# Spinal Immobilization or Not ?



## Legal Eagle (Feb 1, 2011)

Called out to a 50 year old female patient with back pain. Patient is found lying on the couch. Head to toe finds pain in the back radiating to her neck, and weak strength in hands bi-laterally. Pain is 10/10, constant sharp pain, made worse by movement. 
Patient has a history of ETOH abuse, woke up today with severe back pain. Patient is unsure of what caused the back pain and has been drinking today.
When asked states she didn't fall.
Spinal Immobilization required ?


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## DesertMedic66 (Feb 1, 2011)

Legal Eagle said:


> Called out to a 50 year old female patient with back pain. Patient is found lying on the couch. Head to toe finds pain in the back radiating to her neck, and weak strength in hands bi-laterally. Pain is 10/10, constant sharp pain, made worse by movement.
> Patient has a history of ETOH abuse, woke up today with severe back pain. Patient is unsure of what caused the back pain and has been drinking today.
> When asked states she didn't fall.
> Spinal Immobilization required ?



i probably would have. If pain is made worse by movement then putting her on a board would elimate alot of movement (i know that you can still move on a spine board.) Granted it isnt very comfortable on the board. and with a history of ETOH abuse and the patient was drinking its easier to restrain the Pt on a backboard (Im not saying that all abusers and people who have been drinking should get restrained.)


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## adamjh3 (Feb 1, 2011)

I'm not a big fan of c-spine restrictions, I've had elderly patients who have fallen, but did not have any neuro deficits, midline pain, or distracting injuries etc that did not get c-spined. 

I'd have to talk to and assess this Pt myself to make a definite descision either way. What's her med. history like other than the ETOH abuse? Any bruises, marks, cuts, bumps, etc on her body? Did she get black-out drunk and fall down a flight of stairs last night or last week and not remember? 

With the bi-lateral hand weakness and 10/10 pain in the neck, I'd probably c-spine as a CYA technique, no way med control would clear c-spine on this for a Basic. 

It all comes down to your judgment. Just make sure you can justify why you did or didn't c-spine. Follow your protocols and call med-control if you want to breach protocols.


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## NomadicMedic (Feb 1, 2011)

If the patient has been drinking and has a neuro deficit they certainly don't meet my field clearance protocol and I'd be more than likely placing them in spinal precautions.

I mean, who really knows what happened? Did she fall down some stairs in the middle of the night while intoxicated? I wasn't there and she's not a reliable historian.

A collar and LSB seems to be indicated, at least to CYA.


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## DesertMedic66 (Feb 1, 2011)

My instructor made it a point to remember "When in doubt, Board them up". I would much rather bring in a patient on a spine board who didnt need the board then bring in a patient not on a board who needed it.


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## JPINFV (Feb 1, 2011)

firefite said:


> My instructor made it a point to remember "When in doubt, Board them up". I would much rather bring in a patient on a spine board who didnt need the board then bring in a patient not on a board who needed it.


Given the clinical decision tools available, there should be little doubt. 

Unsure mechanism and positive NEXUS criteria? Board based solely on what's provided, but a better HPI could rule out c-spine.


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## certguy (Feb 1, 2011)

*to c spine or not to c spine??*

Firefite said it the best.When in doubt,board em was my sediments exactly.My experience has benn that drunks tend to leave out certain little details you need to know.


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## nakenyon (Feb 1, 2011)

Yup. Per my protocols, she gets a board. As everyone before has said ETOH makes her not a reliable source of information to to by. I had an abuser fall off of her bed once, walk to the couch, then call in the morning for neck pain. I didn't want to board her (big lady), but did as a CYA. Then it turns out she had a C2 (I think) fracture.


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## lampnyter (Feb 1, 2011)

I doubt the pt would want to be backboarded.


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## medicRob (Feb 1, 2011)

*When in Doubt, whip em out.. *


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## NomadicMedic (Feb 1, 2011)

lampnyter said:


> I doubt the pt would want to be backboarded.



That's a shame, isn't it?


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## JPINFV (Feb 1, 2011)

n7lxi said:


> That's a shame, isn't it?



It really depends... I know if I'm ever in an accident and opt for transport, I'm going to need a little more than a twinge of pain to submit to the placebo known as spinal immobilization.


