No C-Spine... Right call?

[Carlos Danger]

No reason to continue something that is incorrectly, improperly or no longer functionally placed.

Obviously. But there was no mention by the OP of the collar being incorrectly placed.

Do you leave collars on every single one of your patients regardless of circumstance?

Yes. You got me. Collars on every patient, every time. The worse they fit, the better.

 

[joshrunkle35]

If you have a question about what a medic is doing, say something. I've had basics ask me similar things or things like, "Are you sure that's the right drug?", or similar. It's usually a good time for me to simply explain the protocols, or explain a technique I've been trained in, or explain my thinking and reasoning. Sometimes it's like, "Holy cow! Thanks for saving my bacon! Yup, that would've been dumb!" Either way, the patient comes first, not our egos. And any medic should be able to explain what they're doing and why they're doing it in very simple terms...I mean, they should be able to explain it to a patient, like anyone in EMS, right? If they can't do that, they need to stop. And sometimes paramedics do need to stop.

On the protocol thing: that paramedic works under their own medical director. That paramedic is the hands of that doctor, doing what that doctor wants done. Protocols should never be the same unless medicine has conclusively decided on something, or unless the doctor/service is lazy and copies someone else's protocols and rubber stamps them.

To answer the original question, you need to know what information that paramedic received/had on scene, the thinking of the paramedic and the protocols from that service's doctor.

I recommend asking next time.

 

[Handsome Robb]

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

Or that medic understands that SMR does nothing good and possibly causes harm because they have more training than you.

You tried something like that in front of me you'd have been removed from my scene and your supe would be hearing about it.

You don't know what you don't know.

 

[BOS 101]

If you have a question about what a medic is doing, say something. I've had basics ask me similar things or things like, "Are you sure that's the right drug?", or similar. It's usually a good time for me to simply explain the protocols, or explain a technique I've been trained in, or explain my thinking and reasoning. Sometimes it's like, "Holy cow! Thanks for saving my bacon! Yup, that would've been dumb!" Either way, the patient comes first, not our egos. And any medic should be able to explain what they're doing and why they're doing it in very simple terms...I mean, they should be able to explain it to a patient, like anyone in EMS, right? If they can't do that, they need to stop. And sometimes paramedics do need to stop.

On the protocol thing: that paramedic works under their own medical director. That paramedic is the hands of that doctor, doing what that doctor wants done. Protocols should never be the same unless medicine has conclusively decided on something, or unless the doctor/service is lazy and copies someone else's protocols and rubber stamps them.

To answer the original question, you need to know what information that paramedic received/had on scene, the thinking of the paramedic and the protocols from that service's doctor.

I recommend asking next time.

Thanks for the info
As far as the medics acting under the medical director, could you tell me a little more in detail how that works for them, how different it is in certain places and such?
I want to gather more on this, seems theres more to it than I knew at first but I'd like to know for my knowledge in case im unsure of a medic, so as to be appropriate and know what is right and what is BS a little better

 

[BOS 101]

Or that medic understands that SMR does nothing good and possibly causes harm because they have more training than you.

You tried something like that in front of me you'd have been removed from my scene and your supe would be hearing about it.

You don't know what you don't know.

thats great and dandy plenty of ppl have already told me as much
what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some

 

[PotatoMedic]

thats great and dandy plenty of ppl have already told me as much
what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some

http://www.tandfonline.com/doi/abs/....884197#/doi/abs/10.3109/10903127.2014.884197

 

[joshrunkle35]

Thanks for the info
As far as the medics acting under the medical director, could you tell me a little more in detail how that works for them, how different it is in certain places and such?
I want to gather more on this, seems theres more to it than I knew at first but I'd like to know for my knowledge in case im unsure of a medic, so as to be appropriate and know what is right and what is BS a little better

Sure...well, I would start with reminding you that this is something you should have learned in EMT school and didn't, or it is something you already learned, but have since forgotten. (We only typically retain about 10% of what we initially learned in school, unless we continue to relearn the material.)

So, I would recommend dusting off that EMT book from school and re-reading the legal section.

In EMS, every state has different laws. So, your state is different than mine, and you need to contact your state EMS board or state certifying/licensing agency or contact an attorney or legal representative for very specific legal advice relating to questions about: you, your service, your medical director and your state.

That being said: typically each state sets forth laws regarding certifications or licenses, and those laws govern training and skills. For example: maybe in one state, an EMT can intubate a patient, and in another state an EMT cannot. Or, maybe in one state an EMT can start an IV, and in another state an EMT cannot. The state says what types of skills an EMT can perform, and then sets training for those skills. The NREMT is just a standardized test of generic information that is similar between all states. It is different than state training, state certification, and the state's guidelines as to what duties an EMT can perform.

