The Public is Watching...

[Goose 188]

I assume most people get the Journal News. I happened to take a glance at the front page about 10 minutes ago to see a picture of an MVA that occurred during the storm yesterday. Quite frankly, it looked a bit shocking and the caption read something to the effect of "Ambulance workers walk the driver of the a truck...to the ambulance." The only point i want to make is that we should all be 1) trying to do the right thing and 2) be acutely aware that the public is watching.

[LTNRFD 266]

I assume most people get the Journal News. I happened to take a glance at the front page about 10 minutes ago to see a picture of an MVA that occurred during the storm yesterday. Quite frankly, it looked a bit shocking and the caption read something to the effect of "Ambulance workers walk the driver of the a truck...to the ambulance." The only point i want to make is that we should all be 1) trying to do the right thing and 2) be acutely aware that the public is watching.

In point #1, did they do the right thing or do you feel differently ??????

[ndpemt519 10]

The NYS DOH has new protocols regarding spinal immobilization. According to these protocols, spinal immobilization is indicated in the following circumstances:

1. Altered Mental Status for any reason, including possible

intoxication from alcohol or drugs (GCS <15 or AVPU other

than A).

2. Complaint of neck and/or spine pain or tenderness.

3. Weakness, tingling, or numbness of the trunk or extremities at

any time since the injury.

4. Deformity of the spine not present prior to this incident.

5. Distracting injury or circumstances (i.e. anything producing an

unreliable physical exam or history).

High risk mechanisms of injury associated with unstable spinal

injuries include, but are not limited to:

• Axial load (i.e. diving injury, spearing tackle)

• High speed motorized vehicle crashes or rollover

• Falls greater than standing height

(from http://www.health.state.ny.us/nysdoh/ems/s...l_protocol.pdf)

If the EMTs/Paramedics on this call determined in their patient assessment that none of these conditions applied, then there isn't a problem at all with them walking the patient to the ambulance.

[Goose 188]

I'm acutely aware of what the protocol is, but i never said a word about protocol. But, on the basic level, this doesn't afford someone the right to clear. The state will tell you themselves that it is not a clearance protocol - this is a digression, but if you forgo immobilization you better have done a damn good assessment of the patient with c-spine being held and good twice over of the car.

Do i feel they did the right thing? Hard to answer that - wasn't there so i can't say definitively. But the picture gives the impression (again IMPRESSION) that the person needed some sort of assistance. Between the person holding him up and what appears to be a grimace on his face i can tell you the whole thing just doesn't sit well with me.

I just don't think a picture like that puts us (primarily EMS) in all that good of a light...

Edited January 29, 2009 by Goose

[texastom791 31]

I was the first one at that accidnet and also called it in and that guy was lucky he didn't end up in the lake he was moving. An ankle injury was the least of his problems.

[ndpemt519 10]

The entire purpose of the new protocol is to allow EMTs/Medics to use their clinical judgement in determining if the patient requires immobilization. It isn't a clearance protocol in the fact that once immobilization has been started, we aren't allowed to discontinue. However, as seen in the flow chart published by the NYS DOH BEMS below, if none of the conditions are met, immobilization is NOT required.

[Goose 188]

I was the first one at that accidnet and also called it in and that guy was lucky he didn't end up in the lake he was moving. An ankle injury was the least of his problems.

Which makes it even worse.

Just goes to show we are our own worst enemy. We need to start doing the right thing and maybe knowing that there are thousands of cameras out there will keep those of us who would otherwise opt to slack off on their toes.

[Bnechis 3,961]

An ankle injury was the least of his problems.

Always leaves a good impression when you walk the patient with an ankle injury..............

[texastom791 31]

Always leaves a good impression when you walk the patient with an ankle injury..............

Yeah well I had nothing to do with the treatment. I just opened the door and made sure he was okay because for a second I thought he was dead by the way he slumped over the wheel. I'm not making excuses for them but I think maybe vehicle placement might have palyed a roll in that because it was a little tight on a bad curve but you could always move the ambulance a little closer.