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## NomadicMedic (Feb 1, 2011)

JPINFV said:


> It really depends... I know if I'm ever in an accident and opt for transport, I'm going to need a little more than a twinge of pain to submit to the placebo known as spinal immobilization.



Same here. I am NOT A FAN of the whole spinal imob procedure.

However, that person with the neuro deficit and back pain, who admits to alcohol on board, who called 911, needs to be on a LSB with a collar. Until things change, that's the standard of care in my system (and I'm guessing in yours too.)


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## 46Young (Feb 1, 2011)

I think pretty much any protocol for selective spinal motion restriction uses ETOH as a disqualifier. In addition, the pt doesn't know how she injured her back. I don't really need to hear anyhting else. That alone is enough for me to initiate SMR.

Edit: If she's adamant about not getting a board and collar, then have her sign a refusal clause for that particular intervention before moving her, provided she demonstrates adequate decisional capacity. 

"Legal Eagle?" First post? Are you an ambulance chaser feeing out the forum to see what's negiligent and what's not, for your client?


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## PotashRLS (Feb 1, 2011)

n7lxi said:


> Same here. I am NOT A FAN of the whole spinal imob procedure.
> 
> However, that person with the neuro deficit and back pain, who admits to alcohol on board, who called 911, needs to be on a LSB with a collar. Until things change, that's the standard of care in my system (and I'm guessing in yours too.)



I agree.  Back pain radiating to the neck with etoh on board.  Immobilize for best patient care and cya.  Plus there is less chance that the receiving ER Doc will chew you butt.


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## NomadicMedic (Feb 1, 2011)

PotashRLS said:


> I agree.  Back pain radiating to the neck with etoh on board.  Immobilize for best patient care and cya.  Plus there is less chance that the receiving ER Doc will chew you butt.



It's really more about the latter two reasons and less about the first.

But, right now it is what it is.


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## JPINFV (Feb 1, 2011)

"Has been drinking today" isn't a whole lot of information, even with the history of abuse. Does having a beer mean that a person lacks capacity? If so, for how long? A person who has had a beer has "alcohol on board" and "has been drinking today."


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## NomadicMedic (Feb 1, 2011)

JPINFV said:


> "Has been drinking today" isn't a whole lot of information, even with the history of abuse. Does having a beer mean that a person lacks capacity? If so, for how long? A person who has had a beer has "alcohol on board" and "has been drinking today."



Sure. And how many beers has EVERYONE had? Everytime you ask?

"Only two, sir."

Riiiiiiiight.

If you've had ANY alcohol, you've been disqualified from my selective spinal imob criteria.


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## JPINFV (Feb 1, 2011)

So if I've had a beer, I lose the right to decline interventions? I, as a patient, don't have to meet a selective spinal imobilization protocol to decline immobilization. Personally, I hardly go past 1 beer when I drink, and almost never go past 2.


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## adamjh3 (Feb 1, 2011)

n7lxi said:


> Sure. And how many beers has EVERYONE had? Everytime you ask?
> 
> "Only two, sir."
> 
> ...



That is a very dangerous line of thinking. Kidnapping is a pretty serious thing to have on your record. 

Someone's had a single beer and they cut their hand while slicing lemons, someone sees a bunch of blood and calls 911. Dude who's cut just wants to AMA. Does the single beer mean they're blackout drunk and might have fallen down a flight of stairs?


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## Handsome Robb (Feb 1, 2011)

I agree that a single beer does not revoke your rights as a Pt. But in a situation like this with a Hx of substance abuse I'd be more inclined to lean towards the Pt having more than one beer onboard, but then again, it all depends on your assessment of the Pt and your better judgement.


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## MrBrown (Feb 1, 2011)

Um, if this patient did not fall or suffer any traumatic event then what good is putting her on a spine board going to do?

Could it be that there is a medical cause and not a traumatic one for her pain and lack of movement?

*Brown smashes head repeatedly on wall


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## NomadicMedic (Feb 1, 2011)

adamjh3 said:


> That is a very dangerous line of thinking. Kidnapping is a pretty serious thing to have on your record.
> 
> Someone's had a single beer and they cut their hand while slicing lemons, someone sees a bunch of blood and calls 911. Dude who's cut just wants to AMA. Does the single beer mean they're blackout drunk and might have fallen down a flight of stairs?



