# Are you allowed to release c-spine, and when?



## patzyboi (May 22, 2013)

Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.) 

Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?


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## DesertMedic66 (May 22, 2013)

1.) if the patient tells you to stop or refuses you have to listen to them unless they are altered. 

2.) so protocols allow it and other protocols do not allow clearance.


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## J B (May 22, 2013)

patzyboi said:


> Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.)
> 
> Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?



Main thing to keep in mind is cover your ***.

1)
I would make damn sure I inform them of the risks involved with refusing treatment, try to make sure there is no altered mental status, and get the refusal signed first.  

If they are getting combative and thrashing around, you might be doing more harm than good by holding c-spine, so that's worth considering.

2)
Again, it's your ***... 99% of the time they're fine, but if there was a significant MOI (ie MVC) and you release c-spine because "pt reported that his pain went away"... Well, that's not going to look good in court when the guy ends up paralyzed and sues you.

I think clinically clearing c-spine actually isn't a terribly complicated thing - there are even youtube tutorials about it.  I think medics can do it in some places.  The big thing is not the difficulty of doing it, but that you're really sticking your neck out to do it.  If you make a mistake, take off the collar and the pt ends up paralyzed... bad situation.  Let the doctor who pays 100k/year in malpractice insurance deal with it.  Not worth the risk to me.

As a basic, if there was an unwitnessed trauma and I can't rule out spine/neck injury, they get collared and boarded.  

At least that's what I was taught, and it makes sense to me though it's a PITA.  If you deviate from protocols you're putting your career/bank account on the line to make the pt's ambulance ride a little more comfortable.  Meh.


I'm a newbie so take with grain of salt...


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## Handsome Robb (May 22, 2013)

Spinal Motion Restriction is grossly over taught in U.S. EMS education. There are plenty of documented cases of SMR cause more harm than help. 

I clear people's c-spine in the field every day. Sometimes multiple times a day. Sometimes multiple times on a call. I'd honest prefer to clear them then board them if I can do it safely.

Google NEXUS or Canadian C-Spine Rule. 

We use NEXUS or close to it.

Even if you can't use one of the above tools to "clear" their c-spine if they're A&O and refusing you have to let them go unless you want to deal with assault, battery and kidnapping charges...


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## cprted (May 22, 2013)

Any complaints of neck or spine pain? No> Palpate neck and spine for deformities or tenderness. None found> Any neurological deficits, numbness or tingling? No> Rotate head slowly left and right, now flex and extend slowly.  Any pain, stiffness, crepitus? No> Spinal cleared.

This obviously assumes a patient that is A/O x3 and GCS of 15.


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## J B (May 22, 2013)

Robb said:


> Spinal Motion Restriction is grossly over taught in U.S. EMS education. There are plenty of documented cases of SMR cause more harm than help.
> 
> I clear people's c-spine in the field every day. Sometimes multiple times a day. Sometimes multiple times on a call. I'd honest prefer to clear them then board them if I can do it safely.



I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?



cprted said:


> Any complaints of neck or spine pain? No> Palpate neck and spine for deformities or tenderness. None found> Any neurological deficits, numbness or tingling? No> Rotate head slowly left and right, now flex and extend slowly.  Any pain, stiffness, crepitus? No. Spinal cleared.
> 
> This obviously assumes a patient that is A/O x3 and GCS of 15.



I could be wrong but I'm pretty sure that, at least as a basic, this gets you fired in my area.

I think the short answer to the OP is: consult your protocols / supervisor / medical direction?


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## Handsome Robb (May 22, 2013)

J B said:


> I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?



Yes, you're correct. 

With that said, with the current evidence many agencies are enacting a spinal clearance protocol if they don't already have one. Most based off of NEXUS or the CCSR. My ILS partner can use this protocol, they don't need me. 

So to truly answer the OP's question. Yes their are tools you can use. No you can't just use them you need to follow your agency's protocol for clearing c-spine in the field.


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## jrm818 (May 22, 2013)

J B said:


> I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?
> 
> 
> 
> ...



If I'm right in guessing your from MA from the other thread - you're right, this isn't ready for prime-time in MA yet, don't do it.  Unfortunately sometimes bad medicine has to continue due to local standards, this isn't worth risking your job over.  In Mass it does seem like there's a certain lag behind other places sometimes...but less backwards c-spine practices may be coming.  I know UMass had started some sort of "NEXUS in the field" study with Worcester EMS at some point at least....


