# Pt with "no neck"



## redbull (Nov 1, 2010)

Treated a geriatric who fell from his walker last week. The patient had no neck (fat, stubby, whatever you want to call him) and after we long boarded the patient we tried to put on the no-neck brace but it was way too tight. Then we tried the short and regular collars - those were too big. So we improvised, and took two bulky bedsheets, rolled them up and placed them at both sides of the head and put adhesive tape over her head twice. Pt was crying all the way to he hosptial complaining that it hurt and her hair was tearing out. We got to the ER and the triage nurse said, "Where's her c-collar?" I told her that the pt couldn't tolerate the collars so we did this and my partner maintained in-line stabilzation during the trip. Triage nurse takes the adjustable collar provided in the hospital and puts it on the pt. "Wow, she really is a "no neck". Duh. She snapped it on the pt without care and told us to roll her off into one of the free bed areas.

In the future, I don't care how much it hurts the pt, i will put the c-collar on. This is one of those things where we're prepared from EMT school to long board/and collar the patient, but a 'no-neck?' This is a first.


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## Akulahawk (Nov 1, 2010)

redbull said:


> Treated a geriatric who fell from his walker last week. The patient had no neck (fat, stubby, whatever you want to call him) and after we long boarded the patient we tried to put on the no-neck brace but it was way too tight. Then we tried the short and regular collars - those were too big. So we improvised, and took two bulky bedsheets, rolled them up and placed them at both sides of the head and put adhesive tape over her head twice. Pt was crying all the way to he hosptial complaining that it hurt and her hair was tearing out. We got to the ER and the triage nurse said, "Where's her c-collar?" I told her that the pt couldn't tolerate the collars so we did this and my partner maintained in-line stabilzation during the trip. Triage nurse takes the adjustable collar provided in the hospital and puts it on the pt. "Wow, she really is a "no neck". Duh. She snapped it on the pt without care and told us to roll her off into one of the free bed areas.
> 
> *In the future, I don't care how much it hurts the pt, i will put the c-collar on.* This is one of those things where we're prepared from EMT school to long board/and collar the patient, but a 'no-neck?' This is a first.


The collar is really a way to remind the patient not to move their own neck. Their musculature is FAR better at stabilizing things than a collar is. Think about this a minute: You have a patient who doesn't fit a collar. You put decide to put one on just so you won't be "talked to" by the ED RN. Then you find out that your patient now can't feel or move from about the armpits down... AFTER you put the collar on. 

Taking yourself down that path... can ultimately lead to you intentionally causing further harm because you don't want to be talked to.


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## Amycus (Nov 1, 2010)

This is where documentation comes into play. Our credo, like doctors, should be to "do no harm." Even in a case like this, improvision is fine. If you had someone holding c-spine the whole time, I maybe would have used a thin pillow or something to cradle her head. Also- a little tip, if you have to use tape across their head, for the sake of PT comfort, don't have the tape stick directly on their hair or face, etc. If it's a critical, load and go type PT, that's one thing, but in a stable case, take the extra time to pinch the tape so it doesn't stick, or pad with a bit of gauze where the tape will cross.


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## adamjh3 (Nov 1, 2010)

redbull said:


> Treated a geriatric who fell from his walker last week. The patient had no neck (fat, stubby, whatever you want to call him) and after we long boarded the patient we tried to put on the no-neck brace but it was way too tight. Then we tried the short and regular collars - those were too big. So we improvised, and took two bulky bedsheets, rolled them up and placed them at both sides of the head and put adhesive tape over her head twice. Pt was crying all the way to he hosptial complaining that it hurt and her hair was tearing out. We got to the ER and the triage nurse said, "Where's her c-collar?" I told her that the pt couldn't tolerate the collars so we did this and my partner maintained in-line stabilzation during the trip. Triage nurse takes the adjustable collar provided in the hospital and puts it on the pt. "Wow, she really is a "no neck". Duh. She snapped it on the pt without care and told us to roll her off into one of the free bed areas.
> 
> *In the future, I don't care how much it hurts the pt*, i will put the c-collar on. This is one of those things where we're prepared from EMT school to long board/and collar the patient, but a 'no-neck?' This is a first.





That is dangerous thinking. What's worse, getting your *** chewed out by a burned out ED RN or your patient being paralyzed because of what YOU did to them? 

