# would you c-spine?



## Anonymous (Oct 17, 2012)

Mid 70s. Mechanical slip and fall. Pain 10/10 to low back/butt. No neck pain. Ambulatory prior to calling but after 1 hour and a vicodin patient is now unable to walk due to pain. Good PMS. Patient sitting on couch. Vitals WNL and alert and oriented.

Anything else just ask.


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## Medic Tim (Oct 17, 2012)

Anonymous said:


> Mid 70s. Mechanical slip and fall. Pain 10/10 to low back/butt. No neck pain. Ambulatory prior to calling but after 1 hour and a vicodin patient is now unable to walk due to pain. Good PMS. Patient sitting on couch. Vitals WNL and alert and oriented.
> 
> Anything else just ask.



Was the fall witnessed? Is the pt a reliable historian? 
Either way the pt is probably getting transport in a position of comfort(or as close to it as you can get)


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## Anonymous (Oct 17, 2012)

Patient was able to answer questions appropriately and fall was witnessed. Leaning on a chair and the chair slipped out, causing pt to lose balance and fall.


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## Epi-do (Oct 17, 2012)

No board.  Transport in the position of least discomfort.


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## Veneficus (Oct 17, 2012)

Epi-do said:


> No board.  Transport in the position of least discomfort.



This, was the pt male or female?


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## Anonymous (Oct 17, 2012)

That is what was done, flatted out. No way hard board would have been tolerated. Got flack from the ED that is why I ask.


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## Milla3P (Oct 17, 2012)

Give flac back. "She wouldn't tolerate, boarding would make it worse"

At first, do no harm.


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## AnthonyM83 (Oct 17, 2012)

Milla3P said:


> Give flac back. "She wouldn't tolerate, boarding would make it worse"
> 
> At first, do no harm.



I'd correct that to do least amount of harm. We do harm with many procedures, but it's supposed to be overall best for them because of condition.

I think this scenario has more to do on whether a board is needed to prevent a worse injury, rather than comfort/toleration (since the ER COULD argue that making him tolerate some pain which could be medicated was better than a worse injuring occurring). Unless of course, he was not tolerating it so badly that he was moving more (like drunk patients).


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## d0nk3yk0n9 (Oct 17, 2012)

Epi-do said:


> position of least discomfort



I'm going to have to start using this phrase, since it seems like such a better description than "position of comfort" for many situations.


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## VFlutter (Oct 17, 2012)

I love when people C spine after the patient has already been ambulatory for an extended period of time.


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## Martyn (Oct 17, 2012)

ChaseZ33 said:


> I love when people C spine after the patient has already been ambulatory for an extended period of time.


 
But sometimes it comes down to the dreaded protocol thing...ours was ANY GLF...C-spine and Backboard


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## Handsome Robb (Oct 17, 2012)

Martyn said:


> But sometimes it comes down to the dreaded protocol thing...ours was ANY GLF...C-spine and Backboard



That's unfortunate. 

I'm not a fan of boarding people but mechanism alone is a crappy reason. 

Random thought about c-spine, I had a guy the other day fall *** over teakettle off his bicycle into a construction trench. Probably the first "legit" backboarding I have ever done. +LOC, +ETOH, - neck pain, - motor but "burning" sensory intact, no abnormalities noted on palpation. Guy ended up having a SCI at C4-5 and is a quad now. You've got to take the whole picture into account.


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## Tigger (Oct 17, 2012)

ChaseZ33 said:


> I love when people C spine after the patient has already been ambulatory for an extended period of time.



Playing devil's advocate here but if your assessment revealed point tenderness, numbness and tingling in the extremities, and an obvious deformity over the cervical spine, would you still not spinal someone if they were walking around? 

I agree that most spinals are unneeded especially if the patient is ambulatory on arrival, but the decision to spinal someone needs to be done via an assessment.


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## leoemt (Oct 17, 2012)

Anonymous said:


> Mid 70s. Mechanical slip and fall. Pain 10/10 to low back/butt. No neck pain. Ambulatory prior to calling but after 1 hour and a vicodin patient is now unable to walk due to pain. Good PMS. Patient sitting on couch. Vitals WNL and alert and oriented.
> 
> Anything else just ask.



Yup would get the board and padding. 