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## Medic Tim (May 22, 2013)

In Maine basics can clear c spine. I believe it is nexus or very similar. Where I work in Canada we use ccsr.


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## Christopher (May 23, 2013)

patzyboi said:


> Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.)
> 
> Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?



Clear is the correct terminology. Although we've overloaded the meaning.

And certainly you can do it. You do it every day. How do you know your medical patient isn't lying to you and didn't fling themselves down the stairs? You don't. They could die of a horrific spinal trauma because you were too lazy to board and collar them.

Yes I know only their belly hurt, but nobody cares about your belly if you have a spinal injury!

I know what you're thinking, "But Christopher, that sounds ridiculous."

Yes, but that is our mode of spinal care.

So let's get back to the more important issues:

(1) Can you "clear" a C-spine in the field?
(2) What does "clear" actually mean?
(3) What tools are available to help me "clear" a C-spine in the field?
(4) So I've cleared the C-spine...what now?!

*1. Can you "clear" a C-spine in the field?*
Yes, most modern EMS systems have been doing this for at least the last 5 years.

*2. What does "clear" actually mean?*
_To you?_ It means not using Spinal Motion Restriction procedures.

_To the hospital?_ It means not imaging the spine.

_To the radiologist?_ It means no significant findings during imaging studies.

It means very different things to different people. Keep in mind _none of these are the same thing_!

*3. What tools are available to help me "clear" a C-spine in the field?*
NEXUS and the Canadian C-Spine Rule are the two most commonly talked about. However, these two rules are not intended to inform YOUR decision about whether to apply SMR procedures, instead they were validated to inform THE HOSPITAL'S decision about whether or not to send the patient for imaging.

This is a huge distinction. But does it matter?

Yes and no. You need to take away from this that the NEXUS and CCR were not designed to inform your opinion about the appropriateness of SMR. It will result in a large about of overtriage from a field perspective because they deal with *radiologically significant* findings. Note that I did not say _clinically significant_.

The ideal EMS tool would inform your opinion about the appropriateness of SMR such that 0 *clinically significant spinal injuries* were missed. Many retrospective and prospective studies exist which have validated the appropriateness of NEXUS and CCR for prehospital use, however, you should understand the difference.

Also note that these studies say nothing of what is appropriate SMR!

*4. So I've cleared the C-spine...what now?!*
Don't be weirded out when you hear that somebody who had a "cleared" C-spine had a "significant spinal injury". Everything is working as expected.

Because clinically significant is not the same as radiologically significant.


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## Mariemt (May 23, 2013)

Sure I can clear it all I want, but I better be clear and gone when my MD and squad director find out. Our protocol has specific "rules " for immobilization,  once we immobilize, we can't clear.  We have certain guidelines to follow, certain moi etc. However, we can let an unaltered patient refuse and can do manual c spine for comfort reasons.

We also hate hard backboards,  but must use them for certain things per protocol. So to limit discomfort we use back rafts which believe it or not make a big difference.


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## augustHorch (May 24, 2013)

Christopher said:


> Clear is the correct terminology. Although we've overloaded the meaning.
> 
> And certainly you can do it. You do it every day. How do you know your medical patient isn't lying to you and didn't fling themselves down the stairs? You don't. They could die of a horrific spinal trauma because you were too lazy to board and collar them.
> 
> ...



Im glad you posted this...

I hate the word "clear" when talking about C-spine because it means TOTALLY different things to different people...

I never clear a c-spine because to me, the definition involves imaging and i dont have the ability to do that in the field. 

I do a C-Spine algorithm that is outlined in my protocol... if they fail, they get boarded. If they pass, i will ask them if they want to be boarded as a precaution, and i will let them know all the risks associated. 

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made. Unless they refuse, then inform them of risks, let go, and document everything.


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## Christopher (May 24, 2013)

augustHorch said:


> Im glad you posted this...
> 
> I hate the word "clear" when talking about C-spine because it means TOTALLY different things to different people...
> 
> I never clear a c-spine because to me, the definition involves imaging and i dont have the ability to do that in the field.



I think it is an Ok term to use when talking among similar providers. Re-use of words is the natural course of any Language. It is when we are not aware of these differences that we run into trouble.

Whether you say "clear", "optional immobilization", "field clearance", or "selective spinal immobilization", does not really matter. So long as you're consistent.

