Mystic Valley Parkway and River St — MVA

Location: Broadway at Grafton St

Time: 01:58 Tuesday

Conditions: Clear and warm

Equipmentfully stocked except down 1 D tank

 

Dispatch

You’ve been running all day. To cap it off, shortly after midnight you’re sent to a chest pain that ends up being a circus, and it takes everything in your bag of tricks to successfully delivery the patient to JUMC.

After clearing out, you’re headed back down Broadway toward HQ, hoping for a few hours of rest. But just as you pass the Thompson Playground by Grafton St, the radio crackles… (click for audio)

[Ambulance 61, respond to Mystic Valley Parkway at River St for the MVA. That’s A61 responding with Ladder 1 to the MVA, Mystic Valley Parkway and River by the Medford line. Time out 1:58. A61?]

Click to expand

 

Response

You yawn and shake yourself, while Steve throws on the lights, grumbling, and spins down River. You’re on scene within two minutes, beating the ladder, but PD arrives moments before you.

You see a gray four-door sedan motionless, still within its lane but at an angle. Its front end appears to have minor damage and there is glass on the ground. Ahead, a blue minivan is parked, with its rear fender slightly dented; an adult male is standing alongside. An SPD cruiser is blip-blip-blipping blue lights in the road, pulled in front to protect the scene; its headlights also provide some helpful illumination, although there is good streetlight coverage. You steer around and park behind the scene, where all the drunk drivers will have to careen through the whole crowd in order to reach you. Pulling on your reflective vest, you hop out, leaving the equipment for the moment while you approach the vehicles.

 

Scene

Although Mystic Valley Parkway is a busy road, at this time of night traffic is sparse; however, you keep an eye out, because the occasional vehicle zooming past is probably not expecting to see you, and probably not sober. For once, you’re glad to be wearing your goofy DoT-approved reflective gear.

Initially you assume two patients at least, and the man standing by the minivan presumably was driving it. You see nobody else inside. You gesture Steve to make sure he’s not secretly dying while you approach the rear sedan, donning a pair of gloves. Inside, an adult male is seated in the driver seat, alert. Damage to both vehicles seems consistent with a simple, low-speed, rear-end collision.

 

Initial Assessment

Reaching the driver door of the sedan, you open it and bend over to peer inside. The driver looks back, appearing a bit dazed. He’s wearing his seatbelt and no airbags are deployed.

“Hi!” you chirp with more goodwill than you feel. “How’re you doing?”

“Okay,” he replies steadily. “I’m okay.”

“What happened?” you ask, both for information’s sake and to get a better sense for his mental status.

“I was just driving along, and he” — he gestures at the other vehicle — “hit his brakes, and I couldn’t stop.”

You find his wrist. His skin is warm and dry, and his radial pulse is strong and fast. He’s breathing a little quickly but without labor.

“How are you feeling now?”

“I’m all right, I think.”

“Does anything hurt?”

He pauses. “My neck…” he presses against it with one hand.

Straightening up, you look back toward where Steve is standing by the minivan. His patient is talking to him animatedly, gesturing, seemingly upset but otherwise in no distress. Steve gives you a thumbs-up.

Red lights and diesel fill the night as SFD arrives; a ladder pulls up to the scene and parks at an angle.

 

 


 

 

As firefighters in turnouts start to mill around, disconnecting things and sweeping up glass, you bend over again to address the driver. As he looks at you, you extend a hand. “I’m Sam, by the way.”

He shakes gravely. “Paul.”

“Okay, Paul. What do you think? Do you want to go to the hospital?”

He hesitates. “I don’t… well, I don’t know. I’m okay, I think… I mean, it wasn’t that bad really. But maybe I should get checked out. What do you think?”

“It is up to you, my friend. I can’t say for sure whether or not you’ve got any injuries. I can tell you that you look generally okay from what I can see, but it’s definitely possible that there could be something else going on, and I can’t rule that out. The safe thing is always to get checked out.”

He nods. “All right.”

To a firefighter who’s materialized beside you, you ask, “Would you mind grabbing the C-spine bag from our truck?” He nods and trots that way. In the mean time, you poke your torso into the car, examining and briefly palpating Paul’s head and neck from all sides. It looks very much like a head and neck. His pupils are midsize and equal, and his cervical spine has no deformity or instability, although he says it has a dull soreness and is slightly tender. He squeezes your fingers strongly and equally with both hands, and although you pass on reaching down into the footwell, he visibly waggles both feet up and down at your request. You pull up his T-shirt to quickly peek at his chest and abdomen, which are unmarked and non-tender upon palpation, with a supple abdomen and seemingly intact ribcage. This all takes a few seconds at most.

