rigidity, swelling, or bruising go to the hospital for evaluation. We inform them of the risks, but in the end, if they are lucid, it's thier decision.
post #10 of 15
Just wondering if the paramedic called local medical control? Just one more step up the chain so that the patient understands they are signing AMA. Our FD protocol always has us call the ER to release a patient unless it's something where we feel like there is no liability.

And just to add, what would you have done if you were the patient? I'm pretty sure I wouldn't have waited around long enough for the medic to get there. It sounds like he was pretty cooperative up until the end.
post #11 of 15
Thread Starter 
Quote:
Originally Posted by 2-turn View Post
You took all the precautions on the hill, you gave him the options and handed him off to ALS who then released him. Why are you second guessing yourself? I'm assuming since he was drinking the night before, he was of legal age. You did all you could, and he was clearing up, so he's probably fine, but even if not, you did all you could.
I've seen full on amnesia getting released to family, and I've seen minor road rash to the spleen area with no rigidity, swelling, or bruising go to the hospital for evaluation. We inform them of the risks, but in the end, if they are lucid, it's thier decision.
2-turn. I am certainly not 2nd guessing our decisions. To me, this is an interesting and challenging situation that can go either way.

With the number of uninsured these days, this is a common scene at most ski areas and invites discussion. That is all.

Z3, yes, the EMT-P who is also a former pro patroller at another nearby hill called medical control and described the situation to a T. What made this more compelling was that the patient was getting a bit aggro.

We were asking ourselves, "is he upset due to having things done against his wishes or because of increasing ICP? Is he experiencing nausea due to increasing ICP or because of the alcohol burning out of his system?
post #12 of 15

Thoughts From a Basic

1. You transfered the care of you patient to an equal or higher level of care than that which you were providing. At that point, the medic was responsible for the care of the patient.

2. I disagree with the medic's decision not to transport. Head injuries, and intoxication, no matter how mild, are reasons to doubt patient reliability. Even if it came down to CYA, I would have transported him. I've had people arrested so I could transport them. But this was the medic's decision, not mine.

3. Wether or not the confusion and agrevation were due to alcohol or the closed head injury is up to the ER to decide after testing and monitoring.
But you claim med control was contacted. Unless your system is set up differently than mine, med control is an ER doctor. This makes me uneasy as the ER doc dismissed the patient as not needing treatment despite his sketchy condition. Yet again, not within your control.

You did what you could for the patient's condition (even calling ALS when many I know wouldn't) and everything that did not feel right was through no fault of your own.
post #13 of 15
Quote:
Originally Posted by Korporal View Post
2. I disagree with the medic's decision not to transport. Head injuries, and intoxication, no matter how mild, are reasons to doubt patient reliability. Even if it came down to CYA, I would have transported him. I've had people arrested so I could transport them. But this was the medic's decision, not mine.
There is no way you could have had this patient arrested so that you could transport them. Did you miss the part where he was A&Ox4? I don't know where you've gained your experience but you sound a little over the top.
post #14 of 15
That didn't come off right. I meant to say I have had patients arrested to be transported. I did not mean to have this guy arrested. There is no way that could have happened.

If the medic wanted to transport he could have used altered mental status as a valid reason. Even though he was A+Ox4, he was becoming agressive, which is considered a change in mental status.
post #15 of 15
Our patroller here did everything exactly right. In our training, potential intoxication can mask spinal or head trauma symptoms, and therefore ups the ante, so to speak, and makes it more likely you'll collar/board the patient.

I wasn't sure if the patient in this case as legally a minor without an adult guardian in attendance. If so, that turns the patroller into the legal guardian, and enables him to make decisions on the patient's behalf, which could include an ambulance ride.

I know it's trite, but when we have serious concerns about a patient imprudently waiving treatment, we sometimes tell him "a $500 ambulance ride is a lot cheaper than life in a wheelchair."
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