# Unconscious kid lying in a room



## EMT1A

You and your partner walk into a room and find a kid lying unconscious on the floor with empty beer bottles laying all around. The roommate is standing there as you enter.

My answer:

BSI
Scene Safety
Have my partner hold c-spine
Check airway
Drop an opa/npa if needed
Start bagging the patient on high flow o2 at 15lpm
Check circulation
Check for any apparent life threats
If circulation is good and no apparent life threats then c collar. If there is, treat the apparent life threats first
Have my partner ask questions, ie history, what happened, patient's medical history, etc
Backboard patient
Transport


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## DesertMedic66

Your question is? Lol

And why would you automatically start bagging the patient? Unconscious does not mean not breathing.


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## EMT1A

Did I miss anything?

When I wrote check airway, I meant to see if the patient is breathing and if the patient has an open airway.


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## Epi-do

Why would you board this patient?  Are you seeing any sort of obvious injuries that would make you think it should be considered?

Does he need bagged?  What is his respiratory rate and effort?  What's his airway like?  Is it clear, or do you need to suction?


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## EMT1A

Wouldn't you automatically assume c spine precautions if you found the patient lying on the floor since there could be possibly a spinal injury? Don't you have to board the patient if you c-spine them and put a c-collar on in order to get them onto a gurney?

When you check airway you would:

1. See if it's open
2. If it isn't open, open the airway either by suction if needed, head tilt chin lift? and use an opa/npa to open the airway?
3. If the airway is open, check if the patient is breathing and their respiratory rate and effort?

Is this correct? Did I miss anything?


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## DesertMedic66

EMT1A said:


> Wouldn't you automatically assume c spine precautions if you found the patient lying on the floor since there could be possibly a spinal injury? Don't you have to board the patient if you c-spine them and put a c-collar on in order to get them onto a gurney?



If you suspect that it is trauma related then yes. If its not trauma related then no. 

(ie if drunk kid jumped off a roof then yes backboard. If said drunk kid laid down and passed out then no backboard)


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## EMT1A

How would you get them onto your gurney or transport the patient if they are unconscious and lying on the floor after you c-spine the patient?


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## Epi-do

But just because someone is on the floor, I don't assume they need to be c-spined.  What does the room mate say happened?  What does the scene tell you?  They could have fallen from standing, but that typically isn't enough to cause a cervical injury in a teen.  Maybe they got onto the floor themselves.  Are they at the bottom of a staircase, and do you have reason to believe they fell down it?  There are a lot of other things to also take into consideration before deciding spinal immobilization is warranted.


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## Epi-do

EMT1A said:


> How would you get them onto your gurney or transport the patient if they are unconscious and lying on the floor after you c-spine the patient?



If they do need a collar and board, then simply pick the board up.  If they don't need that, then have your partner help you pick them up off the floor and put them on the cot.  You can do that by lifting under their arms and legs, using a scoop, or whatever else you can come up with.


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## DesertMedic66

EMT1A said:


> How would you get them onto your gurney or transport the patient if they are unconscious and lying on the floor after you c-spine the patient?



C-spine = C-collar and backboard. Patient gets placed on BB and said BB gets lifted on the gurney...


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## rwik123

EMT1A said:


> How would you get them onto your gurney or transport the patient if they are unconscious and lying on the floor after you c-spine the patient?



You COULD utilize the backboard as a transfer device from the floor to stretcher with maybe 3 straps..but ixnay c-collar, blocks, and full set of immobilizing straps because they don't need to be boarded.


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## EMT1A

I see.

I was taught in my EMT class that you automatically c-spine anyone you find lying down that can't tell you clearly what happened and how they got there in case there is a spinal injury.

Basically c-spine if you think it is needed no matter what since you never really can know what happened. Better safe than sorry.

For example, I had a real life incident where the patient and their family told us that the patient tripped over a step and barely fell. She got up and walked and sat down. Based on this, we didn't c-spine because we didn't think it was necessary. However, we found out while evaluating the patient that what we were told was clearly not the case and that the patient definitely had spinal injury as the patient became incontinent during evaluation and was detiorating and losing consciousness.

After that incident, my mindset is c-spine in case since you can never know what really happened. Not sure if I'm right or not.


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## Aidey

How does losing consciousness equal a c-spine injury?


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## EMTjhk

Aidey said:


> How does losing consciousness equal a c-spine injury?


I noticed that the people asking this are paramedics. At the EMT level we're pretty much taught to c-spine instead of following some algorithm. I guess better safe than sorry.


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## EMT1A

Aidey said:


> How does losing consciousness equal a c-spine injury?



Wouldn't incontinence be a possible indicator of a c-spine injury?


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## EMTjhk

EMT1A said:


> Wouldn't incontinence be a possible indicator of a c-spine injury?


Yep and so would priapism


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## rwik123

EMTjhk said:


> I noticed that the people asking this are paramedics. At the EMT level we're pretty much taught to c-spine instead of following some algorithm. I guess better safe than sorry.



Im a basic and I wouldn't C-Spine this person. Use common sense and judgment on scene. Can either of you provide me with any solid reason they should be c-spined? Other then basic class told me to.


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## rwik123

EMTjhk said:


> Yep and so would priapism



C-spine injury can present in hundreds of ways. Your gunna immobilize because you identify one of them, and only based upon that?


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## CFLA

Book world is book world and real world is real world. If you run every call as if you're reading from your scenario sheet you're going to screw up. 

Focus and use common sense.


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## Medic Tim

If this is for nremt testing purposes then yes board them. If this was real life I do not see a reason to board them.

Better safe than sorry does not = a board. If we were playing the evidence and numbers we wouldn't be boarding anyone. 

With time and experience these types of calls will become easier and easier. It is also a good lesson that you cant believe everything you are told. You need to keep up your education. Other common lines (lies) basics are told in class are: O2 won't hurt anyone or every pt gets it no matter what, ems doesn't diagnose and certain drugs like narcan are harmless and won't cause adverse effects.


