Treatment of GSW Victim

[helicopper 1,050]

http://www.emtbravo.net/index.php?showtopic=36830&pid=209958&st=0entry209958

Just wondering what other EMS providers here think. What mechanism/circumstances would make you treat a GSW to the foot (possibly from a ricochet) ALS?

What would you do to treat a similiar patient who is alert and oriented without other complaint?

[weaselff 6]

http://www.emtbravo.net/index.php?showtopic=36830&pid=209958&st=0entry209958

Just wondering what other EMS providers here think. What mechanism/circumstances would make you treat a GSW to the foot (possibly from a ricochet) ALS?

What would you do to treat a similiar patient who is alert and oriented without other complaint?

The only time this should be ALS is if an arterial bleed is uncontrolled...maybe for no exit wound or long txp time(30min+)?

[x129K 1,393]

There is a big difference between transporting ALS and the Medic riding in the back.....(as you both know no doubt)

It was either a "Dog and Pony Show" or another sign of EMS being too protocol driven and not allowing us (you or them actually...my card is expired!) to actually treat THE PATIeNt!

[ny10570 745]

I know in Mt. Pleasant it use to be, the medics almost always rode any call in no matter how minor unless it was busy or another call was coming in.

Edited May 1, 2010 by ny10570

[WAS967 97]

The only time this should be ALS is if an arterial bleed is uncontrolled...maybe for no exit wound or long txp time(30min+)?

What about pain control? I dunno about you, but I'd imagine being shot in the foot would be rather painful.

Is the general consensus that people are hesitant to treat pain in the field with analgesics? If so, why?

[50-65 205]

The only time this should be ALS is if an arterial bleed is uncontrolled...maybe for no exit wound or long txp time(30min+)?

Given the information in the IA, I don't see anything that would make this ALS. Uncontrolled arterial bleeding, yes. No exit wound or extended transport time? I don't see what an ALS workup would accomplish. An ALS exam, yes, to rule out any other injuries or factors.

Pain control was also mentioned. Maybe. IF there was excrutiating, unbearable pain.

I wouldn't start a line in the field for no reason other than to make the hospitals job easier.

Maybe it was just a case of an EMT-B being medic dependant, unsure of his/her abilities, new and inexperienced?? I don't know.

Edited May 1, 2010 by 50-65

[INIT915 1,119]

Given the information in the IA, I don't see anything that would make this ALS. Uncontrolled arterial bleeding, yes. No exit wound or extended transport time? I don't see what an ALS workup would accomplish. An ALS exam, yes, to rule out any other injuries or factors.

Pain control was also mentioned. Maybe. IF there was excrutiating, unbearable pain.

I wouldn't start a line in the field for no reason other than to make the hospitals job easier.

Maybe it was just a case of an EMT-B being medic dependant, unsure of his/her abilities, new and inexperienced?? I don't know.

Well, the only information you can gather from the IA is very limited. Specifically, the victims age, mental status, and reported location of the wound. And all of this is to be taken with a grain of salt, as we often know over the air, information is incorrect or constantly being updated. And why does pain have to be "unbearable" and "excruciating" to warrant some analgesia? Doesn't just "bad" pain deserve treatment? If your a medic who doesn't want to restock, maybe you hold off on analgesia, but the benchmarks you set are not realistic and protocols are often being increasingly interpreted to handle any significant pain, even if not "excruciating"!! Maybe the patient had some co-morbid factors? As usual, the list goes on and on, and as usual, we are limited to the very narrow information that was transmitted over the air. I have worked with Peekskill EMT's for quite sometime, and I would generally not consider them "medic-dependant".

[INIT915 1,119]

The only time this should be ALS is if an arterial bleed is uncontrolled...maybe for no exit wound or long txp time(30min+)?

Really? Those are the "only" three times ALS would be indicated? Interesting. If that's the case, the medic school I sat through was waaaaayyyyy too long. I could have learned that in 15 minutes.

[WAS967 97]

INIT915: Next beer is on me.

Translation: What he said.

[50-65 205]

Well, the only information you can gather from the IA is very limited. Specifically, the victims age, mental status, and reported location of the wound. And all of this is to be taken with a grain of salt, as we often know over the air, information is incorrect or constantly being updated.

This is very true. Thats why I said based on the IA information.

And why does pain have to be "unbearable" and "excruciating" to warrant some analgesia? Doesn't just "bad" pain deserve treatment?

Yes it does. However, some MD's may want you to limit the use of anagesics so they may better evaluate the patient in the ER.

Maybe the patient had some co-morbid factors? As usual, the list goes on and on, and as usual, we are limited to the very narrow information that was transmitted over the air.

Which is why I said that the patient should be evaualted by a medic.

