# Collar, or no collar? Gsw to the head.



## ITBITB13 (Jan 11, 2015)

So you show up, PD let's you in, and you have a girl with multiple gsw's with one being in the head, in the right temple area. Using a backboard is obvious. However, A couple shifts back I was told to stop, while putting on a c-collar. 
I always put c-collars on. What gives? Have I been doing something wrong all along?

What's the rationale for putting on/not putting on a collar in this situation?


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## Jim37F (Jan 11, 2015)

Just out of curiosity, why a collar and board? Is there any indication of spinal trauma? Why are you wanting to splint the neck?

Personally, the only reason I'd even consider an LSB in this case is to simply move the patient from the ground to the gurney, and then only if it was a large/heavy patient I had to carry up/down stairs, through narrowing hallways etc to get to the gurney, otherwise with an engine company on scene it's a lot quicker and easier to just GS them to the gurney. Save some time from having to head back to the ambulance, grabbing a board, going back to the patient, and then securing them to the board, not to mention saving from having to decon the board later.


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## DesertMedic66 (Jan 11, 2015)

Backboarding a patient like this will take a lot of time to do correctly on scene. So it is just delaying the time before the patient gets to the hospital. 

A GSW to the head is not very likely to cause a C-spine injury from my knowledge. 

And the whole backboard thing is found to not benefit patients at all and new recommendations are saying backboards should only be used as a means to moving the patient to the gurney and then removed immediately.


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## irishboxer384 (Jan 11, 2015)

Possible case for using c-collar/spinal immob is an entry wound with no exit wound due to the round possibly being in proximity to the spinal column. Depends on your county protocols blah blah etc. The guys here have stated the reasons for not using and is the more accepted method of treatment/patient extrication now


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## teedubbyaw (Jan 11, 2015)

Where are her other GSWs?


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## TransportJockey (Jan 11, 2015)

Only reason I'd put a collar on this patient is to aid in maintaining a patent airway after ETI or placing an SGA. Only reason you need a board is ti assist in moving them


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## jrm818 (Jan 11, 2015)

Agree with above.

This is the situation for which there is the best evidence of harm from backboardimg: not just pain/airway difficulty etc., but actually a suggestion of increased mortality.  
Follow your protocols, but if they say immobilize penetrating trauma without evidence of neuro defects, than they are pretty...eh...sub-optimal...

Wouldn't normally link to jems but this is free and gives a good overview

http://m.jems.com/article/patient-care/research-suggests-time-change-prehospita

Also look at the naemsp position paper on cervical immobilization...can't make link work on phone, but easily found via google


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## ITBITB13 (Jan 11, 2015)

teedubbyaw said:


> Where are her other GSWs?


Patient was unresponsive, with another gsw to the flank, and pelvic area. No exit wounds visible.


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## Chewy20 (Jan 11, 2015)

Trauma is a time dependent case, your best bet for them to live is to get them to the hospital so they can go into surgery. Doesn't sound like there's a reason for spinal percausions here, so don't waste time doing them unless reasons stated above. 

You say you put a collar on everyone. Why?


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## Angel (Jan 11, 2015)

I wouldn't. Had a call just like this and all he got was a board to help extricate.


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## CALEMT (Jan 11, 2015)

Like everyone else is saying back boarding just adds time to an already critical situation so I wouldn't backboard in this situation. However I would use a backboard to move the patient as I think Jim37F has already pointed out the uses for it.


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## Handsome Robb (Jan 11, 2015)

Did she have a pulse? If the answer is no then there's no reason for any action, at all.


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## RocketMedic (Jan 11, 2015)

^Agreed. 

With that being said, a board isn't horrible for movement. Immobilization doesn't matter, but a board does make it easier to move the body in a lot of cases.

A collar isn't really necessary, but honestly, there's not really anything medical to be done here. No EMS intervention with the possible exception of airway/breathing will matter.


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## RedAirplane (Jan 12, 2015)

Protocols vary, and as I am learning on this website, the backboard is not the cure for all ailments.

However, I believe the NHTSA standards (from which state protocols may choose to deviate) calls for spinal immobilization with trauma to the head, neck, or spine. A GSW to the head sounds like trauma to the head. I would immobilize to be safe rather than sorry unless I had protocols to the contrary.