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## Akulahawk

EMT1A said:


> Wouldn't incontinence be a possible indicator of a c-spine injury?





EMTjhk said:


> Yep and so would priapism


It could also be an indicator of head injury, too much beer on board and not enough room in the urinary bladder to contain it all... many things. Mostly non-traumatic causes.

EMT1A - much learning you must do. The scene itself often can tell you LOTS about the patient. Unconscious kid lying face down in a room just doesn't tell me much at all. Walk in and start observing the room. Where's the kid relative to other objects in the room? What does the parents, care providers, or any other witnesses tell you about the patient? Can you see the patient breathing? 

These are things you can get answered as you walk up to the patient, before you even begin doing your physical assessment. With experience, you will learn what needs to be done and what doesn't. 

BSI/Scene Safety I do always.
Airway/Breathing - checked as one step. 
Circulation - checked quickly as well. 
_Consider_ the possibility of C-spine
Check Level of Consciousness. 

This all takes just seconds... and I've been assessing since I got there using my eyes, nose, and ears.

Everything else that needs to be done is done as the situation warrants.


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## Asclepius911

You are,  right don't listen to these guys,  in paper and by text book always c-spine for an unwitness fall,  again textbook is theoretic and nremt is as theoretic as book .. in the field we begin doing things in the most practical way that doesn't necessarily follow the book for instance .... in reality what would have happen in this situation,  fire department would already have done opqrst rapid trauma and possibly if indicated have him on a backboard,  all we will do is load him on our rig place o2 mask and go. For drunks,  a medic doesn't really ride with us,  but always make sure patient has a patent airway and prepare for suctioning aspiration is one of the highest killers for drunks.


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## DesertMedic66

Asclepius911 said:


> You are,  right don't listen to these guys,  in paper and by text book always c-spine for an unwitness fall,  again textbook is theoretic and nremt is as theoretic as book .. in the field we begin doing things in the most practical way that doesn't necessarily follow the book for instance .... in reality what would have happen in this situation,  fire department would already have done opqrst rapid trauma and possibly if indicated have him on a backboard,  all we will do is load him on our rig place o2 mask and go. For drunks,  a medic doesn't really ride with us,  but always make sure patient has a patent airway and prepare for suctioning aspiration is one of the highest killers for drunks.



If your in LA county and if you automatically assume fire is on scene first.


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## Sandog

EMT1A said:


> You and your partner walk into a room and find a kid lying unconscious on the floor with empty beer bottles laying all around. The roommate is standing there as you enter.
> 
> My answer:
> 
> BSI
> Scene Safety
> Have my partner hold c-spine
> Check airway
> Drop an opa/npa if needed
> Start bagging the patient on high flow o2 at 15lpm
> Check circulation
> Check for any apparent life threats
> If circulation is good and no apparent life threats then c collar. If there is, treat the apparent life threats first
> Have my partner ask questions, ie history, what happened, patient's medical history, etc
> Backboard patient
> Transport



So when you say kid, I assume we are talking more adolescent age. The beer thing and all. Ever seen a pissed off drunk dude with a NPA sticking halfway out his nose?


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## bahnrokt

Sandog said:


> So when you say kid, I assume we are talking more adolescent age. The beer thing and all. Ever seen a pissed off drunk dude with a NPA sticking halfway out his nose?



He's also half strapped to a backboard and has two guys chasing him with a BVM.


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## Veneficus

EMTjhk said:


> Yep and so would priapism



You cannot figure out if the patient has a potential c-spine injury or not and you are going to determine whether or not they have a painful erectile tissue dysfunction that lasted more than 4 hours without stimulation in a drunk teen?

Good luck with that...

I also wouldn't be overly impressed if somebody told me they use incontinence in a drunk person to determine spinal precaution need.

Just sayin...

Vene's rule of acute medicine #1. Never wrestle with a man holding a lightsaber.


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## NYMedic828

EMTjhk said:


> I noticed that the people asking this are paramedics. At the EMT level we're pretty much taught to c-spine instead of following some algorithm. I guess better safe than sorry.



Does not matter if you are an EMT, paramedic, RN or MD. You need to be competent at your level of care, and better yet above it. Being competent to a level above your own regardless of certification, is what I see as being safe over sorry.

EMS certification programs put WAY too much emphasis on fitting patients into groups instead of treating them as individuals. One day, treating someone like a chef and doing something because the recipe says to, will be wrong (it often is) and will catch up with you.

Also, incontinence in an unconscious/AMS person would probably lead me towards seizure/substance abuse (alcohol) before it would lead me to spinal injury...


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## Doczilla

Veneficus said:


> You cannot figure out if the patient has a potential c-spine injury or not and you are going to determine whether or not they have a painful erectile tissue dysfunction that lasted more than 4 hours without stimulation in a drunk teen?
> 
> Good luck with that...
> 
> I also wouldn't be overly impressed if somebody told me they use incontinence in a drunk person to determine spinal precaution need.
> 
> Just sayin...
> 
> Vene's rule of acute medicine #1. Never wrestle with a man holding a lightsaber.



Plus, who can say it wasn't whiskey d*ck?


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## Aidey

I'm female, so I may have this wrong, but my understanding was that whiskey d!ck was a problem that presented... opposite... of priapism.


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## Aidey

EMT1A said:


> Wouldn't incontinence be a possible indicator of a c-spine injury?



Yes, but you didn't answer my question.


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## Doczilla

(Hoping that you knew this was a joke...lol) 

This condition refers to a state of limbo where you cant cross the finish line due to CNS depression, presumably due to an imbalance between prolactin and dopamine. 

So you're not at "zero", and youre not at "ten." More like a steady "five".


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## Aidey

Oh, I was aware it was a joke, I just misunderstood the term to mean someone who was stuck at 0, lol.


