# Who's still routinely c-spining?



## FiremanMike (Mar 25, 2014)

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.


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## NomadicMedic (Mar 25, 2014)

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"


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## FiremanMike (Mar 25, 2014)

DEmedic said:


> 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..


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## Medic Tim (Mar 25, 2014)

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.


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## Handsome Robb (Mar 25, 2014)

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

We use NEXUS.


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## DrParasite (Mar 25, 2014)

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.


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## Meursault (Mar 25, 2014)

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.


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## medicsb (Mar 25, 2014)

FiremanMike said:


> 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.


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## Tigger (Mar 25, 2014)

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:


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## Handsome Robb (Mar 25, 2014)

Meursault said:


> 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.


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## DrParasite (Mar 25, 2014)

Robb said:


> 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).


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## Medic Tim (Mar 25, 2014)

DrParasite said:


> 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.


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## chaz90 (Mar 25, 2014)

DrParasite said:


> 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.


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## FiremanMike (Mar 25, 2014)

medicsb said:


> 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.


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## medicsb (Mar 25, 2014)

FiremanMike said:


> 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.


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## jrm818 (Mar 25, 2014)

Tigger said:


> 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.


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## Handsome Robb (Mar 25, 2014)

DrParasite said:


> 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.


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## Tigger (Mar 25, 2014)

Robb said:


> 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.


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## Bullets (Mar 26, 2014)

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


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## FiremanMike (Mar 26, 2014)

medicsb said:


> 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.


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## FiremanMike (Mar 26, 2014)

Bullets said:


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



I remember back to emt school when we learned standing take down, and even then I thought "this is the dumbest thing ever!"  



> 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



Cops give oxygen there?


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## NomadicMedic (Mar 26, 2014)

I saw a BLS crew do a standing take down the other day. I just shook my head.


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## Rialaigh (Mar 26, 2014)

DEmedic said:


> I saw a BLS crew do a standing take down the other day. I just shook my head.



I was on the truck with my supervisor the other day and he did one...really made me <_<....alas, low man on the totem pole...


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## Bullets (Mar 26, 2014)

FiremanMike said:


> Cops give oxygen there?



Yeah, they get the EMR/First Responder training class in the Academy. They spend the whole week doing it, so every cop carries a jump kit with 02 in it


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## medicsb (Mar 26, 2014)

FiremanMike said:


> 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..



My new job is pretty awesome and all, but my condescending tone predates it. 



> 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?



Of course not, but I think you should be using a validated method to determining the need for immobilization (whether just a c-collar or full spine board).  If you're going to use MOI and neuro exam findings alone, I just hope you're doing something more in depth than what the majority of prehospital neuro exams consist of: grips, planter/dorsal flexion, and asking if they have any numbness or tingling.  



> 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 don't think it's underestimation, it's more like I'm being realistic given the typical education of paramedics.  Maybe you work at some great place that offers tons of extra education and training, or you all graduate from the best paramedic training program ever, but there is no way for me to know.  Sorry for my skepticism?  



> 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.



Clearly, you misunderstood some of what I said.  But, ask your medical director if your protocol is evidence based.  If it is not, then ask if he is prospectively studying it or if he plans to retrospectively study it and publish the results.  If your simplified protocol works, then the rest of the world would like to know about it.


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## DrParasite (Mar 27, 2014)

FiremanMike said:


> I remember back to emt school when we learned standing take down, and even then I thought "this is the dumbest thing ever!"


totally agreed, and I have been directed by paramedics in NY to do it to ambulatory patients following a MVA.  her justificiation was "your head is like a bowling ball on a broomstick, it's easy to hurt it at an MVA." still makes no sense to me, but I'm no paramedic...





FiremanMike said:


> Cops give oxygen there?


everyone gets oxygen.  cut fingers, abd pn, panic attacks, any job where they don't have cop stuff to do (like traumas and MVA), EMS often walks up to find the pt on a NRB


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## johnrsemt (Mar 27, 2014)

I think it is almost easier to find areas that do still do Full C-spine including Long Backboards now.    Even here in Utah they are starting to go away from it,    and Utah is about as far behind times in some ways in EMS as you can get


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## Handsome Robb (Mar 27, 2014)

Hey john what do you know about Davis County SO?

I'd love to pick your brain about Utah EMS when you've got time.


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## GoldcrossEMTbasic (Mar 27, 2014)

The agencies, around MN, even while in route when dispatcher states rear end minor fender bender. The protocol is C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15. In class we had to go by the book of course. But I think the protocol is that even if we go on call where a patient fell, we collar the pt and backboard too. And the patient usually will state that this is not necessary. And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:


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## Medic Tim (Mar 27, 2014)

GoldcrossEMTbasic said:


> The agencies, around MN, even while in route when dispatcher states rear end minor fender bender. The protocol is C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15. In class we had to go by the book of course. But I think the protocol is that even if we go on call where a patient fell, we collar the pt and backboard too. And the patient usually will state that this is not necessary. And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:




So you are saying that dispatch info dictates what treatment you perform?  That's crazy.
If so that is an area/ agency to avoid. Do they still use mast pants an EOAs?

I hope you do some research on smr and spinal injuries. The  "war stories" often told to students and noobs to scare them are very often over exaggerated with little to no evidence to back them up. 
 Look up nexus and the Canadian Cspine rule if you haven't before. There are even entire states that now use the board for extrication only.
Does you area use regional/ state/ agency protocols?


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## NomadicMedic (Mar 27, 2014)

GoldcrossEMTbasic said:


> The agencies, around MN, even while in route when dispatcher states rear end minor fender bender. The protocol is C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15. In class we had to go by the book of course. But I think the protocol is that even if we go on call where a patient fell, we collar the pt and backboard too. And the patient usually will state that this is not necessary. And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:



This is ridiculous. Please supply a link to the protocol where it states 





> ...C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15.


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## STXmedic (Mar 27, 2014)

GoldcrossEMTbasic said:


> And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:



By far my favorite part of the post :lol: Its got me reminiscent of the story of the guy walking around on his cell phone, then turns his head and dies :lol:


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## jrm818 (Mar 27, 2014)

:wacko: No comment beyond leaving this here (in case anyone hasn't seen it)

https://www.youtube.com/watch?v=0HAGMb_jAdU


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## Medic Tim (Mar 27, 2014)

jrm818 said:


> :wacko: No comment beyond leaving this here (in case anyone hasn't seen it)
> 
> 
> 
> https://www.youtube.com/watch?v=0HAGMb_jAdU




I hate that I love this so much.


