# Spinal Immobilization and Combative patients (with a scenario)



## Amycus (Nov 21, 2010)

Hello everyone.

I'm fairly certain I made a mistake by protocols. Fairly sure I did. However, in the idea of doing no additional harm to a patient, I don't feel my actions were uncalled for. I just want others opinions, even if they are collectively "You made a mistake"

Tonight we got called for a PT, obvious ETOH. Had a good size bump on the head, a lac, and probably broken nose. The guy doesn't fully recall how it happened, just that he walked like 1-2 miles and police found him where we picked him up. PT VERY uncooperative. Doesn't want EMS help, pulls away when I try to assess, I dress/bandage the wound, he rips the dressings off, try to give him an ice pack, throws it away, so on and so forth. This guy adamantly DID want to go. My partner and the PD convinced him he HAD to go get looked at. Here's the thing though-a thought process went through our heads. This FULLY indicates c-spine precautions. He obviously fell, and he's under the influence. However, he's staunchly throwing back any intervention/treatment right back at us, and besides his name, won't give any real relevant information. We opted that the best bet is to keep him cooperative as we possibly can, load him up and keep him as immobile as possible all the way to the ER (about 3 minutes away). Staff was informed the situation and lack of c-spine, and they seemed to agree. He was not c-spined by staff either at this time. Found out he was very uncooperative with staff also.

I'm starting to drill my brain about this. I've been under the mindframe that while this called for C-Spine, and technically when intoxicated, implied consent kicks in- this guy was already very combative toward EMS and did not want our help, but we convinced him to go anyways. I feel that at the end of the day, keeping him as calm as possible and getting him to go in for evaluation was the right thing to do. He was alert and oriented to the present events, but the ETOH attitude was still kickin around

My coworkers feel the proper course would have been to restrain him, force the collar and board on him, and take him in like the regardless of how he acted. I think that's probably the proper course, but maybe I'm wrong in thinking this- couldn't forcing that on him compromise c-spine even further, if you have to be fighting with him to immobilize him? The guy obviously needed medical attention and was under the influence of something- but would that really have been the best course? I'm here to help people, even if I'm a bit of a softy, not to make them suffer/get agitated worse.

Naturally, I documented the living HELL out of the situation, but I just figured I'd get opinions of more seasoned folks, even if the opinions are "protocol is law"

Thanks.

Signed,
An EMT still learning =X


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## reaper (Nov 21, 2010)

You did the right thing. 

He walked 1-2 miles, probably no spinal injuries. But, if it happens to be present, why not let him sit calmly on the stretcher, instead of fighting a man with possible injuries? You did the right thing and documented well. 

Good job!


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## Epi-do (Nov 21, 2010)

If he doesn't remember what happened, what makes you think it was a fall instead of some sort or altercation with someone else?  Not that it matters to answer your question, just curious.

I think you did the right thing.  If attempting to immobilize the patient is going to do more harm, then opting not to do so is definitely the correct choice.  You did good!


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## Amycus (Nov 21, 2010)

Epi-do said:


> If he doesn't remember what happened, what makes you think it was a fall instead of some sort or altercation with someone else?  Not that it matters to answer your question, just curious.
> 
> I think you did the right thing.  If attempting to immobilize the patient is going to do more harm, then opting not to do so is definitely the correct choice.  You did good!



That's very true, it might not have been a fall. The facial injuries, to me, suggested a fall, assuming the worst case MOI, but you're right, he coulda got punched in the face a few times. Another side concern that popped into my head that maybe his attitude was the result of a concussion, not actual ETOH- however PD and my parner all implied they got a small of his breath, and his pupils appeared to be a bit on the constricted and sluggish side. 

I appreciate the resposnes so far. To make a small edit above to my first post (edit button is gone), I meant to say he adamantly DID NOT want to go, not DID want to go. I'm always paranoid about so many calls because, since I"m still learning and seeing alot of stuff for the first time, I try to rethink everything to incoroperate it into future assessments.


