# Mistake?  Should I have backboarded?



## legion1202 (Dec 29, 2012)

So last shift we ran from 630am to 530am the next day. One of my last calls I got was a 20 yr old male who got thrown to the ground in some snow by another male. The pt walked in his house up stairs and called 911 because he hurt his shoulder. We just got hit with a snow storm so he didn't feel like driving. Btw this was my first snow storm I have ever been in as well. I was teching the whole night haha

Anyways I find the pt sitting on his stairs holding his arm. I interview him and he tells me he got into a argument and this guy picked him up and pushed him back. His shoulder hurts and he thinks he re injured his rotator cuff. He denied neck and back pain and refused us carrying him with a stretcher at the time. I looked over his shoulder, back and neck and didn't find anything. His right shoulder hurt with palpating. He had no numbness in his arm or hand and had +cms. He could move his arm but with pain.pt also Denis loc or hitting his head. He walks to the rig fine and vs are perfect. He admits to drinking a few beers but is aaox3. Ride to the er is fine but as I'm bringing him into the er he starts saying he is having pain between his shoulder blades and it hurts for him to look down. I tell the nurse the pain in his back is a new on set and the pt agrees he only had shoulder pain during transport. I finish with the pt and on my next call he is still sitting there talking to the doc.. I hear the pt saying he now thinks something is wrong with his spine. 

My question is should I have boarded c collared this guy? On the fact he got thrown to the ground or was I ok after ruling out neck and spine injury from the start? My gut says board them next time but with the snow and ice on the steps and walk way I thought that would be putting everyone in danger plus he wanted to walk. I guess I could have taken precaution in the truck...


I documented very well to save my *** but who knows if this guy will try to sue..the er nurse thought he was full of poop.. I dunno


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## STXmedic (Dec 29, 2012)

I would've treated it the same way you did. Localized shoulder pain with no other complaints = no board and a nice, comfortable ride to the hospital.


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## VFlutter (Dec 29, 2012)

I would not have boarded him


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## MIT (Dec 29, 2012)

I don't think i would have backboarded or collared him- he didn't complain of neckpain or back pain, moves around without pain, mechanism of injury isn't that indicative, he's young and generally fit? and I assume that there was no pain on palpation? His onset of pain at triage sounds like muscular pain due to being seated and relatively motionless for whatever the transport time was


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## mycrofft (Dec 29, 2012)

Did what I'd do. Especially documentation. If the boss calls you in just tell him like it was, say "Yes Ma'am" or "Sir", and press on.

You didn't, like, have any accidents on the drive in did you? Kidding.

PS: quick data to gather on something like this: document exactly where on shoulder there is pain (versus tenderness to palpation and ROM); have pt extend upper arm (lower arm usually comes along) anteriorly, posteriorly, and laterally, and document which directions if any elicit tenderness; you should  be gently palpating shoulder as he does this, document any crepitus and in which direction it came. Not that it will affect your treatment necessarily (BTW did you sling and swathe it?), but changes in pain and tenderness are helpful at the other end as well as documentation you are uber thorough and couldn't possibly have just let anything slide. It also helps keep The Baron at bay.


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## Medic Tim (Dec 29, 2012)

No board. A nice easy ride in the position of least discomfort. Some morphine if it is really hurting him.


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## Handsome Robb (Dec 29, 2012)

Medic Tim said:


> No board. A nice easy ride in the position of least discomfort. Some morphine if it is really hurting him.



This, but fentanyl instead of MS


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## Jon (Dec 29, 2012)

If you haven't had a patient start complaining of neck or back pain on ED arrival, you haven't been doing this long. 

Usually he RN's understand when we say "that's new". Just document for CYA


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## mycrofft (Dec 29, 2012)

I wasn't referring to "The Red Baron".


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## legion1202 (Dec 29, 2012)

Thanks everyone. Pt didn't want a sling ..  His jacket was very bulky and he didn't want to remove it once in the truck due to the cold. He was comfortable sitting there so I didn't press it..


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## mycrofft (Dec 29, 2012)

Hard to palpate and ROM in a ski suit, but it wasn't apparently emergent. How'd you getg BP throught a heavy coat? (Neck/Palp?   ).


