Who's still routinely c-spining?

[FiremanMike]

Just curious.. Who out there is still routinely c-spining their patients? If so, do you do it because protocol dictates it or because you feel it is necessary and/or appropriate?

As for our department (and region) we are going on about a year now of only back boarding and c-collaring patients with confirmed neuro deficit. Backboard use has gone down exponentially. We were of course sure to involve the local trauma centers before this decision to make sure we were all on the same page.

 

[NomadicMedic]

I find that BLS people still routinely C-spine, because it's what they know. When paramedics arrive on the scene of a traumatic injury, we don't routinely C-spine patients, instead we use selective spinal immobilization criteria.

I also find that if it's a chaotic scene, a backboard and c-collar is more likely to be applied… Because somebody with a white helmet is running around willy-nilly yelling, "get a board"

 

[FiremanMike]

I find that BLS people still routinely C-spine, because it's what they know. When paramedics arrive on the scene of a traumatic injury, we don't routinely C-spine patients, instead we use selective spinal immobilization criteria.

I also find that if it's a chaotic scene, a backboard and c-collar is more likely to be applied… Because somebody with a white helmet is running around willy-nilly yelling, "get a board"

I wasn't really sure where to post it, as c-spine is a BLS skill. From my experience, I agree with what typically happens.

That said, I'm looking for input from all levels of EMS to see where they're at..

 

[Medic Tim]

We use the Canadian c-spine rule where I work ( go figure) . I hate putting people on a board for transport. I avoid doing so as much as I can. For some reason I get a lot of pts who refuse the board but will accept the c-collar. I have heard rumblings that we will not be using boards for transport in the near future.

 

[Handsome Robb]

Wait y'all use the CCSR in Canada? No way...

We use NEXUS.

 

[DrParasite]

hmmmm, last MCI drill I was at (about 2 years ago, 100 patients at the airport), everyone who was tagged yellow or red was directed to be put on a LSB by the transport manager, regardless of complaint. despite my objections (as triage person and later on yellow treatment leader), but I don't have a white helmet.

I still hear of ped struck or MVA's who have neck and back pain being put on a LSB. Also the occasional fall victim (if they have neck or back pain).

Can't wait for the old timers to realize the futility of putting everyone on a LSB, and stop giving the new guys a hard time for not C-spining EVERYONE. then again, this also has to go up through management and the ER & trauma staff as well.

 

[Meursault]

Unfortunately, some of us work in systems that don't recognize selective spinal immobilization (in both senses: they seem not to have noticed me doing it, but they'd tear me a new a:censored:hole if they did).
I've also been to scenes where I would have probably had to fight several FFs and a supervisor in order to not board a patient with no indications for it.

 

[medicsb]

As for our department (and region) we are going on about a year now of only back boarding and c-collaring patients with confirmed neuro deficit. Backboard use has gone down exponentially. We were of course sure to involve the local trauma centers before this decision to make sure we were all on the same page.

How are you checking for neuro defecit? The good ol' grips and plantar/dorsal flexion?

I would hope you're using one of the validated screening tools such as the canadian c-spine rule or NEXUS.

 

[Tigger]

Not routinely but more than I'd like. We have the Nexus criteria which helps cut down on a lot of it if people actually use it.

Yesterday we went to the urgent care for a girl who had fallen while hiking and through x-ray was determined to have an L1 fracture. No CT so the doc would not rule out a c-spine injury despite having no related complaint and meeting Nexus criteria (yes she had a fractured L1 that was painful but she was still answering questions calmly and appropriately so I don't see that as a distracting injury).

I said I would take her with no c-spine precautions and position of comfort, or maybe a collar if it made everyone feel better. The only concession I ended up with was using a scoop not a board. Reason given: if she vomits, I can't control her airway since I can't move her without hurting her. Position of comfort was prone, with head on a pillow. So we put her on the scoops and dramatically increased her pain level despite copious padding and an eventual of 4 of morphine. Yea, we definitely helped her. :glare:

 

[Handsome Robb]

Unfortunately, some of us work in systems that don't recognize selective spinal immobilization (in both senses: they seem not to have noticed me doing it, but they'd tear me a new a:censored:hole if they did).

I've also been to scenes where I would have probably had to fight several FFs and a supervisor in order to not board a patient with no indications for it.

Eh I'm the medical authority so what I say goes.

I'll usually let them do there thing then once we're in the box and have some space (from fire) remove them from it.

 

[DrParasite]

Eh I'm the medical authority so what I say goes.

I'll usually let them do there thing then once we're in the box and have some space (from fire) remove them from it.

interesting... most places that I am familiar with say once a collar and board is applied, it doesn't get taken off until a doctor says to get them off it (liability reasons was the reason I was told many moons ago).

 

[Medic Tim]

interesting... most places that I am familiar with say once a collar and board is applied, it doesn't get taken off until a doctor says to get them off it (liability reasons was the reason I was told many moons ago).

I love the look on peoples faces when I take pts off of a board and or c-collar. They have the same protocol we do but just don't use it for whatever reason. My transports are at a minimum 2-3 hours on very bad roads. I look for every reason I can to not board a pt. The hospitals use the same guideline we do(they actually follow it) as well.

