Tuesday, 9 June 2009

Is it me....................what do you think?

This call occurred a couple of weeks ago and I still find myself questioning one of the decisions made by the DR at A/E.

Our first job of the night was to a child who had fallen from a rope swing that his dad had just put up in the garden. We arrive on scene to be greeted by a panic stricken father who leads the way round to the back of the house. On the floor is a small boy lying on his side, conscious and breathing (always a welcome sight in any ill or injured kid, I'm sure you will all agree) and covered in the customary emergency layers of blankets. A quick assessment reveals that his ABCs are good. However he has bony tenderness in the centre of his neck (C-spine), he also has some thoracic bony spinal tenderness. It is causing him great discomfort despite his mum having already giving him some oral paracetamol solution. He has no neuro deficit and all his limbs are moving. Because of the 'mechanism of injury' we need to be very careful and immobilise him. We pop a collar on him and keep him chatting. Despite the pain he is very compliant and I offer him some oral morphine to ease the pain of which he is grateful. Next we roll him onto a vacuum mattress for comfort and suck the air out. On to the trolley, into the truck and of to hospital with mum. Dad follows in the car. On the way I do the usual observations which are normal for his age and I find out that mum is a paediatric nurse at the local hospital.

Now, back to the mechanism of injury; the swing is my height-over 6' and according to dad the swing managed to unhook it self when the kid was at full height. He landed on grass but his back took the full brunt.

I phone the hospital and speak to one of the Jr DRs, as I know they were busy, just to let them know what we have and how long we will be. We arrive 10 minutes later with a child who is now relatively pain free. This is the bit I'm stuck on. After releasing him from the vacuum mattress I take control of the head and direct the log roll while the DR examines his back.
"when I press you tell me yes if it hurts, OK?" says the DR
"OK" says the child
Pressing on the neck soon generates a yes and another yes and another. Now onto the thoracic spine and another yes etc. The DR then says "I think he'll be OK" and asked the boy to move his head left and then right, no problem. However when the DR asks him to lift his head up off the trolley he can't because it is too painful..................in the middle of his neck and back! The DR still says "I think he will be OK".
Dad shakes my hand and both parents thank us, we book in the patient and are off on the next job.
What I don't understand is why didn't the DR refer him for an X-ray? Yes I know kids have soft bones, yes he landed on grass (which wasn't that soft) and yes he probably will be OK. But if there is CENTRAL bony tenderness over any part of the spine, child or adult, then surely that warrants an x-ray. Again I know x-rays shouldn't be dished out 'willy nilly' but if the mechanism is there.................................


I'm sure/hope he was fine. I should really follow it up (too busy that night) and have a chat with the DR.

This is no way a dig at any A/E DR just my curiosity. I'm pretty sure if it was one of the more senior DRs then investigations might have been slightly different. I don't know.

7 comments:

Tazambo said...

Sounds very dodgy to me.

medicblog999 said...

Hi Mac,

The MOI was clear, your treatment was exactly as it should have been and Im surprised that the doc cleared his spine without an imaging studies.
As you say, maybe he had rationale for doing that, but I would hate to be that guy if something later cropped up!!

Don't know if Rapid response Doc reads your blog (he probably does) but he can give a great insight into this sort of query.

mac said...

Yeah he does. Seeing as RRD is a Consultant it would be nice to have a DRs inout. To be honest there was a slight language barrier with DR and although he could speak english I'm not sure he understood the full MOI.

Anonymous said...

Hi guys,

I was wondering if one of you could help me with a question I have?

I have always wanted to be come a Paramedic and just recently I have applied to become an Ambulance Care attendent which is a stepping stone to becoming a Paramedic. A few years ago I also applied to become a Fire Fighter but I did not go ahead with the application because I suffer from claustrophobia and they clearly stated that the job would not be suitable for people who suffer from this.
What I wanted to know is would this phobia also affect my potential job as a paramedic?
I wouldn't say that my phobia is 'severe' but I'm not sure how much of an affect, if any, it would have on my chances of becoming a Paramedic.

I look forward to your replies!!

Thak you, William.

medicblog999 said...

Mac, hope you don't mind me pitching in here.
William,
Unfortunately, I think the claustraphobia may still be a problem. You news to imagine how you would feel being inside a crushed car caring for a casualty whilst the fire brigade work away at cutting up the car. Could you crawl under a lorry, bus or even a train to get to a patient? There is also the risks of going into many other claustraphobic areas. I have had a few tight squeezes which has certainly raised my heart rate.
Only you knows if you could cope and still be an effective and efficient paramedic in those situations. Good luck!

Scott G said...

Mac,

As an A&E (junior) doctor, I have to say I am surprised (as you were) by that response. In my book, anyone with central bony tenderness and mechanism gets x-rays before collar/blocks/tape etc removed. I also consider mechanism and events in the pre-hospital phase.
I think your management was entirely correct and you are right to question what happened next.
S

RapidResponseDoc said...

Hi there, sorry I didn't reply until now. There is no doubt that, if the child cannot lift his head up off the pillow, then he needs an xray. If he has bony tenderness, then he should have an xray before being moved. End of story. The guidelines are very clear, and very easy to follow. The two possibilities of not following it properly are either irradiating unnecessarily, or giving someone a spinal cord injury. Please pick one...