I have worked with Peekskill EMT's for quite sometime, and I would generally not consider them "medic-dependant".

Not personally knowing them, I'll take your word for it.

As far as "treatment" of any patient, I believe there is a difference between doing something for a patient and doing things to a patient.

[WAS967 97]

Yes it does. However, some MD's may want you to limit the use of anagesics so they may better evaluate the patient in the ER.

What about analgesia makes it difficult to evaluate a foot injury? Even the old fashioned mentality of not treating abdominal pain because "the surgeon will need to evaluate them and analgesia will mask the pain" is right out the window.

I'm not saying we need to jump right on the Morphine (or Fentanyl if you are lucky enough to have it - Albany area does, dunno about anywhere down here) bandwagon but in this day and age we're obligated to address the pain in one fashion or another. Some agencies that are affiliated with hospitals are (arguably) required to treat pain appropriately.

[64FFMJK 21]

also many ER's are Medic dependent.

If you roll into many hospital ED's with what I consider a BLS PT the nurse or Dr. has a fit since there is no line started so that they can have one less thing to do in the ED. :angry:

I have seen way too many great medics that I would want to treat me if needed chastised by ER docs and nurses when the PT was BLS by protocols.

Edited May 1, 2010 by 64FFMJK

[INIT915 1,119]

What about analgesia makes it difficult to evaluate a foot injury? Even the old fashioned mentality of not treating abdominal pain because "the surgeon will need to evaluate them and analgesia will mask the pain" is right out the window.

I'm not saying we need to jump right on the Morphine (or Fentanyl if you are lucky enough to have it - Albany area does, dunno about anywhere down here) bandwagon but in this day and age we're obligated to address the pain in one fashion or another. Some agencies that are affiliated with hospitals are (arguably) required to treat pain appropriately.

Exactly. Extremity trauma (such as we have in this example) and abdominal pain, as previously referenced are two totally different animals. That being said, ER MD's increasingly, especially, newer, younger ones, subscribe less and less to that antiquated argument.

[ny10570 745]

If I can justify it, I'm giving the pt morphine. If nothing else it facilitates treatment and transport by significantly decreasing the volume inside the vehicle.

[PEMO3 523]

Many quotes here have stated "medic dependent" but one thing overlooked is that the medic is the senior qualified medical control on the scene. It is the medic's call if the job goes ALS or BLS. There are a lot of other variables in play in this decision aside from a GSW to the foot such as patient status, overall health pre-GSW of the patient and the presenting trauma score to name a few that may or may not have the medic call the job BLS and relinquish the patient and control.

[50-65 205]

Many quotes here have stated "medic dependent" but one thing overlooked is that the medic is the senior qualified medical control on the scene. It is the medic's call if the job goes ALS or BLS. There are a lot of other variables in play in this decision aside from a GSW to the foot such as patient status, overall health pre-GSW of the patient and the presenting trauma score to name a few that may or may not have the medic call the job BLS and relinquish the patient and control.

When I said "medic dependant" I mean that there are some EMT's that feel the need to have a medic respond to nearly every call. If a BLS unit alone was dispatched to a call, some, because of inexperience or whatever will want a medic. Others will not. In a system that responds with both EMT and Medic to every call, some EMT's won't do anything until told to. I am not saying that any particular EMT or agency is this way. Just that some EMT's are this way.

I understand, and mentioned, that the patient should be evaluated by a medic if one is available.

As far as pain control, at what point would you provide medicated pain relief? If the pt tells you it is 1 on 10 or 10 on 10 pain or some where in between, what would be your deciding factor?

Edited May 2, 2010 by 50-65

[Jybehofd 85]

What about pain control? I dunno about you, but I'd imagine being shot in the foot would be rather painful.

Is the general consensus that people are hesitant to treat pain in the field with analgesics? If so, why?

paper work vs the amount of pain someone is in. ice pack work wonders

[WAS967 97]

As far as pain control, at what point would you provide medicated pain relief? If the pt tells you it is 1 on 10 or 10 on 10 pain or some where in between, what would be your deciding factor?

Combination of things. Do they LOOK uncomfortable? Do they rate the pain over 5-6/10? In mnay cases I ASK them - "Do you feel like you need something more for the pain?" If they say yes, then I strongly consider it.

And the paperwork to give a narcotic isn't THAT bad (what? a continuation form and having to make some copies for QA? Ha!) and is far better than having to deal with the legal issues should a patient turn around a sue you for neglect because you failed to adequately address their pain.

Edited May 3, 2010 by WAS967

[ems-buff 81]

Combination of things. Do they LOOK uncomfortable? Do they rate the pain over 5-6/10? In mnay cases I ASK them - "Do you feel like you need something more for the pain?" If they say yes, then I strongly consider it.