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## Carlos Danger (Mar 27, 2014)

I guess she just doesn't understand the scientific-ness of that test.....


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## Tigger (Mar 27, 2014)

The part that we seem to have the most trouble with is that without traditional SMR procedures, the banged up trauma patient suddenly doesn't immediately have handles. Many of my coworkers recognize that our SMR techniques don't do anything beneficial, but the board and straps makes for an easy transportation and restraint method. 

I'm pushing for more scoop use since it's easy to break it apart when they're on the stretcher but alas it's a struggle. We used it the other day (partner chose to keep the patient on it for the 40 minute transport :glare and when we got to the hospital (a large level II), none of the trauma team had any idea what the scoop was. Then they said something about "that's not how we c-spine people," so I suspect some education will have to occur on the receiving end.


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## Brandon O (Mar 27, 2014)

medicsb said:


> Of course not, but I think you should be using a validated method to determining the need for immobilization (whether just a c-collar or full spine board).  If you're going to use MOI and neuro exam findings alone, I just hope you're doing something more in depth than what the majority of prehospital neuro exams consist of: grips, planter/dorsal flexion, and asking if they have any numbness or tingling.



I'm guessing he's not mentioning some inclusion and exclusion criteria that would probably get things pretty close to NEXUS, which is certainly validated.

Moreover, I think it may be a little optimistic to think that the neuro assessments done in NEXUS (or the Canadian studies) were OSCE-style. (Not a lot of tuning forks in most ED labcoats...) Nor do I think it would necessarily be for the better. I liked the TBI study where they had neurologists examine everyone in the ER lobby and found something like 10% with asymptomatic deficits. Predictive value and all that...

I would expect that the majority of at-risk patients with chronic issues, such as neuropathic diabetics, would be ruled-in by most providers unless it was abundantly clear there was no change from their baseline (probably impossible to say in most cases; in fact, by the spirit of NEXUS this would probably qualify as a condition preventing assessment, similar to inebriation or a distracting injury).


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## GoldcrossEMTbasic (Mar 27, 2014)

No dispatch does not do that! What I am indicating is that when the medics hear dispatch say that there is a mva, with minor injuries, that gives my local ambulance company, at which I do not work for. However, I do know somebody that works for that company and their protocol is that they board and collar the patient even if it it minor.


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## GoldcrossEMTbasic (Mar 27, 2014)

Great Video, That would be great video for EMT training. But I am sure that some do.:rofl:


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## chaz90 (Mar 27, 2014)

GoldcrossEMTbasic said:


> Great Video, That would be great video for EMT training. But I am sure that some do.:rofl:



Some do what?


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## Tigger (Mar 27, 2014)

GoldcrossEMTbasic said:


> Great Video, That would be great video for EMT training. But I am sure that some do.:rofl:



Please, please proofread your posts. We're far from grammar nazis here, but a lot of us are having trouble understanding what you're trying to say in a lot of your posts.


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## Medic Tim (Mar 27, 2014)

chaz90 said:


> Some do what?




Teach that mechanism of injury is more important than assessment finding and that unproven old practices save lives and litigation even though evidence suggests otherwise ..... Just a guess.


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## GoldcrossEMTbasic (Mar 27, 2014)

Show this video in class.


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## STXmedic (Mar 27, 2014)

GoldcrossEMTbasic said:


> Show this video in class.


No, more likely this:



Medic Tim said:


> Teach that mechanism of injury is more important than assessment finding and that unproven old practices save lives and litigation even though evidence suggests otherwise ..... Just a guess.


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## Handsome Robb (Mar 27, 2014)

GoldcrossEMTBasic - when I wrecked my snowmobile in the beginning of December I had extreme midline and perispinal low cervical and high thoracic pain. Also, deformities were present. I partially separated my C6, C7, T1 and T2 costovertebral joints from my spinal column. 

When I laid down the pain was even worse and to the point where I couldn't actually breathe. That was laying in the snow. I couldn't even imagine a hard plastic board, there's no way I would've consented to spinal motion restriction. They'd have had to RSI me if they wanted me on a board that badly.

I'm still walking. 

In HS I subluxed my c2-c3 and also rotated both of them playing football which resulted in a spinal cord impingement and temporary neuro deficits. I wasn't boarded then either.

Still walking. 

Moral of the story, the stories they tell you in school are often to scare you. The patients they talk about losing neuro function would've lost it board or otherwise. Add swelling to a basically enclosed space and there's no where for that pressure to go. Eventually it will impinge on the cord and cause temporary or permanent neuro deficits.


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## medicsb (Mar 27, 2014)

Brandon O said:


> I'm guessing he's not mentioning some inclusion and exclusion criteria that would probably get things pretty close to NEXUS, which is certainly validated.



If he is actually using NEXUS, then conversation over.  The criteria he stated is alarmingly narrow, so I hope it's actually a (unintended) deception or partial truth. 



> Moreover, I think it may be a little optimistic to think that the neuro assessments done in NEXUS (or the Canadian studies) were OSCE-style. (Not a lot of tuning forks in most ED labcoats...) Nor do I think it would necessarily be for the better. I liked the TBI study where they had neurologists examine everyone in the ER lobby and found something like 10% with asymptomatic deficits. Predictive value and all that...



I'd imagine that they were not at all OSCE style and probably quite rudimentary (I'll have to go track down the studies to see if they mention what the neuro exam consisted of).  But, I'd say the NEXUS makes up for a rudimentary exam by considering other factors.  



> I would expect that the majority of at-risk patients with chronic issues, such as neuropathic diabetics, would be ruled-in by most providers unless it was abundantly clear there was no change from their baseline (probably impossible to say in most cases; in fact, by the spirit of NEXUS this would probably qualify as a condition preventing assessment, similar to inebriation or a distracting injury).



I agree.


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## Brandon O (Mar 27, 2014)

medicsb said:


> I'd imagine that they were not at all OSCE style and probably quite rudimentary (I'll have to go track down the studies to see if they mention what the neuro exam consisted of).



As I recall they don't specify the contents of the neuro exam. One presumes the usual standard of care. But I drink heavily and could be wrong.


