# Selective c-spine - would you c-spine this patient



## Epi-do (Oct 29, 2009)

Just looking for some feedback on this one.  So we are all using the same rules, here's my protocol for "clearing" c-spine.


> *Out-of-Hospital Spinal “Clearing”*
> 
> A.	Full spinal immobilization is to be provided to patients with any evidence of spinal injury and considered for patients meeting trauma alert criteria or with a suggestive mechanism of injury.
> 
> ...



Now that we all have the same set of rules, here's the scenario:

You are dispatched to an MVC, along with the engine at your station.  When you arrive onscene there is a single vehicle pulled to the side of the road, just past an intersection.  There is no visible damage to the car.  Airbags did not deploy and the only occupant is the driver, a teenage boy, who is still wearing his seat belt.

The driver appears to be dazed, but acknowledges you as you approach the car.  He is slow to answer your questions at first, but he is able to tell you his name, where he is (street names of intersection), where he was going, and what happened.

The patient states the car in front of him stopped to make a left turn, so he stopped behind them.  The vehicle behind him did not stop in time and bumped him, causing him to hit his head on the steering wheel.  His only complaint is head pain.

Upon palpation of his neck, along the back of his spine, he has no complaints of pain.  He tells you his name is Josh (verified by ID), he was on his way to school, and that it is Thursday morning.  There is no evidence that he is under the influence of anything.  He is exhibiting no obvious neuro deficits and is able to move all extremities without difficulty.  He still appears slightly dazed but is answering questions more quickly.  There are no visually obvious injuries and the patient again denies anything but head pain.  At some point, the patient was clear-headed enough to either contact his mother or have a bystander do it for him, and she arrives before you have the patient out of the car.

So, do you board this patient? I will tell "the rest of the story" after there have been some replies.


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## johnrsemt (Oct 29, 2009)

if you can figure out why he is dazed:    if due to hitting head or drinking or doing drugs, then Yes I would do c-spine;     if it is due to having an accident and being confused that he got hit even though he did everything right:  then no, I would NOT do c-spine.

    keep me informed


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## DigitalSoCal (Oct 29, 2009)

I would c-spine him. The fact that he hit his head on the steering wheel after a rear impact suggests a pretty significant force because the initial reaction would be to be pressed backward into the seat. To then be whipped forward and into the steering wheel would take a good amount of decelerative (is that a word?) force.


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## GoldenBeaR6 (Oct 29, 2009)

Affirmative on the c-spine


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## akflightmedic (Oct 29, 2009)

Ummm, was he really in a car accident???

Only one vehicle yet he was hit hard enough from behind to whip forward and strike the steering wheel? Why no damage on the vehicle if he was hit this hard?

Where is the other car? Why no air bag deployment? The seat belt allowed him to hit his head on the forward momentum?
 No obvious injury (contusion) to his head??? He would also have clavicle or chest pain from a hit hard enough to make him stress the seat belt and strike the wheel.

No I would not cspine him cause I think there is more to this story than a MVC...


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## JPINFV (Oct 29, 2009)

Fits NEXUS criteria for selective spinal immbolization. He's alert, orientated, and awake. He might be slow, but that's a global neurological symptom which isn't indictative of a *spinal column* injury. How often do you see foot ball players go off the field dazed after a hit in full c-spine restriction?


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## Epi-do (Oct 29, 2009)

akflightmedic said:


> Ummm, was he really in a car accident???
> 
> Only one vehicle yet he was hit hard enough from behind to whip forward and strike the steering wheel? Why no damage on the vehicle if he was hit this hard?
> 
> ...



Sorry  I can't provide better answers to your questions, but those are all I have.


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## akflightmedic (Oct 29, 2009)

Did he have an exam that day, parental troubles, girlfriend troubles...were there any witnesses besides him?

Did he have a description of the other vehicle?

I do not buy the story...


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## rescuepoppy (Oct 29, 2009)

Our area does not yet have protocol for clearing C-Spine, but is moving in that direction. In the case that we did I will probably be a little more on the cautious side than some others might be. Due to the fact that with my fractures of c-3, and c-4 last year I had no pain or point tenderness until several hours after the accident. I would probably c-spine this patient because of the knowledge that you can have a completely shattered vertebrae without pain or deficits.


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## cm4short (Oct 29, 2009)

I would C-spine this patient, but, I don't feel this patient requires spinal immobilization. My reasons for c-spine are because this patient has suffered trauma above the clavicles; which requires c-spine application according to our protocols. This could possibly be written off though due to the non specificity of our protocols, as there is no visible head trauma. But, due to legal reasons, you'd most likely get ripped apart in a lawsuit. 