Think about the MOI and the force of energy transfer. PT fell on butt where is the energy going to travel? It is going to go up his spine. Possible (unlikely) spinal injury further up the spinal column as a result of transfer of energy. Injury more likely if pt had sever curve in spine (i.e. looking down) or kyphosis. What if pt had prior back injury? Could definately reagravate it. Most likely this is why you got some flack from the ER.

Pt would be c-spine and backboarded. Heavy padding. Of course, our hospitals clear pts. off of backboards quickly.


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## BassoonEMT (Oct 17, 2012)

http://www.youtube.com/watch?v=YzYxz_uvtSI


sorry... but SOMEONE had to...  ^_^ -_-  ....:unsure:


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## Tigger (Oct 17, 2012)

leoemt said:


> Yup would get the board and padding.
> 
> Think about the MOI and the force of energy transfer. PT fell on butt where is the energy going to travel? It is going to go up his spine. Possible (unlikely) spinal injury further up the spinal column as a result of transfer of energy. Injury more likely if pt had sever curve in spine (i.e. looking down) or kyphosis. What if pt had prior back injury? Could definately reagravate it. Most likely this is why you got some flack from the ER.
> 
> Pt would be c-spine and backboarded. Heavy padding. Of course, our hospitals clear pts. off of backboards quickly.



Assess your patient.


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## Aidey (Oct 17, 2012)

Tigger said:


> Assess your patient.



+1. 

Apparently that extra 100hrs of A&P wasn't as useful as it could have been.


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## VFlutter (Oct 18, 2012)

leoemt said:


> What if pt had prior back injury? Could definately reagravate it.



What kind of back injury? So if your patient previously strained their back then slipped and fell and complained of back pain you are going to backboard them?


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## usalsfyre (Oct 18, 2012)

Nexus.


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## VFlutter (Oct 18, 2012)




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## AnthonyM83 (Oct 18, 2012)

ChaseZ33 said:


> I love when people C spine after the patient has already been ambulatory for an extended period of time.



The patients with spinal fractures do too. We've had a number of local incidents of people walking in to ER's with potentially dangerous spinal fractures secondary to BLUNT trauma. Most of the ones that involved prehospital personnel, they had cspined them anyway, so they were in the clear. Not all, though.

Penetrating is a different story...


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## MediMike (Oct 18, 2012)

+1 to the post above.  We've had several patients in the last two years walk into the ED after slipping down stairs etc., ambulatory for 4-5 days, get films and found to have unstable fxs.  Nexus.


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## Veneficus (Oct 18, 2012)

After reading this thread...

There is no hope for EMS...


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## VFlutter (Oct 18, 2012)

AnthonyM83 said:


> The patients with spinal fractures do too. We've had a number of local incidents of people walking in to ER's with potentially dangerous spinal fractures secondary to BLUNT trauma. Most of the ones that involved prehospital personnel, they had cspined them anyway, so they were in the clear. Not all, though.
> 
> Penetrating is a different story...



So for those patients who were ambulatory do you think it would be better to backboard them over transporting them in position of comfort? What did they do when they got to the ER? Full immobilization?


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## rescue1 (Oct 18, 2012)

Hospital staff readers: if a patient comes to the ER with a complaint suggesting spinal injury, are they immobilized? And if an xray shows a fracture are they then immobilized? In my experience they are not, which makes me wonder why we get so worked up about it prehospitally.


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## Handsome Robb (Oct 18, 2012)

rescue1 said:


> Hospital staff readers: if a patient comes to the ER with a complaint suggesting spinal injury, are they immobilized? And if an xray shows a fracture are they then immobilized? In my experience they are not, which makes me wonder why we get so worked up about it prehospitally.



You figure out the answer to that you let me know. We are one of the last, if not the last countries using the long spine board rather than a collar and scoop or something of the sort. 

I'll echo usalsfyre and say: if you are worried about a spinal injury...NEXUS

I'll echo Tigger as well and say: assess your patient.


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## Medic Tim (Oct 18, 2012)

rescue1 said:


> Hospital staff readers: if a patient comes to the ER with a complaint suggesting spinal injury, are they immobilized? And if an xray shows a fracture are they then immobilized? In my experience they are not, which makes me wonder why we get so worked up about it prehospitally.



