# Immobilize or not?



## HMartinho (Oct 25, 2011)

Our BLS unit was dispatched for an assault victim on a sidewalk. Male, 19  years old that was beaten several times in his belly, back and chest. He complains pain on his ribs, backaches, headaches and some shortness of breath. He's alert and orientated.

BP: 130-85
Pulse: 98
RR: 15
temp: 36,5 ºC/97,7 ºF
pupils are equal and reactive
pulse-ox: 93% on room air
breath sounds are normal
Pain: 5 on a scale between 0 to 10.

History of tipe I diabetes and allergy to penicillin.

On physical examination (head-to-toe), we don't found nothing of concern.

The question is: I proposed a full immobilization (as I learned in these cases), but my partner did not agree, and said: We don't  find nothing special on physical exam,so it is not necessary. After a little reflection, my partner eventually agreed, and the patient was immobilized with backboard, c collar and head stabilizers.

He was transported to the hospital, with 3 liters of oxygen per minute via nasal cannula.

What do you think? We should immobilize or not?


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## usalsfyre (Oct 25, 2011)

Any signs of spinal injury? Absent physiologic signs and symptoms there's no need to apply a treatment that has potential to cause harm. Would you give a patient with no signs of anaphylaxis an epi pen just because a bee stung them?

And for that matter, why the O2?


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## ah2388 (Oct 25, 2011)

You are somewhat limited by local guidelines, and until the receiving facilities embrace the "newish" research outlining the idea that spinal immobilization as performed currently pre hospital is often more harmful than helpful, you are likely limited to immobilizing patients like this.

With that being said, as I read the scenario, the pt does not appear to have any neuro deficit, nor any obvious indication of spinal injury, so I think its reasonable to forego immobilization.


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## fast65 (Oct 25, 2011)

I would not have immobilized him, there were no signs of spinal injury. No neck pain, no deformities/pain/tenderness noted on the spine, and neuros were grossly intact; at least I can infer that info from your post.


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## exodus (Oct 25, 2011)

Does backaches not mean back pain?


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## usalsfyre (Oct 25, 2011)

exodus said:


> Does backaches not mean back pain?



Point tenderness on palpation of the spine vs generalized muscle pain mean vastly different things


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## fast65 (Oct 25, 2011)

exodus said:


> Does backaches not mean back pain?



I consider backaches to imply muscular pain, and with his assessment he didn't specify where the backache was and whether or not there was any pain/tenderness to the spine.


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## HMartinho (Oct 25, 2011)

He had no signs of spinal injury. No paresthesias, and had good  strenght in legs, he only complains of pain,that's why I wanted to immobilize him.

 We gave O2, because he had shortness of breath, and had a pulse ox of 93%. Our med-control along with it.


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## HMartinho (Oct 25, 2011)

exodus said:


> Does backaches not mean back pain?



yes... Sorry about my englishh34r:h34r:

On palpation, he complains back pain.


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## fast65 (Oct 25, 2011)

HMartinho said:


> He had no signs of spinal injury. No paresthesias, and had good  strenght in legs, he only complains of pain,that's why I wanted to immobilize him.
> 
> We gave O2, because he had shortness of breath, and had a pulse ox of 93%. Our med-control along with it.



Pain where though? Pain along the spine, on his neck, with palpation? Point tenderness? Generalized back pain in and of itself is not a good reason to immobilize an assault victim.


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## HMartinho (Oct 25, 2011)

fast65 said:


> Pain where though? Pain along the spine, on his neck, with palpation? Point tenderness? Generalized back pain in and of itself is not a good reason to immobilize an assault victim.



When we arrived, beyond the questions to check alertness and orientation, we asked: Sir di you have any pain? He said my back, chest and head hurts. On palpation, it is more pain at the dorsal. Nevertheless, no paresthesias, and has good strenght  in the legs, and sensitivity in all lower limb.


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## fast65 (Oct 25, 2011)

HMartinho said:


> When we arrived, beyond the questions to check alertness and orientation, we asked: Sir di you have any pain? He said my back, chest and head hurts. On palpation, it is more pain at the dorsal. Nevertheless, no paresthesias, and has good strenght  in the legs, and sensitivity in all lower limb.



