# No C-Spine... Right call?



## Zredmond (May 29, 2015)

Went on a call to a reported fall. Upon arrival found a 35 y.o male who reportedly fell from unknown height in warehouse. Found pool of blood, and broken teeth at sight of fall. Located next to shelves that go approx 25' high. Pt was AAOx2. BP 145/90. HR: 140, everything else who. We started c-spine precautions, medic arrived and told us to remove collar and lift pt onto gurney. I'm not playing Monday morning qb, but is this the right call given situation?


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## EMSComeLately (May 29, 2015)

No...for our selective spinal protocol, GCS under 15 and patient inability to take role in their care to describe pain, location, etc., would buy a board.


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## Jim37F (May 29, 2015)

First and foremost what do your protocols say? Are they a hard and fast "You will board and collar these patients" with no consideration to actual patient condition, or does it give you leeway to decide different levels of SMR based on patient assessment (I.e. full board and collar, collar and position of comfort on gurney, neither, etc) What follow on assessment did the medics do? What was the distal CMS in all four extremities? Was the patient moving around at all, attempting to sit/stand up? Any other injuries besides the broken teeth, where was the bleeding from? How well was the patient tolerating the collar to begin with? (We once had an auto vs. scooter patient we put in a collar, and he immediately began gagging so we took it off) 


FWIW a trauma patient here, with a fall greater than 15 feet, head injury, and ALOC would get a full board and collar and transport to the local Level I or II trauma center (depending on which one is closer), but LA Co SMR policy is still a bit more restrictive than a lot of other places lol


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## TheLocalMedic (May 29, 2015)

I guess my question is in regard to the "unknown height".  Does that mean he could have fallen from something up high?  If he was next to those high shelves, he's ALOC (and the tachycardia is interesting too) I would think that would buy him a board.


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## Zredmond (May 29, 2015)

He didn't even know he fell. But it was next to shelves, that go up to about 25'. Yeah, he was definitely altered.


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## Zredmond (May 29, 2015)

Jim37F said:


> First and foremost what do your protocols say? Are they a hard and fast "You will board and collar these patients" with no consideration to actual patient condition, or does it give you leeway to decide different levels of SMR based on patient assessment (I.e. full board and collar, collar and position of comfort on gurney, neither, etc) What follow on assessment did the medics do? What was the distal CMS in all four extremities? Was the patient moving around at all, attempting to sit/stand up? Any other injuries besides the broken teeth, where was the bleeding from? How well was the patient tolerating the collar to begin with? (We once had an auto vs. scooter patient we put in a collar, and he immediately began gagging so we took it off)
> 
> 
> FWIW a trauma patient here, with a fall greater than 15 feet, head injury, and ALOC would get a full board and collar and transport to the local Level I or II trauma center (depending on which one is closer), but LA Co SMR policy is still a bit more restrictive than a lot of other places lol


I was with fire, and a third party ambulance showed up for transport. That's when the medic took off our collar.


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## Zredmond (May 29, 2015)

TheLocalMedic said:


> I guess my question is in regard to the "unknown height".  Does that mean he could have fallen from something up high?  If he was next to those high shelves, he's ALOC (and the tachycardia is interesting too) I would think that would buy him a board.


I definitely agree, but defined wasn't going to question a medic.


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## Anjel (May 29, 2015)

Zredmond said:


> I definitely agree, but defined wasn't going to question a medic.



Sometimes medics need to be questioned, but at an appropriate time and place. 

He would of got a collar from me. Not a board.


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## Zredmond (May 29, 2015)

Anjel said:


> Sometimes medics need to be questioned, but at an appropriate time and place.
> 
> He would of got a collar from me. Not a board.


Thank you for the input. I agree on at least the collar. I realize we are human beings and we aren't perfect.


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## BOS 101 (May 29, 2015)

Zredmond said:


> Thank you for the input. I agree on at least the collar. I realize we are human beings and we aren't perfect.


honestly, with him being altered and a possible moi like that(blood and teeth on the ground) i would have done full c-spine and ignored the medic
Sorry medic, but thats just a risky call for the patient, and just plain stupid really given the circumstances
Not even a collar? foolish, remember paramedics are individuals, some arent very good, cuz theyre lazy or stupid, same with police, nurses or whatever
they give everyone else a bad name, so we should stop them from making those calls (appropriately), and making us look bad


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## DesertMedic66 (May 29, 2015)

Dakota said:


> honestly, with him being altered and a possible moi like that(blood and teeth on the ground) i would have done full c-spine and ignored the medic
> Sorry medic, but thats just a risky call for the patient, and just plain stupid really given the circumstances
> Not even a collar? foolish, remember paramedics are individuals, some arent very good, cuz theyre lazy or stupid, same with police, nurses or whatever
> they give everyone else a bad name, so we should stop them from making those calls (appropriately), and making us look bad


So if the medic said "hey guys let's not c-spine him" you would have said "too bad, I'm still going to c-spine hime" regardless of the fact that the medic has more training that yourself, and that in thr majority of systems the person with the highest medical training is in charge of patient care? Ooh man, you would have a wonderful time if you did that in the majority of systems (by wonderful I mean calls to your supervisors, write ups, and whatever else could be thrown at you)


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## CALEMT (May 29, 2015)

Anjel said:


> He would of got a collar from me. Not a board.



Same here. With the new spinal immob. protocols they have to meet one of the NSAID requirements. I'm fine with a collar and a position of comfort. But if the medic downgrades then so be it, his decision, his license/ p-card on the line if anything happens.


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## Carlos Danger (May 29, 2015)

You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed? 

That medic sounds like one of those paramedics that gives EMS a bad image.


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## Zredmond (May 29, 2015)

Remi said:


> You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?
> 
> That medic sounds like one of those paramedics that gives EMS a bad image.


That kinda left a bad taste in all of our mouths. The other firefighters and myself were incredibly confused, but we just packed up and went on our way. Plus the tachycardia really doesn't show this guy is in good health


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## Zredmond (May 29, 2015)

CALEMT said:


> Same here. With the new spinal immob. protocols they have to meet one of the NSAID requirements. I'm fine with a collar and a position of comfort. But if the medic downgrades then so be it, his decision, his license/ p-card on the line if anything happens.


Just for my own knowledge, the controversy isn't over collars, it's over LSBs correct?


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## Amelia (May 29, 2015)

If his teeth were smashed in, he hit his head. Hit the head, you crank the neck/spine..... and when in doubt immobilize. And who tells you to take a serious precaution off once its been placed?! Uggg.... I hope the guy is ok.


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## CALEMT (May 29, 2015)

Zredmond said:


> Just for my own knowledge, the controversy isn't over collars, it's over LSBs correct?



Correct.


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## LACoGurneyjockey (May 29, 2015)

Dakota said:


> honestly, with him being altered and a possible moi like that(blood and teeth on the ground) i would have done full c-spine and ignored the medic
> Sorry medic, but thats just a risky call for the patient, and just plain stupid really given the circumstances
> Not even a collar? foolish, remember paramedics are individuals, some arent very good, cuz theyre lazy or stupid, same with police, nurses or whatever
> they give everyone else a bad name, so we should stop them from making those calls (appropriately), and making us look bad


Dat MOI doe...
So you know better than everyone else ever on scene with you? When there is a paramedic with a higher level of education than you, you do what you wanna do because you're right and JESUS LOOK AT THAT MECHANISM!
If you tried that with me you'd be kindly asked to leave my scene, and I'd have your supervisor on the phone. You're ridiculous. Not your patient, not your call once there is a higher level of care on scene. 
Do you go around stopping "lazy and stupid" cops too?


