# Immobilize or not?



## savelives (Feb 21, 2012)

Working event staff for a 46 hour long dance marathon where the dancers do not sit or sleep for 46 hours. At hour 45 a dancer collapses to the floor and is conscious but has a gcs of 3/4/4. The crowd is cheering so loud at the time that we can barely communicate with him however bystanders tell us that they caught him before he hit the ground. Essentially I take this with a grain of salt and begin a rapid trauma, looking for any deformities or sources of pain. I strip his shoes and find pulses present and equal ever. This kid has been standing for 45 hours so obviously he is altered. We get him on the stretcher and halfway to the truck he tells me his neck hurts so immediately I take cspine and declare that he needs to be boarded. My partner feels his neck asking him if certain places hurt and then declares that the pain is purely muscular do we can forget the boarding. My question to you is: is that in our scope of practice to determine if a pain is muscular or skeletal. Was it the right move
Not backboarding him?

Thanks


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## DrankTheKoolaid (Feb 21, 2012)

*re*

That depends on your local protocol *and* level of education/experience to determine if you are comfortable ruling things out in the field vs just boarding everyone.


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## NomadicMedic (Feb 21, 2012)

Do you have a spinal clearance protocol?

(I would not have boarded him)


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## DPM (Feb 21, 2012)

n7lxi said:


> Do you have a spinal clearance protocol?
> 
> (I would not have boarded him)



That's the key here. I think it was Sasha who posted an article to a Backboard study? Have a quick search for that.


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## JPINFV (Feb 21, 2012)

Depends on the examination, which with something like determining skeletal vs muscular pain really does require you to be there.


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## Medic Tim (Feb 21, 2012)

n7lxi said:


> Do you have a spinal clearance protocol?
> 
> (I would not have boarded him)



What he said


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## Tigger (Feb 21, 2012)

I would not have boarded him once he was on the stretcher. Neck pain does not always indicate spinal motion restriction. Given the circumstances above, it's likely he was just sore. 

The whole better safe than sorry line doesn't fly with me. If ,on further assessment spinalling someone is necessary that's fine, but just because one is not absolutely sure of what happened does not mean they need a board.


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## Maine iac (Feb 21, 2012)

All depends on your protocols and how comfortable you feel with the situation (like somebody already said). I would *NOT* have put him/her on a board. The MOI isn't really there IMO (slumping to the ground, with bystanders saying he was caught/lowered to the ground).

http://roguemedic.com/2011/10/video-of-spinal-immobilization-and-abandonment/


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## Aidey (Feb 21, 2012)

Yes, you can determine if pain is muscular or skeletal. I also would not have back boarded him.


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## Mountain Res-Q (Feb 21, 2012)

Wouldn't have regardless of protocol.  Treat the patient based on the medicine, NOT based on a protocol written in 1982.


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## frdude1000 (Feb 21, 2012)

Our protocols in MD state these are the indications for back boarding:
_(2) If patient presents with a traumatic mechanism which could cause cervical spine injury and meets ANY of the following criteria, complete Spinal Immobilization (C-spine and back maintaining neutral alignment and padding when appropriate) should occur.
(a) History of Loss of Consciousness (LOC) or Unconscious?
(b) Disoriented or altered LOC?
(c) Suspected use of Drugs or Alcohol?
(d) Midline Cervical Tenderness or Pain?
(e) Focal Neurologic Deficit?
(f) Has a painful distracting injury that could mask cervical pain or
injury?
(g) Child less than 8 years of age_

I guess in your case the main question is how hard/distance of fall was and if the pain in the neck was midline or not.


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## Mountain Res-Q (Feb 21, 2012)

frdude1000 said:


> our protocols in md state these are the indications for back boarding:
> _(2) if patient presents with a traumatic mechanism which could cause cervical spine injury and meets any of the following criteria, complete spinal immobilization (c-spine and back maintaining neutral alignment and padding when appropriate) should occur.
> (a) history of loss of consciousness (loc) or unconscious?  every night
> (b) disoriented or altered loc?  every morning
> ...



quick... Backboard me!!!


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## Akulahawk (Feb 22, 2012)

JPINFV said:


> Depends on the examination, which with something like determining skeletal vs muscular pain really does require you to be there.


It very much _does_ depend upon me actually being there at the time to do my own assessment to determine whether I'm eliciting muscular pain or skeletal pain. This is not something that can be adequately taught over this kind of medium. 

Ground-level fall with sx that do not lead me to suspect a spinal injury = me not doing a full-on spine boarding. From what little I've gleaned from this thread, I would probably NOT board this patient. The ALOC probably isn't a result of the fall...

That being said, if I'm absolutely directed to board, I'd have to and hate every moment of it.