What I normally see is a c collar and the pt is put in a position of comfort(in a bed) and told to not move.



I understand the some places do not have spinal rule out but don't you need to have a suspicion there may be an injury before you put the pt on a board. (Assessment) Since when has a fall from standing height been a significant moi? Especially if there are no neuro deficits or pain(I know that was not the case here but I see it all the time)


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## rescue1 (Oct 18, 2012)

Technically per PA state protocols a fall from standing is considered significant MOI. However, if the pt denies pain and is not altered (basically, NEXUS), then c-spine can be cleared.

As for the hospital thing, that's what I figured.


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## Medic Tim (Oct 18, 2012)

leoemt said:


> Yup would get the board and padding.
> 
> Think about the MOI and the force of energy transfer. PT fell on butt where is the energy going to travel? It is going to go up his spine. Possible (unlikely) spinal injury further up the spinal column as a result of transfer of energy. Injury more likely if pt had sever curve in spine (i.e. looking down) or kyphosis. What if pt had prior back injury? Could definately reagravate it. Most likely this is why you got some flack from the ER.
> 
> Pt would be c-spine and backboarded. Heavy padding. Of course, our hospitals clear pts. off of backboards quickly.



You need to look at the pt and perform a good assessment. Not look at the (questionable) significant moi, What is the sense of you even doing an assessment if you are not going to use the findings. Just because a pt fell or even hit their head does not mean they need a board. And doing it to be "safe" Is flawed thinking as putting them on a board will be worse(in most situations) than having the pt find a position of comfort and sit still. Show me a study or evidence that it does (becuase we have always done it is not an answer) this is one of the areas where ems needs to catch up with the rest of the medical field
A pt with "sever curve in spine" as you call it is even more reason not to put this pt on the board. With a pt like this if I suspected a c spine injury, would get a collar and transport in a position of comfort.(not on a long board)


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## Medic Tim (Oct 18, 2012)

rescue1 said:


> Technically per PA state protocols a fall from standing is considered significant MOI. However, if the pt denies pain and is not altered (basically, NEXUS), then c-spine can be cleared.
> 
> As for the hospital thing, that's what I figured.



Hopefully ems will catch on to the whole evidence based thing sometime this century.


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## rescue1 (Oct 18, 2012)

Medic Tim said:


> Hopefully ems will catch on to the whole evidence based thing sometime this century.



Your crazy talk of science has no place here, sir.


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## Medic Tim (Oct 18, 2012)

rescue1 said:


> Your crazy talk of science has no place here, sir.



Oops, I forgot I am only an ambulance driver.


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## Veneficus (Oct 18, 2012)

*easy answers*



rescue1 said:


> Hospital staff readers: if a patient comes to the ER with a complaint suggesting spinal injury, are they immobilized? And if an xray shows a fracture are they then immobilized? In my experience they are not, which makes me wonder why we get so worked up about it prehospitally.



You get  worked up about it because the people teaching teach what they know.

They were taught fear instead of knowledge and they pass that on.

They were taught that a spineboard actually stabilizes the spine, which is pretty much BS.

What is does do is reduce spinal motion during extrication.

It is left over from a time when people were guessing what helps with exponsentially less knowledge than we know today.


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## Christopher (Oct 18, 2012)

MediMike said:


> +1 to the post above.  We've had several patients in the last two years walk into the ED after slipping down stairs etc., ambulatory for 4-5 days, get films and found to have unstable fxs.  Nexus.



I would argue that those Fx are by definition *stable* as the patient had no sequelae after 4-5 days...but hey I'm just an engineer not an orthopod.


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## ExpatMedic0 (Oct 18, 2012)

I was not there but if the person is elderly and is complaining of 10/10 pain even from a ground level fall I would not be so quick to dismiss the idea. I would really at least consider a possible fracture until proven otherwise. I have seen elderly women with fractures from ground level falls. Of course many factors may play a roll in deciding to backboard or not.


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## usalsfyre (Oct 18, 2012)

schulz said:


> I was not there but if the person is elderly and is complaining of 10/10 pain even from a ground level fall I would not be so quick to dismiss the idea. I would really at least consider a possible fracture until proven otherwise. I have seen elderly women with fractures from ground level falls. Of course many factors may play a roll in deciding to backboard or not.



