# Rep Giffords was shot in the head, and seeing this picture I ask: Why the C-collar?



## Hockey (Jan 9, 2011)

Photo here.

I notice they have her on a board.  Great, I board pretty much any significant GSW.

But then I noticed they have her collared.  Just wondering, is it really needed to collar someone with that kind of wound?  Traumatic arrest I would I'm sure just to keep the head from moving.  If I have time.  I suppose for precautions when they fallen but can't think of anything else.


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## firecoins (Jan 9, 2011)

First their is the unknown path of the bullet. Than and immediate jerking and fall to the ground. Why would you not put a c collar on?

The person pictured is bleeding from her head.  board and collar seems automatic.


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## JPINFV (Jan 9, 2011)

firecoins said:


> First their is the unknown path of the bullet.


My understanding is that the injury was a through and through gunshot entering at the temple and exiting through the forehead. That seems to be a pretty well known path. 



> Than and immediate jerking and fall to the ground. Why would you not put a c collar on?


So, everyone who suffers a fall needs to be c-spined? Little 8 year old Suzie who trips playing at the park needs to be c-spined? 



> The person pictured is bleeding from her head.  board and collar seems automatic.


http://www.youtube.com/watch?v=YzYxz_uvtSI


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## Hockey (Jan 9, 2011)

Sorry mmiz I didn't think that could violate copyright policy since its a photo and embedding photo into the post.


Either way, this is the original source with better quality 

http://news.yahoo.com/s/yblog_theti...tern-who-likely-saved-gabrielle-giffords-life


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## MMiz (Jan 9, 2011)

Hockey said:


> Sorry mmiz I didn't think that could violate copyright policy since its a photo and embedding photo into the post.
> 
> 
> Either way, this is the original source with better quality
> ...


Fixed, thanks.


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## firetender (Jan 9, 2011)

With a wound that serious to the head, you want to make sure it doesn't fall off.


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## abckidsmom (Jan 9, 2011)

Why cut her clothes off, if it was just a through and through GSW?  

It's because of what you might not know.  Likely the reason why c-spine stays.  Of medics I know, I trust about 10% of them to make a rule in/rule out decision on c-spine based on the actual patient and their full presentation and not how the wind is blowing on a given day or how lazy they feel.  

All the c-spine precaution decision matrices I've ever seen and feel comfortable with require immobilization for any core injury and for any patient with a severe distracting injury.  There's no way somebody with a bullet through their head is going to be able to let you know if they have neck pain or lack light touch sensation.


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## firecoins (Jan 9, 2011)

JPINFV said:


> My understanding is that the injury was a through and through gunshot entering at the temple and exiting through the forehead. That seems to be a pretty well known path.


provided there is no airway issue, that would be a board and collar.  




> So, everyone who suffers a fall needs to be c-spined? Little 8 year old Suzie who trips playing at the park needs to be c-spined?


If the 8 year old was shot, I would highly consider it.


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## EMS49393 (Jan 9, 2011)

I realize this may not seem important to most people, but is there a reason why they couldn't throw a sheet or blanket over her?  She's half naked in a crowd of people and it's January.  Maybe it's because I'm a girl, but patient privacy is very important to me and I can toss a sheet on someone while I'm moving and without delaying any care.

Yeah, I know, bottom on the list of concerns for someone shot in the head, bash away.


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## abckidsmom (Jan 9, 2011)

EMS49393 said:


> I realize this may not seem important to most people, but is there a reason why they couldn't throw a sheet or blanket over her?  She's half naked in a crowd of people and it's January.  Maybe it's because I'm a girl, but patient privacy is very important to me and I can toss a sheet on someone while I'm moving and without delaying any care.
> 
> Yeah, I know, bottom on the list of concerns for someone shot in the head, bash away.



In an MCI shooting, where I am just getting in and out with my red patient, I would like to have her covered, but am not going to be going back and forth to acheive it.  Also, it's January in AZ, where it's not so cold.


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## EMS49393 (Jan 9, 2011)

abckidsmom said:


> In an MCI shooting, where I am just getting in and out with my red patient, I would like to have her covered, but am not going to be going back and forth to acheive it.  Also, it's January in AZ, where it's not so cold.



Understandable, which is why I keep at least two flat sheets folded on my cot, so I won't have to run back and forth and I can cover up while I'm cutting off.


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## JPINFV (Jan 9, 2011)

> provided there is no airway issue, that would be a board and collar.



Would it be for any GSW to the head, or does the fact that it was through and through make a difference?




> Results: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients (93%) was determined either clinically, radiographically, or by review of postmortem results. No patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct spinal injury from bullet passage that were apparent from bullet trajectory. More intubation attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with immobilization versus five attempts in four patients without cervical spine immobilization, p = 0.008).
> 
> Conclusions: Indirect spinal injury does not occur in patients with gunshot wounds to the head. Airway management was compromised by cervical spine immobilization. Protocols mandating cervical spine immobilization after a gunshot wound to the head are unnecessary and may complicate airway management.



http://journals.lww.com/jtrauma/Abs...ith_Gunshot_Wounds_to_the_Head_Do_Not.20.aspx



> Results: One hundred seventy-four charts were available for review; 90 had C-spine radiographs (complete series [49], lateral [33], and computed tomographic scan [8]). Of 84 with no radiographs, 29 were clinically cleared, and 55 died (32 cleared at autopsy). Twenty-three died without evaluation. None of the remaining 151 (87%) had CSI. Literature search yielded only three relevant articles. Combining the data from these articles yielded 534 patients, and CSI was excluded in 507 (95%).
> 
> Conclusion: C-spine immobilization and diagnostic radiography are probably not necessary in patients with isolated GSWs to the head and may complicate and delay emergency airway management.



http://journals.lww.com/jtrauma/Abs...ury_Associated_with_Gunshot_Wounds_to.11.aspx


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## abckidsmom (Jan 9, 2011)

EMS49393 said:


> Understandable, which is why I keep at least two flat sheets folded on my cot, so I won't have to run back and forth and I can cover up while I'm cutting off.



I can imagine that this was a ridiculously chaotic scene, and I'm willing to bet that the providers who ended up with this patient did not arrive at her side in the conventional manner, with their stretcher and their sheets.  I can also imagine that the number of hands (aids and staff) putting her on the stretcher was insane.

These high-profile scenes are fast, fast moving and full of lots of people who, like that aid who the article was centered on, are jumping in and doing a job they don't really know what they're doing, or how they're helping or hindering the actual providers.

Don't get me wrong, this is great that people are jumping in, but it adds a whole 'nuther dimension to the scene management that they don't always address in MCI class.

Those "helpers" are best dealt with by giving them a task, because they just WON'T be shooed away, and they can become a PR nightmare if you just shoo them off.

So, yes.  She should have had a sheet covering her, but notice that she wasn't completely naked (even though she technically should have been), and I don't see a pair of trained medics taking care of her.  Would your partner have remembered a sheet if you were busy with 4 other things?


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## firecoins (Jan 9, 2011)

JPINFV said:


> Would it be for any GSW to the head, or does the fact that it was through and through make a difference?
> ]



No it would not make a difference.  Body shots also get boarded.  

Studied are nice.  Like to see one larger one than 250 patients.  I would still board and collar despite these studies.


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## JPINFV (Jan 9, 2011)

firecoins said:


> No it would not make a difference.  Body shots also get boarded.
> 
> Studied are nice.  Like to see one larger one than 250 patients.  I would still board and collar despite these studies.




Is there any evidence that isolated GSWs to the head causes spinal injuries?


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## firecoins (Jan 9, 2011)

JPINFV said:


> Is there any evidence that isolated GSWs to the head causes spinal injuries?



you mean other than patients shot in the head with spinal cord injuries?


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## JPINFV (Jan 9, 2011)

So you've had a patient with a through and through wound that was no where near the spinal cord who suffered a confirmed spinal injury?


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## firecoins (Jan 9, 2011)

JPINFV said:


> So you've had a patient with a through and through wound that was no where near the spinal cord who suffered a confirmed spinal injury?



I have pts who were shot in the head with a spinal cord injury. It was not a through and through shot. post edit. I have never spent time on a scene examining the path of a bullet nor do I have time. 

The trauma team can do whatever they want once the patient is theirs but they want the patient on a board and collar until x-rays are taken. Fine with me. thats my protocols.


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## Veneficus (Jan 9, 2011)

*Naked on the table*

That is how acute trauma patients should appear.

It pains me to have to point out to pseudohealthcare providers that there is absolutely nothing more or less special about the body or any part of it.

In the acute phase of an emergent trauma victim, providers do not have the benefit of omniscience need to be able to fully assess the victim. It requires complete visualization and exploration. 

There is absolutely no way for a field provider to know that there were not multiple injuries without a complete exam. From the picture I would say they left far more intact than I would have considering the nature of the event.

Whats more, there is a medical necessity to be able to constantly observe the patient over time. Especially in trauma, if you start noticing electronic gadget changes prior to physical changes, you may be hopelessly behind the curve. In the absence of medical imaging, physical findings are the only findings.

A distending abdomen, tracheal deviation, bleeding from the urogential/rectal orifices, paradoxical chest movement, brusing, etc, are essential findings that can be obscured which may have a definitive impact on the outcome. 

The goal is to save a life and preserve function, not modesty. There is little value or use in a modest dead person. 

There was no way prior to a proper exam to know she was only shot in the head. With all the blood likely around and the screaming pandemonium, tracing bullet tracts is not part of EMS response. 

