# Flail chest w/ nemothorax



## nomofica (Apr 6, 2009)

How can this be treated on a BLS level?


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## BossyCow (Apr 6, 2009)

nomofica said:


> How can this be treated on a BLS level?



Well.. first you find nemo and remove him from the thorax??????


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## traumateam1 (Apr 6, 2009)

Pneumothorax***

Open or closed pneumo? 

Open:
Do a 3 way occlusive dressing. High flow 02, be ready to give assisted vents. Package. Load n go. Call for ALS is available in your area.

Closed:
Pretty much all the same except the 3 way occlusive dressing.

Key points:
Load n Go ASAP. Get ALS ASAP. Be ready for your patient to go downhill very quickly.


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## AJ Hidell (Apr 6, 2009)

nomofica said:


> How can this be treated on a BLS level?


It can't..


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## nomofica (Apr 6, 2009)

Yes, pneumothorax. Been a long day; don't ask...

I would assume pt be spineboarded to immobilize any movements that may cause the floating rib sections to puncture any organs, yes?


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## nomofica (Apr 6, 2009)

AJ Hidell said:


> It can't..



Well, to what extent is what I'm asking.

I had a buddy of mine (who is BLS) who came across an MVA roll in which the driver of the rolled vehicle was tossed through the windshield. My buddy just so happened to have an O2/trauma kit in his car at the time. This is what brought up my curiousity as to what extent you can intervene at a BLS level.


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## LucidResq (Apr 6, 2009)

nomofica said:


> Yes, pneumothorax. Been a long day; don't ask...
> 
> I would assume pt be spineboarded to immobilize any movements that may cause the floating rib sections to puncture any organs, yes?



I would backboard this pt. because a trauma significant enough to cause flail chest is definitely significant enough to cause spinal trauma.


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## nomofica (Apr 6, 2009)

LucidResq said:


> I would backboard this pt. because a trauma significant enough to cause flail chest is definitely significant enough to cause spinal trauma.



I guess that's pretty obvious, hey.
/smacks self


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## AJ Hidell (Apr 6, 2009)

A spine board is not indicated, and not likely to immobilize the segments of the rib cage, which will move each time the patient breathes.  Positioning the patient lateral recumbent on the affected side is the textbook preference.  However in reality, the patient should be allowed to assume the position most comfortable to him or her.

Oxygen is obviously indicated, but other than that, there is no treatment, just supportive care.


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## nomofica (Apr 6, 2009)

AJ Hidell said:


> A spine board is not indicated, and not likely to immobilize the segments of the rib cage, which will move each time the patient breathes.  Positioning the patient lateral recumbent on the affected side is the textbook preference.  However in reality, the patient should be allowed to assume the position most comfortable to him or her.
> 
> Oxygen is obviously indicated, but other than that, there is no treatment, just supportive care.



So high flow O2, treat sucking chest wound if open pneumo, treat for shock/keep warm+comfortable(as can be...) and hope that ALS doesn't run into any major problems en route. That about it?


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## AJ Hidell (Apr 6, 2009)

That's it.  And in most cases, I would transport rather than wait for ALS.


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## LucidResq (Apr 6, 2009)

nomofica said:


> I had a buddy of mine (who is BLS) who came across an MVA roll in which the driver of the rolled vehicle was tossed through the windshield.




Mmm... I am reluctant to join the "mindlessly backboard everyone" club, AJ, but I would feel absolutely compelled to backboard who has just come out of the wrong end of the vehicular washing machine cycle. If someone had an isolated flail chest... if they were kicked once by a horse in the chest for example... position of comfort absolutely.


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## AJ Hidell (Apr 6, 2009)

Sorry, I was posting that reply at the same time he was telling the story about being thrown through the windshield, so I didn't have that info at the time.  I was addressing only the pneumo, which can happen any number of ways that would not require immobilization.


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## LucidResq (Apr 6, 2009)

Oh PS am I blind or has splinting the flail segment not been mentioned yet?


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## nomofica (Apr 6, 2009)

AJ Hidell said:


> That's it.  And in most cases, I would transport rather than wait for ALS.



Again, if you're not in uniform + behind the wheel of a personal vehicle (which would probably be more damaging to get the pt inside rather than wait for ALS).

But of course if you were in your EMS rig definitely load up and transport.


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## PotatoMedic (Apr 6, 2009)

I was taught 5 things to remember in my emt class.  Airway, Breathing, Circulation, Control major bleeding, and treat for shock.  

Along with those 5 things I will also pretty much do what AJ said and give the guy a pillow to hug and wrap it to his chest to support the section. (if closed)


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## daedalus (Apr 6, 2009)

gooooooooo bossycow! Finding nemo in the thorax has a bad prognosis!


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## Sasha (Apr 6, 2009)

nomofica said:


> Again, if you're not in uniform + behind the wheel of a personal vehicle (which would probably be more damaging to get the pt inside rather than wait for ALS).
> 
> But of course if you were in your EMS rig definitely load up and transport.



Oooh. How to treat a pnuemothorax off duty? Stay in your car, pull out cellphone, dial 911, keep driving.


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## SauceyEMT (Apr 6, 2009)

nomofica said:


> *MVA roll* in which the driver of the rolled vehicle was *tossed through the windshield*.




Um yeah...board him, no?


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## AJ Hidell (Apr 6, 2009)

SauceyEMT said:


> Um yeah...board him, no?


You better be a really big person, because if you tried to flat board me with a pneumo, I'd hurt you bad.


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## SauceyEMT (Apr 6, 2009)

AJ Hidell said:


> You better be a really big person, because if you tried to flat board me with a pneumo, I'd hurt you bad.




I am 

And I dont know ****...just asking


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## Scout (Apr 6, 2009)

Sasha said:


> Oooh. How to treat a pnuemothorax off duty? Stay in your car, pull out cellphone, dial 911, keep driving.



Can we try and keep this tripe out of a thread asking about treatments. It is really starting to effect the threads if people just come in and bash someone for asking a question.


He ask how is it treated at BLS level not "should I treat at a BLS level". The friend happened across it while off duty which prompted a question as to how it would be treated on duty!!


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## Sasha (Apr 6, 2009)

Scout said:


> Can we try and keep this tripe out of a thread asking about treatments. It is really starting to effect the threads if people just come in and bash someone for asking a question.
> 
> 
> He ask how is it treated at BLS level not "should I treat at a BLS level". The friend happened across it while off duty which prompted a question as to how it would be treated on duty!!



Uhhhm I wasn't bashing anyone, just stating my opinion that the best treatment for a pnuemo secondary to MVC by a bystander is to call 911.


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## Wee-EMT (Apr 6, 2009)

nomofica said:


> How can this be treated on a BLS level?



 At an EMR level:

ABC's
100% O2
Rapid trauma survey
Fully spinal immobilize
Close pneumothorax- Call for ALS
Open Pneumothorax- occlusive dressing taped down on 3 sides
Flail chest- Rigid splint taped down on exhale (cut a ped collar)


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## Scout (Apr 6, 2009)

Sasha said:


> Uhhhm I wasn't bashing anyone, just stating my opinion that the best treatment for a pnuemo secondary to MVC by a bystander is to call 911.




And the opinion has no relevance to the question in the OP


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## Sasha (Apr 6, 2009)

Scout said:


> And the opinion has no relevance to the question in the OP



It does. His question was how to treat it at the BLS level. He did not specify on duty or off duty and even interjected an anecdote about a pnuemothorax that his friend encountered off duty.

And your comment also had no relevance to the OP, so get off my back. You didn't seem to take issue with the nemo reference.


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## Ms.Medic (Apr 6, 2009)

nomofica said:


> Well, to what extent is what I'm asking.
> 
> I had a buddy of mine (who is BLS) who came across an MVA roll in which the driver of the rolled vehicle was tossed through the windshield. My buddy just so happened to have an O2/trauma kit in his car at the time. This is what brought up my curiousity as to what extent you can intervene at a BLS level.



I dont know about your area, but here, you cannot pull up on scene and administer ANY medication without working under the medical directors license, and even then you have to wait for the ambulance to bring equipment, and definately not as a volunteer. Not only that, but we have to have tags/stickers on our vehicle that states what we are carrying on our automobiles...


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## daedalus (Apr 6, 2009)

Wee-EMT said:


> At an EMR level:
> 
> ABC's
> 100% O2
> ...



AKA nothing.


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## Wee-EMT (Apr 6, 2009)

daedalus said:


> AKA nothing.



Precisely.....


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## Ridryder911 (Apr 6, 2009)

Tx. maybe nothing but the key is recognizing and doing the proper thing. 