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## rwik123

Aidey said:


> Oh, I was aware it was a joke, I just misunderstood the term to mean someone who was stuck at 0, lol.



I'm pretty sure that exactly what it is. The inability to achieve the desired result..


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## Handsome Robb

Asclepius911 said:


> You are,  right don't listen to these guys,  in paper and by text book always c-spine for an unwitness fall,  again textbook is theoretic and nremt is as theoretic as book .. in the field we begin doing things in the most practical way that doesn't necessarily follow the book for instance .... in reality what would have happen in this situation,  fire department would already have done opqrst rapid trauma and possibly if indicated have him on a backboard,  all we will do is load him on our rig place o2 mask and go. For drunks,  a medic doesn't really ride with us,  but always make sure patient has a patent airway and prepare for suctioning aspiration is one of the highest killers for drunks.



This is a prime example of why I would never want to find myself in an ambulance in LA. 

You're medics turf unconscious people to BLS crews? 

OP don't listen to us, none of us know what we are talking about 

Asclepius, he asked for input and people gave it to him/her, why would you tell him to disregard information he/she asked for?


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## Achilles

I certainly would not have BB, unless it looked like there was obvious trauma where they jumped from a significant height I would call Al's so they could push narcan or I would transport depending on where they are and ED is.


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## heatherabel3

It almost sounds to me like your prepping for a practical exam. If I am right, and you are, you are gonna have a hard time. I have my practical in a few weeks and last night in class we ran a mock scenario for all the teams to get an idea of what to expect. Out of 6 teams, mine and one other team are the only ones who didn't kill the patient. You can't look at patient assessment as cookie cutter as you are. Yes, consider c-spine but you dont have to take it. Unconscious does not equal a BVM. Beer bottles doesn't always equal drunk passed out kid, maybe they were there from a party 2 nights ago  and this kid has something else wrong and if you dont do a good assessment you won't know that. Like in our scenario last night, patient was in a fight MOI was a baseball bat. There was a hematoma on his forhead, a broken right wrist, and patient was having very rapid respirations. Every other team splinted the wrist and tried to bandage his head. We called for ALS, started bagging the patient in an attempt to bag him down, cut his clothes to reveal a bruised right rib cage. Evaluator called patient was getting hard to bag, we called probable pneumothorax packaged patient and handed off to ALS.  

So my point is, don't get tunnel vision, don't get distracted, and you may not hit every block on the assessment sheet and thats ok.


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## Handsome Robb

Achilles said:


> I certainly would not have BB, unless it looked like there was obvious trauma where they jumped from a significant height I would call Al's so they could push narcan or I would transport depending on where they are and ED is.



Why are you jumping to narcan?

Naloxone is a drug. It has indications. We don't just push it blindly "just in case".


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## Medic Tim

Achilles said:


> I certainly would not have BB, unless it looked like there was obvious trauma where they jumped from a significant height I would call Al's so they could push narcan or I would transport depending on where they are and ED is.



How did you get opiate od out of the info provided. As rob said we don't give a drug for the sake of giving a drug. Even if it was an opiate od, if the pt is maintaining a patent airway and adequate oxygenation there is no need to give narcan. We do not give narcan to wake a pt up. We give it to restore/improve the pts respiratory effort.

I really hope the old coma cocktail is no longer used.......anywhere.


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## bahnrokt

Achilles said:


> I certainly would not have BB, unless it looked like there was obvious trauma where they jumped from a significant height I would call Al's so they could push narcan or I would transport depending on where they are and ED is.



Let's stick an epi pen in his neck.  Maybe there was a bee in one of those bottles of Natty Ice he was downing.


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## Aidey

heatherabel3 said:


> It almost sounds to me like your prepping for a practical exam. If I am right, and you are, you are gonna have a hard time. I have my practical in a few weeks and last night in class we ran a mock scenario for all the teams to get an idea of what to expect. Out of 6 teams, mine and one other team are the only ones who didn't kill the patient. You can't look at patient assessment as cookie cutter as you are. Yes, consider c-spine but you dont have to take it. Unconscious does not equal a BVM. Beer bottles doesn't always equal drunk passed out kid, maybe they were there from a party 2 nights ago  and this kid has something else wrong and if you dont do a good assessment you won't know that. Like in our scenario last night, patient was in a fight MOI was a baseball bat. There was a hematoma on his forhead, a broken right wrist, and patient was having very rapid respirations. Every other team splinted the wrist and tried to bandage his head. We called for ALS, started bagging the patient in an attempt to bag him down, cut his clothes to reveal a bruised right rib cage. Evaluator called patient was getting hard to bag, we called probable pneumothorax packaged patient and handed off to ALS.
> 
> So my point is, don't get tunnel vision, don't get distracted, and you may not hit every block on the assessment sheet and thats ok.



Just because they did the wrong thing doesn't meant you did the right thing. Go ahead and try to "bag down" a conscious and alert pt with a pneumothroax. You'll cause more harm than good, although the harm may end up being caused to you when he starts throwing punches. Plus in this case the tachypnea is an appropriate response to the injury.


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## NYMedic828

NVRob said:


> Why are you jumping to narcan?
> 
> Naloxone is a drug. It has indications. We don't just push it blindly "just in case".



Agreed 110%.

First off, empty beer cans is a good indicator of alcohol being the cause. 

Secondly, unless I need to rule out opiates for an unknown AMS, I only give narcan for respiratory depression.

Alcohol does not cause respiratory depression. If my patient isn't breathing or is not going to be much longer, then it's narcan time. Otherwise, let them stay asleep and be happy and not make my time with them miserable.

Also, speaking of aspiration which someone stated, if you have a very intox patient who is mixed with opioids and you narcan then you are only increasing your risk of withdrawal and inducing the vomiting you are trying to prevent...





NVRob said:


> OP don't listen to us, none of us know what we are talking about :rolleyes



Especially veneficus. That guy doesn't know jack!


