# Question about Neck/Spine Injuries



## Amelia (Mar 15, 2015)

I'm learning about Head/Neck/Spine injuries, and I'm sure this will come up in class, but as I'm reading though these chapters, I can't help but keep thinking about the following:

What do we do when (I know it will happen) we are dispatched to a car accident, and the pt. is unconscious with his head flopped over? How do we safely and effectively straighten and apply manual stabilization minimizing further damage to the neck/spine? My thought is that we gently lift (minimally) and slowly straighten and pray that there's no crepitus?  Like I said- haven't gotten to that part yet. All of the pictures in my book start with "Do your ABCs" then the spine is automatically manually stabilized against the headrest.

Thanks guys!


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## Brandon O (Mar 15, 2015)

This is basically the gist of it. In theory you can try to immobilize it in place, but this is essentially impossible. Gently neutralize it (unless there's some resistance, I suppose), and collar that.


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## voodoomedic90 (Mar 18, 2015)

As far as what to do is really determined by the MOI. If the pt is unconscious and the MVA is that severe, then spinal issues are less of a worry as we are more worried about such things like airway, major bleeding, other life threats. With that said, extrication would be an issue. Put the head midline, if you feel any resistance then splint the best as you can, in whatever position you can manage. BUT DOCUMENT! DOCUMENT! DOCUMENT! I hope this helps


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## Amelia (Mar 18, 2015)

Voodoo- We just learned that tonight!  And I"m not too worried about documentation- I have a BA in Brit Lit (yeah, I know) so I tend to write essays anyway. I do appreciate the input and you're absolutely right. Thanks!


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## OnceAnEMT (Mar 18, 2015)

All of the above nailed it. I had a similar concern, especially coming from a profession where c-spine fx is the holy grail of injuries (read: AT). It varies by protocol and your comfort level, as it should. Its definitely a judgement thing, and you really gotta feel it. It's a whole lot easier with a conscious Pt who tends to do it themselves, but I suppose that's a luxury


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## Amelia (Mar 18, 2015)

Luxury- especially in an auto accident for sure. I know that most of this stuff we'll cover, but it distracts me if I have questions. Sometimes she says is "Stay Tuned!" because she wants us to be hooked into what we're learning and take the initiative. Well, my initiative is to torture everyone here with my plethora of questions.


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## voodoomedic90 (Mar 19, 2015)

I am glad I can help. But as far as documentation,  you can document all that that you want, but if what is documented isn't pertinent to the pt, then it will be discredited in a court room. For this pt I would document something to the effect of; I was taught SOAP charting. If you are unfamiliar with what that is, please ask, I love to teach and help as much as I can:

ATF UNK AGE MALE INVOLVED IN MVA. UNK SPEED. FRONT AND SIDE CURTAIN AIRBAGS DEPLOYED, DEFORMITY NOTED TO STEERING WHEEL, DEFORMITY NOTED TO WINDSHIELD. VEHICLE HAS SEVERE DAMAGE TO DRIVER FRONT; DRIVER SIDE, DRIVER REAR. WITH APPROX 2 FT OF INTRUSION INTO PT DRIVER COMPARTMENT. NO OTHER VEHICLES; ON SCENE; NOTED TO BE INVOLVED IN MVA. PT IS UNCOUNSCIOUS/ ALERT TO PAINFUL STIMULI; GCS 6. SKIN W/P/D; DEFORMITY NOTED TO DISTAL EXTREMITIES. WITH FD ASSISTANCE EXTRICATION WAS COMPLETED; WITH PULSES INTACT BEFORE AND AFTER PT MOVEMENT, PT ATTEMPTS TO WITH DRAWL FROM PAINFUL STIMULI BEFORE AND AFTER MOVEMENT. ATTEMPT TO PUT PT HEAD AND NECK MIDLINE WHERE UNSUCCESSFUL DUE TO NOTED RESISTANCE. PULSES NOTED BEFORE AND AFTER ATTEMPT, SKIN W/P/D DISTALLY BEFORE AND AFTER. PT PLACED INTO FULL SPINAL PRECAUTIONS WITH TOWELS AND PILLOWS USED TO STABILIZE HEAD/NECK. HEAD-TO-TOE ASSESSMENT REVEALS COMPOUND FRACTURE TO L. FEMUR. BLEEDING CONTROLED WITH DRY; STERILE DRESSING. LEG SPLINTED TO SPINAL BOARD, TOWELS/PILLOWS USED TO FILL VOIDS. PULSES NOTED BEFORE AND AFTER SPLINTING. HEENT - UNABLE TO PLACE HEAD/ NECK MIDLINE. OPA PLACED TO MAINTAIN AIRWAY. V/S: BP: 96/62 HR: 126 RR: 6 @ 99% R.A.(PRIOR TO BVM VENTILATIONS) BREATHING ASSISTED WITH BVM @ 14/M WHILE CONNECTED TO 100% O2. PT TX TRAUMA CODE 3. BILAT IVS ESTABLISHED ENROUTE. L. ARM 18G N.S. LOCK; R. ARM 14G IV FLUIDS GIVEN W.O. BLEEDING STILL CONTROLED, V/S: BP: 106/70; HR 122; RR 14 ASSISTED 99% 15L O2. PT TAKEN TO BED 3 U/A TO TRAUMA CENTER. REPORT GIVEN TO PHYSICIAN. UNIT OOS DUE TO DECON.

