# C spine, backboard, and stabbing



## hellofirstresponders (Aug 15, 2009)

Okay need to clarify and confirm my friends. I got my money on this. There's. Pt with a knife to the smack center of their lumbar. The knife on the back is waving to you hello. What you going to do. C spine, backboard, or what


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## MrBrown (Aug 15, 2009)

If there is no evidence or high reasion to be suspicious of a c-spine injury no need for a collar ... put the patient prone on a scoop and make tracks; simple or so I think


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## Ridryder911 (Aug 15, 2009)

Ditto... prone, lateral. What else would you do, lay them supine? .... Apperantly if one places a cervical collar on, then one needs an anatomy lesson and has failed to understand what a cervical collar is for. 

R/r 911


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## Brandon O (Aug 15, 2009)

I think the question was supposed to involve a suspicion of spinal damage due to the placement of the knife.


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## JPINFV (Aug 15, 2009)

Brandon Oto said:


> I think the question was supposed to involve a suspicion of spinal damage due to the placement of the knife.



Your point?


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## Foxbat (Aug 15, 2009)

I would stabilize the impaled object and consider placing the pt. prone or lateral on a backboard. Here's why: with the impaled object in or near his spine I would probably want to prevent patient movement in general. When patient strapped to a backboard it may be easier to transfer him from stretcher to hospital bed without aggravating his injuries, as opposed to using sheets, slide board, etc.
If the knife was not impaled, that's a different story.


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## surname_levi (Aug 15, 2009)

take out the knife, cover wound with duct tape, treat for shock...duh ^_^


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## Brandon O (Aug 15, 2009)

I'm with Fox...



surname_levi said:


> take out the knife, cover wound with duct tape, treat for shock...duh ^_^



Waste of duct tape... just stick your gum in there.


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## traumamama (Aug 15, 2009)

not just spinal inj but also internal. how far did that knife go in? is he already circling the drain? put him on his left side on a backboard. stabilize the knife with bulky dressings. put a pillow under his head so his body is in alignment. put pillows behind him and tell him nighty night. if he fell a great distance you may consider the collar but if he is knifed in the spine he is already compromised. you can watch the front for interenal injuries and do you vitals/ iv easy. say your prayers and beat feet to the er


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## MSDeltaFlt (Aug 15, 2009)

Ridryder911 said:


> Ditto... *prone, lateral*. What else would you do, lay them supine? .... Apperantly if one places a cervical collar on, then one needs an anatomy lesson and has failed to understand what a cervical collar is for.
> 
> R/r 911


 
Yeah, Rid.  Lateral's my first choice, but would quickly go prone if lateral didn't show signs of working.  Depending on how much weight the knife had, prone just might be preferred.


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## Brandon O (Aug 15, 2009)

Seems like prone would give better stability but I'd be somewhat concerned about managing the airway. I don't find it all that easy to breathe lying on my stomach WITHOUT a knife in me. If you need to get in there you're just going to have to turn them sideways anyway.


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## hellofirstresponders (Aug 16, 2009)

Call base. Get md permission. Abc... Take care of the first two. Likely get permission to pull the knife. Which is c. Never compromise airway and breathing.


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## MrBrown (Aug 16, 2009)

hyrisk said:


> Call base. Get md permission. Abc... Take care of the first two. Likely get permission to pull the knife. Which is c. Never compromise airway and breathing.



Do you consider transporting the patient prone unacceptable?


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## Scout (Aug 16, 2009)

hyrisk said:


> pull the knife. Which is c.




Say wha......!!!!!!!!!!


Chances are if the knife is still there when you arrive its in fairly good. When in the be£"$%^Y& would you take it out.....


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## hellofirstresponders (Aug 16, 2009)

We can never, ever put someone in a prone position. Heck, doesn't even matter if they need to be restrained in a prone position. :glare: We have to even put them supine and restrain them.


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## TransportJockey (Aug 16, 2009)

hyrisk said:


> We can never, ever put someone in a prone position. Heck, doesn't even matter if they need to be restrained in a prone position. :glare: We have to even put them supine and restrain them.



So transport them laterally. I bet you would NOT get permission to pull that knife


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## Sasha (Aug 16, 2009)

hyrisk said:


> Call base. Get md permission. Abc... Take care of the first two. Likely get permission to pull the knife. Which is c. Never compromise airway and breathing.



Yeah your C will go to poo as soon as you pull that knife out.