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## teedubbyaw (Jan 12, 2015)

Ivan_13 said:


> Patient was unresponsive, with another gsw to the flank, and pelvic area. No exit wounds visible.



I wouldn't consider it a fault in this case, then, but, realistically, like others said, it's delaying pt care if the pt is still viable. Kind of like applying full spinal precautions to someone in a car engulfed in flames.


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## Shishkabob (Jan 12, 2015)

What do your protocols say?


Is a c-collar needed or beneficial?  No.  However my protocols say "Significant trauma above the clavicles", and I'd argue a GSW is pretty significant... so per my protocols they are to get a c-collar.


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## ITBITB13 (Jan 12, 2015)

To those that say a collar is a waste of time, I understand where you're coming from, but when you have 3+ emts on a scene, and 2+ paramedics, I don't see putting on a collar as being a problem.


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## teedubbyaw (Jan 12, 2015)

Linuss said:


> What do your protocols say?
> 
> 
> Is a c-collar needed or beneficial?  No.  However my protocols say "Significant trauma above the clavicles", and I'd argue a GSW is pretty significant... so per my protocols they are to get a c-collar.



Exactly. 3 GSW's to the torso and head is significant trauma and many protocols dictate spinal precautions.


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## PotatoMedic (Jan 12, 2015)

As many have said... If I have time would he end up on a backboard with a c collar.  My main concerns are ABC's.  Everything else can wait.  If I get a chance then yeah I'll get a collar on him.


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## DesertMedic66 (Jan 12, 2015)

In most systems (especially in SoCal) a C-Collar = backboarding which does take several minutes to do correctly. Those several minutes are better spent enroute to definitive care


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## NomadicMedic (Jan 12, 2015)

Maybe they'd get one before I arrived at the ED, if I had time after doing everything else. 

I wouldn't lose any sleep over it, and if I didn't collar this patient (if required by protocol) I'd document to cover myself.


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## Tigger (Jan 12, 2015)

I have not found any research to suggest that c-spine precautions make a lick of difference in any patient. I have also found studies that show no improvement in outcomes in penetrating trauma patients when c-spine precautions are used. 

http://www.east.org/resources/treatment-guidelines/cervical-spine-injuries-following-trauma

Also, how many people you have on scene is meaningless aside from how fast you can put them in the ambulance. Transport to a trauma center is what improves outcomes.


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## Ensihoitaja (Jan 12, 2015)

Tigger said:


> Also, how many people you have on scene is meaningless aside from how fast you can put them in the ambulance. Transport to a trauma center is what improves outcomes.



This, times about a billion!


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## Jim37F (Jan 12, 2015)

In my mind, a C-Collar is perfectly appropriate if the GSW was to the neck. Besides stabilizing the C-spine itself, a collar would help hold your occlusive dressings and other bandages in place and minimizing movement that would dislodge them, aggravate the injury, etc.

For a penetrating trauma to the head, especially a GSW, if there was enough kinetic energy imparted to transfer to, and compromise the C-spine, well you're probably gonna have some eviscerated grey matter to go along with it...

Now since her we do have 5-6 providers on scene I'm certainly not going to stop you from putting on a C-collar for a head shot, well not unless it was getting in the way of airway management or something else similarly vital.. Now since collars and boards aren't part of our first in kit (unless the engine company is on scene first and asks us to bring it in as we pull up) I'm not going to sit around and wait for you to go get one to move the patient to the gurney and start moving towards the ambulance (though I suppose you could always put one on en route to the trauma center) ESPECIALLY when my county protocols on the matter state very clearly "SMR for penetrating injuries is generally not indicated and transport must not be delayed to apply SMR. Treatment of patients with penetrating trauma should not involve a backboard unless it is required as an extrication device or if there is a significant concomitant blunt mechanism."

Now as others have said, if your local policies and protocols say otherwise that you're supposed to collar and/or board this patient, that kinda overrides my opinion juuuusst a little lol


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## RocketMedic (Jan 13, 2015)

A full-on motion-cancelling sci-fi immobilization field will not resolve the problem- disruption of brain matter by a projectile. Everything else here is gravy. The only real reason to even transport this body is for donation.


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## Jim37F (Jan 13, 2015)

RocketMedic said:


> A full-on motion-cancelling sci-fi immobilization field will not resolve the problem- disruption of brain matter by a projectile. Everything else here is gravy.