As for the collar and board, I wouldn't have bothered. if the cord is severed by a high velocity projectile, immoblization will do little for it. If only the vertebrae were involved the natural splinting will take care of it. The soft cot will also allow parspinal compartment expansion for the inevitable inflammatory response or bleeding into the compartment. 

(Don't forget I am not your medical director, so follow your appropriate standing orders)

If you are really still concerned about modesty, rather than wonder about the medics who appropriately didn't use a sheet, perhaps you could be more concerned with the agency that published the picture. 

I won't dispute that it is the role of the media to record and report, the quest for a sensational story should taake into account the suffering of the victims. 

I have never seen a rape victim's photos published, why should a gunshot victim be afforded less courtesy?

In classical Greek theatre, sensationalism is never acted on stage. The story is reported on stage and never acted or portrayed. Perhaps there is a lesson to be learned there?

(I suffer from broad spectrum intelligence and in addition to having actually enjoyed all of those required educational requirements not directly related to my focus, I actually seek them out for the indirect benefits afforded from pulling informtion from multiple applicable disciplines. It is a curse I know.)


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## Shishkabob (Jan 9, 2011)

Honestly, in an MCI where I'm first on scene, a patients modesty is the least of my concern--- all patients living longer is higher up.

In the auto accident I worked last weekend with 1 dead and 8 wounded, the first person to get a sheet was the deceased.





As for C-spine/backboard, we can clear c-spine, but one of the limiting factors is distracting injuries.  Being shot in the head is pretty distracting...


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## JPINFV (Jan 9, 2011)

Is it really clearing c-spine? What other interventions are considered an "automatic" unless the patient's condition tells you otherwise? Aren't we supposed to only provide interventions when they are indiciated, not just when they aren't contraindicated?


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## firecoins (Jan 9, 2011)

JPINFV said:


> Is it really clearing c-spine? What other interventions are considered an "automatic" unless the patient's condition tells you otherwise? Aren't we supposed to only provide interventions when they are indiciated, not just when they aren't contraindicated?



gunshots to the head indicate a possibility of a c-spine problem. some shots more than others may be more indicative of c-spine injuries than others. Putting them on a board helps move them quickly and the doctors want the collar.  So be it.


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## Veneficus (Jan 9, 2011)

firecoins said:


> gunshots to the head indicate a possibility of a c-spine problem. some shots more than others may be more indicative of c-spine injuries than others. Putting them on a board helps move them quickly and the doctors want the collar.  So be it.



considering the structures of the brain and spine that would be damaged from a head shot, if there was damage it would be readily apparent and irreversible. 

You would lose most if not all of your vegatative functions.


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## usalsfyre (Jan 9, 2011)

In this case the cord's been damaged or it hasn't. Remember the purpose of c-spine control is to prevent further injury in the event of spinal fracture. If the the cord (or more likely the hind brain itself in this case) is scrambled, it's a little like closing the barn door after the whole freakin stable has run off.

The only thing that might, maybe, posibly help is an ultra-rapid trip to a surgeon. Screwing around with a board and collar interferes with this, so I've gotta go with no on the board and collar.


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## reaper (Jan 9, 2011)

I agree with use of the board. Not for c-spine, but for movement. Not only easier movement of pt, but to minimize movement of the head. You have brain trauma. Reducing further jarring of the head, can only help. 

Makes it easier movement to stretcher and carrying to HEMS if needed.


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## lightsandsirens5 (Jan 9, 2011)

EMS49393 said:


> Understandable, which is why I keep at least two flat sheets folded on my cot, so I won't have to run back and forth and I can cover up while I'm cutting off.



I'm sorry, but if I have a GSW to the head, unless there are enough hands to cover the pt, your privacy is my third concern, after both of our safety and your life. 

As for why the collar and why remove the clothes, That bullet has an unknown path no matter where the entrance and exit wounds are. It could have bounced around inside before exiting. I read about I guy who was shot in the side of his chest and the bullet came out the top of his head. You never know. Our protocol is any GSW to the head or core gets fully c-spined. Plus, if you have an expert marksman with an automatic weapon, there may be two bullets, one came out, one stayed in, but both entered the same hole. 

Removing the clothes? There could be hidden bullet wounds. I am amazed how well some bullet wounds hide. Expose, expose, expose. There may be more holes. Can't take the chance of missing one. 

That's my take.


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## JPINFV (Jan 9, 2011)

So, the hypothetical bullet won't have enough energy to penetrate the skull a second time (to make the exit) the first time it hits the inside of the skull, but after several bounces (each of which will transfer energy away from the bullet into the surrounding tissue), it will be able to penetrate the skull? 

Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.


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## usalsfyre (Jan 9, 2011)

Y'all do understand that considering where the bullet entered, it would have to pass THROUGH the area of the brain that controls all of the functions your trying to protect with c-spine precautions right? And that the bullet passing through there would DESTROY said areas and functions, before the impulses ever entered the cord? And finally that survival depends on these areas not being disrupted, and swift, successful surgical management of the areas that are?

If anyone can give a convincing argument as to why boarding and collaring is needed that doesn't involve blind adherence to protocol or QA managers, please post it here.


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## Shishkabob (Jan 9, 2011)

usalsfyre said:


> If anyone can give a convincing argument as to why boarding and collaring is needed that doesn't involve blind adherence to protocol or QA managers, please post it here.



Board:  Easier movement

Collar: Better airway control with a tube 





Where's my cookie?


(Granted, they don't have her tubed, but still!)


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## Veneficus (Jan 9, 2011)

In fairness, I cannot think of any surgical intervention that would help with a GSW that destroyed the structures in question.

Even if they were not damaged directly, there is still temporary cavitation and force transfer, as well as blood being toxic to neurons. 

I think such a trajectory would have been an undisputable kill shot, of course then there actually would be a reason to cover the patient with a sheet.


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## usalsfyre (Jan 9, 2011)

lightsandsirens5 said:


> Plus, if you have an expert marksman with an automatic weapon, there may be two bullets, one came out, one stayed in, but both entered the same hole.



Did he come out of the celing on wires too? Because outside of Hollywood this is probably impossible.


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## Journey (Jan 9, 2011)

Linuss said:


> Collar: Better airway control with a tube
> 
> Where's my cookie?
> 
> (Granted, they don't have her tubed, but still!)



The presence of a C-collar will not make intubation easy especially for an inexperienced Paramedic.



JPINFV said:


> So, the hypothetical bullet won't have enough energy to penetrate the skull a second time (to make the exit) the first time it hits the inside of the skull, but after several bounces (each of which will transfer energy away from the bullet into the surrounding tissue), it will be able to penetrate the skull?
> 
> Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.



With 20 people shot, who's to say there was not more than one shooter or what type of weapon was used? Head injuries also bleed a heck of alot and in this type of situation, it may not always be able to clean off all the blood to see the full extent of the injuries. 

A injury to the head will more than likely present with neuro deficits along with being a distracting injury. How long are you going to screw around on scene trying to figure out whether it is just the head injury or if the fall or a bullet had also caused a spinal injury? 

The fact that they were able to stabilize the c-spine, place the patient on the board and get the patient out of the scene should be noted rather than criticizing their choice of using a c-collar. You were not there and you did not do the assessment on this patient.  There is a good chance many here will never even see one gunshot patient up close and here they had 20 to deal with. C-collar or not, the first responders on this scene deserve respect for a tough day and the decisions made based on their assessment rather then criticism from some arm chair EMTs. 

As far as the patient not being covered, there is a good possibility their extra sheets went to others waiting for another ambulance or the medical examiner. 

My deepest condolences to the victims and their families as well as all of those present on this horrific scene.  This was a senseless act and no amount of training may adequately prepare you for a situation like this. All you can do is what you believe is in the best interest of the patient at that time with safety for everyone a concern.


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## Aidey (Jan 9, 2011)

I had a self-inflicted GSW, 9mm, through and through at the temples. Unconscious, pulse, still breathing (with a gag reflex). We boarded and collared him. My MDs first question on reviewing the run with me was "Why on earth was he put on a back board?". He said there is no point in back boarding or collaring an isolated GSW to the head. 

Now, as much as it pains me to agree with Linuss being a cheeky twit , it is true she may have ended up on a back board for movement. 

Journey, are you keeping up with field practice? It is becoming more common for us to put a c-collar on a patient AFTER they are intubated. It minimizes movement and helps keep the neck midline, reducing the chance of dislodgement. That is what Linuss was talking about.


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## mc400 (Jan 9, 2011)

It was a semi auto pistol with a large capacity magazine. The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.


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## mc400 (Jan 9, 2011)

Uh and I forgot. Expose , tape to the board and drive fast. All interventions done en route unless the were critically needed right away. If I was on an engine I would hop in the ambo with thier medic and go. IV/IO en route, etc. Wouldnt be too worried about the collar. Time is what will save the patient in this scenario.


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## Veneficus (Jan 9, 2011)

Journey said:


> A injury to the head will more than likely present with neuro deficits along with being a distracting injury. How long are you going to screw around on scene trying to figure out whether it is just the head injury or if the fall or a bullet had also caused a spinal injury?


 
I think the point being made is that if the bullet did cause a spinal injury, not only would it be readily apparent since the plethora of structures I am too lazy to type out control everything from your breathing, to BP, to HR, voluntary movement and inhibitaory stimulous to name a few. 

The patient would be dead, or an organ donor.

Spinal injury from a fall from standing in a 40 y/o female? I don't believe it for a second.

