# common c-spine procedures



## c-spine (Aug 4, 2006)

A friend of mine got into a car accident today and I went into the ER shortly after she got there. She was still on the board with the head blocks and c-collar, etc. The doctor came in after however long, and the first thing he did was remove the head blocks.

Ok... no problem.

Then he proceeds to take off the c-collar, throw it in the trash, feel her neck once, and (more or less) say that she was ok. He did his 3-second assessment and was more concerned about the bruises on her knees (she slid down...no seatbelt) than the possibility of a neck fracture/break/etc. He had her bend her neck down to her chest... WTF?!

Is that...normal? 

He didn't order any c-spine x-rays. Only knees. Now...I know this hospital is relatively no good (I've got plenty stories if you don't believe me..hehe) but... isn't the possibility of a c-spine injury usually greeted with neck x-rays????


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## Stevo (Aug 4, 2006)

depends on the scenario , if the patch told them _'bruise cruise'_ or _'low MOI'_ then they'd probably forgo any intense exam, if there was any indication otherwise it'd be the full monty...

~S~


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## Guardian (Aug 5, 2006)

c-spine said:
			
		

> A friend of mine got into a car accident today and I went into the ER shortly after she got there. She was still on the board with the head blocks and c-collar, etc. The doctor came in after however long, and the first thing he did was remove the head blocks.
> 
> Ok... no problem.
> 
> ...




The good doctor was right in this case.  We over-treat our pts because EMS agencies are scared of litigation.  If we aren't careful, this could destroy our health care system.  When I see doctors like this one, I thank god there are still some independent thinkers who are educated enough and articulate enough to "practice" medicine as they see fit instead of listening to lawyers who know almost nothing about medicine.  We can't check for every known disease and injury on everybody who walks into a hospital.  Therefore, we have experts who narrow down the possibilities and only do what is necessary for their pt.  Your friend was involved in a MVC and my guess is that it went something like this.  Your friend was driving along and laterally collided with another car going at a low rate of speed.  There was probably no major damage or intrusion to the car.  There was probably no LOC and I'm guessing the only complaint was a little knee pn.  Well at this point, if I were the doctor, I would order a biopsy to check for cancer.  Whats that?, you think I'm crazy?  Well I think ordering a major trauma work up on this pt is just as crazy and probably a bigger waste of time and money.  I honestly believe we would save more lives by catching cancer early if we ordered biopsies instead of x-rays and CT scans on these pts.  Oh yea, .000000001% of the time, people end up seriously debilitated or dead because of c-spine mistakes made by doctors.  My preceptor never apologized for anything, his response was always, "get over it."  So what do I think about that 1 in a trillion person who has a serious injury that goes unnoticed.  Honestly, I couldn't care less and I'm not sorry for feeling this way so get over it.  Lets try to think this stuff through like intelligent professionals and not ignorant robots.


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## Stevo (Aug 5, 2006)

yuppy , that'd be spot on Guardian

you know i think the radiologists owe us for all the work we provide them too

they should cater the next big ems bash, don't you think?

~S~


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## c-spine (Aug 5, 2006)

I don't think it was a low rate of speed, but I'm probably wrong. The front end of the car is... well... pushed up a great deal, the hood is just about bent in half; the right upper portion of the windshield is pushed out and spiderwebbed. (No bruising, no lacerations, only a headache). But still... I dunno. I was drilled on c-spine through class so I guess it's more a tunnel vision thing. 

-shrug-

thanks for the info, all!



Oh yeah... and go ahead and get that biopsy, Guardian! Better safe than sorry!  lol


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## emtbuff (Aug 5, 2006)

I'll throw my 2 cents in here for you also.  I know as an EMT we are taught C-spine anything and everything if you suspect injury to or possiblity of injury to the neck.  To cover our selfs.  I have seen plenty of doctors assess those that have been c-collared and everything else.  By doing it how you said removing the collar and assessing the neck and having the patient touch their chin to chest.  Unless they are complaining of neck injury or the likes, then everything stays in place and they go for an xray.  This is why its important and I'm guilty of it but taking pictures on scene is a plus and take them along with you to the ER so the doctor can know what they are dealing with.  Some times it helps.  Its kinda like those that are involved in a car that goes in the ditch they get out and go home and pull it out themselves I've seen those and have heard many stories from others who have done so.  They put themselves in the ditch they get out feel fine don't hurt anywhere yet and go home get a friend to help them pull the car out or call a tow truck to take the car out.

So all in all we are still safer off if we got to an MVA to collar and back board the person.  And the doctors show up in the ER decide to take the collar off and throw it away becuase they don't think theres an injury.  After all thats why they get paid the big bucks right?


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## Rangat (Aug 5, 2006)

Gmf... Damn American Doctors!

h34r:


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## gradygirl (Aug 5, 2006)

Stevo said:
			
		

> you know i think the radiologists owe us for all the work we provide them too



My dad's a radiologist. Do you have any idea how many normal/negative films they read every day? I mean, don't get me wrong, I understand the ordering physician's "if it hurts, x-ray it rule," but there have been so many days at the office where every single x-ray, MRI, CT, etc. have been normal.

We were always told in our EMT class, that we aren't x-ray machines, so don't assume something's ok, and I agree about being safe instead of sorry. But if the doc is pretty well certain that the crash wasn't much to be worried about, ok, great.