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## Akulahawk (Nov 21, 2010)

Look, the guy doesn't want to go, he's likely intoxicated OR he's concussed (or both) but either way, he's going to go via implied consent. Fine. He's also REALLY agitated and combative. OK. Try to sweet-talk the guy into getting looked at OR PD takes the guy into protective custody, puts him in hard restraints (hand cuffs) and you get to manhandle a REALLY pissed-off dude... I highly doubt that someone like that's going to willingly allow themselves to be put on a backboard and tied down.

When you get those... let it sink into their head a bit that one way is easier, and the other is WAY less comfy. Let them decide... they think they're getting some control...


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## reaper (Nov 21, 2010)

I had a pt a few months back. Had ran off road and head on into an oak tree. When we arrived on scene, pt was ambulatory and did not want to be touched. Observing the vehicle, there was empty beer cans and half an ounce of cocaine on the floor. Easily could tell pt was inebriated. Pt became hostile if you attempted to come near him. So we called for LEO and just talked to pt, to keep him calm.

We were in a rural area and it took LEO 20 minutes to arrive. Right as LEO arrived, pt passed out and went to the ground. We boarded pt and loaded him up. He came to in the ambulance as we were assessing him. After a short talk with LEO, the pt remained calm the rest of the time.

Went back to trauma center with another pt, later that night. Dr pulled my aside and said that the pt had a complete fx of c5 and c6. He came through with no neuro deficits. Even dr agreed that if we would have fought him onto a LSB, he most likely would have neuro deficits now.

There are times when you have to decide when to pick your battles and when to make the right choice for your pt!


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## Akulahawk (Nov 21, 2010)

Sometimes a chat with a LEO can make a difference... When the patient really doesn't have a choice, they sometimes see that fighting a cop is not a good idea... and cooperation is a better one. I've seen that happen. Choose your battles wisely and make sure you present options that you can actually back up. Otherwise, you any credibility.


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## MrBrown (Nov 22, 2010)

Brown thinks that if the patient is going to move less not being strapped down to go with that.


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## Sam Adams (Nov 22, 2010)

As Reaper mentioned he apparently walked MILES ... if the unsteady gait of an inebriated male w/ a SCI didn't paralyze him I don't think not c-spining him will either. 

Every time you do an intervention think about risk v. benefit:

Are you going to get injured restraining/ c-spining a combative pt? probably.

Is your partner going to get injured? probably.

Is the pt going to get injured? probably.

No need to go further.


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## usalsfyre (Nov 22, 2010)

Amycus said:


> My coworkers feel the proper course would have been to restrain him, force the collar and board on him, and take him in like the regardless of how he acted. I think that's probably the proper course...


There is NOTHING therapeutic about this. Your coworkers are morons who have very, very little understanding of what a long spine board is trying to accomplish if they think this will protect the spine. 




Amycus said:


> ...but maybe I'm wrong in thinking this- couldn't forcing that on him compromise c-spine even further, if you have to be fighting with him to immobilize him? The guy obviously needed medical attention and was under the influence of something- but would that really have been the best course? I'm here to help people, even if I'm a bit of a softy, not to make them suffer/get agitated worse.



A nice, quiet ride to the ED is the best course of action. If you can't get him calmed down to do this with good communication, call ALS and sedate the living snot out of him. 



Amycus said:


> Naturally, I documented the living HELL out of the situation, but I just figured I'd get opinions of more seasoned folks, even if the opinions are "protocol is law"



Protocol is far from the law. Good judgement (both clinical and common sense) will keep you out of far more trouble than blindly following protocol. Just make sure you have a darn good reason if you deviate, and consult with med control as needed. Sounds like you did good in this situation.


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## nakenyon (Nov 22, 2010)

I encountered a similar situation recently with a intoxicated individual and his car had a not so nice encounter with a rock. Patient fled the scene and eventually was found by EMS behind a tree (think the looney toons). Patient would not stay with us and attempted to flee again and was stopped by PD. Patient was adamant that he did not want transported and denied involvement in the accident. Eventually we convinced him to go, but he refused backboard and collar. I contacted medical command and asked if they were ok with us proceeding in without c-spine precautions. Med Command ok'd it and in we went. 