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## heatherabel3

I didn't mean to imply that what we did was 100% right. I'm sure we did get things wrong, it was our first ever scenario. I am still a student myself. What i was trying to say, was that if his question is because he has a practical he's getting ready for, he should be prepared to not follow the assessment verbatim. We never got a history or had time for a secondary assessment. Also not to get side tracked with the small stuff out of the gate and look for tge life threats. I was trying to help, not be an ***.


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## Aidey

But it is also important to remember not to blow things out of proportion to the point that you over treat and aren't able to actually assess the pt because you are so busy bagging a patient who doesn't need it. In this scenario it is important not to get so hung up on c spine you never get around to actually checking for respirations, or a pulse, or a blood sugar.


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## Veneficus

Achilles said:


> I certainly would not have BB, unless it looked like there was obvious trauma where they jumped from a significant height I would call Al's so they could push narcan or I would transport depending on where they are and ED is.



Narcan for a drunk?

How does that work?


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## NomadicMedic

Veneficus said:


> Narcan for a drunk?
> 
> How does that work?



Not very well, I'm told. 



Another example of how the level of education for EMTs is totally inadequate.


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## Veneficus

NYMedic828 said:


> Alcohol does not cause respiratory depression.



As an FYI, alcohol, benzos, and barbiturates all inhibit GABA receptors. (each a different one) 

In the CNS, the limbic system really wants to be inhibited. (it has a lot of these receptors)

while that has to do with inhibition (especially reproduction) and not breathing, from the theorhetical standpoint, if benzos and barbs can inhibit respiritory effort, so can alcohol. 

On the practical side, the pt may die of acute liver failure first, but I am just pointing out the problem with absolute statements. 



NYMedic828 said:


> Especially veneficus. That guy doesn't know jack!



Who is jack?


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## Achilles

Veneficus said:


> Narcan for a drunk?
> 
> How does that work?



How do you know he didn't take drugs?


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## Achilles

n7lxi said:


> Not very well, I'm told.
> 
> 
> 
> Another example of how the level of education for EMTs is totally inadequate.


Sorry I didn't respond right away I had other things going on today which didn't involve monitoring this thread.


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## Achilles

bahnrokt said:


> Let's stick an epi pen in his neck.  Maybe there was a bee in one of those bottles of Natty Ice he was downing.


If you say so.


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## Aidey

Achilles said:


> How do you know he didn't take drugs?



Why assume he did even if the assessment doesn't support it?


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## Veneficus

Achilles said:


> How do you know he didn't take drugs?



How do you know he doesn't have a genetic mitochondrial disorder that inhibits him from aerobic metabolism and doesn't need a dose of bicarb to reverse his acute acidosis?


If it looks like a duck, quacks like a duck, and walks like a duck, it is a duck until proven otherwise.

When you hear hoofbeats, think horses.

If he is breathing, then he doesn't need the narcan anyway.

If he did take drugs, how do you know it was an opioid?

What if it was a benzo, a barbiturate, THC, an amphetamine? A chemical like whiteout or paint? (can you believe they still make that stuff?, who uses it?) 

What if it was a large dose opioid and you have to set up a narcan drip?

But here is the rub. 

The more what if's you know, the less practical it becomes to look for them.

Start with the basics, air in and out, blood round and round.


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## rwik123

Achilles said:


> How do you know he didn't take drugs?



Go lookup something called the Opioid Triad.

Usually by the environment and surrounding of the patient you can make a pretty good assumption on weither or not your dealing with an opioid overdose. 

I have Narcan in my toolkit...should I start pushing it on every drunk that passes out on my campus? 

So much facepalm.


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## Handsome Robb

Achilles said:


> How do you know he didn't take drugs?



You don't. That's why we do thorough assessments. I'm not trying to hate on basics and I am a brand new medic but this is exactly why I don't believe BLS providers should have naloxone in their scope. 

Like Vene said, if it looks like a duck and quacks like a duck, it's probably a duck. 

There are indicators that I look for when giving naloxone. The key ones being evidence of use (empty bottles or other) pinpoint pupils and respiratory depression. 

Even if someone is unconscious after ingesting opiods but still has a good respiratory effort, isn't cyanotic and has a good Sp02 I'm not going to give them naloxone. I don't want to deal with them being grumpy and withdrawing in the back of my ambulance. Like someone else said, titrate to a respiratory effort, not to wake the patient. 

No one is jumping on your case but trialing naloxone in every unresponsive patient is terrible medicine.


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## NYMedic828

Achilles said:


> How do you know he didn't take drugs?




Assessment based management

Let's look at the factors of your assessment.

-Scene - beer bottles all over. Are they open/empty?
-bystanders - what does the roommate know? History of drug abuse?
-patient - incontinent, face down. No signs of injury.
      - odds are he didn't get hurt, or not bad enough for me to think c-spine injury. The human body is meant to fall from standing height and not be injured at that age. C-spine is not a concern to me.
-history - drug abuse? Seizures?
-assessment - glucose, 3 lead, BP, HR, RR. The basics.

You need to consider everything before determining your treatment. Sure maybe he did take opiates. So what. Odds are he is not suffering from a neurological condition be it injury or illness and as long as his breathing ok, I don't care what he took if I can't immediately determine it.

I only need to give narcan if his breathing is hindered. Otherwise, quite honestly while I do care if he took other drugs, I really don't.


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## bigbaldguy

Folks if someone says something that is incorrect feel free to correct them but let's do it in a friendly, professional way. There are those who have lot's of info and experience and those who have little. The one's who have little will stop listening if you slap them down for giving the wrong answer. Eventually they stop trying to answer and then they stop trying to learn. I am disappointed with the tone of some of the posts in this thread.


