By Philip Neuwirth, BS, MICP, CCEMTP, FP-C
After reading the outcome of this case study, please post any comments directly on my blog, rather than Facebook, Twitter or Linkedin. That way everyone can see the comments. And, as always, please click “Like” which helps my page. If you have an interesting case to share, please email me a message at firstname.lastname@example.org. Thank you!
The following blog post is the outcome from “How Would You Treat this Patient?” posted on May 28th. If you haven’t read the case, please click the following link first: http://hemscriticalcare.com/?p=632
Thank you to everyone who replied; I find case reviews an excellent method of learning. Hearing others perspective enables you to think outside-the-box. There were several considerations, at the time, I never thought of, including:
- Sandwiching the patient between two boards, and turning him over.
- Intubating the patient prone, since his head was turned to the right.
- And the issue regarding “refusal of care”, and whether we have the right to sedate and roll the patient over if the patient is refusing.
This case happened to be my flight, and to be honest; if I didn’t know the patient and his level of understanding of the risks associated with leaving him prone, I would have (at the time) probably treated the pain and rolled him over. I now cringe at that thought, because, as you will see in this case, we probably would have done more harm.
My partner and I decided to leave the patient prone. That decision was based on six primary factors:
- The patient had absolutely no sign of a head injury.
- Was alert and oriented, to person, place, time, and event.
- The patient was a co-worker, friend and experienced paramedic who clearly understood our conversation and risks associated with repositioning him.
- The patient refused to move, so if we did roll him over, it was against his will and would have required a large dose of analgesia and sedation. Given that fact, I don’t believe we could have controlled his pain enough without controlling his airway. [On a side note, I know there has been a lot of discussion about the use of pre-hospital Ketamine, which appears to be a favorable drug for both analgesia & sedation while maintaining respiratory drive; a great drug for procedural sedation in the ED. However, I have found the half life of Ketamine to be faster than advertised, which is ok if you are prepared, or have enough time to titrate a drip. So in this case, if the patients BP remained within normal limits, I would have elected to use Fentanyl, Etomidate, Succinylcholine, and Versed]
- Rolling the patient would have extended our on-scene time well past any acceptable standards to definitive care [surgery] for a patient who did not require advanced airway management. Obviously, if the patient were unable to oxygenate or ventilate, we would have resuscitated the patient first.
- And finally, the patient agreed (and new the risks) that if at anytime we needed to take his airway, we would rapidly roll him over.
So, at this point, we prepared the patient for transport, applied our Philips MRX monitored and added ETCO2 nasal prong capnography to monitor patients gas exchange throughout the flight. We administered another dose of Fentanyl and moved the patient from the ambulance and secured him to the aircraft stretcher. The patient was carried to the aircraft and loaded and secured. The patient remained alert and oriented.
The 10-12 minute flight to the trauma center was uneventful; patient remained conscious and alert, requiring additional Fentanyl for pain. The patient reported a slight decrease in his pain after a total of 300 mcg of Fentanyl and 10 mg of Valium. Patient’s vitals remained relatively constant.
When the FT arrived at the trauma center, the trauma surgeon did a quick assessment and slid the board out. Trauma team agreed to leave the patient prone and moved him to CT in that position (we felt better about our decision). After CT, the patient was returned to the ED and patient was prepped for surgery.
Our patient required immediate fusion of L1, and within a week, had surgery to realign and secure his cervical spine. I don’t have a picture of his shattered heal because his name appeared on the scan. But suffice to say, I think he may have more metal in his heel than bone.
So what are the takeaways?
- Always listen to your patient, their perception is their reality.
- Allow patient to splint themselves (if they can).
- If your patient is alert and oriented, (and has a solid understanding of the risks) include them in the decision-making process.
- And, never say never. You wouldn’t believe the countless number of healthcare professionals that told me; I would never transport a patient prone in a helicopter. Obviously, it’s not preferred, but certain circumstances may change your mind.
I spoke to the patient last night. He is expected to be out of work for another six months. The accident occurred November 11/21/2015 and was released home on 1/30/2016 from in-patient rehab. He continues to make excellent progress and is grateful to everyone who has treated him over the past 6+ months. He also plans to present his case in the future, from his new (patient) perspective, rather than the from a caregiver’s perspective.
I want to thank our patient personally for allowing me to post his case. For those who participated in the discussion, thank you again; it was educational for me, and I hope the same for you!
Please post your comments directly on my blog, rather than Facebook, Twitter or Linkedin. That way everyone can see your responses. And, as always, please click “Like” which helps my page. If you have an interesting case to share, please email me a message at email@example.com. Thank you!
Scroll down to see the scans.