Part of the problem is nobody is willing to stand up and say, "YES! I cleared this patient of needing SMR and YES they had a radiologically significant finding during imaging. And YES this was still the right call."

Not needing SMR and not having an injury are also not the same thing...we're just wussies.



augustHorch said:


> I do a C-Spine algorithm that is outlined in my protocol... if they fail, they get boarded. If they pass, i will ask them if they want to be boarded as a precaution, and i will let them know all the risks associated.



I'm making a big push for people to change the way they talk about this topic in general. Instead "if they fail X Y and Z, they get boarded." I'd rather people say, "if they meet criteria X, Y, and Z they receive spinal motion restriction".

This tiny change allows us to talk about the two separately, as they are not the same issue. You're also not talking about what device is used to achieve SMR, which is the most important part.



augustHorch said:


> But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made. Unless they refuse, then inform them of risks, let go, and document everything.



I don't understand this last bit. Just because somebody else starts down the path does not mean I have to.

Besides, there is no more of a risk to the refusal of C-collar/LSB than there is to the application of C-collar/LSB. In fact, it is easier to show the risk of application than the risk of refusal.

I really really wish an entrepreneurial lawyer would start suing the pants off EMS agencies for our spinal practices...since that seems to be the only way to get it to change.


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## augustHorch (May 24, 2013)

Christopher said:


> I don't understand this last bit. Just because somebody else starts down the path does not mean I have to.



I somewhat misspoke here... 

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made *unless they fail something then the rest of the algorithm doesn’t necessarily need to be completed.*. Unless they refuse, then inform them of risks, let go, and document everything.

Basically... if I’m going down this path, I’m not going to stop halfway through and say "i have reason to believe you shouldn’t need any SMR"... I’m going to finish my assessment. And i think someone manually holding c-spine and letting go, even for just a second, is irresponsible c-spine immobilization...

Part of that algorithm includes mechanism of injury and patient reliability. If they fail PT reliability and have mechanism... we don’t do any more of the algorithm. They get boarded

EDIT: I am an EMT-B


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## chaz90 (May 24, 2013)

augustHorch said:


> And i think someone manually holding c-spine and letting go, even for just a second, is irresponsible c-spine immobilization...



Why? People self splint quite well. No one was "holding C-Spine" before you got there, and the patient didn't spontaneously become paralyzed. Also, stopping once you begin some part of spinal immobilization (and believe me, I use that term loosely) is perfectly reasonable. I can't tell you the number of times I've come up to a scene and found someone holding C-Spine before I told them to let go. 

We need to get away from this mindset of taking SMR meaning C-Collar, head blocks, and long spine board. In my ideal world, we would put a C-Collar alone (or yellow sticker to the forehead for all I care) on a narrow subset of patients determined to have a high risk of spinal injury from clinical finding. Even these people would be transported in a position of comfort and simply handled carefully, as all patients should be. The C-Collar would simply be used as a visual reminder that the patient is considered to have a risk of a spinal injury. If the patient complains about discomfort or access is needed to the neck, the collar comes off.


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## Aidey (May 24, 2013)

augustHorch said:


> I somewhat misspoke here...
> 
> But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made *unless they fail something then the rest of the algorithm doesn’t necessarily need to be completed.*. Unless they refuse, then inform them of risks, let go, and document everything.
> 
> ...



That still doesn't make any sense. I've responded to all sorts of calls where someone, either a bystander or first responder, has inappropriately "taken c-spine". I am not going to run through the entire algorithm on a patient that doesn't even meet the criteria for SMR just because someone else is paranoid.


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## augustHorch (May 24, 2013)

chaz90 said:


> Why? People self splint quite well. No one was "holding C-Spine" before you got there, and the patient didn't spontaneously become paralyzed. Also, stopping once you begin some part of spinal immobilization (and believe me, I use that term loosely) is perfectly reasonable. I can't tell you the number of times I've come up to a scene and found someone holding C-Spine before I told them to let go.
> 
> We need to get away from this mindset of taking SMR meaning C-Collar, head blocks, and long spine board. In my ideal world, we would put a C-Collar alone (or yellow sticker to the forehead for all I care) on a narrow subset of patients determined to have a high risk of spinal injury from clinical finding. Even these people would be transported in a position of comfort and simply handled carefully, as all patients should be. The C-Collar would simply be used as a visual reminder that the patient is considered to have a risk of a spinal injury. If the patient complains about discomfort or access is needed to the neck, the collar comes off.