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## spisco85 (Aug 16, 2009)

hyrisk said:


> We can never, ever put someone in a prone position. Heck, doesn't even matter if they need to be restrained in a prone position. :glare: We have to even put them supine and restrain them.



You have to transport people supine all the time? That is awful.


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## JPINFV (Aug 16, 2009)

hyrisk said:


> We can never, ever put someone in a prone position. Heck, doesn't even matter if they need to be restrained in a prone position. :glare: We have to even put them supine and restrain them.



Err, I'm pretty sure that if you say something along the lines of "Well, there's a knife sticking out of their back," I doubt that anyone is going to question it. Additionally, you should never restrain someone prone, but restraining combative patients and just restraining someone for transport is two separate things.


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## Ridryder911 (Aug 16, 2009)

hyrisk said:


> Call base. Get md permission. Abc... Take care of the first two. Likely get permission to pull the knife. Which is c. Never compromise airway and breathing.



I call B.S. on that! Go ask your physician if you they rather you remove an impaled object possibly in the spinal canal or transport prone or lateral? Watch the response, that one would even ask or suggest such.. 


C'mon ..  let's use some basic common sense here. If one has even a half a brain, one can monitor an airway, breathing in a prone and or lateral position. I guess you never heard of "recovery position" as well? 

Time to go back to EMT school. 

R/r 911


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## Brandon O (Aug 17, 2009)

I'm still a little doubtful on prone. Are you suggesting that we might bag someone lying on their stomach? Or the medic might intubate them like that?


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## TransportJockey (Aug 17, 2009)

Brandon Oto said:


> I'm still a little doubtful on prone. Are you suggesting that we might bag someone lying on their stomach? Or the medic might intubate them like that?



I've seen medics intubate someone who is prone, and I've used a combitube on someone who is in that position as well.


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## MrBrown (Aug 17, 2009)

Brandon Oto said:


> I'm still a little doubtful on prone. Are you suggesting that we might bag someone lying on their stomach? Or the medic might intubate them like that?



Common sense would dictate obviously not


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## JPINFV (Aug 17, 2009)

Well, you're kinda of stuck between a rock and a hard place then, because you aren't gonna be pulling that knife out until the patient crashes. Not everything is going to be "ZOMG if I don't do it exactly by the book the patient will die!" Patients are pretty good at not reading the book.


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## Mountain Res-Q (Aug 17, 2009)

This thread is getting kinda weird...  so...  IMAO...

DO NOT TAKE OUT THE KNIFE!!!

Everyone here is going on the assumption that the pt. is unconscious and in need of airway management and assistacne in breathing... so...  NPA, OPA, ETT, and any other airway device can be inserted with a pt. in a lateral postition (even if it ain't what they taught in EMT class).  Do we want the pt. supine?  Heck no!!!  Do we want them prone?  Not the best method for manageing airway and breathing... so lateral will do just fine...  but, wait, what about their spinal issues?  Last time I checked, they are called the ABCs because they come FIRST!  These are life threatening issues.  A _POSSIBLE _lumbar spinal issue is not as important to me as AB... and C (something that could be a huge issue if you remove the knife).  Do I care more about if the spinal cord is cut by the knife... or if the knife has hit one of those vital (blood rich) organs?  On top of that, if the spinal cord is already damaged, all I can do is stabilize the impailed object so as to reduce the likelyhood of further life-threatening damage to vital organs/blood vessels and further spinal damage (what could you cut in the spine if you remove it?).  Therefore, the best method, IMHO, to secure that knife and "do no further harm" is to place the pt. prone if they were conscious and maintaining their own airway and breathing fine... because I want to minimize movement (hard to do lateral in a moving ambo)... but you do what you have to do and lateral may be the best bet if you need to manage the As and Bs in an unconscious pt.  However, since we are all assuming unconsciousness... lets get real... why is he unconscious?  Blood loss make sense to you?  Chances are that the knife hit a vital organ and NO AMOUNT of care is gonna matter, so you do the best you can to maintain the ABCs... spinal issues are in the back of your mind...  and chances of survival are already low... so it is a "lesser of two evils" situation...


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## Ridryder911 (Aug 17, 2009)

Brandon Oto said:


> I'm still a little doubtful on prone. Are you suggesting that we might bag someone lying on their stomach? Or the medic might intubate them like that?



