EMT/Hospital procedures for a concussion & possible neck injury

Factual Questions
21

As far as O[sub]2[/sub] and IVs go, he’d probably get both. I’d say a nasal cannula for the oxygen. I’d start the IV in the rig on the way to the hospital. That’s a standard part of PHTLS. He’d get the IV because he could crash at some point and it’s best to have a line in case that happens.

If you really want him to be on an EKG, have him nail his chest on something on the way down. That’ll give him some pain in his chest, and be reason enough for cardiac monitoring.

Billdo was right about different areas. In the area I work in, all the fire departments are dispatched along with the ambulance. The ambulances are all staffed with two paramedics. Since you’re doing it in your local area, find out what they do. I’m sure if you called around, someone would be happy to tell you what their standard response is.

St. Urho
EMT/Firefighter

22

What’s PHTLS?

I’ve finished the chapter, so thanks everyone for the help. I’ll be sure to give you all a signed copy. :slight_smile: I think I messed up on the O2 (totally forgot it could be a nose-line) and the EKG thing might have to be changed entirely, but I’ll fix those details on rewrite.

Oh, and one more scene came up out of nowhere while writing the “visitation” sequence. Basically, the overnight head nurse (whose personality eerily resembles Nurse Ratched from OFOTCN) hears noise and voices from the Observation Room, and switches on the light to find the TV on, the curtain drawn around his bed, a shattered flower vase on the floor, and our plucky young hero with both arms raised as if he’s fighting off some invisible being. Of course, she assumes he’s having a seizure, and has the orderlies strap him down with leather restraints and pages the doctor. Might be a little unrealistic, but then, this nurse character is the type who does enjoy her job a little too much…

23

Pre hospital trauma life support

24

Describe the scene of the fall to us, what he might have hit on the way down and the way he fell can provide relevant information to the first EMT’s on scene. Was our hero conscious when EMS arrived?

EMT’s will be far more concerned with someone who is still unconscious secondary to the fall, most people shake it off pretty quick unless they are seriously hurt.

St. Urho is far more recent than me even if I have been helping my wife with her ACLS studies.

Ex-EMT Drach takes a stab.

Step 1 assess ABC’s initial vitals and basic physical exam. Describing the steps of a basic EMT PE from the patient POV will please EMS personel that you did your homework.

We have a fall with possible closed head injury, EMTs may mention that raccooning or battles sign are not present. Pupils PERL (Pupils Equal and Reactive to Light) Cervical spine injury is going to be assumed until ruled out by xray/CT, especially in a blow to the head sufficent to cause loss of consciousness.

Full spinal immobilization, and low level O2. Patient should be placed with the head end of the backboard slightly elevated. IV therapy is kinda fuzzy when you have a potential head injury without apparent signs of shock. Pumping fluids into someone with a closed head injury can make things worse but even with stable vitals a med administration route is desireable.

Oh and Dude…DUDE… big NO NO.

Do not tightly restrain someone who is seizing, if he seizes again later while restrained he can tear muscles and dislocate joints.

25

Did I mention this is BAD!!! Like licence suspended/revoked, nurse fired on the spot, go to jail for abusing patients BAD. This would be totally unacceptable and other staff would flat out refuse the order to restrain. unless the patient was definitely combative as opposed to seizing. Once you have seen a grand mal real seizure, there is no mistaking it for anything else.

Seizure activity is addressed with medications not restraints.

Its almost funny to see people try to fake seizures once you know.

26

PICUNURSE’s reference logrolling, turning the patient as one unit without twisting his body or head so as not to aggravate any spinal injuries. It takes 2-3 people to do it correctly.

Backboards are usually very clearly marked as to what agency they belong to. EMT’s will leave them behind and pick up another one at station before going back in service. Many agencies will have people who just go around to the hospitals picking up various types of gear like this and returning it to station, cleaning it, prepping it for use, etc.

27

An ER doc got puked on! I’d pay to see that. Unless you are not paying attention, you will see it coming for a few seconds before and can evade.

If your hero is still immobilized on a backboard the doc would just grab an edge and tip you up to the side so you will not drown in your own vomit (aspiration pneumonia…Suction stat!). Bonus points if you don’t like the person on the other side of the patient.

I did this once to someone elses patient once and they got a nice vomit splatter on their right butt cheek and down his leg for turning away from their patient. He of course begrudgingly thanked me for the assist.

If you really wanna hose the doc you might wanna have someone else flip him while the doc is turned away.

28

When he falls down the stairs, he strikes his head on a staircase railing, hard enough to crack the wood. His Mom witnesses the fall. He’s out cold for a minute or two, and delirious for a minute after that. Then the pain in his neck starts up (which started BEFORE the fall, and is completely non-physical, but of course that’s irrelevant from the EMT’s point of view.) At this point he’s fully conscious & able to move, but can’t move very much because the pain is so bad. The mom gets frightened and dials 911.

