# To clear or not to clear



## rescuepoppy (Mar 3, 2009)

A quick scenario for folks whose systems allow field clearing of C-Spine. You are called out to  motor vehicle crash, on arrival you find your patient seated in a truck with only moderate damage, no deformity to the roof line no intrusion into the passenger compartment by the doors. Your patient is a 47 year old male conscious and alert no alcohol or drugs all vitals are within normal limits. The only complaint the patient has is that something does not feel right in his neck. Patient is denying any pain and no point tenderness there is no evidence of neurological deficit or loss of movement to extremities. Would this patient fall under your criteria to field clear C-Spine?


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## Hastings (Mar 3, 2009)

rescuepoppy said:


> A quick scenario for folks whose systems allow field clearing of C-Spine. You are called out to  motor vehicle crash, on arrival you find your patient seated in a truck with only moderate damage, no deformity to the roof line no intrusion into the passenger compartment by the doors. Your patient is a 47 year old male conscious and alert no alcohol or drugs all vitals are within normal limits. The only complaint the patient has is that something does not feel right in his neck. Patient is denying any pain and no point tenderness there is no evidence of neurological deficit or loss of movement to extremities. Would this patient fall under your criteria to field clear C-Spine?



That is absolute indication for full C-Spine immobilization.

If you release it now, you're a fool.



Could be whiplash. Could be something much more. Gamble?


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## silver (Mar 3, 2009)

after the patient said something doesn't feel right in his neck you would still even consider clearing him at all?


mhmm yeah, immobilize


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## Jon (Mar 3, 2009)

Most of the protocols for selective spinal immobilization that I know of require the patient to not have neck pain. I'd call that sensation "pain".

Jon


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## PapaBear434 (Mar 3, 2009)

Oh hell no I wouldn't clear it.  If you clear when someone says "Something doesn't feel right," you deserve the lawsuit you're going to get.

It might be whiplash.  It might not be.  We can't tell in the field.  It's best to err on the side of caution and CYA.


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## Epi-do (Mar 3, 2009)

"something doesn't feel right" = c-spine precautions.  

Like everyone else has said, it could be nothing, but since they are having a complaint related to their neck I am not going to be the one to clear him and then have to explain it to my employer, medical director, the attorneys, etc.

It could just be the overly cautious new medic that I am, but it seems to me that this is one of those situations where it is better to play it safe.


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## downunderwunda (Mar 3, 2009)

You will find that, regardless of what is described, the protocols that allow for field clearance also have a disclaimer. Put simply, if you have ANY doubt as to spinal injury, regardless of MOI or S&S, treat as for spinal.


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## BossyCow (Mar 3, 2009)

Absolutely would get c-spine precautions.


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## imurphy (Mar 3, 2009)

The way I look at it:

If the MOI has any remote possibility of any form of even minor damage, it'll take a few extra minutes to board and tell them "it's just precautionary"

OR, clear them, either they refuse treatment / transport or you transport them without C-Spine precautions then something IS wrong. Well then you're giving evidence in a trail 4 years later, explaining to your SO why you didn't C-Spine them, and maybe looking for another job.

ABC - Always Be Covered!!

My 0.02c!


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## rescuepoppy (Mar 3, 2009)

Just wanting to hear the opinion of others on this.  This patient was me. As it turned out the inferior vertebral body of C-3 was broken off, and C-4 was shattered to the point of being removed and replaced with cadaver bone. As a side note the two medics who attended on the call wanted to clear me.


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## knxemt1983 (Mar 11, 2009)

rescuepoppy said:


> A quick scenario for folks whose systems allow field clearing of C-Spine. You are called out to  motor vehicle crash, on arrival you find your patient seated in a truck with only moderate damage, no deformity to the roof line no intrusion into the passenger compartment by the doors. Your patient is a 47 year old male conscious and alert no alcohol or drugs all vitals are within normal limits. The only complaint the patient has is that something does not feel right in his neck. Patient is denying any pain and no point tenderness there is no evidence of neurological deficit or loss of movement to extremities. Would this patient fall under your criteria to field clear C-Spine?



negative, our protocols state "if any complaint involving neck or back, the paramedic will use full spinal immobilization precaution". even if it did fall within our guidleines to clear it in the field I would NOT do it, better to immobilize and error on the side of the patient then to make a mistake and hurt the pt.


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## Silverstone (Mar 13, 2009)

Absolutely not.  Full spinal precautions on that one.  My Medical Director has put forth a pretty fool proof spinal clearance protocol:

Any Focal Deficit: Yes -> Spinal Immobilization

No 

Patient >65 or <5 with Significant Mechanism?: Yes -> Spinal Immobilization

No 

Alertness: Any alteration in patient?: Yes -> Spinal Immobilization

No 

Intoxication: Any evidence?: Yes -> Spinal Immobilization

No

Distracting Injury: Any painful injury that might distract the patient from the pain of a c-spine injury?: Yes -> Spinal Immobilization

No

Spinal Exam: Point tenderness or pain to ROM in spinal process?: Yes -> Spinal Immobilization

No

Spinal Immobilization Not Required

In very old and very young patients a normal exam may not be sufficient to rule out spinal injury.

We use the acronym NSAIDS for spinal clearance.  Your "funny feeling" in the neck would fall underneath Focal Deficit, which could range from tingling, reduced strength, or numbness in an extremity.


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## Juxel (Mar 13, 2009)

C-collar, no backboard if he wants to go to the hospital.  If pt refuses transport I'd sign him AMA.

*Edit:
I posted this before reading the rest of the forum and still stand behind it.  Backboarding here (not just my service) is quite rare, almost non-existent in a patient who isn't complaining of back pain, no distraction injuries, and not intoxicated.  If you complain of neck pain you get a c-collar.


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