Okay, who said their not breathing or needs to be intubated, etc..? As stated I have intubated prone patients, lateral side etc... Get experienced and it's amazing what you can do. 

There is NO mention in any curriculum or trauma courses of ever removing an object (unless it is is the facial cheek that is obstructing an airway)

Let's use the KISSS method (Keep It Short Simple, Stupid) 
Second, if they are in traumatic arrest, I probably would not be working them... 

R/r 911


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## ResTech (Aug 17, 2009)

Kinda freaky someone is confident in removing the knife! The golden rule is always to NEVER remove an impaled object unless it is causing airway compromise. 

If if lacerated going in... its going to lacerate coming back out!... so in effect it would kinda like you stabbing the patient a second time... think of it that way. 

I agree lateral or prone.. how else are you going to transport them? Several other factors would come into play with that decision but you obviously cant put them on their back with a knife stuck in it.


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## Akulahawk (Aug 17, 2009)

hyrisk said:


> Okay need to clarify and confirm my friends. I got my money on this. There's. Pt with a knife to the smack center of their lumbar. The knife on the back is waving to you hello. What you going to do. C spine, backboard, or what


 My decision is based on how I found the patient and the patient's status. In general, I'd prefer to stablilize with bulky dressings and tape, transport in a Left lateral position. I might use a spineboard for packaging/transfer purposes, but a flat or scoop stretcher works good for that too. Of course, distal neuros would be checked before & after each transfer...

If I'm concerned at all about a spinal cord injury, I'm going to put my patient in the position that MINIMIZES any movement in the area where the knife is. That position will also be one that's comfortable for the patient. It's no use if your patient is constantly wiggling to find a position of comfort and can't because you've got them restrained in a position that causes them more pain/discomfort. If had a vacuum splint backboard setup, I'd use that...

That knife is staying in place. If it's in the L-Spine area, it's not compromising the patient's airway.


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## Ella~Emt15136 (Aug 21, 2009)

This is similar to a question on my NREMT.  That question was "how to manage the airway on an uncon. pt with a knife in the back"  The options were 1)bulky dressing to secure the knife and place pt. on side 2)bulky dressing to secure knife and leave pt. prone 3)pull knife out and place pt. supine 4)pull knife out and start CPR or something crazy like that.
I went with 1.  Not sure if it was correct.


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## JPINFV (Aug 21, 2009)

traumamama said:


> not just spinal inj but also internal. how far did that knife go in?



Considering that it's below L1, depending on the size of the knife there probably isn't any _spinal_ damage because of the caudate equina. The question is what other structures was damaged, and potentially will be damaged, by blindly pulling the knife out.


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## Ridryder911 (Aug 21, 2009)

Ella~Emt15136 said:


> This is similar to a question on my NREMT.  That question was "how to manage the airway on an uncon. pt with a knife in the back"  The options were 1)bulky dressing to secure the knife and place pt. on side 2)bulky dressing to secure knife and leave pt. prone 3)pull knife out and place pt. supine 4)pull knife out and start CPR or something crazy like that.
> I went with 1.  Not sure if it was correct.



The *most * appropriate answer would be to place in prone position as one easily manage an airway in a lateral position. 

The second close answer would be place in a prone position. 

R/r 911


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## TransportJockey (Aug 21, 2009)

Ridryder911 said:


> The *most * appropriate answer would be to place in prone position as one easily manage an airway in a lateral position.
> 
> The second close answer would be place in a prone position.
> 
> R/r 911



He means most appropriate would be lateral


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## AlphaButch (Aug 23, 2009)

I'd go with stabilize and lateral positioning as well. 

There are only a few reasons for removing an impaled object. Necessary to maintain the airway, necessary to do CPR, or necessary for pt. safety.


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## Ridryder911 (Aug 23, 2009)

AlphaButch said:


> I'd go with stabilize and lateral positioning as well.
> 
> There are only a few reasons for removing an impaled object. Necessary to maintain the airway, necessary to do CPR, or necessary for pt. safety.



If one has to do CPR, then it is time to call for notify medical control to stop resucitation efforts. 

R/r 911


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## AlphaButch (Aug 23, 2009)

Perhaps calling in for a cease would be appropriate, and I personally would advise med control in any case. It would really depend on the totality of the circumstances. I was merely informing the written standards for when an impaled object to the back may be removed as per my training.