Edited January 30, 2009 by texastom791

[Goose 188]

Yeah well I had nothing to do with the treatment. I just opened the door and made sure he was okay because for a second I thought he was dead by the way he slumped over the wheel. I'm not making excuses for them but I think maybe vehicle placement might have palyed a roll in that because it was a little tight on a bad curve but you could always move the ambulance a little closer.

Forget the ambulance. If a backboard and collar were not indicated (i would have given him the KED and backboard from what i see in the picture) we have this novel thing called a stretcher which could have been wheeled over or you could even utilize the stair-chair as a wheel chair and then transfer to the stretcher.

My intention is not to quarterback this. The point is, if this is the treatment that the public sees us giving (because really, this photographers camera lens is the public eye if you will) what the hell is the point? Might as well not even bother coming out on calls or even having ambulance service at all. Thats really the problem i have.

[INIT915 1,119]

I generally believe many systems (not all) over-utilize stair chairs, stretchers for patients that are more than ambulatory. (Nothing to do with this particular incident, as I don't know the specific details.)

I can remember working Mt Vernon ten years ago and you go up in the buildings and the first question from patients/families was "Where's your orange chair at?!"

That being said, I'm the first one to carry those who truly need it, just not those who don't.

Remember your ABC's (Ambulate Before Carry.)

[Guest alsfirefighter]

You could always do a ton of things. And with proper documentation you can do a ton of things in any direction if you can justify it on paper and in the standard of care.

The only point i want to make is that we should all be 1) trying to do the right thing and 2) be acutely aware that the public is watching.

Who says they weren't trying to do the right thing? Medical pictures are very hard in some aspects to comment on unless their is some form of physical safety or skill issue immediately seen. How do you not know the ambulance couldn't get closer? Or where they were was the best spot to block the scene? Or it was unsafe to carry a person on a board? Or the simple fact that the person did not need to be on a backboard?

2) I could care less if I was in the middle of a stadium. I don't do things for the crowd. I do what my patient needs and in some cases doesn't need. If he fit the exclusion criteria then what's the big deal? I have an aggressive medical director that has supported our clinical abilities in clearing c-spine. Never had a problem system wide once.

We need to start doing the right thing and maybe knowing that there are thousands of cameras out there will keep those of us who would otherwise opt to slack off on their toes.

Again Goose...and you are my bro with great insight. The camera's mean nothing to me brother. Statistics show that doing the right thing often means not needlessly backboarding a patient. Some protocols were getting to the point that if you saw the accident you had to be boarded. Ridiculous. Many hospitals use manual assessment to clear c spine with no radiography clearance before removing the collar. How many providers on here have had any patient with a spinal fracture that had either no obvious pain or pain on palp to a vertebrae upon assessment? I never had. Everyone has had either constant pain or pain with proper assessment.

that guy was lucky he didn't end up in the lake he was moving. An ankle injury was the least of his problems.

Was he "moving" as in speed? Also other then the ankle injury...did he have a medical issue? Other signs of trauma? Or other issues as in totally a vehicle and having to have a long talk with the officer?

[texastom791 31]

Was he "moving" as in speed? Also other then the ankle injury...did he have a medical issue? Other signs of trauma? Or other issues as in totally a vehicle and having to have a long talk with the officer?

He was moving as in speed, he had no signs of trauma from what I could see ,he was a little shook up, and a few minutes after the crash he was smoking a cigarette waiting for the cops to show up. Most likely totaling his truck snd destroying his plow was a bigger problem to him becuase he's a landscaper so I'm assuming he's out of a job for a little while now.

Edited January 30, 2009 by texastom791

[OLDGUY19 6]

As if the paper ever gets anything right. But Goose is right with all of the new techno gagets out there, we will be under the microscope more than ever. We should be doing the right things all the time anyway.

[Guest alsfirefighter]

Thanks for clarifying brother. I thought that's what it meant.

Sounds like to me they very well may have done the "right thing."