Please reread my reply. It didn't say *anything* about transport against thier will... it did say, "If you've had ANY alcohol, you've been disqualified from my selective spinal imob criteria." That doesn't mean I'm gonna scoop 'em up and shove 'em in rig while they kick and scream.  

And no, a single beer does not mean the PT loses all rights. It doesn't make any judgement about their level of intoxication or ability to make decisions. It means that MY index of suspiscion is higher and due to the litigeous society we live in, my MPD, the EMS Council and the company I work for, prefer that I (or any other EMS professional) place this person in spinal precautions.

And the cut hand vs the original 10/10 back pain with neuro deficit are two entirely different scenarios. 

And Brown, while you're busy smashing your head, look again at the NEXUS  protocol and see if the criteria in the original scenario precludes field clearance. 

These highlighted points maybe?

_A cervical spine is determined to be stable if:_

There is no posterior midline cervical tenderness
*There is no evidence of intoxication*
The patient is alert and oriented to person, place, time, and event
*There is no focal neurological deficit*
There are no painful distracting injuries (e.g., long bone fracture)

Please, don't be argumentative just for the sake of increasing your post count. Both you and I know that, while in the field, there is NO DEFINITIVE WAY to determine if the pain and neuro deficit is medical vs. traumatic.

I don't know what the MOI was. I don't know if there was ANY injury. What I do know is, the person has alcohol on board, has an injury (or some type) and can't be relied on for a 100% actual and factual account of what happened. 

Here in the states, (I know, we're a country with a sad excuse for EMS) the standard of care is still the C-Collar and LSB.


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## lampnyter (Feb 1, 2011)

MrBrown said:


> *Brown smashes head repeatedly on wall



Sir, we are going to need to backboard you. You may have injured your spine while slamming your head into a wall.


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## Luno (Feb 1, 2011)

*Hmmmm....*



Legal Eagle said:


> Called out to a 50 year old female patient with back pain. Patient is found lying on the couch. Head to toe finds pain in the back radiating to her neck, and weak strength in hands bi-laterally. Pain is 10/10, constant sharp pain, made worse by movement.
> Patient has a history of ETOH abuse, woke up today with severe back pain. Patient is unsure of what caused the back pain and has been drinking today.
> When asked states she didn't fall.
> Spinal Immobilization required ?



Based on what is provided here, there is no evidence of trauma, and without a significant index of suspicion, this does not qualify for NEXUS/Selective Spinal Immobilization because there is no indication of trauma.  Assuming that the rest of the exam/interview does not provide evidence of trauma or something odd, such as bone density issues or something that may lead you down the path of considering spinal injury, this patient does not need a backboard, except maybe to assist movement, but I think that a scoop would be more appropriate.  I think that to treat from an unfounded fear is the worst care we can possibly give our patients and abdicates our role as patient advocates.  In my not so humble opinion...


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## NomadicMedic (Feb 1, 2011)

Luno said:


> Based on what is provided here, there is no evidence of trauma, and without a significant index of suspicion, this does not qualify for NEXUS/Selective Spinal Immobilization because there is no indication of trauma.  Assuming that the rest of the exam/interview does not provide evidence of trauma or something odd, such as bone density issues or something that may lead you down the path of considering spinal injury, this patient does not need a backboard, except maybe to assist movement, but I think that a scoop would be more appropriate.  I think that to treat from an unfounded fear is the worst care we can possibly give our patients and abdicates our role as patient advocates.  In my not so humble opinion...



Maybe. If I had a clear idea as to what happened, like a husband that said, "she was 100% normal last night and she woke up this way and she hasn't been out of bed since 9 last night and she hasn't been out of my sight" _and_ if there was no alcohol in the equation, I would advocate for a scoop as well.

However, with the variables presented in this case, there is far too much that is unknown and the ETOH abuse and alcohol on board raises my index of suspiscion.

So, to that end, I know I will NOT bring a non boarded patient into an ER who is complaining of 10/10 back pain with accompanied neuro deficit, and who, by her own admission, has been drinking and doesn't know what caused the pain.

You can make your own decisions... I know what mine is.


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## firetender (Feb 1, 2011)

Legal Eagle said:


> 50 year old female
> back pain.
> lying on the couch
> pain in the back radiating to her neck
> ...



