No C-Spine... Right call?

[Zredmond]

If his teeth were smashed in, he hit his head. Hit the head, you crank the neck/spine..... and when in doubt immobilize. And who tells you to take a serious precaution off once its been placed?! Uggg.... I hope the guy is ok.

I couldn't agree with you more. But what else can we do

 

[LACoGurneyjockey]

Ok so you seem a little personally offended, not sure why
And, its not an over reaction, If a guy possibly fell over 20 feet and landed on his head is that not a big deal??
The kind of big deal that cspine precautions freaking exist for?
ME ridiculous? You are ridiculous, If you dont think I'm right that he needs cspine, quite frankly you're foolish
This whole "MOI means nothing" thing that people pull seems to have gotten out of hand
I dont have some massive ego, nor think im always right, but i know how to take care of a patient, and I would urge the medic in this case to change his tune if possible or talk to his boss
Dont be so ridiculous yourself, you act like you're 12 geez

My issue was that you said you'll c-spine him anyway regardless of what the higher level of care had to say. Sure, follow your protocols and c-spine him, but don't try and disregard someone with more education (and patient care authority by the way) because you think your way is the right way.
The mechanism tells you what exactly? He's altered and has facial trauma, and he's tachy enough to believe he's bleeding elsewhere. What more do you want to infer from moi?

 

[BOS 101]

My issue was that you said you'll c-spine him anyway regardless of what the higher level of care had to say. Sure, follow your protocols and c-spine him, but don't try and disregard someone with more education (and patient care authority by the way) because you think your way is the right way.
The mechanism tells you what exactly? He's altered and has facial trauma, and he's tachy enough to believe he's bleeding elsewhere. What more do you want to infer from moi?

Well that was me just being passionate, I wouldnt have a fight with the medic cuz that benefits no one
But i would tell him that I would talk to his boss and report it all
I know all of that, higher authority and all, but a dumb move is a dumb move, I dont need to be a medic to know that c spine is indicated heavily, i dont think im right, i know i am
I promise, im not trying to be macho or anything ofcourse i would try to be respectful about it, but patient care first
And the significant moi simply indicates cspine, thats my whole point, along with him being altered
Now im asking you, what do you think of the medics decision?

 

[DesertMedic66]

Well to put it simply, im just being passionate
Obviously I know that the medic has ultimate final say BUT it is obviously stupid to not take cspine precautions here
I would bug and bug the medic as much as I could before I went with it his way, and even then I would talk to his boss afterward
Im not stupid, I realize it wouldnt be beneficial to sit and argue on scene either, but If you think no cspine here is smart, or that this medic is defendable, please show me how

Without knowing the system, protocols, or more information on the call it is hard to say one way or not.

I never stated that I would c-spine the patient or not. I didn't even state if I felt the medic made the right call or not. I only brought up the fact that you would disregard the medics decision on a call and ignore him (as you stated), and how that would create a huge issue and more than likely end up with you being thrown off scene and a lovely call to your supervisors.

Maybe I'm being an entitled ParaGod but once I'm on scene that patient is mine and I make all the choices. I am more than welcome to listen to input but if you disregard my patient care that will not end very well (I'll just politely ask you to get off my call and when the call is over we will have a come to Jesus meeting).

 

[Mufasa556]

Ignoring the medics directions? Getting on the blower to their boss? Notifying supervisors? Let's all slow down.

My best advice for these situations, whether on a CCT shift or 911 medic unit, is follow the directions of your RN of medic on scene. When the calls over, seek them out and, in a non confrontational manner, ask them to explain why they did things the way they did and explain why you thought it should have been done differently. Even if it's condescending, I've found even the grouchiest medic or RN will take the time to explain their thinking and why they handled things a certain way. With their experience and/or higher level of education, they may have noted something you didn't. By asking those involved, In all but maybe a handful of calls, I've learned a little bit more about medicine and came away a little smarter.

If you're not satisfied with the answers and still feel the need to follow through with the "boss", go ahead, but always come to the person and try to start a dialogue first. You may learn something rather than starting a fight with your coworkers.

 

[PotatoMedic]

Im just going to leave this here.
The Journal of Trauma. 2010 Jan; 68; discussion 120-1.

Name of Article– Spine Immobilization in penetrating trauma: more harm then good?

Immobilization is “a tradition that started decades ago” said Dr. Demetriades. “There was never any scientific evidence that it works.”

The author reports first responders would have to immobilize 1,032 patients before potentially benefiting one person. While it only took immobilizing 66 patients before potentially contributing to a death.

Some other bullet points.

MOI is a very poor predictor of spinal injury.

