Mechanism of Injury vs. Physical Findings

[Guest alsfirefighter]

Let's see if we can get this jump started.

With todays newer model cars and "crumple zones," do you find that the MOI is somewhat harder to judge? Do you think some providers are vesting to much into the appearance of vehicles then assessment skills? Will the combo of seat belts, airbags and crumple zones ever make it into newer curriculums?

I personally feel that sometimes certain providers get hung up too much on the appearance of a vehicle when it comes to their opinions on whether or not ALS is warranted. Now not to bash anyone we all start at the B level, this tends to be on the basic side of the house and I feel is in part to the lower standard of patient assessment that they are now giving in the EMT B curriculums. Now just so nobody gets upset, I had a disagreement with a paramedic whom was acting in the capacity of a EMT with her vollie agency. She called for an intercept for a 18 year old female, MVC vic, whom had no LOC, slight abd discomfort to her umbilical area, and pain to her right hip/pelvis area and both knees which were bruised. Airbags deployed, seat belt used and collision was offset head on to passenger side. Front end had moderate to significant damage on passenger side with reported by bls 6" intrusion to passenger dash and 2" on drivers. Patient was immobilized and form experience all her injuries added up to the seatbelt and her knees hitting the dash under the steering wheel. Vitals were great, patient was great...no other physical findings such as bruises and such, L/S clear. While taking into account the reported damage, I found no physical findings really warranting ALS intervention and was going to BLS her which didn't go over well with the other medic in the back of her vollie rig. Either way, even a former medic instructor whom was at the trauma center we went to in that area agreed that ALS really wasn't needed.

Lets hear your input.......

[Remember585 815]

I think this may fall back on the whole "Scene Survey" and "BLS before ALS" mentality, that many providers lack. First, many people think automatically that an MVA w/ airbag deployment is justification for ALS transport. Not true, infact, most vehicles have air-bag deployments in minor fender-benders where the occupants aren't even injured. Sadly, most EMTs are trained by their own agencies that "ALS is always there." Many EMTs that I have noticed over the last 5-6 years kind of step back and observe, when they should be stepping up to the plate. Nobody, and I really mean NOBODY surveys a scene as good as they should anymore. One indicator I like to use to assess vehicle damage is to actually get on the ground and look at the frame and structural members to see how bad the collision actually was. One good indicator too is engine damage. If the engine is intact and not leaking fluids too bad, the damage is most likely minor. Just some personal thoughts....

[WAS967 97]

It definatly all hinges on a good assessment and a thorough understanding of events leading up to, events during, and events after the accident. I honestly feel that half the EMT class should be dedicated to history and physical. For those of you who are in EMT or medic class now, when you do those ER rotations, don't just sit there! Follow a nurse and watch as s/he does thier H&P. I've picked up a lot just listening to ER staff (RN/PA/MD) run through a quick H&P. Take the opportunity to do manual BPs. (PLEASE PLEASE PLEASE drop your reliance on LP-12 autocuffs now before it's too late. And swear that i shall strangle the next person that writes down the HR from the monitor as the patient's pulse. Actually take it! HR does not equal PR. Treat the Patient NOT the monitor). When the nurse/doc listens to breath sounds, listen along with them and ask them about what you heard.

Assessments can often be challengeing, especially in cases of MVAs, since we often do not have the ability to get a good head to toe assessment for various reasons, be it weather (patient is bundled in twenty layers of fleece), vehicle damage (patient is wedged between steering wheel and seat), etc. It's Important to do a quick assessment on what you can, and REPEAT that assessment. How many people do a quick head to toe, immobilize, pile into the ambulance and boogie for WMC, only to sit there and just ask how the patient is doing? Get in there and go head to toe again, cause things can change and change rapidly, especially with mechanisms like pedestrians struck, falls from trees/roofs/etc.

I had a case recently where the patient was punted by a car an unknown distance. First warning sign there is "hit by car" and "unknown distance". Always err on the side of caution. Patient initially only had pain in her shoulder and mentally is A/Ox3(or 4 if you follow that system). Patient later was found to have broken shoulder, pelvis, lumbar spine, and a minor brain bleed.

With the arrival of VERY cold temperature (Bahamas anyone?) thick clothing can make secondary assessment difficult. Often we are faced with a dillema: Do you expose and assess because of the risk of further injury or do you get them out of the 10 degree weather with heavy winds? As EMTs we must all learn to "adapt and overcome". Often we have to get as much of an assessment as possible with the cloths in place, log roll to longboard, manually immobilize the neck (scarves and jackets often prevent collar application), and get into the ambulance. Set that heat to "max" - Don't adjust comfort controls to your comfort but to that of the patients. Elderly and Kids often require temps that make you sweat in order for them to maintain a safe body temp. Other hurdles include the cloths they wear. Once the patient is out of the cold air, you can get back to exposing and assessing.

How many providers on a regular basis ask about how the accident happened, and really delve into that? Did the patient skid on the ice and crash, or did he pass out and crash? Does history indicate a possible deeper problem (diabetic, seizure, cardiac history etc).

Back to the original topic now that my assessment rant is over (for now), it is very true that with the concept of crumple zones, cars can often appear worse than they are. Look at the big picture. How long are the skid marks? Are there any skid marks? Are there signs of rollover? What make year and model of car? (Older cars = less safety features). Is the spider in the windshield from a possible head impact? Or was it caused by airbag deployment? Is the steering wheel deformed/displaced? Does the seatbelt show signs of having been on in the accident? (Many people won't admit to NOT wearing restraints for fear of repercussions.) (Some cars have seatbelt systems that have a small charge that fires on impact and locks the seatbelt in place. In these cars a used seatbelt will appear "limp" and not spring back into place, an unused one will be stiff and stuck in place in the stowed position). Did the first person there see the seatbelt on or off? Did the airbag deploy? Is there a chance it can deploy while you are in the car? Are there a lot of "free" objects in the car that could have become projectiles during the crash and caused a secondary injury? Was the headrest in a position to prevent the patients neck from snaping back after impact like it should? What was the position of the seat? (Seats close to the wheel can be problematic when the airbag deploys, seats in the semi-recline "guido driving" position can be problematic too). The list I'm sure gets longer, but these are just a few of the things I think about when doing a scene size-up.