True



> The only real reason to even transport this body is for donation.


Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.


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## DesertMedic66 (Jan 13, 2015)

Jim37F said:


> True
> 
> Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.


Always double tap


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## RocketMedic (Jan 13, 2015)

Multiple GSW with severe and sudden loc is not likely to survive


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## Christopher (Jan 13, 2015)

Ivan_13 said:


> To those that say a collar is a waste of time, I understand where you're coming from, but when you have 3+ emts on a scene, and 2+ paramedics, I don't see putting on a collar as being a problem.


Well besides being harmful, sure there is no problem ;-)

(I'll grant that the GSW location is likely contributing the most to this patient's M&M; doesn't change the harm inherent in C-Collar/LSB application in penetrating trauma victims)


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## Brandon O (Jan 14, 2015)

Do Not Collar Penetrating Trauma.

It kills people. If we know anything about spinal trauma (hint: we don't know much), we know that. Guidelines and the evidence agree.


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## MedicRx (Jan 14, 2015)

I'm reading an awful lot of posts that are saying to collar and board this patient. My question is why? What exactly are you hoping to achieve? What do you think the collar and board are going to do? If this patient just happened to be the literal one in a million that has spinal trauma from a penetrating injury, that damage is done. All the boards and collars in the world aren't going to repair, or even help, that spinal cord. And unless you're planning on beating your patient, or trying to finish the job that the shooter didn't (hey, maybe you're a psycho killer), SMR won't even help prevent further injury any better than your stretcher. It's a waste of time for a patient that needs definitive treatment, and shouldn't even be considered.


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## SixEightWhiskey (Jan 24, 2015)

My state finally figured out that collaring and boarding everyone is useless. even when 95 year old nana complains of neck pain and extremity numbness s/p fall, we simply collar them and put them on the stretcher. backboards are simply a hard surface for CPR, or an extrication device if need be, which thankfully we have replaced with more practical devices, such as the reeves stretcher (or as i like to call it, god's gift to EMTs). i agree with using a collar on neck trauma to simply keep all the dressings intact, etc. but that is simply for convenience. there's no clinical reason why someone with a penetrating wound to the head needs full board-and-collar c-spine precautions. any time spent on a scene doing this is taking away precious time from a trauma surgeon, and is unequivocally bad medicine.

obviously, follow your medical direction and your state protocols. I just hope they all catch up and use evidence-based medicine as a reference someday, because the c-spine thing is such a quagmire of tradition and policy and CYA stuff, when it really has no added benefit for your patient care.


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## Tigger (Jan 25, 2015)

Jim37F said:


> True
> 
> Less true. Not all GSWs to the head are fatal. There are plenty of patients who have survived (with varying degrees of being) neurologically intact. Granted there are plenty of patients with penetrating head trauma who are beyond mortal resuscitation before hitting the ground. It all depends on the projectile, what it hit, cavitation and other energy transfer to surrounding tissues, etc.


And c-collars have no bearing in improvement of well, anything here.


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## Ensihoitaja (Jan 25, 2015)

DesertEMT66 said:


> Always double tap



And limber up.


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## shindaga (Jan 27, 2015)

No immobilization in penetrating trauma, end of story. It's becoming ever more clear that backboards for immobilization are voodo for anything anyway.


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## Emergency Metaphysics (Jan 27, 2015)

shindaga said:


> No immobilization in penetrating trauma, end of story. It's becoming ever more clear that backboards for immobilization are voodo for anything anyway.



In fact there is an article, I think, in the newest issue of JEMS that covers this topic and backs you up. The data just isn't there to back up c-collars and backboards. The article was emphasizing all the flaws and weaknesses of c-collars, but you're backed up by good science.


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## rescue1 (Feb 14, 2015)

Emergency Metaphysics said:


> In fact there is an article, I think, in the newest issue of JEMS that covers this topic and backs you up. The data just isn't there to back up c-collars and backboards. The article was emphasizing all the flaws and weaknesses of c-collars, but you're backed up by good science.



Its upsetting it only just made it into JEMS, the studies about the (lack of) effectiveness of spine boards and collars have been out for several years.