Maybe I could accept potentially a flexion or extension injury. But that being the case you are still left with a vent dependant quad if things go well.


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## Journey (Jan 9, 2011)

mc400 said:


> The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.



How much is not much? That all depends on what area of the brain was affected, what vessels were disrupted, the amount of swelling and the chance of infection.  Surviving and returning to a normal life can be two very different outcomes.


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## Veneficus (Jan 9, 2011)

mc400 said:


> It was a semi auto pistol with a large capacity magazine. The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.



This is the only info I have seen on the wounds, please post the source that states she was talking on scene.

http://news.yahoo.com/s/ap/us_med_congresswoman_brain_injury


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## Journey (Jan 9, 2011)

Veneficus said:


> I think the point being made is that if the bullet did cause a spinal injury, not only would it be readily apparent since the plethora of structures I am too lazy to type out control everything from your breathing, to BP, to HR, voluntary movement and inhibitaory stimulous to name a few.
> 
> The patient would be dead, or an organ donor.
> 
> ...



So you are saying the EMTs and Paramedics treated this woman all wrong?  

I've seen several spinal injuries in patients a lot younger and with what seemed like minor falls. It all depends on their body position and what they hit on landing. I've also seen irreversible damage done from just bending an picking up a pick of paper.  Just because you think the patient might be a vent dependent quad is no reason to blow off doing a thorough assessment and packaging per your protocols to still try to preserve some function. There is a vast difference in function with what an incomplete vs a complete quad can be rehabilitated to.   

Blanket statements like yours could cause someone to get lax on an assessment and do the wrong thing.  

You might also consider how a patient with a pontine injury or stroke might present. Locked in does not mean they are dead or an organ donor.


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## Aidey (Jan 9, 2011)

Veneficus said:


> Spinal injury from a fall from standing in a 40 y/o female? I don't believe it for a second.



Can that be amended to "healthy 40 y/o female?" I know horses vs zebras, but wouldn't there be a remote chance of injury in someone with a severe osteoporosis process such as OI, poorly managed ESRD, or an eating disorder?



Veneficus said:


> This is the only info I have seen on the wounds, please post the source that states she was talking on scene.
> 
> http://news.yahoo.com/s/ap/us_med_congresswoman_brain_injury



The CNN interview I'm watching currently is with a MD was at the event who says she was alert and conscious but unable to speak, so she was communicating by squeezing his hand. He said she was responsive and interactive the whole time he was with her. The guys name is Dr. Steven Rayle.


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## lightsandsirens5 (Jan 9, 2011)

JPINFV said:


> So, the hypothetical bullet won't have enough energy to penetrate the skull a second time (to make the exit) the first time it hits the inside of the skull, but after several bounces (each of which will transfer energy away from the bullet into the surrounding tissue), it will be able to penetrate the skull?




Actually yes. Let's assume a medium velocity FMJ round. Passes through the skull and enters the brain, it then strikes the inside of the skull at a shallow angle and ricochets away, much like a stone striking the surface of the water at high speed and shallow angle, it skips. Now you have a projectile, still inside the brain bucket, on a completely different course as before. It still has plenty of energy to penetrate the skull if it strikes it at a more acute angle. Now is it is a JHP, in all probability the round has mushroomed so much going through the skull, it will remain inside unless fired at a very short range. 



Not to knock you or anything, but can you prove the above is impossible? I am looking for a link, but I have heard stories of soldiers shot in the head who had rounds enter the skull, pass generally around the brain by ricocheting around the inside of the skull and re-emerging almost directly opposite the entrance. They survive generally neurologically intact. As soon as I can find a link, I'll post it.     




JPINFV said:


> Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.




I can try to get one made. My dad, a former Navy SEAL, has put several rounds in a nickle sized group in moving targets inside kill houses during training. (I don't know how good he is any more. He has been retired for a while now) 



But Machine Pistols exist that have cyclic rates of 2200 plus per minute. That is over 36 rounds per second. It is very possible. 







usalsfyre said:


> Did he come out of the celing on wires too? Because outside of Hollywood this is probably impossible.




Lol. No. See above.


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## Aidey (Jan 9, 2011)

Journey said:


> I've also seen irreversible damage done from just bending an picking up a pick of paper.



And now we are back to back boarding everyone. 

Oh wait, we're talking about preventing secondary injury here. Something that c-collars and back boards have yet to be proven beneficial for.


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## Journey (Jan 9, 2011)

Aidey said:


> The CNN interview I'm watching currently is with a MD was at the event who says she was alert and conscious but unable to speak, so she was communicating by squeezing his hand. He said she was responsive and interactive the whole time he was with her. The guys name is Dr. Steven Rayle.



It was also stated that she was on a ventilator and heavily sedated. The assessment they mentioned was during a sedation vacation for a neurological exam. They will do these periodically. If there is any change, she will probably get a CT Scan and/or go back to the OR.


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## Journey (Jan 9, 2011)

Aidey said:


> And now we are back to back boarding everyone.
> 
> Oh wait, we're talking about preventing secondary injury here. Something that c-collars and back boards have yet to be proven beneficial for.



Ever hear of assessments rather than allowing blanket statements dictate your treatment?

What would you have done for Congresswoman Giffords? Ask her if she could walk to the ambulance?  Maybe that could have been a possibilty but obviously the EMTs and Paramedics on this scene did not feel it was. 

Some have already explained that a backboard is a decent means to get a patient moved to the stretcher and maybe a helicopter. Based on these EMTs and Paramedics' assessment, they may also have felt a c-collar was warranted.  You weren't there.  I wasn't either but in this situation, if they felt a backboard and c-collar was appropriate, so be it. They had enough to worry about with the cameras and knowing some EMT forum would be critiquing all their moves.


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## JPINFV (Jan 9, 2011)

Journey said:


> With 20 people shot, who's to say there was not more than one shooter or what type of weapon was used? Head injuries also bleed a heck of alot and in this type of situation, it may not always be able to clean off all the blood to see the full extent of the injuries.


Ok, so hypothetically multiple gun shot wounds. A backboard doesn't help with bleeding control from the head nor examination, hence being a fairly moot point. Alternatively, are you suggesting that there was a bullet someplace else that, for what ever reason, they might have missed and, because they might have missed a bullet that could have impacted the spine that they should have implemented spinal immobilization just in case? 



> A injury to the head will more than likely present with neuro deficits along with being a distracting injury. How long are you going to screw around on scene trying to figure out whether it is just the head injury or if the fall or a bullet had also caused a spinal injury?


So every neuro deficit or every distracting injury should get immobilized? Does this include atramatic patients, or should we consider what exactly the mechanism of injury is? Sure, no mechanism should be an automatic, but if the mechanism is such to make winning the lottery more likely than a vertebral injury, then I think it's safe to say that the patient doesn't need to be immobilized. 



> The fact that they were able to stabilize the c-spine, place the patient on the board and get the patient out of the scene should be noted rather than criticizing their choice of using a c-collar. You were not there and you did not do the assessment on this patient.  There is a good chance many here will never even see one gunshot patient up close and here they had 20 to deal with. C-collar or not, the first responders on this scene deserve respect for a tough day and the decisions made based on their assessment rather then criticism from some arm chair EMTs.


Oh, that's right. I'm sorry, I forgot that unless you were there you can't examine what exactly was done. After all, it's not like we can't learn from what was done and discuss the whys or why nots. Nope, we might step on someone's fragile ego and we can't have that now, can we. 

Oh, for the record, what are your thoughts on the Michael Jackson trial? Keep in mind that you weren't there when forming any thoughts.


----------



## usalsfyre (Jan 9, 2011)

Veneficus said:


> In fairness, I cannot think of any surgical intervention that would help with a GSW that destroyed the structures in question.
> 
> Even if they were not damaged directly, there is still temporary cavitation and force transfer, as well as blood being toxic to neurons.
> 
> I think such a trajectory would have been an undisputable kill shot, of course then there actually would be a reason to cover the patient with a sheet.



If the lower brain is involved, I agree the outcome is a forgone conclusion. However, if it's not, the only hope for a future that doesn't involve having the mental capacity of things planted in a garden (or for that matter death) is rapid control of the damaged tissue. Whatever damage that has already occured is done, you have to focus on preventing secondary injury (inflamation, hypoxia, ect). Is my thinking correct?


----------



## JPINFV (Jan 9, 2011)

Journey said:


> Some have already explained that a backboard is a decent means to get a patient moved to the stretcher and maybe a helicopter. Based on these EMTs and Paramedics' assessment, they may also have felt a c-collar was warranted.  You weren't there.  I wasn't either but in this situation, if they felt a backboard and c-collar was appropriate, so be it. They had enough to worry about with the cameras and knowing some EMT forum would be critiquing all their moves.



The question is, "Why did they feel it was necessary?" If the answer is, "mechanism of injury," then the issue comes down to the EMS myth of spinal immobilization being some sort of magical treatment for all trauma patients regardless of actually considering whether a spinal injury is likely.


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## Veneficus (Jan 9, 2011)

Journey said:


> So you are saying the EMTs and Paramedics treated this woman all wrong?



Not at all, scene to surgery in 38 minutes. Seems like outstanding work. 

What I am saying is that the board and collar may have been superfulous and I would not have done it, had I been making the decisions. 

I do not see how that criticizes the efforts of the responders. I think you may need to concentrate a little more on what is said vs what you seem to want to think is said.  



Journey said:


> I've seen several spinal injuries in patients a lot younger and with what seemed like minor falls. It all depends on their body position and what they hit on landing. I've also seen irreversible damage done from just bending an picking up a pick of paper.