This documentation still has a few holes in it that I would address, but that would be the general picture I would paint for this scenario.


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## Amelia (Mar 19, 2015)

That's fantastic. Do you know how the pt. did after the accident? Sounds like his vitals were improving...


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## ecphotoman (Mar 19, 2015)

Amelia said:


> I'm learning about Head/Neck/Spine injuries, and I'm sure this will come up in class, but as I'm reading though these chapters, I can't help but keep thinking about the following:
> 
> What do we do when (I know it will happen) we are dispatched to a car accident, and the pt. is unconscious with his head flopped over? How do we safely and effectively straighten and apply manual stabilization minimizing further damage to the neck/spine? My thought is that we gently lift (minimally) and slowly straighten and pray that there's no crepitus?  Like I said- haven't gotten to that part yet. All of the pictures in my book start with "Do your ABCs" then the spine is automatically manually stabilized against the headrest.
> 
> Thanks guys!


Have someone hold cspine while two of you pull the pt out using a KED. Using a short board or full board instead is unsafe, but sometimes is the only option if your company doesn't provide you with a KED. Just document all your interventions and anything you may fear will come back in the form of litigation.


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## chaz90 (Mar 19, 2015)

ecphotoman said:


> Have someone hold cspine while two of you pull the pt out using a KED. Using a short board or full board instead is unsafe, but sometimes is the only option if your company doesn't provide you with a KED. Just document all your interventions and anything you may fear will come back in the form of litigation.


How does using a KED help with the difficulty the OP mentioned? Also, how is using a short board or LBB instead of a KED any more unsafe than the others?


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## chaz90 (Mar 19, 2015)

It's as simple as Brandon O wrote. As long as you're still stuck using a backboard just move the head to neutral and "immobilize" it there. If they were paralyzed before you got there you're not going to fix/hurt them, and if no SCI exists you're probably not going to do further damage by gently moving the head inline.


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## Amelia (Mar 19, 2015)

Thats what I was thinking- I just wanted to double-triple check.


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## ecphotoman (Mar 19, 2015)

chaz90 said:


> How does using a KED help with the difficulty the OP mentioned? Also, how is using a short board or LBB instead of a KED any more unsafe than the others?


Our agency(ICEMA) and the neighboring REMSA are going towards the NSAID rule for C-spine. We are now being trained to avoid long and shirt boards unless they meet the NSAID rule criteria. The rationale behind it is that the long board will place undue pressure on the lower spine and cause more harm than good. I'm just going off of our latest protocol update. I've used the KED countless times for vehicle extrications, it supports the neck on the way out of the vehicle and I've never had an issue with it.
http://www.emsworld.com/article/10987099/prehospital-spinal-injury-care-and-backboards


I don't know, that's just the way we've started doing it out here.


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## Jim37F (Mar 19, 2015)

If the patient is ambulatory we generally just have them walk out of the car and into our gurney.

If they're not ambulatory, then generally we'll slide a board under them on the seat, and just kind of slowly and gently slide them sideways, down, and back until they're properly positioned on the board and carry them to the gurney (where under the old protocols they got strapped into the board complete with headblocks and all, new protocol says we only have to strap them to the board if there's back pain, abnormal spinal exam such as step offs or other deformity, tenderness, instability, or crepitus to the spinal column, or if there's any neurological deficit noted...otherwise no back pain, deficits, or other abnormal findings we can remove the board. Of course some of the older, saltier medics who resist change will strap them in anyway just 'cause of the mechanism and justify it under the line about providers judgement, but funnily enough they tend to work mostly at the stations that only get a couple calls a day...

