Or feel free to substitute another word (or two) that start with B.S.
Dispatched to a call for a motorcycle versus car accident. As a general rule of thumb, the smart money bets on the car to win. Physics and all that dictates that the object with the most mass will win. Velocity of course mediates that, but the soft tissue riding on top of the motorcycle is still bound to lose either way. By how much is a matter of what he or she hits, protective gear (helmets are good), and sheer dumb luck. Sometimes the motor cycle rider will walk away with minor injuries when logic and the afore mentioned laws of physics tell you that the should be. Of course sometimes the rider will die when the impact seems relatively minor. While mechanism may give you some good rules of thumb for assessing for potential injuries, mechanism is not definitive by any definition of the word.
Back to our patient, or rather our patient’s motorcycle and the car it hit. Looking at the back of the car, which is where the motorcycle impacted, the damage looked impressive. Impressive to a body man, that is. My first thought when I looked at the back of the car was “Crumple zone”. A crumple zone is the term used for parts of cars that are designed to collapse and thus absorb energy from the collision. The entire reason for having them is to trade sheet metal (and plastic) for a reduction in injury. A crumpled fender or trunk lid has absorbed a lot of energey which would otherwise be transmitted to the patient. Motorcycles don’t have crumple zones because their body work is minimal. They also don’t have seat belts, bumpers, or airbags. As a result only the luckiest of riders escape all injuries in accidents. The #1 killer of motorcyle riders is head injury. Protect the noggin and the patient will stand a good chance of living, even if they have serious injuries to the torso. No guarantee, but it improves the odds. The better the helmet, the more protection is provides, which makes sense. No helmet means no protection and then the rider is depeding on pure luck. Good luck with that, as the saying goes.
Back to our patient. Who was conscious, had a pretty good recollection of what happened, was able to give us a complete medical history, and cooperate with the exam. Vital signs were good, and other than some cuts, bruises, and maybe a fractured wrist, he was pretty much uninjured. That’s luck of the good kind.
Mechanism, by itself, without a thorough examination, would dictate (in some systems) that this patient be given a full ALS work up. Which is why using mechanism alone is silly. Should this patient go to a trauma center? Very possibly, since there might be occult injuries that will only show up later. Should this patient go to a trauma center by ALS ambulance? A tougher question, with a lot of variables. The chief amongst them is the travel time to a trauma center or other capable hospital. If the patient has no airway issues, the trauma center is within a shortish distance, and the EMTs are capable, there doesn’t seem to be any real reason to travel by ALS ambulance.
Certainly mechanism alone should not be a criteria for anything. Mechanism with physical findings suggestive or indicative of serious injury are a different story. Or even a finding of serious injury without a mechanism for that matter.
A case in point. 30 or so years back I had an acquaintance who wanted to be a police officer. Specifically, he wanted to be a motorcycle officer. He had that part down, the motorcycle that is. He rode one whenever the weather permitted. In fact he rode a Harley Davidson, which as you probably know is a big motorcycle. One day he was stopped at a traffic light and somehow lost his balance. He and his HD fell over and one end of the handle bar dug into his flank. As luck (bad luck) would have it the end dug into his flank right over one of his kidneys. Which promptly started bleeding, which required a trip to the hospital, and removal of the injured kidney. A stupid accident caused him to end up in the operating room, the loss of his kidney, and thus disqualification from becoming a police officer. Remember what I said about luck and how it works both ways? Here’s an example of bad luck and a serious injury with no mechanism to suggest it.
It’s the examination of the patient that counts, not the amount of damage or “mechanism”.
Which is something that a lot of EMTs and all too many paramedics can’t seem to understand.
And then you have cases like Nola Walker from Cairns.
In which mechanism didn’t play a major part. She was examined, offered and had recommended, transport to a hospital, which she refused. Had she gone to the hospital, she might have lived. Then again, she might not have. There was disagreement as to the cause of the rib fractures and it’s possible, although unlikely that the splenic injury was caused by CPR. Add to all of that her age and her intoxication, and it’s not too surprising that her refusal of transport played a part in her death.
The fact is that “mechanism” should be something that helps focus a more critical eye on some things compared to others. It isn’t a finding of its own.
I remember a motorcyclist…he’d been working back-to-back 16 hour days for a week. Then he, his wife, and some other MC couples went for their weekly “road trip” out to the edge of the metro and back. On the way through the city, he dozed off. We found him some 20 yards from the highway. He had good recollection. The bike left the roadway and he awoke to find himself airborne and proceeded to tuck and roll. He never lost consciousness (after his rude awakening…”I dreamtI was falling…and I was!”). Had a nasty posterior hip dislocation…but no other injuries. Moving around at the scene to help flag us down.
I saw little reason for a backboard, but that’s what my partner brought up..made a decent spatula for him to lay on his side. Got him to the truck, IV, morphine and a trip to the hospital. Now, we were going to a trauma center because it was closest and appropriate, but we didn’t rush in. The senior resident heard the call and prepped the stabilization room, and was miffed when I pointed out that all he needed was an ortho bed and consult…and was right. He got stuck on the mechanism “Motorcycle at highway speeds” as opposed to the presentation.
Bob
The other problem here is that our teachings and practices haven’t kept up with the engineering and the facts.
In the 1960s and 1970s, cars were big, heavy, powerful, and did not have today’s sophisticated engineering. Crashes resulted in the transfer of energy to the occupants. The data from those periods were used to build the whole “mechanism” argument and “kinematics of trauma.” Then, 30 or 40 years went by, car parts turned to plastic, and energy absorbing engineering changed the picture radically.
But we continue to work like our patients are crashing in 1970 Chevy Monzas and AMC Gremlins. Guess what? They aren’t! We need some new science!
It’s not that we continue to work patients this way, it’s that we are TAUGHT to work up patients this way. The educational foundation is outmoded and outdated. You’d think that the people who write the PHTLS and ITLS curricula would update the science. I dug out my 2007 CD of Version 6. In the Kinematics Power Point, many of the pictures were of 1960s vintage automobiles. As you note, the slides and the science need to be updated.