As to the question, no board or collar unless needed for intubation or extrication. My protocols actually specifically exclude penetrating head injury as a reason to immobilize. And assuming I had leeway, I wouldn't anyway, because spine boards and collars don't provide clinical benefit to anyone, penetrating trauma or no.


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## Eleventy7 (Feb 28, 2015)

Agree with the general sentiment. Boards for movement, collars for intubation. Even then, you'd be better off convincing your dept to replace the boards with BOTs. The only thing I'd recommend for your patient is a good ole fashion diesel bolus.


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## COmedic17 (Feb 28, 2015)

I would do it.

If I was running this same call in my "territory" I would have ample resources on scene and it would take no time to get done. If there's no exit wounds, I have zero idea where the bullet ended up. I wouldn't waste time back boarding the pt the way I would a pt who fell off a ladder,  but I would still implement the backboard. If the patient codes, which is likely, the backboard is now my CPR board. The c-collar will help maintain the head when/ if the patient gets tubed. Also while log rolling the pt, I would check the posterior for any additional entry/exit wounds. If there's enough resources to get it done in a time efficient manner, I would def do it.  It covers me for any "why isn't this pt back boarded" backlash, allows me to check the posterior, is a ready to go CPR board, and will keep the head from moving when the pt is incubated. If it was just me and a partner, and I knew it would take time that the patient didn't have, It wouldn't be at the top of my list. I wouldn't do it if it was going to waste time. I would need the resources there to consider it.


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## Eleventy7 (Feb 28, 2015)

Anyone coming at you aggressively with, "Why isn't this patient boarded?" needs to have a better understanding of "immobilization."


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## Brandon O (Mar 1, 2015)

I would suggest that you can roll a patient onto a board for carrying (and inspection/exposure of the posterior) without the whole immobilization rigamarole.

I get what you're saying in that there are probably plenty of hands available, but it's not like you've got other things to do while an engine company boards your patient. You probably shouldn't be doing anything but getting the heck out of there. There is almost nothing "worth doing" on scene with an uncontrolled hemorrhage.

(Obviously in this case it's all probably moot, but still...)


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## COmedic17 (Mar 1, 2015)

Eleventy7 said:


> Anyone coming at you aggressively with, "Why isn't this patient boarded?" needs to have a better understanding of "immobilization."


You can be the one explaining to the trauma doc/medical director why you want to argue over boarding and immobilizationwhen when its what they deem fit for the situation. Its a ship that doesn't sail far.


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## COmedic17 (Mar 1, 2015)

Brandon O said:


> I would suggest that you can roll a patient onto a board for carrying (and inspection/exposure of the posterior) without the whole immobilization rigamarole.
> 
> I get what you're saying in that there are probably plenty of hands available, but it's not like you've got other things to do while an engine company boards your patient. You probably shouldn't be doing anything but getting the heck out of there. There is almost nothing "worth doing" on scene with an uncontrolled hemorrhage.
> 
> (Obviously in this case it's all probably moot, but still...)


To roll someone on their side, slap a board back there and strap and go, with 6 people there, takes MAYBE ten seconds. I could be getting IV/meds ready. Prepping for intubation. 
Multitasking IS a thing. And the more people, the faster things get done. 


As stated, "I would not spend time boarding a pt like I would someone who fell from a ladder"

But where I work, if I didn't board, I better have a very very valid excuse. If I say I didn't have time with 6 people on scene, they are going to be less then pleased.


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## Eleventy7 (Mar 1, 2015)

They can try to justify it as much as they want. Isn't going magically make immobilization real. Isn't going to change the fact that that very, very, very few people have an injury that would be better managed with a board, that boarding pt's with penetrating trauma show worse outcomes after boarding, that c collars don't actually prevent **** all cervical movement, that c collars can increase ICP, or that c collars can worsen high c spine injuries.


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## Brandon O (Mar 1, 2015)

If you're mandated to do it in your system, then that's that. Very unfortunate since there is excellent evidence now that immobilizing penetrating trauma is clearly harmful and has no benefit.

But in a more general sense, protocols aside, I'm happiest when uncontrolled bleeding is pretty much tossed over one's shoulder and carried away like a damsel by a Viking raiding party. (Don't even park the rig...) If it doesn't absolutely have to be done on scene, it shouldn't be. A beautifully-packaged fully-ALSed gunshot victim rolling into the ED makes me strongly suspicious they could have been there ten minutes earlier.