Let's stick with the GSW patient we are talking about rather than infinite "what ifs." I don't have the time or the motivation to type out every possible outcome to every possible scenario when making a comment on a thread. If people reading this cannot figure out that in all of medicine there are no absolutes or If:Then, but rather sometimes:maybe:depends, then they are retards who have no place in healthcare.



Journey said:


> Just because you think the patient might be a vent dependent quad is no reason to blow off doing a thorough assessment and packaging per your protocols to still try to preserve some function.



Let's pretend for a moment, that I don't actually put patients on spineboards.   Let us take it a bit farther and assume I don't actually blindly follow guidlines without clinical judgement. And for the final coup de gras, let's assume that based on my rather respectable medical education, I don't actually believe spineboards do anything to help and nobody has put forth any evidence or study that they do. Just conjecture based on opinion formulated more than 30 years ago.
(pay no attention to the sarcasm)

But if you read even my comments in this thread, you might notice that I carry the banner for assessment. It also may have escaped your attention that immobilizing a spine has very little to do with actual assessment. Some mechanism perhaps, but totally unreliable.




Journey said:


> There is a vast difference in function with what an incomplete vs a complete quad can be rehabilitated to.



So what? It is still a considerable decline from preinjury function, which was the point of my statement.   



Journey said:


> Blanket statements like yours could cause someone to get lax on an assessment and do the wrong thing.



I don't see how any of my comments could possibly cause somebody to be lax in assessment. They usually like in this case, call for people to give more indepth consideration to the index of suspicion.  



Journey said:


> You might also consider how a patient with a pontine injury or stroke might present. Locked in does not mean they are dead or an organ donor.



Consider what? It doesn't alter the fact that the preinjury state will never return.

I am afraid your attempts at obscure disease processes doesn't impress me. It seems a rather pityful attempt to sound smart to me, and attempt to interject some points about the unpredictable prognosis of a handful cases as a way to refute my statements which you did not address but perverted into some false argument. 

My blanket statement stands. I'll use small words. The quality of life for somebody suffering significant brain or cord damage really sucks.

Unless you can produce a patient that says their life is better and they would rather be paralyzed than fully functional, I am not convinced that the ability to restore the most meanial of function should be considered an outstanding success. I have never put much value in measuring success as better than yesterday. The unyielding goal is perfection, and though it is currently unobtainable, it doesn't make it less the measure. 

Save your delusions. These replies are so outrageous, you have been placed on ignore.

"People can change." 

I will not stipulate, show me the evidence.


----------



## EMDispatch (Jan 9, 2011)

JPINFV said:


> Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.



I've seen autopsy reports (granted involving automatic weapons) where there have been several more bullets in the victim than entry wounds. One was something like 50 entry wounds and 65 bullets.


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## Aidey (Jan 9, 2011)

Journey said:


> It was also stated that she was on a ventilator  and heavily sedated. The assessment they mentioned was during a sedation  vacation for a neurological exam. They will do these periodically. If  there is any change, she will probably get a CT Scan and/or go back to  the OR.



By _"at the event"_, I meant a doctor who was on scene, attending  the event, who is reporting on how she was acting on scene. This was a  direct reply to Vene, who was asking someone to cite the source that  said she was talking on scene. She wasn't, nor would I expect her to be.  In fact, based on the information known I will be somewhat surprised if  she can recover her ability to speak. The path of the bullet appears to  have taken out Broca's area, and depending on what source you listen  to, it may have hit Wernicke's too. Granted she may be one of those  people who have speech lateralized to the right side of the brain, and  she wasn't able to speak for other reasons, but I digress.




Journey said:


> Ever hear of assessments rather than allowing blanket statements dictate your treatment?
> 
> What would you have done for Congresswoman Giffords? Ask her if she could walk to the ambulance?  Maybe that could have been a possibilty but obviously the EMTs and Paramedics on this scene did not feel it was.
> 
> Some have already explained that a backboard is a decent means to get a patient moved to the stretcher and maybe a helicopter. Based on these EMTs and Paramedics' assessment, they may also have felt a c-collar was warranted.  You weren't there.  I wasn't either but in this situation, if they felt a backboard and c-collar was appropriate, so be it. They had enough to worry about with the cameras and knowing some EMT forum would be critiquing all their moves.



Ever hear of sarcasm? What the rest of us are talking about is assessment based treatment. Not automatically performing a procedure  based on "ZOMG SHE FELL!". That also means not automatically not performing a procedure based on a questionable "MOI". Based on the information known in this case people feel a  c-collar and back board were not necessary. As I pointed out I treated a similar case where my MD told me that patient, and others like him, did not need to be automatically back boarded. 

 How are we ever going to get anywhere if we can not discuss scenarios  and the pros and cons of treatment methods? No one here is insulting the  Arizona responders, instead we are discussing alternative options and  the necessity of certain types of treatment based on the information  available. No, none of us were there, but that does not mean we can't discuss the treatment options hypothetically.


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## Veneficus (Jan 9, 2011)

usalsfyre said:


> If the lower brain is involved, I agree the outcome is a forgone conclusion. However, if it's not, the only hope for a future that doesn't involve having the mental capacity of things planted in a garden (or for that matter death) is rapid control of the damaged tissue. Whatever damage that has already occured is done, you have to focus on preventing secondary injury (inflamation, hypoxia, ect). Is my thinking correct?



I think your thinking is sound.

My point is with the damage that would likely have happened in such a scenario, I think that preventing secondary injury is a moot point.


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## Aidey (Jan 9, 2011)

Interesting tid bit. Still have CNN on for the noise, and they are interviewing one of her Interns, who was a CNA. He says he sat her up on scene to keep the blood from going in her mouth.


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## Journey (Jan 9, 2011)

Veneficus said:


> Unless you can produce a patient that says their life is better and they would rather be paralyzed than fully functional, I am not convinced that the ability to restore the most meanial of function should be considered an outstanding success. I have never put much value in measuring success as better than yesterday. The unyielding goal is perfection, and though it is currently unobtainable, it doesn't make it less the measure.
> 
> Save your delusions. These replies are so outrageous, you have been placed on ignore.
> 
> ...



I don't kwow what your education or experience is but it definitely lacks in neuro situations. Strokes and brain injuries including those to the pontine region are not that rare. Spinal cord injuries happen to all ages including infants. You as an EMT do not have the right to determine what a patient wants on scene to alter your treatment and cause death.  I find your assessment of this situation and your blanket statements to be ridiculous.


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## lightsandsirens5 (Jan 9, 2011)

Journey said:


> I don't kwow what your education or experience is but it definitely lacks in neuro situations. Strokes and brain injuries including those to the pontine region are not that rare. Spinal cord injuries happen to all ages including infants. You as an EMT do not have the right to determine what a patient wants on scene to alter your treatment and cause death.  I find your assessment of this situation and your blanket statements to be ridiculous.



Whoa, whoa, whoa! Don't talk that way to one of the smartest people on the forum please. 

Lets not turn this into a war, thus getting the thread locked and preventing valuable and constructive discussion on this subject. I know I am not an admin, but you all know what I say is true. B)


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## ffemt8978 (Jan 9, 2011)

lightsandsirens5 said:


> Whoa, whoa, whoa! Don't talk that way to one of the smartest people on the forum please.
> 
> Lets not turn this into a war, thus getting the thread locked and preventing valuable and constructive discussion on this subject. I know I am not an admin, but you all know what I say is true. B)



Believe him ... I've been watching this thread for a while now.


----------



## Journey (Jan 9, 2011)

Aidey said:


> Ever hear of sarcasm? What the rest of us are talking about is assessment based treatment. Not automatically performing a procedure  based on "ZOMG SHE FELL!". That also means not automatically not performing a procedure based on a questionable "MOI". Based on the information known in this case people feel a  c-collar and back board were not necessary. As I pointed out I treated a similar case where my MD told me that patient, and others like him, did not need to be automatically back boarded.



She did not just fall, she was shot and without being at scene we do not know what she might also have struck on her way down. Again, I am not going to judge these EMTs and Paramedics based on a blanket statement from Vene about a woman who is not elderly falling can not have spinal injuries along with the head injury from the bullet.  This is what I meant by doing an assessment and making a clinical judgement. If the EMTs and Paramedics at this scene saw there was a need for spinal immobilization because of what they saw or that they could not determine whether the neuro deficits were only from the head trauma or if there was a spinal injury, who are you to say they are setting EMS backwards by applying a backboard and c-collar.



Aidey said:


> How are we ever going to get anywhere if we can not discuss scenarios  and the pros and cons of treatment methods? No one here is insulting the  Arizona responders, instead we are discussing alternative options and  the necessity of certain types of treatment based on the information  available. No, none of us were there, but that does not mean we can't discuss the treatment options hypothetically.



Discussing scenarios are a great learning tool. But, criticizing those in a very stressful situation for applying a backboard and c-collar is a little over the top.   You don't know what they assessed at scene. A patient can still be talking and show neuro defiicts.  

There is also a lot more treatment done at the hospital even for some CVA patients than what you do in the truck or in the ED.  This woman will spend time on a ventilator and may go back to the OR again. She definitley will go back to have her skull replaced later. Her rehab will also be extensive even it this is what some neuro specialists will consider a lucky strike. 

Considering the magnitude of this situation, maybe sarcasm and the cutesy humor might not be appropriate for this discussion. Yes, laughter is great medicine but there is a time and place. Jokes, sarcasm and criticisms directed at the providers in this situation is distasteful at all levels.  Maybe another thread would be more appropriate for sarcasm and jokes.