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## BOS 101 (May 30, 2015)

DesertEMT66 said:


> So if the medic said "hey guys let's not c-spine him" you would have said "too bad, I'm still going to c-spine hime" regardless of the fact that the medic has more training that yourself, and that in thr majority of systems the person with the highest medical training is in charge of patient care? Ooh man, you would have a wonderful time if you did that in the majority of systems (by wonderful I mean calls to your supervisors, write ups, and whatever else could be thrown at you)


 
Well to put it simply, im just being passionate
Obviously I know that the medic has ultimate final say BUT it is obviously stupid to not take cspine precautions here
I would bug and bug the medic as much as I could before I went with it his way, and even then I would talk to his boss afterward
Im not stupid, I realize it wouldnt be beneficial to sit and argue on scene either, but If you think no cspine here is smart, or that this medic is defendable, please show me how


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## BOS 101 (May 30, 2015)

LACoGurneyjockey said:


> Dat MOI doe...
> So you know better than everyone else ever on scene with you? When there is a paramedic with a higher level of education than you, you do what you wanna do because you're right and JESUS LOOK AT THAT MECHANISM!
> If you tried that with me you'd be kindly asked to leave my scene, and I'd have your supervisor on the phone. You're ridiculous. Not your patient, not your call once there is a higher level of care on scene.
> Do you go around stopping "lazy and stupid" cops too?


 
Ok so you seem a little personally offended, not sure why
And, its not an over reaction, If a guy possibly fell over 20 feet and landed on his head is that not a big deal??
The kind of big deal that cspine precautions freaking exist for?
ME ridiculous? You are ridiculous, If you dont think I'm right that he needs cspine, quite frankly you're foolish
This whole "MOI means nothing" thing that people pull seems to have gotten out of hand
I dont have some massive ego, nor think im always right, but i know how to take care of a patient, and I would urge the medic in this case to change his tune if possible or talk to his boss
Dont be so ridiculous yourself, you act like you're 12 geez


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## Zredmond (May 30, 2015)

Amelia said:


> If his teeth were smashed in, he hit his head. Hit the head, you crank the neck/spine..... and when in doubt immobilize. And who tells you to take a serious precaution off once its been placed?! Uggg.... I hope the guy is ok.


I couldn't agree with you more. But what else can we do


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## LACoGurneyjockey (May 30, 2015)

Dakota said:


> Ok so you seem a little personally offended, not sure why
> And, its not an over reaction, If a guy possibly fell over 20 feet and landed on his head is that not a big deal??
> The kind of big deal that cspine precautions freaking exist for?
> ME ridiculous? You are ridiculous, If you dont think I'm right that he needs cspine, quite frankly you're foolish
> ...


My issue was that you said you'll c-spine him anyway regardless of what the higher level of care had to say. Sure, follow your protocols and c-spine him, but don't try and disregard someone with more education (and patient care authority by the way) because you think your way is the right way.
The mechanism tells you what exactly? He's altered and has facial trauma, and he's tachy enough to believe he's bleeding elsewhere. What more do you want to infer from moi?


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## BOS 101 (May 30, 2015)

LACoGurneyjockey said:


> My issue was that you said you'll c-spine him anyway regardless of what the higher level of care had to say. Sure, follow your protocols and c-spine him, but don't try and disregard someone with more education (and patient care authority by the way) because you think your way is the right way.
> The mechanism tells you what exactly? He's altered and has facial trauma, and he's tachy enough to believe he's bleeding elsewhere. What more do you want to infer from moi?


 
 Well that was me just being passionate, I wouldnt have a fight with the medic cuz that benefits no one
But i would tell him that I would talk to his boss and report it all
I know all of that, higher authority and all, but a dumb move is a dumb move, I dont need to be a medic to know that c spine is indicated heavily, i dont think im right, i know i am
I promise, im not trying to be macho or anything ofcourse i would try to be respectful about it, but patient care first
And the significant moi simply indicates cspine, thats my whole point, along with him being altered
Now im asking you, what do you think of the medics decision?


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## DesertMedic66 (May 30, 2015)

Dakota said:


> Well to put it simply, im just being passionate
> Obviously I know that the medic has ultimate final say BUT it is obviously stupid to not take cspine precautions here
> I would bug and bug the medic as much as I could before I went with it his way, and even then I would talk to his boss afterward
> Im not stupid, I realize it wouldnt be beneficial to sit and argue on scene either, but If you think no cspine here is smart, or that this medic is defendable, please show me how


Without knowing the system, protocols, or more information on the call it is hard to say one way or not. 

I never stated that I would c-spine the patient or not. I didn't even state if I felt the medic made the right call or not. I only brought up the fact that you would disregard the medics decision on a call and ignore him (as you stated), and how that would create a huge issue and more than likely end up with you being thrown off scene and a lovely call to your supervisors. 

Maybe I'm being an entitled ParaGod but once I'm on scene that patient is mine and I make all the choices. I am more than welcome to listen to input but if you disregard my patient care that will not end very well (I'll just politely ask you to get off my call and when the call is over we will have a come to Jesus meeting).


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## Mufasa556 (May 30, 2015)

Ignoring the medics directions? Getting on the blower to their boss? Notifying supervisors? Let's all slow down. 

My best advice for these situations, whether on a CCT shift or 911 medic unit, is follow the directions of your RN of medic on scene. When the calls over, seek them out and, in a non confrontational manner, ask them to explain why they did things the way they did and explain why you thought it should have been done differently. Even if it's condescending, I've found even the grouchiest medic or RN will take the time to explain their thinking and why they handled things a certain way. With their experience and/or higher level of education, they may have noted something you didn't. By asking those involved, In all but maybe a handful of calls, I've learned a little bit more about medicine and came away a little smarter.

If you're not satisfied with the answers and still feel the need to follow through with the "boss", go ahead, but always come to the person and try to start a dialogue first. You may learn something rather than starting a fight with your coworkers.


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## PotatoMedic (May 30, 2015)

Im just going to leave this here. 
The Journal of Trauma. 2010 Jan; 68; discussion 120-1.

Name of Article– Spine Immobilization in penetrating trauma: more harm then good?

Immobilization is “a tradition that started decades ago” said Dr. Demetriades. “There was never any scientific evidence that it works.”

The author reports first responders would have to immobilize 1,032 patients before potentially benefiting one person. While it only took immobilizing 66 patients before potentially contributing to a death.  

Some other bullet points.

MOI is a very poor predictor of spinal injury.

A proper Physical Assessment can rule out most spinal injuries.

Most EMS protocols call for unnecessary spinal immobilization.


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## PotatoMedic (May 30, 2015)

I will add I know that it is regarding penetrating trauma.  But it still has some interesting information regarding the effectiveness of backboards.


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## Akulahawk (May 30, 2015)

Dakota said:


> Well that was me just being passionate, I wouldnt have a fight with the medic cuz that benefits no one
> But i would tell him that I would talk to his boss and report it all
> I know all of that, higher authority and all, but a dumb move is a dumb move, I dont need to be a medic to know that c spine is indicated heavily, i dont think im right, i know i am
> I promise, im not trying to be macho or anything ofcourse i would try to be respectful about it, but patient care first
> ...


Mechanism indicates NOTHING but a potential for injury. You can have a most amazingly awesome MOI and not have actual injury at all. All injury will have a positive mechanism. All of them. What you need to learn is how to _read_ the MOI. 

Once you learn that, you'll find that MOI will tell you where to look for a potential injury, but you still have to take the next step and look for injury. Will I place someone in spinal motion restriction? Yes, if it's indicated. In this particular instance, there's a spectacular potential MOI and some injury that supports a blow to the head. Great! If the patient is moving all his fingers and toes, chances are quite good that the cord hasn't been severed. That the patient is "altered" simply tells me that there's a high possibility of a closed head injury. No crepitus and no step-offs and I'm not likely to put the patient on a LSB. I might put a collar on though.

I agree with the other posters here about asking that Paramedic about the reasoning behind the removal of SMR from that patient. You might learn something _other_ than how to blindly follow protocol.


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## BOS 101 (May 30, 2015)

DesertEMT66 said:


> Without knowing the system, protocols, or more information on the call it is hard to say one way or not.
> 
> I never stated that I would c-spine the patient or not. I didn't even state if I felt the medic made the right call or not. I only brought up the fact that you would disregard the medics decision on a call and ignore him (as you stated), and how that would create a huge issue and more than likely end up with you being thrown off scene and a lovely call to your supervisors.
> 
> Maybe I'm being an entitled ParaGod but once I'm on scene that patient is mine and I make all the choices. I am more than welcome to listen to input but if you disregard my patient care that will not end very well (I'll just politely ask you to get off my call and when the call is over we will have a come to Jesus meeting).