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## Handsome Robb (Feb 22, 2012)

I agree with everyone else. From the information provided I wouldn't have boarded this guy but, like everyone else, I'd have to be there and make my own decision.


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## Bullets (Feb 22, 2012)

Im actually surprised so many said do not backboard

According to NEXUS

1. No posterior midline cervical spine tenderness
   and
2. No evidence of intoxication
   and
3. Normal level of alertness
   and
4. No focal neurological deficit
   and
5. No painful distracting injuries

Patient has to pass all of those, and he fails #1 and #3 so it looks like SMR


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## Aidey (Feb 22, 2012)

First, in order for nexus to apply we have to have reason to suspect a cervical injury. I don't. We also have no idea what the OP means by altered. Did the kid fail to know what day it was because he has been awake for 45 hours? In addition it sounds like his partner ruled out midline pain.


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## Maine iac (Feb 22, 2012)

How about we change it a little..... You are in your ambulance driving wherever because dispatch has you changing stations and you see a few drunk people, one falls over and is now on the ground. 

Do you 
a) Flip the lights and sirens on for a second, pull a U turn and go over to check out the group?

b) Do everything in option 'a' but because the person fell, is intoxicated and is now combative do you assume he has a spinal injury and a head injury, and gets all the medical torture that we do to those patients?

c) Slow down to see if anybody in the group notices you are going by and tries to wave you down?


Jokes aside, with all of my patients they have to score specific points before I provide a treatment. Those points might be the parts a, b, and c on my protocols or how I choose to evaluate them.  For this patient, how it is presented in the OP they do not move past me checking for MOI.


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## JPINFV (Feb 22, 2012)

D: Turn down an ally before anyone has a chance to wave you down.


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## savelives (Feb 22, 2012)

frdude1000 said:


> Our protocols in MD state these are the indications for back boarding:
> _(2) If patient presents with a traumatic mechanism which could cause cervical spine injury and meets ANY of the following criteria, complete Spinal Immobilization (C-spine and back maintaining neutral alignment and padding when appropriate) should occur.
> (a) History of Loss of Consciousness (LOC) or Unconscious?
> (b) Disoriented or altered LOC?
> ...



he was definitely altered, and it was probable that he had a LOC. hmm. i appreciate all the answers to my thread but i'm only about a year experienced and I'm confused as to why you would not backboard him just to be safe?

thanks guys


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## Aidey (Feb 22, 2012)

Go to pubmed.com search for articles about c-collars or backboards. Spend some time reading them and you will be able to answer your own question.


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## Mountain Res-Q (Feb 22, 2012)

savelives said:


> he was definitely altered, and it was probable that he had a LOC. hmm. i appreciate all the answers to my thread but i'm only about a year experienced and I'm confused as to why you would not backboard him just to be safe?
> 
> thanks guys



Because it was not medically reasonable and has a high chance of causing more pain, suffering, injury, resources, and expense than you realize.


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## NomadicMedic (Feb 22, 2012)

I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them.  In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours.  I still vote for no backboard.


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## Tigger (Feb 22, 2012)

n7lxi said:


> I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them.  In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours.  I still vote for no backboard.



Your brain = far more superior tool than backboard.


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## epipusher (Feb 23, 2012)

n7lxi said:


> I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them.  In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours.  I still vote for no backboard.



How is the provider able to absolutely rule out that the patient is altered only due to being tired? As far as the thud, the provider is putting their full faith and trust in a witness that is essentially a bystander. Too many what if's.


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## Veneficus (Feb 23, 2012)

epipusher said:


> How is the provider able to absolutely rule out that the patient is altered only due to being tired? As far as the thud, the provider is putting their full faith and trust in a witness that is essentially a bystander. Too many what if's.



There are no absolutes in clinical medicine.

You just have to use your judgement as to the reliability of the information you get.

I am also rather fond of physical exam findings that give credibility to the story.

Backboarding every patient because of "what if..." is just as stupid as giving every patient chemo  because "what if..."


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## HMartinho (Feb 23, 2012)

We just immobilize if  the height of fall is greater than the height of the victim, or if the neurologic exam shows neurologic deficits, signs of TBI or spinal cord injury.


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## epipusher (Feb 28, 2012)

wow.....just wow.


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## AMF (Feb 28, 2012)

It's important to understand that there are rules for these kinds of things which of course vary from place.  The "provider before patient" rhetoric they teach you in school for scene safety applies to treatments as well, and your protocols are (should be) designed to accomodate the practice of an entire career of individuals, not just the basic with one year of experience.  If you don't feel comfortable using a rule-out protocol, don't use it.  Nevertheless, backboards are absolutely not a benign treatment, and the sooner you become comfortable ruling out patients, the better.


