hope springs eternal
I still have hope that any EMS provider reading here can distinguish the difference between a discussion of benefit and potental complications from lack of resources in the field. If providers can't handle that they need to join my level, I am not lowering to them.
Additionally I have said it more than once, US practicioners have to be careful about reliance on imaging. I have had the honor of working at one of the finest trauma centers in the US for almost 4 years, clinical decision making is more important than mindlessly following protocols based on abstract studies and imaging.
And how many are in wheel chairs? If one person loses their quality of life because it was assumed there was no fracture because of the statistics in a piece of literature without reading the methodology or other literature with differing views, poor training/education or from what someone read on an anonymous forum, that is one too many..
You make it sound as if I just troll the web for studies and have no experience at all. There is a time for conservative measures, but this panic idea that every trauma patient is critically ill is foolish. Infact most of them are not. The amount of overtriage is currently unsustainable both economically and logistically. (particularly in the US) also, when I think of the list of exceptional trauma centers, no place in Florida even makes the list. Trauma surgeons who do not have other critical care aspects of practice are also a dyng breed.
That is why future doctors are taught to do an assessment as well as reading the literature but they are also taught their own limitations and the exceptions...
It should be no different for any providers. But the limitations cannot always be overcome, and unlike other providers, a doctor who signs the chart may not have the luxery of having all he/she wants. Furthermore, sometimes they even have to reach into the vast bank of knowledge and make something up because there is no protocol or "expert" consult.
Just like some Paramedics who believe they know everything about a patient even though they have no lab data and just a field exam to back it up, doctors are taught to make use of the tools they have and not assume everything in all cases.
I don't think it is ever good to assume, but i also don't think you need to perform every medical test available to man to make a dx either. It is a waste of all kinds of resources.
A backboard may not always be the best method of immobilizing a patient but log rolling the patient onto it so the patient can be moved without further damaging the spine is better than just having a patient struggle on their own to get to their feet or doing an extremity pull or lift. In MRI or CT Scan a slide board may have to be used anyway to position the patient without pulling on the shoulders and head. The patient probably will not stay on the board at a trauma center much longer than it takes to do an x-ray and/or CT or onto something they can maneuver the patient more easily and safely on.
the CT? A total body scan (now routinely utilized in trauma around the US) of head, neck, chest, abd, pelvis can take up to 45 minutes. Provided there is no wait for the scanner. Add some plain films and that could be an hour or more. Totally unacceptable. Thinking trauma care is the same even between two level I centers is inaccurate.
Often both a CXR and CT Scan is done but for different reasons. Many times a central line, ETT and OG are placed. These are all done within the first 5 minutes of arrival. The sooner confirmation of correct positioning, the sooner those 3 devices can be used especially when it comes to stabilizing a flail chest and preventing further trauma to the lungs.
The standard bed side xrays in trauma around the world is a chest, pelvis and cross table lateral of the spine. Some centers forgo these because they utilize the "pan and scan" CT. An xray to confirm tube placement is truthfully icing on the cake. There are other ways. The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway. Measuring CVP and confirming line placement takes place after stabilization in the critically injured trauma patients. (sometimes postop)
Not everyone will get or should get a CT Scan. However, in the case of a flail chest, there are many reasons to do a CT Scan besides the spinal column.
If the director of trauma believes the studies of xrays being inadequete they will get a CT. That is a large percentage. Yes you can see many things on CT, like shadows on the aortic arch. (which in a trauma patient is likely not a clot. Infact it is normal artifact usually, and more than one intensivist has been reprimanded for starting anticoags based on that finding I have been at M&M meetings personaly where it was brought up.)
Yes there are a large number of patients that get sent home without invasive procedures for spinal fxs. But, in the field, do you know that fracture is stable? How many even suspect there is a fracture because there may be NO deficits?
With the way EMS uses spineboards today I can't imagine a provider not suspecting an injury, even when it would qualify as impossible. "The if even one patient..." arguement while noble, is unrealistic, we'd have to run every test on every patient.
In the field I would say it would start with some real education and not dire warnings to inspire panic that every patient is on death's door and the end of the world at hand.
Will it remain stable if you don't take some precautions? The statistics there may only lead one to be more cautious. These are the ones that may get documented by the ED and sent to your medical director saying you will be one lucky EMT(P) if the patient doesn't suffer permanent damage. So, you may still be darned if you do and darned if you don't. That is where you must have the support of your medical director,
I never suggested not having to take precautions, but i do call into question the effectiveness of the standard method. There is absolutly nothing I have seen showing a LSB makes any difference. If you demand controlled double blind macro studies for new treatments the same standard needs to apply to all treatments.
Getting the medical directors support and furthering medicine requires discussion and argument that starts somewhere. If it can be done over a bar napkin, it can be done on a forum. If providers cannot see the difference between calling a treatment into question and changing treatment without going through the proper channels, it is probably just a matter of time before they make a terrible mistake, what they read here probably will only speed up the inevitable.
your guidelines or protocols and your documentation must be very thorough. Stating with one blanket sentence, no abnormalities or deficits noted will not hold up.
I worked in a system where literal interpretation of protocols was the culture of everyone except the medical director. It is not practical or reasonable, there will always be some vagueness and need for deviation. Otherwise every possible situation would have to be defined.
Poor documentation rests on the provider.