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## FiremanMike (Mar 27, 2014)

I'll admit I had to look up "NEXUS" because in my 16 years practicing and 10 years teaching, I'd never actually heard that term.  What I found was the basic c-spine rule out exam that's been taught as long as I can remember.


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## NomadicMedic (Mar 27, 2014)

In the majority of programs, EMTs are not taught any C-spine rule out and continue to put ANY fender bender victim on a board. 

In fact, one of the EMS instructors here was advocating that BLS keep putting accident victims on a board because "we don't carry an x-ray or MRI on the ambulance"

FACE. PALM. 

Congratulations that you've been proactive keeping people off boards as long as you have.

... And 15lpm on an NRB goes great with that board and collar. Because, OXYGEN.


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## jrm818 (Mar 27, 2014)

Brandon O said:


> As I recall they don't specify the contents of the neuro exam. One presumes the usual standard of care. But I drink heavily and could be wrong.



Drinking slightly more  lightly but I think you're right...I think such details are explicitly ommitted, as are details about what constitutes a distracting injury.  Ive heard Dr Hoffman ( not personally...panel sessions from the all LA conference for em residents used to be posted publically) be very emphatic that nexus is a decision aid not decision maker and depends on clinical judgement.


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## Brandon O (Mar 27, 2014)

FiremanMike said:


> I'll admit I had to look up "NEXUS" because in my 16 years practicing and 10 years teaching, I'd never actually heard that term.  What I found was the basic c-spine rule out exam that's been taught as long as I can remember.



Well, that's where it came from. Are you guys using similar criteria -- i.e. patient can't be altered, no major distracting injuries, etc?


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## jrm818 (Mar 27, 2014)

DEmedic said:


> In the majority of programs, EMTs are not taught any C-spine rule out and continue to put ANY fender bender victim on a board.
> 
> In fact, one of the EMS instructors here was advocating that BLS keep putting accident victims on a board because "we don't carry an x-ray or MRI on the ambulance"
> 
> ...



Agree..and .even for physicians nexus was important probably more because it officially gave evidence based permission to practice the way most knew was right without as much fear of unfair liability


And sorry can't figure out multiquote...but in reference to no one in particular....I never again want to hear criticism of requirements  in  health science programs for things like general English classes or any analytical liberal art subject for that matter.  The value of suchgeneral eduxarion  classes even in seemingly unrelated programs should be immediately apparent to anyone perusing this thread...


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## Handsome Robb (Mar 27, 2014)

JRM for multiquote click the button next to quote on the posts you want to multiquote then once you've selected them when you get to the last post you want to quote click the actual quote button. 



NEXUS and CCSR originally were developed to decide whether or not imaging was indicated.


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## FiremanMike (Mar 28, 2014)

Heh, I just remembered an IFT I was involved in.  Trauma patient being transferred from outlying to a trauma center, isolated extremity injury, etoh on board.  Patient had already been removed from the backboard, c-collar, c-spine X-rays were already done and negative.  Sending physician demands we place the patient back in full spinal immobilization prior to transport.  I diplomatically suggested this may be unnecessary, but he wasn't hearing it.. Patient was placed back on a board with a new collar..


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## Tigger (Mar 28, 2014)

Did a standing take down just now. I feel dirty, need a shower right quick. 

Slowly I work for change but obviously it takes a long while.


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## Medic Tim (Mar 28, 2014)




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## Handsome Robb (Mar 28, 2014)

FiremanMike said:


> Heh, I just remembered an IFT I was involved in.  Trauma patient being transferred from outlying to a trauma center, isolated extremity injury, etoh on board.  Patient had already been removed from the backboard, c-collar, c-spine X-rays were already done and negative.  Sending physician demands we place the patient back in full spinal immobilization prior to transport.  I diplomatically suggested this may be unnecessary, but he wasn't hearing it.. Patient was placed back on a board with a new collar..



The patient consented to that?

There is the possibility of a SCIWORA but not super common, especially without neuro deficits presenting.


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## FiremanMike (Mar 28, 2014)

Robb said:


> The patient consented to that?
> 
> There is the possibility of a SCIWORA but not super common, especially without neuro deficits presenting.



Patient had etoh on board.. I'll be honest I wasn't quick enough at the time to try and play the consent angle, but in retrospect the doctor would have just said "her lack of consent is invalid because of the alcohol"...


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## mycrofft (Mar 28, 2014)

Yeah, that's what I want. Someone subject to vomiting or becoming combative or claustrophobic, strapped down prone on a hard board on my ambulance litter.


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## DrParasite (Mar 28, 2014)

mycrofft said:


> Someone subject to vomiting or becoming combative or claustrophobic, strapped down prone on a hard board on my ambulance litter.


isn't that how you kill someone?  positional asphyxiation and all that crap?

I wouldn't want to do that either.  it might be detrimental to my career.


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## Handsome Robb (Mar 28, 2014)

mycrofft said:


> Yeah, that's what I want. Someone subject to vomiting or becoming combative or claustrophobic, strapped down prone on a hard board on my ambulance litter.



I think you were looking for supine 

I'm sure you're right as to what their response would be but ETOH =/= automatically remove a patient's ability to consent. If they're drunk but able to follow what's going on, reiterate risks and other things they're told I'd say they have every right to refuse but that's just me. 

You're also talking to the Medic who had a Physician complaint because I refused to backboard a patient with a confirmed lumbar fracture who ambulated into the Urgent Care two days after the injury. 

The patient wrote a letter thanking my agency for the care I provided so that got squashed pretty quickly.


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## rockyfortune (Apr 4, 2014)

DEmedic said:


> 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"





We were taught to cspine everyone until we knew definitively that they didn't need it..even then they said..put a collar on them.  most of the medics that i talk to all say..''when you are out in the real world, forget that :censored::censored::censored::censored:."


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## Melclin (Apr 7, 2014)

Tigger said:


> 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:



I don't quite follow. What type of L1 fracture was it? I figure maybe burst? Regardless of what you might feel about SMR, its still indicated in one form or another for unstable injury. You haven't mentioned whether this was an unstable type fracture.

Also, my understanding is that the literatire supports the idea that 1) Xrays are less than perfect and 2) once an xray shows a fracture, the likelihood of other fractures becomes vastly higher and a CT scan is pretty much mandated. 

You couldn't control her pain with morphine? Are you limited dose wise? Was 4 the only pain relief she got?




