# in trouble



## Aerin-Sol (Apr 1, 2011)

Had an MVA pt with minor injuries - sore knee, neck pain - walking around when we pulled on scene. We didn't board or collar her, and I just had a supervisor tell me I could lose my numbers over this. Is that true?


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## Shishkabob (Apr 1, 2011)

Depends.  Do you have spinal clearance protocols?  If not, did the patient state they did not want to be backboarded?  If your protocols state that EVERYONE with neck pain gets a backboard, and someone wants to press the issue, something could happen.

The easiest way around outdated protocols is if you truly think the patient doesn't need a backboard, ask them if they want to be backboarded, and explain why.  It's called patient consent, can't do much without it.





However, why didn't you c-collar/backboard when they were complaining of neck pain?


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## MMiz (Apr 1, 2011)

We can give you advice based on our protocols, but what really matters is following _your_ protocols.  I can't imagine you'd lose your license over something like this, but depending on the patient outcome the situation has the potential to turn into a mess.

Sitting here in my computer chair I'd say that based on mechanism of injury and neck pain I would have backboarded the patient.


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## Bieber (Apr 1, 2011)

What does "lose your numbers" mean?

Do your guidelines/protocols call for spinal immobilization of patients in this case?  Did the patient consent to spinal immobilization?  If yes to both, why didn't you do it?  The science doesn't support it, but until your protocols reflect the science you've either got to "stick to your guns" and risk this kind of thing happening, or go along with it until your medical director revises your protocols.


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## Shishkabob (Apr 1, 2011)

Bieber said:


> What does "lose your numbers" mean?



I'm assuming it means losing their cert.


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## 46Young (Apr 1, 2011)

I hope it was documented that the pt refused the board and collar, otherwise you've got problems. I don't know of any spinal motion restriction protocols that allow clearing C-spine with a c/o neck pain. If they were combative you could argue against SMR. Otherwise, the OMD is going to be displeased to say the least.

Edit: What are your protocols, exactly?

Also, back where I used to work, there were two EMT's, and two medics working a fall pt. No one boarded her. She developed distal paresthesias in the ED. The medics had transported. Both medics got fired. One of the EMT's also got fired, and the other got a six month learning contract. Just because you work with a medic, you're still just as responsible for BLS care. Maybe not legally, but the dept may discipline you nonetheless. If you speak up to the medic in regards to negligent actions, then you have recourse.


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## rhan101277 (Apr 1, 2011)

Here is our spinal immobilization protocol.  Its the paramedics final decision.  Even though it has "B" by each procedure.


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## TXMEDIC5317 (Apr 2, 2011)

its all comes down to protocols. should have had an incharge clear the pt if you were unsure.


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## Aidey (Apr 2, 2011)

46Young said:


> I hope it was documented that the pt refused the board and collar, otherwise you've got problems. I don't know of any spinal motion restriction protocols that allow clearing C-spine with a c/o neck pain.



I just want to point out that it can be important to define neck pain. I've had patients tell me "oh my neck hurts", and then when I palpate, or ask them to point to the pain, it is actually shoulder pain (think where the seat belt passes over that area). On palpation they have no midline neck pain, or even lateral neck pain, but to them that is still their neck.


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## Amycus (Apr 2, 2011)

There could be alot going on beyond the original scenario posed, but that sounds like a standing takedown scenario. Were you first on scene? If no, why didn't fire step up and take cspine? Where was your partner in all this? If you're worried about being in trouble, so should he or she. You're in it together.

I'm a huge stickler for documentation. If there was a damn good documented reason for not cspining, perfect. If not, well, what have you learned from this scenario? I'd preemptively email your clinical director.

Of course, no one is perfect. I'm still booting myself in the *** for describing a febrile seizure baby as 'warm' instead of 'hot
 Despite a fever of 104.3 (which was documented...oops)


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## 18G (Apr 2, 2011)

It doesnt sound like a situation where you would lose your certification. Sounds like an overzealous Supervisor. 

I think it all comes down to your documentation. If you provided sound justification for why you didn't immobilize then that will help your case. All neck pain does not involve the spine. Was it a superficial pain? Seatbelt rub the side of the neck? Did the neck show any abrasions or other markings? This is where you need good documentation. 