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## mycrofft (Feb 28, 2012)

Where are the retrospective studies linking height of fall to degree of likelihood and insult to C spine (or any spine, or skull)? Where are the studies of iatrogenic insult due to use of LSBoard? (Articles have been cited in EMTLIFE linking airway establishment delays to spineboarding, and studies show outcome of pts with spineboard left on in ED versus  taken off upon entering ED, are about the same).

Not to be bad here, and I'm always the guy who tells the new person to follow protocols, but just because the adoption of the use of the spineboard and the creation of EMT's were on the same date and time, and medical controllers have always had some reasons to distrust EMT discretion in the field, there are reasons NOT to use spine boards so widely and arbitrarily.


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## tnoye1337 (Feb 29, 2012)

I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.


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## Aidey (Feb 29, 2012)

tnoye1337 said:


> I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.



What trauma?!


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## tnoye1337 (Feb 29, 2012)

Aidey said:


> What trauma?!


Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.


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## DPM (Mar 1, 2012)

So if I whiteness the death of a family member do I need to be put into spinal restrictions? According to your definition Trauma is an entirely emotional condition... and it clearly doesn't apply here.

I feel like some common sense is needed. Was the mechanism enough that it could cause a spinal injury that would require a back board? I'd say no, but stick to your protocols.


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## Mountain Res-Q (Mar 1, 2012)

tnoye1337 said:


> I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.



Malpractice much?



tnoye1337 said:


> Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.



Emotional trauma and physical trauma are two different things.  And even when talking about physical trauma, the fact is that trauma does not equal backboarding.  



DPM said:


> I feel like some common sense is needed. Was the mechanism enough that it could cause a spinal injury that would require a back board? I'd say no, but stick to your protocols.



Cookbook Medicine: the biggest reason why EMS is viewed and treated as a trade and not a profession.  Common sense first needs to be common, then it all makes sense.  Case in point; the absolutism of this statement:



tnoye1337 said:


> I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.


  <_<


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## tnoye1337 (Mar 1, 2012)

Mountain Res-Q said:


> Emotional trauma and physical trauma are two different things.  And even when talking about physical trauma, the fact is that trauma does not equal backboarding.



You're totally swaying away from the topic. If someone is injured from dancing for forty hours,  you have absolutely no clue as to what happened, wouldn't you rather be safe? What happens if he has an underlying injury and he had no neuro function to that area... A GCS of 11 is pretty damn low and to not backboard someone to cover your own *** is just stupid.


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## Mountain Res-Q (Mar 1, 2012)

tnoye1337 said:


> You're totally swaying away from the topic. If someone is injured from dancing for forty hours,  you have absolutely no clue as to what happened, wouldn't you rather be safe? What happens if he has an underlying injury and he had no neuro function to that area... A GCS of 11 is pretty damn low and to not backboard someone to cover your own *** is just stupid.



Have you read any of the previous research?  "Covering your ***"?  I thought this was about the patients best interest.  I treat patients based on the medicine of what I can do for them that will provide the most benefit, not what a protocol says to do because "all patients are the same" and "all we want you with your pathetic 120 hours or training to do is perform the same 'awesome life saving skill' that actually hurts more people than it helps".  Things you are taught as fact at a BLS level (and sometimes at the ALS level) are often relics of 20, 30, plus years ago.  While modern medicine and research advances, EMS protocol tends to lag behind.  This is why pre-hospital EMS is a trade and not the profession it should be.  Instead of EDUCATING people to think, analysis, and treat the patient, they can get away with a few hundred hours of TRAINING by teaching people HOW to do it, but not WHY or when.  This goes to the "should EMS degrees be the standard" thread.  And the answer is YES, this is why.  I just had this situation where some uneducated "shiny new card" First Responders boarded a patient because (correct quote) "we have to, it is in the protocol".  ALS shows up and is not happy.  They made the choice in 5 seconds of history to board based on MOI.  No educated assessment based on medicine?  Now this case is my problem because the FR took patient care away from an EMT who didn't want to board but is not part of the county system and thought that he had to hand over care to officially sanctioned responders.  The result of the dubious thinking is a lowering in the standard of care and unnecessary pain, suffering, expense, and resource usage in order to "cover your ***".  There is a time and place for spinal restriction, but this situation IS NOT one of them.  Every attempt MUST be taken to "think and assess you way out of water boarding, I mean back boarding, your patient."