Now, I do not feel this person requires c-spine immobilization. C-spine refers to cervical spinal immobilization. This involves c1-c7. Immobilization of the cervical spine without associating injuries is just another example of repetitive ignorance, our lack of knowledge and medical decision.


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## Epi-do (Oct 29, 2009)

I really wish I could give you more info.  The officer onscene wanted the patient boarded.  I told him that I wasn't going to do it because he didn't need it done.  Per protocol, I was able to determine it wasn't needed.  The officer insisted, I said some things I shouldn't have said and the patient was boarded.  I ended up not going in on the ambulance, and another medic was put on the truck with my partner.


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## JPINFV (Oct 29, 2009)

Epi-do said:


> The officer insisted, I said some things I shouldn't have said and the patient was boarded.



Was it something along the lines of "Where did you go to medic school?"


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## Sasha (Oct 29, 2009)

JPINFV said:


> Was it something along the lines of "Where did you go to medic school?"



Her officer is an EMT!!


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## johnrsemt (Oct 29, 2009)

I have been known to get in trouble with officers and supervisors for this very thing  (and anyone that knows me ,  will have problems believing that I know).

    I have always stated that I have no problems working for Supervisors or officers that are NOT medics,  as long as they don't try to tell me what to do with patient care  at the scene with the patients.     When they start telling me how to do my job,  I start having problems.     this is a prime case.

    Epi was perfectly justified in NOT cspining this patient,  it is in her protocols as a MEDIC;   but not in the officer's protocols as a BASIC.   so he thought he was right;  but he shouldn't have argued with the medic.      BUT at the same time she shouldn't have argued with the officer on something that didn't and wouldn't cause patient harm.

      No Win situation  for Epi


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## emtfarva (Oct 29, 2009)

I would have used C-Spine precautions... I would have let the Doc take the responsibility to clear him. Just by the fact that he was slightly altered, I would think head bleed. (I tend to think the worse case). Did you take VS? I am wondering what they were. I would guess that you might have gotten a CBG? We can't clear C-Spine, but I would still have taken the precaution.


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## JPINFV (Oct 29, 2009)

emtfarva said:


> Just by the fact that he was slightly altered, I would think head bleed. (I tend to think the worse case).



What would c-spine do for a head bleed? You don't splint every arm with a fresh bruise on it, right?


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## emtfarva (Oct 29, 2009)

JPINFV said:


> What would c-spine do for a head bleed? You don't splint every arm with a fresh bruise on it, right?


Nope, but every head bleed that we have taken to Boston required a C-collar and a board, not by our choice, it was required by ER Doc. I would have just because he had head pain. Thats the way I roll. I have boarded and collared for less.


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## emtfarva (Oct 29, 2009)

I have been burnt before. My partner and I have not boarded someone that fell from standing and ended up having a C-2 fracture. He had no pain, or couldn't tell us he had pain due to the fact he didn't speak english. Now, if we think that there might be spine damage, we c-spine.


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## Epi-do (Oct 29, 2009)

So, here's the rest of the story.  After the patient was boarded and put in the truck, he was transported BLS to the ER.  

The crew asked additional questions about the incident, and while the general story was consistent, the details would change.  The kid didn't have a single mark on his face, not even a red mark to show any sort of impact.  He was wearing glasses and there were no marks from them, either.  They were completely undamaged.

During the transport, he would act completely normal and then be a bit slow to answer questions again, although he was still answering them correctly. 

The medic that transported said he believes whatever was going on with the kid (if anything) had nothing to do with the accident.  He said he couldn't help but wonder if there was something else going on that the kid wouldn't/didn't tell us, or that he was trying to get out of something.  His other thought was that there was something like an anuerism that was causing the symptoms.  He also believed the patient should not have been boarded.

Also, the part you have all been waiting for - the board & collar came off pretty much immediately after getting to the ER.


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## emtfarva (Oct 29, 2009)

Epi-do said:


> So, here's the rest of the story. After the patient was boarded and put in the truck, he was transported BLS to the ER.
> 
> The crew asked additional questions about the incident, and while the general story was consistent, the details would change. The kid didn't have a single mark on his face, not even a red mark to show any sort of impact. He was wearing glasses and there were no marks from them, either. They were completely undamaged.
> 
> ...


Epi, I was thinking that, but i would let the Doctor take the hit if there was something major wrong with him. And plus from what he said about the MVC, I would have boarded and collared him just on MOI alone... Like I said I have boarded for less. And yes, all those Pt's have had C-Spine removed right away.