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## Tigger

I'm a bit tired of hearing how basics shouldn't have naloxone in their scope because they don't know enough about it. Most basics that answer a scenario with "they should get narcan" don't have the ability give it. All their "education" on it is second and third hand. And then there are those of us that do have it, and received actual education in its use. If someone actually gets formally educated in its use, they would more than likely have a better grasp on its use. It's a bit absurd to say that a medication or skill shouldn't be given to basics because they don't know how it works. Well duh, no one has educated them on it! You don't give a medic a new med or skill and tell them figure it out either...


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## Aidey

It isn't just about the narcan. As many many threads here illustrate and through real life experience, it as been shown that when all you have is a hammer, everything looks like a nail. Everyone gets oxygen. Everyone gets backboards. You get the picture. Until there is a fundamental change in EMT education and how they are taught to approach the differential diagnosis I have a hard time supporting expanding their scope to include more medications.


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## abckidsmom

Doczilla said:


> (Hoping that you knew this was a joke...lol)
> 
> This condition refers to a state of limbo where you cant cross the finish line due to CNS depression, presumably due to an imbalance between prolactin and dopamine.
> 
> So you're not at "zero", and youre not at "ten." More like a steady "five".



And the award goes to Doczilla for the most amusing family friendly explanation of a sensitive topic. 

I've got nothing to add here other than this.


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## Tigger

Aidey said:


> It isn't just about the narcan. As many many threads here illustrate and through real life experience, it as been shown that when all you have is a hammer, everything looks like a nail. Everyone gets oxygen. Everyone gets backboards. You get the picture. Until there is a fundamental change in EMT education and how they are taught to approach the differential diagnosis I have a hard time supporting expanding their scope to include more medications.



Point taken. I guess it just sucks to be lumped into a group of people that are capable of nothing more than the minimum. The obvious solution is to increase my education, which is unfortunately just not in the cards right now.


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## Akulahawk

Veneficus said:


> *Start with the basics, air in and out, blood round and round.*


Any deviation from that is bad... And if you find something wrong with the air going in and out and/or the blood going round and round, fix it or get the patient to someone that can.

The basics aren't all that hard... the minutae is what'll drive ya batty!


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## UsualSuspect147

Veneficus said:


> How do you know he doesn't have a genetic mitochondrial disorder that inhibits him from aerobic metabolism and doesn't need a dose of bicarb to reverse his acute acidosis?
> 
> 
> If it looks like a duck, quacks like a duck, and walks like a duck, it is a duck until proven otherwise.
> 
> When you hear hoofbeats, think horses.
> 
> If he is breathing, then he doesn't need the narcan anyway.
> 
> If he did take drugs, how do you know it was an opioid?
> 
> What if it was a benzo, a barbiturate, THC, an amphetamine? A chemical like whiteout or paint? (can you believe they still make that stuff?, who uses it?)
> 
> What if it was a large dose opioid and you have to set up a narcan drip?
> 
> But here is the rub.
> 
> The more what if's you know, the less practical it becomes to look for them.
> 
> Start with the basics, air in and out, blood round and round.


GREAT post.


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## medichopeful

EMT1A said:


> How would you get them onto your gurney or transport the patient if they are unconscious and lying on the floor after you c-spine the patient?



If you c-spine them, then yes backboard is the way to go (or possible a scoop).  If you didn't c-spine them, pick them up and put them on whatever you're using to bring them to your ambulance or stretcher (for example, stair-chair->stretcher->ambulance)


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## medichopeful

EMT1A said:


> Wouldn't incontinence be a possible indicator of a c-spine injury?



Not necessarily.  Other things can cause incontinence too.


----------



## medichopeful

Tigger said:


> Point taken. I guess it just sucks to be lumped into a group of people that are capable of nothing more than the minimum. The obvious solution is to increase my education, which is unfortunately just not in the cards right now.



You are increasing it Tobias, just not with new certs!  Teaching yourself and learning is a GREAT way to increase understanding.


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## crispy91

Honestly, I wouldn't have backboarded the pt. Sounds like something alcohol related, with no trauma. On scene, remember to focuss on your life threats, then worry about things like hx, hpi, and all that. The roomate would probably be your most valuable source of information. As far as your assessment goes, remember that the unresponsive pt needs to be tx to the hospital immediately. Worry about hx either en route, or before you leave. Just my opinions though. Other than that, you did pretty good.


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## Doczilla

abckidsmom said:


> And the award goes to Doczilla for the most amusing family friendly explanation of a sensitive topic.
> 
> I've got nothing to add here other than this.



Yay!


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## Veneficus

bigbaldguy said:


> Folks if someone says something that is incorrect feel free to correct them but let's do it in a friendly, professional way. There are those who have lot's of info and experience and those who have little. The one's who have little will stop listening if you slap them down for giving the wrong answer. Eventually they stop trying to answer and then they stop trying to learn. I am disappointed with the tone of some of the posts in this thread.



Sorry,

I think there is some residual anghst from the last thread on giving narcan to EMT-Bs. 

After pages of why it should or shouldn't be permitted, a few posts here basically unwittingly proved the point on why basics don't need more tricks in their bag.

In my initial response, I did phrase the question because I wanted to hear the reason for the answer. I expected 1 of 2

1. Because my instructor told me.
2. "just in case"

As an interesting anecdote I was having lunch with a Dr. last year during a PALS class we were teaching. 

This Dr. and I do not see eye to eye on just about anything, but we can tolerate each other and work well together.

During the meal he brought up a good point I think is worth sharing in this thread.

The new students saw us instructors as the absolute authority on the topic by virtue of nothing more than our instructor title. 

The next time they take a PALS class, they will challenge their "new" instructors if they relate anything in contra to what we said.

They have absolutely no way to judge a competent instructor from a poor one other than how the instructor makes them feel.

If you make them feel good, they will say you are a good instructor no matter how little they learned.

If you make them feel bad, they say that you were terrible no matter how much they learned. 

But they still have no idea who is competent and who is not.