So based on that, why did you immobilize? At what level of the spine was this back pain?


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## DesertMedic66 (Oct 25, 2011)

Back pain or any kind of pain in the back possibly caused by trauma = C-spine. I would have been ripped to shreads if I arrived at the hospital without C-spine.


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## HMartinho (Oct 25, 2011)

fast65 said:


> So based on that, why did you immobilize? At what level of the spine was this back pain?



He complains more pain in dorsal level.


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## HMartinho (Oct 25, 2011)

firefite said:


> Back pain or any kind of pain in the back possibly caused by trauma = C-spine. I would have been ripped to shreads if I arrived at the hospital without C-spine.



Just as I learned


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## fast65 (Oct 25, 2011)

HMartinho said:


> He complains more pain in dorsal level.



From my knowledge, dorsal implies the back side, not really a particular level. Was it lumbar, thoracic, or cervical spine pain?


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## HMartinho (Oct 25, 2011)

fast65 said:


> From my knowledge, dorsal implies the back side, not really a particular level. Was it lumbar, thoracic, or cervical spine pain?



In Portugal we use different terminology: cervical, dorsal and lumbar. So, our dorsal is your thoracic. He had more pain in thoraccic level.


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## fast65 (Oct 25, 2011)

HMartinho said:


> In Portugal we use different terminology: cervical, dorsal and lumbar. So, our dorsal is your thoracic. He had more pain in thoraccic level.



Ah, ok, thank you for the clarification.


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## HMartinho (Oct 25, 2011)

I do I have to thank. I'm an English forum, so I have to use English terminology.

And sorry about my english. Gradually, I believe it will improve. h34r:


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## exodus (Oct 25, 2011)

HMartinho said:


> I do I have to thank. I'm an English forum, so I have to use English terminology.
> 
> And sorry about my english. Gradually, I believe it will improve. h34r:



Don't worry, you're doing fine! We're understanding you for the most part and you're willing to clarify!


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## adamjh3 (Oct 25, 2011)

As has been said it will depend on your local protocols. A lot of EMTs here in California would hear "back pain" and immediately jump to putting the patient in spinal restrictions. If the pain was not mid-line (along the spine) and the patient displayed no neuro deficits I likely would not have placed him in spinal restrictions. 

You did fine, spinal immobilization was probably beat into your head in EMT school, and we always fall back to our training. 

Sent from my DROIDX using Tapatalk


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## Tigger (Oct 25, 2011)

firefite said:


> Back pain or any kind of pain in the back possibly caused by trauma = C-spine. I would have been ripped to shreads if I arrived at the hospital without C-spine.



Out of curiosity, who does the ripping? I've definitely brought in patients with similar presentations and had nurses thank me for not boarding them. I hardly ever see a doc during handoffs but I imagine they would feel similar. Plus if a nurse makes noise about not spinaling someone I am happy to explain my reasoning. Usually an explanation is all it takes for cool heads to emerge. If you I can't justify my lack of treatment then maybe I have a problem, but that is not going to happen.

Somewhat related: my job in Sports Medicine has given me the opportunity to learn a much better neuro exam than in basic class. Is performing a neuro exam out of scope for me as a basic for anything beyond poops and giggles? Can I use that info to help guide my treatment?

Sent from my out of area communications device.


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## Handsome Robb (Oct 25, 2011)

Tigger it's gonna come down to your protocols. Are you allowed to clear c-spine in the field? As a basic, my first guess is no. If they meet the criteria per your protocols your hands are tied unless you have a really good reason to justify your actions such as having to fight a patient onto a board.


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## mycrofft (Oct 25, 2011)

*Parsing:*

1. Follow local protocol.
2. If he wants to get out of it, have the AMA ready to sign.


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## Tigger (Oct 25, 2011)

NVRob said:


> Tigger it's gonna come down to your protocols. Are you allowed to clear c-spine in the field? As a basic, my first guess is no. If they meet the criteria per your protocols your hands are tied unless you have a really good reason to justify your actions such as having to fight a patient onto a board.