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## Pyromedic (Oct 29, 2009)

I wouldn't have boarded him or C-spine him. just because the MOI was a MVC I dont believe it was strong enough to cause any damage. IMO


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## JPINFV (Oct 29, 2009)

Let me preface this. Farva, this isn't directed at you specifically, but at the prevailing wisdom of 'letting the doctor take the hit.'

Why can we (we being EMS) expect other people to have confidence and trust in our assessments and judgement if we ourselves do not? If you essentially know that a c-spine injury doesn't exist (and if the patient is negitive on NEXUS, essentially he doesn't have a c-spine injury), then why go through the dog and pony show of c-spine? So we can pawn it off on the physician (who's hands aren't any magically better at invoking pain in a tender area. Nor does he have x-ray vision. Of course pain might be present after laying on a hard board during transport)? We keep wanting more trust, more tools, and more interventions, yet when actually given the oppertunity to use that trust and use those tools, collectively we're too scared to do so without someone holding our hands through the process.


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## emtfarva (Oct 29, 2009)

JPINFV said:


> Let me preface this. Farva, this isn't directed at you specifically, but at the prevailing wisdom of 'letting the doctor take the hit.'
> 
> Why can we (we being EMS) expect other people to have confidence and trust in our assessments and judgement if we ourselves do not? If you essentially know that a c-spine injury doesn't exist (and if the patient is negitive on NEXUS, essentially he doesn't have a c-spine injury), then why go through the dog and pony show of c-spine? So we can pawn it off on the physician (who's hands aren't any magically better at invoking pain in a tender area. Nor does he have x-ray vision. Of course pain might be present after laying on a hard board during transport)? We keep wanting more trust, more tools, and more interventions, yet when actually given the oppertunity to use that trust and use those tools, collectively we're too scared to do so without someone holding our hands through the process.


In some cases I agree with you on EMS in the field clearing C-spine. In this case I do not. Even though the Pt is CAOx4, he is slow to respond and details change. I feel either he is faking, he has something really wrong, or something is going on besides the MVC. But you bring up a good point about a Doctor not have a special touch, or having x-ray vision. But a doctor also has about 10 years more education then we do as a EMS profesionals. They are trained to clinically clear c-spine we as EMS (speaking about MA) are not. I would have placed this Pt in C-spine precautions, and I bet I could ask about 10 medics in my company and they would do the same. I wasn't there, but I my gut is telling me something is up. Something doesn't fit right with me.


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## Epi-do (Oct 29, 2009)

emtfarva said:


> Epi, I was thinking that, but i would let the Doctor take the hit if there was something major wrong with him. And plus from what he said about the MVC, I would have boarded and collared him *just on MOI alone*... Like I said I have boarded for less. And yes, all those Pt's have had C-Spine removed right away.



But, what mechanism?  There was no damage to the vehicle, so it wasn't a hard hit.


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## JPINFV (Oct 29, 2009)

emtfarva said:


> They are trained to clinically clear c-spine we as EMS (speaking about MA) are not.



The funny thing about MA's statewide protocol is that either it's essentially written to imply selective spinal immobilization or who ever actually wrote it doesn't have a good command of the English language. Section 4.7 looks like it was written based off of the Canadian C-Spine rule, but any protocol that lists indications as "high risk factors" that should be "considered" is asking to be loosely interpreted.


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## emtfarva (Oct 29, 2009)

Epi-do said:


> But, what mechanism? There was no damage to the vehicle, so it wasn't a hard hit.


Yeah, but you said that the Pt went forward and hit the wheel... wait a sec, see this is why it doesn't feel right... He was hit from behind? wouldn't his head go backward toward the headrest... I have been in a rear end MVC my head went backwards not forward. I don't epi, i wasn't there... But I can't justify why I would do it, but I would.


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## emtfarva (Oct 29, 2009)

JPINFV said:


> The funny thing about MA's statewide protocol is that either it's essentially written to imply selective spinal immobilization or who ever actually wrote it doesn't have a good command of the English language. Section 4.7 looks like it was written based off of the Canadian C-Spine rule, but any protocol that lists indications as "high risk factors" that should be "considered" is asking to be loosely interpreted.


But it doesn't give us the ability to clinically clear C-spine.


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## JPINFV (Oct 29, 2009)

Well, that depends on how you look at it. There's really two ways to look at it. Either

1. in trauma (and this should be *any* trauma) c-spine is to be taken until cleared. Stub your toe? C-spine. Cut? C-spine. So on and so forth. Anything else is clearing it.

