Minuteman Bikeway — assault

Location: SEMS HQ

Time: 20:13 Thursday

Conditions: Cool and clear

Equipmentfully stocked

 

Dispatch

“It’s just the economy. Everyone in the area’s getting squeezed.”

“We were getting squeezed before the economy took a dump. Twenty years ago we had minimum coverage 8 BLS and four ALS during the day… minimum! But that was when Scenarioville liked to parade us around. They started cutting when Hendricks moved into city hall.”

“The fire department hasn’t suffered.”

“Exactly… well, not since the big cut in ’97. Remember, they used to run six engines.”

“Yeah, sure. And they never did anything.”

“They were there for The Big One, then everyone decided to rely on mutual aid and figured The Big One can just burn until everyone gets there.”

“The point is, now we’re getting sent BLS to codes and babies not breathing, and the medics are so overworked they don’t want to take the calls they do catch.”

“No, the point is that we have to spend half the goddamned day posting in strip malls instead of parking our ass on the sofa like god intended. Do you remember the West End base? Biggins had that huge espresso machine set up, it was like living in a Starbucks.”

“Sully in the office told me that, on average, posting us cuts two minutes off responses from the base. Two minutes. People can goddamned wait.”

Your little bitch session is cut short when the base radio crackles

[Ambulance 61, A61, responding priority 1 to the Minuteman Bikeway for the adult female status post assault, conscious and breathing. That’s on the Bikeway… area of… sounds like north of Lake Street, by Marion Circle, no access nearby. 61, access from the crossing at Lake Street, PD will attempt to bring the patient to you. Fire responding mutual aid from Medford, update the need. 61?]

Click to expand

 

Response

“You see? What am I saying here?” you remark as you acknowledge on the base radio.

“I’m sure Medford is going to tear up the blacktop,” comments one of the P1 medics.

“Did he say someone was assaulted? A salted what?”

You roll your eyes and leave the rest of the peanut gallery in the crew room. You and Steve jump in the truck and start rolling.

“Why can’t we access from Marion Circle?” you wonder.

“No walkway there,” answers Steve.

“Yeah, but isn’t it just like, a little dirt hill?”

“Some spots it’s pretty easy to get across, but some places there’s bushes and stuff too.”

“Whatever.”

Pulling down Mass Ave, you reach Lake Street. At the side of the road is a walkway to the Minuteman Bikeway, which cuts across a good portion of the city — it’s mostly paved, a nicely scenic route to ride a bike in the summer. You’re not a cyclist yourself, but that’s probably why your midsection keeps expanding.

 

Scene

Steve parks at the curb and you hop out. Peering down the path, you don’t see anyone, even when you throw on the floodlights.

“Want to ask PD over the air?” Steve asks you from the driver’s seat.

“Eh.” Although you do have the police band on your UHF radio, you try not to talk on it much. Police are weird. “Maybe just ask dispatch.”

From the background, you hear him hailing Operations and asking for an update. But a moment later, you see movement from the path, and a couple SPD officers walk into the light, with a young adult female walking between them. “Hey, here we go,” you remark.

As they approach, you meet them and say, “Hi guys. What’s up?”

“Kicked in the head,” replies one of the cops.

 

Initial Assessment

Greeting the woman, you say, “Hi there, I’m Sam. What happened?”

“I got friggin’ fucked up by like three fucking –”

“Hey, take it easy,” one of the officers says.

“I was just walkin’ down the path to meet some friends and these three dudes jumped me and kicked me in the head and stole all my shit and my money and my phone and –”

“Okay, so you got kicked in the head?” In the light, you can see a small lump on her forehead.

“Yeah.”

She appears otherwise grossly unharmed and is walking fairly well. She’s breathing without labor, although she seems a little agitated, and her skin is a bit pale.

 

 


 

 

Palpating a quick radial pulse, you find it weak, regular, and a little tachy. Her skin is cool, but so is the night air.

Steve is behind you by the open cab door. “Wanna cancel fire?” you ask him. He nods and ducks inside to grab the radio.

The woman is starting to go off again. You raise a placating hand. “Okay, slow down, let’s start over here. What’s your name?”

“M… Maureen.”