 

[chaz90]

interesting... most places that I am familiar with say once a collar and board is applied, it doesn't get taken off until a doctor says to get them off it (liability reasons was the reason I was told many moons ago).

I've taken many people off boards who didn't meet original indications for it but were immobilized by BLS anyway. Everyone has the selective spinal immobilization protocol, but many seem not to use it. I, on the other hand, do at every available opportunity.

 

[FiremanMike]

How are you checking for neuro defecit? The good ol' grips and plantar/dorsal flexion?

I would hope you're using one of the validated screening tools such as the canadian c-spine rule or NEXUS.

Appropriate mechanism of injury plus numbness, tingling, or paralysis.

 

[medicsb]

Appropriate mechanism of injury plus numbness, tingling, or paralysis.

Yikes. Your medical director should know that neuro deficits can be much more varied than what you have cited. Changes in reflexes, proprioception, vibratory sense, strength, tone, etc. all can be just as worrisome.

With many patients, numbness and tingling is status quo (e.g. those with peripheral neuropathies, or those with radiculopathies), so don't be surprised if you're boarding a disproportionate number of diabetics.

 

[jrm818]

Not routinely but more than I'd like. We have the Nexus criteria which helps cut down on a lot of it if people actually use it.

Yesterday we went to the urgent care for a girl who had fallen while hiking and through x-ray was determined to have an L1 fracture. No CT so the doc would not rule out a c-spine injury despite having no related complaint and meeting Nexus criteria (yes she had a fractured L1 that was painful but she was still answering questions calmly and appropriately so I don't see that as a distracting injury).

I said I would take her with no c-spine precautions and position of comfort, or maybe a collar if it made everyone feel better. The only concession I ended up with was using a scoop not a board. Reason given: if she vomits, I can't control her airway since I can't move her without hurting her. Position of comfort was prone, with head on a pillow. So we put her on the scoops and dramatically increased her pain level despite copious padding and an eventual of 4 of morphine. Yea, we definitely helped her. :glare:

Totally agree with your perspective in general - this doesn't sound like a pt. that needed c-spine precautions, even if we grant that they do anything helpful.

that said,just a little note about "meeting NEXUS criteria" - if I recall correctly from some of the "CT vs plain films" literature on c-spine injuries, once a single injury has been found somewhere in the spine, the rate of finding a second injury is much higher than the injury rate in the general "might have hurt their back" patient population.

That might make NEXUS or CCR usage inappropriate in this particular patient, as both tests are predicated on a pretty low pretest probability of injury, and the presence of a confirmed spinal injury in this patient puts her in a higher risk cohort than the rules were derived and validated for.

Just a thought I wanted to throw out there for other patients that may be more of a gray area. Regardless, the "no related complaint" part of your assessment is probably the key: without any cervical area complaints whatsoever, your decision making sounds appropriate to me.

 

[Handsome Robb]

interesting... most places that I am familiar with say once a collar and board is applied, it doesn't get taken off until a doctor says to get them off it (liability reasons was the reason I was told many moons ago).

I've heard of things like that but if they meet our clearance protocol I'll remove them from it. Never been talked to about it.

We clear people off boards all the time at the ski resort. Their protocols are very restrictive. Back pain = board no matter what.

 

[Tigger]

I've heard of things like that but if they meet our clearance protocol I'll remove them from it. Never been talked to about it.

We clear people off boards all the time at the ski resort. Their protocols are very restrictive. Back pain = board no matter what.

One ski area out here does headache with "significant MOI" means c-spine. Never mind the whole altitude component.

 

[Bullets]

We basically have the Yale New Haven protocol, so ambulatory patients get a collar only

Nonambulatory patients with neuro deficit, distracting injury, altered or unreliable get a board but that may be changing. Trying to get approval to remove them from the board once they are on the cot


Also, I'll take patients off the board all the time.... Just like I'll take them off oxygen if a cop puts on a NRB that's not indicated. It's a treatment like any other

 

[FiremanMike]

Yikes. Your medical director should know that neuro deficits can be much more varied than what you have cited. Changes in reflexes, proprioception, vibratory sense, strength, tone, etc. all can be just as worrisome.

With many patients, numbness and tingling is status quo (e.g. those with peripheral neuropathies, or those with radiculopathies), so don't be surprised if you're boarding a disproportionate number of diabetics.

Yikes? I see you're a PGY-0, so I'll excuse some of your condescension as just excitement over your new position in life..

Do you really think that we should be wasting time on the roadside doing a full on neurologist-worthy neuro exam to evaluate tone as we're deciding whether or not to initiate full spinal precautions on someone?

I really think you underestimate our ability to take mitigating factors into account such as PVD/distal neuropathy of unknown etiology, so that the 1:1,000,000 trauma patient with significant mechanism of injury with bilateral numbness can be ruled out for spinal injury in favor of "what's normal"? Of course, you do understand that "what's normal" would probably be pretty quickly asked in such zebra cases..

I'll tell you what though, our medical director is actually very approachable and really loves to teach. If you'd like, I can pass along some contact info from you to him, I'm sure he'd love to hear from you about how we're underprepared and back boarding too many diabetics and too few trauma patients.