2. You treat c-spine as any other intervention. There are indications and contraindications to it's use. If it doesn't meet the indications for use, then you shouldn't be using it. I honestly think that we look at c-spine bass ackwards. Do you initially approach every patient with the intent of putting the patient on 15 l/m supplemental O2 via NRB and then "clear oxygen" based on the assessment? Alternatively, do you choose whether to initiate O2 treatment based on your assessment?


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## wyoskibum (Oct 29, 2009)

emtfarva said:


> But a doctor also has about 10 years more education then we do as a EMS profesionals. They are trained to clinically clear c-spine we as EMS (speaking about MA) are not.



Selective spinal immobilization criteria is not clinically clearing c-spine.  It is a criteria to determine if spinal immobilization is indicated.  Just like we use criteria to determine if other body parts need splinting.   We apply a traction splint because the patient meets a certain criteria.  We use a sling & swathe because the patient meets the criteria.

Any patient that need to have their c-spine clinically cleared then should be on long board with c-collar and transported to hospital.


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## emtfarva (Oct 29, 2009)

right, but the MOI in this case was an MVC... not saying that you are not right JP.


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## JPINFV (Oct 29, 2009)

Since you're using MOI as the indication, was it a "MVC at 30+ mph, or rollover or ejection?"


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## emtfarva (Oct 29, 2009)

JPINFV said:


> Since you're using MOI as the indication, was it a "MVC at 30+ mph, or rollover or ejection?"


nope, but it also had enough force to jerk the kids head, if his story is true.


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## JPINFV (Oct 29, 2009)

So everyone who goes on a rollercoaster should get c-spined after getting off even if their neck doesn't hurt? Also, the "30 MPH..." quote was straight from the MA statewide EMS protocol.


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## emtfarva (Oct 29, 2009)

JPINFV said:


> So everyone who goes on a rollercoaster should get c-spined after getting off even if their neck doesn't hurt? Also, the "30 MPH..." quote was straight from the MA statewide EMS protocol.


Guidelines... and yes if they wanted to go to the hospital i would use c-spine precautions..


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## JPINFV (Oct 29, 2009)

emtfarva said:


> Guidelines... and yes if they wanted to go to the hospital i would use c-spine precautions..



So if you had a dehydrated patient at an amusement park, you'd c-spine them based on the fact that they were on a roller coaster?


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## emtfarva (Oct 29, 2009)

JPINFV said:


> So if you had a dehydrated patient at an amusement park, you'd c-spine them based on the fact that they were on a roller coaster?


no, i was joking... but still on a roller coaster ride you are expecting it, in a MVC you are not


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## JPINFV (Oct 29, 2009)

How does expecting it change anything? Plenty of roller coasters are designed so that you don't necessarilly know which direction you're going to go in next. Especially wooden roller coasters.


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## emtfarva (Oct 29, 2009)

yep, but still, I was taught in school to keep c-spine in mind, he had MOI, whether it was true or not, I don't care whether he had pain or not, I would still have boarded and collared him... He stated that his head went forward and he struck the wheel... thats enough for me... he gets a board.


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## Epi-do (Oct 29, 2009)

And that was why I posted my protocol.  No where in it does it say head pain = c-spine precautions/boarded.  I did keep c-spine in mind, but then decided it wasn't warranted.

Do you board every passenger from a fender bender that you run on?  Essentially, this was, at best, a fender bender.


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## emtfarva (Oct 29, 2009)

Epi-do said:


> And that was why I posted my protocol. No where in it does it say head pain = c-spine precautions/boarded. I did keep c-spine in mind, but then decided it wasn't warranted.
> 
> Do you board every passenger from a fender bender that you run on? Essentially, this was, at best, a fender bender.


no, because most of the people in fender benders refuse, or complain of neck/back pain and then I have to board. I hate people that think they can get money out of a minor MVC... and even if they say that they have back or neck pain i will go the whole nine yards... Collar, Ked, and back board... I don't be the EMT that they pull into court to say that you didn't follow your protocol


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## emtfarva (Oct 29, 2009)

Here is a question that no one asked... did you say to the Pt that you might have to place the Pt on a LBB? If you did what did he say?


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## Smash (Oct 29, 2009)

emtfarva said:


> But I can't justify why I would do it, but I would.



I synch cardiovert every patient with a heart rate above 100. I can't justify why I do it, but I just do. It's just how I roll.


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## emtfarva (Oct 29, 2009)

Smash said:


> I synch cardiovert every patient with a heart rate above 100. I can't justify why I do it, but I just do. It's just how I roll.


wouldn't it be above 150?


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## JPINFV (Oct 29, 2009)

...probably 100 just to be safe. You don't want to miss anything and get sued for not following the protocols afterall.