“Okay, so you were walking, these guys showed up and… kicked you in the head? While you were walking?”

“Yeah.”

Hokay. “And then what? Did you fall down? Did they keep hitting you?”

“I fell and they kept wailing on me.”

“Did you hit your head? When you fell?”

“Yeah.”

“Did you pass out?”

“For a second, yeah.”

“And then they hit you some more or what?”

“They kicked me in the head.”

“All right. So how are you feeling right now?”

“My head hurts.”

“Where?”

She points to the bruise on her forehead. It’s about a centimeter across, closed, and located on her upper right forehead.

“Anywhere else? Where did you hit it on the ground?”

She points to a spot under her hair on her upper left occiput. Palpating, you feel another small lump.

“Okay. Are you hurting anywhere else?”

“No, but they took my wallet, and my phone, and –”

“Okay, okay. The police are going to take care of that. We’re here for you. Are you having any weakness, numbness, tingling in your hands or your feet?”

“Nah.”

“How’s your neck feel?”

“Okay.”

You palpate around, noting as you do that her pupils are equal and midsize. There’s no tenderness or deformity of the cervical spine, but when you press the side of her neck in the middle of the trap, she grunts. “That’s sore.”

“Gotcha. Do you have any medical problems?”

“I’m… no… I’m pregnant.”

“How far along?”

“I don’t know, I just found out today, I took a test.”

“When was your last period?”

“Uh… I don’t know… I just had a baby four months ago.”

This is a really enriching conversation. You briefly examine her abdomen. There’s no visible or palpable fundus, and she’s soft and non-tender. “Are you taking any medications?”

“Uh, Klonopin, clonidine.”

“Have you had anything to drink today?

“I was out, I had… like three drinks.”

“Any drugs?”

“No, no.” Brilliant stuff Sam, like she’d tell you in front of the police.

“Okay. So what do you think? Do you want to go to the hospital?”

“No, I… I think I’m… what do you think?”

“It’s up to you. That’s always the safe choice.”

“Yeah, but… I’m feeling… you’re going to get those motherfuckers, right?”

You shrug. “These gentlemen are going to sort that out” — meaning the police. “The question right now is whether you’d like us to bring you into the hospital to get checked out.”

“Uh…” she seems lost.

 

 


 

 

You’re not sure how hard you want to lean on her, but then one of the cops steps in. “Look, you’ve got to go, okay? Get in there and get checked out. You’re pregnant for christ’s sake!”

“But –”

“No, you got to go. If you’re so hurt, you’re going to the hospital. You don’t go and we’re not gonna help you out.”

You turn slowly to stare at him. Thanks asshole.

“Well… all right,” Maureen mutters.

Rubbing your temples, you sigh. Suddenly you feel very tired. “Okay. Squeeze my hands?”

She squeezes your fingers with equal strength.

“Can you feel that? Same on both sides?” You pinch the backs of her hands.

“Yeah.”

“Push down?” You offer a hand under each forefoot. She presses with equal strength.

“Pull up?” She lifts her toes, dorsiflexing with equal strength.

“That feels the same?” You pinch underneath both knees.

“Yeah.”

“All right. Can you turn your head for me? Chin toward each shoulder?” She does.

“And chin to your chest?” She pulls off that one too.

“Does that hurt at all?”

“No, not really.” Overall, she’s cooperative, clearly agitated, and probably tipsy, but not drunk enough to impair her function much.

“Great. Okay, is there a hospital you usually go to?”

“Uh… I’ve been… Memorial I guess.”

“All right, great. Okay to walk over here?”

You guide her over to the truck and have her step inside, clear the stretcher and park her on it. Blanket, straps, and you give Steve a thumbs-up. “Memorial on a 3.”

“Gotcha.” He climbs up front and starts rolling.

Finding a cuff, you pull a set of vitals — a pulse of 94, pressure of 130/90, breathing about 20.

“Any allergies you know about?”

“Um… sulfa.”

“Thanks. Can you just spell out your full name for me?” You can’t remember if she mentioned her last name, but since you usually forget names about 2.1 seconds after hearing them, you’ve developed a large arsenal of ways to hide it.

“M-a-u-r-e-e-n P-o-t-t-s.”

“And your date of birth?”

“November first, 1980.”