Not unheard of...but is a board going to help clinically in any way?


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## VFlutter (Oct 18, 2012)

christopher said:


> i would argue that those fx are by definition *stable* as the patient had no sequelae after 4-5 days...but hey i'm just an engineer not an orthopod.



+1000


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## ExpatMedic0 (Oct 18, 2012)

Well that all depends on what was suspected based primarily on the assessment and of course other factors like hx, moi, ect.

What are we suspecting? Based on the limited information regarding the physical examination and having not been there myself. I am not sure if I should suspect a fractured coccyx, pelvis, something even more serious or simply a soft tissue injury. I do not think at least seriously entertaining these ideas, and ruling them out is a bad idea, do you? 

 Maybe a backboard with padding, maybe a KED, maybe a pelvic sling, maybe just some padding with position of comfort.


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## usalsfyre (Oct 18, 2012)

But the board still doesn't particularly help an injured spine in any way. I think it could probably be safely argued the stretcher mattress does a better job of reducing spinal movement than a board.


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## ExpatMedic0 (Oct 18, 2012)

So your arguing against the use of a backboard for any spinal immobilization procedures, or just for this scenario?


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## NYMedic828 (Oct 18, 2012)

Has anyone mentioned how much the process of spinal immobilizing actually hinders an efficient auto extrication?

Half the time we can get someone out through the back seat or the trunk of a minivan or they could just climb out on their own but we insist that for the sake of their survival they must remain still and wait for us to rip their vehicle apart and/or try and slide them out in an extremely uncomfortable manor.

I wonder how many patients involved in major MVAs may actually have survived had we yanked them from the car in a more rapid manor and just gotten them to a surgeon that much faster? (Not many I'm sure, but still an interesting thought)


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## Veneficus (Oct 18, 2012)

schulz said:


> So your arguing against the use of a backboard for any spinal immobilization procedures?



I would, except as an extrication device.

I know there are some neuro studies from the 70s and 80s that state it is useful, but there were too many unaccounted for variables in my opinion.


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## ExpatMedic0 (Oct 18, 2012)

I have read some rather discouraging study's regarding back boarding patients. I would like to read more study's about it before I completely cast it aside as a tool. I would agree that most patients are back boarded with out spinal injury's, but what about those with spinal injury's? You could argue against it, however for the time being it would appear its still expected of us since its written in all modern paramedic text books I am aware of, still a national practical exam required for certification and still written into protocols which Medical Doctors continue to approve and publish in various forms.


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## rmabrey (Oct 18, 2012)

And I thought my service was halfway progressive by allowing us a rule out protocol.........then I read it and changed my mind


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## Christopher (Oct 18, 2012)

schulz said:


> I have read some rather discouraging study's regarding back boarding patients. I would like to read more study's about it before I completely cast it aside as a tool. I would agree that most patients are back boarded with out spinal injury's, but what about those with spinal injury's? You could argue against it, however for the time being it would appear its still expected of us since its written in all modern paramedic text books I am aware of, still a national practical exam required for certification and still written into protocols which Medical Doctors continue to approve and publish in various forms.



Modern paramedic text books and protocols written by medical directors still support Esophageal Detector Devices and don't require waveform end-tidal capnography...they state/require LOTS of things which would be negligent if lawyers had half a clue (apologies in advance Gene if you read this page). If your protocols aren't updated at least biannually they probably support treatments that are no longer the standard of care.

There is no physical or mechanical basis for the assumption that strapping someone down to a *level*, rigid board decreases spinal motion and reduces sequelae from spinal trauma. The spine is not level for starters...

You're responsible for knowing how to appropriately treat your patients *in spite of* what your textbook said, what NREMT tests on, and what your protocols say.


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## ExpatMedic0 (Oct 18, 2012)

Christopher said:


> You're responsible for knowing how to appropriately treat your patients *in spite of* what your textbook said, what NREMT tests on, and what your protocols say.


 
That is a quite a dangerous statement to make for someone with what is often 1 year of vocational training don't you think? Just because your read some study's in a professional journal or formed a hypothesis does not give you the right to deviate from what is the current national standard of care.