R/r 911


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## daedalus (Apr 6, 2009)

Ridryder911 said:


> Tx. maybe nothing but the key is recognizing and doing the proper thing.
> 
> R/r 911



Exactly. It is easy for an EMT to rattle off the BLS bandaid "treatment" algorithm but could they actually recognize it in the heat of the moment?


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## fma08 (Apr 6, 2009)

daedalus said:


> gooooooooo bossycow! Finding nemo in the thorax has a bad prognosis!



Think of the sepsis! Oh won't somebody please think of the sepsis!


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## nomofica (Apr 7, 2009)

I can see why users believe this forum is going downhill.
-_-

To those who have posted useful/helpful information, thank you.

To those who haven't, well...


On a side note; I realize my questions are pretty "noobish". I'm a student and I'm still naive.  But we all start off some place.


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## AJ Hidell (Apr 7, 2009)

nomofica said:


> I realize my questions are pretty "noobish". I'm a student and I'm still naive.  But we all start off some place.


There was nothing unreasonably n00bish about this question.  It was a good question.  And you got some good answers.  But certainly you must have noticed that a lot of people here are quite serious about improving the professional image of EMS.  Consequently, I believe it was your presentation, and not the question itself, that some took issue with.  Come on, man... you gotta admit that butchering the word "pneumothorax", which I am sure was in your EMR book, is fair game for a little joking.  You can either sulk off mad at the world, or else you can take the lighthearted hint that then intended and go on to improve yourself with greater attention to professional detail in the future.


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## marineman (Apr 7, 2009)

question for those more knowledgeable than me, I know at the ALS level (at least in my area) we tube the patient. My understanding is we wrap the flail segment to splint the outside and ventilating through the tube basically splints from the inside. At the BLS level could a combitube be used to achieve a similar effect? It hasn't been mentioned yet so I figured I'd throw it out there. I'll admit I have less understanding of this particular area than I'd like so feel free to help me understand if the reasoning for the tube or anything else is wrong. I have thick skin.


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## 2630 (Apr 8, 2009)

check your protocols! for me a basic cannot place an airway (ett) for anyone unless they are confirmed to be not breathing.
i had a run a few weeks ago where my pt was crushed between a small truck and the back wall of a garage. she had bilateral flail segments with diminished sounds on the right and absent on the left. trachea deviated to the right and rice crispies (sub-q emphysema) on the left. other then stabilizing the segments there was not much more to do with them (emt-i's are not allowed to decompress per protocol). once the flight nurse got onboard, she decompressed and then didn't think again about it.


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## nomofica (Apr 8, 2009)

AJ Hidell said:


> There was nothing unreasonably n00bish about this question.  It was a good question.  And you got some good answers.  But certainly you must have noticed that a lot of people here are quite serious about improving the professional image of EMS.  Consequently, I believe it was your presentation, and not the question itself, that some took issue with.  Come on, man... you gotta admit that butchering the word "pneumothorax", which I am sure was in your EMR book, is fair game for a little joking.  You can either sulk off mad at the world, or else you can take the lighthearted hint that then intended and go on to improve yourself with greater attention to professional detail in the future.



I acknowledged my mistake quite early in the thread. I'm not upset about that at all (hell, I'd make fun of myself too). And yes, some of the replies were witty (and I did laugh at my own expense). I've just noticed a slight sense of negativity that hovers in this forum. Shame, really...


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## Moxiy (Apr 19, 2009)

I just finished my EMT course and our professor, a 10 year medic, says to treat this you are supposed to put pressure on the flail chest, put a trauma dressing over it, and do your best to tape it down to the non flail portion of the chest to avoid further internal puncture.


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## nomofica (Apr 19, 2009)

Moxiy said:


> I just finished my EMT course and our professor, a 10 year medic, says to treat this you are supposed to put pressure on the flail chest, put a trauma dressing over it, and do your best to tape it down to the non flail portion of the chest to avoid further internal puncture.



If I'm not mistaken, won't putting any sort of pressure on a flail chest will not only get the patient pissed off at you, but also increases chance of pushing the flail segment into an organ?


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## Tincanfireman (Apr 19, 2009)

The "hug a pillow" method in conjunction with a couple of elastic roller bandages will stabilize without putting undue pressure on the rib cage (Vent, jump in here and hit me with a wet noodle if I'm off base). The thing you want to avoid is localized pressure on the underlying bone structure/organs.  The pillow will diffuse the force and still support the thoracic structure.


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## nomofica (Apr 19, 2009)

Tincanfireman said:


> The "hug a pillow" method in conjunction with a couple of elastic roller bandages will stabilize without putting undue pressure on the rib cage (Vent, jump in here and hit me with a wet noodle if I'm off base). The thing you want to avoid is localized pressure on the underlying bone structure/organs.  The pillow will diffuse the force and still support the thoracic structure.



Yeah, I've heard of EMS grabbing the pillows off of their cots and "taped" them on to the patient


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## Flight-LP (Apr 19, 2009)

Ms.Medic said:


> I dont know about your area, but here, you cannot pull up on scene and administer ANY medication without working under the medical directors license, and even then you have to wait for the ambulance to bring equipment, and definately not as a volunteer. Not only that, but we have to have tags/stickers on our vehicle that states what we are carrying on our automobiles...



Care to elaborate???

My former agency, the largest ESD in Harris County, had plenty of ALS first responders, some of which were volunteers. All were fully ALS equipped and most didnt have to wait for the unit to arrive. None have any sort of tag or sticker, never heard of that one. Is it a local thing for you?????


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## nomofica (Apr 20, 2009)

Ms.Medic said:


> I dont know about your area, but here, you cannot pull up on scene and administer ANY medication without working under the medical directors license, and even then you have to wait for the ambulance to bring equipment, and definately not as a volunteer. Not only that, but we have to have tags/stickers on our vehicle that states what we are carrying on our automobiles...



We have Good Samaritan laws that state you can do anything up to the extent of your medical knowledge ONLY if the patient consents (either expressed or implied from patient OR a family member in the case of a child or incompetent adult) . If a lay person knows CPR and a person needs it, the lay person administers. If a BLS EMT happens across an MVA that requires medical attention, the off-duty EMT is allowed to administer whatever he can with the available equipment until a rig arrives.

As soon as you start administering treatment, you CANNOT stop until:
A) a more qualified individual arrives on scene (exception to this is if they ask for your assistance for two-rescuer CPR or whatever they need) If they need your help, YOU HELP.
B )"injuries are obviously incompatible with life". If the patient's brain is eviscerated from the skull, etc, obviously  he's (due to a lack of better words...) a "goner".
C) You are too exhausted to continue (as with CPR)


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## EMTelite (May 5, 2009)

3 way flutter valve occlusive dressing high flow oxygen via non rebreather be prepared for BVM  which more than likley will need to be used because of poor tidal volume, apply bulky dressing too the affected side secure in place witha roller bandage


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## LAS46 (May 6, 2009)

AJ Hidell said:


> A spine board is not indicated, and not likely to immobilize the segments of the rib cage, which will move each time the patient breathes.  Positioning the patient lateral recumbent on the affected side is the textbook preference.  However in reality, the patient should be allowed to assume the position most comfortable to him or her.
> 
> Oxygen is obviously indicated, but other than that, there is no treatment, just supportive care.



I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions. You can adjust your straps to work around the injury. Spider straps would not be recommended, insted I would use nylon seat belt type straps. And like everyone else has said NRB 15lpm, treat for shock, Call for ALS to meet you enroute, and occlusive dressing if open.

Dustin
NREMT-B Student


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## Sasha (May 6, 2009)

LAS46 said:


> I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions. You can adjust your straps to work around the injury. Spider straps would not be recommended, insted I would use nylon seat belt type straps. And like everyone else has said NRB 15lpm, treat for shock, Call for ALS to meet you enroute, and occlusive dressing if open.
> 
> Dustin
> NREMT-B Student



Ahhh we're going to get in to a discussion about spine boards and their useless now. Wasn't their popcorn floating around on another thread??


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## Veneficus (May 6, 2009)

LucidResq said:


> I would backboard this pt. because a trauma significant enough to cause flail chest is definitely significant enough to cause spinal trauma.



I must respectfully disagree, the thoracic cage requires considerably less force both directly or indirectly to fx than a spine. 

also bear in mind when you board a patient, you restrict chest expansion, which will inhibit breathing, but the actual cause of death is the aortic occlusion. 