“So… you’re… thirty…”

“Thirty two.”

“And you’re taking… clonidine… and Klonopin? What are those for?”

“I have PTSD.” She trails off.

“Great. Okay, you want to hold that to your head there?” You crack an ice pack for her goose egg.

Scooting over, you grab the radio and hail Memorial Hospital. When they acknowledge, you ramble off with… (click for audio)

[Hi Memorial, Scenarioville Ambulance 61. We’re six minutes out with a 32-year-old female, kicked several times in the head and fell. Neurologically intact, minimal complaints, vitals stable, doing okay. See you soon; questions?]

“Thanks,” they reply curtly and click off.

You do a quick reexam in the light, and grab another set of vitals, but find nothing exciting. For most of the trip you just try to calm her down a little; she explains what she’d like to do to the guys who did this, and it sounds like something from Grand Theft Auto.

Finally, you’re backing into the Memorial ambulance bay, and Steve opens the hatch. When you roll inside, a weary charge nurse takes a few seconds to notice you, and eventually points you to a nearby room.

“Okey, going down?” You lower the stretcher and let her walk over to the bed. Once she’s situated, you wander outside, and a nurse who clearly hasn’t shaven today materializes.

“Whatcha got?”

You check your notes and drawl this report… (click for audio)

[So this’ll be Ms. Maureen Potts, 32; she was out on the town when she got jumped by a few guys. She’s saying they kicked her in the head while she was walking around, which seems… odd… and she fell, conked her head on the ground, passed out for a second, got kicked a bit more, and they took off. So now she has a decent contusion on the forehead and one on the back left where she hit the ground, no other pain, doesn’t seem to be any other trauma. No neuro signs, she was walking around with the police for something like fifty miles; she has some neck pain laterally, middle of the right trap, but she’s been turning and flexing her head with no problem. Says she had three drinks tonight, seems a little loose but not drunk. Not much history, she did discover today that she’s pregnant, doesn’t know anything about that yet, didn’t really want to share many details. Takes Klonopin and clonidine for PTSD and whatever, allergic to sulfa.]

“How come she’s not on a board?” he asks, managing not to sound too accusatory.

You shrug. “Seemed low risk.” You’re too tired to justify yourself more. If he wants to cause trouble he can. He just nods and heads into the room.

Someone from registration drops by and takes Maureen’s name and DOB, and pretty soon you’re back outside. Sliding into the truck, you sigh. “I am tired, Steve. Can we go home?”

“Nope.”

 

Discussion

Diagnosis: contusion, mild concussion

A common challenge faced by EMS providers is the question of whether to immobilize the spine of patients who suffered blunt trauma involving the neck, yet seem low-risk. Compounding the problem is the fact that our prehospital protocols often may not specify in holy writ whether a borderline patient should be boarded and collared, yet our employers, medical directors, or regional governing bodies may interpret them to mean otherwise.

Many of us respond by C-spining everybody. But if you feel you can get away with it, there are effective ways of screening patients to determine who is truly low-risk. (Not that even the high-risk patients necessarily benefit from immobilization; in fact, there’s never been any evidence that any real human being has benefitted from the practice, ever. But your boss may not believe that.)

The most common approaches are the NEXUS criteria and the Canadian C-spine Rule. NEXUS is simpler, essentially boiling down to whether the patient has neck pain or any factor that would impair their ability to report neck pain (such as altered mental status). However, the Canadian rule has been shown both to be more specific and more sensitive, and appealingly, lets you rule out some patients who do have neck pain — and pretty much everybody has neck pain. Our patient here is a gray area according to NEXUS, given her lateral (not midline) neck pain and questionable level of intoxication, but she does clear by the Canadian rule. For those interested, there’s plenty to read on this subject in the DRL.

Your best attempts at triage, of course, can still be foiled by the involvement of police or firefighters (good intentioned or otherwise). Cest la vie.

Comments

  1. cn exam, transport? would probably get a collar and backboard in my system, based on the head pain

    • D’you know, I totally missed that Sam neglected to do much of a neuro exam here. (Not that you ever forget to do anything in the field…) I’m sure he’ll remedy that shortly.

      But yep, I agree, that’s probably how it’d go in my area.

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