GoldcrossEMTbasic said:


> The agencies, around MN, even while in route when dispatcher states rear end minor fender bender. The protocol is C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15. In class we had to go by the book of course. But I think the protocol is that even if we go on call where a patient fell, we collar the pt and backboard too. And the patient usually will state that this is not necessary. And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:



As others have said, this sort of story is largely mythical. I can certainly point you in the direction of some relevant literature if you would like. Please forgive me if I'm wrong or English isn't your first language or something, but *Goldcross*, level with us mate, are you sure you aren't just having us on with that sort of example and one or two other thing you've said? You might have noticed by now that you've referenced a few issues that are commonly used to troll prehospital providers and if thats just because you're starting out, then great, we've all been there and I am happy to correspond with you and help you with a ton of great resources because you're obviously keen. But common mate, if you're having a laugh, now is the time to tell us.




Tigger said:


> Did a standing take down just now. I feel dirty, need a shower right quick.
> 
> Slowly I work for change but obviously it takes a long while.



I honestly didn't know that was still a thing. Out of interest, is there a justification document laying around or some guidance for your clinical department on why they require you to do that? I don't suppose you have an electronic copy of your guidelines do you? I'd be interested to see them.



FiremanMike said:


> Patient had etoh on board.. I'll be honest I wasn't quick enough at the time to try and play the consent angle, but in retrospect the doctor would have just said "her lack of consent is invalid because of the alcohol"...



That raises an interesting issue. In your area, does intoxication remove a person's right to refuse care? I wouldn't have thought so. 


While I'm sure you could argue until blue in the face about who can REALLY make informed consent, the drunk issue has been tested here with consistent findings that drunk idiots have the right to be idiots even when they're potentially head injured as well. Summarized somewhat more appropriately bellow. I would be fairly surprised if it was drastically different in the US. I thought you chaps/chapettes were all about the right to make the wrong choice?

"...if they can understand your advice that they should go to hospital, that they have suffered an injury that needs attention, if they can in fact consider that and weigh it up against their competing desire to keep drinking, or go home, or do whatever else they want to do, and they can make that clear to you, then they retain their competence."


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## Melclin (Apr 7, 2014)

rockyfortune said:


> We were taught to cspine everyone until we knew definitively that they didn't need it..even then they said..put a collar on them.  most of the medics that i talk to all say..''when you are out in the real world, forget that :censored::censored::censored::censored:."



I really hate this street vs book type thing and always have. 

If some reasonable practice is genuinely acceptable, then why is some utterly different 'theoretical' alternative being taught as gospel? Currently one of the local universities is teaching that pts be rigidly interviewed along "AMPLE" lines after an initial complaint is established, because, you know, when your pt has chronic lumbar back pain as a starting point, really nailing down that last meal is super important. Additionally the DOLOR mnemonic has been recently taught as an assessment tool for any and all pain. Obviously everyone, including all (as far as I know) the academics teaching this acknowledge this isn't and shouldn't be what actually happens but I've never actually been able to extract an answer as to why this sort of BS goes on. 

Conversely, if real world practice doesn't reflect practice being taught at an academic institution where, theoretically at least, the best evidence should be the corner stone of all the teachings, then far from throwing out the book, the real world needs to get on board with the science. 

I don't see that the whole real world vs school BS makes any sense from either perspective. I get that there is, in all fields, a differences between the leading edge academic gold standard and otherwise current or standard practice. Practice & culture will always take a while to catch up with fast paced evidence based change. But that is quite a different notion.


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## firecoins (Apr 7, 2014)

I only C-Spine my CHF patients.


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## highglyder (May 3, 2014)

This is one of the few areas were our standards are grey.  It simply states to immobilize the c-spine if trauma is known, suspect, or cannot be ruled out.  Soooo....in this world of OMG!OMG!OMG!OMG!OMG!OMG!, out comes the collar and backboard.

Many of my colleagues await the arrival of an algorithm in order to decreased the amount of patients that get collared and boarded, but I say do it yourself.  I get many odd looks when someone complains of neck pain and I don't whip out the C&B.


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## rails (May 4, 2014)

Melclin said:


> <snip>
> If some reasonable practice is genuinely acceptable, then why is some utterly different 'theoretical' alternative being taught as gospel? Currently one of the local universities is teaching that pts be rigidly interviewed along "AMPLE" lines after an initial complaint is established, because, you know, when your pt has chronic lumbar back pain as a starting point, really nailing down that last meal is super important. Additionally the DOLOR mnemonic has been recently taught as an assessment tool for any and all pain. Obviously everyone, including all (as far as I know) the academics teaching this acknowledge this isn't and shouldn't be what actually happens but I've never actually been able to extract an answer as to why this sort of BS goes on.
> <snip>



I think a part of it is ensuring that everyone knows SAMPLE, as a baseboard to spring from. That way when we go into a scene, we have SAMPLE in our mind. But yes, the books teach "always do a full SAMPLE", while real paramedics say "sometimes I skip over certain parts of SAMPLE". There is some disconnect there.


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## Bearamedic (Jun 1, 2014)

I do it for protocol, but. . .

http://www.mdcalc.com/nexus-criteria-for-c-spine-imaging/
These 5 criteria put it on par with an xray clearing. add in female over 65? 80?and you have surpassed xray clearing

Link is just what i found, cant find a list that includes the elderly female tidbit.


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## 9D4 (Jun 1, 2014)

My protocols still call for pretty routine c-spine. 



Edit: I did want to clarify. SMR can be as little as just a C collar and be within protocols. However, everyone in my area seems to think that SMR means full spinal immobilization. I've only seen it omitted completely once, a collar maybe a half dozen times and the rest of the time it is full backboard.


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## Brandon O (Jun 1, 2014)

Bearamedic said:


> These 5 criteria put it on par with an xray clearing. add in female over 65? 80?and you have surpassed xray clearing
> 
> Link is just what i found, cant find a list that includes the elderly female tidbit.



Where did you get the female component? That's not part of NEXUS.



9D4 said:


> My protocols still call for pretty routine c-spine.



Interesting. Looks like they've combined the Canadian C-spine rule and the NEXUS criteria so you have to pass both.


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## rescue1 (Jun 1, 2014)

In PA we still use what is basically NEXUS, per protocol. In Maryland there was a recent switch to clinical judgement (Protocols state "the provider shall determine the appropriate immobilization device for the patient"). 

Hopefully that trickles north to PA by next year...