Dont get me wrong, I whole heartedlly support and look up to medics, they are awesome
but this is just a case of an individual making a bad decision and my attitude towards him
I ofcourse would be appropriate about how I would deal with it, and ignoring him was an exaggeration i didnt expect to be taken literally, to clarify that
And i totally respect your authority as the higher level of care, and if you are on scene i got your back, and i would especially appreciate that you would listen to my concerns
Its not about rebelling against his authority, just that (to me at least) this seems very black and white, and I would have urged and pushed for cspine precautions, I believe the patient would be in endangered without taking them


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## BOS 101 (May 30, 2015)

FireWA1 said:


> I will add I know that it is regarding penetrating trauma.  But it still has some interesting information regarding the effectiveness of backboards.


 
Is any of that (specifically the 1032 before it helps one patient) accurate at all regarding blunt trauma?
I would hope the numbers are different for that
this is interesting but some of my protocols say that penetrating trauma without neuro deficits dont need cspine anyway


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## BOS 101 (May 30, 2015)

Akulahawk said:


> Mechanism indicates NOTHING but a potential for injury. You can have a most amazingly awesome MOI and not have actual injury at all. All injury will have a positive mechanism. All of them. What you need to learn is how to _read_ the MOI.
> 
> Once you learn that, you'll find that MOI will tell you where to look for a potential injury, but you still have to take the next step and look for injury. Will I place someone in spinal motion restriction? Yes, if it's indicated. In this particular instance, there's a spectacular potential MOI and some injury that supports a blow to the head. Great! If the patient is moving all his fingers and toes, chances are quite good that the cord hasn't been severed. That the patient is "altered" simply tells me that there's a high possibility of a closed head injury. No crepitus and no step-offs and I'm not likely to put the patient on a LSB. I might put a collar on though.
> 
> I agree with the other posters here about asking that Paramedic about the reasoning behind the removal of SMR from that patient. You might learn something _other_ than how to blindly follow protocol.


 
well its not about blindly following protocol
Like you said, significant moi, altered, and obvious trauma to the face/head
The chance of spinal injury is high(my speculation) and your right, assess
But even without current deficits, I would still want to immobilize(at least a collar) so that nothing gets worse while moving him, and then he shows deficits and such
Because he's altered, you cant reliably palpate his spine for pain(depending, I wasnt there but this could be true) and even with no step ups or drop offs there can be things that are there that we cannot see or feel
Thats the whole reason we take the precautions, so the ER doc can determine when to safely abandon precautions
I dont mean that every little fall or trauma is getting precautions, if its no big deal and they arent complaining of neck or back pain yadda yadda then i would rule it out and go, use our judgement and all
I really like your point about reading the moi, thats a great point that not a lot of people get


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## PotatoMedic (May 30, 2015)

I think this will be a good read for you.  All the facts are cited to studies.

http://www.emsworld.com/article/10964204/prehospital-spinal-immobilization


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## Ensihoitaja (May 30, 2015)

Remi said:


> You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?



I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined that patient, though.


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## BOS 101 (May 30, 2015)

Ensihoitaja said:


> I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined that patient, though.


I back that


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## Akulahawk (May 30, 2015)

Dakota said:


> well its not about blindly following protocol
> Like you said, *significant* moi, altered, and obvious trauma to the face/head unknown, was apparently unwitnessed
> *The chance of spinal injury is high(my speculation) and your right, assess *Just your speculation. You're stuck on MOI. Assessment will generally yield a physiologic or anatomic problem, if present.
> But even without current deficits, I would still want to immobilize(at least a collar) so that nothing gets worse while moving him, and then he shows deficits and such
> ...


I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.


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## BOS 101 (May 30, 2015)

Akulahawk said:


> I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.



Yes but because he is altered (well depending on how altered) He isnt necessarily reliable to rule out cspine
And the MOI isnt the only reason i would use precautions, the broken teeth and blood mean he hit his head so now the MOI has a tangible injury on him that i can look at and say, hey that all went straight to his head and neck, he could have something wrong
And i respect what you say about assessing, but even with nothing present beyond the head trauma i would like to use a collar just to immobilize the neck(I agree LSB's are somewhat useless and over used) but on the same token to cover my *** I would go full c spine in reality
You can kinda say You're right, MOI does mean something big here to me cuz its possibly so big and just because he may not have any current deficits, doesnt mean I wanna say forget cspine and then something happen to him enroute
I'm Saying i would prefer to take precautions here, mainly because he is altered and there is obvious trauma with sigMOI, so that I do no harm
This putting the studies about spinal precautions aside for now, until they become protocol and can save my ***, and prove beyond a doubt that precautions arent needed


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## BOS 101 (May 30, 2015)

Akulahawk said:


> I think you haven't quite found my point. I'm not saying that I would or wouldn't have put this patient in SMR. I'm saying that without a good assessment and seeing the potential MOI's involved (which will help point me toward a more specific assessment), I won't be able to make that call. My own suspicion is that there's likely no C-Spine injury, but perhaps a more significant CHI.


 So to make it simple and avoid being to vague, I agree with what you say about assessing further
BUT to me the MOI with head trauma(and likely neck in that case) And an altered status is enough for me personally to want the patient in precautions
It is your call with your patients, and i know that it is complicated because we werent there for the actual call to get any more info, but tell me what would you see to make you not want precautions, and what would make you want precautions(aside from the obvious)?


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## Tigger (May 30, 2015)

I was going to do a whole big multi quote, but then again...

*No spinal motion restriction techniques used by EMS have ever been shown to have any sort of benefit to patients. *

Would I have placed this guy on a vacuum mattress? You bet, that's what my protocols dictate for altered patient who has fallen from an unknown height. But I am not deluding myself into thinking it's making a lick of difference.

So for the newer providers here that think c-spine is so important, please prove it. Passion is great and all, but medicine requires us to justify our treatments with more than that.


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## Medic Tim (May 30, 2015)

Obviously follow your guidelines.....But protocols and what is right for your pt can be at odds with one another. EMS is riddled with bro science, anecdote and tradition. Thankfully the tide is shifting towards evidence based medicine and science based medicine. 
It is very difficult for many to accept change or accept the fact that what they have been doing for years... And told was saving lives...... Actually doesn't.... And can make it worse.
Because we have always done it that way is one of the scariest phrases you can hear.
It doesn't help that our training is skills focused ... And many have no idea why we do certain things let alone the science behind it. Many thankfully take their education into their own hands and fill the gap.


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## BOS 101 (May 30, 2015)

Tigger said:


> I was going to do a whole big multi quote, but then again...
> 
> *No spinal motion restriction techniques used by EMS have ever been shown to have any sort of benefit to patients. *
> 
> ...


Fair enough and when it comes to LSB i have a gripe
But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
As far as Collars, what is your opinion?


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## BOS 101 (May 30, 2015)

Medic Tim said:


> Obviously follow your guidelines.....But protocols and what is right for your pt can be at odds with one another. EMS is riddled with bro science, anecdote and tradition. Thankfully the tide is shifting towards evidence based medicine and science based medicine.
> It is very difficult for many to accept change or accept the fact that what they have been doing for years... And told was saving lives...... Actually doesn't.... And can make it worse.
> Because we have always done it that way is one of the scariest phrases you can hear.
> It doesn't help that our training is skills focused ... And many have no idea why we do certain things let alone the science behind it. Many thankfully take their education into their own hands and fill the gap.


But unfortunately it puts you in the spot of, do I follow protocol or put my butt in harms way
An unfortunate dilemma, I just dont want to test what I can get away with either


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## Medic Tim (May 30, 2015)

Dakota said:


> But unfortunately it puts you in the spot of, do I follow protocol or put my butt in harms way
> An unfortunate dilemma, I just dont want to test what I can get away with either


I have a lot of leeway where I work. We also have a great medical director who encourages .... Expects us to deviate as our guidelines are just that... Guidelines.