At the basic level, call med control and tell them what you see and ask them what to do when you are already on the way to the hospital. If you have a significant transport time, they may consider walking you through a decompression.

splinting the flail is a great idea, it will help the breathing.

the bright side is an open pneumo you can treat and a closed one will last a fair amount of time before decompensation depending on the size of the pneumo. (estimated by breath sounds in the field)

If I wanted to be smart, I could say the treatment is going to paramedic school


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## Veneficus (May 6, 2009)

LAS46 said:


> I would place this PT on a spine board even though you say it is not indicated. If the PT was in a MVA then they should be in full c-spine precautions.



Why?








10characters


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## LAS46 (May 6, 2009)

Veneficus said:


> Why?
> 10characters



Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.

MOI- MVA with PT thrown from vehicle.

Dustin
NREMT-B Student


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## emtjack02 (May 6, 2009)

At the risk of opening the boarding debate..are you questioning why they would board them?  Or that this pt does not need to be boarded.


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## LAS46 (May 6, 2009)

emtjack02 said:


> At the risk of opening the boarding debate..are you questioning why they would board them?  Or that this pt does not need to be boarded.



Like I said with the MOI that the PT has displayed with I would be inclined to follow NREMT protocol and have the PT is full c-spine care.

Dustin
NREMT-B Student


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## Sasha (May 6, 2009)

Might i refer you to this thread from our abstract service that find the harm and uselessness in backboarding?

http://www.emtlife.com/showthread.php?t=12256

And even doing a search will find you many more threads that debate backboarding.

Blindly following protocols may do more harm then good to your patient. With the dyspnea and pain that follows a pnuemo, they're likely to squirm and try to get more comfortable. Have you been on a backboard for ANY amount of time? Healthy as a clam, it's very uncomfortable.  I can imagine that laying supine on a stiff non anatomical board, strapped down with a hole in your lung feels much worse. 

And what is someone's instinct when you're having trouble breathing? Sit up.


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## Shishkabob (May 6, 2009)

LAS46 said:


> Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.
> 
> MOI- MVA with PT thrown from vehicle.
> 
> ...



First, NREMT doesn't have protocols.


Second, and I hope you teacher taught you this, what is taught in class and in the book should never be followed blindly and without thought.

Example-- "By the book", you do 30 compressions and then 2 breaths.  Real world, you do compressions while doing breaths.


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## LAS46 (May 6, 2009)

Linuss said:


> First, NREMT doesn't have protocols.
> 
> 
> Second, and I hope you teacher taught you this, what is taught in class and in the book should never be followed blindly and without thought.
> ...



For this PT and the experience I have in the EMS field I would still back board this PT to keep from risking further injury. As you know as  EMT-P with a flail chest wound if the PT moves around a lot they can cause them selves more injuries... so by using full c-spine precautions you will be doing more good for your PT than not. And even if there was no flail chest wound full c-spine care would be in order due to the MOI.

Dustin 
NREMT-B Student
Graduating EMS School Tonight


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## VentMedic (May 6, 2009)

Veneficus said:


> Why?


 
The first 10 vertebrae are fixed with their articulation to the thoracic cage.​ 
For some mechanisms that cause flail chest, especially motorcycle accidents, can cause forced hyperflexion of the thoracic spine. The anatomically narrow thoracic spinal canal also leads to a high incidence of associated neurologic complications. The higher the rib fxs the more chance of also finding spinal injuries. The younger the child, the more chance of spinal injuries since it takes great force to break the flexible ribs of the very young. ​ 
These patients will almost always get a CT scan to rule out organ damage and spinal fractures. ​ 
While the back board is not always the best method of stabilizing the spine, consideration of spinal injuries should still be there.  Also, neurologic deficits may not always be initially present.  Once they become apparent, the patient's spinal injuries may have progressed from stable to unstable.​


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## syd (May 6, 2009)

What is the proper way to splint a flail chest?  I was told in my class that it was to splint it when it's "in"... is that right?


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## emtjack02 (May 6, 2009)

If the MOI supports boarding as do your protocols I think one should evaluate if the pt is going to tolerate it..if so board.

To address the example if you have an advanced airway then by all means you can vent/comp asynchronously.


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## LAS46 (May 6, 2009)

emtjack02 said:


> If the MOI supports boarding as do your protocols I think one should evaluate if the pt is going to tolerate it..if so board.
> 
> To address the example if you have an advanced airway then by all means you can vent/comp asynchronously.



I just spoke to our medical director for my area and he said ALL trauma PTs must be backboarded even if they present with a Flail Chest wound. He also said of course most PTs will not like being on a spine board but they need to be until xrays and CTs can be done to r/o and spine or further internal injuries.

Dustin
NREMT-B Student
Graduating EMS School Tonight


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## Veneficus (May 6, 2009)

VentMedic said:


> The first 10 vertebrae are fixed with their articulation to the thoracic cage.​
> they are planar joints, which do freely move connected by dense connective tissue to limit that movement. Just as when you fall on an outstretched hand, you are more likely to rupture a joint capsule that produce a collies fx. I amnt saying it can't or doesn't happen, it is not as common.
> 
> 
> ...




undoubtly, are you suggesting I don't know the course of the treatment after the pt reaches the hospital or how to care for different age groups? But look at the treatment of spinus or transverse process fractures and many other non subluxations. what weight is given to ischemic cord injury (by far the most common) rather than transection or penetration? There has to be a very serious injury for a spinal surgery to be attempted. 


There is also the knowledge that those with c or t fractures also have fractures of the opposite which show up on imaging and are often missed during examination. The day there is a one size fits all trauma treatment, I am quiting.

We could also talk about osteomalacia and osteoporosis in the elderly too, but i am trying hard to work with what was given and not debate every possibility. c'mon.



VentMedic said:


> While the back board is not always the best method of stabilizing the spine, consideration of spinal injuries should still be there.



and I agree with this fully, but there is a difference between realistic index of suspicion, especially when you consider the rareness of cord injuries in a modern automobile and mechanism by speed or damage shown not to be reliable. 

Additionally without critical thinking, there can be no improvement of patient care.


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## Veneficus (May 6, 2009)

*sorry got confused*

I accidentally mixed this reply with one on a different board, I guess i am fired. 


but my opinion still stands.


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## VentMedic (May 6, 2009)

Veneficus said:


> *undoubtly, are you suggesting I don't know the course of the treatment after the pt reaches the hospital or how to care for different age groups?* But look at the treatment of spinus or transverse process fractures and many other non subluxations. what weight is given to ischemic cord injury (by far the most common) rather than transection or penetration? There has to be a very serious injury for a spinal surgery to be attempted.
> 
> 
> There is also the knowledge that those with c or t fractures also have fractures of the opposite which show up on imaging and are often missed during examination. The day there is a one size fits all trauma treatment, I am quiting.
> ...


 
You have seriously taken this at a personal level. 

I am quoting things that every Med Student learns as they come to educate themselves at a trauma center. 

Did you notice my comments:


> _The anatomically narrow thoracic spinal canal also leads to a high incidence of associated neurologic complications. The higher the rib fxs the more chance of also finding spinal injuries. The younger the child, the more chance of spinal injuries since it takes great force to break the flexible ribs of the very young. _


 
_Without critical thinking and assessing the patient for more than just the obvious or from a limited knowledge, you have a patient with a life changing event in a wheel chair, suprapubic catheter and a daily bowel program. _

_Blankets statements or intentionally blowing off other possibilities are signs of irresponsible teaching and guidance in a world where accidents don't always happen as perfectly as some would like. You also can not ignore other disease processes and age which are also taken into consideration in trauma activation in some areas. Doing a thorough assessment means considering different possibilities and not just selective things to make YOUR own point. Do what is best for the patient._

_*The situation given is a flail chest.* Do some research or spend some time at a trauma center or spinal injury rehab center. Shortcuts are great for the very experienced and properly educated but should not be taught for all nor should assumptions always be made especially when the literature may state otherwise.  The medical director of the EMT student you were questioning may  have a stack of literature to base his/her protocols from.  _


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## Melbourne MICA (May 8, 2009)

*Treading carefully*

Since the thread went past the original query about what can a BLS operator do for this pt, did anyone mention pain relief? I assume the pt was in pain so settle the pt down with some morph (if available and within laws and guidleines). 

This will help in avoiding unnecessary movement and clearly ejection is a high risk mechanism for c-spine injury plus the points Venty made. I don't see any reason why this pt can't be fully packaged.

If one area of treatment like the board has potential to compromise another area, like the pts ventilations, we have tools to manage this problem such as assisted ventilation or high flow or high concentration O2. 

Besides shouldn't we apply what we have to manage immediate problems rather than speculate what may or may not happen if we do or don't?