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## Medic Tim (Jun 1, 2014)

https://www.itrauma.org/wp-content/uploads/2014/05/SMR-Resource-Document-FINAL.pdf
Position paper from ITLS on SMR.


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## Bearamedic (Jun 2, 2014)

Brandon O said:


> Where did you get the female component? That's not part of NEXUS.



I dont know, i think it might have been in a slide show during a ce class.

The elderly female reasoning was osteoporosis increased the chances of fx which may be completely asymptomatic, and the common subtle neurological diminishment masked symptoms or positive criteria as well. Those two things together seemed to be significant enough in a prehospital setting to not safely "field clear"

I tried to find a citation that would be useful for a physician assistant student in a hospital setting, but could find none. :sad:


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## Brandon O (Jun 2, 2014)

Bearamedic said:


> The elderly female reasoning was osteoporosis increased the chances of fx which may be completely asymptomatic, and the common subtle neurological diminishment masked symptoms or positive criteria as well. Those two things together seemed to be significant enough in a prehospital setting to not safely "field clear"



I can sort of see where you're coming from. I don't think osteoporosis is associated with neurological impairment, but it is associated with fracture risk.

However, it's worth remembering that in the NEXUS validation studies, this was not one of the components and there were still essentially no significant misses. So if you start adding more caveats just because they make some physiological sense, you're creating a new rule and there may not be any need for it. (Where does it end? Should we rule out diabetics, macho men with high pain tolerance, and folks with big heads?) After all, the whole notion of prophylactic immobilization is based on the idea that it "makes sense," and that's what we're trying to move away from using the evidence we have available now.

I understand the urge to fret, but I think the best way to find reassurance is to look back at the validation studies and really wrap your head around them. If you'd personally seen hundreds and hundreds of patients and cleared them using the defined NEXUS criteria (or the Canadian rule), even in cases where you might have been uncertain, then eventually you'd probably start to believe in it. That hasn't happened to you -- not yet anyway -- but it has happened in the studies. So believe!


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## Bearamedic (Jun 2, 2014)

I wasnt meaning to imply that osteoporosis caused neurological deficit, only the increased fx risk for females. And then combined with old age neurological changes, explained the false negatives. It was mentioned that the nexus didnt have enough in the age range to be conclusive (over 65 or 80?)

Im not really in a position to safely clear, as my protocols dont allow it. Nor do i get the chance to followup.

But i understand your more rules point, this may have been targeted at prehospital setting where attention to detail can be diminished or misinterpreted as patient distractions.


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## Bearamedic (Jun 2, 2014)

Lol, Just randomly found another potential reference to my info. 

http://www.emtlife.com/showpost.php?p=390923&postcount=33


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## Brandon O (Jun 3, 2014)

Hm.

Well, it's fair to say that the validity of NEXUS hasn't been demonstrated AS STRONGLY in patients over 75 or 85 or wherever you want to draw the line. That's just a statistical inevitability; most of the studies took patients of all ages, and the average age was much younger (30s or 40s usually), so focusing on a subset of the age range means the study size goes from thousands down to much less. That would be equally true if you asked about validity for patients "age 26-29," but I realize there's a better reason to think that the oldest group may actually have a different risk.

It's hard to see exactly how many old folks it's been validated in. Neither the original NEXUS derivation (Hoffman 1992) nor the validation (Hoffman 2000) give full age breakdowns, although the range does go up past 100, so there were SOME patients in that older group. Similar story in a retrospective chart application using NEXUS (****inson 2004), and in a study that compared NEXUS with the Canadian rule (Stiell 2003). These are all studies with thousands enrolled, so even in the subsets the numbers should have some weight.

Domeier 2005 studied a modified NEXUS for prehospital use, and they do give an age breakdown; eyeballing the chart it looks like about 1900 enrolled age 75+. Their sensitivity was a little lower than in the other studies, about 92%, and it's true that a fair number of their injuries were in the older cohort, but none of the missed injuries mattered (no clinical sequelae).

Goode 2014 just came out and seems to be the only study specifically addressing this. They concluded that NEXUS wasn't very sensitive with age >65, with sensitivity only 65.6%. However, the sensitivity BELOW 65 was only 84.2%, which is dramatically less than in the other studies, so I have to wonder what they're doing differently; if we trust these numbers we shouldn't be using NEXUS for anybody.

So with all that said, I think that it may be overreaching to say that older patients don't qualify for NEXUS. Although they may be at higher risk for fracture, that isn't quite the issue; the issue is whether the rule can detect those fractures, and I don't think there's any good reason to say that all old patients can't reliably report pain or neuro deficits. Obviously selected patients (e.g. with dementia or diabetic neuropathy or MS or something) may be a different story, but hopefully your clinical judgment would already tell you that you may not be able to clinically clear those people anyway.

I'll grant that there isn't much evidence specifically addressing this question, except the aforementioned study by Goode. The easiest way to get a bit more data would be to write to the NEXUS authors (Hoffman et al) and ask for the specific age breakdown in their studies; then you could get those exact numbers. I'll also grant you that the Canadian rule does use age >65 as a rule-out; I suppose if you're worried you could just start using their rule, which has also been validated for EMS use.

(Most of the cited studies are available at the DRL if you want to read up.)


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## Brandon O (Jun 3, 2014)

Reading into the Goode study a bit more, their difference is probably explained by enrolling a different population; they're looking at HIGH RISK injury, not just all blunt trauma. Meaning: "... associated injuries from high-energy mechanisms (e.g., pelvic/long bone fractures), ejection from a vehicle, death in same compartment vehicle, fall from greater than 20 feet, vehicle speed greater than 40 mph, major vehicle deformity/significant intrusion, and pedestrian struck with speed greater than 5 to 20 mph."

Now that's risky! Which helps explain why their rate of C-spine fracture is 7.4% in the young and 12.8% in the old, both of which are waaaaay higher than in any other studies (like 5-10x higher). This was based on a previous study by the same folks which found similar results in all-age severe trauma.

I think this has very little relevance to the topic at hand. Most providers are not trying to clear an 80-year-old (or in many cases a 30-year-old) who just got ejected from a vehicle without some imaging, and most EMS personnel are probably giving that guy a collar. NEXUS is for the little old lady who fell.


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## raieghn (Jun 17, 2014)

*C-Spine*

I agree with DEmedic. I find that EMT-B's are more likely to routinely C-spine because that is what is drilled into their head. In my situation it usually depends on how many hands I have. If its just my partner and myself, I have far more important things I need them doing other than c-spine because once you are on it, you are stuck on it. 