 I am not saying I am a strong advocate of back boarding, in fact I am advocate of clearing C spine in the field if permissible in your area. However to imply if we DO suspect a possible spinal injury and intentionally refuse to backboard based on your own personal standard of care and opinion, that is not the way this works man.

What if I disagree with the efficiency of amiodarone in cardiac arrests? Does that give me the right to deviate from ACLS (which we are all required to certify in) and protocols? 

What if I decide 1 day that all those articles we have been reading on the in efficiency of pre hospital intubation is true, so I refuse to intubate anyone from now on as a result.

Yes you can deviate from protocols and use good clinical skills to make decisions. If you can explain why you did what you did more power to you, so long as a jury of your peers and your medical director will concur.

 It does not give you the right to do whatever  you want because you disagree with your scope of practice, the education system, your medical director, and the whole system.

If you decide not to backboard someone because you DO NOT suspect a spinal injury and you can justify it or justify why the spinal immobilization was unnecessary based on the injury... that is great. I am not saying to blindly follow our protocols and avoid clinical judgments. 

If you want things to change speak to your medical director about changing the spinal immobilization protocols, speak to the American College of Surgeons about changing there current guidelines for us, your state EMS office, the National Registry or emergency medical technicians, act to change textbooks, go back to college and earn a degree which can further the progression of these ideas, conduct EMS research study's and become involved with epidemiology, join professional organizations which create change.


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## VFlutter (Oct 18, 2012)

schulz said:


> So your arguing against the use of a backboard for any spinal immobilization procedures, or just for this scenario?



IMO, spinal immobilization is greatly over used based based off blind obedience to protocol and fear of "what if". We have all been force fed the stories of that one time some guy that fell from standing height, had a step off injury, and was paraylzed, and sued and use it as justification to backboard every remotely related MOI. Also when it is used it has been shown to be poorly done and not all that effective (if it all)


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## ExpatMedic0 (Oct 18, 2012)

ChaseZ33 said:


> IMO, spinal immobilization is greatly over used based based off blind obedience to protocol and fear of "what if".


I agree completely. 
However, what I am saying is... what if YOU DO suspect a spinal injury? Would you not backboard?


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## Christopher (Oct 18, 2012)

schulz said:


> That is a quite a dangerous statement to make for someone with what is often 1 year of vocational training don't you think? Just because your read some study's in a professional journal or formed a hypothesis does not give you the right to deviate from what is the current national standard of care.



I've had a few years outside of vocational training, but that wouldn't change what I'm saying.

My point is you are ultimately responsible for doing what is right/best for your patient. It doesn't matter whether that came from a guideline, protocol, medical control, NREMT, a textbook, latest research, etc.

If we're not actively critical of standards, well they aren't really useful to anyone. Does your system even know what evidence supports its standards? Thankfully our local protocols go beyond old standards (NREMT is the _low_ end).



schulz said:


> I am not saying I am a strong advocate of back boarding, in fact I am advocate of clearing C spine in the field if permissible in your area, but to imply  if we DO suspect a possible spinal injury and intentionally refuse to backboard based on your own personal standard of care and opinion, that is not the way this works man.



It is not my personal standard but rather an accepted standard. Perhaps you're right that NREMT doesn't agree.



schulz said:


> What if I disagree with the efficiency of amiodarone in cardiac arrests? Does that give me the right to deviate from ACLS (which we are all required to certify in) and protocols?



You're free to deviate from ACLS whenever you please. ACLS is not a protocol, it is instead a guideline that is often used when creating protocols. As you note though, you're probably not as free to deviate from your protocols.

Due to many issues with the drug, when given the option I avoid using amiodarone altogether in favor of procainamide. In cardiac arrest it doesn't really matter, they're similar in efficacy to a saline flush.



schulz said:


> What if I decide 1 day that all those articles we have been reading on the in efficiency of pre hospital intubation is true, so I refuse to intubate anyone from now on as a result.



I'm not sure where electing not to intubate a patient becomes bad clinical judgement. Good clinical judgement quite often means making the decision to not intubate a patient, you learn that well in an RSI system.



schulz said:


> Yes you can deviate from protocols and use good clinical skills to make decisions. If you can explain why you did what you did more power to you, so long as a jury of your peers and your medical director will concur.



