Is it bad to over-react in Emergency Medicine?
I came on the scene, the patient was lying prone in firm snow, on a fairly steep bank on the uphill side of a trail. His right ski was still on his foot, and his left boot was externally rotated to what appeared to be opposite of the bend in the knee. Neither of his ski boots were buckled correctly, and consequence of such, were very loose. He was relatively calm, probably about 10 years old. I asked him what happened...
He said that he had fallen and twisted his ankle, and now it felt "weird". He said he couldn't walk on it. He used words like tingling, burning, electricity, numbness. The patient denied other injuries and there was no spinal point tenderness on palpation. The position he was in, plus the possibility of an in-boot spiral tib/fib were my main concerns. I tried to palpate for deformity/open wounds in his boot. After a slight scare that turned into melted snow, I ruled out any bleeding, but I couldn't tell on deformities one way or the other.
I called for a backboard and a set of hands because the patient was in relative comfort in the position found, and I didn't want to have to flip him, and end up have him screaming as his leg flopped around, or both of us go sliding down the hill and cause more significant injury to his leg.
When help arrived, we managed to log roll the patient onto the backboard, which caused no discomfort at all, the patients injured foot was stable, and didn't rotate to either direction. After more assessment I finally asked the right question...
"Have you ever hurt yourself before?"
"Yeah, but I've never broken anything, just bruises"
"How much does your ankle hurt compared to that?"
"Less..."
We took him off the board, he sat up, and we got him down, he walked just fine.
If I just went on the level of discomfort this patient was in, I could have figured he just twisted his ankle. But I had been in a similar situation; the EMTs were certain I didn't break my femur because I wasn't screaming enough. I'm sure they had learned in the back room of some fire house that femur injuries hurt like hell and the patient will be screaming their bloody cords out. There are so many subjective measures in what we do, the only thing that we can do is what we think is best for the patient at the time.
On scene, for a moment, I was slightly worried about overreacting, for a split second I was concerned what folks would say for me calling for a backboard for a patient with a twisted ankle, but I am glad that I immediately thought about what would happen to this patient did have a fracture, and if I did try to flip them on my own and take care of the situation without help. There would be a chance that we would have slipped a few dozen feet down the slope.
As I read over this post, and think about this situation I guess if I had asked the patient if they could flip on to their back or sit up, he would have, and been fine, but I assumed that no one would lie face down in the snow unless that WAS the most comfortable position, but I guess the way his leg was presenting put that out of my mind right away. I guess you can call that defensive assumptions.
One thing I know for certain is that I can only do what I think is best for the patient at that moment in time. It is easier to justify our actions for the worst case scenario than to say "I didn't think it was that bad"
As I read over this post, and think about this situation I guess if I had asked the patient if they could flip on to their back or sit up, he would have, and been fine, but I assumed that no one would lie face down in the snow unless that WAS the most comfortable position, but I guess the way his leg was presenting put that out of my mind right away
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