As for c-collars.... I am not a fan. I would like to see the soft collars come back.... Assuming they will have benefit.
I am in my phone so k can't post studies but there are many out there showing c-collars are frequent applied wrong, not sized right and like lsb just don't do what they are hyped to do. There is a great video somewhere showing a c-collar being applied to a cadaver under x-ray of fluoroscopy. The amount of cervical manipulation and traction was unreal.


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## NomadicMedic (May 30, 2015)

> Fair enough and when it comes to LSB i have a gripe
> But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
> Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
> As far as Collars, what is your opinion?




I'll bet everyone is happy that YOU view collars as useful, because you've seen doctors use them.

SMH


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## Tigger (May 30, 2015)

Dakota said:


> Fair enough and when it comes to LSB i have a gripe
> But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
> Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
> As far as Collars, what is your opinion?



I use them on low risk patients because I am told to. Most c-collar applications I see are done with poorly fitted collars, which we know do nothing, and possibly hyperextend the patient, which is potentially detrimental. There is also some research showing that cervical collars may increase ICP, which can be detrimental as well.

The body does a pretty good job of self splinting after injury and a few pieces of soft plastic are not likely to improve that.

Here's a recent Dr. Bledsoe article with a variety of studies included. 
http://www.jems.com/articles/print/.../why-ems-should-limit-use-rigid-cervical.html

As and aside, "circumstantial statistics bs" probably beats the rationale of "a doctor uses one so therefore so do I."


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## BOS 101 (May 30, 2015)

Medic Tim said:


> I have a lot of leeway where I work. We also have a great medical director who encourages .... Expects us to deviate as our guidelines are just that... Guidelines.
> 
> As for c-collars.... I am not a fan. I would like to see the soft collars come back.... Assuming they will have benefit.
> I am in my phone so k can't post studies but there are many out there showing c-collars are frequent applied wrong, not sized right and like lsb just don't do what they are hyped to do. There is a great video somewhere showing a c-collar being applied to a cadaver under x-ray of fluoroscopy. The amount of cervical manipulation and traction was unreal.



I just read up on that thanks to our friend, i had heard some stuff but i dont like to jump into anything without some proper sources
I too would like to see the soft collars put to the test and hopefully they could be of more use
cspine also gets more negative reaction due to human error in application, not defending all of it but its a fair point


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## BOS 101 (May 30, 2015)

DEmedic said:


> I'll bet everyone is happy that YOU view collars as useful, because you've seen doctors use them.
> 
> SMH


I mean doctors tend to be decently trained, and its something i'm using as reasoning not forcing anything on you so no need to be spiteful


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## BOS 101 (May 30, 2015)

Tigger said:


> I use them on low risk patients because I am told to. Most c-collar applications I see are done with poorly fitted collars, which we know do nothing, and possibly hyperextend the patient, which is potentially detrimental. There is also some research showing that cervical collars may increase ICP, which can be detrimental as well.
> 
> The body does a pretty good job of self splinting after injury and a few pieces of soft plastic are not likely to improve that.
> 
> ...



That was a very good read, thank you, There is all too much to read about and look into in there I will have to do some more studying
I would like to see soft collars and vacuum mattress put to the test, and the natural splinting of your body i wonder how long it lasts 
Anyway, I don't mean to seem mindless or "o i just do what the doc says" but its the same as listening to the medic which everyone threw a fit about beforehand so i see it as justifiable when considering Rx
But this link is very cool, thanks


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## NomadicMedic (May 30, 2015)

Dakota said:


> I mean doctors tend to be decently trained, and its something i'm using as reasoning not forcing anything on you so no need to be spiteful



As you gain experience you'll see plenty of doctors do plenty of things that are no where near reasonable. 

However, they have a fair amount of education and are licensed to kill. You, on the other hand, have around 120 hours of basic first aid education and really lack the knowledge to make any real decisions as to treatment modality except "mongo put on board". 

Not being spiteful, I'm just sayin'.


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## BOS 101 (May 30, 2015)

DEmedic said:


> As you gain experience you'll see plenty of doctors do plenty of things that are no where near reasonable.
> 
> However, they have a fair amount of education and are licensed to kill. You, on the other hand, have around 120 hours of basic first aid education and really lack the knowledge to make any real decisions as to treatment modality except "mongo put on board".
> 
> Not being spiteful, I'm just sayin'.



I get that, like i said much earlier in the thread every medical professional is an individual and even a doctor can be a dummy but as a general rule a doctor is a decent person to take tips from, I work in an ER currently and know bad ones and good ones
And im not trying to make all the decisions or do anything other than what i should(if thats what youre getting at\wording threw me off sorry), protocol (even if its outdated) still sides with smr for most occasions 
Thanks for the input


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## Carlos Danger (May 30, 2015)

Ensihoitaja said:


> I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined *that* patient, though.


Well clearly, we are talking about that patient....


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## Akulahawk (May 30, 2015)

Dakota said:


> Yes but because he is altered (well depending on how altered) He isnt necessarily reliable to rule out cspine
> And the MOI isnt the only reason i would use precautions,* the broken teeth and blood mean he hit his head so now the MOI has a tangible injury* on him that i can look at and say, hey *that all went straight to his head and neck*, he could have something wrong
> And i respect what you say about assessing, but even with nothing present beyond the head trauma i would like to use a collar just to immobilize the neck(I agree LSB's are somewhat useless and over used) but on the same token to cover my *** I would go full c spine in reality
> You can kinda say You're right, MOI does mean something big here to me cuz its possibly so big and just because he may not have any current deficits, doesnt mean I wanna say forget cspine and then something happen to him enroute
> ...


Is there "obvious trauma" present? Yes, to the teeth/mouth. What's the MOI? If you know that, does the MOI show a transfer of force to the cervical spine? It's easily possible to cause injury to the teeth/mouth without transferring any significant forces to the c-spine while causing a concussion. Ever watch a boxing match? 

I'm not saying that you're necessarily wrong, just that you have much to learn, one of which is to discard the idea of "significant MOI" because MOI alone doesn't mean much. 

If I walked up to  you and slammed your right tibia with a 20# sledge hammer, there's MOI for potential tibial fracture. You fall to the floor in an "unwitnessed" manner because other than you and I, there were no other witnesses, and I'm gone...When you fell, you kind of collapsed toward the right and somehow managed to slow your fall with an outstretched right arm. There's now MOI for wrist/forearm injury. You remain very still on the floor until EMS shows up. They want to put  you in c-spine precautions because you're apparently altered (babbling something about a guy with a sledge hammer and otherwise screaming a lot), you're in a setting of trauma, and you might have hit  your head when you fell (you didn't and there are no lumps/bumps or c-spine step-offs). Oh, and you somehow managed to bite your tongue while falling and jarred some teeth when you landed so you now have some oral bleeding. 

None of this has any significant level of force being transferred to your c-spine. You might be injured pretty painfully, but you don't need SMR and SMR isn't going to easily manage the injuries you're likely to have sustained. Notice that of the above, I have written primarily _Mechanism_ and very little about _Assessment_?


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## ERDoc (May 31, 2015)

Speaking from the physician side of things, I would like to see this pt with a cervical collar.  LSB is optional, but coming off upon arrival at the ER.  You cannot clear the c-spine in this pt with either NEXUS or CCS rule, which means they need imaging.  If they need imagining, then they need a cervical collar.  Is there evidence that it will do anything?  No, but it will remind them not to move (sometimes) until we can clear them.


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## BOS 101 (May 31, 2015)

Akulahawk said:


> Is there "obvious trauma" present? Yes, to the teeth/mouth. What's the MOI? If you know that, does the MOI show a transfer of force to the cervical spine? It's easily possible to cause injury to the teeth/mouth without transferring any significant forces to the c-spine while causing a concussion. Ever watch a boxing match?
> 
> I'm not saying that you're necessarily wrong, just that you have much to learn, one of which is to discard the idea of "significant MOI" because MOI alone doesn't mean much.
> 
> ...