Spinal immobilization is like oxygen administration for me... its EMS indications are mostly BS and unsupported in the majority of cases. Like someone else mentioned though until your protocols change you do have to follow them. 

If you don't feel a patient needs backboarded, then just explain to them the situation and ask them if they want to be backboarded. As long as the patient makes an informed decision to refuse, its acceptable and you can avoid the unnecessary, uncomfortable, and awkward motions of putting someone on a backboard. 

You don't lose your certification for not being perfect. Unless of course you kill someone


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## medicstudent101 (Apr 2, 2011)

Varies per your protocol. But with them C/O neck pain, regardless of how minor, it'd be in your best intrest to CYA. I honestly couldn't see your cert. being pulled but as mentioned above, really depends on the specifics of the situation, along with the overall outcome of your pt. There's a few questions that should be answered. Did you end up transporting? I see that you're a Basic, nothing against that by any means, but was your partner a medic? What did your pt. specific assessment reveal as it pertains to their neck pain? Your overall assessment of your pt? Was the MOI potential enough to suggest there's legitimate cause for concern? 
Going from the limited amount of info you mentioned, I'm going to say that you probably aren't in any danger of losing your cert. A slap on the hand will more than likely be the extent to this. It's never any good to be a 'cookbook' medic(or basic), but when it comes to things like this it's better to play it safe and CYA. Best of luck! B)


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## mycrofft (Apr 2, 2011)

*Generically, follow protocols, but if you can't or won't, document.*

Three reasons not to follow protocol: informed refusal, apparent likelihood that on this circumstance it will cause more harm, or physical inability (i.e., no room, no supplies, pt too big, etc). DOCUMENT EVERYTHING!!
Note that I did not write "Ignorance".

Failure to treat in an informed and prudent manner might be grounds for action by your EMS control if a complaint is lodged, but loss of certification for a first occurance like this is not likely.

Your supervisor is impressing you with the seriousness of this. Whether or not  "losing your numbers" is a likelihood, you do not want to los sight of the bigger picture, plus your image in your boss's mind can be tarnished.


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## 46Young (Apr 2, 2011)

Aidey said:


> I just want to point out that it can be important to define neck pain. I've had patients tell me "oh my neck hurts", and then when I palpate, or ask them to point to the pain, it is actually shoulder pain (think where the seat belt passes over that area). On palpation they have no midline neck pain, or even lateral neck pain, but to them that is still their neck.



That's true. The problem is, It sounds like they documented neck pain secondary to an MVC. If it was like you say, and they have a protocol to clear C-spine, then they would be okay.


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## Trevor (Apr 3, 2011)

Man, I'd be hesitant to work for a company that talked about canning me (or worse, trying to pull my cert) for not spinally imobilizing someone... I probably would've been canned several times over already (and I board a lot more patients then most)... 

Spinal motion restriction has not been proven to help AT ALL!!!! However, most places have this in their protocols still... 

Some systems (mine is one thankfully) have clearance algorithms... But you should document why you did, or did not apply it. This is VERY IMPORTANT... Just like any treatments or decsisions you should have rationale for why you did (or in this case) didnt do it. A supervisor, after reading your report, should be able to understand why, or why you didnt do something (Immobilization included)... EMS is notorious for crappy documentation...

I would be VERY suprised if something serious happened to you. Maybe some "re-education", a "hand slap", or a conversation??? Sure, but i wouldnt be toooooo worried. Just learn from your mistakes, and dont do it again. The real problem comes when you start making the same mistake over, and over again...


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## systemet (Apr 9, 2011)

46Young said:


> I hope it was documented that the pt refused the board and collar, otherwise you've got problems. I don't know of any spinal motion restriction protocols that allow clearing C-spine with a c/o neck pain. If they were combative you could argue against SMR. Otherwise, the OMD is going to be displeased to say the least.