A proper Physical Assessment can rule out most spinal injuries.

Most EMS protocols call for unnecessary spinal immobilization.

 

[PotatoMedic]

I will add I know that it is regarding penetrating trauma. But it still has some interesting information regarding the effectiveness of backboards.

 

[Akulahawk]

Well that was me just being passionate, I wouldnt have a fight with the medic cuz that benefits no one
But i would tell him that I would talk to his boss and report it all
I know all of that, higher authority and all, but a dumb move is a dumb move, I dont need to be a medic to know that c spine is indicated heavily, i dont think im right, i know i am
I promise, im not trying to be macho or anything ofcourse i would try to be respectful about it, but patient care first
And the significant moi simply indicates cspine, thats my whole point, along with him being altered
Now im asking you, what do you think of the medics decision?

Mechanism indicates NOTHING but a potential for injury. You can have a most amazingly awesome MOI and not have actual injury at all. All injury will have a positive mechanism. All of them. What you need to learn is how to read the MOI.

Once you learn that, you'll find that MOI will tell you where to look for a potential injury, but you still have to take the next step and look for injury. Will I place someone in spinal motion restriction? Yes, if it's indicated. In this particular instance, there's a spectacular potential MOI and some injury that supports a blow to the head. Great! If the patient is moving all his fingers and toes, chances are quite good that the cord hasn't been severed. That the patient is "altered" simply tells me that there's a high possibility of a closed head injury. No crepitus and no step-offs and I'm not likely to put the patient on a LSB. I might put a collar on though.

I agree with the other posters here about asking that Paramedic about the reasoning behind the removal of SMR from that patient. You might learn something other than how to blindly follow protocol.

 

[BOS 101]

Without knowing the system, protocols, or more information on the call it is hard to say one way or not.

I never stated that I would c-spine the patient or not. I didn't even state if I felt the medic made the right call or not. I only brought up the fact that you would disregard the medics decision on a call and ignore him (as you stated), and how that would create a huge issue and more than likely end up with you being thrown off scene and a lovely call to your supervisors.

Maybe I'm being an entitled ParaGod but once I'm on scene that patient is mine and I make all the choices. I am more than welcome to listen to input but if you disregard my patient care that will not end very well (I'll just politely ask you to get off my call and when the call is over we will have a come to Jesus meeting).

Dont get me wrong, I whole heartedlly support and look up to medics, they are awesome
but this is just a case of an individual making a bad decision and my attitude towards him
I ofcourse would be appropriate about how I would deal with it, and ignoring him was an exaggeration i didnt expect to be taken literally, to clarify that
And i totally respect your authority as the higher level of care, and if you are on scene i got your back, and i would especially appreciate that you would listen to my concerns
Its not about rebelling against his authority, just that (to me at least) this seems very black and white, and I would have urged and pushed for cspine precautions, I believe the patient would be in endangered without taking them

 

[BOS 101]

I will add I know that it is regarding penetrating trauma. But it still has some interesting information regarding the effectiveness of backboards.

Is any of that (specifically the 1032 before it helps one patient) accurate at all regarding blunt trauma?
I would hope the numbers are different for that
this is interesting but some of my protocols say that penetrating trauma without neuro deficits dont need cspine anyway

 

[BOS 101]

Mechanism indicates NOTHING but a potential for injury. You can have a most amazingly awesome MOI and not have actual injury at all. All injury will have a positive mechanism. All of them. What you need to learn is how to read the MOI.

Once you learn that, you'll find that MOI will tell you where to look for a potential injury, but you still have to take the next step and look for injury. Will I place someone in spinal motion restriction? Yes, if it's indicated. In this particular instance, there's a spectacular potential MOI and some injury that supports a blow to the head. Great! If the patient is moving all his fingers and toes, chances are quite good that the cord hasn't been severed. That the patient is "altered" simply tells me that there's a high possibility of a closed head injury. No crepitus and no step-offs and I'm not likely to put the patient on a LSB. I might put a collar on though.

I agree with the other posters here about asking that Paramedic about the reasoning behind the removal of SMR from that patient. You might learn something other than how to blindly follow protocol.

well its not about blindly following protocol
Like you said, significant moi, altered, and obvious trauma to the face/head
The chance of spinal injury is high(my speculation) and your right, assess
But even without current deficits, I would still want to immobilize(at least a collar) so that nothing gets worse while moving him, and then he shows deficits and such
Because he's altered, you cant reliably palpate his spine for pain(depending, I wasnt there but this could be true) and even with no step ups or drop offs there can be things that are there that we cannot see or feel
Thats the whole reason we take the precautions, so the ER doc can determine when to safely abandon precautions
I dont mean that every little fall or trauma is getting precautions, if its no big deal and they arent complaining of neck or back pain yadda yadda then i would rule it out and go, use our judgement and all
I really like your point about reading the moi, thats a great point that not a lot of people get

 

[PotatoMedic]

I think this will be a good read for you. All the facts are cited to studies.

http://www.emsworld.com/article/10964204/prehospital-spinal-immobilization

 

[Ensihoitaja]

You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?