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## abckidsmom

Veneficus said:


> Sorry,
> 
> I think there is some residual anghst from the last thread on giving narcan to EMT-Bs.
> 
> After pages of why it should or shouldn't be permitted, a few posts here basically unwittingly proved the point on why basics don't need more tricks in their bag.
> 
> In my initial response, I did phrase the question because I wanted to hear the reason for the answer. I expected 1 of 2
> 
> 1. Because my instructor told me.
> 2. "just in case"
> 
> As an interesting anecdote I was having lunch with a Dr. last year during a PALS class we were teaching.
> 
> This Dr. and I do not see eye to eye on just about anything, but we can tolerate each other and work well together.
> 
> During the meal he brought up a good point I think is worth sharing in this thread.
> 
> The new students saw us instructors as the absolute authority on the topic by virtue of nothing more than our instructor title.
> 
> The next time they take a PALS class, they will challenge their "new" instructors if they relate anything in contra to what we said.
> 
> They have absolutely no way to judge a competent instructor from a poor one other than how the instructor makes them feel.
> 
> If you make them feel good, they will say you are a good instructor no matter how little they learned.
> 
> If you make them feel bad, they say that you were terrible no matter how much they learned.
> 
> But they still have no idea who is competent and who is not.



This is an extremely good point. It also applies to their preceptors and the senior guys they work with. When you learn a trade, the authority is in experience. When you are a professional, you learn from the science and theory of whatever it is you're learning. 

I see this extreme well represented in the fire service as well. 

It's not ever as simple as "if this, do that." There should always be some thinking applied to the problem. 

Heck, I had a narc overdose this week that I chose just to manage the airway of and not give Narcan because of his extended down time and the associated pharmaceuticals he also indulged in. He was nicely anesthetized, why mess with that?


----------



## Doczilla

That's so rare and beautiful, this common sense. 

Some  firefighters tube, (then carve another "tube"  notch with their Smith and Wesson jackhawk 9000 knives) , then give narcan anyway. 

"Hey, can you hand me tape----" 

(Patient) "mmmmfffff!!! BLAAAARGHHHH" 

"He's buckin' the tube' Git the etomidate!"


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## leoemt

Epi-do said:


> Why would you board this patient?  Are you seeing any sort of obvious injuries that would make you think it should be considered?
> 
> Does he need bagged?  What is his respiratory rate and effort?  What's his airway like?  Is it clear, or do you need to suction?



OP sounds like a student. In EMT class and in many protocols they teach to board and initiate spinal precautions for an unresponsive person when no one is around to tell you what happened. 

If the kid's collapse was unwitnessed then back boarding would be appropriate.


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## Asclepius911

LA county is always on scene first, if they aren't first on scene and we are closer they will make us post near the scene till we get approval to show up


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## NYMedic828

leoemt said:


> OP sounds like a student. In EMT class and in many protocols they teach to board and initiate spinal precautions for an unresponsive person when no one is around to tell you what happened.
> 
> If the kid's collapse was unwitnessed then back boarding would be appropriate.



Not to criticize you, because this is absolutely  what they preach be it wrong or right, but as a general point to this thread:

A picture is worth a 1000 words. I don't always need someone to blatantly tell me what happened.


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## Melclin

(EDIT): Redacted. I'm too young to have a stroke. I'm not ganna get involved.

(EDIT#2): Just one point to add. Seriously, you've presumably all been out on the turps. How many times have _you_ been/been with mates who were semi conscious/lying on the ground/fell over drunk. If your first thought was that you/they needed spinal precautions until they got CT'd and not that you should shave one of their eye brows off, then I'm here to tell you that you're doing it wrong.


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## Veneficus

NYMedic828 said:


> A picture is worth a 1000 words. I don't always need someone to blatantly tell me what happened.



I always love to ask what happened.

Not because I need anyone to tell me, because people come up with the most amazing lies ever. 

"How did you do that?"

is usually followed up with:

"would you like to revise your statement?"


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## abckidsmom

Veneficus said:


> I always love to ask what happened.
> 
> Not because I need anyone to tell me, because people come up with the most amazing lies ever.
> 
> "How did you do that?"
> 
> is usually followed up with:
> 
> "would you like to revise your statement?"



My favorite is "what made you decide that was a good idea?"   When you get something other than I don't know, it's hillarious.


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## msaver

Okay you suspected a spinal injury, so you would never do the head chin tilt. Do jaw thrust. And you would only bag the guy if his breathing was inadequate.


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## NYMedic828

msaver said:


> Okay you suspected a spinal injury, so you would never do the head chin tilt. Do jaw thrust. And you would only bag the guy if his breathing was inadequate.



Did you read any of the thread


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## Veneficus

msaver said:


> Okay you suspected a spinal injury, *so you would never *do the head chin tilt. Do jaw thrust.



Never say "never" in medicine.

If you cannot maintain an airway with a jaw thrust, then you should do a head tilt chin lift.

A patient may have a spinal injury (unlikely) but they will certainly die without an airway.


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## shiroun

Veneficus said:


> Never say "never" in medicine.
> 
> If you cannot maintain an airway with a jaw thrust, then you should do a head tilt chin lift.
> 
> A patient may have a spinal injury (unlikely) but they will certainly die without an airway.



x2. Life over limbs. Anyone who says never for head-tilt on a spinal injury has never tried a modified jaw thrust. that does NOT get any amount of air in, even with bagging. Gastric distension will occur quite a bit with it.

Also, do you really want to backboard an unconscious patient who may be etOH? Think about this. IF he vomits, you have to tilt the entire board, and he may aspirate before you do that. C-collar, fine. But boarding? Cmon now.


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## Tigger

shiroun said:


> x2. Life over limbs. Anyone who says never for head-tilt on a spinal injury has never tried a modified jaw thrust. that does NOT get any amount of air in, even with bagging. Gastric distension will occur quite a bit with it.
> 
> Also, do you really want to backboard an unconscious patient who may be etOH? Think about this. IF he vomits, you have to tilt the entire board, and he may aspirate before you do that. C-collar, fine. But boarding? Cmon now.