I can't clear c-spine in the field as I am a basic, as you note. I'm not really talking about clearing c-spine though. I'm thinking more along the lines of a typical unnecessary c-spine situation, where someone ends up on the board based purely on mechanism and not any complaints. A neuro exam seems like a good way to "talk my partner off the ledge" when it comes to a ground level fall with no complaint of neck or back pain. I hate when someone ends up on the board just because some misguided EMT was told by a misguided instructor that every fall patient should be boarded as a CYA measure. If a patient has neck or mid line back pain secondary to a traumatic event, they are going on a board because that is the standard of care in the area and we lack a better immobilization technique presently. Nowhere do the protocols state that someone should be boarded based on mechanism, so I could do a neuro exam to "prove" that someone does not need a board.

Would doing such a thing constitute clearing c-spine, even though c-spine precautions were probably not indicated to begin with?


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## DesertMedic66 (Oct 26, 2011)

Tigger said:


> Out of curiosity, who does the ripping? I've definitely brought in patients with similar presentations and had nurses thank me for not boarding them. I hardly ever see a doc during handoffs but I imagine they would feel similar. Plus if a nurse makes noise about not spinaling someone I am happy to explain my reasoning. Usually an explanation is all it takes for cool heads to emerge. If you I can't justify my lack of treatment then maybe I have a problem, but that is not going to happen.



that would be the nurses at the recieving facility who in turn would contact my sup and my treatment choice. If I can explain why I had a good reason not to do something then they are fine with that. But I'm not going to try to talk my way out from not using C-spine when they have back pain. Defiantly not as a Basic.


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## Handsome Robb (Oct 26, 2011)

Is it midline back pain or generalized back pain? There's a big difference. In all honesty a pt complaining of generalized back pain will more times than not be in more pain by the time you get to the ED if you put them on a board than if you left them alone and transported in a POC.

There's a huge difference between "back pain" and "midline back pain". You can discern the difference with a proper assessment.


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## JPINFV (Oct 26, 2011)

I hate the term "clearing c-spine." Simply saying that there is no indication for immobilization is not clearing anything. Do you clear emergency transport and downgrade to non-emergent transport because of the vital signs?

What other intervention is considered to always be indicated unless certain conditions are met? Shouldn't all interventions be considered to not be necessary until history and physical findings indicates them to be necessary?


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## Tigger (Oct 26, 2011)

JPINFV said:


> I hate the term "clearing c-spine." Simply saying that there is no indication for immobilization is not clearing anything. Do you clear emergency transport and downgrade to non-emergent transport because of the vital signs?
> 
> What other intervention is considered to always be indicated unless certain conditions are met? Shouldn't all interventions be considered to not be necessary until history and physical findings indicates them to be necessary?



That's my line of thinking, but I can think of only one partner who agreed with me. 

Everyone (generalized) else is of the opinion that every fall/MVC patient has a c-spine injury until proven otherwise. I think that's a reasonable line of thought until an assessment is done. That said, an assessment needs to dictate treatment, not an assumption. If you assume c-spine injury but your assessment reveals no compromise, the patient should not be spinaled. Yet I keep seeing patients with no signs or symptoms brought in on a board. Many cite fear of ER RNs where I work as well, but I don't think that theory is warranted. At least where I am, no RN is going to say anything for not providing a treatment that is *not indicated*. 

Sorry to belabor the point, I guess I'm just having trouble trying to get my partners to look at things and think critically about what needs to be done instead of basing treatments off misguided and archaic assumptions.


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## JPINFV (Oct 26, 2011)

I've never gotten the fear of random ED RNs to begin with. "Oh noes, the big bad nurse will yell at me." Fornicate that. If you can justify your treatment, justify it and move on. I've gone toe to toe with ED RNs more than once when I was an EMT, and if I can justify my treatment decisions, I'll do it every time. For example, I'm not going to call 911 for paramedics when I'm a minute away from the ED just because some RN got her panties in a bunch that she had to start an IV.