Protocols form the foundations of care, they are not intended to be the limits.



schulz said:


> It does not give you the right to do whatever  you want because you disagree with your scope of practice, the education system, your medical director, and the whole system.



I don't disagree with my scope and I've not exceeded it with my statements on C-spine.

As an educator I teach the standard and teach students to evaluate the statements critically.

I disagree with my medical director on occasion and he disagrees with me on occasion...seems par for the course. I'm not actually in disagreement with my system, I think it runs pretty well for C-spine issues.

_I removed the rest of it as it strays off topic_


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## ExpatMedic0 (Oct 18, 2012)

Ah ok, so YOU ARE following some kind of standard in place. I misunderstood you and thought you as an individual where choosing not to backboard people because of your own personal vendetta. Its been a while, but I have spoke to people following the Canadian C-spine rule and I have herd good things. Here is a question for you then, If you have a high index of suspension for a spinal injury with altered Pulse Motor Sensation and significant Mechinsm, how do you manage it in your system with out a backboard?


Christopher said:


> We use a modified Canadian C-Spine rule that the state office put in place. It works pretty well.




Cool, I am working on finishing my undergraduate degree as we speak.


Christopher said:


> My BSc is in computer science and I work outside EMS in a field with active engineering research. I skipped a masters to get into EMS.


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## Anonymous (Oct 18, 2012)

Okay now in this case, you pull up on scene after fire. As you walk up they say grab the flat. Their assessment is already done and they have decided they are going to flat her out. Family is around and patient is in excruciating pain. Just from what you have gathered in the little time you have been on scene you agree flat would cause least discomfort (not necessarily saying is best for treating pt)

Would you say "hold up, we need to c-spine this person?" if you thought that was the case.


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## rescue1 (Oct 18, 2012)

Another question, this one for the LSB haters.
Say you get called for a fall off a roof. Your patient is complaining of severe back pain and has some deficit in both his legs. Your partner is all like "Bro, this is totally a spinal fracture". 
How do you this patient from the lawn to the cot, then from the cot to the hospital bed? Carrying him unsupported is likely to exacerbate the injury as he bends in the middle. If you log roll and board him, its a pain to take the board out from the under him once he's on the cot, same with a scoop.
What would be your way of transporting him from ground to cot to bed without boarding him? And is the technique you suggest used anywhere else?


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## Christopher (Oct 18, 2012)

rescue1 said:


> Another question, this one for the LSB haters.
> Say you get called for a fall off a roof. Your patient is complaining of severe back pain and has some deficit in both his legs. Your partner is all like "Bro, this is totally a spinal fracture".
> How do you this patient from the lawn to the cot, then from the cot to the hospital bed? Carrying him unsupported is likely to exacerbate the injury as he bends in the middle. If you log roll and board him, its a pain to take the board out from the under him once he's on the cot, same with a scoop.
> What would be your way of transporting him from ground to cot to bed without boarding him? And is the technique you suggest used anywhere else?



Scoop stretcher. Funny enough, scoop stretcher at least has SOME evidence.


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## Christopher (Oct 18, 2012)

schulz said:


> ...Here is a question for you then, If you have a high index of suspension for a spinal injury with altered Pulse Motor Sensation and significant Mechinsm, how do you manage it in your system with out a backboard



The honest answer is I usually have no choice as my first responders will have them packaged prior to my arrival probably 60-70% of the time. When I have my druthers out will come a scoop stretcher or a reeves sleeve and padding.


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## rescue1 (Oct 18, 2012)

Christopher said:


> Scoop stretcher. Funny enough, scoop stretcher at least has SOME evidence.



That makes sense. Do you have the big plastic ones or the smaller metal ones?


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## Handsome Robb (Oct 18, 2012)

Anonymous said:


> Okay now in this case, you pull up on scene after fire. As you walk up they say grab the flat. Their assessment is already done and they have decided they are going to flat her out. Family is around and patient is in excruciating pain. Just from what you have gathered in the little time you have been on scene you agree flat would cause least discomfort (not necessarily saying is best for treating pt)
> 
> Would you say "hold up, we need to c-spine this person?" if you thought that was the case.



If they need to be spinaled, absolutely. 

"Get a line and monitor, I'm going to draw some fent then once it starts working we will roll her onto the board."