In my opinion, I think you did what was best for the patient. Getting him medical treatment that I'm certain he needed. Forcing a patient to do something that they will resist will wind up causing them more harm
then good. But that's just my 0.02.


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## Bullets (Nov 22, 2010)

"Upon arrival found pt ambulatory, presenting with multiple lac to head, AMS, ETOH evidence. Pt combative with EMS personnel initially states no desire to seek AMA, depite MOI, advisal of treatment options, Pt refused C-Spine by action. EMS gain approval to transport, still refusing c-spine, pt placed on cot, T W/O I NYPH"

thats how my report would read, generally. Refusal by action, applicaple in may situations


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> There is NOTHING therapeutic about this. Your coworkers are morons who have very, very little understanding of what a long spine board is trying to accomplish if they think this will protect the spine.
> 
> 
> A nice, quiet ride to the ED is the best course of action. If you can't get him calmed down to do this with good communication, call ALS and sedate the living snot out of him.
> ...



I like the way you think.


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## usalsfyre (Nov 22, 2010)

Bullets said:


> "Upon arrival found pt ambulatory, presenting with multiple lac to head, AMS, ETOH evidence. Pt combative with EMS personnel initially states no desire to seek AMA, depite MOI, advisal of treatment options, Pt refused C-Spine by action. EMS gain approval to transport, still refusing c-spine, pt placed on cot, T W/O I NYPH"
> 
> thats how my report would read, generally. Refusal by action, applicaple in may situations



While I'm not advocating tying this guy down, I'm not sure this flies either. First off, I've never heard of "refusal by action". Not saying it doesn't exist, but again I've never heard of it and a brief Google search returns nothing. 

Secondly, a key tenant of consent and refusal is that a patient is informed of the risk and benefits of both the treatment and the refusal there of. Proving informed refusal would be tough in this situation.


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> While I'm not advocating tying this guy down, I'm not sure this flies either. First off, I've never heard of "refusal by action". Not saying it doesn't exist, but again I've never heard of it and a brief Google search returns nothing.
> 
> Secondly, a key tenant of consent and refusal is that a patient is informed of the risk and benefits of both the treatment and the refusal there of. Proving informed refusal would be tough in this situation.



Sounds like a local lingo for physically resisting the intervention. I haven't deciphered the rest of the garbage yet.


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## Bullets (Nov 22, 2010)

usalsfyre said:


> While I'm not advocating tying this guy down, I'm not sure this flies either. First off, I've never heard of "refusal by action". Not saying it doesn't exist, but again I've never heard of it and a brief Google search returns nothing.
> 
> Secondly, a key tenant of consent and refusal is that a patient is informed of the risk and benefits of both the treatment and the refusal there of. Proving informed refusal would be tough in this situation.


Refusal by action, like you arrive and the patient is gone, locked the door, runs away from you, ect.


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## usalsfyre (Nov 22, 2010)

Veneficus said:


> I like the way you think.



Vene, the feelings mutual. I also must say I'm a bit jealous, and sometimes wished at 17 I had thought "being a doctors cool" instead of "being a firemedic is cool"


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## Veneficus (Nov 22, 2010)

usalsfyre said:


> Vene, the feelings mutual. I also must say I'm a bit jealous, and sometimes wished at 17 I had thought "being a doctors cool" instead of "being a firemedic is cool"



I didn't figure out being a doctor was cool until I had 15 years in EMS and Fire. 

Medicine is a journey, some are longer than others.


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## Amycus (Nov 22, 2010)

Bullets said:


> "Upon arrival found pt ambulatory, presenting with multiple lac to head, AMS, ETOH evidence. Pt combative with EMS personnel initially states no desire to seek AMA, depite MOI, advisal of treatment options, Pt refused C-Spine by action. EMS gain approval to transport, still refusing c-spine, pt placed on cot, T W/O I NYPH"
> 
> thats how my report would read, generally. Refusal by action, applicaple in may situations