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## Aidey (Dec 29, 2012)

1. No, he didn't need a LSB.

2. Epic, epic assessment fail. His jacket should have been removed. It is cold is a crappy excuse. Turn on the heat in the back. Give him a blanket. Have him take his arms out so the coat can be draped over his shoulders.


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## Bullets (Dec 29, 2012)

If he didn't allow you to take off his coat, sling his arm, take vitals or do a physical assessment then I would have had a hard time taking him. If at any point prior to its leaving he said he called us just because he doesn't want to drive that probably would have ended as no medical merit and our service wasn't needed


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## Veneficus (Dec 29, 2012)

125mg methylprednisone, 60mg ketorlac, problem solved...


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## legion1202 (Dec 29, 2012)

Whoa... He had no jacket when i checked him out in his house guys.. We put it on before leaving..


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## legion1202 (Dec 29, 2012)

Heat was on in the truck he didnt want to take his jacket iff again because it took us 10 mins to get it on.. Which caused pain to the pt  i should have said that at the start


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## abckidsmom (Dec 29, 2012)

legion1202 said:


> Heat was on in the truck he didnt want to take his jacket iff again because it took us 10 mins to get it on.. Which caused pain to the pt  i should have said that at the start



Why did you put it on?


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## NYMedic828 (Dec 29, 2012)

I never have a patient put their jacket fully on unless they are calling for nonsense and fully capable of putting in on and taking it off normally...

It always has to come off when we get to the ER and for our assessment so why put it on... Just put it on like a blanket or put it on backwards so it pulls right off.


I'm sure it was already stated, but any patient with debilitating pain, especially that which interferes with proper assessment should be administered analgesics.


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## legion1202 (Dec 29, 2012)

Pt wanted to walk to truck.. Refused stretcher.. Did not want ice pack or sling in his house. It was 14 degrees with freezing rain and wind.. The man wanted his coat.. He could move his arm.. But with 4/10 pain. I took v/s just fine and he was able to walk with no discomfort. His jacked was also helping stablizing his arm in a postion of comfort.. Like i said at the start i tried to do more in the truck but he refused.. He could drive to er becAuse he had a stick.. Transport time was 2-3 mins due to icey hills.. I guess i could have had hom refuse and have hin walk or go bu police car =)


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## legion1202 (Dec 29, 2012)

Oh and from his door to the truck was about 200yrd.. I was more worried about keeping pt warm then about having to take jacket off again.. I had no problem taking it off if i had too.. I the man had more layers of cloths on i would have put it on backwards but all he had was a t-shirt. Pt didn show that he was in a lot of pain untill he got to the er. My gut said he wanted to get checked out so he could report it and sue the guy who threw him.. I doubt there was anything wrong with him.. He was alao smoking a ciggette with that are when we arrived.. 

I agree i could have done something diffrent but its done now


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## Veneficus (Dec 29, 2012)

I have never seen so much focus on a coat before...

Let us think logically about this?

What likely happened? Guy was thrown to the ground with some soft tissue injury. 

As the inflammatory process advanced, pain (increased sensitivity, not to mention pain and cold receptors are the same), swelling, loss of range and motion restriction,

Considering the anatomy of how neurovascular tracts run from the upper extremity to the spine, a shoulder injury is likely to aggrivate nerves.

Chronic degenrative upper spinal diseases also manifest similar to this.

Obviously I wasn't there and have no idea what happened to this guy, but if I was a betting man, soft tissue injury described above puts the odds heavily in my favor.


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## legion1202 (Dec 29, 2012)

Are=arm.. Sorry for the other miss spellings  and grammer


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## NYMedic828 (Dec 29, 2012)

legion1202 said:


> *4/10 pain.*





legion1202 said:


> *20 yr old male*
> *thrown to the ground in some snow*
> *hurt his shoulder*.
> *he didn't feel like driving*.
> ...



There is literally nothing in the above that warrants the slightest consideration of backboarding.

He was pushed into snow. Which is natures cushion at that point. The human body, especially that of a 20 year old is designed to fall from its own height. It would take substantial outside force to cause cervical spinal injury which is not present from another human pushing him.