[ny10570 745]

If the patient in my judgement does not need to be immobilized he will be assisted to the bus. I don't care the patient is, who is watching, or what the paper may think. I have no problem discussing incidents based upon photos and videos, but from a quote or caption in a rag like the journal news. I can't find the picture on their maze of a website but just because he has a broken ankle doesn't mean he needs to be immobilized or that he didn't want to hobble to the bus.

[texastom791 31]

Thanks for clarifying brother. I thought that's what it meant.

Sounds like to me they very well may have done the "right thing."

Your welcome.

[Guest alsfirefighter]

BTW...the paper did get it wrong....here is a link to the page with the photos..(pleural)...there is more that after "walking" him to the ambulance..they get him from being in the snow...to the road and then on to the stretcher right in front of the truck.

The pics on what I'm viewing are on the top row.

LoHud Photo Gallery

Good job guys making a sound decision to not needlessly board your patient from what it looks like.

[OoO 24]

Anyone have a link to the picture in question?

[Goose 188]

The two photos are a bit confusing, but i stand somewhat corrected. Glad to see that the guy wasn't completely walked to the ambulance. Still have to be careful in this ultra connected world.

[INIT915 1,119]

The two photos are a bit confusing, but i stand somewhat corrected. Glad to see that the guy wasn't completely walked to the ambulance. Still have to be careful in this ultra connected world.

Generally, by reading the blogs on LoHud and many other news sites, the public has no idea what we do or why we do it, which are often evidenced by their 'comments'.

That being said, I still feel, if your doing the right thing, there is no need to put on a show, so to speak, for the benefit of a photographer.

[texastom791 31]

Anyone have a link to the picture in question?

I think this is the picture. http://jukebox.lohud.com/photos/popup/inde...09&offset=2

[Guest alsfirefighter]

Forget the ambulance. If a backboard and collar were not indicated (i would have given him the KED and backboard from what i see in the picture) we have this novel thing called a stretcher which could have been wheeled over or you could even utilize the stair-chair as a wheel chair and then transfer to the stretcher.

My intention is not to quarterback this. The point is, if this is the treatment that the public sees us giving (because really, this photographers camera lens is the public eye if you will) what the hell is the point? Might as well not even bother coming out on calls or even having ambulance service at all. Thats really the problem i have.

From what I saw in the picture..I still wouldn't make a decision until I physically assessed my patient. (For the pics go back to post at the bottom of the first page, I posted the link to LoHud). Again my point is that I don't give treatment for the public, crew members, firefighters or anyone else around or on scene. I do what is appropriate for my patient. Fact is also if he was significantly injured the public wouldn't see what I was doing being he'd be in the bus. I've seen one too many provider prompted to do something by an EMT that gets in their ear that seems to know better...medevac's because fire personnel keep mentioning it, etc. The only decision that I would make as a paramedic would be to defer to BLS the decision as to board or not if turning over patient care to them.

Funny the KED was brought up and this might be a good topic on its own. There has been some documentation showing that you actually get more movement of the spine with the use of the KED then without it in many cases.

Also has anyone been taught, seen or used the blanket roll removal technique. I was first introduced to it yesterday while in Saratoga Springs while doing a PHTLS instructor course. Pretty nifty concept, minimal movement...100 times faster then the KED and also makes it as if you have a 3rd set of hands on the patient.

[Bnechis 3,961]

Funny the KED was brought up and this might be a good topic on its own. There has been some documentation showing that you actually get more movement of the spine with the use of the KED then without it in many cases.

The primary problem is spinal compression and that was documented in a US Army Study that was done at Ft. Sam Huston.

The real issue is not the "short boards" its which one. Rick Kendrick (inventor of the KED) "improved" upon the short backboard, by stiching a canvus around wood slats and "testing" it on a VW behind the fire station.

1) He was comparing the KED to a short backboard, which has never been tested to determine if it "works" to immobilize the spine.

2) The KED is easier to place, but the only testing that was done was to see if it worked compared to the short board.

A few years after he sold the KED, I spoke with him at an EMS convention where he was helping SKEDCO promote the Oregon Spine Splint (OSS) which was designed after 20 years of looking at the good & bad points of the KED.