Someone in a c-collar is still at significant risk of aspiration if they vomit and are supine. They will still need positioning assistance should they begin to vomit, which may be easier to achieve if the patient is on a board and can be moved as a unit. If you let them roll themselves over there is no reason to have even put them in a c-collar because it is doing absolutely nothing for them once they manipulate themselves to vomit "normally." 

As for the jaw thrust, I've used it before and was able to bag the patient for a time but the amount of neck extension required to do so seems like it may have negated any benefit should the patient had c-spine issues. We're only doing it because the hallway was too small for two people to be next to the head.


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## jwk

Read every post thinking "when I get to the end of the thread, I'm going to post something about putting the patient on their side" - and then I get to the very end of the thread and two people in a row say something about positioning.  Damn.


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## leoemt

NYMedic828 said:


> Not to criticize you, because this is absolutely  what they preach be it wrong or right, but as a general point to this thread:
> 
> A picture is worth a 1000 words. I don't always need someone to blatantly tell me what happened.



I agree with you and the cop side of me always looks at what evidence I have to tell me what likely happend. 

However, here in WA (at least in Seattle) they backboard any unresponsive / unwitnessed fall. 

I don't have much experience at Harborview, but when I have been there patients on backboards have been taken off within 15 minutes of arrival.


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## Akulahawk

leoemt said:


> I agree with you and the cop side of me always looks at what evidence I have to tell me what likely happend.
> 
> However, here in WA (at least in Seattle) they backboard any unresponsive / unwitnessed fall.
> 
> I don't have much experience at Harborview, but when I have been there patients on backboards have been taken off within 15 minutes of arrival.


Basically they're treating the "what if" patient who is being cared for by the lowest-capable provider when they direct a provider to backboard unwitnessed/unresponsive fall victims. And I'm not at all surprised to hear that many of those patients are taken off the board within 15 minutes of arrival. Why? The backboard's job is done at that point, even if it was necessary during extrication from the scene and transport.


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## MKwolek

EMT1A said:


> Wouldn't you automatically assume c spine precautions if you found the patient lying on the floor since there could be possibly a spinal injury? Don't you have to board the patient if you c-spine them and put a c-collar on in order to get them onto a gurney?
> 
> When you check airway you would:
> 
> 1. See if it's open
> 2. If it isn't open, open the airway either by suction if needed, head tilt chin lift? and use an opa/npa to open the airway?
> 3. If the airway is open, check if the patient is breathing and their respiratory rate and effort?
> 
> Is this correct? Did I miss anything?



If you are assuming c-spine precautions then you shouldn't be doing a head-tilt chin lift. You need to use a jaw thrust manuever. Right?


----------



## Medic Tim

MKwolek said:


> If you are assuming c-spine precautions then you shouldn't be doing a head-tilt chin lift. You need to use a jaw thrust manuever. Right?



ever done one on a person before?

 If the person is not breathing you do what you have to to get the airway.


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## MKwolek

Medic Tim said:


> ever done one on a person before?
> 
> If the person is not breathing you do what you have to to get the airway.



I understand you need to get the airway open above all else, so you're right but I am assuming this question was asked for testing purposes. 

What movie is your picture from?


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## NomadicMedic

leoemt said:


> I don't have much experience at Harborview, but when I have been there patients on backboards have been taken off within 15 minutes of arrival.



100% false. Patients on backboards at HMC are only taken off backboards when cleared by the trauma doc. It sometimes takes hours. Spend a busy Friday or Saturday there. Youll find MVC patients in Resus 2 and 4 that have been on boards for several hours. In fact, there have been several instances that I've witnessed at HMC where patients that arrived via ambulance, non boarded that were placed on backboards that were fetched from outside in the ambulance bay. Often the poorly fitting C-collar applied by EMS is removed and a plastic Philly style collar is applied by the ED staff as well. 

The docs at Harborview practice CYA just like everyone else. If the PT can't be cleared, they wait on imaging.


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## Medic Tim

MKwolek said:


> I understand you need to get the airway open above all else, so you're right but I am assuming this question was asked for testing purposes.
> 
> What movie is your picture from?



Bringing Out the Dead


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## nemedic

Medic Tim said:


> Bringing Out the Dead



http://youtu.be/grbSQ6O6kbs


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## mospensa

on scene, simple as

BSI Scene safety.

ABC's for treatment.

intervene as needed

for assessment 

as far as C-spine if it was witnessed and there are signs of possible MOI then without a doubt instant spinal precautions. 

but look at the scene if the roommate is there ask what happened. if they called 911 and stuck around for you to arrive chances are they are concerned enough to tell you everything they know (i have been on some sketchy AMS or LOC calls where the roommates have seemed to hold info back but never have they not told me enough to get a clue of what they know), if pt fell, if pt had taken any drugs, if pt had simply drunk them selves into a LOC, dont forget that this person lives with the pt, there is your link to past medical Hx, medications, allergies to potential "shifty" activity out side of the norm recently. maybe this kids chick just dumped him and hes now a potential behavioral patient. may have taken something other than the alcohol. 

use your senses. 
look around what does the rest of the house look like. was this a party or is this guy the only guy drinking. (could key you in on how much alcohol this guy has had.) if a party happened and this guy got sick or hurt (everyone else bailed) theres signs of alcohol everywhere, whos to say this guy even had a drop? 

assuming this guy has a patent airway (managed or not) and is breathing (assisted or not) and is not actively bleeding and is adequately perfusing, pack him up (assuming nothing on scene indicated spinal immobilization then) position lateral recumbent. full set of vitals to include spO2, BGL, pupils, and skin condition. monitor if you've got it. reassess enroute ABC. vitals every 5. transport code 2 (routine). 




> 100% false. Patients on backboards at HMC are only taken off backboards when cleared by the trauma doc. It sometimes takes hours



my battalion doc is an emergency medicine physician I guarantee she would agree with this statement 100%. 