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## ffemt8978 (Aug 5, 2006)

c-spine said:
			
		

> I don't think it was a low rate of speed, but I'm probably wrong. The front end of the car is... well... pushed up a great deal, the hood is just about bent in half; the right upper portion of the windshield is pushed out and spiderwebbed. (No bruising, no lacerations, only a headache). But still... I dunno. I was drilled on c-spine through class so I guess it's more a tunnel vision thing.
> 
> -shrug-
> 
> ...



Given the fact that most newer cars are designed with crumple zones to absorb the energy of the impact, this is not unusual in even low speed MVC's.

I think we should all have a method/protocol for clearing c-spine in the field, especially since a patient that is *****ing about being on a backboard may not be telling you what else hurts.


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## akflightmedic (Aug 5, 2006)

First off, taking pictures of the accident is no longer a useful tool. We stopped doing that years ago at the request of the Level I trauma surgeons. WHy?...cause of the increased safety of cars today and the improved crumple zones...they do not paint an accurate picture anymore. I have been on many accidents where the cars looked like crap, all balled up and it was from a low impact. How a car is damaged may help steer you to certain injuries, but the amount of damage is useless. 

As for docs clearing cspine with no xrays...GREAT JOB! They do it all the time here. We in EMS treat to avoid lawsuits instead of treating for the injury. This mentality has been drilled into us for so long, we can not even contemplate not cspining someone...why,,,cause our *** would be on the line.

There are many studies out there that have proven over and over that cspining a patient actually makes injuries worse and/or has created new ones.

Approximately 8-10 years ago, Johanesburg, SOuth Africa released an excellent study that compared  patients driven in by cab or family fared no worse than ones taken in by EMS. Yes there will always be a few that slip through the cracks, but that is life. We are not here to save them all and neither should we. Death is natural, it happens. The same people did a study on the use of cspine and LSB...for those of you that are not familiar, Johanesburg is like the trauma capital of the world, anyways, they did this over several years and out of thousands of patients not immobilized, less than 1 percent were found to have an injury that was missed and should have been immobilized.


I have worked in a system where we used selective spinal immobilization. We did not clear cspines, however if they met certain criteria, we could elect not to immobilize them. It worked great. I miss that.

I long for the day when we treat patients and not potential lawsuits.....


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## ffemt8978 (Aug 5, 2006)

Then again, sometimes it does pay off:

http://www.emtlife.com/showthread.php?p=34933#post34933


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## fm_emt (Aug 5, 2006)

akflightmedic said:
			
		

> I long for the day when we treat patients and not potential lawsuits.....



That would be nice. Too bad there are just too many blood sucking lawyers that make too much money off of what 'could' happen. :-(


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## akflightmedic (Aug 6, 2006)

Your cspine paid off because you used good judgement.

You stated the patients was CAO yet repetitive. DING DING DING...theres your sign. The pt was repetitive indicating an insult to the brain. Then he also presented with neurological defecit, no matter how minor a thumb being numb may seem. Of course you should have cspined him and maintained a high index of suspicion.

It is the thousands and thousands of cases we do every year of minor MVCs or elderly slip and falls that do not need full immobilization every time.


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## Ridryder911 (Aug 6, 2006)

Ditto.. he was symptomatic and had indications of spinal precautions. I agree we have lost perspective of why we immobilize, and as well indications Hopefully, as EMS matures and medics actually become more educated in emergency medicine, we will screen patients for those that need immobilization and those that need to be monitored. Studies as well has shown and demonstrated we in fact are sometimes causing further harm to patients by having patients to remain immobilized on a LSB for a period of time until clearance is made.

R/r 911


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## MariaCatEMT (Aug 6, 2006)

*Great discussion, I'm sorry I have nothing to contribute.....other than we, too, C-Spine anything and everything remotely suspicious, and that I've seen MDs remove blocks in a heart-beat. I appreciate all of you here, I learn a lot! Thank you! I am confident that if I brought questions here, they would be answered.*


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## Rangat (Aug 6, 2006)

where are you from akflightmedic?

How do you know about JHB? and SA crime? vbmenu_register("postmenu_34931", true);


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## ffemt8978 (Aug 6, 2006)

He wasn't repetitive until after we had him loaded in the ambulance.

The reason he was c-spined was per our protocols for the LOC.


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## akflightmedic (Aug 6, 2006)

I am currently in Florida working, contemplating another contract in the mid east. I have worked in the arctic and in south east asia...I have several friends in SA that keep me in the loop. I also read a lot.

I never mentioned crime when talking about SA, only said they have a lot of trauma.

Am I incorrect?


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## gradygirl (Aug 8, 2006)

You know, this reminds me of a scene I ran that really pissed me off. We had an intoxicated girl who fell, but no one knew any of the details of the fall. My partner and I took c-spine procautions, but when the transporting crew arrived, the EMT pulled her out of my hands without clearing c-spine. This same partner team had ambulated an MVC patient a few months earlier that I was a witness to (pt. was a friend), again without clearing anything.

I'm very concerned about this lack of attention to procedure. Anyone have any ideas?


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## c-spine (Aug 8, 2006)

Bring it up to medical control... they should be aware of the negligent handling of patients. 

I think?


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## KEVD18 (Aug 8, 2006)

while i dont clear c-spin in the field, i do choose not to implement the procedure for pt's i dont feel warrant it. i have had a few of my runs pulled for cqa and have sufficiently justified myself every time. we should have a field c-spine procedure, IMHO


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