An EMT works under a medical director, who is a Doctor. The doctor can limit the skills that the state allows you to perform: for example, if your state allowed EMTs to give IVs, your medical director could say, "Yeah, but I don't feel comfortable with EMTs giving IVs, so my EMTs won't be doing that." The doctor could also give guidelines as to when and how to perform the skill. For example, the doctor could tell you to splint any injury you think might be broken, or the doctor could tell you to only splint an injury you have confirmed is broken. The medical director can tell an EMT not to do something that the state allows, or they can tell the EMT when or when not to perform the skill that the state allows, but they cannot tell the EMT to perform a new skill that the state does not allow. For example, they couldn't tell you to perform open heart surgery on a person who just had an MI. The medical director "tells" the EMT how and when to perform the skill by writing down the how's and when's in the form of protocols, also known as offline medical direction. You could contact a doctor at a hospital when you are enroute with a patient. That Doctor would then temporarily give you "medical direction". This is known as online medical direction. The doctor could tell you to perform a certain skill a certain way, but it cannot be contrary to the protocols that you already have from your medical director, and it cannot exceed what the state allows you to do.

In most states, you cannot perform these EMT skills on your own, though, there are exceptions. Every single state has its own rules. For example, in my state, Ohio, I can perform the skills under a medical director, but I cannot perform them on my own...unless...I happened to be walking down the street and helped someone during an emergency...then I would be covered under my state's "Good Samaritan laws". But, if I arrived with some Benadryl that I kept in a medical kit in my trunk to help others in an emergency, well, then I'd be practicing medicine without a license, because I intended to help others but had no medical direction. But, if I used benadryl on someone else from a medical kit that I kept in my trunk that was only in my trunk because I kept it there for personal emergencies, well, that would be perfectly fine, according to my state's laws. The law has less to do with how you do something, but rather why and when you do it.

So, in your scenario, you and the person from the other service most likely have two different medical directors. Your medical director might say to c-spine everyone. Your state's EMT training might teach something like, "C-Spine everyone unless your protocol says otherwise." The other person's medical director might have written a protocol on when not to C-Spine, or how to clear C-Spine. For example, my service has protocols on how to clear C-Spine, but of the two other nearby services, one other also does, and one does not (to my knowledge).

If you transferred the patient to the paramedic, now, his medical director's protocols are in play. The paramedic is operating under the direction of their medical director, under that doctor's license, performing the skills that medical director wants done.

Trying to be polite, and trying to help you learn, I would agree that this is a case of you don't know how much you really don't know. Now, this is not a bad thing. We have all been woefully unaware of things before. Take this as a learning opportunity. Pull your EMT book back out and re-read the legal section, specifically about how medical directors and protocols work. Then, you, as everyone in EMS needs to do, need to get out your protocols and learn them word for word.

We are in a business where constant learning is the order of the day for all of us. I'm re-reading sections of other books on other topics myself. Don't get discouraged. Educate yourself.

 

[BOS 101]

Sure...well, I would start with reminding you that this is something you should have learned in EMT school and didn't, or it is something you already learned, but have since forgotten. (We only typically retain about 10% of what we initially learned in school, unless we continue to relearn the material.)

So, I would recommend dusting off that EMT book from school and re-reading the legal section.

In EMS, every state has different laws. So, your state is different than mine, and you need to contact your state EMS board or state certifying/licensing agency or contact an attorney or legal representative for very specific legal advice relating to questions about: you, your service, your medical director and your state.

That being said: typically each state sets forth laws regarding certifications or licenses, and those laws govern training and skills. For example: maybe in one state, an EMT can intubate a patient, and in another state an EMT cannot. Or, maybe in one state an EMT can start an IV, and in another state an EMT cannot. The state says what types of skills an EMT can perform, and then sets training for those skills. The NREMT is just a standardized test of generic information that is similar between all states. It is different than state training, state certification, and the state's guidelines as to what duties an EMT can perform.

An EMT works under a medical director, who is a Doctor. The doctor can limit the skills that the state allows you to perform: for example, if your state allowed EMTs to give IVs, your medical director could say, "Yeah, but I don't feel comfortable with EMTs giving IVs, so my EMTs won't be doing that." The doctor could also give guidelines as to when and how to perform the skill. For example, the doctor could tell you to splint any injury you think might be broken, or the doctor could tell you to only splint an injury you have confirmed is broken. The medical director can tell an EMT not to do something that the state allows, or they can tell the EMT when or when not to perform the skill that the state allows, but they cannot tell the EMT to perform a new skill that the state does not allow. For example, they couldn't tell you to perform open heart surgery on a person who just had an MI. The medical director "tells" the EMT how and when to perform the skill by writing down the how's and when's in the form of protocols, also known as offline medical direction. You could contact a doctor at a hospital when you are enroute with a patient. That Doctor would then temporarily give you "medical direction". This is known as online medical direction. The doctor could tell you to perform a certain skill a certain way, but it cannot be contrary to the protocols that you already have from your medical director, and it cannot exceed what the state allows you to do.