You made the right call for this scenario, your patient should not leave you any worse off than when you found them if it can be helped. Our field is a dynamic one, and one must improvise to do what is best for our patients. 

How would it stand up in a court of law when your answer to why you left a c-collar in place that obviously did not fit and caused them physical pain or worse is that you didn't want to get scolded by an RN? 

Again, you made the right call. Take everything your told and shown with a grain of salt, do your own research and come to your own conclusion of what is best for your patient.


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## vquintessence (Nov 1, 2010)

Maybe I'm misinterpreting what you wrote, but you secured the pt to the LSB and then attempted to apply a cervical collar?  That seems.. backwards.

Just my $0.02 but were you shown the horse collar method for those no neck situations?  It is the best CYA in my opinion instead of "just making a collar fit".  It still does require thorough documentation on your part to explain the circumstances of using unconventional restrictive devices.

What does your service typically use for headblocks; do you always rig your own?  In the future to avoid your tape situation, consider using kling.  It does take a little more time & coordination, but otherwise will provide greater comfort.


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## redbull (Nov 2, 2010)

vquintessence said:


> Maybe I'm misinterpreting what you wrote, but you secured the pt to the LSB and then attempted to apply a cervical collar?  That seems.. backwards.
> 
> Just my $0.02 but were you shown the horse collar method for those no neck situations?  It is the best CYA in my opinion instead of "just making a collar fit".  It still does require thorough documentation on your part to explain the circumstances of using unconventional restrictive devices.
> 
> What does your service typically use for headblocks; do you always rig your own?  In the future to avoid your tape situation, consider using kling.  It does take a little more time & coordination, but otherwise will provide greater comfort.



hi, no we were not shown a horse collar method. my partner maintained in-line stabilization and did not let go until she was strapped in.


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## redbull (Nov 2, 2010)

adamjh3 said:


> That is dangerous thinking. What's worse, getting your *** chewed out by a burned out ED RN or your patient being paralyzed because of what YOU did to them?
> 
> You made the right call for this scenario, your patient should not leave you any worse off than when you found them if it can be helped. Our field is a dynamic one, and one must improvise to do what is best for our patients.
> 
> ...



maybe i was harsh in my words, sorry


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## adamjh3 (Nov 2, 2010)

redbull said:


> maybe i was harsh in my words, sorry



Don't apologize. The post wasn't made to rip on you, it was made to give you a different view of the situation. Sometimes we all get so set on thinking that 2 plus 2 equals 4 that we overlook that one of the 2s is a 3.


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## CAOX3 (Nov 2, 2010)

Does you system allow for deviation from your protocol, the fact tha t he was in more pain after you put him on the board may be a sign that something isn't right,  the elder y don't fit uniformly on a backboard.  Wa s it a witnessed fall, did he have neck our back pain?  Do you clear c spine in the field, how about his hips, any shortening or rotation?

Just asking because intended treatments are not supposed to create more pain, as a provider we need to look past the robotic mentality, if anything else get on the phone with a doc ask his opinion or call for als if the pain is from injury they can snow him.  

The cover your *** mentality is really becoming a problem especially if its to the detriment of your patient.  I don't do my job in fear of litigation, I do what's best for the my patient if that means no board and collar then that's what it means.


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## slb862 (Nov 2, 2010)

Horse collar...great idea.  A bath blanket works the best.  Horse Collars are great for use in rapid extracation.  Used it plenty of times, and have never had a problem.  Also when taking into consideration pt. comfort, it is much softer for those fragile bones of the elderly.

A Horse Collar:  take a bath blanket, roll it (so it is long), twist it, place the middle to the back of the neck, coming around to the front, cross ends over the chest and place each end under armpits.  Great for lifting out of cars.

We have some made up ahead of time, and put tape around the blanket in areas, to keep it from unraveling.

Hope this helps...


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## Boston.Tacmedic (Nov 3, 2010)

redbull said:


> Treated a geriatric who fell from his walker last week. The patient had no neck (fat, stubby, whatever you want to call him) and after we long boarded the patient we tried to put on the no-neck brace but it was way too tight. Then we tried the short and regular collars - those were too big. So we improvised, and took two bulky bedsheets, rolled them up and placed them at both sides of the head and put adhesive tape over her head twice. Pt was crying all the way to he hosptial complaining that it hurt and her hair was tearing out. We got to the ER and the triage nurse said, "Where's her c-collar?" I told her that the pt couldn't tolerate the collars so we did this and my partner maintained in-line stabilzation during the trip. Triage nurse takes the adjustable collar provided in the hospital and puts it on the pt. "Wow, she really is a "no neck". Duh. She snapped it on the pt without care and told us to roll her off into one of the free bed areas.
> 
> In the future, I don't care how much it hurts the pt, i will put the c-collar on. This is one of those things where we're prepared from EMT school to long board/and collar the patient, but a 'no-neck?' This is a first.