He called an ambulance because he didn't want to drive himself and when he got to the ER he claims spinal injury? Hes playing the game.




Veneficus said:


> I have never seen so much focus on a coat before...
> 
> Let us think logically about this?
> 
> ...




Can't you be less smart  for one day!


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## legion1202 (Dec 29, 2012)

Thanks ny.. 

Thats what i was thinking on scene but i didnt know if because i was tired if i should have done something diffrent.


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## NYMedic828 (Dec 29, 2012)

legion1202 said:


> Thanks ny..
> 
> Thats what i was thinking on scene but i didnt know if because i was tired if i should have done something diffrent.



Unless some legitimate circumstances present themselves, if a 20 year old told me he called an ambulance because his friend pushed him into the snow and he got a boo boo, but didn't want to drive... I would for lack of a better word consider him a whiny :censored::censored::censored::censored::censored:.


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## medic417 (Dec 29, 2012)

NYMedic828 said:


> Unless some legitimate circumstances present themselves, if a 20 year old told me he called an ambulance because his friend pushed him into the snow and he got a boo boo, but didn't want to drive... I would for lack of a better work consider him a whiny :censored::censored::censored::censored::censored:.



You might do that but then you would transport because you work for a you call we haul department.


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## NYMedic828 (Dec 29, 2012)

medic417 said:


> You might do that but then you would transport because you work for a you call we haul department.



Hate to break it to you but 99% of the US works for a you call we haul agency. Doesn't make the kid less of a wimp.


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## Veneficus (Dec 29, 2012)

NYMedic828 said:


> Hate to break it to you but 99% of the US works for a you call we haul agency. Doesn't make the kid less of a wimp.



Old school, I like it.


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## medic417 (Dec 29, 2012)

NYMedic828 said:


> Hate to break it to you but 99% of the US works for a you call we haul agency. Doesn't make the kid less of a wimp.



Guess that puts me in the 1% club then.  

Wimp or not though if you must transport keep in mind a patient can refuse any and all treatments and all you can do is document the refusals.


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## Tigger (Dec 29, 2012)

Aidey said:


> 1. No, he didn't need a LSB.
> 
> 2. Epic, epic assessment fail. His jacket should have been removed. It is cold is a crappy excuse. Turn on the heat in the back. Give him a blanket. Have him take his arms out so the coat can be draped over his shoulders.



Sheesh, a "double epic" fail. 

I've taken plenty of people that didn't want to take their coat off. Heat in the back cranked up, all the blankets we have, still doesn't matter sometimes. If they want their coat, they want their coat.

If it's raining/snowing and the patient can put on a jacket, we will. Not that hard to take off in the truck and we aren't bringing piles of blankets into the house usually. I don't think most people carry much more than a sheet, bath blanket, and a wool blanket on their stretcher. If it's 14 degrees out that's nothing. If I already assessed them in the house and we are going 5 minutes to the ED there's not much point in exposing them again.


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## Veneficus (Dec 29, 2012)

Tigger said:


> Sheesh, a "double epic" fail.
> 
> I've taken plenty of people that didn't want to take their coat off. Heat in the back cranked up, all the blankets we have, still doesn't matter sometimes. If they want their coat, they want their coat.
> 
> If it's raining/snowing and the patient can put on a jacket, we will. Not that hard to take off in the truck and we aren't bringing piles of blankets into the house usually. I don't think most people carry much more than a sheet, bath blanket, and a wool blanket on their stretcher. If it's 14 degrees out that's nothing. If I already assessed them in the house and we are going 5 minutes to the ED there's not much point in exposing them again.



There is a joke in the ICU called "positive glasses sign."

If a patient wakes up, realizes they are not wearing their glasses. Knows they need them, and has the presence of mind and dexterity to look for them and put them on...

The prognosis is very good and discharge likely very soon.

I think deciding before hand you need a coat, despite injury suffer through putting it on, knowing you have to endure the pain again to take it off at the hospital, clearly means you are not hurt that bad.


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## NYMedic828 (Dec 29, 2012)

medic417 said:


> Guess that puts me in the 1% club then.
> 
> Wimp or not though if you must transport keep in mind a patient can refuse any and all treatments and all you can do is document the refusals.