I think you are probably correct...

Its just the protocols that have been drilled into me


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## highglyder (May 26, 2013)

We have no specific standard on SMR.  Many standard do require us to consider c-spine injuries and immobilisation is indicated if it is obvious, suspect, or cannot be ruled put.  The problem is that there is no standard manner in which to rule it out.  It boils down to a good assessment and experience, something which makes many uncomfortable.

Many also think that collars and boards can only be applied together.  I've often used only a board when the injury is isolated to the thoracic or inferior regions.  I've also used collars for comfort when I determined that their neck pain is muscular in origin.

I am a minimalist.  I do things that are clinically required rather than because the book says so.  I document my rational and that's usually the end of it.  I have been questioned about certain things in the past and successfully defended my actions.  Perhaps such experiences have allowed me to forgo certain typical concerns in matters of CYA.


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## Bullets (May 27, 2013)

J B said:


> 2)
> Again, it's your ***... 99% of the time they're fine, but if there was a significant MOI (ie MVC) and you release c-spine because "pt reported that his pain went away"... Well, that's not going to look good in court when the guy ends up paralyzed and sues you.
> 
> 
> ...



Significant MOI isnt enough to apply SMR

Unwitnessed trauma is just that, unwitnessed and not enough evidence to apply SMR

Do they have cervical pain? Do they have neuro deficits? Do they have a distracting injury and wouldnt be able to tell you they have pain?

Just because a car flips isnt a reason to apply SMR, ive had patients roll their cars, take 30 minutes to extricate and they crawl out and walk away. If and when you take an extrication course and you see the technology in cars, you understand that they can take a beating will litle damage to the cab.


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## medic741 (Jul 9, 2013)

Just do it. We have Selective Spinal Immobilization protocols in the region I work in, but don't know a provider that 'clears' spines. It's not worth my card, my liability, or my job.


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## Christopher (Jul 9, 2013)

medic741 said:


> Just do it. We have Selective Spinal Immobilization protocols in the region I work in, but don't know a provider that 'clears' spines. It's not worth my card, my liability, or my job.



If you follow the protocol you are fine. If you do not follow the protocol, you're opening yourself up to liability.

I hope lawyers get smart and start suing agencies that immobilize patients needlessly.


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## Medic Tim (Jul 9, 2013)

medic741 said:


> Just do it. We have Selective Spinal Immobilization protocols in the region I work in, but don't know a provider that 'clears' spines. It's not worth my card, my liability, or my job.



So much fail

You are opening yourself up to trouble by not following you policies.
This kind of attitude is what keeps EMS from progressing.(among others)


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## EpiEMS (Jul 9, 2013)

Christopher said:


> I hope lawyers get smart and start suing agencies that immobilize patients needlessly.



This would be truly beautiful.


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## lanceavil (Jul 9, 2013)

I live in Central CA, our local protocals say that c-spine (and backboard) can only be removed by a physician after they determine if it's needed or not. But if patient is refusing treatment, and is A&O x4, it just depends on the situation. It's easier to explain why you did something than why you didn't. If they don't want treatment, and you already c-spined, just make sure they sign a refusal.


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## Christopher (Jul 9, 2013)

lanceavil said:


> I live in Central CA, our local protocals say that c-spine (and backboard) can only be removed by a physician after they determine if it's needed or not. But if patient is refusing treatment, and is A&O x4, it just depends on the situation. It's easier to explain why you did something than why you didn't. If they don't want treatment, and you already c-spined, just make sure they sign a refusal.



At our organization you will receive verbal coaching, followed by a remedial training plan, and if that doesn't fix it disciplinary measures for excessive/unnecessary procedures. So no, it is not easier to just do something.

Then again, we're not in CA (the land before time apparently).


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## medicnick83 (Jul 9, 2013)

In South Africa, basics and intermediates are not allowed to clear C-Spine - Even if we could, I wouldn't, I'd rather let a doctor or a x-ray clear it.


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## Hwnorth (Jul 10, 2013)

interesting


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## Carlos Danger (Jul 10, 2013)

There is a big difference between "clearing" a c-spine, and simply choosing not to immobilize someone because it isn't indicated.

"Clearing" implies that there is in fact a significant potential for needing cervical immobilization, but that I'm using assessment skills to determine that such an injury doesn't exist. That's dicey considering that in the hospital, anyone with a significant chance of having a cervical injury is only "cleared" by a combination of clinical exam _and_ imaging, and only by an MD.

"Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different. 

We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria. 

When you pick up a patient with chest pain and you don't cardiovert them because they are in NSR at 90, would you say you "cleared" their rhythm from needing cardioversion? No - you wouldn't say anything at all about cardioversion, because it would have never even entered your mind because it's just not called for. 

That's how we should view the person who fell from standing and has no neck pain and almost zero chance of an unstable cervical fracture. We aren't "clearing" those people's c-spines; we just aren't implementing a procedure because it isn't indicated.


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## TransportJockey (Jul 10, 2013)

If they refuse then I let them go and document the crap out of it.

As for 'clearing c-spine' we technically can't do it... but if it's not indicated I don't do it. Hell, I've brought in rollovers just sitting on my cot w/out boarding.


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## jefftherealmccoy (Jul 11, 2013)

We have a 5 step procedure to clear c-spine in the field-

1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
3. If pt is glasgow 15, A&O x 4, step 4, if not IMMOBILIZE
4. If pain or deformity at any point of spine, IMMOBILIZE, if not, 5
5. If circulation, motor and sensory is normal, spine is clear, if not, IMMOBILZE
When in doubt, IMMOBILIZE. 

Our medical control doc is actually pretty cool on this.  He has told us that our cot is pretty much as effective as the backboard.


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## chaz90 (Jul 11, 2013)

jefftherealmccoy said:


> We have a 5 step procedure to clear c-spine in the field-
> 
> 1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
> 2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
> ...



That actually seems pretty restrictive. Immobilization based on mechanism alone is ridiculous, and by that algorithm, you couldn't even proceed past step two for any "high mechanism." My favorite part of our selective spinal immobilization protocol is "ambulatory at any time." That removes a lot of the nonsense.


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## Christopher (Jul 11, 2013)

Halothane said:


> There is a big difference between "clearing" a c-spine, and simply choosing not to immobilize someone because it isn't indicated.



It means a lot of things to a lot of people (EMS, ED, radiology, etc).



Halothane said:


> "Clearing" implies that there is in fact a significant potential for needing cervical immobilization, but that I'm using assessment skills to determine that such an injury doesn't exist. That's dicey considering that in the hospital, anyone with a significant chance of having a cervical injury is only "cleared" by a combination of clinical exam _and_ imaging, and only by an MD.
> 
> "Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different.



I think I brought this up either earlier or in another thread, but the language used is "overloaded" (in computer science speak).

NEXUS and CCR "clear" a C-spine w.r.t. *imaging need*.

Selective spinal motion restriction protocols "clear" a C-spine w.r.t. *splinting need*.

I frankly do not care if they have an unstable radiological finding.

I care about clinically unstable spines.



Halothane said:


> We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria.



Amen. 



Halothane said:


> That's how we should view the person who fell from standing and has no neck pain and almost zero chance of an unstable cervical fracture. We aren't "clearing" those people's c-spines; we just aren't implementing a procedure because it isn't indicated.



"You wouldn't put a traction splint on due to mechanism alone?"


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## firecoins (Jul 11, 2013)

Only allowed to release during definite positive spinal injury.


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## Bullets (Jul 11, 2013)

jefftherealmccoy said:


> We have a 5 step procedure to clear c-spine in the field-
> 
> 1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
> 2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
> ...



LOC, Drugs and Alcohol, distracting injuries and bone disease have nothing to do with MOI

MOI should not determine your treatment EVER. MOI is a clue to inform you of POSSIBLE injuries, and requires a basic understanding of physics that you dont get in EMT class to fully evaluate. If you see a rolled car, you should realize what forces were placed on the body and how that COULD cause injury

We had a patient yesterday fall 20 feet onto a wood floor. had some lumbar pain. Walked out of the hospital that night with 4 fractured carpals in a cast. MOI says trauma alert, his injuries did not



Halothane said:


> "Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different.
> 
> We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria.
> 
> ...



Now if i can just get Medics, Nurses and Doctors to understand this and STOP GIVING ME A HARD TIME AT THE HOSPITAL

sorry


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## Carlos Danger (Jul 11, 2013)

Christopher said:


> NEXUS and CCR "clear" a C-spine w.r.t. *imaging need*.
> 
> Selective spinal motion restriction protocols "clear" a C-spine w.r.t. *splinting need*.



Well, here's the thing......