The firefighter returns with the nylon duffel. You extract an adjustable collar as you tell Paul, “What we’re going to do is slip a collar around your neck, and then strap you onto a board, okay? Just as a precaution in case there’s any damage to your spine.” He nods in agreement.

Peering at him in profile, you estimate his neck length and adjust the collar. Then you slip the front under his chin and wrap around the back until it velcros snugly. The fit looks good, it’s centered, and he’s not being grotesquely stretched or mistreated. “How’s that feel?”

“Okay.”

“Okay, hang on one second.” Leaving him with the firefighter, you walk briskly to your ambulance. Opening the back, you retrieve the stretcher, undo the straps, and plop a backboard onto it. (Although they try, SFD firefighters seem to have trouble with stretchers.) Wheeling it back toward the car, you position it alongside and drop it down to a sitting height.

To Paul, you say, “We’re just going to have you step out, turn, and sit on this, okay?” You pat the board. “Then turn and lie down.”

Taking his hands, you help him rotate out of the car, stand, pivot, and sit. Then you support his back while the firefighter lifts his legs, and rotate him up into a supine position with minimal manipulation.

“Beautiful. Now, I know this isn’t particularly comfortable, so hopefully they’ll be able to get you off it as soon as you get to the hospital; they just need to check you out first to make sure you’re okay.” Pulling straps from the bag, you run them horizontally across his upper chest, pelvis, and knees. Once they’re snug, you pull the board upward until about 8 inches clear the top of the stretcher, and the firefighter holds two headblocks against the sides of Paul’s head while you wrap cloth tape around his forehead and chin. It’s not very pretty, but it works. You slide the board back down, buckle the stretcher straps, and elevate the stretcher.

Steve comes trotting up holding the computer. “My guy’s all set. Got a refusal from him.”

“Great. Can you load him up? I just need a second.” He takes the stretcher and starts rolling Paul toward the truck.

Reaching for the lapel mic of your radio, you key it and say, “Operations, A61.”

“Go ahead, 61.”

“We’re going to be transporting one patient in a moment. One refusal.”

“Copy, one transport and one refusal.”

You take a moment to walk around the sedan and inspect the damage. Although it’s seen better days, the only immediate harm seems to be a 1-2 inch dent spanning the front bumper. It involves the hood, but just barely, and one headlight lens is smashed. Inside, you see no damage to the steering wheel, windshield, or lower dash, and no marks upon the driver’s side post. Nothing else is notable, although the back seat could use some tidying.

Walking to the minivan, you greet the other driver, who is letting the police copy information from his license. “Doing okay?” you ask.

He nods. “I’m fine.”

“Can you tell me what happened?”

“I slowed down for the light, and I guess he didn’t. Rear-ended me.”

“Did you hit your head, bounce around at all?”

“Nah, just thrown forward into my seatbelt a little.”

“Any idea how fast?”

He shrugs. “I was mostly stopped. I don’t know about him. Normal speeds I guess.”

You take a look at his vehicle. There’s about 4-5 inches of intrusion to the rear bumper, no damage inside the compartment, and no airbag deployment. Wishing the driver luck, you return to your truck where Paul is loaded up, and relieve Steve on the bench seat.

 

 


 

 

“Is there a hospital you usually go to?” you ask Paul, leaning over so he can see you.

“Not really. I don’t really go to the hospital. I guess University.”

“Okay.” Turning to the door where Steve is standing, you tell him, “We can go.”

While you slip a blood pressure cuff around an arm, you ask Paul, “Do you have any medical problems?”

“No… well, I have asthma sometimes, not very bad. And I had my left knee replaced.”

“Recently?”

“Oh, no, four or five years ago.”

“How’s your breathing now?”

“Fine.”

“Chest feel okay?”

“Yeah.”

“Any numbness or tingling in your hands or feet?”

“No.”

“Do you take any medications?”

“Just a vitamin.”

You prop up his arm and palpate a brachial pulse; while counting, you ask, “Allergic to anything?”

“Dust.”

“Not to any drugs?”

“Not that I know…”

His pulse is 88. Estimating his respirations at the same time, you count around 18/minute. You place your scope on the same spot and obtain a pressure of 136/88.

“So when’s the last time you were at the hospital?”

“Oh… when they did my knee. I was born there too.”

Up front, Steve pops the truck into gear, and over your portable radio you hear him call the 61 transporting to Jefferson University. You take a moment to flick a penlight into Paul’s eyes, noting nice contraction, and briefly auscultate both sides of his chest; strong, clear sounds are heard bilaterally. A somewhat more cautious exam of his abdomen and pelvis reveals nothing remarkable. You pat down his arms and legs with no findings, find strong and equal movement from his feet, warm and non-edematous legs, and no swelling or tenderness to the knees (which often get bumped by the dashboard).

Feeling particularly lazy, rather than moving to grab the mounted mobile radio, you just click your portable radio to the medical patch channel and hail JUMC. To Paul: “How old are you, Paul?”

“41.”

You make this entry notification (click for audio):

[Hi Jefferson, this is Scenarioville Ambulance 61. We’re four minutes out with a 41-year-old male, driver in a low-speed MVA. Complaining of mild neck pain, otherwise okay. No deficits, vitals are unremarkable, he’s currently boarded. We’ll see you shortly; any questions?]

“No thank you; we’ll be waiting, thank you 61.”

“Can I get your full name?” you ask Paul.

“Paul Schiffer.” He spells it out.

“Date of birth?”

He provides it, and you scribble them down.

A few moments later, you hear beeping as Steve backs into the bay at JUMC, and soon you’re standing in triage. Yawning, you tell the nurse this as she taps at a computer (click for audio):

[This is Paul Schiffer, S-c-h-i-f-f-e-r. 12/5/71. You should have him in there. He was driving straight down the parkway when a car ahead braked, he couldn’t quite stop, rear-ended them straight on. Maybe 15-20 MPH, low city speeds. Just some dinged bumpers, the other driver refused care. Had his seatbelt on, no airbag deployment, didn’t knock into anything. Now just complaining of a little soreness in the back of his neck, no other pain or anything, normal neuro exam. No real history except a knee replacement and asthma, no meds. Just looking for an eval.]

Once they’ve typed everything in and recorded a set of vitals, they direct you to Area B. You move Paul into his bed, throw a blanket over him, and leave him there with rails up and a promise to return. When you come back a few minutes later to get his signature, he’s already off the board, although still wearing the collar.

“What about my car?” he asks.

“Talk to the police,” you advise. “I believe they had it towed.”

Shake his hand, reclaim your backboard, and away you go. Dispatch directs you to post at Alpha, and you wonder if you’ll be able to grab a quick nap.

 

Discussion

Diagnosis: muscle strain

A fairly straightforward car crash. In modern vehicles with appropriate safety mechanisms (i.e. seatbelts worn) and reasonable speeds, this is typically what you see; a few people with sore heads, necks, or backs from being snapped around, maybe bruises from the belts or on the knees, even some abrasions or irritation from airbag deployment, but otherwise no injury. In almost all cases, those sore necks are merely strained muscles or the like.

Even in progressive systems, it’s tough to avoid spinal immobilization in a trauma patient with neck pain. There is no evidence that it’s ever helped anybody, and some evidence it’s harmful, but nevertheless people worry about liability. On the flip side, the textbook extrication using a KED or short-board is almost never seen in the real world; the type of nominal extrication depicted (“come sit here”) with cursory immobilization is much more common, and frankly — particularly without any real suspicion for spinal injury — perfectly adequate. But don’t tell your medical director I said that.

Points to consider for these patients are: were they restrained? How does the mechanism look (did airbags deploy, is the windshield starred, how much external damage, etc.)? Did they strike anything in the compartment? What caused the crash? (Paul may have been drinking, but it’s not obvious, he’s probably not going to tell us, and it hardly matters anyway.) Are there neurological findings? Are there medical conditions that make a patient high-risk?

There is no indication here for diversion to a trauma center, but the requested hospital happened to be one, and was the nearest destination anyway. In fact, if Paul had wanted to refuse transport (as the other driver did) there would be little reason to lean on him.

Comments

  1. Minivan guy will probably be a signoff, but can most likely give us some information as to what happened in the crash. We have no idea whether that information will actually be accurate, but it’s still better than nothing.

    The other driver needs an assessment. I’d like to know medical history, as well as if he’s been drinking or using any drugs. I’d like to rule out any significant trauma as well with a quick head-to-toe. If he has no significant complaints that warrant immediate attention, he should get a c-collar -> KED -> backboard and be transported. If we do find anything that we need to deal with right away, have fire assist with a rapid extrication to a long board, get him in the ambulance, and treat en route to the hospital.

    Of course, the research says that spinal immobilization doesn’t actually help and may in fact be harmful, but with a complaint of neck pain there’s no way I can get away with not doing full immobilization.

    Nearest facility is the University Hospital, so that makes our destination decision easy.

    • Sounds pretty good to me. We’ll talk briefly about the immobilization topic on Friday. Suffice to say that, like Sam and yourself, I wouldn’t want to do it, but would probably have to. As for the KED, well, whatever the textbook says, in two states and multiple systems I think I’ve seen it used about twice…

  2. Evan Rosser says:

    I agree with Brandon here, you had the patient stand out of the vehicle with a potential for a c-spine injury. C-collars help stabilize but they don’t do all the work, and for a situation like this a KED board is a must to prevent spinal compromise. Other than that good writing!

Speak Your Mind

*