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## Journey (Jan 9, 2011)

This thread probably should be locked and removed due to the lack of respect for the providers at this Arizona scene who did what they thought was best for the patient.  A thread not directly related to this scene should have been started to discuss the criticisms of spinal immobilization.


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## jjesusfreak01 (Jan 9, 2011)

Journey said:


> This thread probably should be locked and removed due to the lack of respect for the providers at this Arizona scene who did what they thought was best for the patient.  A thread not directly related to this scene should have been started to discuss the criticisms of spinal immobilization.



We already have many threads about spinal immobilization. They are simply applying their opinions to a real life situation.

@Aidey, thanks for pulling out that the aid was a CNA. It sounded like there was some medical training there, I just couldn't tell what.


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## ffemt8978 (Jan 9, 2011)

Journey said:


> This thread probably should be locked and removed due to the lack of respect for the providers at this Arizona scene who did what they thought was best for the patient.  A thread not directly related to this scene should have been started to discuss the criticisms of spinal immobilization.



You're free not to participate in this thread if you don't want to, but at this point I do not see a reason to lock this thread simply because a discussion of spinal immobilization is associated with a well publicized and emotional event.  The fact of the matter is that the thread title is directly associating spinal immobilization with this shooting means that the events of this incident are a part of the discussion.

That being said, I do feel that some of the posts have come inappropriately close to specifically criticizing the responders on scene for their actions based upon information that only they have access to.  We weren't there, we didn't see what they saw, and we don't have access to the reasons for their actions.

Based upon that, this thread may continue as long as it is used in an educational matter.  General comments and criticisms of treatment procedures in a general matter will be allowed.  Specific criticisms of a specific treatment for this incident will not.


----------



## Aidey (Jan 9, 2011)

Journey said:


> She did not just fall, she was shot and without being at scene we do not know what she might also have struck on her way down. Again, I am not going to judge these EMTs and Paramedics based on a blanket statement from Vene about a woman who is not elderly falling can not have spinal injuries along with the head injury from the bullet.  This is what I meant by doing an assessment and making a clinical judgement. If the EMTs and Paramedics at this scene saw there was a need for spinal immobilization because of what they saw or that they could not determine whether the neuro deficits were only from the head trauma or if there was a spinal injury, who are you to say they are setting EMS backwards by applying a backboard and c-collar.


 
This is exactly what I have to say on the subject:



JPINFV said:


> The question is, "Why did they feel it was  necessary?" If the answer is, "mechanism of injury," then the issue  comes down to the EMS myth of spinal immobilization being some sort of  magical treatment for all trauma patients regardless of actually  considering whether a spinal injury is likely.



I'm pretty sure that I also brought up scenarios in which a younger person would be more likely to sustain an injury when falling from standing. Also Vene did not say "Fall from standing and hitting their head" or any of the other exceptions you have pointed out. Index of suspicion for a spinal injury in a healthy individual who fell from standing to the ground without any additional impacts on the way down is very low. 

In a hypothetical case where someone is shot and then falls down we are looking at 2 separate MOIs, a GSW and a fall. In a situation with an isolated GSW to the head, followed by a fall from standing neither of the MOIs individually appear to warrant spinal precautions being taken, so I'm not sure why both of them together would. 

It could be argued that the GSW would increase the chances becuase the patient is not likely to do anything to stop themselves from falling. However, that then brings up the issue of all the syncopal, diabetic, CVA and seizure patients that fall from standing and aren't considered a high risk for a spinal injury. So I'm really not convinced the GSW makes it more likely the person would sustain a spinal injury when falling.


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## Melclin (Jan 9, 2011)

JPINFV said:


> http://www.youtube.com/watch?v=YzYxz_uvtSI



God, that made my day. 

One thousands internets for you sir.


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## lightsandsirens5 (Jan 9, 2011)

Aidey said:


> So I'm really not convinced the GSW makes it more likely the person would sustain a spinal injury when falling.



I agree. 

However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.

I know from calls I have run that you have no idea whatsoever where that projectile went while inside the body. You have to be a firearms and forensic ballistics expert to even begin to understand it, in my opinion. But my opinion is not worth much.  

I agree with Vene, or was it JP.....I dunno.......when they said that if the projectile has already severed the spinal column all the c-spine in the world won't help. But there is that slight chance that the projectile has fractured a vertebra and not severed the spinal cord. I know the benefits of c-spine are debated, but my protocols say that a suspected spine injury gets c-spined, so that is what I will do for now.


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## usafmedic45 (Jan 9, 2011)

> pass generally around the brain by ricocheting around the inside of the skull and re-emerging almost directly opposite the entrance


I wouldn't call a bullet that rides around the inner table of the skull like a bobsleder in the chute "ricocheting".  It's well documented as having happened (not to mention that I have seen it personally) but it's not a "ricochet" which would imply an uncontrolled careening of the round inside the skull which would result in the brain being damaged.  Also keep in mind that even if the round does ride the curve of the skull around, it doesn't mean that it's not doing a tremendous amount of damage in the process.  The shockwave can inflict a significant contusion to the cerebrum or damage to the blood vessels supplying the brain (most notably the bridging veins).


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## Aidey (Jan 9, 2011)

lightsandsirens5 said:


> I agree.
> 
> However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.
> 
> ...



*shrug* My medical director has said it is not necessary to c-spine isolated GSWs to the head with a trajectory that does not involve the spinal area. The specific patient he was talking about was unconscious, so we weren't even able to assess for deficits.


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## JPINFV (Jan 9, 2011)

Journey said:


> Discussing scenarios are a great learning tool. But, criticizing those in a very stressful situation for applying a backboard and c-collar is a little over the top.   You don't know what they assessed at scene. A patient can still be talking and show neuro defiicts.


Criticizing? Who is doing that? There's a lively discussion on the merits of c-spine in patients suffering a gun shot to the head, but I don't see anyone saying that what these EMTs and paramedics did was tantamount to malpractice. There's a huge gray zone between perfection and malpractice and our (collective as health care providers) is to be closer to perfection than malpractice. The second any of us begin to believe that our care is not worthy of discussion or debate because we're perfect is the second that that individual needs to get out of health care. This is doubly true for a field such as EMS that too often relies on blanket rules, such as anyone with a mechanism gets a back board regardless of assessment. 

Personally, I welcome people questioning any care that I provide. If I cannot justify it with a reasonable medical assessment on why a patient needs a specific treatment, than it's very likely that I shouldn't have administered or ordered that treatment. No health care professional, paraprofessional, or technician should ever be beyond question or reproach regardless of the combination of the letters behind his or her name. 

What's especially troublesome is that you are questioning the need to have a discussion on the care provided on a discussion board. If all this board was supposed to be was mindlessly patting each other on the butt for being in health care, then I could just as easily get that fix watching football. Thankfully, there's more to discussions than that. 




> Considering the magnitude of this situation, maybe sarcasm and the cutesy humor might not be appropriate for this discussion. Yes, laughter is great medicine but there is a time and place. Jokes, sarcasm and criticisms directed at the providers in this situation is distasteful at all levels.  Maybe another thread would be more appropriate for sarcasm and jokes.



If you're so uptight, why be involved with a discussion at all regarding it. After all, what sort of discussion is there if everyone has the same opinion?

In regard to the distastfulness of discussing the incident and, in some cases (I take it a reference to the Mechanism of Injury video), sometimes the best way to expose the insanity of a concept is with parody. If that's too much, then...


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## lightsandsirens5 (Jan 9, 2011)

Aidey said:


> *shrug* My medical director has said it is not necessary to c-spine isolated GSWs to the head with a trajectory that does not involve the spinal area. The specific patient he was talking about was unconscious, so we weren't even able to assess for deficits.



Well, you may have a better med director than I do!  I see you reasoning believe me. 