Apply the treatments with care on the basis of a thorough assessment, reassess thereafter and modify management as needed. If you have a board and collars use them. If not, basic packaging including the 3 sided dressing and chest wrap, limit movement, best position for ventilation and make sure someone had called 911 if you are off duty.

Regarding the breathing issue, for all you know even back boarded the pt may maintain their Spo2's. But you won't know until you try. If the pt deteriorates markedly with this approach and you ahev limited tools at your disposal to correct the problem then the ABC's must apply so ventilation must take priority.

For all the difficulties a chest injury presents we have quite a few options to manage that problem and concurrent problems as well, though not as many at BLS level of course. 

Trauma jobs in particular always come with more than one clinical problem.

In a nutshell, act upon what you can manage with what you have, accept the limitations of the situation and above all be prepared for changes in the pts condition.

Thats what I reckon.

MM


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## daedalus (May 8, 2009)

LAS46 said:


> Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.
> 
> MOI- MVA with PT thrown from vehicle.
> 
> ...



Reliance on protocols and cookbook procedure is the mark of an ineffective and inexperienced provider. You should know the whys and pathophysiology, and that will be your guide on selecting the appropriate treatment. On this forum, as in real life, we are in the company of people who have a vast amount of more education than you or I do as EMT-Bs. Vent and Vene here are debating certain pathologies that you may not even be aware of. Be aware that, here, just as in real life, you will be required to back up your statements are treatments. If a MD or RN or RRT asks why you initiated c-spine, or oxygen, or some other treatment, and you say because it is protocol, you will lose a lot of respect/


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## LAS46 (May 11, 2009)

Well at the same time if we do not follow simple protocols then we may end up in much more trouble for not... According to my receiving facility if this PT came in not in full c-spine care then we would get into a lot of trouble... yes your PT with a flail chest and a nemothorax will be uncomfortable... but that PT who has been ejected out of the vehicle may have a spine injury and we have to take simple precautions for that... I am sorry to say but Saving Lives is more important than comfort for your PT in a case like this...

DC


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## Sasha (May 11, 2009)

LAS46 said:


> Well at the same time if we do not follow simple protocols then we may end up in much more trouble for not... According to my receiving facility if this PT came in not in full c-spine care then we would get into a lot of trouble... yes your PT with a flail chest and a nemothorax will be uncomfortable... but that PT who has been ejected out of the vehicle may have a spine injury and we have to take simple precautions for that... I am sorry to say but Saving Lives is more important than comfort for your PT in a case like this...
> 
> DC



Do yourself a favor and google  harmful effects of backboarding. its more than just discomfort. there is evidence suggesting backboarding is just as effective at preventing further injury than not backboaring. id post links but thats hard from a phone but i will post them later.

doctors and rrts and nurses tend to seemm to appreciate people  capable of critical thinking over chefs.


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## JPINFV (May 11, 2009)

Nemothorax?  

Just keep swimming, just keep swimming.


PS. Directed at people who are continuing to use the term, and not at the OP who has atoned for his sins.


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## VentMedic (May 11, 2009)

Sasha said:


> Do yourself a favor and google harmful effects of backboarding. its more than just discomfort. there is evidence suggesting backboarding is just as effective at preventing further injury than not backboaring. id post links but thats hard from a phone but i will post them later.
> 
> doctors and rrts and nurses tend to seemm to appreciate people capable of critical thinking over chefs.


 
While the evidence is there, the medical director must also be on board with developing a protocol, training and documentation to effectively meet the criteria. 

*Selective Spinal Immobilization*
http://www.emsresponder.com/print/Emergency--Medical-Services/Selective-Spinal-Immobilization/1$2223


*Danger at the Door (Bledsoe)*

*http://www.ems1.com/ems-products/patient-immobilization/articles/426350-danger-at-the-door/*


*Incomplete Spinal Cord Injury*
*http://www.ems1.com/ems-products/patient-immobilization/articles/456767-incomplete-spinal-cord-injury/*

*The NEXUS Study*
*http://www.fieldmedics.com/articles/the_nexus_study.htm*


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## triemal04 (May 11, 2009)

Unfortunately, even with everything said, using/not using a backboard in the given situation is a moot point for almost all services; it will have to be done.  All 3 (Nexus, Canadian and Harborview) agree that this type of pt does need cervical spinal immobilization until an x-ray/CT is done.  And there are very few places that will allow their personell to place a collar on someone and not use a board or other immobilization device (KED) at the same time.  (if anyone works for a place like that, speak up)  What really needs to be addressed is whether or not full immobilization or only cervical immobilization needs to be taken.


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## marineman (May 11, 2009)

Just to add another view for the links Vent posted (thanks by the way a couple new sites I hadn't seen before)

This is only the abstract, can't find a link to the full study without paying.
http://www3.interscience.wiley.com/journal/120143495/abstract?CRETRY=1&SRETRY=0 

The guidelines of the Nexus study is what we use when clearing C-spine. No I couldn't clear it on this patient and would have to fully immobilize. Life over limb tells me to fix the breathing before c-spine and my doc would have no problem with that but if I'm able to intubate and ventilate while immobilized I'd have my *** in a sling if he wasn't long boarded.


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## Melbourne MICA (May 12, 2009)

triemal04 said:


> What really needs to be addressed is whether or not full immobilization or only cervical immobilization needs to be taken.



This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.

You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.

MM


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## Melbourne MICA (May 12, 2009)

*Extra*



Melbourne MICA said:


> This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.
> 
> You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.
> 
> MM



I typically always add the caveat that thinking operators wil always use best judgement in the interests of the pt and are not just slaves to the dictum of protocol. After all, EMS trully is the art of improvisation and flying by the seat of your pants. 

Nonetheless, the all or nothng approach in spinal management by EMS is well founded by both research *and* practice in pre-hospital.

MM

MM


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## CAOX3 (May 12, 2009)

Flail chest with a pneumo?  I think that would be considered distracting injury. 

With the NEXUS criteria that buys you a board.


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## Veneficus (May 12, 2009)

Melbourne MICA said:


> This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.
> 
> You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.
> 
> MM



I think what the point being argued, yet again, is whether or not a long board, head blocks, and a collar actually do prevent damage. The most convincing one I htink is the dallas malaysia one, as it actually has a control group. (those boarded compared to those not boarded) I have seen only anecdotes detailing whether a board helps. I am not convinced it does. Though I have seen other methods that seem more likely to help if there is benefit. 

You can argue what is done and where all day, but it doesn't make it right. The amount of spinal fx missed on xrays makes a strong arguement for only CTs, but there are also limitations to that. Why do facilities constantly still perform xrays looking for spinal fx? (i have a few theories, not least of which s lack of physical exam skill)

If you really want a brain teaser on spinal fx, compare how many patients are sent home after a few hours or days with a collar compared to those who have surgery or more invasive splinting. (like a halo)


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## VentMedic (May 12, 2009)

Veneficus said:


> You can argue what is done and where all day, but it doesn't make it right. The amount of spinal fx missed on xrays makes a strong arguement for only CTs, but there are also limitations to that. Why do facilities constantly still perform xrays looking for spinal fx? (i have a few theories, not least of which s lack of physical exam skill)
> 
> If you really want a brain teaser on spinal fx, compare how many patients are sent home after a few hours or days with a collar compared to those who have surgery or more invasive splinting. (like a halo)


 
And how many are in wheel chairs? If one person loses their quality of life because it was assumed there was no fracture because of the statistics in a piece of literature without reading the methodology or other literature with differing views, poor training/education or from what someone read on an anonymous forum, that is one too many. That is why future doctors are taught to do an assessment as well as reading the literature but they are also taught their own limitations and the exceptions. Just like some Paramedics who believe they know everything about a patient even though they have no lab data and just a field exam to back it up, doctors are taught to make use of the tools they have and not assume everything in all cases. 

A backboard may not always be the best method of immobilizing a patient but log rolling the patient onto it so the patient can be moved without further damaging the spine is better than just having a patient struggle on their own to get to their feet or doing an extremity pull or lift. In MRI or CT Scan a slide board may have to be used anyway to position the patient without pulling on the shoulders and head. The patient probably will not stay on the board at a trauma center much longer than it takes to do an x-ray and/or CT or onto something they can maneuver the patient more easily and safely on. 

Often both a CXR and CT Scan is done but for different reasons. Many times a central line, ETT and OG are placed.  These are all done within the first 5 minutes of arrival. The sooner confirmation of correct positioning, the sooner those 3 devices can be used especially when it comes to stabilizing a flail chest and preventing further trauma to the lungs. Not everyone will get or should get a CT Scan. However, in the case of a flail chest, there are many reasons to do a CT Scan besides the spinal column. 