I totally get that you're right, moi doesn't prove spinal injury and it matters just as much hire the mechanism injured the person etc
But it's in this scenario fairly possible for spinal injury if not likely,  so as a precaution I would do it (the collar mainly)
this of course not taking into account recent studies about effectiveness, just that it is protocol and for  an altered patient who may not be careful with their neck and may harm themself further


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## Tigger (May 31, 2015)

Dakota said:


> I totally get that you're right, moi doesn't prove spinal injury and it matters just as much hire the mechanism injured the person etc
> But it's in this scenario fairly possible for spinal injury if not likely,  so as a precaution I would do it (the collar mainly)
> this of course not taking into account recent studies about effectiveness, just that it is protocol a*nd for  an altered patient who may not be careful with their neck and may harm themself further*



It has been shown that this is a very, very unlikely occurrence.


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## Akulahawk (May 31, 2015)

ERDoc said:


> Speaking from the physician side of things, I would like to see this pt with a cervical collar.  LSB is optional, but coming off upon arrival at the ER.  You cannot clear the c-spine in this pt with either NEXUS or CCS rule, which means they need imaging.  If they need imagining, then they need a cervical collar.  Is there evidence that it will do anything?  No, but *it will remind them not to move (sometimes) until we can clear them.*


Bingo! If the scene (and patient) is how I imagine that it was, I would have likely put a collar on the patient. If the patient still has good muscular control about the cervical region, then the patient should be able to provide greater c-spine stability than a simple collar is capable of providing on its own. My point is that the OP shouldn't rely on MOI alone to make these decisions.


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## Bullets (May 31, 2015)

You say you see doctor's use a collar in the EW, are they using the same stiff neck select EMS collar? Or are they using a Philadelphia collar or a soft wrap collar?


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## BOS 101 (May 31, 2015)

Bullets said:


> You say you see doctor's use a collar in the EW, are they using the same stiff neck select EMS collar? Or are they using a Philadelphia collar or a soft wrap collar?


 "Pro Care Patriot adult" appears to be the same stiff neck stuff I've used on the amb
But im speaking for one ER in AZ so others are varied I'm sure


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## RocketMedic (Jun 14, 2015)

Remi said:


> You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?
> 
> That medic sounds like one of those paramedics that gives EMS a bad image.



I've done it plenty of times. No reason to continue something that is incorrectly, improperly or no longer functionally placed. Do you leave collars on every single one of your patients regardless of circumstance?


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## RocketMedic (Jun 14, 2015)

With that being said, I'd likely scoop this patient to the cot with an aporopriately sized collar or towel roll. Probable TBI.


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## EMTinCT (Jun 15, 2015)

Collar yes, board no. Boards are *only* for moving a patient, *not* for transport.


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## Carlos Danger (Jun 15, 2015)

RocketMedic said:


> No reason to continue something that is incorrectly, improperly or no longer functionally placed.



Obviously. But there was no mention by the OP of the collar being incorrectly placed.



RocketMedic said:


> Do you leave collars on every single one of your patients regardless of circumstance?



Yes. You got me. Collars on every patient, every time. The worse they fit, the better.


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## joshrunkle35 (Jun 16, 2015)

If you have a question about what a medic is doing, say something. I've had basics ask me similar things or things like, "Are you sure that's the right drug?", or similar. It's usually a good time for me to simply explain the protocols, or explain a technique I've been trained in, or explain my thinking and reasoning. Sometimes it's like, "Holy cow! Thanks for saving my bacon! Yup, that would've been dumb!" Either way, the patient comes first, not our egos. And any medic should be able to explain what they're doing and why they're doing it in very simple terms...I mean, they should be able to explain it to a patient, like anyone in EMS, right? If they can't do that, they need to stop. And sometimes paramedics do need to stop. 

On the protocol thing: that paramedic works under their own medical director. That paramedic is the hands of that doctor, doing what that doctor wants done. Protocols should never be the same unless medicine has conclusively decided on something, or unless the doctor/service is lazy and copies someone else's protocols and rubber stamps them. 

To answer the original question, you need to know what information that paramedic received/had on scene, the thinking of the paramedic and the protocols from that service's doctor. 

I recommend asking next time.


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## Handsome Robb (Jun 17, 2015)

Dakota said:


> Well to put it simply, im just being passionate
> Obviously I know that the medic has ultimate final say BUT it is obviously stupid to not take cspine precautions here
> I would bug and bug the medic as much as I could before I went with it his way, and even then I would talk to his boss afterward
> Im not stupid, I realize it wouldnt be beneficial to sit and argue on scene either, but If you think no cspine here is smart, or that this medic is defendable, please show me how


Or that medic understands that SMR does nothing good and possibly causes harm because they have more training than you. 

You tried something like that in front of me you'd have been removed from my scene and your supe would be hearing about it.

You don't know what you don't know.


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## BOS 101 (Jun 18, 2015)

joshrunkle35 said:


> If you have a question about what a medic is doing, say something. I've had basics ask me similar things or things like, "Are you sure that's the right drug?", or similar. It's usually a good time for me to simply explain the protocols, or explain a technique I've been trained in, or explain my thinking and reasoning. Sometimes it's like, "Holy cow! Thanks for saving my bacon! Yup, that would've been dumb!" Either way, the patient comes first, not our egos. And any medic should be able to explain what they're doing and why they're doing it in very simple terms...I mean, they should be able to explain it to a patient, like anyone in EMS, right? If they can't do that, they need to stop. And sometimes paramedics do need to stop.
> 
> On the protocol thing: that paramedic works under their own medical director. That paramedic is the hands of that doctor, doing what that doctor wants done. Protocols should never be the same unless medicine has conclusively decided on something, or unless the doctor/service is lazy and copies someone else's protocols and rubber stamps them.
> 
> ...


 Thanks for the info
As far as the medics acting under the medical director, could you tell me a little more in detail how that works for them, how different it is in certain places and such?
I want to gather more on this, seems theres more to it than I knew at first but I'd like to know for my knowledge in case im unsure of a medic, so as to be appropriate and know what is right and what is BS a little better


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## BOS 101 (Jun 18, 2015)

Handsome Robb said:


> Or that medic understands that SMR does nothing good and possibly causes harm because they have more training than you.
> 
> You tried something like that in front of me you'd have been removed from my scene and your supe would be hearing about it.
> 
> You don't know what you don't know.


 thats great and dandy plenty of ppl have already told me as much
what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some


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## PotatoMedic (Jun 18, 2015)

Dakota said:


> thats great and dandy plenty of ppl have already told me as much
> what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
> Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some


http://www.tandfonline.com/doi/abs/....884197#/doi/abs/10.3109/10903127.2014.884197


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## joshrunkle35 (Jun 18, 2015)

Dakota said:


> Thanks for the info
> As far as the medics acting under the medical director, could you tell me a little more in detail how that works for them, how different it is in certain places and such?
> I want to gather more on this, seems theres more to it than I knew at first but I'd like to know for my knowledge in case im unsure of a medic, so as to be appropriate and know what is right and what is BS a little better



Sure...well, I would start with reminding you that this is something you should have learned in EMT school and didn't, or it is something you already learned, but have since forgotten. (We only typically retain about 10% of what we initially learned in school, unless we continue to relearn the material.) 

So, I would recommend dusting off that EMT book from school and re-reading the legal section. 

In EMS, every state has different laws. So, your state is different than mine, and you need to contact your state EMS board or state certifying/licensing agency or contact an attorney or legal representative for very specific legal advice relating to questions about: you, your service, your medical director and your state.

That being said: typically each state sets forth laws regarding certifications or licenses, and those laws govern training and skills. For example: maybe in one state, an EMT can intubate a patient, and in another state an EMT cannot. Or, maybe in one state an EMT can start an IV, and in another state an EMT cannot. The state says what types of skills an EMT can perform, and then sets training for those skills. The NREMT is just a standardized test of generic information that is similar between all states. It is different than state training, state certification, and the state's guidelines as to what duties an EMT can perform. 

