# C-Spine Scenario



## Connor (Oct 1, 2013)

So first of all I could be in the wrong forum. Not sure.

Had a pt today during a football game, states someone from the other team grabbed onto his helmet and twisted his head laterally. Got on scene, ran through all the things. Vitals were all normal, a&ox4, pain 8/10 compared to a broken tib - localized just lateral of the midline. Spinal palpation felt normal, and no paresthesia. I suspected it was muscular since he could turn his head the opposite way from which it was pulled just fine, no pain. So we sat him up and brought him to the bench, applied ice. 

He said pain went down to 1/10 within 5 mins with full ROM. My question is, is it normal for ice to work so well, so quickly? I've never seen that before. I'm worried he could have been lying to me out of fear or anxiety since we had to board 3 people so far in the past 2 days.

Would you have immobilized him? 

Coach benched him anyways and I documented the heck out of it. I'm still pretty green so I may or may not be second guessing my decision. Thoughts?


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## Medic Tim (Oct 1, 2013)

From what you are saying I would not have boarded this pt.

Did you follow the AHS C spine clearance protocol or just wing it?


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## JPINFV (Oct 1, 2013)

I wouldn't have boarded him either.

On a side note, did his opponent at least get the 15 yard personal foul for facemask?


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## Connor (Oct 1, 2013)

Medic Tim said:


> From what you are saying I would not have boarded this pt.
> 
> Did you follow the AHS C spine clearance protocol or just wing it?



I did follow AHS c-spine protocol, but since I'm working as a MFR it's technically out of my scope.



JPINFV said:


> On a side note, did his opponent at least get the 15 yard personal foul for facemask?



Not sure, I would hope so. I have no clue how football works lol.


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## Medic Tim (Oct 2, 2013)

Connor said:


> I did follow AHS c-spine protocol, but since I'm working as a MFR it's technically out of my scope.
> 
> 
> 
> Not sure, I would hope so. I have no clue how football works lol.



The protocol is for EMR through medic... Unless your service has modified it.
Or is MFR different from EMR ?


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## Connor (Oct 2, 2013)

Medic Tim said:


> The protocol is for EMR through medic... Unless your service has modified it.
> Or is MFR different from EMR ?



MFR is different. It's a volunteer thing. We're not involved with ACP and we can't do BGL, transport, or any medications. We're technically just advanced first aiders, though a lot of us have EMR or EMT.

And by immobilizing someone, I mean having someone manually holding cspine and calling 911. Then we can assist the AHS medics with immobilization, etc.


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## Medic Tim (Oct 2, 2013)

Connor said:


> MFR is different. It's a volunteer thing. We're not involved with ACP and we can't do BGL, transport, or any medications. We're technically just advanced first aiders, though a lot of us have EMR or EMT.
> 
> And by immobilizing someone, I mean having someone manually holding cspine and calling 911. Then we can assist the AHS medics with immobilization, etc.



Ahh gotcha. Way back when I was in hs I was a first responder (old name I am sure it is mfr or something else now) with St. John Ambulance for games and other public events.


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## Mariemt (Oct 2, 2013)

Since we backboard for stubbed toes, I might have had too.... but,  of nobody was looking. I would have cleared him. Gave him some ice and had him sit a while.

Kids are resilient. Pain subsides fast. I can see it dissipating fast


Kidding about the toe


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## Connor (Oct 2, 2013)

Medic Tim said:


> Ahh gotcha. Way back when I was in hs I was a first responder (old name I am sure it is mfr or something else now) with St. John Ambulance for games and other public events.



Small world! It is in fact MFR these days. I'm getting lots and lots of practical experience before moving into the big bad world of ACP.


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## TheLocalMedic (Oct 2, 2013)

You did fine.  Sounds like you know what to check for.  Personally, I only board people when there's a significant reason to do so.  Makes fire guys a little nuts when I don't board "trauma patients", but unless they have a glaringly obvious c-spine issue (like deformity or neuro deficit) I do my best not to c-spine them.


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## chri1017 (Oct 2, 2013)

If I had transported the patient I probably would.  Due to the MOI as well as the distracting injury.  It would be a sure way to avoid a QA flag.


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## Medic Tim (Oct 2, 2013)

chri1017 said:


> If I had transported the patient I probably would.  Due to the MOI as well as the distracting injury.  It would be a sure way to avoid a QA flag.



Moi in the absence of neuro deficits is a very poor predictor of injury. Most places do not consider this kind of pain a distracting injury. If you go the phtls route it is a long bone fx or similar. 
Doing something to your pt for your own benefit is not good medicine. We are supposed to be pt advocates.

That said I understand some people have very strict protocols/ medical directors and that thy can be frustrating to work with.


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## lilredstang (Oct 2, 2013)

I would have backboarded him due to MOI ( head twisted by force ) , ALS or BLS we can't clear in the field and I wouldn't want too. ABC, PMS, A&O, vitals with treatments enroute, downgrade transport.