And the paperwork to give a narcotic isn't THAT bad (what? a continuation form and having to make some copies for QA? Ha!) and is far better than having to deal with the legal issues should a patient turn around a sue you for neglect because you failed to adequately address their pain.

Just to play devils advocate, what if the medic was a new medic, and didn't feel comforable giving a G.S,W, away to BLS.. Maybe it was a member of service, who shot himself. All these "what if's" are possiblites, but untill someone who was on scene, or the medic himself desides he would like to explain why he did what he did. We will never know.. As far as for WAS's question about pre hospital pain management, thank you, I often wonder the same thing.

[Guest alsfirefighter]

This is very true. Thats why I said based on the IA information.

And why does pain have to be "unbearable" and "excruciating" to warrant some analgesia? Doesn't just "bad" pain deserve treatment?

Yes it does. However, some MD's may want you to limit the use of anagesics so they may better evaluate the patient in the ER.

Maybe the patient had some co-morbid factors? As usual, the list goes on and on, and as usual, we are limited to the very narrow information that was transmitted over the air.

Which is why I said that the patient should be evaualted by a medic.

I have worked with Peekskill EMT's for quite sometime, and I would generally not consider them "medic-dependant".

Not personally knowing them, I'll take your word for it.

As far as "treatment" of any patient, I believe there is a difference between doing something for a patient and doing things to a patient.

First the practice of leaving a patient in pain based on the evaluation clause is outdated and it has been shown and any provider at any level with experience from boy scout first aid to doctor can tell you that patients who are comfortable are easier to evaluate and studies have shown with better success in diagnosis when pain is at ease as you can do a thorough evaluation versus someone guarding or retracting.

WAS you certainly know myself and my co workers have no hang ups and to be honest administration of narcotics have minimally increased with the change in protocol which speaks volumes of the patient care we give.

As far as ALS'ing a foot injury...I guess this can go both ways as I've seen and still get BLS canceling ALS on calls they shouldn't..and then don't on calls they should. I had a case where a male was stabbed right below the umbilicus with a small knife found on a pair of nail clippers...I was canceled enroute the police station...luckily I was just pulling up and waited for them to come out to the bus. They had no vitals, etc and based it on the size of the knife which was about 1 1/2". I looked at the patient...and saw some things to be alert about but waited for vitals and they were borderline compensated shock. I re assigned myself to the call and took him to WMC where it was found it hit a moderate sized artery.

The moral of this story is....PARAMEDIC INTERPRETATION! I can't say I would have ALS'd that call based on the info given but the provider on scene felt it was the appropriate thing to do for whatever reason.

Don't know what ones you've worked with INIT..and now I'm wondering who exactly you are..as if you've worked with them..then we've worked together on jobs then also. However...overall..the entire region is medic dependent on a high ratio. There are very few who know and do their jobs..and they are ones that I rode and learned from as an EMT-B.

Jybehofd...while I'm thinking your kidding...just in case your not...that's because either you have never been in enough pain to know that everyone has varying levels of tolerance....you're new...you're patient care priorities are out of whack...or your lazy. So excruciating pain...ice pack...does that mean if you have to facilitate intubation that you just bag...I mean so much paperwork to tube someone. Or do you not work trauma as that can generate the same amount of paperwork?

[INIT915 1,119]

And why does pain have to be "unbearable" and "excruciating" to warrant some analgesia? Doesn't just "bad" pain deserve treatment?

Don't know what ones you've worked with INIT..and now I'm wondering who exactly you are..as if you've worked with them..then we've worked together on jobs then also. However...overall..the entire region is medic dependent on a high ratio. There are very few who know and do their jobs..and they are ones that I rode and learned from as an EMT-B.

Sorry, I could have been more clear. I meant in comparison to other agencies, specifically some with much lower call volumes. Something, I personally, have associated with a level of medic-dependentness.

[Goose 188]

Ultimately ALS is the standard of care...or it should be in my opinion. Having a paramedic up-triaging or riding something in because vital signs are borderline isn't a bad thing. Just because abdominal pain, sicks and stabbings go BLS in NYC (i say NYC because so much goes BLS) doesn't mean that that is in the patient's best interest/proper thing to do.

[Guest alsfirefighter]

I didn't read the IA for this thread but once I did I had to giggle as it is one of my co workers and one who has 12 years as a Paramedic with experience not just in the high volume system as a FF/Paramedic but Yonkers as well. But with that said another point to keep in mind is the location where this injury occurred is a major NYS Guard facility where numerous law enforcment agencies also train. So even if it were a minor injury a couple of things could have happened...1 the BLS agency didn't have a full crew and the medic covered it for them. Or it was a solider or LEO and he as I also would have stayed to assist a colleague through the event. Other then that..I think nuff said.