I do monitor though to make sure the PT understands not to move, or I will place towels on either side of their head for light support. But unless I have the manpower, Which is usually not the case, I don't


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## Jim37F (Jun 17, 2014)

Here's LA County's new SMR guidelines, what do y'all think?

http://ems.dhs.lacounty.gov/policies/Ref1300/1334.pdf



> Potential for unstable spinal injury?
> 
> Strongly consider SMR in patients at high risk:
> 
> ...


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## Novice001 (Jun 23, 2014)

*C-spining*

It's true most BLS medics use C-spine. It's pretty much what I was taught. However, when it comes to traumatic injuries i.e. MVA, crush injuries, falling from a height, head injuries etc. I would still use C-spine. You need to take into account the MOI. Pts in a car accident need to have a cervical collar and put on a backboard or other types of immobilization equipment.


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## chaz90 (Jun 23, 2014)

Novice001 said:


> It's true most BLS medics use C-spine. It's pretty much what I was taught. However, when it comes to traumatic injuries i.e. MVA, crush injuries, falling from a height, head injuries etc. I would still use C-spine. You need to take into account the MOI. Pts in a car accident need to have a cervical collar and put on a backboard or other types of immobilization equipment.


Please oh please read the rest of this thread before chiming in here. Catch up on the current research a little bit. It likely isn't best practice to use SMR on anyone, let alone the incredibly broad patient population you're describing. MOI is also increasingly being deemphasized as unreliable with extremely poor predictive value for injury or mortality. Your last sentence is alarmingly inaccurate. No immobilization of any kind is necessary in the vast majority of MVAs.


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## Medic Tim (Jun 23, 2014)

Novice001 said:


> It's true most BLS medics use C-spine. It's pretty much what I was taught. However, when it comes to traumatic injuries i.e. MVA, crush injuries, falling from a height, head injuries etc. I would still use C-spine. You need to take into account the MOI. Pts in a car accident need to have a cervical collar and put on a backboard or other types of immobilization equipment.


just because you learn something in school or it is a current protocol does not mean it is the right thing to do. there is a ton of research out there on smr. it has been there for a while. We are just now seeing the wave of change. 
at my current service I am still supposed to collar and board most pts but If I can... I don't. 

there are several threads here on this subject. I hope you look at it or do some digging in your own.


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## Novice001 (Jun 24, 2014)

*C-spining*

Thanks for the input, guys. Much appreciate it. However, I would like to remind you things are different here in SA than what they are in the States.


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## Tigger (Jun 24, 2014)

Novice001 said:


> Thanks for the input, guys. Much appreciate it. However, I would like to remind you things are different here in SA than what they are in the States.



I'll give you that protocols might differ from place to place, but the human body does not.


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## Medic Tim (Jun 24, 2014)

Novice001 said:


> Thanks for the input, guys. Much appreciate it. However, I would like to remind you things are different here in SA than what they are in the States.




That is true ... But it doesn't change the data and research. Hopefully your system is open to change and evidence based practice. 

This isn't just a USA thing either. It is being done in several countries across the world. My service in Canada is looking into it as well.
Do the field medics there have an avenue for protocol suggestions or changes?


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## WildlandEMT89 (Jul 3, 2014)

My department has just switched from full c-spine every time to a new Spinal Motion Restriction (SMR) protocol in the last month or so. 
Our new protocol allows us to intervene on a sliding scale based on the severity of the incident ,pt risk factors (age/MOI) and if several factors are cleared in the field (distal function/ no evidence of severe spinal trauma). The goal is to maintain proper pt care while still giving the pt some level of comfort if possible.


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## brian328 (Jul 5, 2014)

i am a basic and our protocol follows the acronym "NSAIDS". if they fail any one of exams, they get boarded. i do think this will be changed in the future..


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## jboz7089 (Jul 6, 2014)

*rural AK*

Hey everyone,

New member here. I live in rural AK on an island that flourishes due to the fishing industry.  We routinely have to use a backboard, or a Reeves sleeve to transport our patients due to the close quarters of fishing vessels.  The Reeves sleeve also allows us to hook into the boats crane, and lift the patient off the vessel, rather then trying to hall them up the steep stairs.  Typically, we don't C-collar the patient, unless absolutely necessary.


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## Bullets (Jul 10, 2014)

jboz7089 said:


> Hey everyone,
> 
> New member here. I live in rural AK on an island that flourishes due to the fishing industry.  We routinely have to use a backboard, or a Reeves sleeve to transport our patients due to the close quarters of fishing vessels.  The Reeves sleeve also allows us to hook into the boats crane, and lift the patient off the vessel, rather then trying to hall them up the steep stairs.  Typically, we don't C-collar the patient, unless absolutely necessary.


And you wont find anyone here chiding you for using the LBB as intended, a tool for extrication and movement.


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## Handsome Robb (Jul 10, 2014)

What he said ^^^^


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## mflaws (Jul 10, 2014)

*cspine*

I took a recent trauma class and a lot of what i have been hearing is that c collaring and backboarding people is cause more damage to them then good. Also ive noticed a lot of people are having slight trouble calming down enough to measure and apply everything in the correct manor. Also some people dont relise when we strap people down really tight to the board some peoples lower back does not even touch the board so we are forcing people into uncomfortable positions. What is everybodys thought?


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## chaz90 (Jul 10, 2014)

mflaws said:


> I took a recent trauma class and a lot of what i have been hearing is that c collaring and backboarding people is cause more damage to them then good.



Yep. That's the point of the rest of this thread.


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## Kevinf (Jul 10, 2014)

Plenty of backboarding going on over here:


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## mfd229 (Jul 17, 2014)

Our protocols have not changed yet, although they are being reviewed. We routinely backboard patients with suspected injury. Our transports are short however and have a relatively low risk of further injury by being on a backboard for too long.


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## Streetdoc (Jul 25, 2014)

DEmedic said:


> I saw a BLS crew do a standing take down the other day. I just shook my head.



They not only still teach it here, but I have seen a few FF/EMT's try to do it to someone who is standing, JUST so they could do it. Any other time, they are all "short of breath? Okay, lets walk out to the unit".:wacko:


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## ILemt (Aug 6, 2014)

The trauma centers in this area require that all patients transported for a Fall, MVA, GSW, or Syncope MUST be wheeled into the ER with complete spinals, cardiac monitor, pulse ox, o2, finger stick bgs, and at least 1 large bore in place. Selective criteria while officially "in the protocol book" is only allowed with on-line direction which is given almost as often as orders for an EMS pericardialcentesis.