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## Tigger (Mar 1, 2015)

Being mandated to do so by an archaic system does not mean you are doing the right thing.

Spinal precautions are not indicated for penetrating trauma with no deficits, and there really isn't much to support their use when deficits do exist. The argument that it doesn't take any extra time is silly, considering that the intervention does not improve outcomes. At all.


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## Jim37F (Mar 1, 2015)

Even in L.A. County, protocol specifically says we should not spend any time applying SMR to penetrating trauma patients....I still think that in the specific case of a GSW to the _neck _a collar can be useful in holding everything together, but only when applied while in the back _enroute_ to the trauma center...after airway, breathing, bleeding, shock, and other life threats are being managed.

For the original topic of a GSW to the head (and not the neck), a C-collar and LSB are generally about as useful as your traction splint...


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## Handsome Robb (Mar 1, 2015)

Jim37F said:


> Even in L.A. County, protocol specifically says we should not spend any time applying SMR to penetrating trauma patients....I still think that in the specific case of a GSW to the _neck _a collar can be useful in holding everything together, but only when applied while in the back _enroute_ to the trauma center...after airway, breathing, bleeding, shock, and other life threats are being managed.
> 
> For the original topic of a GSW to the head (and not the neck), a C-collar and LSB are generally about as useful as your traction splint...


I'd argue that even with a GSW to the neck that a collar isn't useful. It very easily could mask a dressing which is becoming saturated in blood that would indicate poorly controlled or even uncontrolled bleeding. 

No one is advocating to violate your local protocols however as protocols change due to evidence against SMR I'd hope that people would change with them and not continue to do it "because that's how we always have."


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## Eleventy7 (Mar 1, 2015)

Remember your first day of EMT class?_ Primum non nocere._ If the choice are: follow protocols that endager my pt, or do what's best or my pt... I'm risking the lashing.


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## Tigger (Mar 1, 2015)

COmedic17 said:


> But where I work, if I didn't board, I better have a very very valid excuse. If I say I didn't have time with 6 people on scene, they are going to be less then pleased.



Would a valid "excuse" be that several studies show that SMR increases poor outcomes in penetrating trauma patients?


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## COmedic17 (Mar 1, 2015)

Tigger said:


> Would a valid "excuse" be that several studies show that SMR increases poor outcomes in penetrating trauma patients?


Not when it's your protocol. 
I don't like backboards. I like collars for tubes. I find it easier to secure tubes with a collar on. But that's about it.


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## Handsome Robb (Mar 1, 2015)

COmedic17 said:


> Not when it's your protocol.
> I don't like backboards. I like collars for tubes. I find it easier to secure tubes with a collar on. But that's about it.


I think what most are getting at is it's not a valid excuse to site protocol as why you disagree with current evidence. If you acknowledge the evidence but continue the practice due to your protocol that's different. Also, protocols can be changed, why not bring current EBM when it comes to SMR to the attention of your medical direction?


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## Tigger (Mar 1, 2015)

COmedic17 said:


> Not when it's your protocol.
> I don't like backboards. I like collars for tubes. I find it easier to secure tubes with a collar on. But that's about it.


It's technically in my protocol to immobilize all "traumatic" neck pain. I don't. I explain myself if someone is pissy (rare), and move forward. Still gainfully employed.


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## SandpitMedic (Mar 1, 2015)

Here- collar. Unless it is a neck wound.


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## MedicRx (Mar 2, 2015)

Tigger said:


> It's technically in my protocol to immobilize all "traumatic" neck pain. I don't. I explain myself if someone is pissy (rare), and move forward. Still gainfully employed.


This. Even though that isn't my protocol, is still do similar things. To me, protocols are guidelines, and not hard and fast rules to live by. If I can explain myself and provide evidence as to why I did something, my medical director has no issue with it. As he shouldn't. Protocols are in place to prevent the bad providers from killing people, not prevent the good providers from helping their patients.


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## RebelAngel (Mar 4, 2015)

Protocol in this state is if you collar you backboard and if you backboard you collar. As far as GSW to the head, ABCs trump immobilization. My state has lightened up on the back boarding and leaves it to the discretion of the EMT. 