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## usalsfyre (Oct 26, 2011)

So revealing some biases here but, let's face it, a long spine board is a pseudo-treatment, and as such can't have any REAL indications. As such, it gets used when that other voodoo that's taught to EMS (mechanism) suggest it.


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## HMartinho (Oct 26, 2011)

Just to clarify a few things, in Portugal, the EMT's-B have little autonomy. If I go to the hospital with a patient who was beaten multiple times in the back, chest and belly, with back pain on palpation, without a full spine immobilization, probably the ER triage nurse and Attending physician, will "crushing me against the wall".

I who am EMT-B and I can not make diagnoses. We do not have paramedics (who can do a more thorough clinical evaluation, and make a diagnosis). We only have emergency critical care nurses and physicians, which in this case were not dispatched to the scene.

This does not mean I do not know how to do a neurological examination, as I did with my colleague, and as we found it, I decided to "play it safe", and make a full spine immobilization.


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## Handsome Robb (Oct 26, 2011)

I'm not doubting you or your treatment. I'm still wondering what everyone is referring to as back pain? Generalized? Midline? Scapular? My point is "back pain" is a very generalized statement.


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## JPINFV (Oct 26, 2011)

HMartinho said:


> I who am EMT-B and I can not make diagnoses.



Do you perform a history and physical exam?

Do you use that history and physical exam to come to some sort of conclusion about what's going on?

Do you you that conclusion to help guide your treatment, even if it's simply to pick a protocol?

If you answered "yes" to the above questions, then you make a diagnosis, regardless of what you want to call it.


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## BrushBunny91 (Oct 26, 2011)

When in doubt? c-spine. unconscious? Unknown moi? c-spine.


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## STXmedic (Oct 26, 2011)

BrushBunny91 said:


> When in doubt? c-spine. unconscious? Unknown moi? c-spine.



Sadly, I'm pretty sure this one IS serious


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## adamjh3 (Oct 26, 2011)

BrushBunny91 said:


> When in doubt? c-spine. unconscious? Unknown moi? c-spine.



Why? 

Sent from my DROIDX using Tapatalk


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## BrushBunny91 (Oct 26, 2011)

adamjh3 said:


> Why?
> 
> Sent from my DROIDX using Tapatalk



Its been beaten into my head that When faced with a unconscious patient and unknown moi, you expect the worst and c-spine. It's better to be safe then sorry.
How would you handle that?


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## JPINFV (Oct 26, 2011)

Depends on the physical exam. 


Oh, noticing you're still a student, ask your instructor why, if you're trying to stabilize a fracture, you'd strap a curved group of bones to a flat board. Just something to think about.


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## Handsome Robb (Oct 26, 2011)

Is there any signs of a traumatic MOI? Situational awareness is worth its weight in gold. Pinpoint pupils or other signs of OD ie empty pill containers, suicide note, history of suicide attempts? Kussmaul's Respirations? Medic alert tag indicating a medical condition such as Diabetes? There are a decent amount medical conditions that can cause unresponsiveness that have no need for c-spine unless the onset lead the patient to experience a traumatic event. Now if the pt is at the bottom of a set of stairs all scraped and bruised that's a different story.

Per NREMT, sadly you are correct, in the real world its not the case.


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## BrushBunny91 (Oct 26, 2011)

Thanks for going easy on me guys and understanding I am still a student 
Am I correct in saying I would try to realign the limb once to better spint and if that fails then splint as is? I would take into consideration the patients level of comfort and not attempt to move a very serious open fracture 
Yes, I would try to take other findings into account such as medical alert tags, pupil dilation/constriction, and objects found near the patient. But in the sole case of unconscious and unknown moi, I would attempt to c-spine.


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## DesertMedic66 (Oct 26, 2011)

BrushBunny91 said:


> Thanks for going easy on me guys and understanding I am still a student
> Am I correct in saying I would try to realign the limb once to better spint and if that fails then splint as is? I would take into consideration the patients level of comfort and not attempt to move a very serious open fracture
> Yes, I would try to take other findings into account such as medical alert tags, pupil dilation/constriction, and objects found near the patient. But in the sole case of unconscious and unknown moi, I would attempt to c-spine.