Yes there are a large number of patients that get sent home without invasive procedures for spinal fxs. But, in the field, do you know that fracture is stable? How many even suspect there is a fracture because there may be NO deficits? Will it remain stable if you don't take some precautions? The statistics there may only lead one to be more cautious. These are the ones that may get documented by the ED and sent to your medical director saying you will be one lucky EMT(P) if the patient doesn't suffer permanent damage. So, you may still be darned if you do and darned if you don't. That is where you must have the support of your medical director, your guidelines or protocols and your documentation must be very thorough. Stating with one blanket sentence, no abnormalities or deficits noted will not hold up.


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## Veneficus (May 12, 2009)

*hope springs eternal*

I still have hope that any EMS provider reading here can distinguish the difference between a discussion of benefit and potental complications from lack of resources in the field. If providers can't handle that they need to join my level, I am not lowering to them.

Additionally I have said it more than once, US practicioners have to be careful about reliance on imaging. I have had the honor of working at one of the finest trauma centers in the US for almost 4 years, clinical decision making is more important than mindlessly following protocols based on abstract studies and imaging. 



VentMedic said:


> And how many are in wheel chairs? If one person loses their quality of life because it was assumed there was no fracture because of the statistics in a piece of literature without reading the methodology or other literature with differing views, poor training/education or from what someone read on an anonymous forum, that is one too many..



You make it sound as if I just troll the web for studies and have no experience at all. There is a time for conservative measures, but this panic idea that every trauma patient is critically ill is foolish. Infact most of them are not. The amount of overtriage is currently unsustainable both economically and logistically. (particularly in the US) also, when I think of the list of exceptional trauma centers, no place in Florida even makes the list. Trauma surgeons who do not have other critical care aspects of practice are also a dyng breed. 



VentMedic said:


> That is why future doctors are taught to do an assessment as well as reading the literature but they are also taught their own limitations and the exceptions...



It should be no different for any providers. But the limitations cannot always be overcome, and unlike other providers, a doctor who signs the chart may not have the luxery of having all he/she wants. Furthermore, sometimes they even have to reach into the vast bank of knowledge and make something up because there is no protocol or "expert" consult.



VentMedic said:


> Just like some Paramedics who believe they know everything about a patient even though they have no lab data and just a field exam to back it up, doctors are taught to make use of the tools they have and not assume everything in all cases.



I don't think it is ever good to assume, but i also don't think you need to perform every medical test available to man to make a dx either. It is a waste of all kinds of resources.



VentMedic said:


> A backboard may not always be the best method of immobilizing a patient but log rolling the patient onto it so the patient can be moved without further damaging the spine is better than just having a patient struggle on their own to get to their feet or doing an extremity pull or lift. In MRI or CT Scan a slide board may have to be used anyway to position the patient without pulling on the shoulders and head. The patient probably will not stay on the board at a trauma center much longer than it takes to do an x-ray and/or CT or onto something they can maneuver the patient more easily and safely on.



the CT? A total body scan (now routinely utilized in trauma around the US) of head, neck, chest, abd, pelvis can take up to 45 minutes. Provided there is no wait for the scanner. Add some plain films and that could be an hour or more. Totally unacceptable. Thinking trauma care is the same even between two level I centers is inaccurate.



VentMedic said:


> Often both a CXR and CT Scan is done but for different reasons. Many times a central line, ETT and OG are placed.  These are all done within the first 5 minutes of arrival. The sooner confirmation of correct positioning, the sooner those 3 devices can be used especially when it comes to stabilizing a flail chest and preventing further trauma to the lungs.



The standard bed side xrays in trauma around the world is a chest, pelvis and cross table lateral of the spine. Some centers forgo these because they utilize the "pan and scan" CT. An xray to confirm tube placement is truthfully icing on the cake. There are other ways. The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway. Measuring CVP and confirming line placement takes place after stabilization in the critically injured trauma patients. (sometimes postop)



VentMedic said:


> Not everyone will get or should get a CT Scan. However, in the case of a flail chest, there are many reasons to do a CT Scan besides the spinal column.



If the director of trauma believes the studies of xrays being inadequete they will get a CT. That is a large percentage. Yes you can see many things on CT, like shadows on the aortic arch. (which in a trauma patient is likely not a clot. Infact it is normal artifact usually, and more than one intensivist has been reprimanded for starting anticoags based on that finding I have been at M&M meetings personaly where it was brought up.)



VentMedic said:


> Yes there are a large number of patients that get sent home without invasive procedures for spinal fxs. But, in the field, do you know that fracture is stable? How many even suspect there is a fracture because there may be NO deficits?



With the way EMS uses spineboards today I can't imagine a provider not suspecting an injury, even when it would qualify as impossible. "The if even one patient..." arguement while noble, is unrealistic, we'd have to run every test on every patient.

In the field I would say it would start with some real education and not dire warnings to inspire panic that every patient is on death's door and the end of the world at hand.



VentMedic said:


> Will it remain stable if you don't take some precautions? The statistics there may only lead one to be more cautious. These are the ones that may get documented by the ED and sent to your medical director saying you will be one lucky EMT(P) if the patient doesn't suffer permanent damage. So, you may still be darned if you do and darned if you don't. That is where you must have the support of your medical director,



I never suggested not having to take precautions, but i do call into question the effectiveness of the standard method. There is absolutly nothing I have seen showing a LSB makes any difference. If you demand controlled double blind macro studies for new treatments the same standard needs to apply to all treatments.

Getting the medical directors support and furthering medicine requires discussion and argument that starts somewhere. If it can be done over a bar napkin, it can be done on a forum. If providers cannot see the difference between calling a treatment into question and changing treatment without going through the proper channels, it is probably just a matter of time before they make a terrible mistake, what they read here probably will only speed up the inevitable.



VentMedic said:


> your guidelines or protocols and your documentation must be very thorough. Stating with one blanket sentence, no abnormalities or deficits noted will not hold up.



I worked in a system where literal interpretation of protocols was the culture of everyone except the medical director. It is not practical or reasonable, there will always be some vagueness and need for deviation. Otherwise every possible situation would have to be defined. 

Poor documentation rests on the provider.


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## VentMedic (May 12, 2009)

Veneficus said:


> I
> 
> the CT? A total body scan (now routinely utilized in trauma around the US) of head, neck, chest, abd, pelvis can take up to 45 minutes. Provided there is no wait for the scanner. Add some plain films and that could be an hour or more. Totally unacceptable. Thinking trauma care is the same even between two level I centers is inaccurate.


 
You need to update yourself on imaging technology or find a more modern and up to date trauma center to work in. Not every hospital in the U.S. is as backwards as you may think by the one you have experience with. I haven't spent that long in CT with a patient in about 15 years. 

It takes 2 minutes to scan a head and neck. Many scanners now have the ability to do the whole body without turning the patient around. Have you seen the ED models in Europe where the scanner sled is the ED stretchers? Major trauma centers will usually have their own scanner which eliminates the waiting. They may also prioritize the patient for the scanner based on a good report from the Paramedics. 



> The standard bed side xrays in trauma around the world is a chest, pelvis and cross table lateral of the spine. Some centers forgo these because they utilize the "pan and scan" CT. An xray to confirm tube placement is truthfully icing on the cake. There are other ways. The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway. Measuring CVP and confirming line placement takes place after stabilization in the critically injured trauma patients. (sometimes postop)


 
Have you only worked in one trauma center? 

We do not need surgeons to place our lines. For the technology and meds we may utilize, we prefer to safely confirm placement. As they say *haste makes waste.* Have you ever seen what happens if an HFOV placed on a patient where the ETT is too close to the carina? How about meds placed in grossly misplaced lines? First rule of medicine: Do no "additional" harm. 



> The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway.


 
Subclavian? 

We do IJs which allows us more flexibility for various monitoring devices especially if a TBI is also suspected. 




> when I think of the list of exceptional trauma centers, no place in Florida even makes the list.


 
If you don't like the U.S. system you don't have to work here. As you keep saying you are a dual citizen. Why waste your time in this country if you believe our medical practices are so inferior? Florida has some pretty good trauma centers associated with teaching hospitals that do some outstanding work. Some of our research even makes it to Europe. I also thought Europe's ED model of having a CT scanner at practically even bedside was fairly ridiculous also but they seem to have some logic behind that setup. 

The human body is complex and it is difficult to get one recipe to fit everyone. Thus, some doctors do error on the side of caution and not just go by some statistical data that says only 1% possibility of something if there might be a possibility that that one patient will be part of that one percent. And as I already stated, not all of our patients get the total body workup.