How s your service not a "you call we haul" agency?

If the person calls, your job is ultimately to haul them to the hospital like everyone else in America...


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## abckidsmom (Dec 29, 2012)

Veneficus said:


> There is a joke in the ICU called "positive glasses sign."
> 
> If a patient wakes up, realizes they are not wearing their glasses. Knows they need them, and has the presence of mind and dexterity to look for them and put them on...
> 
> ...



Amen.  

Also the wet hair sign in EMS.  If you have been sick for several days, and feel terrible, but are in clean clothes and have showered recently enough that your hair is wet, I am not terribly concerned and wish you would have ridden to the doctor in one of the 8 cars in the driveway.


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## NYMedic828 (Dec 29, 2012)

abckidsmom said:


> Amen.
> 
> Also the wet hair sign in EMS.  If you have been sick for several days, and feel terrible, but are in clean clothes and have showered recently enough that your hair is wet, I am not terribly concerned and wish you would have ridden to the doctor in one of the 8 cars in the driveway.



To quote Vene...

Can you walk?

No...

Have you tried?


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## Veneficus (Dec 29, 2012)

NYMedic828 said:


> To quote Vene...
> 
> Can you walk?
> 
> ...



That was not my quote, I learned it on my first day of EMT class. The instructor who said it is now a fire chief in Ohio.


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## Tigger (Dec 29, 2012)

Veneficus said:


> There is a joke in the ICU called "positive glasses sign."
> 
> If a patient wakes up, realizes they are not wearing their glasses. Knows they need them, and has the presence of mind and dexterity to look for them and put them on...
> 
> ...



Or you are drunk.

99% of the patients I transport are not hurt that bad. I accept it. I then take them to the hospital, because if I do not I will struggle to remain employed. Most people have an alternative way to get to the hospital, but for whatever reason they chose me. I take them because it is easier and it is what they  and my bosses want. Hopefully I will not work in such a system for much longer, but for now I see little alternative.

The place I work is pretty aggressive taking 911 backups from the city. In most other places this would be foolish, as the risk of reimbursement is high. But in glorious Massachusetts everyone has insurance, so we are pretty much guaranteed to break even every transport (so I am told). If they have additional insurance, well that's just a bonus.


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## Veneficus (Dec 29, 2012)

Tigger said:


> Or you are drunk.
> 
> 99% of the patients I transport are not hurt that bad. I accept it. I then take them to the hospital, because if I do not I will struggle to remain employed. Most people have an alternative way to get to the hospital, but for whatever reason they chose me. I take them because it is easier and it is what they  and my bosses want. Hopefully I will not work in such a system for much longer, but for now I see little alternative.
> 
> The place I work is pretty aggressive taking 911 backups from the city. In most other places this would be foolish, as the risk of reimbursement is high. But in glorious Massachusetts everyone has insurance, so we are pretty much guaranteed to break even every transport (so I am told). If they have additional insurance, well that's just a bonus.



I agree with you.

I never suggested they did not need, deserve, or should not be transported by ambulance. 

I simply stated they are not hurt that badly and their prognosis is good. I guess I should have added it means you don't have to be too broken up about worrying about occult spinal injury and the lack of immobilization.


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## STXmedic (Dec 29, 2012)

medic417 said:


> You might do that but then you would transport because you work for a you call we haul department.



Glad mines not a haul-all department  Take yourself or a taxi. Hell, I'll even give you a "free" taxi voucher...


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## STXmedic (Dec 29, 2012)

NYMedic828 said:


> How s your service not a "you call we haul" agency?
> 
> If the person calls, your job is ultimately to haul them to the hospital like everyone else in America...



Not like everyone else. Mine is certainly not that way. If the tools at my dept are allowed to initiate refusals/no loads, there's no way we're the only ones.


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## NYMedic828 (Dec 29, 2012)

PoeticInjustice said:


> Not like everyone else. Mine is certainly not that way. If the tools at my dept are allowed to initiate refusals/no loads, there's no way we're the only ones.



We can initiate a refusal  but I don't know anyone who has ever done it because the process is more work and massively more time consuming than just transporting the patient for whatever their nonsense be.