I feel like I'm trouble what with voodoo's report screaming at me like that


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## ecphotoman (Mar 19, 2015)

Jim37F said:


> If the patient is ambulatory we generally just have them walk out of the car and into our gurney.
> 
> If they're not ambulatory, then generally we'll slide a board under them on the seat, and just kind of slowly and gently slide them sideways, down, and back until they're properly positioned on the board and carry them to the gurney (where under the old protocols they got strapped into the board complete with headblocks and all, new protocol says we only have to strap them to the board if there's back pain, abnormal spinal exam such as step offs or other deformity, tenderness, instability, or crepitus to the spinal column, or if there's any neurological deficit noted...otherwise no back pain, deficits, or other abnormal findings we can remove the board. Of course some of the older, saltier medics who resist change will strap them in anyway just 'cause of the mechanism and justify it under the line about providers judgement, but funnily enough they tend to work mostly at the stations that only get a couple calls a day...
> 
> I feel like I'm trouble what with voodoo's report screaming at me like that


Were running in to that quite often. People are resistant to change, but if your medical director advises otherwise good luck getting any backing if you screw the pooch.


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## Jim37F (Mar 19, 2015)

Those are pretty much the new county SMR guidelines we're all supposed to follow now, plus our medical director did an inservice training for the whole department so everyone was supposed to have been brought up to speed (I say supposed to because the inservice was one day for each shift and what with overtime and trades and people getting calls during the scheduled time period means not everyone ended up going to the one day training session).


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## ecphotoman (Mar 19, 2015)

Jim37F said:


> Those are pretty much the new county SMR guidelines we're all supposed to follow now, plus our medical director did an inservice training for the whole department so everyone was supposed to have been brought up to speed (I say supposed to because the inservice was one day for each shift and what with overtime and trades and people getting calls during the scheduled time period means not everyone ended up going to the one day training session).


It was in our last protocol update and now its part of our 24hour refresher course. In about another year everyone should have cycled through, I hope lol.


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## Amelia (Mar 19, 2015)

Yup! We got the brand new algorithm of when to backboard and when not to. I guess it came out this year?


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## voodoomedic90 (Mar 20, 2015)

that wasn't really a pt I had ever, it was purely an example


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## voodoomedic90 (Mar 20, 2015)

111111111


chaz90 said:


> It's as simple as Brandon O wrote. As long as you're still stuck using a backboard just move the head to neutral and "immobilize" it there. If they were paralyzed before you got there you're not going to fix/hurt them, and if no SCI exists you're probably not going to do further damage by gently moving the head inline.


what does SCI mean?


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## Handsome Robb (Mar 20, 2015)

Spinal Cord Injury


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## Rescuelou123 (Mar 20, 2015)

HEY AMELIA HI HOW ARE YOU. LISTEN IN TRUTH MOI DICTATES  YOU IN THE WAY TO MAKING YOUR RIGHT CHOICE. IF YOU FIND THAT THE PTS. IS UNCONSCIOUS AND  YOU DO YOUR FAST HEAD TO TOE ASSESSMENT AND FIND OUT THAT THE PT. BLEEDING OUT FROM IMPACT OR ABDOMINAL REGON IS RIGIDY  CHANCES ARE THEY'RE BLEEDING INTERNALLY AND MANUAL C-SPINE IMMOBILIZATION IS SECOND TO TRAUMA.THE FIRST THING TO DO IS EXTRICATION THAT PERSON C- SPINE IS ALREADY COMPRIMSED ANYWAY BECAUSE OF THE MOI. YOU KNOW WHAT I MEAN.


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## Rescuelou123 (Mar 20, 2015)

I HOPE THAT I WAS HELPFUL


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## Tigger (Mar 20, 2015)

MOI determines pretty much nothing.

Also after rereading that post several times, I do not know what you mean. At all. 

No points.


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## PotatoMedic (Mar 20, 2015)

Tigger said:


> MOI determines pretty much nothing.


Except for the national registry!


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## Rescuelou123 (Mar 20, 2015)

How can you say that Tigger. When you know that it's true. You roll up to an MVA and you see pt. Lugde over the steering wheel unconscious and the car is mangled up and the pt. Needs to be extricated. You are going to tell me that you not going to color that person and extricate fast.