Also…and this makes things more complicated, of course…the kid’s a pathological liar. The mom tells this to the EMT’s flat out. And yes, the kid does stupid shit like saying he sees four fingers instead of two, etc.

I know what “raccooning” is, but what is “battles sign”? “Pupils PERL” – would they say “PERL” as a word, or use the initials? That would tie in great with a theme that’s already established, both as the oyster-made jewel and the computer language.

Oh, would it be likely for him to have a nosebleed? I can’t imagine striking my head that hard and NOT having at least a small bleed, maybe just a trickle.

And when the kid pukes, it’s from the doctor doing an abdominal exam, so unfortunately I can’t work it so he gets the full spray. :wink: (And yeah, the kid lied about not being nauseous, too…)

Phew! Ok, forget seizure, he’s being combative. That’s already established. Would that be acceptable? The way I’ve written it, the orderlies stand on each side BUT DO NOT TOUCH HIM while she asks him questions about the TV, the vase, the curtain, and when he can’t explain everything (he’s lucid, and trying to play it off as a nightmare) she gives the order to strap him down.

I’m guessing, since combativeness can be a sign of brain injury, she uses that and excuse to strap him down. Basically, that’s her game – finding excuses to hurt patients that are “logical” by all outside witnesses. Would that work?

29

Generally they would use the word like “pearl”

Bleeding from the nose and or ears after a severe blow to the head is a bad thing. Maybe he bonked his nose, maybe not. The EMT’s would touch the blood to the corner of some kind of bandaging material or maybe a piece of paper to see if they get a double ring effect (spot of blood with a wet area that visibly extends away from the blood) This would indicate cerebrospinal fluid mixed into the blood meaning definite skull fracture

Even then hard restraints for more than a few minutes as a patient safety measure is outside an RN’s scope of practice without a MD’s order. (Example to avoid a disoriented and seriously injured person from climbing out of bed.)

30

Wow, I didn’t realize that was so universal. When I was in my 20’s I was going down a snowy hill in a saucer and hit a bump so hard it knocked me out from the shock up the spine. I was only out for a minute, but was pretty disoriented when I came to. My girlfriend took me to the ER.

The admitting nurse asked me what day it was, and I wasn’t sure. She asked me who the president was, and I knew it was Reagan.

Then she asked who the previous president was, and I said Jimmy Carter in a perfect Georgia accent. She had no sense of humor. Then she asked my age. I actually didn’t know. I knew I was in my 20’s but I couldn’t think of my exact age. Which I thought was pretty funny, but again, the nurse maintained her deadpan.

They x-rayed me then let me go with no treatment whatsoever, except instructions for my girlfriend to wake me up in the night and check my eyes (pupils same size, respond to light, etc.). I had an astonishing stiff neck for a week.

31

Discoloration/bruising behind and below the ear that is indicative of basal skull fracture (a bad thing that will get you an E-ticket ride straight into an Operating Theatre).

32

EMT training is pretty consistent nationwide, the scope of practice and methods are pretty universal.

Also its a good reasonable question that anyone should know. The challenges are when you run into a disoriented deaf person who does not want to read what you write and just rants at you in ASL.

33

Thats a razor thin line you are walking, since her “witnesses” in many cases will be other licenced staff who could also be held accountable if they felt it was inappropriate and allowed to it go on. A pattern of complaints of rough handling would also come out relatively quickly if this nurse was some kind of sadist who felt the need to express it on her patients.

Someone like this would not last long in an acute care setting, convalescent facilities would be a more likely territory for this flavor of wacko since many of the patients are less able to report it effectively.

34

For what it’s worth, I learned it as PERRL. Pupils Equal Round and Reactive to Light.

Also, I agree with drachillix about the likelihood of him being restrained. He’d have to be physically combative, and even then he might not get restraints for a while.

St. Urho
EMT/Firefighter

35

Well, I think I have an out here. It’s a horror novel, with a strong element of vampirism & demonic possession, and the line between reality and “unreality” gets very thin itself, esp. for our young hero. There’s also a HUGE element of people in the “real” world who abuse their authority, just because they can.

For instance, only four medical staff are involved in this scene – the evil nurse, the two orderlies (who are basically her “dogs”, under her control) and the absent-minded doctor, who doesn’t even realize the kid’s restrained until the kid himself points it out. (“Aw, that’s not really necessary,” is all he says, although the evil nurse does convince him to leave one arm restrained, for another hour anyway.)

I know, it does sound rather ludicrous out of context. My main concern, of course, is having any situation where the reader will say, “Oh, no WAY would that happen!” and throw the book away. I’ll cut the scene if I have to, but if I understand what you’re saying that it might happen, it’s just very unlikely, well that might be enough to work with. :wink: