Ambulance Driver and Rogue Medic have a really good multi-blog discussion going on stemming from an article by AD over at EMS1.com.  Go read AD’s article, then the comments at his blog, then go read RM’s post and comments.  Back already? OK.

I agree with both AD and RM that the mechanism of injury indicates your index of suspicion for certain injury types or patterns.  In other words, the mechanism of injury should guide your patient assessment.  The bottom line: You still have to assess the patient. Just because a patient experienced a mechanism of action that has an injury potential does not mean that the patient actually was injured.  The MOI may raise or lower your index of suspicion for injury, but your assessment should rule in or rule out your suspicions, and you should treat based upon your assessment.

Treat the patient, not the MOI.

Let us examine the following comment excerpts and the EMT/Paramedic liability issues raised regarding patient assessment, over/under treatment, and over/under triage:

AD: But what about the restrained driver of a multiple rollover, who self-extricated from the vehicle, called the police himself to report the wreck, denies loss of consciousness, is totally lucid and oriented, denies any significant complaint, and whose NEXUS exam and other assessment findings are totally benign?

You gonna board and collar that guy, start two IVs, and fly him on the helicopter?

RM:  It is appropriate to overtriage, rather than undertriage patients to trauma centers.

The patient in AD’s scenario has a high index of suspicion for a multitude of serious injuries.  So, our assessment of this patient needs to be very thorough to either rule in, or rule out, our suspicions of obvious or hidden injuries.  We ideally should triage and treat the patient based on our patient assessment and in accordance with our local protocols.

Does this mean if you don’t c-collar, long spine board, gain IV access, and fly him on the helicopter you are more likely to be sued for negligence?  The likelihood of a suit usually depends on the patient outcome.  The better questions to ask though are how thoroughly did I assess the patient, how well did I document my assessment, and did my assessment based treatment follow current protocols?

A plaintiff lawyer’s worst nightmare is the EMT or Paramedic who can recite in detail how they performed a thorough and professional assessment, how they treated the patient according to protocol based on that assessment, and have adequate documentation to support their assessment and treatment.

I would agree with RM that its is best to err on the side of over triage rather than under triage of your patients.  A long term care facility manager told me once that they activate E911 for just about any resident complaint.  His rationale: Families don’t get upset if you send Grandma to the ER when she doesn’t need to go, but they will definitely sue you if you don’t send her to the ER when she did need to go.  I have heard and/or read this same statement elsewhere, so perhaps it is a training point of emphasis for nursing home managers and staff.

In any event, your triage and treatment should be based on your patient assessment, not merely on the mechanism of injury.   I am not aware of any instances where an EMT or Paramedic was deemed negligent for the over triage of a patient, although that may change depending on the outcome of some of the recent helicopter EMS crash lawsuits.

From here, the comment discussion between AD, RM and commenter TED morph into a broader discussion on particular treatments and evidence based medical research supporting or not supporting particular treatments, leading to RM’s post linked above.

From my perspective this discussion raises four additional points for us to examine regarding EMT/Paramedic liability:

1.  Spinal Immobilization vs. Spinal Immobilization Clearance;

2.  Current Evidenced Based Research vs. Your Protocols and Treatment;

3.  Present Mental Capacity; and

4.  Informed Consent in EMS.

These four points and their associated liability issues are distinct enough to warrant their own posts.  Stay tuned, as we will examine all four in turn.