The "Canadian C spine rule" allows the patient not to be backboarded if the onset of neck pain is delayed or there's no midline tenderness.  This is one widely used protocol, and might be applicable in this situation.  The mechanism of injury hasn't been adequately defined yet.

http://www.ohri.ca/emerg/cdr/docs/cdr_cspine_poster.pdf

This is compared with NEXUS (which I think also allows c-spine rule out if there's no midline tenderness) in this article here (free full text)

http://www.nejm.org/doi/full/10.1056/NEJMoa031375

Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, Wells GA.
The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.  N Engl J Med. 2003 Dec 25;349(26):2510-8.

The problem for OP is going to be that (i) they're probably not going to be answering to a physician but another EMT or paramedic who's best justification for c-spine might be "we've always done this this way", (ii) their c-spine rule out protocol seems to explicitly state that all patients with neck pain are to be immobilised, regardless of onset or localisation.


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## Aerin-Sol (Apr 9, 2011)

Well, nothing's happened yet, and I've worked several shifts since this incident, & ran into the supervisor a few days ago with no mention of this, so I think I'm in the clear. Thanks for all of the reassurances and I'll try and remember that my company's protocols take precedence over studies I read here.


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## mct601 (Apr 9, 2011)

Protocols always come first. Every state, company, and sometimes county are different.  If you're still worried about it confront the supe and talk it over. I wouldn't want to work under that supe anymore, though.


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## EMTinNEPA (Apr 10, 2011)

Sounds like your supervisor is unfamiliar with how legal disciplinary action actually works.

The first question is if you were grossly negligent.

The second question is if the patient had a negative outcome.

The third question is if the negative outcome was a direct result of your negligence.

If you can answer yes to all three, you may have a problem.  If you would answer no to any of them, I don't think you have much to worry about.


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## zmedic (Apr 10, 2011)

That would be true for legal action, ie the likelyhood that you would lose a lawsuit. It has nothing to do with your chances of getting fired, suspended, having your certification revoked or other disciplinary action. All they have to show for that is that someone violated protocol.


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## spike91 (Apr 11, 2011)

I don't think you need to worry about a suspension or revocation of your tags. As long as you did proper and thorough documentation of why the patient wasn't immobilized I wouldn't be terribly concerned.

As a general rule, however, its typically better to immobilize the patient if they have any complaint of H/N/B pain with that type of mechanism of injury (assuming the immobilization doesn't exacerbate the issue). The reason its spinal immobilization *precautions* is because we really can't diagnose that in the field; its a matter of keeping them in good shape until they can be cleared at the ER. 

Any time i have a patient that refuses immobilization, they sign a refusal which gets attached to my PCR. Better safe than sorry


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## Trevor (Apr 11, 2011)

Before i post this, i will say I am pretty conservative with Spinal Immobilization. I tend to backboard a lot more people then those i work with...

It's not really a matter of "keeping them in good shape", its a matter of protecting yourself from liability... There have been various studies that show that 1) immobilization doesnt decrease injury, but in fact can induce injuries and 2) we dont do this effectively anyway.... Unfortunately, it remains (and probably will remain) the standard of care in the U.S.

check out... 
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02615.x/pdf
    (And before i get burned in Effogy, I know there are several flaws with this study. But... It brings up a good topic for the conversation)




spike91 said:


> I don't think you need to worry about a suspension or revocation of your tags. As long as you did proper and thorough documentation of why the patient wasn't immobilized I wouldn't be terribly concerned.
> 
> As a general rule, however, its typically better to immobilize the patient if they have any complaint of H/N/B pain with that type of mechanism of injury (assuming the immobilization doesn't exacerbate the issue). The reason its spinal immobilization *precautions* is because we really can't diagnose that in the field; its a matter of keeping them in good shape until they can be cleared at the ER.
> 
> Any time i have a patient that refuses immobilization, they sign a refusal which gets attached to my PCR. Better safe than sorry


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## AMF (Apr 11, 2011)

Trevor said:


> Before i post this, i will say I am pretty conservative with Spinal Immobilization. I tend to backboard a lot more people then those i work with...
> 
> It's not really a matter of "keeping them in good shape", its a matter of protecting yourself from liability... There have been various studies that show that 1) immobilization doesnt decrease injury, but in fact can induce injuries and 2) we dont do this effectively anyway.... Unfortunately, it remains (and probably will remain) the standard of care in the U.S.
> 
> ...



