Melclin
Forum Deputy Chief
- 1,796
- 4
- 0
It has been my practice for a while now that I omit spinal immobilisation in a certain group of patients. Namely, the very old in high care nursing facilities, with significant comorbidities. These are patients that cannot be clinically cleared because of their age, comorbities or are poorly reliable to examine. They do of course also have a mechanism of injury that for a person of their frailty could cause an unstable injury.
I'm asking for your collective opinion on account of my practice stimulating discussion at work today regarding where I draw the line in terms of my not being absolutely sure who is a candidate and who isn't (a legitimate criticism). Additionally some argued it was an ethically dicey situation in which to put myself. It is also not strictly supported by my guidelines but, typical of our system, nobody seems to be too bothered by that part. Take today's pt for example:
95YOF, moderate to high care at nursing home, hx advanced dementia (nil ability to converse or interact meaningfully, apparently has little quality of life, occasionally able to answer questions like "where does it hurt" in a round about sort of way but rarely), depression, osteoporosis, osteo arthritis, visually impaired, traumatic intracranial haemorrhage from similar previous fall. Not for resus. Pushed to ground by another resident, nil LOC, head strike on ground, large haematoma on occiput.
I do this because I see no point in submitting them to the discomfort and complications of immobilisation given that they will most probably, in my opinion, not be candidates for surgical decompression/stabilisation or other significant non-surgical management, or be highly unlikely to have a good outcome if they do.
I also generally argue, especially for patients with dementia, that, should I be wrong about their candidacy for management, better motion restriction will be achieved by letting them lay still on the stretcher rather than attempt to fight off a collar etc the whole way to hospital. This, however, is not my primary argument. Its the first argument that is really in question.
Lets try and ignore any question of whether or not immobilisation works. Lets accept for this thread that it is the current standard of care. This is an issue of the patients potential for good outcome, similar to the idea that we do not generally intubate a this type of patient.
Opinions? Be brutally honest.
I'm asking for your collective opinion on account of my practice stimulating discussion at work today regarding where I draw the line in terms of my not being absolutely sure who is a candidate and who isn't (a legitimate criticism). Additionally some argued it was an ethically dicey situation in which to put myself. It is also not strictly supported by my guidelines but, typical of our system, nobody seems to be too bothered by that part. Take today's pt for example:
95YOF, moderate to high care at nursing home, hx advanced dementia (nil ability to converse or interact meaningfully, apparently has little quality of life, occasionally able to answer questions like "where does it hurt" in a round about sort of way but rarely), depression, osteoporosis, osteo arthritis, visually impaired, traumatic intracranial haemorrhage from similar previous fall. Not for resus. Pushed to ground by another resident, nil LOC, head strike on ground, large haematoma on occiput.
I do this because I see no point in submitting them to the discomfort and complications of immobilisation given that they will most probably, in my opinion, not be candidates for surgical decompression/stabilisation or other significant non-surgical management, or be highly unlikely to have a good outcome if they do.
I also generally argue, especially for patients with dementia, that, should I be wrong about their candidacy for management, better motion restriction will be achieved by letting them lay still on the stretcher rather than attempt to fight off a collar etc the whole way to hospital. This, however, is not my primary argument. Its the first argument that is really in question.
Lets try and ignore any question of whether or not immobilisation works. Lets accept for this thread that it is the current standard of care. This is an issue of the patients potential for good outcome, similar to the idea that we do not generally intubate a this type of patient.
Opinions? Be brutally honest.
Last edited by a moderator: