Emergency outside of work

EllaBella1, BSN · Nov 6, 2017

My take on this (and I could be wrong as I've never been a medic) is that the medic was responding with a first responder stabilize and prevent further injury mentality, whereas you were thinking in terms of more of a nursing/hospital based assess and treat mentality. I see both sides of this. On one hand, you assessed essential functions- LOC, breathing, pulse. I fully appreciate your desire to assess pupils, etc, but in reality what would it have done for you at that point in time aside from giving you more info to tell the ambulance when they arrived? Sure it could have given you info to pass along as a baseline neuro assessment immediately post accident, but what if he had an unstable c-spine fracture and even subtle movement made his injury worse? I do agree with not releasing his helmet strap unless he was clearly asphyxiating because of that risk.

I think you will build confidence in your skills and become more assertive naturally in time. You did the right thing by coming to the patient's aid- I just think that the differences in how pre-hospital care and in-hospital care are delivered made this situation uncertain, and the medics confidence in their process seems to have won out. I wouldn't get too caught up worrying about how you handled the situation. You did fine!

Davey Do · Nov 6, 2017

I have been the first responder at numerous MVAs and the like throughout the years, sbtr50, and have always received respect from the Police and/or EMS.

However...

Perhaps the strangest code took place several years ago in a bog. Belinda and I were on vacation and had bicycled to this park. I was walking around on one side of the park when a Fella called out "Anyone know CPR?!" I sloshed through the water to find a Guy doing compressions on an unconscious Man lying in a couple inches of water on a sandbar. Another Fella was at the head of the unconscious Man, but not in the position to give ventilations. Several People were just standing around.
I identified myself as a Nurse and began giving ventilations, mouth to mouth. The Guy doing compressions said he was a Medic and that his friend had collapsed and was found to be in cardiac arrest.
During CPR, I felt the Victim's head move. I said to stop compressions, sat back, and saw his head move back and forth. The Guy who was at the head of the Victim had stuck his hands under the Victim's head and was moving it! I asked, "Are you moving his head?! Stop it!" The Guy replied "I'm a Medic!" I checked the carotid, found no pulse, and we resumed CPR.
In the meantime, 911 had been called and a Life Guard from the park brought a backboard. We ceased CPR, log rolled the Victim, got him on the board, and then resumed CPR.
EMS drove up and started out toward us. A couple of Guys started to pick up the backboard and I said, "Do not cease CPR!" and resumed compressions. One of the Guys pushed me away from the victim and into the water. They picked up the backboard and started toward the shore. The Guys from EMS saw them coming in with the victim and turned around to walk back to shore!
Weird, right?
Belinda had stayed at the restaurant when I went wandering around the park and came to the area when she heard the sirens. I told her what had happened and had to have her give me a reality check!

We can only do so much.

Here.I.Stand, BSN, RN · Nov 6, 2017

If an off-duty medic and I as an off-duty nurse both respond, personally I would NOT try to "take control." A medic is MUCH more qualified to respond in the field than a nurse typically is.

I wouldn't check pupils in the field, because it's really not useful. As a previous poster said, even if you did see a blown pupil, there is NOTHING you can do about it in that moment. That pt will be getting a head CT at the hospital -- THAT will give the team the info they need.

Also agree that the helmet was to stay put. Undoing the strap wouldn't have prevented vomiting or a seizure, and it was loose enough so as not to asphyxiate the pt before the fall...so presumably is loose enough NOW to not choke him.

Davey Do · Nov 6, 2017

You made some really good points Here.I.Stand.

I wouldn't check pupils in the field, because it's really not useful.

I check pupils in the field because it gives me an idea the severity of the trauma and for report when EMS arrives.

Off the top of my head, on different occasions head injuries were involved. A Farmer had been thrown from his tractor and a Guy riding a three-wheeler had crushed into a concrete bridge. On both occasions, Friends and Family were relieved to hear that, even though unconscious, VS were within normal limits and PERRLA.

On another occasion with an MVA, the Individual's pupils were fixed and dilated. A Policeman and I did CPR in the car since we were unable to remove the Individual from the vehicle. EMS arrived, took over, hooked the Individual up to a monitor, found asystole, and the ERP radioed to cease measures.