Doesn't that mean you backboard liberally?

And yes, we are constantly reminded of how much we overuse longboards, oxygen, ALS, etcetera


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## JPINFV (Apr 11, 2011)

Trevor said:


> It's not really a matter of "keeping them in good shape", its a matter of protecting yourself from liability...


If there are evidence based methods to determine when immobilization is indicated besides the presence or absence of trauma, is immobilizing patients where immobilization is not indicated really protecting you from liability?




> Unfortunately, it remains (and probably will remain) the standard of care in the U.S.


Is it the standard of care? Meh, maybe. Is the standard of care slowly changing to where the indication for immobilization is more restricted than "trauma? Y/N?" Definitely. Will there be a day when backboards go the way of mast pants? Most likely.


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## Trevor (Apr 11, 2011)

AMF said:


> Doesn't that mean you backboard liberally?
> 
> And yes, we are constantly reminded of how much we overuse longboards, oxygen, ALS, etcetera



yup, your correct, sorry i was distracted by my partner's snoring when i typed that...


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## Trevor (Apr 11, 2011)

JPINFV said:


> If there are evidence based methods to determine when immobilization is indicated besides the presence or absence of trauma, is immobilizing patients where immobilization is not indicated really protecting you from liability?
> 
> No its not... Im talking about backboarding people, when it IS indicated (like as the OP made it sound like it was), when you have a pretty good feeling that backboarding, as a whole, doesnt do what it is "thought" to do. Ex: You ever run those car wrecks where there is almost NO mechanism, but someone says they have midline C spine tenderness? Do i board those people? You bet your *** i do? Not because i think they have a C spine injury (despite there being a VERY, VERY, VERY, VERY small chance they may) but because its 1) standard of care and 2) in the off chance they do have a spinal injury (and i dont "borad em' " I could be hung out to dry... (by both my company AND a lawyer...
> 
> *Is it the standard of care? Meh, maybe. Is the standard of care slowly changing to where the indication for immobilization is more restricted than "trauma? Y/N?" Definitely. Will there be a day when backboards go the way of mast pants? Most likely.*



I dont see backboarding going away anytime in my career...


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## usalsfyre (Apr 11, 2011)

When I was brand new I never thought atropine would go mostly out of ACLS, three stacked shocks would go away, titrated O2 would be a recommendation, we wouldn't intubate arrest...

That's just in a decades time.


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## Akulahawk (Apr 11, 2011)

Trevor said:


> [/B]
> I dont see backboarding going away anytime in my career...


I don't see back-boarding going away completely either. I see it evolving to a more assessment-based determination of whether or immobilize or not. Of course that will mean that there'll have to be more education in the area of physical examination of the spine...

I also see a change in HOW we do spinal immobilization. In particular, I see hard boards going away and some variant of that used for the "transfer" between the scene and an appropriately set-up ambulance cot along with a LOT more in-depth neuro checks performed at each transfer. This will, however, have to coincide with a change in lawsuit mentality, in particular, fear of the lawsuit as what will have to occur on that end is that lawsuits will have to be tossed out on their ear as long as proper procedure and documentation is done. 

IMHO, it's not simply number of hours of education one is exposed to... it's the quality of education within those hours that matters and whether or not the student has absorbed that material.


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## MassEMT-B (Apr 11, 2011)

JPINFV said:


> If there are evidence based methods to determine when immobilization is indicated besides the presence or absence of trauma, is immobilizing patients where immobilization is not indicated really protecting you from liability?
> 
> 
> Is it the standard of care? Meh, maybe. Is the standard of care slowly changing to where the indication for immobilization is more restricted than "trauma? Y/N?" Definitely. Will there be a day when backboards go the way of mast pants? Most likely.



I would just like to point out Rhode Island still uses EOAs and MASTs .


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## Trevor (Apr 12, 2011)

MassEMT-B said:


> I would just like to point out Rhode Island still uses EOAs and MASTs .



And i pity thowse people, both the Medics and patients...


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