ABOVE EMS's level of care but her protocol for clearing a neck before removing full spinal immobilization is

1. no distracting injuries
2. sober
3. no neurological deficits
4. GCS of 15
5. no midline tenderness 

all 5 criteria met = spineboard removed.
the other may call for imagery


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## Veneficus

mospensa said:


> ABOVE EMS's level of care but her protocol for clearing a neck before removing full spinal immobilization is
> 
> *1. no distracting injuries*
> 
> Does pain caused by the board count?
> 
> *2. sober*
> 
> Surely you jest? It is not often in civilian life you find a fine upstanding citizen who was just returning his library books at 230am when he was assaulted by the 2 dudes because he was minding his own business.
> 
> *3. no neurological deficits*
> 
> Is being stupid a neuro deficit? We will never get these people off of the board...
> 
> *4. GCS of 15*
> 
> I love this!
> 
> GCS is a prognotic tool, it is not validated to guide treatment.
> 
> *5. no midline tenderness *
> 
> If the patient lays on the board long enough they will get midline tenderness :huh:
> 
> all 5 criteria met = spineboard removed.
> the other may call for imagery



Might as well quit wasting time and just send them to CT for their total body scan with spinal recons.

All joking aside, I strongly suspect this criteria came from consensus and a legal department.


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## mospensa

Veneficus said:


> Might as well quit wasting time and just send them to CT for their total body scan with spinal recons.
> 
> All joking aside, I strongly suspect this criteria came from consensus and a legal department.



Remember this is her criteria for removing immobilization for pt's who have suffered from or come from scenes that indicated significant MOI. 

1. Distracting injury indicated from MOI. That's not talking about a c-collar that is too long for the pt.

2. Sober. This guy was injured to the point where a responder on scene decided he needs a back board. Not just any etoh pt. what's the difference between CNS depression to etoh or CNS depression to spinal injury. Priapism/ lack of? Not all spinal injuries will result in priapism. 

3. Neurological deficits such as paralysis, paresthesia, priapism. 

4. If you don't like GCS how about AMS? If they aren't A+O then they may need imagery. 

5. Sure spine boards are uncomfortable. She also said this is one of the first things she does when she receives a patient. So if there is point tenderness on bony structures when they arrive they may need imagery. 

PHTLS also follows this criteria for prehospital spinal clearance with the added part of significant MOI presence. 

If they fail any one of those most likely they would go to imagery as soon as possible. 

There isn't much if any time wasted in 1,3,4,5 all of which are part of your detailed physical exam anyway. Number 2 is the only one that may take a while.


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## Veneficus

mospensa said:


> Remember this is her criteria for removing immobilization for pt's who have suffered from or come from scenes that indicated significant MOI.
> 
> Despite MOI being unreliable?
> 
> 1. Distracting injury indicated from MOI. That's not talking about a c-collar that is too long for the pt..



Despite MOI being unreliable?




mospensa said:


> 2. Sober. This guy was injured to the point where a responder on scene decided he needs a back board. Not just any etoh pt. what's the difference between CNS depression to etoh or CNS depression to spinal injury. Priapism/ lack of? Not all spinal injuries will result in priapism.



???

What is the difference between a brain injury and a spinal cord injury?

There are some rather key differences. 

Just off the top of my head you could have herniation and its sequele which presents far different from neuro-sensory impairment. 

Even on an unconscious patient vegatative functions vs reflexes are a big difference. 



mospensa said:


> 3. Neurological deficits such as paralysis, paresthesia, priapism.



I'm just going to leave this alone.




mospensa said:


> 4. If you don't like GCS how about AMS? If they aren't A+O then they may need imagery.



I do not think you understand. It has nothing to do with choosing one scoring system over another.

the GCS scoring system is scientifically validated for prognosing recovery.

It is not scientifically validated on kids, it is not scientifically validated for intubation, nor determinging imaging. 

It is clinicians who choose to use GCS scoring outside of its intended and proven purpose as a memory aid or treatment guidline.



mospensa said:


> 5. Sure spine boards are uncomfortable. She also said this is one of the first things she does when she receives a patient. So if there is point tenderness on bony structures when they arrive they may need imagery.



My rather sarcastic point is, since being transported on a board or laying on one for the better part of an hour or two can cause this tenderness, physicians might wat to quit wasting time and just send them for imaging anyway. In modern times, that means a CT.



mospensa said:


> PHTLS also follows this criteria for prehospital spinal clearance with the added part of significant MOI presence..



Who cares? 

PHTLS is a watered down version of ATLS based on what is believed is safest practice for the least common denominator of field provider. 

If a physician is making decisions based on PHTLS, they might want to get a thicker book.



mospensa said:


> If they fail any one of those most likely they would go to imagery as soon as possible..



Which is most patients. My point again, rather than trying to clear them, might as well just send them to CT. 



mospensa said:


> There isn't much if any time wasted in 1,3,4,5 all of which are part of your detailed physical exam anyway. Number 2 is the only one that may take a while.



Seems to me like range of motion deficit should probably be added to this list?

Anyway, you cannot summarize best practice from the personal choices of one clinician second hand. I would wager there is probably considerably more to the thought process behind who gets imaging and who doesn't that she is leaving unsaid.


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## Melclin

Veneficus said:


> Seems to me like range of motion deficit should probably be added to this list?
> 
> QUOTE]
> 
> And perhaps some sort of age cut off or precaution of some description. A few studies raise concerns about unstable injuries being missed in this cohort.


----------



## Veneficus

Melclin said:


> And perhaps some sort of age cut off or precaution of some description. A few studies raise concerns about unstable injuries being missed in this cohort.



For certain, the non-specific compliants in the elderly create a lot of headaches due to the increased diagnostic requirements.

As well, the high compensatory ability of kids can also give a false sense of security. 

I have seen in person kids "stabilized" by numbers code moments later on a trauma table while everyone was congratulating themselves.


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