While I see your thought process, if I turned in a narrative like this, our QA/QI department would burn me at the stake. Thats why I provided ample reasons we did not board. I think I repeated myself a half dozen times in the narrative how he was resisting treatments, uncooperative, etc. If I just said once that he was uncooperative so I didn't board, I'd prolly get burned


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## Bullets (Nov 22, 2010)

Amycus said:


> While I see your thought process, if I turned in a narrative like this, our QA/QI department would burn me at the stake. Thats why I provided ample reasons we did not board. I think I repeated myself a half dozen times in the narrative how he was resisting treatments, uncooperative, etc. If I just said once that he was uncooperative so I didn't board, I'd prolly get burned



I also don't know the full extent of his actions against you. My report would be much more detailed with the requisite knowledge


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## Veneficus (Nov 22, 2010)

Bullets said:


> Refusal by action, like you arrive and the patient is gone, *locked the door, runs away from you*, ect.



In my experience when an altered person does this sort of thing, the door gets forcefully opened, and/or PD gets involved in "convincing" him to go to the ED.


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## Bullets (Nov 22, 2010)

Veneficus said:


> In my experience when an altered person does this sort of thing, the door gets forcefully opened, and/or PD gets involved in "convincing" him to go to the ED.



i didnt say the person was altered...thats a whole other can o worms

ive had people of sound mind and body refuse to sign the RMA, but then lock the door, run away, or call 911 then decide to drive themselves without telling us.


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## Veneficus (Nov 22, 2010)

Bullets said:


> ive had people of sound mind and body refuse to sign the RMA, but then lock the door, run away, or call 911 then decide to drive themselves without telling us.



That is a win.


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## EMSslick536 (Nov 23, 2010)

*Sounds Good.*

Espically if the PD is requesting for him to go. Did you already contact the ER? Otherwise, good job.


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## Fox800 (Dec 5, 2010)

Always weigh how still and calm the patient will be unrestrained vs. fighting to put them on a backboard, and having them fight to take it off after it's applied.

You didn't do a bad thing in my book. Just document things well.


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## RUGBY66X (Dec 5, 2010)

Fox800 said:


> Always weigh how still and calm the patient will be unrestrained vs. fighting to put them on a backboard, and having them fight to take it off after it's applied.
> 
> You didn't do a bad thing in my book. Just document things well.



when i was in the ER one day i was talking to a doc about this. there was an elderly pt. who was also heavily intoxicated with a collar o but it was around her face obviously not doing much good and i asked if i should take it off and he kept telling me know not till he got his x-rays back and the pt. insisted she would calm down and sit still with it off it was just irritating her because every time i put it back in place it slid back up. she needed a "no-chin" collar instead of a "no-neck" haha


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## MS Medic (Dec 6, 2010)

I've been in this situation and called in online med control CYA. That is the only possible thing I would have done differently.


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## Bieber (Dec 6, 2010)

Just a student, but honestly I wouldn't sweat it.  That's one of those situations where the diverge between the book and real life comes into play.  I don't know how your system is, but in mine we board if there is a significant mechanism (i.e. mva) or if the patient complains of head/neck/back trauma or pain; however for, say, a simple fall denying loss of consciousness, hitting the head/neck/back or any pain there, I don't board and collar them.  Despite this rule, though, I've had plenty of patients that either didn't want the board or that couldn't or wouldn't have tolerated it.  Just do your best and document the hell out of it.

One example I can think of was an elderly patient who fell while outside his house working his house (guy used a walker to get around but didn't have it outside with him) who'd been overcome by the wind and fell against the house hitting his head, had a pretty good gash from it.  It was FREEZING outside and raining to boot, and the guy didn't sound like he wanted to come with us.  So I walked the patient inside because I'm not going to sit out there watching him freeze and getting him inside and out of the cold where I could assess him was more important than the board.  Guy ended up refusing transport despite my best efforts.

Oh, but a little tip one of my classmates shared with me for restraining an intoxicated or otherwise altered patient on an LSB (this is more for physical restraint of a violent patient that you NEED to restrain for your own safety) is to turn the buckles upside of the board/cot upside down.  Apparently when the button's not facing up it confuses the hell out of them trying to figure out how to get the belts off.


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