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## luke_31 (Mar 20, 2015)

Louie Patrizi said:


> How can you say that Tigger. When you know that it's true. You roll up to an MVA and you see pt. Lugde over the steering wheel unconscious and the car is mangled up and the pt. Needs to be extricated. You are going to tell me that you not going to color that person and extricate fast.


There are studies out there that show MOI is not a strong indicator for possible spinal cord injuries. Look at roguemedic's blog he has studies on there that show MOI is a poor indicator of potential spinal cord injuries.


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## Tigger (Mar 20, 2015)

Louie Patrizi said:


> How can you say that Tigger. When you know that it's true. You roll up to an MVA and you see pt. Lugde over the steering wheel unconscious and the car is mangled up and the pt. Needs to be extricated. You are going to tell me that you not going to color that person and extricate fast.


I really have no idea what you are saying. Your post is nonsensical and makes too many assumptions.

When I show up to a traffic accident, I prefer to assess the patient and treat those findings. Kinda like I do with well, all the patients.


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## chaz90 (Mar 20, 2015)

Louie Patrizi said:


> How can you say that Tigger. When you know that it's true. You roll up to an MVA and you see pt. Lugde over the steering wheel unconscious and the car is mangled up and the pt. Needs to be extricated. You are going to tell me that you not going to color that person and extricate fast.



Oh boy. Not really treating the mechanism at that point are we? Yes, even I would still be forced to COLLAR that patient, and yes I would get the patient out as safely and quickly as possible, but these choices are based on patient assessment rather than some nebulous concept of "MOI." If I arrive on scene of this very same call with the same damage to the vehicle and find the patient walking around outside without complaint and stable vitals, I would not board and collar this patient, would not call a Trauma Alert, and would likely choose to send him to the hospital BLS if he wanted to go at all.


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## Ewok Jerky (Mar 21, 2015)

Louie Patrizi said:


> How can you say that Tigger. When you know that it's true. You roll up to an MVA and you see pt. Lugde over the steering wheel unconscious and the car is mangled up and the pt. Needs to be extricated. You are going to tell me that you not going to color that person and extricate fast.


I would be treating the patient because they are unresponsive not because of the mechanism.

You have obviously never rode up on the scene of a rollover where the occupants have self extricated and are walking around without injury. You treat your patient and your findings on assessment.  

MOI is an indication of what to look for on assessment but does not trump clinical judgment.


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## Carlos Danger (Mar 22, 2015)

Louie Patrizi said:


> HEY AMELIA HI HOW ARE YOU. LISTEN IN TRUTH MOI DICTATES  YOU IN THE WAY TO MAKING YOUR RIGHT CHOICE. *IF YOU FIND THAT THE PTS. IS UNCONSCIOUS* AND  YOU DO YOUR FAST HEAD TO TOE ASSESSMENT *AND FIND OUT THAT THE PT. BLEEDING OUT* FROM IMPACT *OR ABDOMINAL REGON IS RIGIDY*  CHANCES ARE THEY'RE BLEEDING INTERNALLY AND MANUAL C-SPINE IMMOBILIZATION IS SECOND TO TRAUMA.THE FIRST THING TO DO IS EXTRICATION THAT PERSON C- SPINE IS ALREADY COMPRIMSED ANYWAY BECAUSE OF THE MOI. YOU KNOW WHAT I MEAN.



UNRESPONSIVENSS, OBVIOUS BLEEDING, AND ABDOMINCAL RIGIDITY ARE PHYSICAL ASSESSMENT FINDINGS, NOT MOI!!!!!

WHAT WOULD YOU DO IF YOU ROLLED UP ON A ROLLOVER MVC AND THE PATIENTS ARE OUT, WALKING AROUND, AND HAVE NO OBVIOUS INJURIES AND NO COMPLAINTS!?! WOULD YOU STILL TREAT THEM AS CRITICAL JUST BECAUSE THEY WERE IN A ROLLOVER!?!!?

AS OTHERS HAVE SAID, MOI DICTATES NOTHING!! PERHAPS ELEVATED SUSPICION OF SERIOUS INJURIES, BUT NOTHING MORE THAN SUSPICION!!! 

MOI IS NOT A DIAGNOSIS!!!!!