I'd treat this as a "splint her as she lays"
Let her know she must go to the hospital.
Explain she'll be transferred on to your gurney,
You'll be moving her over to it with as little adjustment from her current position as possible.
Once on the gurney, explain you'll be supporting her in the most comfortable position possible for her for the ride. 
Stabilize her in position, one segment at a time with folded towels, sheets, pillows, what not. Use duct tape if it's useful! 
If there is any movement needed, ask her to initiate it. 
Don't be afraid to let her know you WILL need to get her on board within a few minutes.

I forgot to put the title up:

*Protocol and the elimination of Discernment!*


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## 22cent (Feb 1, 2011)

Backboards are bad. If your system gives you any leniancy, consider a more humane approach to immobilizing. Our system utilizes a vacuum type mattress that does the job fine without leaving nasty side effects like pressure sores and decreased circulation. I mean really? Have you ever spent more than a few minutes on a LSB? They are an archaic vestige of old medicine with very few facts to support the benefits versus risk.


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## Aidey (Feb 1, 2011)

Legal Eagle said:


> Called out to a 50 year old female patient with back pain. Patient is found lying on the couch. Head to toe finds pain in the back radiating to her neck, and weak strength in hands bi-laterally. Pain is 10/10, constant sharp pain, made worse by movement.
> Patient has a history of ETOH abuse, woke up today with severe back pain. Patient is unsure of what caused the back pain and has been drinking today.
> When asked states she didn't fall.
> Spinal Immobilization required ?




I want more information before I make a decision. 

Does the patient live in a rancher or a 3rd floor walk up? Is there anyone else in the home? What time of the day is it? What has the patient been doing up until the time she called 911? Does she have a history of back pain/problems? How much alcohol has she had today? How much alcohol does she have normally? What does she normally do during the day? 

Past history and meds? Past surgeries? Physical exam results - where exactly is the pain, "back pain" is pretty nebulous, bruising, swelling etc? Define weak strength? Are we looking at a neuro deficit or a woman with a normally weak grip strength? What does the rest of the neuro exam show (or not show?). What are her vital signs? EKG? 12 lead? Yes, I want a 12 lead - *50* yo *female*, *back pain that radiates*.

More information is needed.


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## CAOX3 (Feb 2, 2011)

She denied trauma, why would you board her?  If she strolled into the ER with the same symptoms would they board her, I think not.

I dont do my job in fear of litigation, so CYA never enters into my decisions, nice comfy ride to the ER in position of comfort.


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## MSDeltaFlt (Feb 2, 2011)

Legal Eagle said:


> Called out to a 50 year old female patient with back pain. Patient is found lying on the couch. Head to toe finds pain in the back radiating to her neck, and weak strength in hands bi-laterally. Pain is 10/10, constant sharp pain, made worse by movement.
> Patient has a history of ETOH abuse, woke up today with severe back pain. Patient is unsure of what caused the back pain and has been drinking today.
> When asked states she didn't fall.
> Spinal Immobilization required ?



From where does the back pain originate?  What does it look like?  How does it feel to your hands?  Is she C-A-O X 4 and verbally appropriate?  Is the pain from the spine?  Or is it from the erector spinae?  Maybe latissimus dorsi.

Regardless of which I can't come up with a legitimate reason to package this pt based on pain radiating TO the neck.  FROM?  Yes.  TO?  No.

However, I might use the LSB to move her. But that's about it.


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## Lady_EMT (Feb 3, 2011)

Eh, this is up in the air for me.
Per the patient, there's no trauma. I'm more than willing to transport this patient in her position of comfort. But, with proper padding, and the patient being backboarded and collared properly could alleviate some of the pain she's experiencing. Because she's being strapped down to a stationary in-line position, and she won't be able to flop around, she'll remain more comfortable.

But, obviously, if she starts adamently refusing the backboard and won't tolerate it, then I'm not going to subject her to it.


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## TransportJockey (Feb 3, 2011)

Scoop w/ padding would be my choice. No bloody collar or stupid LSB. No trauma mechanism means she doesn't even open my SI protocol


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## zzyzx (Feb 4, 2011)

Nope, no spinal immoblization on this patient. Doesn't meet criteria, and, most importantly, would not be in the patient's best interest.


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