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## Anonymous (Oct 18, 2012)

NVRob said:


> If they need to be spinaled, absolutely.
> 
> "Get a line and monitor, I'm going to draw some fent then once it starts working we will roll her onto the board."



ALS was cancelled by fire prior to arrival. No pain management for this pt other than the vicodin taken an hour beforehand.

If it clears up any confusion the system here uses a private company for transport. ALS and Fire are separate....


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## ExpatMedic0 (Oct 18, 2012)

Patient is in there 70's correct? Does the physical exam reveal anything abnormal at the location of injury site or anywhere along the spine or pelvis? What was your general impression and did you suspect a fracture of any kind?


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## Handsome Robb (Oct 18, 2012)

Anonymous said:


> ALS was cancelled by fire prior to arrival. No pain management for this pt other than the vicodin taken an hour beforehand.
> 
> If it clears up any confusion the system here uses a private company for transport. ALS and Fire are separate....



If she's uncomfortable enough to have to worry about how you are going to cause the least amount of harm during transport she needs pain management. 

I'll add another to my original response, first responders don't tell me what they need, they give me a report and I make the decisions unless there's extenuating circumstances such as an confined space or high-angle rescue. In that case it's their sandbox and I don't want to intrude on that.


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## AnthonyM83 (Oct 18, 2012)

ChaseZ33 said:


> So for those patients who were ambulatory do you think it would be better to backboard them over transporting them in position of comfort? What did they do when they got to the ER? Full immobilization?



Ah, you're drawing me into a different argument. Does immobilization work, etc?
I replied to your original statement "I love when people C spine after the patient has already been ambulatory for an extended period of time."

Your quote implies that you DO agree with "C spine". You disparage C spine AFTER the patient has been ambulatory for an extended period of time, making the implication that it SHOULD be done if that patient has NOT been ambulatory.

Then, why are you asking me about "full immobilization" in general? I wasn't addressing useful not of full immobilization in general. I was addressing your implication that if that patient has been ambulatory, the we shouldn't C spine (in a situation in which you otherwise would have).


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## AnthonyM83 (Oct 18, 2012)

Veneficus said:


> You get  worked up about it because the people teaching teach what they know.



Have them start teaching vastly different ways of doing things and see how quickly the local EMS agency (and their medical doctors) shoot them down. What you must remember is that we ARE held to a standard of care, one that is enforced by agencies run by doctors who DEMAND that standard of care.



Christopher said:


> You're responsible for knowing how to appropriately treat your patients *in spite of* what your textbook said, what NREMT tests on, and what your protocols say.


 You're also responsible to treat according to what they say.

Nice situation we're in.


Additionally, as the standard of care changes, it needs to be accepted by at least some communities (local agency, NREMT, etc) to be valid. Say someone read the first couple major spinal immobilization studies when they started gaining momentum a few years ago. Some of them had CRAPPY information. The authors were under the impression that we still used SANDBAGS as a standard for head immobilization! BUT what if some providers had taken that article and ran with it, started pushing for change and even violating protocols. That wouldn't be evidence based.

BUT NOW, as more evidence comes out, it IS evidence based. But I don't trust the individual or hell even most people at the local EMS agency to be deciding what the standard is. I want my medicine checked and double checked by various experts. SO THEN, if the local agencies don't apply the new information, THEN, they're in violation of evidence based medicine...


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## Veneficus (Oct 19, 2012)

AnthonyM83 said:


> Have them start teaching vastly different ways of doing things and see how quickly the local EMS agency (and their medical doctors) shoot them down. What you must remember is that we ARE held to a standard of care, one that is enforced by agencies run by doctors who DEMAND that standard of care....



I think many in EMS seriously underestimate the actual amount of time or efforts doctors give to EMS.

Many of these practices (which are nothing more than outdated expert opinion) don't change because nobody actually wants to waste time doing studies on it. 

You see one of the purposes of research is to get it published. It is an aweful lot of work to do for nobody to read it. 

As well, in the US, a medical director is simply  name on a paper. They are instantly replacable and in many agencies any doctor who tries to buck the status quo is replaced with a compliant one.

Many in EMS have never even met their medical director or would know what he/she looked like. Do you think that is the mark of an involved and caring leader?

Many US medical directors are not even compensated. How much time and effort do you think they spend with EMS. In my experience as little as possible. 