In most states, you cannot perform these EMT skills on your own, though, there are exceptions. Every single state has its own rules. For example, in my state, Ohio, I can perform the skills under a medical director, but I cannot perform them on my own...unless...I happened to be walking down the street and helped someone during an emergency...then I would be covered under my state's "Good Samaritan laws". But, if I arrived with some Benadryl that I kept in a medical kit in my trunk to help others in an emergency, well, then I'd be practicing medicine without a license, because I intended to help others but had no medical direction. But, if I used benadryl on someone else from a medical kit that I kept in my trunk that was only in my trunk because I kept it there for personal emergencies, well, that would be perfectly fine, according to my state's laws. The law has less to do with how you do something, but rather why and when you do it.

So, in your scenario, you and the person from the other service most likely have two different medical directors. Your medical director might say to c-spine everyone. Your state's EMT training might teach something like, "C-Spine everyone unless your protocol says otherwise." The other person's medical director might have written a protocol on when not to C-Spine, or how to clear C-Spine. For example, my service has protocols on how to clear C-Spine, but of the two other nearby services, one other also does, and one does not (to my knowledge).

If you transferred the patient to the paramedic, now, his medical director's protocols are in play. The paramedic is operating under the direction of their medical director, under that doctor's license, performing the skills that medical director wants done.

Trying to be polite, and trying to help you learn, I would agree that this is a case of you don't know how much you really don't know. Now, this is not a bad thing. We have all been woefully unaware of things before. Take this as a learning opportunity. Pull your EMT book back out and re-read the legal section, specifically about how medical directors and protocols work. Then, you, as everyone in EMS needs to do, need to get out your protocols and learn them word for word.

We are in a business where constant learning is the order of the day for all of us. I'm re-reading sections of other books on other topics myself. Don't get discouraged. Educate yourself.

Thank you for the info, I did know most of that, although some of it was a good refresher
Mainly I wanted to be sure that there isnt a separate way that paramedics get to make decisions with their patients
I mean by that, they dont have a different set of rules from emts for treating patients and making treatment calls blah blah i babble
But you seem to confirm that it is roughly the same thing, just at a paramedic set of skills obviously
And you're right I do need to remember to think about other states protocols, I may look into them just to see how far they vary on things
Thanks

 

[BOS 101]

http://www.tandfonline.com/doi/abs/....884197#/doi/abs/10.3109/10903127.2014.884197

thank you

 

[Handsome Robb]

thats great and dandy plenty of ppl have already told me as much
what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some

Here's an article in JEMS, not the greatest source but it's well written and cites it's sources with a great list of studies at the bottom of the article.

http://www.jems.com/articles/print/...research-suggests-time-change-prehospita.html

Here is a paper from the National Association of EMS Physicians and American College of Surgeons.

http://www.naemsp.org/Documents/Pos...e of the Long Backboard_Resource Document.pdf

A collar is effective although current standard designs may not be the best since they generally place the patient in a position of cervical extension rather than neutral which is where we want these patients to be. If you want to use the board to get him to the gurney then remove it fine but leaving people with a naturally curved spine strapped to a hard plastic flat board does nothing good for the PT. Honestly if he can follow commands and can ambulate or is actively trying to get up I'd consider letting him stand and pivot with assistance to the gurney after placing a collar. I wouldn't be opposed to allowing him to do it since even in his altered state will instinctually protect his spine however this may increase his ICP which I'm going to talk about next so it's a risk vs benefit call. Also, in this case where a TBI/CHI is high on the list of differentials placing him on an uncomfortable board will cause him to squirm and move and depending on how altered he is potentially fighting against the SMR which increases ICP which worsens outcomes in TBI patients. Furthermore the catecholamine release from pain/discomfort alone can increase ICP even if they're sitting still.

I'm not trying to be a ****, I love teaching and will gladly explain my reasoning to other providers who express an interest to learn however there is a time and a place. In the middle of a call is rarely that time or place as it disrupts patient care and can harm the patient/provider rapport which doesn't help anyone involved.

I'm on my phone but can get you more sources tomorrow at work if you'd like.