The point of realigning a limb is to regain a pulse (PMSC's) in the limb. If the limb has valid PMSC's then splint in place.


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## BrushBunny91 (Oct 26, 2011)

In the case of a serious fracture will I ask the patient to attempt the Motor of the pmsc?


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## DesertMedic66 (Oct 26, 2011)

BrushBunny91 said:


> In the case of a serious fracture will I ask the patient to attempt the Motor of the pmsc?



yeah. It may hurt them or it may not. Just have the pt do small movements. "sir/mam can you wiggle your fingers/toes for me?".


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## Handsome Robb (Oct 26, 2011)

Why not? "Sir/Ma'am can you wiggle your toes/fingers?" they don't have to squeeze your fingers or do the push/pull or your hands to demonstrate motor function.


edit: Eff you firefite! haha


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## BrushBunny91 (Oct 26, 2011)

Thanks guys ^_^


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## DesertMedic66 (Oct 26, 2011)

NVRob said:


> Why not? "Sir/Ma'am can you wiggle your toes/fingers?" they don't have to squeeze your fingers or do the push/pull or your hands to demonstrate motor function.
> 
> 
> edit: Eff you firefite! haha



Should have been faster. My GF says I'm always fast...


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## Handsome Robb (Oct 26, 2011)

firefite said:


> Should have been faster. My GF says I'm always fast...



Yea...thats definitely not something to go galavanting around the internet with :rofl:


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## DesertMedic66 (Oct 26, 2011)

NVRob said:


> Yea...thats definitely not something to go galavanting around the internet with :rofl:



Whoops.... h34r:


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## BrushBunny91 (Oct 26, 2011)

firefite said:


> Should have been faster. My GF says I'm always fast...



I didn't know emts had a life outside of being a hero to find the time to keep a girlfriend


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## DesertMedic66 (Oct 26, 2011)

BrushBunny91 said:


> I didn't know emts had a life outside of being a hero to find the time to keep a girlfriend



Well the GF is an EMT student right now.. Haha


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## BrushBunny91 (Oct 27, 2011)

Are you her skills instructor?


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## DesertMedic66 (Oct 27, 2011)

BrushBunny91 said:


> Are you her skills instructor?



Uhhhh actually... :unsure:


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## BrushBunny91 (Oct 27, 2011)

:rofl:
Well I hope she's getting some extra skills practice! It would be a waste if not


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## Tigger (Oct 27, 2011)

BrushBunny91 said:


> Yes, I would try to take other findings into account such as medical alert tags, pupil dilation/constriction, and objects found near the patient. But in the sole case of unconscious and unknown moi, I would attempt to c-spine.



Don't assume, assess. 

Wise words I got from my boss yesterday. He's been a highly regarded athletic trainer for over 30 years now with more education than about any non MD I know.



Sent from my out of area communications device.


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## BrushBunny91 (Oct 27, 2011)

Assume makes an ***** out of *U* and *ME*


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## ksmith3604 (Oct 27, 2011)

we use NEXUS.  If the patient clears nexus we do not have to immobilize.  As long as there are 1.no focal neurological deficits present, 2. no midline spinal tenderness, 3. No altered level of conciousness, 4. no intoxication present, 5. No distracting injury present. If any of these five things are noted, they MUST be immobilized.  If all of those 5 are negative, bring em into the ER sitting on the pram and no one will say boo to you.


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## usalsfyre (Oct 27, 2011)

ksmith3604 said:


> we use NEXUS.  If the patient clears nexus we do not have to immobilize.  As long as there are 1.no focal neurological deficits present, 2. no midline spinal tenderness, 3. No altered level of conciousness, 4. no intoxication present, 5. No distracting injury present. If any of these five things are noted, they MUST be immobilized.  If all of those 5 are negative, bring em into the ER sitting on the pram and no one will say boo to you.



Quick question, does your system define altered LOC and distracting injury. If not, how do you define it?


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## hjscm (Nov 5, 2011)

i would be worried about the o2 sat being low and only on 3 liters.  being beaten in chest i would listen to lung sounds.  if he is short of breath with a low o2 wouldn't you want higher LPM?