I just don't agree totally with my med dir or totally with you. That's all. Hope you don't mind. 

~~~~~~~~~~

uasf: I stand corrected. My choice of words was inappropriate.


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## usafmedic45 (Jan 9, 2011)

> Criticizing? Who is doing that?



I read his response as "You don't agree with me, so you are criticizing _____".   It seems to be a matter of perspective and whether one believes in constructive criticism or not.


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## usafmedic45 (Jan 9, 2011)

> uasf: I stand corrected. My choice of words was inappropriate.



No worries.  Just figured I would clarify what actually happens in the circumstance you were describing since I have seen it firsthand.


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## JPINFV (Jan 9, 2011)

lightsandsirens5 said:


> I agree.
> 
> However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.



However, not all energy transferred is the same. A pick axe delivering and a sledge hammer is going to transfer the energy differently. Similarly, a bullet which pierces a bone is going to transfer much less energy than one that lodges in a bone. Especially with a through and through where the bullet distributes the remaining energy elsewhere after leaving.


----------



## JPINFV (Jan 9, 2011)

usafmedic45 said:


> I wouldn't call a bullet that rides around the inner table of the skull like a bobsleder in the chute "ricocheting".  It's well documented as having happened (not to mention that I have seen it personally) but it's not a "ricochet" which would imply an uncontrolled careening of the round inside the skull which would result in the brain being damaged.  Also keep in mind that even if the round does ride the curve of the skull around, it doesn't mean that it's not doing a tremendous amount of damage in the process.  The shockwave can inflict a significant contusion to the cerebrum or damage to the blood vessels supplying the brain (most notably the bridging veins).



However does any of those scenarios (the richochet, the bobsled, or the in and out) change the need for spinal immobilization. Just because the damage is great or minor to the brain doesn't change how immobilization works.


----------



## JPINFV (Jan 9, 2011)

usafmedic45 said:


> I read his response as "You don't agree with me, so you are criticizing _____".   It seems to be a matter of perspective and whether one believes in constructive criticism or not.



Alternatively, maybe medicine isn't as straight forward as we (collective "we") would like it to be.


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## usafmedic45 (Jan 9, 2011)

JPINFV said:


> However does any of those scenarios (the richochet, the bobsled, or the in and out) change the need for spinal immobilization. Just because the damage is great or minor to the brain doesn't change how immobilization works.


Effectively, it does not.  Personally, my main concern would be with the collar being applied too tight and compressing the superficial veins that drain the head.  Other than that, I see no harm in putting a C-collar on this patient.


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## lightsandsirens5 (Jan 9, 2011)

JPINFV said:


> However, not all energy transferred is the same. A pick axe delivering and a sledge hammer is going to transfer the energy differently. Similarly, a bullet which pierces a bone is going to transfer much less energy than one that lodges in a bone. Especially with a through and through where the bullet distributes the remaining energy elsewhere after leaving.



Exactly. I did not say that very well. I am not saying the impact with the head itself is enough to cause spinal injury. Just stating that there is a lot of energy behind that projectile and it will do unexpected things. 

I am by no means an expert in ballistics and firearms, so I am wide open to any correction on things I say. I appreciate it actually.


----------



## usafmedic45 (Jan 9, 2011)

JPINFV said:


> Alternatively, maybe medicine isn't as straight forward as we (collective "we") would like it to be.


Of course it's not.  I was just commenting on the vibe I picked up from the posts you were responding to.


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## reaper (Jan 9, 2011)

Ok ladies and gentlemen,
There are valid points all the way around.

I do not agree with boarding every pt. A pt should be assessed and determined to have a factor for spinal immobilzation. 

Now, there are maybe a handful of providers here that have ever worked a MCI shooting. I myself have worked 3 in 22 years. When you are in a situation like this, you do not have the luxury of being able to perform a full neuro assessment. The time is not there for this to happen. So you do the next best thing. You expect the worst and package them fully for transport and get them en route to a trauma center. If this was a single shooting. You may have more leeway on this option. 

Next, most services that have a spinal clearance protocol all follow the same standards for field clearance. In that standard is one little catch! "No distracting injuries". A GSW to the head is a very distracting injury. So, that kinda takes the clearance out of the equation. 

So let's be objective to all sides of the argument and not let personal feelings towards a poster, get in the way of a good discussion.


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## JPINFV (Jan 9, 2011)

usafmedic45 said:


> Of course it's not.  I was just commenting on the vibe I picked up from the posts you were responding to.



I was agreeing with you and offering another alternative. I'll offer that immobilizing this patient would not be wrong (in the sense of malpractice "wrong"), just not the best treatment. Essentially good care, just not ideal care.


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## ffemt8978 (Jan 9, 2011)

JPINFV said:


> I was agreeing with you and offering another alternative. I'll offer that immobilizing this patient would not be wrong (in the sense of malpractice "wrong"), just not the best treatment. Essentially good care, just not ideal care.



And therein is the crux of this discussion.


----------



## Shishkabob (Jan 9, 2011)

Journey said:


> The presence of a C-collar will not make intubation easy especially for an inexperienced Paramedic.



A) I never said, or implied, the first part.

B )  Where does the second part even come from?


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## lightsandsirens5 (Jan 9, 2011)

reaper said:


> So let's be objective to all sides of the argument and not let personal feelings towards a poster, get in the way of a good discussion.



No personal feelings here. ^_^

You make some excellent points that completely escaped me earlier. Thanks. 

I have never worked a scene with more than one GSW pt. So I am sorely lacking in the _multiple-critical-GSW-pt-adrenaline-rush-general-chaos-and-triage-scene-experience _department. 

(In addition to multiple other departments. )


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## lightsandsirens5 (Jan 9, 2011)

Linuss said:


> A) I never said, or implied, the first part.
> 
> *B )  Where does the second part even come from?*



Linuss's hackles are up. h34r:


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## JPINFV (Jan 9, 2011)

reaper said:


> Next, most services that have a spinal clearance protocol all follow the same standards for field clearance. In that standard is one little catch! "No distracting injuries". A GSW to the head is a very distracting injury. So, that kinda takes the clearance out of the equation.



I think there's another way to look at this. Before a spinal clearance protocol can be put into place, spinal immobilization needs to be indicated first. Is spinal immobilization indicated in a patient with a gun shot wound? If it's not indicated, like a patient with a significant mechanism (again, do we routinely consider immobilizing children who slip and fall?), then there's no reason to rule it out with a clinical decision making tool like NEXUS.


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## usafmedic45 (Jan 9, 2011)

lightsandsirens5 said:


> Linuss's hackles are up. h34r:


I'll get the popcorn.


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## reaper (Jan 10, 2011)

> > Next, most services that have a spinal clearance protocol all follow the same standards for field clearance. In that standard is one little catch! "No distracting injuries". A GSW to the head is a very distracting injury. So, that kinda takes the clearance out of the equation.
> 
> 
> 
> ...



Well, the problem there is most medical directors are still including full immobilization for any GSW to head or trunk, in there protocols. Until a significant study produces evidence to the contrary, most will continue to do so. 

So then you are looking at a clearance issue.


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## abckidsmom (Jan 10, 2011)

reaper said:


> Now, there are maybe a handful of providers here that have ever worked a MCI shooting. I myself have worked 3 in 22 years. When you are in a situation like this, you do not have the luxury of being able to perform a full neuro assessment. The time is not there for this to happen. So you do the next best thing. You expect the worst and package them fully for transport and get them en route to a trauma center. If this was a single shooting. You may have more leeway on this option.



Absolutely.  I've not done more than a 5 patient shooting, but there was a whole lot of LET'S GET THESE PEOPLE OFF THE SCENE RIGHT NOW.  And none of those scenes lasted more than 15 minutes once we made patient contact.

Best thing or not the best thing, getting a patient boarded takes as long as stripping them completely and looking for more holes.  Giving yourself 1.5 -2 full minutes to really look the patient all over and get them immobilized is completely a fair game.


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## Aidey (Jan 10, 2011)

Just because the protocol says it is so, is it really so? Going with the less-is-more school of medicine where are the studies saying spinal immobilization is indicated in those patients? To me to makes more sense to prove that an intervention is necessary than prove that it is not.


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## lightsandsirens5 (Jan 10, 2011)

usafmedic45 said:


> I'll get the popcorn.



I got soda pop! 

/end of hijack


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## ParaPrincess904 (Jan 10, 2011)

mc400 said:


> The congress woman was talking on scene and prior to surgery.



The article quoted the intern, who said she was not talking. Alert, but unable to talk, so the possibility for injury is there, is it not?


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## Aidey (Jan 10, 2011)

What kind of injury are you talking about? 

A brain injury, definitely. A spinal cord injury, not so much. She was shot on the left side of the head. In most people the language areas are lateralized to the left side of the brain, making it very likely one or both of the main language areas were damaged.


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## usalsfyre (Jan 10, 2011)

Another thought is it is impossible to elevate the head of the bed to 30 degrees, which can help reduce ICP, if the patient is on a spine board. 
(Don't have references right now, let me get coffee)


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## CAOX3 (Jan 10, 2011)

I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area, I understand and even agree with the research, however we work in systems designed by others more educated, so as I may disagree with some decisions they really are not mine to make.  I don't have a problem with these providers decision and I certainly am not second guessing their actions.   

Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury.  So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.

If you have a problem with a protocol or SOP then gather the information and present your case to medical direction.  Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope.  A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.


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## usalsfyre (Jan 10, 2011)

CAOX3 said:


> I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area



Of course



CAOX3 said:


> I understand and even agree with the research, however we work in systems designed by others more educated,



HIGHLY debatable. Even if someone holds a medical degree if they haven't kept up with current research and practice I'd be hard pressed to consider them "more educated" in our area of specialty. 



CAOX3 said:


> so as I may disagree with some decisions they really are not mine to make.  I don't have a problem with these providers decision and I certainly am not second guessing their actions.



I don't think anyone has a "problem" per say, just pointing out that the LSB may have been pointless. 



CAOX3 said:


> Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury.  So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.