An EMT works under a medical director, who is a Doctor. The doctor can limit the skills that the state allows you to perform: for example, if your state allowed EMTs to give IVs, your medical director could say, "Yeah, but I don't feel comfortable with EMTs giving IVs, so my EMTs won't be doing that." The doctor could also give guidelines as to when and how to perform the skill. For example, the doctor could tell you to splint any injury you think might be broken, or the doctor could tell you to only splint an injury you have confirmed is broken. The medical director can tell an EMT not to do something that the state allows, or they can tell the EMT when or when not to perform the skill that the state allows, but they cannot tell the EMT to perform a new skill that the state does not allow. For example, they couldn't tell you to perform open heart surgery on a person who just had an MI. The medical director "tells" the EMT how and when to perform the skill by writing down the how's and when's in the form of protocols, also known as offline medical direction. You could contact a doctor at a hospital when you are enroute with a patient. That Doctor would then temporarily give you "medical direction". This is known as online medical direction. The doctor could tell you to perform a certain skill a certain way, but it cannot be contrary to the protocols that you already have from your medical director, and it cannot exceed what the state allows you to do. 

In most states, you cannot perform these EMT skills on your own, though, there are exceptions. Every single state has its own rules. For example, in my state, Ohio, I can perform the skills under a medical director, but I cannot perform them on my own...unless...I happened to be walking down the street and helped someone during an emergency...then I would be covered under my state's "Good Samaritan laws". But, if I arrived with some Benadryl that I kept in a medical kit in my trunk to help others in an emergency, well, then I'd be practicing medicine without a license, because I intended to help others but had no medical direction. But, if I used benadryl on someone else from a medical kit that I kept in my trunk that was only in my trunk because I kept it there for personal emergencies, well, that would be perfectly fine, according to my state's laws. The law has less to do with how you do something, but rather why and when you do it. 

So, in your scenario, you and the person from the other service most likely have two different medical directors. Your medical director might say to c-spine everyone. Your state's EMT training might teach something like, "C-Spine everyone unless your protocol says otherwise." The other person's medical director might have written a protocol on when not to C-Spine, or how to clear C-Spine. For example, my service has protocols on how to clear C-Spine, but of the two other nearby services, one other also does, and one does not (to my knowledge). 

If you transferred the patient to the paramedic, now, his medical director's protocols are in play. The paramedic is operating under the direction of their medical director, under that doctor's license, performing the skills that medical director wants done. 

Trying to be polite, and trying to help you learn, I would agree that this is a case of you don't know how much you really don't know. Now, this is not a bad thing. We have all been woefully unaware of things before. Take this as a learning opportunity. Pull your EMT book back out and re-read the legal section, specifically about how medical directors and protocols work. Then, you, as everyone in EMS needs to do, need to get out your protocols and learn them word for word. 

We are in a business where constant learning is the order of the day for all of us. I'm re-reading sections of other books on other topics myself. Don't get discouraged. Educate yourself.


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## BOS 101 (Jun 18, 2015)

joshrunkle35 said:


> Sure...well, I would start with reminding you that this is something you should have learned in EMT school and didn't, or it is something you already learned, but have since forgotten. (We only typically retain about 10% of what we initially learned in school, unless we continue to relearn the material.)
> 
> So, I would recommend dusting off that EMT book from school and re-reading the legal section.
> 
> ...


Thank you for the info, I did know most of that, although some of it was a good refresher
Mainly I wanted to be sure that there isnt a separate way that paramedics get to make decisions with their patients
I mean by that, they dont have a different set of rules from emts for treating patients and making treatment calls blah blah i babble
But you seem to confirm that it is roughly the same thing, just at a paramedic set of skills obviously
And you're right I do need to remember to think about other states protocols, I may look into them just to see how far they vary on things
Thanks


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## BOS 101 (Jun 18, 2015)

FireWA1 said:


> http://www.tandfonline.com/doi/abs/....884197#/doi/abs/10.3109/10903127.2014.884197


thank you


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## Handsome Robb (Jun 19, 2015)

Dakota said:


> thats great and dandy plenty of ppl have already told me as much
> what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
> Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some



Here's an article in JEMS, not the greatest source but it's well written and cites it's sources with a great list of studies at the bottom of the article. 

http://www.jems.com/articles/print/...research-suggests-time-change-prehospita.html

Here is a paper from the National Association of EMS Physicians and American College of Surgeons.

http://www.naemsp.org/Documents/Pos...e of the Long Backboard_Resource Document.pdf

A collar is effective although current standard designs may not be the best since they generally place the patient in a position of cervical extension rather than neutral which is where we want these patients to be. If you want to use the board to get him to the gurney then remove it fine but leaving people with a naturally curved spine strapped to a hard plastic *flat* board does nothing good for the PT. Honestly if he can follow commands and can ambulate or is actively trying to get up I'd consider letting him stand and pivot with assistance to the gurney after placing a collar. I wouldn't be opposed to allowing him to do it since even in his altered state will instinctually protect his spine however this may increase his ICP which I'm going to talk about next so it's a risk vs benefit call. Also, in this case where a TBI/CHI is high on the list of differentials placing him on an uncomfortable board will cause him to squirm and move and depending on how altered he is potentially fighting against the SMR which increases ICP which worsens outcomes in TBI patients. Furthermore the catecholamine release from pain/discomfort alone can increase ICP even if they're sitting still. 

I'm not trying to be a ****, I love teaching and will gladly explain my reasoning to other providers who express an interest to learn however there is a time and a place. In the middle of a call is rarely that time or place as it disrupts patient care and can harm the patient/provider rapport which doesn't help anyone involved. 

I'm on my phone but can get you more sources tomorrow at work if you'd like.


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## BOS 101 (Jun 19, 2015)

Handsome Robb said:


> Here's an article in JEMS, not the greatest source but it's well written and cites it's sources with a great list of studies at the bottom of the article.
> 
> http://www.jems.com/articles/print/...research-suggests-time-change-prehospita.html
> 
> ...


Thanks robb, I know time and place and all, I was really just being a wee bit dramatic, I handle myself very appropriately on the job, I should have known It would be taken more literal
Thanks for your input


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## Tigger (Jun 19, 2015)

Dakota said:


> thats great and dandy plenty of ppl have already told me as much
> what i would pay attention to is if you give me a link or send me in the direction of some other article or things that show what your saying about smr
> Im not close minded, but im not just going to take what people say as truth either i would like some evidence based info, I have been shown some, but Id like more if you know of some


Part of how this works also includes you justifying your position. We are happy to provide information but at times like this it's important to consider how and why you justify your actions. Does your position have any evidence? If not, maybe it's not what should be done.


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## BOS 101 (Jun 20, 2015)

Tigger said:


> Part of how this works also includes you justifying your position. We are happy to provide information but at times like this it's important to consider how and why you justify your actions. Does your position have any evidence? If not, maybe it's not what should be done.


 Fair enough most cases, but here I was only coming from the stand point of this is what were taught and what is protocol
So for me to change what im going to do or think someone has to provide me with evidence to the contrary(which if legit i can fully accept), you know? not to be stubborn cuz i haven't done experiments or studies myself in order to prove the way I was taught, just being weary, altho I should be weary of what I was taught as well, I know


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## Handsome Robb (Jun 20, 2015)

Dakota said:


> I was only coming from the stand point of this is what were taught and what is protocol



I may have missed it if it was addressed already but are you sure that's what the protocols he was following say? They may be your department's protocols but his may be more liberal.


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## BOS 101 (Jun 20, 2015)

Handsome Robb said:


> I may have missed it if it was addressed already but are you sure that's what the protocols he was following say? They may be your department's protocols but his may be more liberal.


Yes they did,  thank you though


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## LiveForTheTones (Jun 21, 2015)

Anjel said:


> Sometimes medics need to be questioned, but at an appropriate time and place.
> 
> He would of got a collar from me. Not a board.





Zredmond said:


> Thank you for the input. I agree on at least the collar. I realize we are human beings and we aren't perfect.



County Fire Rescue where I live is doing away with backboards. If they need CPR or need to be airlifted, boards will be used. But if you're being transported from a MVC, you're going to get c-collar and a stretcher.
To lessen the "pain and stress."


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## Bullets (Jun 22, 2015)

Remi said:


> You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?
> 
> That medic sounds like one of those paramedics that gives EMS a bad image.


If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?


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## Carlos Danger (Jun 22, 2015)

Bullets said:


> If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?


Really?

I can accurately quantify oxygenation status and objectively rule out hypoxia. Which of course would be reflected in my documentation.