What was patient's priority? Did you suspect injury to the back or neck? Did you use emergency, urgent, or non-urgent moves?


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## DesertMedic66 (Mar 4, 2015)

RebelAngel said:


> Protocol in this state is if you collar you backboard and if you backboard you collar.


So if you have a isolated hip fracture and the easiest/safest way to get the patient to the ambulance is using a backboard you would have to put a collar on the patient?


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## RebelAngel (Mar 5, 2015)

Yep.


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## Eleventy7 (Mar 5, 2015)

Just when I thought we were getting away from cookbook medicine.


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## Jim37F (Mar 5, 2015)

So...use a scoop? Remove it as soon as she's on the gurney? Or does the protocol still demand a collar as well in that case?


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## DesertMedic66 (Mar 5, 2015)

Jim37F said:


> So...use a scoop? Remove it as soon as she's on the gurney? Or does the protocol still demand a collar as well in that case?


The only place I have seen a scoop around these parts is at my college for the EMT program haha


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## Jim37F (Mar 5, 2015)

DesertEMT66 said:


> The only place I have seen a scoop around these parts is at my college for the EMT program haha


That sucks, each ambulance here in my dept. carries one. What do you use in it's place, do you only have backboards? Or at least have one of those folding/break away litter stretchers? 

Back to your scenario, remove granny from the board once on the gurney and simply document the patient was carried to the gurney? Still seems better to selectively word the PCR than force a patient into full SMR for a hip injury. Unless of course the Receiving Facility docs insist on splinting a patient's neck and back for a non neck/back injury and will complain to Rebel's supervisors causing grief...

That's how I've started referring to C-collars when talking through scenarios with our new guys....why didn't we board and collar the 80 something year old patient involved in the TC? Well he was walking around on scene as well as you and me without any traumatic injuries, in fact his chief (and only) complaint was extreme hypertension. "Yeah but, because of his age and mechanism".....so should we have also applied our bilateral Sager splint on his legs, air splints on his arms and taped trauma dressings to his chest to stabilize possible flail chest segments? No, because we found zero signs/symptoms of those injuries, just like we found zero s/s of a neck or back injury, and just like we don't break out the Sager based on mechanism alone, neither do we with collars or boards.

To circle this mini rant back to the original topic, no collar for a GSW to the head, default of no for the GSW to the neck...but as I've said I can envision a scenario where it can be helpful...but default is no.


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## DesertMedic66 (Mar 5, 2015)

Jim37F said:


> That sucks, each ambulance here in my dept. carries one. What do you use in it's place, do you only have backboards? Or at least have one of those folding/break away litter stretchers?
> 
> Back to your scenario, remove granny from the board once on the gurney and simply document the patient was carried to the gurney? Still seems better to selectively word the PCR than force a patient into full SMR for a hip injury. Unless of course the Receiving Facility docs insist on splinting a patient's neck and back for a non neck/back injury and will complain to Rebel's supervisors causing grief...
> 
> ...


We will use what we call a break away flat. It's great for moving people short distances. Once you get them on the gurney you can unlock the hinges at the side and it allows the patient to sit up in a semi fowler position. However due to it being slightly flimsy we do not usually take it anywhere we have to hike to the patient. Each of our ambulances are stocked with one of the flats and 2 backboards.


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## RebelAngel (Mar 5, 2015)

Jim37F said:


> So...use a scoop? Remove it as soon as she's on the gurney? Or does the protocol still demand a collar as well in that case?


Scoop is not immobilization device, just transport device


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## Ensihoitaja (Mar 6, 2015)

RebelAngel said:


> Scoop is not immobilization device, just transport device



It can be. When we do immobilize someone, we nearly always use a scoop. Then, when we get to the hospital, we can move them to the bed and break apart the scoop so they don't need to stay on the board.


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## Jim37F (Mar 6, 2015)

RebelAngel said:


> Scoop is not immobilization device, just transport device


Besides the fact that you don't need to immobilize a patient's head, neck and back for a hip injury (unless there's signs/symptoms of a spinal injury), my local protocol says I can use a scoop stretcher as a method of Spinal Motion Restriction:





> SMR Methods: (least to most invasive) cervical collar in fowler’s, semi-fowler’s or supine on the stretcher, vacuum mattresses/scoops/skeds, shortboards and keds, backboard and head blocks with straps.
> http://file.lacounty.gov/dhs/cms1_206145.pdf


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## Tigger (Mar 6, 2015)

RebelAngel said:


> Protocol in this state is if you collar you backboard and if you backboard you collar. As far as GSW to the head, ABCs trump immobilization. My state has lightened up on the back boarding and leaves it to the discretion of the EMT.
> 
> What was patient's priority? Did you suspect injury to the back or neck? Did you use emergency, urgent, or non-urgent moves?