> With the way EMS uses spineboards today I can't imagine a provider not suspecting an injury, even when it would qualify as impossible. "The if even one patient..." arguement while noble, is unrealistic, we'd have to run every test on every patient.
> 
> In the field I would say it would start with some real education and *not dire warnings to inspire panic that every patient is on death's door and the end of the world at hand.*


 
I am not going to criticize an EMT(P) who puts a patient on a back board because of what they have seen at the scene even if the patient's initial assessment appears negative. Our doctors will usually listen to the EMS providers if they express concern about the way they found the patient. 

However, the OP was about a flail chest and I think I have justified why I would back board that patient. Ribs can bend to almost 30 degrees and if there is still enough force to break those, I can NOT ignor other possibilities for injuries. That may be backwards in your ideal world but even those of us in Florida can manage to save lives occasionally in our trauma centers and do have EMS providers that can give good care in the field.


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## Amack (May 12, 2009)

nomofica said:


> How can this be treated on a BLS level?



With a fishing pole...to get "Nemo" out of the thorax


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## Veneficus (May 12, 2009)

VentMedic said:


> You need to update yourself on imaging technology or find a more modern and up to date trauma center to work in. Not every hospital in the U.S. is as backwards as you may think by the one you have experience with. I haven't spent that long in CT with a patient in about 15 years. .



I doubt a manufacturers test site is operating with old equipment, especially considering we were testing the latest advances before it was available on the market. 




VentMedic said:


> It takes 2 minutes to scan a head and neck..



yea, a head, but what about the neck, chest, add, and pelvis? those magically get done in no time?



VentMedic said:


> Many scanners now have the ability to do the whole body without turning the patient around...



I have never seen one where you had to turn the patient around.



VentMedic said:


> Have you seen the ED models in Europe where the scanner sled is the ED stretchers?...



once or twice.



VentMedic said:


> Major trauma centers will usually have their own scanner which eliminates the waiting. They may also prioritize the patient for the scanner based on a good report from the Paramedics. .



and in busy hospitals you can have a wait for the dedicated trauma scanner.




VentMedic said:


> Have you only worked in one trauma center? .



worked at length in one, seen many across the world as the guest of others.



VentMedic said:


> We do not need surgeons to place our lines. For the technology and meds we may utilize, we prefer to safely confirm placement. As they say *haste makes waste.* Have you ever seen what happens if an HFOV placed on a patient where the ETT is too close to the carina? How about meds placed in grossly misplaced lines? First rule of medicine: Do no "additional" harm..



I guess I conceed that nobody does anything advanced or correct except you guys. 

according to your statements nobody sees patients except you anyway. 





VentMedic said:


> Subclavian?
> 
> We do IJs which allows us more flexibility for various monitoring devices especially if a TBI is also suspected.



perhaps other places do not make the line location based on findings, but i doubt it. 




VentMedic said:


> If you don't like the U.S. system you don't have to work here. As you keep saying you are a dual citizen. Why waste your time in this country if you believe our medical practices are so inferior? Florida has some pretty good trauma centers associated with teaching hospitals that do some outstanding work. Some of our research even makes it to Europe. I also thought Europe's ED model of having a CT scanner at practically even bedside was fairly ridiculous also but they seem to have some logic behind that setup. .



It is not abot liking or disliking the system, it is about recognizing no system is perfect and using the best from each. If the practice was perfect it would be economically sustainable, which it clearly isn't. I think you put a little too much faith in what you see in florida.




VentMedic said:


> The human body is complex and it is difficult to get one recipe to fit everyone. Thus, some doctors do error on the side of caution and not just go by some statistical data that says only 1% possibility of something if there might be a possibility that that one patient will be part of that one percent. And as I already stated, not all of our patients get the total body workup..



epidemiology is one of those tools, if not all patients get a total body workup why would you expect an EMS provider to always do every treatment they can? Are they that inferior?



I am not going to criticize an EMT(P) who puts a patient on a back board because of what they have seen at the scene even if the patient's initial assessment appears negative. Our doctors will usually listen to the EMS providers if they express concern about the way they found the patient. 



VentMedic said:


> However, the OP was about a flail chest and I think I have justified why I would back board that patient. Ribs can bend to almost 30 degrees and if there is still enough force to break those, I can NOT ignor other possibilities for injuries.



There is a difference between an occult injury and an imaginary one. 



VentMedic said:


> That may be backwards in your ideal world but even those of us in Florida can manage to save lives occasionally in our trauma centers.



clearly, it is nobody else who can



VentMedic said:


> and do have EMS providers that can give good care in the field.



Not the way you describe the inadequecies of EMS.

I must say, you seem to know all about every aspect of medicine professor, how foolish it was of me to think medical school could teach me something about medicine that can't be covered in an RRT or paramedic course. I sure did waste a lot of money and effort.

I really hope one day to match the knowledge and ability of an ancillary provider whos education will never let them take full responsibility for a patient.

Maybe the rest of the world will figure out whatever magic the perfect Florida system has. How dare I suggest it is not the only perfect way.

Sorry professor, you will never be a "doctor" guess you'll have to reconcile that sooner or later.


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## Amack (May 12, 2009)

Cynical aren't we?

lol


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## VentMedic (May 12, 2009)

Veneficus said:


> I must say, you seem to know all about every aspect of medicine professor, how foolish it was of me to think medical school could teach me something about medicine that can't be covered in an RRT or paramedic course. I sure did waste a lot of money and effort.


 
Thank you for acknowledging my title.  I have worked hard to get to that level.    However, it doesn't mean I still can not be proud of my RRT and Paramedic credentials.    

I have been in EMS long enough to know the deficiencies that exist in it.  If you haven't noticed I am not the only one on this forum that notices it.  Those that want to just stick their head in the sand and acknowledge their EMS system is perfect may be part of the problem.  

We have providers of many levels and different ages or experiences on this forum.   I try to make statements of caution and post links for them to do more reading on their own.   One shouldn't make their title of future doctor sound as a voice of authority and this is how it should be done.



> Maybe the rest of the world will figure out whatever magic the perfect Florida system has. How dare I suggest it is not the only perfect way.


 
I never said any one system was perfect.  I was replying to your rather obvious insult to Florida.
Here is the quote by you again.


> when I think of the list of exceptional trauma centers, no place in Florida even makes the list.


 
Do you know anything about the Ryder Trauma Center?  Orlando Regional? Tampa General?  
How about other states? 
San Francisco General?  R. Adams Cowley Shock Trauma Center? 

You  have a very opinionated view of how things are done in a trauma center based on the one you have worked at.  Also, just seeing a trauma center is not always the same as actually working in one.  Some things do change as different patients come in and different attendings are managing the rotations.  The next day may be very different.  That is the beauty of medicine.  There are many ways to accomplish similar goals.   

You have made alot of blanket statements.   Yet even in the hospitals there will be protocols that may need to be followed even as a doctor.  Don't expect an EMT(P) to challenge or disobey the written protocols of their medical directors just because you say so or try to call them incompetent for doing what is required of them.  Some systems do have elaborate guidelines and not just recipes.  However, there too they should not be bullied into going against their own judgement because you believe something is backwards by your own standards.  You are not a doctor but you have made your opinions sound like you already are because you are a "med student" who does not have the full or any responsibility of a patient.  That makes the licensed providers responsible for that patient and you when you are at that bedside.    

You still have a long way to go in med school once you do get accepted.  You may not even achieve your goals at all for whatever reasons.    I can guarantee your low opinions of other healthcare providers in EMS, nursing and the allied health professions will not be to your benefit.


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## ResTech (May 12, 2009)

Here is a great video that shows a actual patient with a flail chest. 
[YOUTUBE]http://www.youtube.com/watch?v=e0VNBDbr67U[/YOUTUBE]

Just to add to the previous replies... on a BLS level (and even ALS level) there isn't a whole lot you can do specific to treating the actual flail segment. Your treatment is focused on the result of that flail segment which is ensuring an airway and maintaining adequacy of breathing.  

Flail segments can result in an alteration of the normal mechanics of breathing (ie disrupts the pressure balance inside the chest) which can decrease gas exchange by not "drawing in" a normal tidal volume by a decreased expansion of the chest. So by stabilizing the flail segment you achieve two goals: 1) Protect the flail and vulnerable segment from additional injury during pt. movement and extrication. 2) Limit the movement of the flail segment to aid in chest expansion and reduce pts. pain. Don't look for significant result of splinting the chest but it is sometimes helpful. The pt. may also choose to self splint as well with their hand/arm. 