 

[BOS 101]

Here's an article in JEMS, not the greatest source but it's well written and cites it's sources with a great list of studies at the bottom of the article.

http://www.jems.com/articles/print/...research-suggests-time-change-prehospita.html

Here is a paper from the National Association of EMS Physicians and American College of Surgeons.

http://www.naemsp.org/Documents/Position Papers/EMS Spinal Precautions and the Use of the Long Backboard_Resource Document.pdf

A collar is effective although current standard designs may not be the best since they generally place the patient in a position of cervical extension rather than neutral which is where we want these patients to be. If you want to use the board to get him to the gurney then remove it fine but leaving people with a naturally curved spine strapped to a hard plastic flat board does nothing good for the PT. Honestly if he can follow commands and can ambulate or is actively trying to get up I'd consider letting him stand and pivot with assistance to the gurney after placing a collar. I wouldn't be opposed to allowing him to do it since even in his altered state will instinctually protect his spine however this may increase his ICP which I'm going to talk about next so it's a risk vs benefit call. Also, in this case where a TBI/CHI is high on the list of differentials placing him on an uncomfortable board will cause him to squirm and move and depending on how altered he is potentially fighting against the SMR which increases ICP which worsens outcomes in TBI patients. Furthermore the catecholamine release from pain/discomfort alone can increase ICP even if they're sitting still.

I'm not trying to be a ****, I love teaching and will gladly explain my reasoning to other providers who express an interest to learn however there is a time and a place. In the middle of a call is rarely that time or place as it disrupts patient care and can harm the patient/provider rapport which doesn't help anyone involved.

I'm on my phone but can get you more sources tomorrow at work if you'd like.

Thanks robb, I know time and place and all, I was really just being a wee bit dramatic, I handle myself very appropriately on the job, I should have known It would be taken more literal
Thanks for your input

 

[Tigger]

thats great and dandy plenty of ppl have already told me as much
what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some

Part of how this works also includes you justifying your position. We are happy to provide information but at times like this it's important to consider how and why you justify your actions. Does your position have any evidence? If not, maybe it's not what should be done.

 

[BOS 101]

Part of how this works also includes you justifying your position. We are happy to provide information but at times like this it's important to consider how and why you justify your actions. Does your position have any evidence? If not, maybe it's not what should be done.

Fair enough most cases, but here I was only coming from the stand point of this is what were taught and what is protocol
So for me to change what im going to do or think someone has to provide me with evidence to the contrary(which if legit i can fully accept), you know? not to be stubborn cuz i haven't done experiments or studies myself in order to prove the way I was taught, just being weary, altho I should be weary of what I was taught as well, I know

 

[Handsome Robb]

I was only coming from the stand point of this is what were taught and what is protocol

I may have missed it if it was addressed already but are you sure that's what the protocols he was following say? They may be your department's protocols but his may be more liberal.

 

[BOS 101]

I may have missed it if it was addressed already but are you sure that's what the protocols he was following say? They may be your department's protocols but his may be more liberal.

Yes they did, thank you though

 

[LiveForTheTones]

Sometimes medics need to be questioned, but at an appropriate time and place.

He would of got a collar from me. Not a board.

Thank you for the input. I agree on at least the collar. I realize we are human beings and we aren't perfect.

County Fire Rescue where I live is doing away with backboards. If they need CPR or need to be airlifted, boards will be used. But if you're being transported from a MVC, you're going to get c-collar and a stretcher.
To lessen the "pain and stress."

 

[Bullets]

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?

That medic sounds like one of those paramedics that gives EMS a bad image.

If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?

 

[Carlos Danger]

If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?

Really?

I can accurately quantify oxygenation status and objectively rule out hypoxia. Which of course would be reflected in my documentation.

I cannot, however, rule out a potentially unstable cervical injury in a patient with a not-insignificant risk for one. Nor can I prove to a jury that my removing the collar was not the proximate cause of any neuro deficit that may manifest later. Nor can I even really give a good reason why I removed it, assuming it was properly placed and not causing any problems.

One action is clearly contraindicated (NRB in a patient who is oxygenating just fine) and can be defended as such with objective data. Another action (removing the collar) is controversial and cannot be objectively justified.

 

[Chewy20]

If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?

Apples and oranges my friend. You can look at RR, SPO2 and ETCO2, listen to lung sounds etc. Unless you have an imaging system on your box then meh...

 

[Noncreative]

Yeah, I'd agree that a collar is the right call, at least where I am, the combo of the possible height and altered LOC would call for C-Spine, but if the medic wanted it off, I'd let them remove it and document it for my sake when it comes to court.