Define distracintg injury (which very few people are able to do BTW). Is she able to participate in an exam calmly? Just because it's distracing to us doesn't mean it is to her. Is CQI interested in why a descion was made and correcting flaws, or just hammering people because they "broke protocol"? The former is real quality improvment, unfortunately the latter is standard EMS QI/QA



CAOX3 said:


> If you have a problem with a protocol or SOP then gather the information and present your case to medical direction.  Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope.  A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.



Good advice.


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## JPINFV (Jan 10, 2011)

CAOX3 said:


> I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area,



I completely disagree. The ideal treatment is the ideal treatment. The question is, does your system recognize and allow for the ideal treatment. Just because a system is behind in the times does not mean that what they mandate is automatically ideal. So the question still remains, does the ideal treatment plan for this patient include spinal immobilization?



> I understand and even agree with the research, however we work in systems designed by others more educated, so as I may disagree with some decisions they really are not mine to make.


So because others are more educated, their decisions are automatically beyond question? Especially for interventions with a large psychomotor component and plenty of short cuts (like spinal immobilization), provider  buy-in is drastically important. Doing immobilization just for show is useless, and if providers feel that it isn't important, but because the protocol has to be followed regardless of assessment, then they are more likely to take shortcuts. Beware of the system where asking "Why?" is discouraged. 



> Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury.  So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.


Again, what is the indication for c-spine? A bullet wound? Now the serious question is, "Is spinal immobilization beneficial (thus indicated) in a gun shot victim?" You can't clear someone from an intervention that was never indicated in the first place. 




> If you have a problem with a protocol or SOP then gather the information and present your case to medical direction.  Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope.  A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.



Who is advocating flying by the seat of their pants? Is suggesting that people make an assessment and form a treatment plan based on assessment and index of suspicion instead of blindly following a protocol the same as advocating flying by the seat of their pants? Finally, if protocols are supposed to be followed without question, are paramedics and EMTs really "professionals" or are they simply technicians? 

Does the treatment plan change because of it being high profile? Should medical providers do things just to make it look like they're doing something because cameras are on scene?


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## terrible one (Jan 10, 2011)

I'd love to see the day EMS moves beyond a plastic c-collar, some tape and a rigid board for what it calls 'cervical immobilization'


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## jrm818 (Jan 10, 2011)

usalsfyre said:


> Of course
> 
> Define distracintg injury (which very few people are able to do BTW). Is she able to participate in an exam calmly? Just because it's distracing to us doesn't mean it is to her. Is CQI interested in why a descion was made and correcting flaws, or just hammering people because they "broke protocol"? The former is real quality improvment, unfortunately the latter is standard EMS QI/QA



And NEXUS is explicitly designed to be used as a decision tool (the way you describe) not as a strict protocol.

In the NEXUS criteria, "distracting" was left intentionally undefined for the reason you state.  It was decided that there was too much clinical variation to create an all-encompassing list of objectively distracting vs. non-distracting injuries, (not that anyone would realistically remember the entire list if they did), and instead the rule requires that a provider utilize good assessment, clinical judgment, and their gestalt to determine if a patient is eligible.


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## usalsfyre (Jan 10, 2011)

jrm818 said:


> And NEXUS is explicitly designed to be used as a decision tool (the way you describe) not as a strict protocol.
> 
> In the NEXUS criteria, "distracting" was left intentionally undefined for the reason you state.  It was decided that there was too much clinical variation to create an all-encompassing list of objectively distracting vs. non-distracting injuries, (not that anyone would realistically remember the entire list if they did), and instead the rule requires that a provider utilize good assessment, clinical judgment, and their gestalt to determine if a patient is eligible.



You hit my point exactly. Two of the terms I find providers have the hardest time defining are "distracing injury" and "agitation".


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## Shishkabob (Jan 10, 2011)

usalsfyre said:


> You hit my point exactly. Two of the terms I find providers have the hardest time defining are "distracing injury" and "agitation".



Well, if you ask Jimmy E at work, EVERYONE is agitated


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## usalsfyre (Jan 10, 2011)

Linuss said:


> Well, if you ask Jimmy E at work, EVERYONE is agitated



Yeah, my threshold for treatment of agitation is a bit uhh, lower than some others. Remeber kiddies, lorazepam makes EVERYONE feel better B).


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## Shishkabob (Jan 10, 2011)

Two vials for me, 1 vial for the patient, 1 vial for the random bystander that stops at the scene 


I much prefer Versed to Ativan... I can give it IV/IO/IM and IN.  Ahh.. IN Benzos... I love you so.


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## firecoins (Jan 10, 2011)

Aidey said:


> What kind of injury are you talking about?
> 
> A brain injury, definitely. A spinal cord injury, not so much. She was shot on the left side of the head. In most people the language areas are lateralized to the left side of the brain, making it very likely one or both of the main language areas were damaged.



how did you rule out a spinal injury?  
how do you know that the bullet didn't fragment into her spine?  or that it was the only gunshot? 
how did you know she did not incure a spinal injury falling to the ground?  

we have the hindsight of doctors with the full array of equipment found in a trauma center.  None of us responded. 

I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute.  I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.


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## Sandog (Jan 10, 2011)

Oops posted to wrong thread...


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## frdude1000 (Jan 10, 2011)

If you were the aid that first treated her, with no equipment, what would you have done?  Would you have lifted her head like he did?


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## Veneficus (Jan 10, 2011)

firecoins said:


> I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute.  I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.



If I could speak on a situation of potential spinal damage that was clearly not the case in this incident??

You arrive on scene of a mass shooting, there are wounded and blood in large quantity.

The triage officer sets you upon a patient deemed "red" for immediate transport. 

You move over to the patient who is vocered in blood, witnesses tell you she was shot in the head.

With a patient whose head and in all likelyhood upper torso is covered in blood, how do you decide the only wound is to the head? 

Do you take the word of the bystander? 

Would your treatment change if there was also a wound to the thorax?

Multiple wounds to the face and neck which could further complicate your treatment of airway and bleeding control?

How do you clear away enough dried or still wet blood to properly assess?

Do you decide the wound looks grevious and forgo a more detailed assessment?

Once boarded and collared, in the back of the moving rig, how to you perform a significant enough exam on the posterior?

From your posts, I would be quite sure you have experience with penetrating wounds. From either a knife or a gun, it is sometimes very difficult to detect or identify small surface wounds caused by them I no doubt think you have experienced. Especially with any quantity of blood.

I don't think that the extent of the injuries cold be assessed even enough for life saving treatment in the back of an ambulance, on an already boarded patient. Privacy or not. (Which is not a concern of mine in a life threatening injury)

As for bullet splinters, it is entirely possible such an event could take place. But the fragments cannot damage a structure without damaging everything in it's path. In the case of a head wound from the posterior, the cerebellum, and entire brain stem would be subject to damage. It the wound was truly a through and through,the midbrain would be destroyed as well. 

Similarly if the projectile entered through the front, the damage would be in reverse order and to enter the spine in addition to the many other critical structures the projectile or even fragment would likely cause massive damage to the basilar artery. 

I don't think it would be likely to have such an injury without obviously apparent findings.

I agree with you that finding all injuries is not important, but finding the lifethreatening ones or ones that would define your treatment certainly would be important, which cannot be done with accuracy or precision on a immobilized patient, in the back of an ambulance.

It would be quite tragic for a responder to be distracted by a spectacular wound to the head, and miss the potential wound to the neck or upper thorax which led to among other complications too numerous to list, things like an open pneumo, carotid dissection, expanding hematoma that comprimises the airway or cerebral circulation, etc, etc.

What's more, how do you reassess over time the neck region or signs like JVD, flattening veins, early tracheal deviation, etc? Those are findings that may develop over time and not be readily apparent on scene. 

As I often say and only partially in jest, you might find yourself with a perfectly protected spine on a dead person.

Do you think the risk of missing a managable life threatening wound is lesser than the possibility of an occult spinal injury? (given the index of suspicion of the structures most likely involved for such a spinal injury to exist?)

I wouldn't call it wrong to immobilize this type of patient, I just don't think it would help.

If I had to choose between taking time to immobilize or doing a more complete exam, I would choose exam. But that is the decision of the individual provider.


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## Veneficus (Jan 10, 2011)

frdude1000 said:


> If you were the aid that first treated her, with no equipment, what would you have done?  Would you have lifted her head like he did?



Absolutely, it sounds as if it was done to protect the airway.


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## Probi (Jan 10, 2011)

im honestly so newb.   But..  
Fall = Collar.   Even if fall is from a GSW

AND

Who knows how Fox News would have anally penetrated them if they did not look like they were being as professional as possible.   Collar looks pro to the average person,  no collar... kinda sounds like a law suit :S  but im so newb so who knows.


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## abckidsmom (Jan 10, 2011)

Veneficus said:


> As I often say and only partially in jest, you might find yourself with a perfectly protected spine on a dead person.
> 
> Do you think the risk of missing a managable life threatening wound is lesser than the possibility of an occult spinal injury? (given the index of suspicion of the structures most likely involved for such a spinal injury to exist?)
> 
> ...



How long does it take you to do an exam?  I really am able to put a high priority on examining while immobilizing.  I completely agree in this case that a single shot to the head with a mentating patient looks pretty unlikely for a c-spine injury, but I bet that board was pretty convenient from the er bed to the ct scanner to the or table.

I groaned when I saw it happen, but there were times when patients were still on backboards when they arrived in our trauma ICU after stops here and there on the radiology floor of the hospital up to 6 hours.  If they were actually sick, sometimes they just weren't stable enough for the turns, and it completely made it easier to move them from place to place.

Hmmm...new marketing gimmick:  Backboards- pallets for people.  

Just watch the pressure ulcers start forming now.


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## Aidey (Jan 10, 2011)

Probi said:


> *Fall = Collar.*   Even if fall is from a GSW



Why?


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## JPINFV (Jan 10, 2011)

I didn't realize that the most important thing about providing good medical care was to make it look like you were doing something.

