# Better c-spine?



## Seaglass (Nov 7, 2009)

I've been getting stuck holding c-spine for rather long periods, and I've noticed that my ability to keep a good hold goes down fairly rapidly after the first several minutes, especially if I have a patient that keeps trying to move. Does anyone have suggestions for exercises that would help me improve the right muscles? Or is this one of those things, like CPR, that can only be done for so long?


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## akflightmedic (Nov 7, 2009)

Seaglass said:


> I've been getting stuck holding c-spine for rather long periods, and I've noticed that my ability to keep a good hold goes down fairly rapidly after the first several minutes, especially if I have a patient that keeps trying to move. Does anyone have suggestions for exercises that would help me improve the right muscles? Or is this one of those things, like CPR, that can only be done for so long?



Question is, why are you holding cspine for so long?

How long does it take to immobilize someone?

If they are in a car and need extrication, utilize your resources better. Are they conscious? Tell them not to move their head.

Are you able to gain access to treat the patient while the extrication takes place? If so, place a collar, tell them not to move. You are there to care for them should anything else develop and if your hands are committed to holding them still when they are perfectly capable of doing after a collar placement, then you now need another provider possibly.

Take actual hands on cspine when you are going to move the patient or if they need assistance in maintaining an airway. Other wise keep your hands free.


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## daedalus (Nov 7, 2009)

akflightmedic said:


> Question is, why are you holding cspine for so long?
> 
> How long does it take to immobilize someone?
> 
> ...



I fully agree with this, even more so in light of the fact there is little evidence to suggest the need for spinal immobilization in the first place and even some evidence suggesting it is not needed. However, other people on scene (FD and partners) and my supervisors would find this unacceptable since everyone believes that c-spine is a commandment delivered from God Himself. 

I also find the OP's comments very interesting. In fact, my hands to get very tired rapidly and I am sure that after a few minutes holding c-spine, my grip is probably as effective as no grip at all. Potential area to study....


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## akflightmedic (Nov 7, 2009)

While you say potential area to study, I say a weakening grip while holding cspine is a useless study, IF you address the actual need for cspine to begin with as we both mentioned already.

To say you need exercises to improve your cspine holding ability or a study should be done on the effects of a lesser grip, is quite simply addressing the wrong issue and is a complete distractor from the root cause of it all to begin with.


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## Akulahawk (Nov 7, 2009)

A person who doesn't have spinal cord compromise can limit their own movement far better than probably any external device can... assuming they're going to cooperate.

Personally, I'd wonder why you're in a position for a long time having to hold manual c-spine. Quite simply, you shouldn't be. Hold manual cspine only as long as necessary to put mechanical methods in place and recruit your patient's assistance in not moving as much as possible. As to why you weaken... the muscles that get tired are likely the ones you don't exercise on a regular basis. When you figure out which muscles those are, search for how to strengthen those muscles.

It's not rocket surgery...


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## RyanMidd (Nov 7, 2009)

Additionally, there are wildly varying theories vs. practices for C-spine immobilization.

In class, they may have taught you things like "Never do it from your knees, as you can be knocked over", etc.

I find that if I'm going to be holding it, I get myself into whatever position I can that will let me keep doing so. If all else fails, make eye contact with somebody and ask them, "Can you hold c-spine for a moment while I readjust my legs?".


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## mycrofft (Nov 7, 2009)

*OP, what stance are you adopting, and what's getting worn out?*

I tend to get up really close and support my arms on my thighs. I also have to fight sweating into the pt's face. In a pinch your thighs can offer lateral immob, but there are other issues there as well, such as falling over and newsphotos.

Back extensors and not assuming a tenuous position as you accept traction will help also.

Oh, and be sure you empty your bladder before starting.


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## karaya (Nov 7, 2009)

daedalus said:


> However, other people on scene (FD and partners) and my supervisors would find this unacceptable since everyone believes that c-spine is a commandment delivered from God Himself.


 
Not God as much as that is how you were taught. The fact is that for now at least, c-spine immobilization is the current standard of care. Exception of course to EMS providers that have adopted c-spine clearance protocols. None of my publishers (Elsevier Mosby, Prentice Hall Brady, Jones and Bartlett) will take any photos of mine that do not show proper c-spine maintenance.  

Yes, your right, there are arguments that evidence does not support this; however, until that evidence is brought up and accepted as the standard of care, the OP would be well advised to maintain what he was taught and not heed contrary advice from social networks. Particularly networks where advice is drawn from members who hide their identity behind monikers. He should consult his company supervisor or training officer for such specifics.


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## akflightmedic (Nov 7, 2009)

At no point does it say you need to immediately take and hold cspine, especially if the situation does not warrant it.

A standard of care is placing the collar and telling them not to move. You are not committed to holding them with your hands until such time you actually place your hands on them. Once you have done that, then yes you should maintain it.

What good is it if he is on scene say 10-15 mins before the ambo gets there? Do you immediately seize cspine or do you keep the victim calm and keep reminding them to restrict their movement and then take cspine when it is time to move the patient.

What if he takes cspine but then something with the patients condition changes requiring him to release cspine. Oh boy, he will get chewed out on that one for sure; however if he never assumed it to start with....

It is all about common sense and utilizing critical thinking skills.

Having said that, yes your service dictates what you should do, but then we get back to my original question which was "why are you finding yourself holding cspine for long periods of time"?


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## Seaglass (Nov 7, 2009)

My county protocols dictate that I, as a basic, need to take it immediately upon suspiscion of head or neck injury, and that I don't get to release it until a patient is backboarded, not just collared. Simply telling them not to move or putting on a collar isn't enough. C-spine can be cleared by a medic, but they're not going to clear it if there's a reason to suspect head or neck injury. 