I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined that patient, though.

 

[BOS 101]

I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined that patient, though.

I back that

 

[Akulahawk]

well its not about blindly following protocol
Like you said, significant moi, altered, and obvious trauma to the face/head unknown, was apparently unwitnessed
The chance of spinal injury is high(my speculation) and your right, assess Just your speculation. You're stuck on MOI. Assessment will generally yield a physiologic or anatomic problem, if present.
But even without current deficits, I would still want to immobilize(at least a collar) so that nothing gets worse while moving him, and then he shows deficits and such
Because he's altered, you cant reliably palpate his spine for pain(depending, I wasnt there but this could be true) and even with no step ups or drop offs there can be things that are there that we cannot see or feel
Thats the whole reason we take the precautions, so the ER doc can determine when to safely abandon precautions
I dont mean that every little fall or trauma is getting precautions, if its no big deal and they arent complaining of neck or back pain yadda yadda then i would rule it out and go, use our judgement and all
I really like your point about reading the moi, thats a great point that not a lot of people get

I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.

 

[BOS 101]

I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.

Yes but because he is altered (well depending on how altered) He isnt necessarily reliable to rule out cspine
And the MOI isnt the only reason i would use precautions, the broken teeth and blood mean he hit his head so now the MOI has a tangible injury on him that i can look at and say, hey that all went straight to his head and neck, he could have something wrong
And i respect what you say about assessing, but even with nothing present beyond the head trauma i would like to use a collar just to immobilize the neck(I agree LSB's are somewhat useless and over used) but on the same token to cover my *** I would go full c spine in reality
You can kinda say You're right, MOI does mean something big here to me cuz its possibly so big and just because he may not have any current deficits, doesnt mean I wanna say forget cspine and then something happen to him enroute
I'm Saying i would prefer to take precautions here, mainly because he is altered and there is obvious trauma with sigMOI, so that I do no harm
This putting the studies about spinal precautions aside for now, until they become protocol and can save my ***, and prove beyond a doubt that precautions arent needed

 

[BOS 101]

I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.

So to make it simple and avoid being to vague, I agree with what you say about assessing further
BUT to me the MOI with head trauma(and likely neck in that case) And an altered status is enough for me personally to want the patient in precautions
It is your call with your patients, and i know that it is complicated because we werent there for the actual call to get any more info, but tell me what would you see to make you not want precautions, and what would make you want precautions(aside from the obvious)?

 

[Tigger]

I was going to do a whole big multi quote, but then again...

No spinal motion restriction techniques used by EMS have ever been shown to have any sort of benefit to patients.

Would I have placed this guy on a vacuum mattress? You bet, that's what my protocols dictate for altered patient who has fallen from an unknown height. But I am not deluding myself into thinking it's making a lick of difference.

So for the newer providers here that think c-spine is so important, please prove it. Passion is great and all, but medicine requires us to justify our treatments with more than that.

 

[Medic Tim]

Obviously follow your guidelines.....But protocols and what is right for your pt can be at odds with one another. EMS is riddled with bro science, anecdote and tradition. Thankfully the tide is shifting towards evidence based medicine and science based medicine.
It is very difficult for many to accept change or accept the fact that what they have been doing for years... And told was saving lives...... Actually doesn't.... And can make it worse.
Because we have always done it that way is one of the scariest phrases you can hear.
It doesn't help that our training is skills focused ... And many have no idea why we do certain things let alone the science behind it. Many thankfully take their education into their own hands and fill the gap.

 

[BOS 101]

I was going to do a whole big multi quote, but then again...

No spinal motion restriction techniques used by EMS have ever been shown to have any sort of benefit to patients.

Would I have placed this guy on a vacuum mattress? You bet, that's what my protocols dictate for altered patient who has fallen from an unknown height. But I am not deluding myself into thinking it's making a lick of difference.

So for the newer providers here that think c-spine is so important, please prove it. Passion is great and all, but medicine requires us to justify our treatments with more than that.

Fair enough and when it comes to LSB i have a gripe
But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
As far as Collars, what is your opinion?