The OSS was also tested in that ARMY study. and afterwards they issued it national stock numbers for all US & NATO units. The ARMY study included a full xray comparrison of units with step by step x-rays during extrication (nice to be able to do a study with dozens of x-ray exposure).

When I've compared different units, KED, ZED, OSS, Sherman Short Board, Kansas Board, XP1 and a bunch of others that I cant remember the names of, some work, some dont...the OSS is by far the best.

THe KED has been around about 40 years and in NYS, too many EMS leaders are stuck on it. How many instructors are willing to show other equipment?

Compare the two side by side.

[Guest]

To keep the KED talk going, who else thinks its ridiculous that in CT the state could care less whether or not you can properly backboard someone, which EVERY EMT does, and quite often, while the KED is one of the mandatory stations, something that (at least in my area) is rarely if ever used, and requires proper backboarding afterward anyways?

[Guest alsfirefighter]

Barry...you would probably like the blanket roll method. And yes NY is too stuck on the KED. Also on a side note I believe the study a colleague was talking about was recent and had nothing to do with the army and compression wasn't the issue but actual c spine movement. They used sensors very similiar to that of the video gaming industry and movies to computerize human movement.

I think there are instructors out there willing to show different devices. Not too many but there are some out there.

[IzzyEng4 427]

A trauma is a trauma is a trauma. Have to thing mechanism first.

[Guest alsfirefighter]

A trauma is a trauma is a trauma. Have to thing mechanism first.

Absolutely correct..but while it may one of the first things you take into account...it isn't the only thing. Doing such is why we have so many people being flown to trauma centers needlessly in this area. Physical findings also accounts for a large part of the decision making process. Which is also a reason I've never been a fan of the whole EMT assessment change years ago and why I'm glad to be hearing that there is a possibility that it may get switched back to the old method. Good bye focused exam and whatever else they call it.

His mechanism (from the pics) wasn't anything overly concerning in my view. Notable...yes. But any hint of a physical finding would change my decision...which he looks pretty stable to me standing up.

[ny10570 745]

A trauma is a trauma is a trauma. Have to thing mechanism first.

No, and this is something I see people foul up constantly. Trauma is an injury. The severity of the injury or potential injury dictates the treatment. Sprain your ankle stepping off a curb wrong and you've suffered a trauma. Step off a curb and get hit my car doing 20 mph and you've also suffered a trauma. I'm tired of seeing things like a kid with a broken wrist hauled off to a trauma center for something that could be handled in any ER or even an orthopedists office. There is trauma, Major Trauma, and the gray area in between.

In Westchester, a 70 y/o woman falls and breaks her hip. Which hospital do you go to? I'd strongly consider Phelps. They have an excellent orthopedic surgery program and one of the best in house PT programs in the county. Yeah, there are a lot of other factors but far too often people see injury and start looking for excuses to go to the Trauma center.

[NWFDMedic 58]

Barry...you would probably like the blanket roll method. And yes NY is too stuck on the KED. Also on a side note I believe the study a colleague was talking about was recent and had nothing to do with the army and compression wasn't the issue but actual c spine movement. They used sensors very similar to that of the video gaming industry and movies to computerize human movement.

I think there are instructors out there willing to show different devices. Not too many but there are some out there.

I was shown the blanket roll method in my 2004 PHTLS class, but not in my 2008 class. I really liked the idea.

The issue with the new spinal immobilization protocol is this... which apparently some don't understand in this thread. Just because you don't have to immobilize someone if the appropriate criteria are met and you are comfortable not immobilizing the patient, doesn't mean you walk them to the ambulance. Apparently things may have been done correctly on this call, but that doesn't excuse some of the comments here. Do not immobilize doesn't mean "walk to the ambulance". Would any of you even think of doing that with a patient on icy roads who was just in an accident? If you think the legal risk from the 1 in 100,000 that may have an unstable c-spine fracture is bad, consider the chances of someone who is rattled after an auto accident being walked to an ambulance falling while he was in your "care".

With VERY, VERY rare exception, everyone I pick up gets put onto the stretcher and not walked to the ambulance. Doing anything different is sheer laziness.