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## STXmedic (Dec 29, 2012)

Our guys probably overuse it (pisses me off sometimes), but it's not at all difficult. As simple as "Have your spouse drive you and sign here."


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## medic417 (Dec 29, 2012)

NYMedic828 said:


> How s your service not a "you call we haul" agency?
> 
> If the person calls, your job is ultimately to haul them to the hospital like everyone else in America...



Actually no.  We have the right to say no to transport.  We actually can treat the problem if they need treatment then tell them no to ambulance transport.  Just because they call and request ambulance transport does not mean they get transport.


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## mycrofft (Dec 29, 2012)

In this case, LSB not needed 99% probably. If I recall, pt was intoX and had "an alcohol-like odor", so that affects everything including pharmacy.

OP, did good with VS and etc. We can't always say NO, and it's not our job to sort out Munchausens when neuro departments have trouble as well. 

Schelp em into the ambo and think of England.

EDIT: word was supposed to be "INTOX"


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## NYMedic828 (Dec 29, 2012)

medic417 said:


> Actually no.  We have the right to say no to transport.  We actually can treat the problem if they need treatment then tell them no to ambulance transport.  Just because they call and request ambulance transport does not mean they get transport.



Must be nice...

In NYC it's damn near a mortal sin to so much as tell the patient you don't think they need an ER.


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## medic417 (Dec 29, 2012)

NYMedic828 said:


> Must be nice...
> 
> In NYC it's damn near a mortal sin to so much as tell the patient you don't think they need an ER.



Most services have that same philosophy and yet wonder why people abuse ambulance use.


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## NYMedic828 (Dec 29, 2012)

medic417 said:


> Most services have that same philosophy and yet wonder why people abuse ambulance use.



Everyone is under the impression that by suggesting the patient could just sleep it off and see a private doctor the next day that they are liable for anything that happens in their absence after leaving.

At a minimum it would be quite difficult in a court of law to prove anything the patient claims a provider told them. It's he said she said and no documented proof but what we write on the report.


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## mycrofft (Dec 29, 2012)

NYMedic828 said:


> Everyone is under the impression that by suggesting the patient could just sleep it off and see a private doctor the next day that they are liable for anything that happens in their absence after leaving.
> 
> At a minimum it would be quite difficult in a court of law to prove anything the patient claims a provider told them. It's he said she said and no documented proof but what we write on the report.



"Sleep it off" has particular dangers. Other conditions can mimic alcohol intoxication, and even ETOH can get you dead through respiratory arrest, aspiration/airway embarrassment while unconscious, wandering into danger when in toxic psychosis or withdrawls DT's, or other intoxications. Jail medical screenings arose from dead diabetic in Booking area holding tanks.


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## NYMedic828 (Dec 29, 2012)

mycrofft said:


> "Sleep it off" has particular dangers. Other conditions can mimic alcohol intoxication, and even ETOH can get you dead through respiratory arrest, aspiration/airway embarrassment while unconscious, wandering into danger when in toxic psychosis or withdrawls DT's, or other intoxications. Jail medical screenings arose from dead diabetic in Booking area holding tanks.



I was referring more to the person who called EMS because they stubbed their toe or have a cold for more than a day...


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## mycrofft (Dec 30, 2012)

NYMedic828 said:


> I was referring more to the person who called EMS because they stubbed their toe or have a cold for more than a day...



Gotcha. I liked those who went to sleep drunk/high and woke up with unbearable back pain about 2 AM.


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## Outbac1 (Dec 31, 2012)

I see nothing in the OP to indicate a LSB etc. To walk a pt 200yd to the amb in winter,  and I believe in the ABCs, I would hope he wants his coat. It's not a big deal. Put the injured arm in first or wrap the coat around him and zip it up. Please step this way and mind the ice and snow. 
A suggestion for someone else to drive him may be made but if they want to pay the bill...


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## NYMedic828 (Dec 31, 2012)

Outbac1 said:


> I see nothing in the OP to indicate a LSB etc. To walk a pt 200yd to the amb in winter,  and I believe in the ABCs, I would hope he wants his coat. It's not a big deal. Put the injured arm in first or wrap the coat around him and zip it up. Please step this way and mind the ice and snow.
> A suggestion for someone else to drive him may be made but if they want to pay the bill...