But mechanism alone is definatly not a sure fire indicator of patient injury. How many people roll thier cars today and walk away? How many cars have you seen that were totaled, yet the driver is walking around smoking a cigarette and talking on a phone? How many accidents have we seen where the damage is minor, yet the patient is suffers some odd severe injury? In the end it all comes down to a good H&P and a good EMT to see the whole picture.

[x635 4,066]

I agree with alot of the great points made here so far.

I feel the most important skill in a trauma situation is speed.

The patient needs the surgeon typically alot more than they need us. As ALS providers, we must be careful to treat any underlying causes or complications that we can reverse, but in most cases , the patient needs the surgeon.

As for trauma assesment/MOI question, I feel alot of the skills come from experience AND training. You hear "Sick vs. not sick".....well in trauma, it can be "Damaged vs. Not Damaged...the patient, NOT the car". Do your assesment for life threatening stuff (ABC's)....while your partner(s) are packaging the patient and GET THE PATEINT TO THE HOSPTIAL!!!!! Finish your secondary assesment,etc enroute. I've seen cars demolished, and the victims walk away without a scratch. In the field, even as an ALS provider, do I have the capabilties to say they're fine? No. I do have the capabilty to NOT get tunnel vision, and say the patient is stable and send them BLS, and preserve myself for other calls where my skills can be better used and applied instead of on a "very remote chance, just in case" call.

I feel the main problem here is the loss of self-sufficency and skill of some BLS providers nowadays who have become to dependent on ALS. Especially patient assesment, which is your most important skill. In trauma, scene times need to be cut.Even with ALS, if you can't get the tube, can you maintain a good BLS airway? MOVE! Get the patient to DEFINITIVE CARE.

On an added note. While one partner is initially assesing the patient,assuming they are not critical, the other can quickly asses the mechanism.

[x635 4,066]

One more thing....

It's important to be able to paint a picture to the ER staff of what happened. Letting the staff, and yourself too, know how the injury happened and occured as opposed to how badly damaged the car was is crucial. By knowing this, you can also predict other injuries associated with the mechanism.

[WAS967 97]

Regarding EMT's reliance on ALS: I've recently put EMTs to work on patient doing assessments. (Of course on stable patients) I think they get more nervous than anything, thinking we are looking over them and ready to judge. But I'd rather see them practice the skills they were taught than to loose them to lack-of-use. Sometimes I need to give em a little help or a push to get started, but some actually take off quite nicely once they get on track.

As far as relay of info to ERs, I would love to see more agencies carry some kind of camera that can take pictures of the mechanism and actually SHOW the ER staff what the car looked like, or how far they fell, etc. Some agencies carry polariods, but not enough if you ask me. In a perfect world, everyone would carry pocketsized digital cameras with memorystick storage or the like. Then when you get to the ER, you pop the memory stick into a computer and up on a screen (mmmm.....65" plasma) pops the pictures taken on scene. Put i know the moment anyone puts something expensive like a digital camera on a rig, it's gonna walk.

[Oswegowind 17]

Speaking from personal experience (i.e. rolled my car last Feb.) damage does not constitute injuries. My car was totaled, it was such a mess that my paramedic friend whom came over to help told me to clean it up. Roof buckled at sunroof, engine compartment destroyed, side impact moderate. Vehicle rolled onto roof at approx. 45 MPH (I know, that sucks!!!!!). No airbags, was wearing my belt. No injuries!!!!!!!!!!!!!! I walked away literally until my brother-in-law could pick my up. The car looked as though it may require extrication, however my door opened and I simply got out after I fell out of the seat (remember, when upside down, don't undo the seatbelt until you are ready to roll over, otherwise you fall, kind of hard). I didn't even have any physical ailments within the next few days nor weeks, just mental anguish. It was a beautiful car!

Damage does not mean anything these days with all the safety features that vehicles require and some of the add-ons that are configured by different companies such as Honda, Volvo, and Subaru. Don't be subjective, be objective!!! Find out what hurts before you make a small thing a big thing!

Some a!! cut me off on the Taconic and just kept going while I went sledding into the woods!!!! If you know who it was give me their name and address, I have some words for them!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!

[WAS967 97]

Words? I think I'd be utilizing some kinetic energy of my own on the guy. Maybe we should post a topic about idiot drivers. But that would go on forever. I swear that people are taking offensive driving insead of defensive driving.

[Guest alsfirefighter]

As long as we add to the title "Idiot ambulance/apparatus/emergency vehicle" along with just drivers. As an EVOC instructor I'm starting to see a lot more crazy, idiotic and overly aggressive happenings amongst our colleagues also.

[WAS967 97]

I like plain "idiot drivers" since it is global and can refer to anyone from Grandma Moses to the 13 year old kid out joyriding in daddy's porsche. And yes, I know the problem can be within as well. I came within a second or two of getting creamed by an Fire Engine in our favorite city once which blew through a red light like there was no tommorrow, and was in the back of a rig that almost flipped over in a snow storm because the driver just plain doesn't know how to drive in snow. Needless to say, I made sure I had my seatbelt on. :->