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## JPINFV (Mar 22, 2015)

voodoomedic90 said:


> I am glad I can help. But as far as documentation,  you can document all that that you want, but if what is documented isn't pertinent to the pt, then it will be discredited in a court room. For this pt I would document something to the effect of; I was taught SOAP charting. If you are unfamiliar with what that is, please ask, I love to teach and help as much as I can:
> 
> ATF UNK AGE MALE INVOLVED IN MVA. UNK SPEED. FRONT AND SIDE CURTAIN AIRBAGS DEPLOYED, DEFORMITY NOTED TO STEERING WHEEL, DEFORMITY NOTED TO WINDSHIELD. VEHICLE HAS SEVERE DAMAGE TO DRIVER FRONT; DRIVER SIDE, DRIVER REAR. WITH APPROX 2 FT OF INTRUSION INTO PT DRIVER COMPARTMENT. NO OTHER VEHICLES; ON SCENE; NOTED TO BE INVOLVED IN MVA. PT IS UNCOUNSCIOUS/ ALERT TO PAINFUL STIMULI; GCS 6. SKIN W/P/D; DEFORMITY NOTED TO DISTAL EXTREMITIES. WITH FD ASSISTANCE EXTRICATION WAS COMPLETED; WITH PULSES INTACT BEFORE AND AFTER PT MOVEMENT, PT ATTEMPTS TO WITH DRAWL FROM PAINFUL STIMULI BEFORE AND AFTER MOVEMENT. ATTEMPT TO PUT PT HEAD AND NECK MIDLINE WHERE UNSUCCESSFUL DUE TO NOTED RESISTANCE. PULSES NOTED BEFORE AND AFTER ATTEMPT, SKIN W/P/D DISTALLY BEFORE AND AFTER. PT PLACED INTO FULL SPINAL PRECAUTIONS WITH TOWELS AND PILLOWS USED TO STABILIZE HEAD/NECK. HEAD-TO-TOE ASSESSMENT REVEALS COMPOUND FRACTURE TO L. FEMUR. BLEEDING CONTROLED WITH DRY; STERILE DRESSING. LEG SPLINTED TO SPINAL BOARD, TOWELS/PILLOWS USED TO FILL VOIDS. PULSES NOTED BEFORE AND AFTER SPLINTING. HEENT - UNABLE TO PLACE HEAD/ NECK MIDLINE. OPA PLACED TO MAINTAIN AIRWAY. V/S: BP: 96/62 HR: 126 RR: 6 @ 99% R.A.(PRIOR TO BVM VENTILATIONS) BREATHING ASSISTED WITH BVM @ 14/M WHILE CONNECTED TO 100% O2. PT TX TRAUMA CODE 3. BILAT IVS ESTABLISHED ENROUTE. L. ARM 18G N.S. LOCK; R. ARM 14G IV FLUIDS GIVEN W.O. BLEEDING STILL CONTROLED, V/S: BP: 106/70; HR 122; RR 14 ASSISTED 99% 15L O2. PT TAKEN TO BED 3 U/A TO TRAUMA CENTER. REPORT GIVEN TO PHYSICIAN. UNIT OOS DUE TO DECON.
> 
> This documentation still has a few holes in it that I would address, but that would be the general picture I would paint for this scenario.


Why the caps lock? If I ever find the person who trains people to document in caps lock I will kill them slowly and painfully.


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## gotbeerz001 (Mar 22, 2015)

JPINFV said:


> Why the caps lock? If I ever find the person who trains people to document in caps lock I will kill them slowly and painfully.


Agreed. I think it stems from the notion that hand-written PCRs you are supposed to written in CAPS (for those with terrible hand-writing)...


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## JPINFV (Mar 22, 2015)

gotshirtz001 said:


> Agreed. I think it stems from the notion that hand-written PCRs you are supposed to written in CAPS (for those with terrible hand-writing)...




Wait, hand written documentation is supposed to be in all caps? F that as well.


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## Rescuelou123 (Mar 22, 2015)

What


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## Akulahawk (Mar 22, 2015)

The only thing that MOI tells you is where to look. Nothing more, nothing less. You do NOT base your treatment upon MOI. You base it on your findings. An extreme example of MOI telling you where to look woul d be if someone stubbed their toe on something, you wouldn't put the person in SMR. The stubbed toe MOI doesn't indicate an energy transfer that would compromise the spine. You would look at (perhaps) the ankle, mid-foot, and toes for potential injury. 

Unfortunately the EMS system where I now work is well behind the times in this area and they generally require SMR for a lot of traumas. I hope that changes soon. In the ER, we try to get the patients off the board as soon as possible, so that's at least a plus.