No CPR = DRT, Remove object + CPR = Possible DRT, Possible spinal injury, Possible recovery. If it were me on the floor, I'd at least want you to give the AED a shot before writing me off.


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## eveningsky339 (Sep 16, 2009)

Mountain Res-Q said:


> DO NOT TAKE OUT THE KNIFE!!!



Thank you!  Removing an impaled object is always a bad idea unless its blocking the airway.  I have no idea why some are advocating removing the knife.  Reminds me of a horror story a doctor told me-- a moronic surgical resident thought it would be a good idea to take a screwdriver out of a patient's head...


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## fiddlesticks (Sep 16, 2009)

Id transport the pt in the lateral postion and stabilize the knife,(was never taught to remove an impaled object not sure what they teach you in the us.) and stop any major bleeding, put and NRB on and get a line going and make tracks.


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## ah2388 (Sep 16, 2009)

*1st post*

Kind of hard to believe that there are people here trying to justify pulling the knife straight away.

With the group here, if CPR was required and the blade was compromising it, I'm calling MD for orders to stop CPR, and if for whatever reason I dont do that, I'm sure calling MD to get orders to pull that knife in order to continue.

In this case, transport A & O pt lateral or prone, take extra precautions to stabilize the blade to try to keep it from moving around during transport.


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## eveningsky339 (Sep 16, 2009)

ah2388 said:


> Kind of hard to believe that there are people here trying to justify pulling the knife straight away.
> 
> With the group here, if CPR was required and the blade was compromising it, I'm calling MD for orders to stop CPR, and if for whatever reason I dont do that, I'm sure calling MD to get orders to pull that knife in order to continue.
> 
> In this case, transport A & O pt lateral or prone, take extra precautions to stabilize the blade to try to keep it from moving around during transport.



That's really all there is to it.  Other than complications with performing CPR, this is a straightforward scenario per training even at the basic level.


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## Mountain Res-Q (Sep 16, 2009)

ah2388 said:


> Kind of hard to believe that there are people here trying to justify pulling the knife straight away.
> 
> With the group here, *if CPR was required and the blade was compromising it*, I'm calling MD for orders to stop CPR, and if for whatever reason I dont do that, I'm sure calling MD to get orders to pull that knife in order to continue.
> 
> In this case, transport A & O pt lateral or prone, take extra precautions to stabilize the blade to try to keep it from moving around during transport.



Once again (as we are revisting this crazy thread)... If CPR is needed with a knife inpalement, the reason for the arrest is likely a result of the knife...  THEY ARE DEAD!!!  Unless they were stabbed and coded in a Trauma Center they do not stand a chance...  in which case, we still do not remove the knife... the investigator and coroner will be pretty pissed if you tamper with the evidence...

Need CPR...  DEAD... Leave Knife

No need for CPR...  Remove Knife...  DEAD

Patient Stable... Leave Knife in... Bulk Dressing...  Place patient in a postition of comfort that does not have the potential to cause more damage... IVs...  mointor... supportive care... transport very gently...  and for Gods Sake... DO NOT REMOVE THE KNIFE unless you want to be the one the invesigators, the coroner, and State EMS are investigating...  (any meaningful treatment that has a chance of saving an unstable patient can be done with a patient not in a suppine position!)


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## ah2388 (Sep 16, 2009)

I mainly meant to emphasize that I'm never pulling the knife wo orders that's all


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## EMSLaw (Sep 16, 2009)

This sounds like a situation where the absolute best thing that can be done for the patient is rapid transportation to a trauma center.  Especially since this is in the BLS forum - ALS-level practitioners might have a few more tricks up their sleeve, but even paramedics aren't trauma surgeons.  

An impaled object is not something that can be effectively treated in the field.  If you stay and play with a backboard, the patient may bleed out.  Time to kick it old school - ABCs, stabilize the object with bulky dressings, then scoop and run for the hospital.


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## JPINFV (Sep 16, 2009)

I imagine that the absolute best thing for the patient was to avoid being stabbed in the first place...


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## arsenicbassist (Sep 16, 2009)

*i must agree*



JPINFV said:


> I imagine that the absolute best thing for the patient was to avoid being stabbed in the first place...



HAHAHA, I would have to say the same thing. Lateral placement would be the best though. If it's smack dab center, you can assume it has not damage caudal equina and probably attempt testing of dermatomes. And counsel pt on the importance of bringing a gun to a knife fight.