I didn't realize that Fox News, or any other MSM derermined how we were to practice medicine. 

Have you ever fell down? Did you remember to take c-spine precautions when you did?


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## JPINFV (Jan 10, 2011)

firecoins said:


> how did you rule out a spinal injury?
> how do you know that the bullet didn't fragment into her spine?  or that it was the only gunshot?
> how did you know she did not incure a spinal injury falling to the ground?


I still don't get why anyone has anything buy a low index of suspicion for a spinal injury.



> I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute.  I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.



You take spinal precautions because you have a high index of suspicion that a spinal injury occurred. As such, why would you remove the precautions in side an ambulance bumping down the road?


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## Veneficus (Jan 10, 2011)

abckidsmom said:


> How long does it take you to do an exam?



Depends on what I am examining for, but I am pretty quick and very detailed when it comes to trauma. But it requires things like total exposure and more than the cursory pat down I often see.



abckidsmom said:


> but I bet that board was pretty convenient from the er bed to the ct scanner to the or table.?



I don't see any problem with this at all, but if a provider does not suspect a cspine inujry, and is going to se the LSB for ease of pt. transfer, what is the point securing the head? It forces the constant control and reassessment of the airway, since the pt cannot move to protect it. 

Backboard, slideboard, whatever yo need to move a pt. But if that is the motive, call a spade a spade, and don't try to hide it with some wild "suspicion" of a spinal injury. 



abckidsmom said:


> I groaned when I saw it happen, but there were times when patients were still on backboards when they arrived in our trauma ICU after stops here and there on the radiology floor of the hospital up to 6 hours.  If they were actually sick, sometimes they just weren't stable enough for the turns, and it completely made it easier to move them from place to place.



I once worked for an EMS service that had custom slideboards that fit on the middle 1/3 of the stretcher under the sheet and above the matress, a bit more forgiving than a spineboard, and really made moving easier. I thought it was brilliant.


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## Probi (Jan 10, 2011)

well because in a chaotic situation like that theres no way to tell what happened to your patient on the way down,  or since she was alert but not verbal, theres no way to quickly and effeciently check for nero defecits... so why not play it safe for both parties and just collar?   I mean im a newb though so Im more looking for enlightenment not to challenge an epic pool of knowledge 

And I have fallen before,  But never from a GSW to the skull    Have you?  
and Fox news seems to do what they want for ratings, not for the moralistic presentation of information to the masses. But this Fox news tid bit is TOTALLY irrelevant to the post, and i apologise for that


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## Smash (Jan 10, 2011)

I'm confused.  Not that that is anything new.  I could have sworn that the Launoix and Kaups studies were posted way back on page 2.

So we have some pretty compelling evidence that c-spine injuries do not occur from gunshot wounds to the head (unless, as has been pointed out, ad nauseam) the bullet transects the spinal column, in which case it's lights out anyway. 

Would anybody in the "Yay Spineboard!" camp like to put forward some evidence that a c-collar and spine board are anything other than detrimental in this subset of patients? (hell, in any subset of patients for that matter)


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## CAOX3 (Jan 10, 2011)

It isn't about if we believe that the action its fruitless, its about who you answer too.  Trust me I understand we backboard way to many people  yada, yada, yada  I can't make it any more simple then that.  Its about whet the medical control physician expects of us.  We don't get to change the rules because a study its published there are channels, it takes time it doesn't happen over night.

My point is implying a provider forgo immobilization in this scenario is dangerous, maybe it isn't an exit would, maybe she has multiple lacerations from the fall.  I don't have sixty minutes, I'm not in a controlled environment where I can study every opening this woman has.  

I pull the bull :censored::censored::censored::censored: card on the majority who say they wouldn't immobilize this patient, its easy to practice google medicine but when it comes down to it  and your in that situation I'm guessing most providers here are going to immobilize them and monday morning quarterback later.


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## usalsfyre (Jan 10, 2011)

CAOX3 said:


> It isn't about if we believe that the action its fruitless, its about who you answer too.  Trust me I understand we backboard way to many people  yada, yada, yada  I can't make it any more simple then that.  Its about whet the medical control physician expects of us.  We don't get to change the rules because a study its published there are channels, it takes time it doesn't happen over night.
> 
> My point is implying a provider forgo immobilization in this scenario is dangerous, maybe it isn't an exit would, maybe she has multiple lacerations from the fall.  I don't have sixty minutes, I'm not in a controlled environment where I can study every opening this woman has.
> 
> I pull the bull :censored::censored::censored::censored: card on the majority who say they wouldn't immobilize this patient, its easy to practice google medicine but when it comes down to it  and your in that situation I'm guessing most providers here are going to immobilize them and monday morning quarterback later.



You can call BS on me all you want. My last GSW to the head didn't get a board or collar, so yes I put my money where my mouth is. 

If you disagree with the current protocol, why not work on getting it changed? There's a crapload of evidence on this thread alone to help you with that goal. Or have you bothered to present this evidence to medical director? NEXUS is over 10 years old now, Maine has been using it with out ill effects for the same amount of time. Maybe the impetus is on the providers to affect the change, not the medical director who's shown he's not going to change without a push.


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## SunnyEMT (Jan 12, 2011)

In no way qualified to contribute to the discussion from experience or training (I start EMT-B next week  ) but there's a very strong likelihood that the school I'm attending trained some of the EMTs on scene. When an appropriate time presents itself, I'll put it to them and pass on the response.

On a side note, it was reported in local news that she and her Director, Ron Barber (who was the second person shot and standing right next to her) were both found slumped against the glass window of the store.  Wouldn't this indicate that they had been thrown backwards from the force of the shot/s and therefore possible they sustained some kind of injury that would make a c-collar/ board advisable?  Again, a totally ignorant question! lol

And if at all relevant, she was transported by chopper.


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## DrewCox (Jan 12, 2011)

In years of experience with gsw's that involves the head....as stated, you never know the genuine path of the bullet until xray. I may see an entrance wound and an exit, but it may not be the direct path of the bullet. Many times partial fragments from the round can be found near or in the spinal cord, vertabrae, or elsewhere. Secondary use of the c-collar could simply be they are limited by basic protocol by the OMD to c-collar any and all gsw's to the head. In addition the c-collar is a great tool to have in place for an airway issue. It has become the standard to c-collar pts for traumatic intubation. Stay safe


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## usafmedic45 (Jan 12, 2011)

> as stated, you never know the genuine path of the bullet until xray



Even then, plain radiographs are a miserable way of determining that. 



> It has become the standard to c-collar pts for traumatic intubation.



Honestly, I know a lot of people who c-collar anyone intubation in the field to minimize tube movement.


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## spike91 (Jan 12, 2011)

In this case as long as there was no airway issues created or exacerbated by the collar, I'd sure as hell do it. Like it has been said several times, its not what you see. Its what you do *NOT* see. Its a trauma involving the head, most likely an unconscious patient or an AMS patient (fair guess considering the hole in her head). Also, given the violent nature of the injury, how do you know the perp didn't kick her a** a bit before he put the bullet through her head? Its called spinal immobilization *precautions* for a reason.


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## Aidey (Jan 12, 2011)

Putting someone in a c-collar and on a back board is not a benign procedure. What many of us are talking about is proving an intervention is necessary before it is done, and whether or not that intervention is even useful in this case.


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## Fish (Jan 12, 2011)

firecoins said:


> First their is the unknown path of the bullet. Than and immediate jerking and fall to the ground. Why would you not put a c collar on?
> 
> The person pictured is bleeding from her head.  board and collar seems automatic.



Agreed, all this picture tells me is GSW to the head(without knowing where the bullet ended up). Automatically gets board and collar, there is no board and no collar in c-spine precautions with GSW it is all or nothing.


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## firecoins (Jan 12, 2011)

Aidey said:


> Putting someone in a c-collar and on a back board is not a benign procedure. What many of us are talking about is proving an intervention is necessary before it is done, and whether or not that intervention is even useful in this case.



The c-collar does prevent movement of the neck which is what I am trying to do. The backboard keeping things still is another question but it does make moving the patient easier. I am not an expert at determining  bullet trajectory or bullet fragmentation and I do not have x-ray vision.  Patients shot in the head usually fall on top of being shot, have AMS and may or may not have neurological deficits. Maintaining C-Spine precautions does indeed cover my ash in case some ambulance chasing attorney wants to sue if the patient had incurred any c-spine damage. 

With any major trauma, I am doing a rapid assessment on scene and a full one enroute to a trauma center. I put but them on the board and collar on scene based on a rapid assment and MOI. It remains on until we get to the hospital, even if my full assessment indicates it may not be necessary.  If the trauma team doesn't like the board and collar, they can remove it. On every major trauma I have had, the MDs kept the collar on until x-ray comes. That at least indicates they want it on until they can see the x-rays.


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## Aidey (Jan 12, 2011)

A question for all you guys who are saying board and collar automatically, no questions asked, what would your response be to a ER MD saying it isn't necessary, as there is no MOI. 

Sure, doc leave on collars all the time after taking people off of the back board. Why don't we do that? I get that it is easier to move someone on a back board at times, but doing that and back boarding someone are not the same thing.


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## Shishkabob (Jan 12, 2011)

Aidey said:


> , what would your response be to a ER MD saying it isn't necessary, as there is no MOI.



"La la la la, I'm not listening, la la la la" *plugs ears*


It's worked for me before!


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## Aidey (Jan 12, 2011)

I hope the doc slapped you upside the head, a la Gibbs from NCIS.


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## Melclin (Jan 13, 2011)

Aidey said:


> A question for all you guys who are saying board and collar automatically, no questions asked, what would your response be to a ER MD saying it isn't necessary, as there is no MOI.
> 
> Sure, doc leave on collars all the time after taking people off of the back board. Why don't we do that? I get that it is easier to move someone on a back board at times, but doing that and back boarding someone are not the same thing.



I'd tell him to do a thorough literature search, then use that to bolster an argument for operational change in an application for guidelines change made to the company. 

Mind you I wouldn't have put the poor bird in a collar to begin with, although based on our guidelines I probably should.


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