Where did the two football fields come from? 


Side note, where I come from the bill more often than not doesn't get paid. Not in full anyway. Furthermore, the amount that does get paid, comes out of my paycheck... I'd much rather them drive themselves.


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## Outbac1 (Dec 31, 2012)

legion1202 said:


> Oh and from his door to the truck was about 200yrd.. I was more worried about keeping pt warm then about having to take jacket off again....



It was in another post on pg 2 I think.

 I have nothing to do with billing. I'm sure some don't get paid but most do.


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## Gheed (Jan 20, 2013)

Technically he meets S.D. protocol to back board since he was ETOH + and competing pain.  On the other hand if your assessment was thorough and he refused treatment then you are fine.  I would just make sure he didn't smell of ETOH, no impairment in LOC or sign of intoxication which can distort pain.  Make sure he didn't hear any cracking or popping when hitting the snow. I would have asked if the snow was powder, compact or icy and if their were any hard objects underneath.


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## firecoins (Jan 21, 2013)

No backboard needed.


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## Christopher (Jan 21, 2013)

Veneficus said:


> There is a joke in the ICU called "positive glasses sign."
> 
> If a patient wakes up, realizes they are not wearing their glasses. Knows they need them, and has the presence of mind and dexterity to look for them and put them on...
> 
> ...



Reminds me of the "Positive Texting Sign" w.r.t. MVC patients on backboards.


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## Christopher (Jan 21, 2013)

legion1202 said:


> My question is should I have boarded c collared this guy?



Good news: there are no indications to place a patient on a backboard for cervical spine immobilization, only tradition.


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## mycrofft (Jan 21, 2013)

Christopher said:


> Good news: there are no indications to place a patient on a backboard for cervical spine immobilization, only tradition.



Pt in car after a collision with LOC, doors crammed down so they don't open, now c/o neck pain (general and point tenderness) and hands are tingling. 

So, you going to use a spine board now? A KED? AT least for extrication?


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## Christopher (Jan 21, 2013)

mycrofft said:


> Pt in car after a collision with LOC, doors crammed down so they don't open, now c/o neck pain (general and point tenderness) and hands are tingling.
> 
> So, you going to use a spine board now? A KED? AT least for extrication?



(now now? I'm bound by protocol to cause harm and ignore science; working on fixing that locally)

Extrication sure, and the C-collar is indicated provided it fits. If you truly believe you need motion restriction then a backboard does not make physiologic sense for anything but movement to a stretcher. The pressures generated at the tissue-backboard interface almost guarantees that motion (during transport specifically) will be translated anteriorly thru the spinous processes. Moving them to a vacuum mattress once extricated would be ideal.

Even when we've done extrication right, the car is clamshelled and basically torn down to the chassis, there almost always is non-trivial motion of the C-spine. Thankfully, external motion doesn't correlate 1:1 with motion in the spinal column otherwise we'd be killing them every day.

{I've used a Reeve's sleeve once during an automobile extrication, but that patient was down in a ditch and I convinced folks it would be easier to slide up the slope and would thus confer greater protection (i.e. 100% better than 0 is still 0).}


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## mycrofft (Jan 21, 2013)

Christopher said:


> (now now? I'm bound by protocol to cause harm and ignore science; working on fixing that locally)
> 
> Extrication sure, and the C-collar is indicated provided it fits. If you truly believe you need motion restriction then a backboard does not make physiologic sense for anything but movement to a stretcher. The pressures generated at the tissue-backboard interface almost guarantees that motion (during transport specifically) will be translated anteriorly thru the spinous processes. Moving them to a vacuum mattress once extricated would be ideal.
> 
> ...



OK, I'm mostly with you. I reserve the right to remain curmudgeonly.

As for this: "Thankfully, external motion doesn't correlate 1:1 with motion in the spinal column otherwise we'd be killing them every day", my dollar is on the square that reads "Hardly ever is the spinal cord so damaged or threatened by uncontrolled vicious force to the point that a conscientious use of proper equipment will create further exacerbation"._ E.G_., the damage is done, you have to be a Gomer to screw it up worse, but there ARE Gomers out there.


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