When does a patient need to be "cleared" of an injury? Only when there was significant suspicion that the injury may exist in the first place. 

And if there was significant suspicion in the first place, I'm not sure that I as a paramedic want to be the one to state, definitively, that such an injury doesn't exist. Which is exactly what you are doing when you say "I cleared the c-spine".

On the other hand, simply choosing not to apply cervical spinal precautions because your patient doesn't meet the criteria for that procedure (neuro deficit, neck pain, etc.), while seemingly the same in practice, is a very different approach medico-legally.

In the first approach you are basically saying "This patient suffered trauma that made a c-spine injury a possibility, but my clinical exam finds that he does not in fact have such an injury". In the second approach, you are saying "I didn't place him in c-spine precautions because he had no clinical evidence of a cervical injury". Again, they are very different things to the risk-managment folks.

The authors of the NEXUS study may have used the terminology "cleared", because they are physicians and that's what physicians do. Paramedics don't typically "clear" patients of injuries.

If someone has an MOI that indicates the potential for a femur injury, but you choose not to put a traction splint on because their is no evidence of trauma to their leg, do you chart that you "cleared" their femur? No. You just chart that there was no indication for a traction splint.

It may seem like semantics, but in the legal sense, there is a BIG difference between "clearing" a patient, and simply choosing not to perform a procedure because it isn't indicated. This was explained to me years ago by a lawyer who is also a paramedic. 

Of course, one could argue that all of that only matters IF you ever get sued for not applying cervical precautions. And that is a really decent point. However, that's placing a lot of faith in the criteria, and in your ability to always implement it without error. 

I'm not sure if NEXUS will ever catch on widely. There are several studies that dispute it's validity, and x-rays are relatively easy and cheap.




Christopher said:


> I frankly do not care if they have an unstable radiological finding.
> 
> I care about clinically unstable spines.



Is there such thing as an unstable radiological finding vs. and unstable clinical finding?


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## Christopher (Jul 11, 2013)

Halothane said:


> Well, here's the thing......
> 
> When does a patient need to be "cleared" of an injury? Only when there was significant suspicion that the injury may exist in the first place.
> 
> ...



I think we're on the same page, as I'm not looking to "clear" a patient of injuries. I'm looking to answer: Do they need restriction?



Halothane said:


> The authors of the NEXUS study may have used the terminology "cleared", because they are physicians and that's what physicians do. Paramedics don't typically "clear" patients of injuries.



NEXUS and CCR identify patients for imaging studies. Cleared meant no imaging, not no injury.



Halothane said:


> If someone has an MOI that indicates the potential for a femur injury, but you choose not to put a traction splint on because their is no evidence of trauma to their leg, do you chart that you "cleared" their femur? No. You just chart that there was no indication for a traction splint.



I don't know if I would even chart that much. No closed Fx, no traction splint. 



Halothane said:


> It may seem like semantics, but in the legal sense, there is a BIG difference between "clearing" a patient, and simply choosing not to perform a procedure because it isn't indicated. This was explained to me years ago by a lawyer who is also a paramedic.



Which is why I think the terminology isn't useful. My concern is not with clear or not clear. My concern is with a clinically unstable fracture that requires splinting.



Halothane said:


> Of course, one could argue that all of that only matters IF you ever get sued for not applying cervical precautions. And that is a really decent point. However, that's placing a lot of faith in the criteria, and in your ability to always implement it without error.



Many of the CCR/NEXUS trials look at these "misses" and they always boil down to: radiologically significant vs clinically significant. 



Halothane said:


> I'm not sure if NEXUS will ever catch on widely. There are several studies that dispute it's validity, and x-rays are relatively easy and cheap.



CCR seems to supplanting NEXUS around here.



Halothane said:


> Is there such thing as an unstable radiological finding vs. and unstable clinical finding?



Yep. Radiologists will note "unstable cervical spinal injuries" with nasty case reports about this "big miss", which were patients walking around for days, etc. Came in due to something vague like "neck pain" or "neck stiffness", "finally" get "appropriate" imaging and are found to have something requiring intervention.

My point is, if you can walk around with it for days, it is not "unstable" clinically and it did not need stabilization/splinting. The patient _perhaps_ should have received earlier imaging, but an imaging finding does not mean splinting was necessary.

By adopting NEXUS/CCR in the field for "clearance" or "selective immobilization" (whatever you want to call it), you're effectively using "predicted need for imaging" as a surrogate. My point is this is a poor surrogate for true need.