JustBeachyNurse, LPN · Nov 6, 2017

Never loosen or remove a helmet unless trained to do so. In the field unless you are a prehospital RN the Emt's and medics are the higher authority with field training. There was nothing to take charge of. Most nurses are not trained in prehospital care.

The medic was correct. You do not touch or loosen the helmet. He was breathing and not blue so no risk of asphyxiation. Moving him to check pupils was unnecessary.

When I was a tech there was a pedestrian struck in front of the hospital as the night shift left. Who took charge? EMTs & medics

The EMT techs held c-spine stabilization, security got a backboard and c-collar. The EMTs & medics were trained in quick assessment, stabilization and packaging the patient.

Strongly recommend not yelling "but I'm a nurse" in any scenario. Unnecessary attention and can adjust expectations and increase your liability. Don't lie but don't volunteer either

akulahawkRN, ADN, RN, EMT-P · Nov 6, 2017

Out of the box, so to speak, nurses generally get zero training in prehospital care. I'm not saying that nurses can't learn how to do it, it's just that there's much they don't know. I'm both a Paramedic and an RN. In this instance, I'm speaking as a Paramedic. In this specific instance, you generally do not want to remove the helmet unless there's an airway issue. Holding on to the helmet will help you provide stabilization of the head without compromising the cervical spine. The helmet generally does a very good job of protecting the head as long as it's reasonably well fitted. As such, it holds onto the head quite well. If you absolutely must remove the helmet and there's a Paramedic (or even an EMT) on scene, follow their lead and instructions exactly as they say to. They've been instructed how to emergently remove a motorcycle helmet.

Neck straps, as long as they're done right, will not compromise a patient's airway. If you find one that does, the helmet will be severely damaged and you'll need to remove the helmet anyway. Otherwise do not touch it unless you're removing the helmet. With respect to vomiting, seizures, and closed head injury signs, there's nothing you can do in the role you were in to address any of those except be ready to support the head and neck in a neutral position or log roll the patient on to their side to allow for drainage of emesis. Unless the helmet has a full face shield and some kind of mask on it that traps fluid, any emesis will drain out.

Most of the time, by the time you've started thinking through what's going on, a competent medic will have completed his or her primary and secondary surveys and will have a pretty good idea what needs to be done next and can easily transition care from them to the on-duty crew in a nearly seamless manner.

In short, they're specialists in doing that job and unless you have specific training and education in working in the prehospital environment, they're going to be much better at it than you are. Let them do their job. There's a reason why I both maintain my Paramedic License and have it with me. It allows me to do things and be of greater help than if I had simply identified myself as an RN.

akulahawkRN, ADN, RN, EMT-P · Nov 6, 2017

You made some really good points Here.I.Stand.
I check pupils in the field because it gives me an idea the severity of the trauma and for report when EMS arrives.
Off the top of my head, on different occasions head injuries were involved. A Farmer had been thrown from his tractor and a Guy riding a three-wheeler had crushed into a concrete bridge. On both occasions, Friends and Family were relieved to hear that, even though unconscious, VS were within normal limits and PERRLA.
On another occasion with an MVA, the Individual's pupils were fixed and dilated. A Policeman and I did CPR in the car since we were unable to remove the Individual from the vehicle. EMS arrived, took over, hooked the Individual up to a monitor, found asystole, and the ERP radioed to cease measures.

I don't check pupils in my primary survey. It's not relevant data at that point. I might get to it in a secondary survey but if my patient is dead and I'm compelled to even begin CPR on a trauma patient in the field, I guarantee I won't get far enough down the assessment path to check pupils until I am able to step back from doing CPR because I'm running a 1 minute strip in 2 different leads to check for cardiac activity that is compatible with life.