Can you show us what your protocol actually says?

Cause that's just downright absurd.


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## Tigger (Mar 6, 2015)

Also I heart the scoop. Just wish we could get some new ones with latches that work properly and don't destroy my fingers.


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## RebelAngel (Mar 6, 2015)

Tigger said:


> Can you show us what your protocol actually says?
> 
> Cause that's just downright absurd.


I talked to the head of the EMS bureau in our county about the person's scenario specifically. She said yes, we would have to collar if using backboard because of protocols but that the protocols will be changing about back boarding.


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## RebelAngel (Mar 6, 2015)

The scoop...wow. That's not how it is at all going by my state's protocols. Strictly moving device for non trauma pts.


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## Tigger (Mar 6, 2015)

RebelAngel said:


> I talked to the head of the EMS bureau in our county about the person's scenario specifically. She said yes, we would have to collar if using backboard because of protocols but that the protocols will be changing about back boarding.


Be a healthcare provider, not a robot. No tool has a single use if you are using a board for patient movement, why would you collar? And don't say "protocol."

Also the scoop is awfully useful for a variety of trauma patients. Do you really think your protocol is outlawing it for use with hip fractures? Of course not. 

Critical thinking and problem solving, you can't do this job without them.


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## RebelAngel (Mar 6, 2015)

You raise a lot of good question and I have contacted the head of the EMS bureau to help me understand. I know my state is *** backwards and behind in the times. Changes to protocols are coming slowly, but they are coming.

The only answer I have for that is "protocols", sorry. 

Three questions I have about all the posts are:

1-How can you be 100% sure with a hip fracture that there is no injury to the neck or spine? 

2-From my practice in class and based on my knowledge the patient in the scoop has to move (wiggle) so they're not pinched. It also doesn't have very good support for the spine. Based on those two things how can you ensure that no further harm would be done to a trauma patient's spine/neck?

3-What have you found in your personal experience that the scoop is useful for?



Tigger said:


> Be a healthcare provider, not a robot. No tool has a single use if you are using a board for patient movement, why would you collar? And don't say "protocol."
> 
> Also the scoop is awfully useful for a variety of trauma patients. Do you really think your protocol is outlawing it for use with hip fractures? Of course not.
> 
> Critical thinking and problem solving, you can't do this job without them.


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## gotbeerz001 (Mar 6, 2015)

RebelAngel said:


> You raise a lot of good question and I have contacted the head of the EMS bureau to help me understand. I know my state is *** backwards and behind in the times. Changes to protocols are coming slowly, but they are coming.
> 
> The only answer I have for that is "protocols", sorry.
> 
> ...


The scoop is very useful. I like it on codes with the Lucas since it cradles device better. 

I even used a KED the other day for a fall down basement steps: Super limited space and too tight of corners for a full board.


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## MedicRx (Mar 6, 2015)

RebelAngel said:


> You raise a lot of good question and I have contacted the head of the EMS bureau to help me understand. I know my state is *** backwards and behind in the times. Changes to protocols are coming slowly, but they are coming.
> 
> The only answer I have for that is "protocols", sorry.
> 
> ...


1. You can never be 100% sure of anything. Even with imaging studies, small fractures can be missed. That being said, your physical assessment, if performed correctly and thoroughly, should help rule out spinal injury rather well.

2. This is exactly the point. Backboards don't actually prevent further harm. If you have a patient who has injured their vertebrae and/or spinal cord, that damage is done. Unless you plan on further assaulting your patient, they shouldn't get worse. All injuries are the result of a mechanism that generally exceeds the normal parameters of movement. If a patient is allowed to stand, walk, and/or sit on a stretcher in a calm, self-controlled manner, they shouldn't exceed those normal parameters. It has actually been proven in biomechanics studies that patients who self-extricate and move to the stretcher on their own actually have less spinal movement than those who are moved onto backboards by EMS.