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## Medic Tim (Oct 2, 2013)

lilredstang said:


> I would have backboarded him due to MOI ( head twisted by force ) , ALS or BLS we can't clear in the field and I wouldn't want too. ABC, PMS, A&O, vitals with treatments enroute, downgrade transport.



why wouldn't you want to clear c-spine or follow a selective c-spine protocol??


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## Connor (Oct 2, 2013)

lilredstang said:


> I would have backboarded him due to MOI ( head twisted by force ) , ALS or BLS we can't clear in the field and I wouldn't want too. ABC, PMS, A&O, vitals with treatments enroute, downgrade transport.



MOI wasn't high risk. It is sketchy, but not high risk.

I didn't necessarily clear c-spine, I just never decided to put him on a board.

Protocol plus my other observations (lack of paresthesia, lack of midline pain - it was close but not midline - a&ox4, normal & stable vitals, etc) didn't indicate SMR.


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## Tigger (Oct 2, 2013)

Connor said:


> .
> 
> I didn't necessarily clear c-spine, I just never decided to put him on a board.



Bravo! This is the line of thinking that needs to become more prevalent!

If the patient is not at risk for c-spine compromise then they don't need SMR so you aren't clearing c-spine. 

Clearing c-spine and SMR not being indicated are two entirely different things.


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## Medic Tim (Oct 2, 2013)

Connor said:


> MOI wasn't high risk. It is sketchy, but not high risk.
> 
> I didn't necessarily clear c-spine, I just never decided to put him on a board.
> 
> Protocol plus my other observations (lack of paresthesia, lack of midline pain - it was close but not midline - a&ox4, normal & stable vitals, etc) didn't indicate SMR.



most excellent. 

there is hope.


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## Akulahawk (Oct 2, 2013)

lilredstang said:


> I would have backboarded him due to MOI ( head twisted by force ) , ALS or BLS we can't clear in the field and I wouldn't want too. ABC, PMS, A&O, vitals with treatments enroute, downgrade transport.


MOI is a very poor predictor of _actual_ injury. My eval would probably have been a bit different, compared to what the OP did. The end result would have been identical. Walks off under his own power, gets some ice (yes, it works _that_ fast) and refer to Primary Care Physician for follow-up, or ED if symptoms get worse. 

Yes, I _have_ done this a few times...

Then again, that's my _other_ background coming out. If I were working as a medic, I'd almost be required to put this guy in SMR because of the complaint of neck pain... but I'd be strongly inclined to find a way to _not_ do that in the first place. I may be a bit rusty, but I haven't forgotten everything I've learned before I became a Paramedic! (Some of what I learned is in this little green book written by Hoppenfeld...)


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## mycrofft (Oct 2, 2013)

A danger of "working down" (holding a higher experience and qualification than the current assignment) is that, on one hand, you are civilly and ethically responsible to act to your highest capability, but on the other hand contractually and legally limited to and required to follow the lower one.

Aiming high can get your fired, but produce better outcomes.


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## Connor (Oct 3, 2013)

Akulahawk said:


> MOI is a very poor predictor of _actual_ injury. My eval would probably have been a bit different, compared to what the OP did. The end result would have been identical. Walks off under his own power, gets some ice (yes, it works _that_ fast) and refer to Primary Care Physician for follow-up, or ED if symptoms get worse.



pt. presented midfield laying on his side, about 17 y/o M. Trainer already holding cspine

Here's what I did: 
Asked him what he thinks happened (stated the same as coach told me), stuck a pulse ox on his finger and got the partner started on a set of base vitals. Vitals were all normal, full loc, pulse was a bit elevated but he was just running a minute ago. Pupils were constricted. No numbness/tingling, had motor and sensory function in all extremities. I went through opqrst, he stated the pain was slightly delayed onset. Severity 8/10 to a broken tib.

3-5 mins on scene time by now

Started to palpate, he localized pain just to the right of the spine. No abnormalities. Rolled him supine, slowly and with as little movement as possible. Took his helmet off, and had him very slowly move his head as if he were saying "no". He managed to move his head past 45deg without much difficulty. So we got him to slowly sit up, and he moved to the benches just fine all on his own. I wanted to be kind of quick because we were in the middle of the field holding up play.

8-10 mins scene time.

Went through SAMPLE and all that good stuff, got a second set of vitals (all normal, pulse at resting rate now) and iced his neck. Examined him a bit more and he said there was no pain other than where it was initially. Got info from him for the PCR, made contact with his mother by phone and explained my recommendation - that he sits out the game and goes to the clinic to have a physician look at it, sooner was better than later. His mother said it was fine if he wanted to go back into the game and thanked me for letting her know. 

17-18 mins scene time.

I asked him how the pain was after that (about 5min) and was shocked when he said 1/10 w/ full ROM. I had no idea ice worked _that_ fast. Coach was insisting on benching him anyways.

How would your assessment been different? What could I have done better?

Thanks for all the helpful responses guys.


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## NBFFD2433 (Oct 12, 2013)

I wouldn't have.


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