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## icefog (Nov 25, 2011)

I'd keep an eye on his breathing, too, first of all - even if something serious like a pneumothorax is *highly *unlikely and the SpO2 can be explained by the shortness of breath due to pain, cold fingers, bla bla. Breath sounds are what matters here.

As for immobilizing, I wouldn't, unless he displayed neuro deficits or expressed pain upon palpation of the spine. But I wouldn't roll my eyes at all if anyone immobilized, either - stick to the protocol and all's good. On the other hand, if my partner suggested it despite me saying there's no need, I'd do it his way and immobilize - I think the value in giving your partner the peace of mind is pretty important, and the discussions about whether or not it's warranted can wait. It's not like he's asking to do a cric on him.

To be honest, though, I agree with the others on this, even if your protocol says immobilize and you don't *in this particular case* (no specific indication), I don't think anyone's gonna be able to do more than whine as long as you can justify that decision.


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## jjesusfreak01 (Nov 26, 2011)

I would want to know specific MOI. Was he beaten with fists or bats, maybe metal bats or rods? If there was significant MOI, even manual weapons, I might consider c-spine precautions, because a significant beating is likely to be a distracting injury in any case.


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## HMartinho (Nov 27, 2011)

Thank you all for the answers. This is what I like in a forum, everyone can learn from each other.

He was kicked several times. Perhaps the full immobilization was unnecessary, but our protocols are very strict, and in my EMT-B program (a few months ago), we learn to "play safe".


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## DJRedNight (Dec 5, 2011)

HMartinho said:


> Our BLS unit was dispatched for an assault victim on a sidewalk. Male, 19  years old that was beaten several times in his belly, back and chest. He complains pain on his ribs, backaches, headaches and some shortness of breath. He's alert and orientated.
> 
> BP: 130-85
> Pulse: 98
> ...



To put it simply, yes. Beatings are considered a trauma situation. You dont know how or where he got hit unless you actually viewed the beating. Immobilization of the spine and neck is KEY and should be treated as a trauma scenario. the means doing DCAPP-BTLS, PMS, HIGH flow oxygen at 15L/min on a NBR, (3L/min on nasual canula just doesn't cut it for 93% SpO2 levels) cutting off clothes if needed and checking for step offs and other misc injuries on his back. I agree with you and not your partner. Sounds like to me you might want to discuss this over with your partner and figure out whos taking charge on calls. Sometimes going OVERBOARD on things is best.

Hell, i boarded someone last week, who was in a minor fender bender at 5 miles and hour in a freaking parking lot. she was 22, and in perfect health. hypochondriac in my opinion... but we did it anyways because she complained of back and neck pain. doesn't matter if injuries are apparent or not or even after palpation. If they say they have back or neck pain. BOARD EM!


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## Smash (Dec 5, 2011)

DJRedNight said:


> To put it simply, yes. Beatings are considered a trauma situation. You dont know how or where he got hit unless you actually viewed the beating. Immobilization of the spine and neck is KEY and should be treated as a trauma scenario. the means doing DCAPP-BTLS, PMS, HIGH flow oxygen at 15L/min on a NBR, (3L/min on nasual canula just doesn't cut it for 93% SpO2 levels) cutting off clothes if needed and checking for step offs and other misc injuries on his back. I agree with you and not your partner. Sounds like to me you might want to discuss this over with your partner and figure out whos taking charge on calls. Sometimes going OVERBOARD on things is best.
> 
> Hell, i boarded someone last week, who was in a minor fender bender at 5 miles and hour in a freaking parking lot. she was 22, and in perfect health. hypochondriac in my opinion... but we did it anyways because she complained of back and neck pain. doesn't matter if injuries are apparent or not or even after palpation. If they say they have back or neck pain. BOARD EM!



American EMS, I weep for you.


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## DJRedNight (Dec 5, 2011)

Smash said:


> American EMS, I weep for you.



I weep for me too. lol


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## Handsome Robb (Dec 5, 2011)

Smash said:


> American EMS, I weep for you.



I was thinking the exact same thing.


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