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## chaz90 (Aug 6, 2014)

ILemt said:


> The trauma centers in this area require that all patients transported for a Fall, MVA, GSW, or Syncope MUST be wheeled into the ER with complete spinals, cardiac monitor, pulse ox, o2, finger stick bgs, and at least 1 large bore in place. Selective criteria while officially "in the protocol book" is only allowed with on-line direction which is given almost as often as orders for an EMS pericardialcentesis.


These are some of the most idiotic requirements I've ever seen. Spinal immobilization for penetrating trauma? Large bore IV for all falls? Utterly ridiculous.


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## Handsome Robb (Aug 6, 2014)

ILemt said:


> The trauma centers in this area require that all patients transported for a Fall, MVA, GSW, or Syncope MUST be wheeled into the ER with complete spinals, cardiac monitor, pulse ox, o2, finger stick bgs, and at least 1 large bore in place. Selective criteria while officially "in the protocol book" is only allowed with on-line direction which is given almost as often as orders for an EMS pericardialcentesis.




Wow.

The 90s called they want their medicine back.


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## Handsome Robb (Aug 6, 2014)

I guess the 00s too


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## ILemt (Aug 7, 2014)

chaz90 said:


> These are some of the most idiotic requirements I've ever seen. Spinal immobilization for penetrating trauma? Large bore IV for all falls? Utterly ridiculous.



I would tend to agree, but like I said, that is what the trauma docs have ordered.
It has only been in the last few years they quit demanding an NRB on all of the aforementioned pt.


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## avdrummerboy (Aug 7, 2014)

Our county/ area has done away with it for every 'trauma' call. We use what's called NSAID criteria, which in reality is what we would c-spine for before the change anyway, but at least now we can rule it out and it has drastically cut down on needless back boarding.


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## KTisaPhillyFan (Aug 20, 2014)

I had this issue just last night.  MVC involving 4 cars, 3 total patients - all priority 3.  My patient had self-extricated, ambulating around the scene.  Airbag did deploy.  Upon initial examination, he was A&O x4, no head injury, no complaint of back/neck pain.  Only complaint was superficial lacerations on right lower leg from kicking out driver side window to self extricate and right ankle pain without swelling or ecchymosis.  Initial BP was 193/140, all other vital signs within normal limits.  No significant past medical history other than anxiety.  Medications include Celexa, Prilosec, baby aspirin daily.  The patient ambulated to the ambulance to be further evaluated.  Due to his presentation and complaints, I did not feel that backboard and collar were necessary.  I was questioned about it upon presentation to the ER.  Gave reportr with my findings, etc.  They put the patient in the urgent care.  While at the hospital, an acquaintance who rides volunteer with one of our mutual aid stations and is an ER nurse said that in the future to CYA I should backboard and collar all of 'em.  When I got back to the station, one of the captains (former EMS captain) and I were talking and he said absolutely due to MOI the patient should have been backboarded and collared.  I do not agree.  I still stand by my decision.  I did take into account the MOI, etc, but after examining the patient and listening to the patient, I still feel that collar and backboard were not necessary.  The patient was discharged early this morning after being given a clean bill of health.

I just feel that you need to examine the whole situation and not EVERY single patient involved in an MVC needs to be backboarded and collared.  Why stress the patient even more with unnecessary treatments?  Just because we can do it doesn't mean it needs to be done.


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## DesertMedic66 (Aug 20, 2014)

KTisaPhillyFan said:


> I had this issue just last night.  MVC involving 4 cars, 3 total patients - all priority 3.  My patient had self-extricated, ambulating around the scene.  Airbag did deploy.  Upon initial examination, he was A&O x4, no head injury, no complaint of back/neck pain.  Only complaint was superficial lacerations on right lower leg from kicking out driver side window to self extricate and right ankle pain without swelling or ecchymosis.  Initial BP was 193/140, all other vital signs within normal limits.  No significant past medical history other than anxiety.  Medications include Celexa, Prilosec, baby aspirin daily.  The patient ambulated to the ambulance to be further evaluated.  Due to his presentation and complaints, I did not feel that backboard and collar were necessary.  I was questioned about it upon presentation to the ER.  Gave reportr with my findings, etc.  They put the patient in the urgent care.  While at the hospital, an acquaintance who rides volunteer with one of our mutual aid stations and is an ER nurse said that in the future to CYA I should backboard and collar all of 'em.  When I got back to the station, one of the captains (former EMS captain) and I were talking and he said absolutely due to MOI the patient should have been backboarded and collared.  I do not agree.  I still stand by my decision.  I did take into account the MOI, etc, but after examining the patient and listening to the patient, I still feel that collar and backboard were not necessary.  The patient was discharged early this morning after being given a clean bill of health.
> 
> I just feel that you need to examine the whole situation and not EVERY single patient involved in an MVC needs to be backboarded and collared.  Why stress the patient even more with unnecessary treatments?  Just because we can do it doesn't mean it needs to be done.



Brand new member with this view point?! We are going to like you here


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## vcuemt (Aug 20, 2014)

KTisaPhillyFan said:


> I had this issue just last night.  MVC involving 4 cars, 3 total patients - all priority 3.  My patient had self-extricated, ambulating around the scene.  Airbag did deploy.  Upon initial examination, he was A&O x4, no head injury, no complaint of back/neck pain.  Only complaint was superficial lacerations on right lower leg from kicking out driver side window to self extricate and right ankle pain without swelling or ecchymosis.  Initial BP was 193/140, all other vital signs within normal limits.  No significant past medical history other than anxiety.  Medications include Celexa, Prilosec, baby aspirin daily.  The patient ambulated to the ambulance to be further evaluated.  Due to his presentation and complaints, I did not feel that backboard and collar were necessary.  I was questioned about it upon presentation to the ER.  Gave reportr with my findings, etc.  They put the patient in the urgent care.  While at the hospital, an acquaintance who rides volunteer with one of our mutual aid stations and is an ER nurse said that in the future to CYA I should backboard and collar all of 'em.  When I got back to the station, one of the captains (former EMS captain) and I were talking and he said absolutely due to MOI the patient should have been backboarded and collared.  I do not agree.  I still stand by my decision.  I did take into account the MOI, etc, but after examining the patient and listening to the patient, I still feel that collar and backboard were not necessary.  The patient was discharged early this morning after being given a clean bill of health.
> 
> I just feel that you need to examine the whole situation and not EVERY single patient involved in an MVC needs to be backboarded and collared.  Why stress the patient even more with unnecessary treatments?  Just because we can do it doesn't mean it needs to be done.