As for why it might take awhile to get a backboard, it depends. Maybe we were dispatched to a call that had nothing to do with trauma with a patient that's well away from the nearest road, and we need to send someone back to the road to get the backboard. Maybe we're waiting on lift assist. Maybe extrication is taking forever. 

As for why me, in particular... I'm often the most junior member of a crew, so tasks like endless c-spine, holding the vomit bucket, and the like typically fall to me. As such, I'm not in a position to dictate the best use of resources, or dispute our protocols. If we have enough people on scene, I can trade off once I get tired. But that isn't always the case. 

As for position, it depends on the situation and patient. But it's most often sitting in the car seat behind the patient and reaching over the back of their seat, kneeling, or sitting cross-legged. I'm not having any trouble with staying in the positions I assume. It's my forearms and hands that are getting tired.


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## Epi-do (Nov 7, 2009)

karaya said:


> Not God as much as that is how you were taught. The fact is that for now at least, c-spine immobilization is the current standard of care. *Exception of course to EMS providers that have adopted c-spine clearance protocols.*



Ahhh.....if only that were true.  I have selective c-spine protocols and was recently informed that "We have always boarded every MVA patient.  It's how we do things around here.  Since it doesn't hurt anyone to be put on a board, if I tell you to do it, you *will* do so."  (Told to me by the EMT-B that is the officer at my station, hence, dictating which ALS protocols I can & cannot use.  And that is just the very beginning of the issues I have with that statement.)


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## Seaglass (Nov 7, 2009)

Epi-do said:


> Ahhh.....if only that were true.  I have selective c-spine protocols and was recently informed that "We have always boarded every MVA patient.  It's how we do things around here.  Since it doesn't hurt anyone to be put on a board, if I tell you to do it, you *will* do so."  (Told to me by the EMT-B that is the officer at my station, hence, dictating which ALS protocols I can & cannot use.  And that is just the very beginning of the issues I have with that statement.)



That's really bad. Around here, level of training+experience=authority. So you might find a basic who's had more extrication training telling everyone how they're going to get someone out of a car, but you'd never find a basic telling a medic what sort of care a patient will receive.


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## Seaglass (Nov 9, 2009)

Quick update: I've been asking around about this offline, and everyone says they get worn out within several minutes, especially with a patient who keeps trying to move or a situation that forces the person holding c-spine into an awkward position. Apparently I'm also often getting stuck with it more often because I'm smaller, stronger and/or more flexible than many of our other basics or first responders, and because I don't do a whole lot of complaining...


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## JPINFV (Nov 9, 2009)

Epi-do said:


> Ahhh.....if only that were true.  I have selective c-spine protocols and was recently informed that "We have always boarded every MVA patient.  It's how we do things around here.  Since it doesn't hurt anyone to be put on a board, if I tell you to do it, you *will* do so."  (Told to me by the EMT-B that is the officer at my station, hence, dictating which ALS protocols I can & cannot use.  And that is just the very beginning of the issues I have with that statement.)



Serious question. How did you keep from laughing to his face during that? 

Second quick question. You did kick that up to your paramedic supervisor, right?


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## Seaglass (Nov 9, 2009)

Epi-do said:


> Since it doesn't hurt anyone to be put on a board...



Missed that the first time around. That guy needs to be boarded and left for a good long while before saying it doesn't hurt...


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## Epi-do (Nov 9, 2009)

JPINFV said:


> Serious question. How did you keep from laughing to his face during that?
> 
> Second quick question. You did kick that up to your paramedic supervisor, right?



Actually, laughing didn't even cross my mind.  I was just so utterly frustrated with the entire thing.  It doesn't matter what sort of evidence you give this guy to support your stance, he just looks at it, basically says "oh, that's nice", and then tells you that it is going to be his way regardless of what you have to say.

I really want to take this further, but I have spent more time in this guys office in the last 6 months or so than I have with all the other officers/supervisors I have had in the last 10 years.  There is a major personality clash there when it comes to patient care/doing the job.  I don't want to be labeled a trouble-maker because of this guy, so I am sort of in limbo at the moment.



Seaglass said:


> Missed that the first time around. That guy needs to be boarded and left for a good long while before saying it doesn't hurt...



I did tell him that even though there may not be any permanent damage done, there is pain caused by being on a board, that soft tissue damage begins to occur after 30 minutes that can ultimately lead to pressure ulcers, and some of the other studies out there.  He just blatantly ignored that portion of the conversation.


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## RyanMidd (Nov 9, 2009)

Epi-do said:


> there is pain caused by being on a board, that soft tissue damage begins to occur after 30 minutes that can ultimately lead to pressure ulcers,



I've had to board several MVC and vehicle vs. wildlife patients. I know 2 of them personally, and they have quarter-sized bald spots on their occipitus from being on the board for...wait for it....less than 2 hours each.

Any small amount of movement, jostling, or friction causes tissue damage. I agree with whoever said that supervisor needs to be boarded and transported from a remote location.


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## Seaglass (Nov 9, 2009)

RyanMidd said:


> I've had to board several MVC and vehicle vs. wildlife patients. I know 2 of them personally, and they have quarter-sized bald spots on their occipitus from being on the board for...wait for it....less than 2 hours each.



Yikes--I've never encountered that. Guess our county's head beds aren't so awful after all, or maybe my scalp is just more resilient than most. I was boarded for about six hours once, and just came away with massive bruising and a week where I could barely move. I remember it hurting a bit, but the injury that put me there was way worse, and my LOC wasn't the greatest at the time.


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