3. Our scoops are actually designed as backboards that come apart (I believe they go by the name Combicarrier). They provide the same support, but they're more useful. I use them pretty much any time I need to move the patient from a tight place, such as a back bedroom or bathroom, or whenever I can't get the stretcher close enough to the patient. Easier to use than the backboard, and all the same benefits.


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## cprted (Mar 6, 2015)

Look at the shape of the spine






Look at the shape of a spine board





How well do you think a flat board actually supports a human spine?


For further reading:
http://www.emsworld.com/article/10813735/evidence-against-routine-spinal-immobilization
http://roguemedic.com/2012/11/stop-...y-spinal-immobilizations-in-the-field-part-i/


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## samiam (Mar 6, 2015)

Ivan_13 said:


> multiple gsw's with one being in the head, in the right temple area.


 Just to be clear, the opposite side of her head from the GSW to the temple is still there right? Because if not I dont think she needs a c collar.



Jim37F said:


> Not all GSWs to the head are fatal.



That is true! I had a guy come in once saying he was pistol whipped and knocked unconscious. Had a little laceration to his forehead/temple area. Took a CT had a bullet in his head. Made the tiniest dent in skull, no fracture or penetration.  Powder in the  bullet must have been wet.

If it was indeed in the temple, the bone there is so thin so I imagine the outcome would not be great.


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## CALEMT (Mar 6, 2015)

Tigger said:


> Be a healthcare provider, not a robot. No tool has a single use



This, theres not a snowballs chance in hell that I would throw a collar on a person if I'm moving them with a backboard. I would get the "dude what the hell are you doing" look from everyone.


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## gotbeerz001 (Mar 7, 2015)

samiam said:


> Just to be clear, the opposite side of her head from the GSW to the temple is still there right? Because if not I dont think she needs a c collar.
> 
> 
> 
> ...


A guy I went to high school with shot himself through the head; in one temple, out the other. Today, he has minor vision impairment to his R eye and scars on both temples. All neuro sensory function is intact. 

Not the norm by any stretch, but GSWs to the head are not always fatal.


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## samiam (Mar 7, 2015)

gotshirtz001 said:


> A guy I went to high school with shot himself through the head; in one temple, out the other. Today, he has minor vision impairment to his R eye and scars on both temples. All neuro sensory function is intact.



Wow that is impressive. I would love to see his scans and records!


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## samsbgm (Mar 7, 2015)

We don't spinal gsw. Actually we don't spinal much anymore. The only reason I would spinal a gsw is to move them onto the stretcher. I wasn't there but from the info you gave us this sounds like something I would not transport.


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## gotbeerz001 (Mar 7, 2015)

samiam said:


> Wow that is impressive. I would love to see his scans and records!


ME TOO!!! I ran into him the other week (transported his mom) and had a brief chat with him in the waiting room. While nice to talk to, I can't help but think he caught me checking out the scars.


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## highglyder (Sep 12, 2015)

Jim37F said:


> That's how I've started referring to C-collars when talking through scenarios with our new guys....why didn't we board and collar the 80 something year old patient involved in the TC? Well he was walking around on scene as well as you and me without any traumatic injuries, in fact his chief (and only) complaint was extreme hypertension. "Yeah but, because of his age and mechanism".....so should we have also applied our bilateral Sager splint on his legs, air splints on his arms and taped trauma dressings to his chest to stabilize possible flail chest segments? No, because we found zero signs/symptoms of those injuries, just like we found zero s/s of a neck or back injury, and just like we don't break out the Sager based on mechanism alone, neither do we with collars or boards.



As written in the JEMS article _Research Suggests Time for Change in Prehospital Immobilization_ by Jim Morrissey
"Especially troubling has been the lack of emphasis on the assessment of the patient before making a decision about immobilization.  Historically, more emphasis has been placed on what happened to the vehicle or the best guess on how far someone may have fallen, instead of what actually happened to the person."

In other words, medics should be taught to not treat the scene, just as one would not treat the monitor.  Yeah, what happened to the other guys is not necessarily as important as we think since he is the other guy.  Different people, different factors, different variables, different presentations = different treatment.  Use the scene to help you guide your assessment, but not how to treat the patient.


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