I cannot, however, rule out a potentially unstable cervical injury in a patient with a not-insignificant risk for one. Nor can I prove to a jury that my removing the collar was not the proximate cause of any neuro deficit that may manifest later. Nor can I even really give a good reason why I removed it, assuming it was properly placed and not causing any problems.

One action is clearly contraindicated (NRB in a patient who is oxygenating just fine) and can be defended as such with objective data. Another action (removing the collar) is controversial and cannot be objectively justified.


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## Chewy20 (Jun 22, 2015)

Bullets said:


> If BLS or LE arrived before you and place the patient on 15l NRB, do you leave it on them for the duration of your interaction?



Apples and oranges my friend. You can look at RR, SPO2 and ETCO2, listen to lung sounds etc. Unless you have an imaging system on your box then meh...


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## Noncreative (Jul 2, 2015)

Yeah, I'd agree that a collar is the right call, at least where I am, the combo of the possible height and altered LOC would call for C-Spine, but if the medic wanted it off, I'd let them remove it and document it for my sake when it comes to court.


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## BigBadWolf (Jul 10, 2015)

Collar and board from me and if my medic made the call to remove it I would certainly be asking later why just to see if I had missed something.


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## TransportJockey (Jul 10, 2015)

BigBadWolf said:


> Collar and board from me and if my medic made the call to remove it I would certainly be asking later why just to see if I had missed something.


Backboards are bad news in general. No proof of helpfulness in anything other than an extrication device. Proof of harm when used as a transport device.


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## Amber Lance (Jul 10, 2015)

Had a patient in a clinical rotation who was 93 with altered mental status who had fallen from a standing height and hit her head. We didn't know her medical history so we weren't sure if she had dementia or something else was going on (ICP, etc). She had no CMS deficits. She had a rigid c-collar (unknown if placed by EMS or ER) and it was clearly the wrong size. It kept riding up to where the part that was supposed to be under her chin was up around her nose. Being a student I wasn't allowed to adjust without permission so I told a nurse and she fixed it but it rode up again after about 5 minutes. Rinse and repeat for the next 6 hours until the patient finally figured out how to take it off. The nurse went "eh" and threw it out. The patient had been getting increasingly agitated and upset. When she took the collar off, she calmed down and fell asleep almost immediately. CT scan came back no bleed or skull fracture and her son called and said she had dementia. The whole thing just kind of left me scratching my head.


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## chaz90 (Jul 10, 2015)

@Amber Lance
Say the CT results came back positive for some sort of traumatic bleed or there was indeed a skull fracture. Would the hemostatic C-Collar we so desperately cling to help treat this patient or manage them more effectively in any way?

It's good you're asking these questions. Much of what we're taught today at face value could be disproven in the future, and it's good to research these topics on your own to learn the how and why whenever possible. In almost any case, if an agitated and altered patient is more combative and causing more movement due to an attempt at "spinal immobilization" it is a good idea to remove the source of increasing agitation. I like to think we've moved past the days of tackling and wrestling an uncooperative "spinal injury" patient so we can apply our life saving C-Collar, head blocks, and backboard with spider straps.


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## Zredmond (Jul 10, 2015)

chaz90 said:


> @Amber Lance
> Say the CT results came back positive for some sort of traumatic bleed or there was indeed a skull fracture. Would the hemostatic C-Collar we so desperately cling to help treat this patient or manage them more effectively in any way?
> 
> It's good you're asking these questions. Much of what we're taught today at face value could be disproven in the future, and it's good to research these topics on your own to learn the how and why whenever possible. In almost any case, if an agitated and altered patient is more combative and causing more movement due to an attempt at "spinal immobilization" it is a good idea to remove the source of increasing agitation. I like to think we've moved past the days of tackling and wrestling an uncooperative "spinal injury" patient so we can apply our life saving C-Collar, head blocks, and backboard with spider straps.


You know that's a very interesting point, and I definitely see where you are coming from. As someone who has been boarded post traumatic injury I understand the discomfort.


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## BigBadWolf (Jul 10, 2015)

TransportJockey said:


> Backboards are bad news in general. No proof of helpfulness in anything other than an extrication device. Proof of harm when used as a transport device.


 
Really?  I just finished class a month ago and they taught us to backboard damn near everything.  ALOC, pain in the neck, back or hips, cant speak english, MOI, you all get backboarded.   I will say having done an MCI and been backboarded for almost half an hour I would love to see studies showing us to throw them out even if just for patient comfort, those things suck.


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## ERDoc (Jul 10, 2015)

BigBadWolf said:


> Really?  I just finished class a month ago and they taught us to backboard damn near everything.  ALOC, pain in the neck, back or hips, cant speak english, MOI, you all get backboarded.   I will say having done an MCI and been backboarded for almost half an hour I would love to see studies showing us to throw them out even if just for patient comfort, those things suck.


Yup, really.  That class sounds like a huge mistake.  Want to see the studies?  Pubmed is your friend.


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## BigBadWolf (Jul 11, 2015)

ERDoc said:


> Yup, really.  That class sounds like a huge mistake.  Want to see the studies?  Pubmed is your friend.


 
Well there is probably a reason that the instructor and both assistants were let go right after the class finished and the next class canceled lol.  My medic has us using a study that has 5 indicators for c-spine that seems much more reasonable but my mind just blanked on the name of the study.


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## chaz90 (Jul 11, 2015)

BigBadWolf said:


> Well there is probably a reason that the instructor and both assistants were let go right after the class finished and the next class canceled lol.  My medic has us using a study that has 5 indicators for c-spine that seems much more reasonable but my mind just blanked on the name of the study.


NEXUS criteria? Canadian C Spine rules? Both were created in order to clinically clear possible cervical spinal injuries without using imaging, but many EMS protocols have adopted or modified them.


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## BigBadWolf (Jul 11, 2015)

chaz90 said:


> NEXUS criteria? Canadian C Spine rules? Both were created in order to clinically clear possible cervical spinal injuries without using imaging, but many EMS protocols have adopted or modified them.


 
Nexus thats the one.  Seems very reasonable to me and with my limited knowledge the study seemed to strongly support its use.


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## ERDoc (Jul 11, 2015)

But remember, NEXUS and CCS only apply to cervical spine, not long board.


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## TransportJockey (Jul 11, 2015)

ERDoc said:


> But remember, NEXUS and CCS only apply to cervical spine, not long board.


Which is another reason LSBs need to die a slow and fiery death


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## ERDoc (Jul 11, 2015)

But but but, Transport, we've always done it that way.  I try to get the pt off the board and give the board and straps back to the crew before they leave.  Do they still teach standing takedowns in EMT classes?


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## chaz90 (Jul 11, 2015)

ERDoc said:


> But but but, Transport, we've always done it that way.  I try to get the pt off the board and give the board and straps back to the crew before they leave.  Do they still teach standing takedowns in EMT classes?


God help us all, but yes they do :/ I was an unwilling witness/participant in a call with two simultaneous standing takedowns just a couple months ago. Stupidity reigned.


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## ERDoc (Jul 11, 2015)

chaz90 said:


> God help us all, but yes they do :/ I was an unwilling witness/participant in a call with two simultaneous standing takedowns just a couple months ago. Stupidity reigned.



It doesn't have any affect on me in the ER, but I feel for you out there in the field.


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## BigBadWolf (Jul 12, 2015)

ERDoc said:


> But but but, Transport, we've always done it that way.  I try to get the pt off the board and give the board and straps back to the crew before they leave.  Do they still teach standing takedowns in EMT classes?


Finished my class a month ago and while they showed them to us they said there is no reason to use them.  If the patient is already mobile just ask them to lay down on the board that is on the stretcher.


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## DesertMedic66 (Jul 12, 2015)

BigBadWolf said:


> Finished my class a month ago and while they showed them to us they said there is no reason to use them.  If the patient is already mobile just ask them to lay down on the stretcher.


Fixed it for you.


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## Amber Lance (Jul 12, 2015)

Unfortunately LSB is still in the NREMT skill list so we had to be taught (and tested on) standing takedowns and full immobilization in AEMT class even though it is almost completely absent from local protocols in NM.  Does anyone know if it might be taken out of NREMT anytime soon? That would go a long way towards stopping the madness.