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## JPINFV (Sep 16, 2009)

arsenicbassist said:


> If it's smack dab center, you can assume it has not damage caudal equina and probably attempt testing of dermatomes. And counsel pt on the importance of bringing a gun to a knife fight.



Unless your a Johns Hopkins student with a samurai sword.


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## arsenicbassist (Sep 16, 2009)

*samurai swords*

In that case, we're all screwed!


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## ah2388 (Sep 17, 2009)

keep in mind, that in my state anyway...EMT B's have to call MD to receive permission to fore go or stop revival efforts


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## Bosco578 (Sep 17, 2009)

hyrisk said:


> Okay need to clarify and confirm my friends. I got my money on this. There's. Pt with a knife to the smack center of their lumbar. The knife on the back is waving to you hello. What you going to do. C spine, backboard, or what


 
Point and Laugh....:glare:


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## wvditchdoc (Sep 17, 2009)

Brandon Oto said:


> I'm still a little doubtful on prone. Are you suggesting that we might bag someone lying on their stomach? Or the medic might intubate them like that?


 
Seriously? :glare:  Walks away shaking his head......


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## TransportJockey (Sep 17, 2009)

wvditchdoc said:


> Seriously? :glare:  Walks away shaking his head......



Yea, there's a lot of that feeling


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## EMSLaw (Sep 17, 2009)

JPINFV said:


> I imagine that the absolute best thing for the patient was to avoid being stabbed in the first place...



Ah, but at that point, he wasn't a patient.  He became a patient when the ambulance showed up.  

Though maybe one of the local SuperEMTs or Paragods has the ability to reverse the flow of time and stop the stabbing, giving a new meaning to 'preventative medicine'.


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## Brandon O (Sep 17, 2009)

wvditchdoc said:


> Seriously? :glare:  Walks away shaking his head......



Anything I can clarify for you?


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## arsenicbassist (Sep 17, 2009)

EMSLaw said:


> Ah, but at that point, he wasn't a patient.  He became a patient when the ambulance showed up.
> 
> Though maybe one of the local SuperEMTs or Paragods has the ability to reverse the flow of time and stop the stabbing, giving a new meaning to 'preventative medicine'.



I'm working on that, but I can't quite get the 1.21 gigawatts I need to get this DeLorean to freakin' work.

Cheers


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## wvditchdoc (Sep 17, 2009)

Brandon Oto said:


> Anything I can clarify for you?


 
_*Of course*_ you can bag someone on their stomach, intubate in other than the normal "flat on their back" position, and immobilize a patient in other than the supine position. Is it ideal? Is it the norm? No way, but not everything you encounter on the streets fits in the perfect little scenario you did in class or that is outlined in your protocols. 

Bit of a hijack here...have you ever immobilzed a child in a car seat with a towel and some tape? Have you ever had to "make do" with what you had available to you because the patient just didn't fit? 

One needs to approach Emergency Medicine with an open mind and learn from other's experiences. To look at things from one point of view based on limited personal experience or "because my protocol(s)/company policy says so" is absolutely insane.


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## EMSLaw (Sep 17, 2009)

With enough cravats and duct tape, anything is possible!


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## Brandon O (Sep 17, 2009)

wvditchdoc said:


> _*Of course*_ you can bag someone on their stomach, intubate in other than the normal "flat on their back" position, and immobilize a patient in other than the supine position. Is it ideal? Is it the norm? No way, but not everything you encounter on the streets fits in the perfect little scenario you did in class or that is outlined in your protocols.



Okay. It really was just a query, kind sir.

I've never bagged a prone patient and imagine it might be tough getting a seal; I'll take your word for it. And I have no idea how a medic would feel about intubating someone like that, and assumed it would be extremely difficult; again, apparently not. How would you visualize the airway? Would you crouch down?

Lateral was my preference anyway...



> Bit of a hijack here...have you ever immobilzed a child in a car seat with a towel and some tape? Have you ever had to "make do" with what you had available to you because the patient just didn't fit?



You can attach anything to anything with tape and tourniquets <_<

Actually, although I haven't done it, I seem to recall the car seat thing (towel, tape and all) was taught in my EMT course. Some practicalities do make their way from the field to the classroom.



> One needs to approach Emergency Medicine with an open mind and learn from other's experiences. To look at things from one point of view based on limited personal experience or "because my protocol(s)/company policy says so" is absolutely insane.



I agree. I guess you're just venting.


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