The significant force it took to cause the flail chest is going to be causing the pt. a LOT of pain. So look for the pt. to be hypoventilating to try to reduce the chest movement as much as possible. For ALS, this is where analgesics can improve ventilation... by reducing the pain... pt. is able to breathe deeper... which equals greater tidal volume and improved ventilation. It may also be necessary to provide overdrive ventilation. 

A flail segment is definitely a serious injury.... but more importantly it is the underlying pulmonary injury that warrants greater concern and will be causing the pt's. greater deal of respiratory compromise. If the force was great enough to cause a flail segment... imagine what the transfer of the blunt force did to the lungs and potentially the heart.... pulmonary/myocardial contusion, hemithorax, and pneumothorax are most common. 

So tx wise.... BLS... high-flow O2, assist ventilations (BVM) PRN, splint/support flail segment.... and realize the possibility of a pneumo that may progress to a tension.... arrange for ALS... and appropriate trauma facility. 

Hope this helps....


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## Veneficus (May 12, 2009)

*last reply to this foolishness*



VentMedic said:


> I have been in EMS long enough to know the deficiencies that exist in it.  If you haven't noticed I am not the only one on this forum that notices it.  Those that want to just stick their head in the sand and acknowledge their EMS system is perfect may be part of the problem. .


 
That is an interesting spin, but after reading your often degrading comments to and about EMS providers, residents, and junior physicians, I think you just harbor some kind of resentment. It must be hard to watch new people who  will advance themselves beyond you, but you chose your path. You are not the only one wo has worked hard.




VentMedic said:


> We have providers of many levels and different ages or experiences on this forum.   I try to make statements of caution and post links for them to do more reading on their own.   One shouldn't make their title of future doctor sound as a voice of authority and this is how it should be done..



I have decided my contribution was to share some of the techncal medical knowledge I have aquired. I would like to think it is not my title or perspective title that gives credibility to my posts but the knowledge and thought behind them.

Any provider is more than capable of measuring the merits of my opinions. I will not accept they are mindless sheep.

It is not me that constantly reminds EMS providers how undereducated and incapable they are, it is you.





VentMedic said:


> I never said any one system was perfect.  I was replying to your rather obvious insult to Florida.
> Here is the quote by you again.



I have ignored many insults from you on my knowledge, capability, and contributions, it will not happen again.

Your zeal for improvement has turned into elite fanaticism over the last few months.




VentMedic said:


> Do you know anything about the Ryder Trauma Center?  Orlando Regional? Tampa General?



I can honestly say in my international travels I have never heard of them nor provider from them, perhaps I don't get out enough or spend enough time with trauma, but as it has been the focus of my professional persuits for almost 10 years, I don't think that is the case.



VentMedic said:


> How about other states?
> San Francisco General?  R. Adams Cowley Shock Trauma Center?



Yes, I have heard of them, been to Shock Trauma, as well as centers all over the US and Europe, I admit I have yet to make it to Asia and look forward to a rotation in Israel and South Africa, where I have met great providers from, I didn't make the list of recognized trauma centers, but I know who is on it.



VentMedic said:


> You  have a very opinionated view of how things are done in a trauma center based on the one you have worked at.



You like to suggest how limited my travels and views are, as somebody who has traveled often at my own expense seeking out how things are done in other places in order to seek out those with outstanding practice and contribution, I find your remarks on such completely without merit. 



VentMedic said:


> Also, just seeing a trauma center is not always the same as actually working in one.  Some things do change as different patients come in and different attendings are managing the rotations.  The next day may be very different...



Yes, individual shifts can be different, but in my visits, some lasting as long as 14 days, I have been treated exceptionally well by great physicians who I admire and have a considerable higher opinion of my knowledge, experience, and dedication than you do. I just do't understand how senior surgeons seem to treat me better than an ancillary provider. But like many non physicians, they often like to sling mud to make up for their own inadequecies.



VentMedic said:


> That is the beauty of medicine.  There are many ways to accomplish similar goals..



again, backpeddling. Everytime I have made such a suggestion you have nit picked some detail, questioned my experience and knowledge, and suggested i am corrupting the youth that you call under educated and incapable of making a decision. 



VentMedic said:


> You have made alot of blanket statements.   Yet even in the hospitals there will be protocols that may need to be followed even as a doctor.



Yes I have, and yes I know there are protocols, I am quite familiar with mine. But in order to have a discussion there has to be a starting point. You can nit pick because people like me make a blanket statement that can be clarified based on specific circumstances. But your what if or once upon a time critisism is old. 



VentMedic said:


> Don't expect an EMT(P) to challenge or disobey the written protocols of their medical directors just because you say so or try to call them incompetent for doing what is required of them..



First of all, I have warned against doing such, critisized those who suggested doing such, and suggested the proper professional way to suggest changes to protocol. I encourage all providers to think. I realize they have to follow the orders of their superiors, but again, I believe they have the ability to recognize that my opinion doesn't supercede their medical directors authority. For a self proclaimed academian you have a very narrow view of things you don't agree with and seem to frown on challenging practices while touting evidence based medicine. I have always been told questioning is a fundamental part of basic science. Einstein decided one day Newton's laws of physics were incomplete, it has changed the world.

seems kind of silly to hear you profess to want to advance EMS with "you're not capable do as your told."




VentMedic said:


> However, there too they should not be bullied into going against their own judgement because you believe something is backwards by your own standards.  You are not a doctor but you have made your opinions sound like you already are because you are a "med student"..



Your words not mine, I present what I think, which is perfectly within my providence, The only reason I elude t being a med student in my profile is because I am tired of being told I don't have enough knowledge as just a paramedic. I have no doubt people think that my opinions have merit, I'd like to think they are sound based on my education thus far. I am not a doctor, an vehemently dissuade people from referring to me as such. (ask around) I do that becuase unlike you I understand and have the highest respect the rigors of medical school and the lifestyle sacrifices associated. I do not try to substitute other courses for world accepted medical curriculum. There is no country on the map that doesn't recognize a doctor. How many can say the same of paramedics or RRTs? Infact as far as I know, more recognize prehospital providers than RRTs. That makes it a very niche market I think.



VentMedic said:


> who does not have the full or any responsibility of a patient.  That makes the licensed providers responsible for that patient and you when you are at that bedside.



extremely true and accurate, but the difference is I am encouraged to think and question by those providers because they are grooming me so that in some distantfuture I will the one responsible. You will never be, so maybe you should hold off on the statements of how little others know or experience.



VentMedic said:


> You still have a long way to go in med school once you do get accepted..



It seems interminable.



VentMedic said:


> You may not even achieve your goals at all for whatever reasons..



If I can breath, I will succeed. No matter where I have to go, or what I have to do. The goal is set, I will offer no excuses about family, difficulty, distance from home, or any other nonsense of I couldn't make it because...



VentMedic said:


> I can guarantee your low opinions of other healthcare providers in EMS.



Funny, I was thinking the same thing about you.



VentMedic said:


> nursing and the allied health professions will not be to your benefit.



Actually I do have a high regard and respect for members of those professions, but I have a great deal of contempt for specific indviduals in those professions who forget that the journey to "doctor" is considerably longer and harder or try to somehow "shortcut" the process with alternative curriculums and then have a lack of respect for those who actually go to medical school and subsequently residency or direct to practice depending on the nation.


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## VentMedic (May 12, 2009)

> Originally Posted by *VentMedic*
> 
> 
> _Do you know anything about the Ryder Trauma Center? Orlando Regional? Tampa General?_





Veneficus said:


> I can honestly say in my international travels I have never heard of them nor provider from them, perhaps I don't get out enough or spend enough time with trauma, but as it has been the focus of my professional persuits for almost 10 years, I don't think that is the case.


 
You insult the trauma centers of Florida but yet you have not heard of any of the centers in Florida that I have mentioned.



> Yes, I have heard of them, been to Shock Trauma, as well as centers all over the US and Europe,


 
And you contradict yourself. 



> seems kind of silly to hear you profess to want to advance EMS with "you're not capable do as your told."


 
You don't advance until you have the education, backing of the profession and your medical director. There is no magic pill to take that gives one or a profession credibility over night. 



> But like many non physicians, they often like to sling mud to make up for their own inadequecies.


 


> The only reason I elude t being a med student in my profile is because I am tired of being told I don't have enough knowledge as *just a paramedic.*


 


> There is no country on the map that doesn't recognize a doctor. How many can say the same of paramedics or RRTs? Infact as far as I know, more recognize prehospital providers than RRTs. That makes it a very niche market I think.


 


> Actually I do have a high regard and respect for members of those professions,


 
You really seem to be bothered by the thought of being just a Paramedic or some other lower level provider in the healthcare hierarchy.   Not everyone wants to be a doctor and yet they can still provide care to a patient. 

Your attitude and dislike for RRTs and RNs have now been evident in several posts. Were you denied entry into one of their programs of study? 

Your contradictions and insecurities are too obvious. Maybe once you do finally get into medical school, you can feel more secure but you may also find out that med students often complain they don't get any respect until they are near the end of their residency. 




> It must be hard to watch new people who will advance themselves beyond you, but you chose your path.


 
I don't believe you have advanced passed me in either education or experience. That would definitely include my years of experience as *just a paramedic. *

At least I am consistent on my stance to being pro education for EMS. You have varied your stance on many topics on the different forums. As well, I will usually provide links for addition reading to allow others to form their own opinions. I link to resources so that others can learn from other information and not just from someone on an anonymous forum. I don't ask people to take my word for anything because I may not always have the right answer. Thus, the links to other sources are included in many of my posts.


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## Veneficus (May 12, 2009)

*do you actually believe this crap or do you just like to fight?*



VentMedic said:


> You insult the trauma centers of Florida but yet you have not heard of any of the centers in Florida that I have mentioned.
> And you contradict yourself.


 
I have heard and been to shock trauma, I have heard of SF General, I have not heard of any in Florida, I can only conclude because they have not done anything to draw attention outside of Florida that has made it to main stream. It is not my fault that Florida trauma centers, which you seem to think are somehow superior to others, are not as well known as others. If you are insulted by that, maybe you should become a marketing director? 

Is it really a contradiction to hear of famous trauma centers but not less well known ones?

I think you will need a better argument or should i believe that you couldn't figure out I had heard of some but not all of the ones you posted. Amazing I have heard of Groote Shuur hospital in South Africa, and Sourasky in Israel, but nothing from Florida. What can I say? "Sorry your facility didn't make the list." haven't heard of any in Montana, Alabama, Alaska, Maine, and I am sure a few other places either. 



VentMedic said:


> You don't advance until you have the education, backing of the profession and your medical director. There is no magic pill to take that gives one or a profession credibility over night. .



How dose debasing EMS providers help with any of that? Trying to goad them to action?

(Can't remember if it was Jefferson or Franklin that mentioned if you really want to stir somebody to action, insult them.) 



VentMedic said:


> You really seem to be bothered by the thought of being just a Paramedic or some other lower level provider in the healthcare hierarchy.



I do hate defending being a "paramedic." I have worked hard, perhaps more than some and less than others. Some may do the minimum I am not of that crowd and do not like being identified as part of it.



VentMedic said:


> Not everyone wants to be a doctor and yet they can still provide care to a patient.



So what? There is a difference between providing patient care and second guessing physicians while possessing lesser medical education. I think some people do not see the difference between being a healthcare provider and a medical provider. (more people than you, have to use small words so I am not accused of contradicting myself)



VentMedic said:


> Your attitude and dislike for RRTs and RNs have now been evident in several posts. Were you denied entry into one of their programs of study? .



I wouldn't say that, but I have to say after reading some of your posts, I would be embaressed to be associated with RRTs. You stand out among your peers I guess. 

I have never applied to any program I was not accepted to. I am a proponent of economy of force and winning before I fight, not fighting to win. 

RNs are their own breed, some great, some not so good, but I have seen a lot of them trash talk other providers. Seems kinda hypocritical for them to talk about other providers and not like thier flaws being pointed out? sort of like the pot calling the kettle black.



VentMedic said:


> Your contradictions and insecurities are too obvious.



Really? I'd love to hear them. I think you are finding things that aren't there. Maybe you should see a doctor about that? (or a medicine man if that is your thing)



VentMedic said:


> Maybe once you do finally get into medical school, you can feel more secure but you may also find out that med students often complain they don't get any respect until they are near the end of their residency..



LOL, that is awesome. "When I do finally get into med school."  I must admit, I don't really know what to say to that. As for respect, from both my peers and superiors, I do quite well. 



VentMedic said:


> I don't believe you have advanced passed me in either education or experience. That would definitely include my years of experience as *just a paramedic. *..



I don't really hold much stock in your beliefs. I wasn't speaking of you having to watch me advance past you, but I have seen your comments on junior residents. I would think they are well on their way to exceeding you, most probably have already, it doesn't seem like much of a task. 

I believe you are educated far beyond your intelligence, but I doubt it matters to you, so I guess we play on a level field. 



VentMedic said:


> At least I am consistent on my stance to being pro education for EMS. You have varied your stance on many topics on the different forums.



Yes, my views have moderated over time, and as conflicting with EMS providers and agences doesn't seem to work, I am working on inclusion. Call it a softer sell. But I guess that might label me a flip flopper not fit for a republican ticket. 



VentMedic said:


> As well, I will usually provide links for addition reading to allow others to form their own opinions. I link to resources so that others can learn from other information and not just from someone on an anonymous forum. I don't ask people to take my word for anything because I may not always have the right answer. Thus, the links to other sources are included in many of my posts.



I get a lot of information from these things called a "textbooks," strange concept I know, but I figured somebody with your education in healthcare might recognize basic science when you see it or figure out how to google any information you think is invalid. Nobody is obligated to consider my opinion valid. I am a semi anonymous internet source. But anonymity does not automatically preclude knowledge. I am not a slave to money or fame.

"pay no attention to the man behind the curtain"
---The wizard (L. Veneficus) of Oz.


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## VentMedic (May 12, 2009)

Veneficus said:


> I have heard and been to shock trauma, I have heard of SF General, I have not heard of any in Florida, I can only conclude because they have not done anything to draw attention outside of Florida that has made it to main stream. It is not my fault that Florida trauma centers, which you seem to think are somehow superior to others, are not as well known as others. If you are insulted by that, maybe you should become a marketing director?
> 
> Is it really a contradiction to hear of famous trauma centers but not less well known ones?


 

So I ask you again, if you know nothing about Florida or its trauma centers, why did you feel it necessary to make the comments about them? 

I could pick a lot of names off the internet to brag about also. However, I prefeer to use disclaimers when I do not know much about an area. I am not that familiar with north Florida so I usually allow Reaper to discuss that area. Sasha knows Orlando better than me and I respect that. Blsboy know the East Central coast better and FL_Medic knows the west central coast. 



Veneficus said:


> Nobody is obligated to consider my opinion valid.


 
You have wasted a lot of time trying to discredit "just paramedics", RNs, RRTs and other professionals just to prove your point which I don't even know what it was. You started rattling off stuff about yourself and clearly distracted from the subject of this thread. 

And what is with the medicine man statement? Have you ran out of insults for "just paramedics" and other health care professions that you now must insult other cultures also?

As I stated in the earlier posts in this thread, you take things very personally. You can not stand the fact that "just a Paramedic" or an RRT would guestion one of your posts. Actually I believe this debate started with a question from an EMT-B which really must have offended your high standards for the professionals level which don't include anyone but doctors. 

ResTech posted a great response to the OP. Take your personal issues to another thread of its own under personal musings or something and let the OP have his thread back.


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## LAS46 (May 12, 2009)

*Wrong Place to Argue*

I think the best place to take arguements as such is to private message... this is not to the place to do this in my opinion.


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## VentMedic (May 12, 2009)

LAS46 said:


> I think the best place to take arguements as such is to private message... this is not to the place to do this in my opinion.


 
You do know that it was one of your posts that initiated this discussion which turned into a hysterical display of egos?


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## nomofica (May 12, 2009)

aaaaaaaaaaand cue lock thread.


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## MSDeltaFlt (May 12, 2009)

Okie dokie.  Back on topic before admin locks this bad boy.

On the BLS level.  Treatment for a flail segment and pneumothorax is definitely splinting as others have already said.

As far as the rabbit chasing goes as far as to board or not, assess your pt.  If you need to board them, then board them.  If they are unable to tolerate lying flat on a LSB, who says they have to lie on a LSB for C-Spine Precautions?  Spinal restrictions are for the *spine*.  It does not mention the whole entire body.  Short spine boards or KED's will work fine.  Put them on one of these and elevate the head.  Yes, it does work.

I'm living proof you can lay in bed in Semi-Fowler's with an unstable Hangman's Fx for over a week off of a board and not yet on a halo and still be cleared to go back to work without restrictions in less than a year.  Let's look at the big picture, people.

As far as this heated debate goes, I'm going to let Admin address this.


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## parapaulieFL (May 13, 2009)

*yeah*

Well you guys are right about spinal immob for just the flail segment...not gonna do much. But obviously consider MOI. Position of comfort wouldn't be acceptable for someone thrown through the windshield


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