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## Rescuelou123 (Mar 22, 2015)

Hey I know what to do on a MVA and I know all about moi ok. And for your information  moi does dictate  what treatment you need to give and do as well.


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## Rescuelou123 (Mar 22, 2015)

Also I want to point  out to you mr. Or mrs. Emt if you roll up to an MVA and you see the driver alert but head laceration you mean your not going to collar the person.
Or you going treat for bleeding first and not worry about moi. And take a chance on paralyzing that person because  your first thing you did was control bleeding you dumbbell


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## Ewok Jerky (Mar 22, 2015)

Louie Patrizi said:


> Hey I know what to do on a MVA and I know all about moi ok. And for your information  moi does dictate  what treatment you need to give and do as well.


you were taught wrong...unless you want to blame your protocols. But since you are calling us dumbbells and arguing with us about it...


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## NomadicMedic (Mar 22, 2015)

Ah @Louie Patrizi, ya almost got us. 

I smell a troll.


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## CALEMT (Mar 22, 2015)

Louie Patrizi said:


> And for your information moi does dictate what treatment you need to give and do as well.



No it doesn't. If I have a patient that was involved in a head on collision at 50 mph and said patient does not meet NSAID requirements, I can technically put the patient on the gurney with no spinal precautions what so ever. Even if the pt does meet one of the NSAID requirements I can throw a collar on with no backboard. Like others have said previously MOI means nothing, its what you find in your assessment that determines if you collar or not.


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## chaz90 (Mar 22, 2015)

Ugh. I've had enough of trying to reason here.  Whether he's a troll or simply unbelievably stubborn, he's clearly made up his mind.


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## voodoomedic90 (Mar 23, 2015)

JPINFV said:


> Why the caps lock? If I ever find the person who trains people to document in caps lock I will kill them slowly and painfully.


does it matter that much that it is in all caps? Who cares?


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## JPINFV (Mar 23, 2015)

voodoomedic90 said:


> does it matter that much that it is in all caps? Who cares?


It makes it harder to read, which is the entire point of written communication. Seriously, people do read EMS (and nursing, I swear, there has to be an entire class for nurses titled "Caps lock and you" and it's consists of logging on and immediately toggling caps lock before documenting) reports, and it makes it much harder to read than a written report that uses proper grammar and paragraphs. It's like people write things and then expects no one to ever read what they write.


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## OnceAnEMT (Mar 23, 2015)

The documentation software at the ED I am at actually errors if you don't use all caps In most fields. Woo.


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## Tigger (Mar 23, 2015)

voodoomedic90 said:


> does it matter that much that it is in all caps? Who cares?



Yes. Me.

It is infinitley harder to review charts written in all caps. And it serves zero purpose.


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## voodoomedic90 (Mar 24, 2015)

Tigger said:


> Yes. Me.
> 
> It is infinitley harder to review charts written in all caps. And it serves zero purpose.



I actually disagree especially in a world of electronic charting now. I agree with paper charts it was for sure harder, but with computer charts caps makes it so much easier. For instance, "I" looks like "l" in some fonts. Which is which? where in all caps "I" does not look anything like a "L." I am not daft enough to realize that this will cause very little confusion, however in a society that has more attorneys on speed dial then a pizza delivery guy... I will write in all caps


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## Rescuelou123 (Mar 24, 2015)

Listen truth I know MOI means nothing . I was just playing around because I had nothing better to  so LOL.


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## Rescuelou123 (Mar 24, 2015)

Yo let's talk about something else more on the true side.


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## Rescuelou123 (Mar 24, 2015)

Pick a topic.


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## Ewok Jerky (Mar 24, 2015)

Oh @Louie Patrizi  you are such a joker! You really had me this time.


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## NomadicMedic (Mar 24, 2015)

Louie Patrizi said:


> Pick a topic.



I'll take "go away" for 500 Alex.


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## Rescuelou123 (Mar 24, 2015)

Ah why do yo say that Mr. Hand


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## CALEMT (Mar 24, 2015)

Where's the don't feed the troll emoji when you need it...


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## STXmedic (Mar 24, 2015)

I smell Tor...


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## redundantbassist (Mar 24, 2015)

Obvious troll. Look at his other posts. Surprised he hasn't been banned. 
http://emtlife.com/threads/photos-to-sell.40938/#post-568379

(hey @Chimpie ..?)


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## Scott33 (Mar 24, 2015)

+ 1 for banning the troll. Whatever happened to adult discussion?


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