A fall that the hospital gave me grief about

[mycrofft]

The NHTSA decided prehospital extrication and care were to blame for many traffic deaths and so they invented EMTs...(P)aramedics and (A)mbulance.

 

[johnrsemt]

My old area was very liberal with medics not c-spining:

The protocol basically read:

--Patient 5 years old or older
--Patient understands what you are asking: (if they only speak spanish and you have someone who speaks spanish that can translate, etc)
--No distracting injuries (that will take your or the patients mind off of what you are asking the patient
--No point tenderness along spinal column (C1-about mid shoulder blades)
--No neuro problems; (equal numbnes or tingling {takes care of the 1 numb hand from airbag}).
--Medic discretion: If you were concerned do it anyway.
--If first responders had already placed a c-collar medics could NOT remove it.

It was good, it saved us from the old school of having to c-spine an isolated hand injury (I was written up by fire LT for not c-spining a patient who ran his hand through a table saw).

In over 10 years of doing this in a busy metro area they have never had one go wrong from not c-spining

 

[Veneficus]

The NHTSA decided prehospital extrication and care were to blame for many traffic deaths and so they invented EMTs...(P)aramedics and (A)mbulance.

This is an interesting point.

It probably has a lot to do with spinal immobilization techniques and the dogma that has perpetuated from it.

Back in those days and the very early part of my career, cars were made of steel, seatbelt usage optional, and engineered safety features basically nonexistant.

A MVA (i refuse to adopt the insurance indusrty idea of MVC to establish liability) was sure to mean somebody was really messed up. (which I found quite exciting actually, still do, it just takes more to impress me)

Force transfer from metal to people was very large, even patients with no obvious injuries could, and often did, have severe occult ones.

People would often bounce off the windshield, even go through it twice. (once partially out, and then back in) Others would bounce around the inside of the car at all angles.

As I stated above, there wasn't significant understanding of what caused secondary spinal injury. I strongly suspect (primitive)EMS caught an undue share of the blame. Delayed clinical onset of symptoms being attributed to provider mishap.

As this "secondary" mechanism was popularly accepted, it seems other attempts to equate it to various traumatic injuries such as falls were establised.

The more recent studies demonstrating mechanism as being unreliable, also do not seek to address why. Only correlation. (poor science)

EMS and its physician leadership haven't put a whole lot of effort in even exploring and refining what EMS does. (most of the evidence I see is usually antiEMS, from physicians seeking to point out its flaws rather than help.)

Everytime I read a reply about "but that is protocol and it is unyielding, we must follow," while certainly true, and i am certainly not advocating ignoring them, I really think that change in EMS practice is going to have to come from the providers, through the proper channels, and at the proper time.

Perhaps the new EMS fellowship trained physicians will create the required environment?

Because most EMS medical directors are less than useless, they directly impede progress, which detracts from quality patient care.

Since there are already numerous threads that have devolved into discussions on professionalism, to avoid that, i will say only this:

Recognizing and admitting inadequecy, then finding ways to make it better is the mark of a professional.

Claiming that a practice is right or must be good because somebody said so is not.

 

[94H]

In some places it is. Some places are so risk averse you will never see it because they don't want to adopt the tiniest bit of liability.

Once you get some time in where your voice will be respected a little you can always tactfully suggest to senior personnel what the literature says. They may not be aware of it because, quite honestly, prehospital research was virtually nonexistent in the past.

I took a Selective Spinal Immobilization course with my Squad's Captain when the protocols were amended in NYS. I asked him if we would backboard less people now, he told me "No way, thats too much liability"

 

[Remeber343]

I would just like to say that... your big brains are scaring these people off... I was looking forward to a reply from Ackmaui. I am quite interested in his justification... Thats all, carry on!

 

[Arovetli]

I would just like to say that... your big brains are scaring these people off...

A little knowledge is a dangerous thing,
drink deep or taste not the Pierian spring

-Pope

 

[mycrofft]

H'as we were! Carry on!

 

[Veneficus]

A little knowledge is a dangerous thing,
drink deep or taste not the Pierian spring

-Pope

I like that.

 

[zzyzx]

Just to throw my 2 cents it, we do have to keep in mind that when the NEXUS criteria was developed, they didn't study an elderly population. I'm very careful about considering possible cervical spinal injuries in the elderly even when the MOI is pretty mild, like a fall from a standing position. A little old lady with osteoporosis can break a whole bunch of bones from just a little fall. That said, I won't argue that improper backboarding couldn't make things worse.

 

[mycrofft]

I think the indications are that there needs to be a better spinal immobilization armamentorium as well as protocols.

 

[crazycajun]

Wow!!!! So many complaints on here I do not know where to start. First of all to the OP.... You did the right thing. Geriatric PT's never seem to present with text book signs and symptoms. Many play off their pain as simply getting old or hide their pain in fear of needing surgery. All of the studies I have read never involve geriatrics in them. They also never follow up on the case to see if spinal issues presented later and if they could be tied to the original event. Now on to those who are complaining.... If this same PT did not fall but did have a CC of lower lumbar pain. What would your treatment be??? No other complaints just the back pain. And lastly to those that don't like boarding people because it is a pain and makes their job harder.... Please for the safety of my family and others FIND A NEW CAREER!!!!!!