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## highglyder (Sep 12, 2015)

Zredmond said:


> Just for my own knowledge, the controversy isn't over collars, it's over LSBs correct?


Rigid c-collars are also controversial.  Some studies have them increasing ICP by as much as 25 mmHg.  Not something you'd want in a head injury.


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## Martyn (Sep 13, 2015)

LACoGurneyjockey said:


> Dat MOI doe...
> So you know better than everyone else ever on scene with you? When there is a paramedic with a higher level of education than you, you do what you wanna do because you're right and JESUS LOOK AT THAT MECHANISM!
> If you tried that with me you'd be kindly asked to leave my scene, and I'd have your supervisor on the phone. You're ridiculous. Not your patient, not your call once there is a higher level of care on scene.
> Do you go around stopping "lazy and stupid" cops too?



Really?


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## highglyder (Sep 14, 2015)

Medic Tim said:


> .....But protocols and what is right for your pt can be at odds with one another. Many thankfully take their education into their own hands and fill the gap.



There has been, in many cases, a divergence between what is correct and what is right.  If a medic knows that the correct thing to do is procedure _x_ for condition _y_ based on outdated standards of care, is it or is it not ethical and moral to do so, especially if it has the potential to harm the patient?

Thinking about LSBs alone, we know it to be dangerous, painful, and of zero benefit.  We also know we're bound by protocols.  So where do we draw the line?  When does applying a protocol because the book says cross the line into unethical territory?  I think this is something that EMS lacks....the ability to justify one's actions by the application of ethics.  And besides, since when did it ever become okay to say _We know this will hurt, but it's for your own good?_  Pain = stop!  No?


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## 68wildcat (Sep 14, 2015)

Dakota said:


> honestly, with him being altered and a possible moi like that(blood and teeth on the ground) i would have done full c-spine and ignored the medic
> Sorry medic, but thats just a risky call for the patient, and just plain stupid really given the circumstances
> Not even a collar? foolish, remember paramedics are individuals, some arent very good, cuz theyre lazy or stupid, same with police, nurses or whatever
> they give everyone else a bad name, so we should stop them from making those calls (appropriately), and making us look bad


Collar and board, all the way to the hospital. How is this even being questioned? Unless you got an MRI in your truck to accurately determine if there are bone fragments around the spinal cord then the collar stays on. Immobolize! Prevent further injury if at all possible. Holy shmokes!


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## highglyder (Sep 14, 2015)

68wildcat said:


> Collar and board, all the way to the hospital. How is this even being questioned? Unless you got an MRI in your truck to accurately determine if there are bone fragments around the spinal cord then the collar stays on. Immobolize! Prevent further injury if at all possible. Holy shmokes!



How is this being questioned?  Because we started doing this in the 60s after ONE surgeon decided that the reason 29 people had delayed onset paralysis was due to the people that touched them first.  No study, no evaluations, just an opinion.  In today's world, opinions like that don't hold water and if LSBs were to be introduced today, they would never, ever, ever, ever, be approved for use.  I see you are new and on the presumption that you are new to EMS...... always question the status quo.  It drives learning, which in turn drives evidence and science based care, which in turn drives better patient outcomes.

For this call, the collar is sensible.  The board, however, is not.  Instead of hashing it all out again, you can fine plenty of evidence here: https://www.reddit.com/r/ems/comments/33apry/since_we_like_to_talk_about_backboards_so_much/

Of interest, a study was conducted comparing patients from Albuquerque and Malaysia. The USA immobilisation rate was 100%, the Malaysian rate was 0%.   ll being equal (demographics, in hospital care, MOI, etc...) the patients from New Mexico had a 21% disability rate.  The Malaysian rate was 11%.  That's a whopping 10% less.


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## chaz90 (Sep 14, 2015)

68wildcat said:


> Collar and board, all the way to the hospital. How is this even being questioned? Unless you got an MRI in your truck to accurately determine if there are bone fragments around the spinal cord then the collar stays on. Immobolize! Prevent further injury if at all possible. Holy shmokes!


Please oh please, read the rest of this thread and consider catching up with one or two of the developments in medicine from the past few decades :/


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## DesertMedic66 (Sep 14, 2015)

highglyder said:


> How is this being questioned?  Because we started doing this in the 60s after ONE surgeon decided that the reason 29 people had delayed onset paralysis was due to the people that touched them first.  No study, no evaluations, just an opinion.  In today's world, opinions like that don't hold water and if LSBs were to be introduced today, they would never, ever, ever, ever, be approved for use.  I see you are new and on the presumption that you are new to EMS...... always question the status quo.  It drives learning, which in turn drives evidence and science based care, which in turn drives better patient outcomes.
> 
> For this call, the collar is sensible.  The board, however, is not.  Instead of hashing it all out again, you can fine plenty of evidence here: https://www.reddit.com/r/ems/comments/33apry/since_we_like_to_talk_about_backboards_so_much/
> 
> Of interest, a study was conducted comparing patients from Albuquerque and Malaysia. The USA immobilisation rate was 100%, the Malaysian rate was 0%.   ll being equal (demographics, in hospital care, MOI, etc...) the patients from New Mexico had a 21% disability rate.  The Malaysian rate was 11%.  That's a whopping 10% less.


You need to start posting here more often haha


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## Jim37F (Sep 14, 2015)

We did a standing take down earlier today....I feel like I need a shower...


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## Tigger (Sep 14, 2015)

68wildcat said:


> Collar and board, all the way to the hospital. How is this even being questioned? Unless you got an MRI in your truck to accurately determine if there are bone fragments around the spinal cord then the collar stays on. Immobolize! Prevent further injury if at all possible. Holy shmokes!


I suppose you did not read the six pages prefacing this then....


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## 68wildcat (Sep 15, 2015)

No I didn't,, and I jumped before thinking beyond the text book taught protocols. Kinda feeling foolish...'medicine is ever evolving, try to keep up', said a very good teacher to our class.


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## Flying (Sep 15, 2015)

Guys, we found a keeper.


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## CALEMT (Sep 15, 2015)

Holy crap someone owning up to their mistakes on this forum? Hell is freezing over!


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## chaz90 (Sep 15, 2015)

Cool. Thanks for the reply 68wildcat! Now go forth, read the primary sources of research, and share them with others.


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## Brandon O (Sep 15, 2015)

highglyder said:


> Because we started doing this in the 60s after ONE surgeon decided that the reason 29 people had delayed onset paralysis was due to the people that touched them first.  No study, no evaluations, just an opinion.



Which surgeon do you mean?


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## highglyder (Sep 15, 2015)

Brandon O said:


> Which surgeon do you mean?


Geisler.  Check out this video 



  (Linked to the history, but the entire thing should be mandatory viewing for all new medics).


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## Brandon O (Sep 15, 2015)

Yep. It goes back perhaps as early as the year before (Kossuth), but along with Farrington the next year Geisler probably published the earliest influential references.


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## highglyder (Sep 15, 2015)

Brandon O said:


> Yep. It goes back perhaps as early as the year before (Kossuth), but along with Farrington the next year Geisler probably published the earliest influential references.


Good to know.  Thanks.


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## EOPFD (Sep 26, 2015)

with a possible fall of 25 feet and the pt was surrounded by a pool of blood and his teeth. I would of have done a full C-Spine Immobilization.. Board and all


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## LACoGurneyjockey (Sep 26, 2015)

Kennedy said:


> with a possible fall of 25 feet and the pt was surrounded by a pool of blood and his teeth. I would of have done a full C-Spine Immobilization.. Board and all


Please read the rest of the thread and take advantage of the available resources to educate yourself.


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## CALEMT (Sep 26, 2015)

Kennedy said:


> with a possible fall of 25 feet and the pt was surrounded by a pool of blood and his teeth. I would of have done a full C-Spine Immobilization.. Board and all


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## TransportJockey (Sep 26, 2015)

Surrounded by pool of blood and teeth is a great reason for me to not want to board this patient. Unless you want me to RSI them to take control of their airway so you don't kill them with aspirated blood


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