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## tnoye1337 (Mar 1, 2012)

Mountain Res-Q said:


> Have you read any of the previous research?  "Covering your ***"?  I thought this was about the patients best interest.  I treat patients based on the medicine of what I can do for them that will provide the most benefit, not what a protocol says to do because "all patients are the same" and "all we want you with your pathetic 120 hours or training to do is perform the same 'awesome life saving skill' that actually hurts more people than it helps".  Things you are taught as fact at a BLS level (and sometimes at the ALS level) are often relics of 20, 30, plus years ago.  While modern medicine and research advances, EMS protocol tends to lag behind.  This is why pre-hospital EMS is a trade and not the profession it should be.  Instead of EDUCATING people to think, analysis, and treat the patient, they can get away with a few hundred hours of TRAINING by teaching people HOW to do it, but not WHY or when.  This goes to the "should EMS degrees be the standard" thread.  And the answer is YES, this is why.  I just had this situation where some uneducated "shiny new card" First Responders boarded a patient because (correct quote) "we have to, it is in the protocol".  ALS shows up and is not happy.  They made the choice in 5 seconds of history to board based on MOI.  No educated assessment based on medicine?  Now this case is my problem because the FR took patient care away from an EMT who didn't want to board but is not part of the county system and thought that he had to hand over care to officially sanctioned responders.  The result of the dubious thinking is a lowering in the standard of care and unnecessary pain, suffering, expense, and resource usage in order to "cover your ***".  There is a time and place for spinal restriction, but this situation IS NOT one of them.  Every attempt MUST be taken to "think and assess you way out of water boarding, I mean back boarding, your patient."



Okay, well I clearly don't have half the experience as you do, so you have to see my side. I'm going by what I was taught in my class. I'm still a virgin to this field just looking to pop my cherry.


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## Aidey (Mar 1, 2012)

tnoye1337 said:


> Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.




The next time you trip and fall I hope someone calls 911 and they backboard you. After all, that is trauma isn't it? 

*facepalm*

Go to pubmed.com and search for things like c-spine, backboard and c-collar and start reading. Don't stop until you understand why we are all telling you that you are wrong.


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## tnoye1337 (Mar 1, 2012)

Well, I guess I'm wrong, but in my defense I didn't read the part where they said it was CLEARLY muscle pain.


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## mycrofft (Mar 1, 2012)

It's OK to be wrong. I'm a walking example.*

Revisit the event.

On feet 45 hrs, no mech of injury, I assume normal vital signs (???...), LOC on feet and fell to floor. No obvious external s/s. When regains consciousness after lying supine, _then_ c/o neck pain. Another possible cause: did the pt just finish a long, long delayed toilet break?

1. What were vital signs? Most likely causes of LOC in this event would be: what? (I'm thinking dehydration, orthostatic hypotension, hypoglycemia, sheer fatigue, or fell asleep...pun unintended). Vital signs would hopefully reveal if there was a cardiac component. Get pt hx.

2. How bad is neck pain? Is it self-relieved by repositioning? (Holding that 6 lb melon we call a head up on that pencil we call a neck for 45 hrs alone could be the cause).

3. If I had the pt calm and on the litter, I might sandbag the head and be careful in movement, but otherwise don't additionally move the pt unless there are other signs; drive carefully, and don't wake him up.


(*Ask Mom)


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## epipusher (Mar 1, 2012)

I love how in real life, and especially in this forum and among others, anyone who plays it safe is a "cookbook" medic. And playing it safe is therefore a detriment to our profession. Pushing 16 years in EMS with over half as a medic,  I will play it safe every time. Feel free to blame me, along with the majority of my "cookbook" co-workers, as bringing down the profession as a whole.


edit: my fellow motor bicycle riders can blame me as well for killing our cool look due to the fact I wear a helmet.


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## mycrofft (Mar 1, 2012)

A generalization, but some folks do throw the "cookbook" thing around pretty casually.

You have to follow your educated sense of the situation at hand as long as it is within prudent practice. Hopefully it meets protocols, and 90+% percent of the time the protocol is right, _as long as your eval and conclusions are right_. If you break protocol  due to a faulty conclusion, then good luck to the pt and to you. If you are cautious and tend to be conservative without harming the pt, it minimizes the chances you will go afoul or get in trouble.

That said, having helped write them, the prospect of someone slavishly following a protocol to a bad end (due to undetected complications or an errant conclusion or eval) was one of my nightmares.

My assumption is that, in this case, and with the eval we were given, the pt was not in need of spine boarding simply on the complaint of a sore neck. If it had involved a motor vehicle accident or alteration, I'd entertain a higher index of suspicion and might have taken the calculated risk to spine board the pt. However, if it met local protocols, then board if you will, whether it makes overall sense or not. Might catch something nobody had detected.

(Someone told me I'm wishy-washy about these nothings. I am ambivalent; but only when I don't have the pt in front of me. Forty years seeing victims and patients tells me that armchair DX'ing is always hit or miss).


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