But...! Look at that mechanism of injury!


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## jrm818 (Aug 20, 2014)

KTisaPhillyFan said:


> I had this issue just last night.  MVC involving 4 cars, 3 total patients - all priority 3.  My patient had self-extricated, ambulating around the scene.  Airbag did deploy.  Upon initial examination, he was A&O x4, no head injury, no complaint of back/neck pain.  Only complaint was superficial lacerations on right lower leg from kicking out driver side window to self extricate and right ankle pain without swelling or ecchymosis.  Initial BP was 193/140, all other vital signs within normal limits.  No significant past medical history other than anxiety.  Medications include Celexa, Prilosec, baby aspirin daily.  The patient ambulated to the ambulance to be further evaluated.  Due to his presentation and complaints, I did not feel that backboard and collar were necessary.  I was questioned about it upon presentation to the ER.  Gave reportr with my findings, etc.  They put the patient in the urgent care.  While at the hospital, an acquaintance who rides volunteer with one of our mutual aid stations and is an ER nurse said that in the future to CYA I should backboard and collar all of 'em.  When I got back to the station, one of the captains (former EMS captain) and I were talking and he said absolutely due to MOI the patient should have been backboarded and collared.  I do not agree.  I still stand by my decision.  I did take into account the MOI, etc, but after examining the patient and listening to the patient, I still feel that collar and backboard were not necessary.  The patient was discharged early this morning after being given a clean bill of health.
> 
> I just feel that you need to examine the whole situation and not EVERY single patient involved in an MVC needs to be backboarded and collared.  Why stress the patient even more with unnecessary treatments?  Just because we can do it doesn't mean it needs to be done.



Basically everyone here will agree with you, but if you want something a bit more concrete to spread around, this is short enough to print out and sprinkle around liberally: http://www.naemsp.org/Documents/Pos...autions and the Use of the Long Backboard.pdf


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## drl (Aug 20, 2014)

jrm818 said:


> Basically everyone here will agree with you, but if you want something a bit more concrete to spread around, this is short enough to print out and sprinkle around liberally: http://www.naemsp.org/Documents/Position Papers/POSITION EMS Spinal Precautions and the Use of the Long Backboard.pdf



Good read, thanks for the share.


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## Jason (Aug 21, 2014)

We have reviewed NEXUS and the Canadian c-spine rule.  Our protocol follows the Canadian c-spine rule. 
In our protocol book, the guidelines are pretty well laid out.  There are inclusion and exclusion criteria, so we don't have to backboard everyone.


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## KTisaPhillyFan (Aug 22, 2014)

drl said:


> Good read, thanks for the share.


 
Yes, thank you for that share!!  That backs up my decisionmaking process.


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## DEurich (Aug 22, 2014)

I recently got my basic about a month ago. I was taught to always immediately do C-Spine on unconcious trauma patients, and then to just ask if they fell if they were concious, so you can rule it out. Better safe then sorry.


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## Medic Tim (Aug 22, 2014)

DEurich said:


> I recently got my basic about a month ago. I was taught to always immediately do C-Spine on unconcious trauma patients, and then to just ask if they fell if they were concious, so you can rule it out. Better safe then sorry.



Did you learn the nexus or Canadian c spine rules? Or any other clearance guideline?There is much more to clearing Cspine than asking if they fell. Research also suggests that boards do not prevent but may actually cause or worsen injuries. Unfortunately many schools and providers are stuck in the past and resist evidence based medicine.


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## DEurich (Sep 5, 2014)

Medic Tim said:


> Did you learn the nexus or Canadian c spine rules? Or any other clearance guideline?There is much more to clearing Cspine than asking if they fell. Research also suggests that boards do not prevent but may actually cause or worsen injuries. Unfortunately many schools and providers are stuck in the past and resist evidence based medicine.


I have not heard any of those actually. I'll do some research though. I would much rather know a safer way, thanks for the input


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## Fayettecong (Oct 3, 2014)

Just depends on the nature of illness/MOI. If the patient complains of any neck or back pain a board comes out. Severe MOI, patient gets the backboard. Patient who was in a fender bender complaining of knee pain, I don't see a need for a board.


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## Medic Tim (Oct 3, 2014)

Fayettecong said:


> Just depends on the nature of illness/MOI. If the patient complains of any neck or back pain a board comes out. Severe MOI, patient gets the backboard. Patient who was in a fender bender complaining of knee pain, I don't see a need for a board.


It is a shame that so many services still do this to people.


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## OnceAnEMT (Oct 3, 2014)

Medic Tim said:


> It is a shame that so many services still do this to people.



Specifically if "pain" and MOI are the only judges. There are so many other s/s that could be present without pain and still be indicative (hell, more indicative) of an injury to the spinal column or cord itself. Sure pain and MOI play a part, but its just like using vitals to fix your differential. Thready pulse doesn't mean shock. Thready pulse, low BP, and high/shallow resps indicate shock.


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## Brandon O (Oct 4, 2014)

Grimes said:


> Specifically if "pain" and MOI are the only judges. There are so many other s/s that could be present without pain and still be indicative (hell, more indicative) of an injury to the spinal column or cord itself. Sure pain and MOI play a part, but its just like using vitals to fix your differential. Thready pulse doesn't mean shock. Thready pulse, low BP, and high/shallow resps indicate shock.



Well... I dunno. Cord-compromising injury without neck pain is awfully rare.


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## vcuemt (Oct 26, 2014)

http://www.scancrit.com/2013/10/10/cervical-collar/

*The Curse of the Cervical Collar*



> For many years, ATLS has dictated cervical collar as part of the A in ABC, and any patient that enters a trauma bay gets a cervical collar slapped on before anyone cares about airways, breathing and circulation. The last couple of years, some rougue docs have tried opposing the validity of the extreme focus on cervical collars, and it is finally starting to trickle into the system. Here’s the case against cervical collars – and for bringing the focus back on the important parts of the ABC to save your patient.


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