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## Epi-do (Oct 29, 2009)

Smash said:


> I synch cardiovert every patient with a heart rate above 100. I can't justify why I do it, but I just do. It's just how I roll.





JPINFV said:


> ...probably 100 just to be safe. You don't want to miss anything and get sued for not following the protocols afterall.


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## Epi-do (Oct 29, 2009)

emtfarva said:


> Here is a question that no one asked... did you say to the Pt that you might have to place the Pt on a LBB? If you did what did he say?



I never said any such thing.  I had no intentions of putting him on a backboard.


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## emtfarva (Oct 29, 2009)

JPINFV said:


> ...probably 100 just to be safe. You don't want to miss anything and get sued for not following the protocols afterall.


Ahhh... funny...


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## JPINFV (Oct 29, 2009)

emtfarva said:


> Ahhh... funny...



I try. Or is it I'm trying. I always get those two mixed up.


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## emtfarva (Oct 29, 2009)

Epi-do said:


> I never said any such thing. I had no intentions of putting him on a backboard.


 ok... just wondering... I still would of boarded him just IMO


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## emtfarva (Oct 29, 2009)

JPINFV said:


> I try. Or is it I'm trying. I always get those two mixed up.


I try is fine.

But, as you might know being in Mass, a lot of people are sue happy in MA.


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## Smash (Oct 29, 2009)

Sorry, I was just being silly. No sensible, professional EMT or paramedic with at least half a brain would provide unecessary, uncomfortable, distressing and potentially dangerous treatments with no rationale, justification or basis in science would they...


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## denverfiremedic (Oct 30, 2009)

no c-spine.. If your going to for this guy you might as well do it for everyone that complains of a head ache .. if any further problems noted MAYBE


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## Epi-do (Oct 31, 2009)

Just some additional food for thought.  I have spent the last couple days reading various studies, abstracts, etc, regarding EMS and boarding patients.  There are plenty of them out there, and I would be happy to go back and get the links to the ones I read if anyone wants them.

There are those in EMS that use the thought that, "If I am not sure, I will board them because it doesn't hurt them if I do."  That may not be the case.

Along with having to make sure a patient doesn't aspirate, there are other things to consider.  One study I read, albiet a small study, found that spinal precautions cause a  statistically significant raise in ICP.  While this rise isn't large enough to be clinically significant for a healthy patient, what about the one with an undiagnosed anuerism, or some other similar medical condition?  

On average, the boarded patient with no spinal injury spends an average of 1 hour on a backboard.  There are several studies of healthy volunteers with no neck or back pain who agreed to be placed in full spinal precautions for the same period of time.  One study found that after one hour, 80% of those volunteers reported significant pain at the end of one hour, which remained one hour after being removed from the board.  A large number of those volunteers began complaining of pain after 30 minutes.  Twenty-four hours after being removed from the board, up to 20% still had some degree of pain.  Granted, with time, all volunteers became pain free again, but the fact that we were the ones who caused that pain seems to me to go against the idea of "doing no harm."  Because these healthy, uninjured people had pain after a minimum of 30 minutes, how many of our patients are subjected to unnecessary radiological tests because they are positive for midline neck or back pain at the ER?

Further studies looked at pressure ulcers in patients who have been boarded.  They found those who spent 2 or more hours flat on a board where more likely to have sacral pressure ulcers one week later, if hospitalized.  It has also been found that soft tissue damage resulting in pressure ulcers can begin in as little as 30 minutes when laying on a flat, unpadded  backboard.

So, by boarding patients that are candidates for not being backboarded are we really "not hurting them"?


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## johnrsemt (Oct 31, 2009)

very good points on C-spine not hurting someone.

   also to the poster who stated that they couldn't clear c-spine due to the patient not speaking the same language:  Epi's protocols state "the patient has to be able to understand you"  be it  patient is over 5 years old,  or speak a language that you do.


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## redcrossemt (Nov 2, 2009)

emtfarva said:


> But a doctor also has about 10 years more education then we do as a EMS profesionals. They are trained to clinically clear c-spine we as EMS (speaking about MA) are not.



What education do you need to do a spinal immobilization assessment, like indicated in NEXUS and many of our protocols? A little bit of anatomy, the able to ask the patient "does this hurt?", and the smarts to check off some boxes?

I would not have boarded this patient because I have a selective spinal immobilization protocol. I understand that some others do not have a similar protocol and must board patients with a MOI suggestive of any injury. However, as said many, many times before, those with selective protocols that board to CYA are just hurting their patients more.


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