I do tend to get very worried about unconscious people in the setting of trauma that do not wake up reasonably quickly. At some point in my secondary survey of an alive but unconscious trauma patient, I'll check pupils but a single snapshot in time means little unless you find a dilated pupil or two... or if you see one that is dilated that wasn't before.

sbtr50 · Nov 6, 2017

Got ya. I didn't ever intend on unstraping helmet but I can see now where any touch and even checking pupils would cause unnecessary movement. I also didn't want to take over the situation ( I worded that wrong previously) especially since I'm new. I've learned a lot from this and from you all. Next time or if I could do it different I would identify myself to the medic only and offer assistance. Of course my friend was yelling out that I was a nurse which caused me to feel much more pressure. I really didn't know my role at that moment other than making sure his heart was beating, he was breathing and no one moved him. I think I was feeling like there was more I should be doing, therefore tried doing other assessments. I realize now, not a good idea. I just need to gain confidence in these areas. ThAnks!

akulahawkRN, ADN, RN, EMT-P · Nov 6, 2017

I have been the first responder at numerous MVAs and the like throughout the years, sbtr50, and have always received respect from the Police and/or EMS.
However...
Great story about a code! Not often you come upon something like that. (Sorry, I don't want to do a quote within a quote, too much length.)
We can only do so much.

About that code, you have to get that victim to dry ground. That means you might have to stop compressions to do so and carry the victim to shore. Lifeguards know this. Once on shore you can dry off the victim and apply a defibrillator... I don't know about you but I'm not about to spark someone that's lying in a couple inches of water out on a sandbar. I have no place to put my monitor/defib where it's not going to get water damage and a couple hundred joules of electricity and water generally don't mix.

That's the Paramedic and Lifeguard side of me coming out.

Guest219794 · Nov 6, 2017

Hi all,
I had a situation today. I was out with my husband with some friends. A motorcycle lost control pulling off the parking lot and the rider went down hitting his head and knocking him unconscious. I'm a new RN of 2 weeks on the job and an Lpn of many years. I responded along with others but I was the only nurse along with a " medic". I monitored pulse and respirations while someone else held his head stable. I was also concerned if the neck strap to his helmet may be a little tight and affect his breathing so I went to feel for tightness and the medic told me not to. I also was concerned for vomiting and possibility of seizures. I wanted to check his pupils too but the medic again told me no. The patient regained consciousness and went in the ambulance when they arrived. I didn't speak to actually say what my intentions were and I feel I may have been timid and should have took more control or spoken up more. The patient was taken care of and that's most important. I find in other situations other people tend to take over and I feel incompetent because I don't feel I took enough of a role. I don't really know how to react . I feel like I did the right thing but I'm not really the type that jumps up and yells "I'm a nurse!!" Because I'm not that confident yet.

You did some stuff very right:

You were concerned for airway. You were aware vomiting in a head injury is not unlikely.

You were concerned for breathing. While a helmet chinstrap is unlikely to cause breathing problems, it is correct to assess for the problem, and correct it if needed. Loosening a helmet strap is highly unlikely to exacerbate a spine injury, and if it caused a breathing problem, should be loosened.

So far, you have addressed A and B. Now, on to C. Breathing, so clearly has a pulse. Any reason to suspect a life threatening bleed? No obvious blood on scene, and given your description of the mechanism and presentation it's not likely. In a perfect world, somebody would have donned gloves and done a sweep under the pt, but again, not likely.

D- you were concerned for disability- Checking pupils at that point is not wrong, and not going to cause any problems. Assuming you can't think of any other helpful assessment or intervention, no harm, and it provides a bit of information. The medic was also concerned for D, and was protecting the spine by limiting movement.

That is your primary survey. Given your location, a secondary assessment isn't critical, but if you had the time, that would be the point at which you would do a quick head to toe, get a set of vitals, and med history. On an unresponsive patient, you would do that by checking for medic alerts, medications being carried, med lists, etc. Out in the middle of the street in an urban environment, what you did sounds about right.

The one thing I would add would be what pre-hospital providers do before the primary assessment. Scene size up. This is the point at which you make sure that nobody else is going to get hurt, especially you. That means having somebody directing traffic, leaving your vehicle in a position in which t protects you, that sort of thing.

I have no idea why this stuff is not taught in nursing school. Nurses have the knowledge and skills to be effective first responders with just a little extra training. Like 1-2 days out of the 2-4 years of training.

Trauma Columnist · Nov 6, 2017

I'm both a nurse and a pre-hospital RN. The two roles are very different.