What we do not want to miss are patients with unstable fractures which are clinically significant. These are the real patients who benefit from spinal motion restriction.


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## jefftherealmccoy (Jul 12, 2013)

I don't see why people say MOI isn't enough to board someone.  I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.  

My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.  

If a pt is in a significant wreck and completly denies injury but wants to be evaluated, there are times that I won't backboard.  But for the most part, they're going on a board.  

And @ bullets-
No crap LOC, Drugs and Alcohol, distracting injuries and bone disease have nothing to do with MOI.  The protocol is like a page long and I was paraphrasing.


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## Carlos Danger (Jul 12, 2013)

jefftherealmccoy said:


> My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.



Do you not see how that story is actually a perfect example of _why_ backboarding isn't necessary, even when cervical injuries _do_ exist.....?


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## Christopher (Jul 12, 2013)

jefftherealmccoy said:


> I don't see why people say MOI isn't enough to board someone.  I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.



Because backboards are not helpful, that is why.



jefftherealmccoy said:


> My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.



A backboard would not have stopped those deficits. Those are from secondary cord injuries, usually inflammation or hypoxia to the cord.



jefftherealmccoy said:


> If a pt is in a significant wreck and completly denies injury but wants to be evaluated, there are times that I won't backboard.  But for the most part, they're going on a board.



If that is your protocol go ahead, but don't kid yourself into thinking you're actually _helping_ them.


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## TransportJockey (Jul 12, 2013)

jefftherealmccoy said:


> I don't see why people say MOI isn't enough to board someone.  I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.
> 
> .


Because studies show little to no benefit, increased risk and detriment to the patient, not to mention they are overused.  More and more protocols are pulling backboarding all together. Look at the news release from Maine earlier this year


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## jefftherealmccoy (Jul 12, 2013)

TransportJockey said:


> Look at the news release from Maine earlier this year


 
I would like to read that.  Got a link?


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## TransportJockey (Jul 12, 2013)

jefftherealmccoy said:


> I would like to read that.  Got a link?



When I get a chance to look I'll post it. I'm on shift on a truck today


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## eonefireemt3 (Jul 13, 2013)

We are moving that way. Evidence shows that over aggressive immobilization can be harmful to the patient. Our agency just switched over to the x collar. It is a cervical splinting system that provides a more complete cervical immobilization.

In the past, if we had a neck pain patient, we were required to board them. Now we can just use the x collar without the board.

Of course, if you have a fully alert patient, who wants to refuse any treatment, they are within their rights to refuse. As long as you document that you warned of the consequences and they sign off, you're good.


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## chri1017 (Sep 18, 2013)

How about patients with minor head traume......ie scrapes and bruises after a insignificant moi.  Are people comfortable not boarding these patients assuming they meet all the criteria?


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## Medic Tim (Sep 18, 2013)

chri1017 said:


> How about patients with minor head traume......ie scrapes and bruises after a insignificant moi.  Are people comfortable not boarding these patients assuming they meet all the criteria?



head injury or trauma does not = spinal injury.
MOI alone is no reason to board someone(though some protocols disagree).


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## Christopher (Sep 18, 2013)

chri1017 said:


> How about patients with minor head traume......ie scrapes and bruises after a insignificant moi.  Are people comfortable not boarding these patients assuming they meet all the criteria?



I'll play Rogue Medic for this one.

Are you comfortable not placing traction splints on patients with leg pain?

Are you comfortable not placing a patient on high flow O2 even though you do not have ABG's?

Are you comfortable not needle decompressing a patient's chest even though you have diminished lung sounds?

I'm uncomfortable using a procedure that has zero indications on a patient merely because it used an anatomical word that is roughly in the same region as another anatomical word related to the procedure.


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## chaz90 (Sep 18, 2013)

Christopher said:


> I'll play Rogue Medic for this one.
> 
> Are you comfortable not placing traction splints on patients with leg pain?
> 
> ...



Ohhhh, I like this so much.


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## the_negro_puppy (Sep 18, 2013)

We now use CCR as a guide over nexus. BUT we are allowed to deviate using our clinival judgement. We do not even have backboards here. I avoid using c-collars on patients that don't need it.


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## Bullets (Sep 18, 2013)

At this point, with the publication of NAEMSP/ACSCOT joint position paper, NOT changing your protocols to reflect their stance is negligent


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## oleg (Sep 18, 2013)

interesting


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