 

[Aidey]

Did you even read any of the links I posted? It has nothing to do with laziness or making our job easier. It is about providing the best evidence based care possible. Back boards were introduced because someone thought they were a good idea without any proof they actually helped.

 

[firecoins]

you expect crazy cajun to read the thread?

 

[crazycajun]

Did you even read any of the links I posted? It has nothing to do with laziness or making our job easier. It is about providing the best evidence based care possible. Back boards were introduced because someone thought they were a good idea without any proof they actually helped.

Yes I have read the links as I have done plenty in the past as this is part of my job. You seem to fail to realize that most of the studies are done on healthy individuals in the 20 to 30 age group and on cadavers. The studies are also minimal on test subjects ranging from 5 to around 1600. With that said there is still not enough factual based evidence to rule out spinal precautions especially in a geriatric PT w/ unwitnessed fall. I will agree there are instances (combative PT not wanting to be boarded, PT refusal, PT CAOx4 walking w/ no complaint of Pain) that we should not board. I have also seen cases where the PT was cleared by the ER physician, taken off the board and out of C-collar only to find out later in x-ray there was in fact a spinal injury. And yes there are plenty on here that can't stand to backboard because it makes there job harder. Not saying you are one of them but read the post and you will easily see who made the statements.

 

[crazycajun]

you expect crazy cajun to read the thread?

If I want your opinion I will pull your chain

 

[Smash]

Just to throw my 2 cents it, we do have to keep in mind that when the NEXUS criteria was developed, they didn't study an elderly population. I'm very careful about considering possible cervical spinal injuries in the elderly even when the MOI is pretty mild, like a fall from a standing position. A little old lady with osteoporosis can break a whole bunch of bones from just a little fall. That said, I won't argue that improper backboarding couldn't make things worse.

Both NEXUS and CCR did post-hoc sub-group analysis on the elderly population (age > 64) and both were found to be safe and effective. There is of course the recognition that most elderly patients are at a higher risk for c-spine injury and SCIWORA, however this does not negate the various decision rules, but rather it makes one have to actually think about what one is doing rather than blindly following any protocol.

Yes I have read the links as I have done plenty in the past as this is part of my job. You seem to fail to realize that most of the studies are done on healthy individuals in the 20 to 30 age group and on cadavers. The studies are also minimal on test subjects ranging from 5 to around 1600. With that said there is still not enough factual based evidence to rule out spinal precautions especially in a geriatric PT w/ unwitnessed fall.

You are absolutely correct that the studies refuting the efficacy of using long-boards and collars are small. Perhaps though, you could post the large, multi-center RCTs that have established that long-boards and collars are effective and safe?

However slim the evidence against collars and boards is, it is orders of magnitude greater than the evidence in favour. Yet we persist with something that has dubious biological plausibility, no hard evidence of good and mounting evidence of harm associated with it.

I will agree there are instances (combative PT not wanting to be boarded, PT refusal, PT CAOx4 walking w/ no complaint of Pain) that we should not board. I have also seen cases where the PT was cleared by the ER physician, taken off the board and out of C-collar only to find out later in x-ray there was in fact a spinal injury.

The plural of anecdote is not evidence. These "spinal injuries" you have witnessed post clinical clearance: have any of them actually done any harm to the patient? I'm pretty sure we aren't looking at a large population of high spinals because of clinical clearance.

And yes there are plenty on here that can't stand to backboard because it makes there job harder. Not saying you are one of them but read the post and you will easily see who made the statements.

Strawman much? Care to quote whoever is complaining about back-boarding making their life more difficult?

 

[Epi-do]

Would I board and collar this patient? Absolutely not. I could beat a dead horse and list all the same reasons for not doing it that have already been presented, but why bother.

Instead, a little food for thought - Why is it that boarding/collaring a patient is just about the only thing we, as a whole, typically approach with the attitude that the need for it must be ruled out, instead of approaching it with the attitude that we need to assess and determine there is a need in the first place?

Think about it. You don't show up on a scene and assume every patient is going to get oxygen, any sort of airway adjunct, any of the meds that are in your box, or 360j of electricity coursing through them. Why should using a backboard and c-collar be any different?

 

[Aidey]

Would I board and collar this patient? Absolutely not. I could beat a dead horse and list all the same reasons for not doing it that have already been presented, but why bother.

Instead, a little food for thought - Why is it that boarding/collaring a patient is just about the only thing we, as a whole, typically approach with the attitude that the need for it must be ruled out, instead of approaching it with the attitude that we need to assess and determine there is a need in the first place?

Think about it. You don't show up on a scene and assume every patient is going to get oxygen, any sort of airway adjunct, any of the meds that are in your box, or 360j of electricity coursing through them. Why should using a backboard and c-collar be any different?

It shouldn't, but for some stupid reason the myth persists. People have done a very good job of propagating the falsehood that backboards are beneficial and save lives. There are also all the threats of lawyers and lawsuits and people being paralyzed left and right.

 

[Farmer2DO]

You don't show up on a scene and assume every patient is going to get oxygen

Actually, lots of people do.

 

[Aidey]

And those people deserve to be strapped to a backboard and beaten with a nonrebreather.