If I said about EMS providers even 1/2 the things I regularly hear doctors (including US EMs) say about them, people here might start cutting their wrists.

There is a difference between a person who respects you and a person who is polite or nice to you.

I know more than a handful of docs who still try to advance and be involved in EMS. But they are less than 1% of all doctors.

Do you believe when a medical director asks his anesthesia or neuro surg collegue what could be improved in EMS (if she even has such collegues, and if they actually spend time talking about EMS for more than a second in the elevator) that they don't just decide there are too many variables, "keep doing what you are doing?"

Bottom line:

Doctors largely don't give a rat's *** about EMS. Certainly not enough to spend the effort to change things.

I also know many who have spent great effort and time trying to pull EMS up to speed. Most of them quit or are now just involved in critical care transport.

US EMS providers do not want to change a vast majority of doctors don't want to waste time trying to change them.


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## mycrofft (Oct 21, 2012)

I wonder if there is a disconnect betwen NHTS and NIH about field EMS? Does NHTSA still hold the reins, and if so, is it becuase NIH doesn't want it?
That could explain why change from the top is slow, infrequent, hesitant, and seems not to recognize changs in the science.


SIDEBAR: I'm thinking about changing my signature line to "LSB + KED + C-COLLAR= MOTHER'S MILK". Any thoughts?


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## stairchair (Nov 12, 2012)

Well he dose not meet my departments c spine clearing Protocol and our x ray is broke so I would say board him ( if he consented) after being informed about the procedure.


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## KellyBracket (Nov 12, 2012)

rescue1 said:


> Hospital staff readers: if a patient comes to the ER with a complaint suggesting spinal injury, are they immobilized? And if an xray shows a fracture are they then immobilized? In my experience they are not, which makes me wonder why we get so worked up about it prehospitally.



Your experience serves you well. The only time we use a backboard in the ED is to get a patient off the floor.

It's worth it to point out that ATLS (the standard trauma course for docs) teaches that the backboard is only utilized for transport to the ED. _Everyone_ comes off the board in the ED. 

In fact, patients with evident spinal cord injury (e.g. paraplegia) are supposed come off the board _immediately_, given the high risk of skin breakdown and subsequent infection.

The collar usually stays on. Remember; removing the backboard ≠ clearance!


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## d_miracle36 (Nov 13, 2012)

We recently had a trauma symposium in my state were some of the local hard hitting trauma docs attended. There was a paramedic who gave a lecture on spinal immobilization and brought up many of the references that many of you already know. There was one that was new to me and it has been hitting our area fast. Has anyone read it yet?

I uploaded the attachment, not sure if it worked or not but here is the short pubmed version. http://www.ncbi.nlm.nih.gov/pubmed/22962052

May not be new to many of you but it was to me. Anyway so after the lecture one of the docs stood up and said I have a question for the crowd. Would anyone say anything to ems if they brought a patient with a c-collar and no backboard, and no one stood up. Was interesting since the hospital who hosted the symposium is the most critical hospital I have seen when it comes to spinal immobilization.


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## sneauxpod (Nov 13, 2012)

Personally no I wouldnt, but according to my protocol I have to for any fall or traumatic event where any type of back pain is involved.


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## RocketMedic (Nov 18, 2012)

Veneficus said:


> I think many in EMS seriously underestimate the actual amount of time or efforts doctors give to EMS.
> 
> Many of these practices (which are nothing more than outdated expert opinion) don't change because nobody actually wants to waste time doing studies on it.
> 
> ...



What do they say about us?


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## RocketMedic (Nov 18, 2012)

stairchair said:


> Well he dose not meet my departments c spine clearing Protocol and our x ray is broke so I would say board him ( if he consented) after being informed about the procedure.



Corrected: "Well, he doesn't meet my department's c-spine clearing protocol..."


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## rescue1 (Nov 24, 2012)

KellyBracket said:


> Your experience serves you well. The only time we use a backboard in the ED is to get a patient off the floor.
> 
> It's worth it to point out that ATLS (the standard trauma course for docs) teaches that the backboard is only utilized for transport to the ED. _Everyone_ comes off the board in the ED.
> 
> ...



I figured. Well, maybe one day this standard of care will also be used pre-hospitally.


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