You did well, also in the future supinate and board said PT. Then place 2 IV bags one on each side of head and tape head to board. I have used it before with difficult cervical PT it works well.


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## SanDiegoEmt7 (Nov 3, 2010)

CAOX3 said:


> Does you system allow for deviation from your protocol, the fact tha t he was in more pain after you put him on the board may be a sign that something isn't right,  the elder y don't fit uniformly on a backboard.  Wa s it a witnessed fall, did he have neck our back pain?  Do you clear c spine in the field, how about his hips, any shortening or rotation?
> 
> Just asking because intended treatments are not supposed to create more pain, as a provider we need to look past the robotic mentality, if anything else get on the phone with a doc ask his opinion or call for als if the pain is from injury they can snow him.
> 
> The cover your *** mentality is really becoming a problem especially if its to the detriment of your patient.  I don't do my job in fear of litigation, I do what's best for the my patient if that means no board and collar then that's what it means.



Unrelated to the collar issue, but I have put elderly patients, who would not tolerate a LSB, in a KED before with padding.  The padding and being able to their knees up reduces the discomfort greatly, while also covering us under protocols.  The ED staff were comfortable with it and appreciated our efforts.  Does get some interesting looks at first when we roll in.


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## redbull (Nov 3, 2010)

Boston.Tacmedic said:


> You did well, also in the future supinate and board said PT. Then place 2 IV bags one on each side of head and tape head to board. I have used it before with difficult cervical PT it works well.



Thanks guys. The pt had already fallen and was in a lateral recumbent position with a pillow and blankets under him as he lay on the flloor. he also fell a few days prior to this and was not taken to the hospital. 

- We didn't have IV bags - we're a BLS bus but I'll keep that in mind if I'm ever on an ALS. 

- We log rolled the pt WITH the board so that he was supine on her back -- although I'm sure once he was supine he was feeling more pain being in a different position, but again, we weren't thinking of KED and this was our first trauma call (we're transport, we generally get just transports or respiratory distress). 

- In my judgment, the no-neck brace would've cut off her air supply, it was a really tight fit from the end of the C-collar to the velcro padding. Therefore, we used the bulky sheets and adhesive tape.

STILL, the pt kept bobbing her head forward when she was on the board, when we told her to keep it flat, thus most likely causing her more injury. We tried to comfort her as best we could en bumpy route to the hospital.


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## Aidey (Nov 3, 2010)

Why was the patient backboarded?


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## adamjh3 (Nov 3, 2010)

Aidey said:


> Why was the patient backboarded?



I'm going to guess it's because "OMG fall, protocol, protocol, protocol!" mentality paired with an inability to know what to look for. Most EMT classes will tell you The patient fell (and might be complaining of pain somewhere on their back or neck, nevermind if it's midline, or it's where they scraped the side of the kitchen counter on the way down, or if all neurological function is in tact) so they are getting full c-spine restrictions. 

This back to not being able to see that even though we have 2+2, 4 is not the answer we're looking for. 

Truth be told, if I hadn't found this site and the discussions between Vene and a few others on c-spine restrictions, I probably would have boarded and collared this pt as well, simply out of the (lack of) education provided to most Basics.

OP, this is not a rip on you, it's on the system.


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## redbull (Nov 3, 2010)

adamjh3 said:


> I'm going to guess it's because "OMG fall, protocol, protocol, protocol!" mentality paired with an inability to know what to look for. Most EMT classes will tell you The patient fell (and might be complaining of pain somewhere on their back or neck, nevermind if it's midline, or it's where they scraped the side of the kitchen counter on the way down, or if all neurological function is in tact) so they are getting full c-spine restrictions.
> 
> This back to not being able to see that even though we have 2+2, 4 is not the answer we're looking for.
> 
> ...



What would you have done? Just curious.


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## JPINFV (Nov 3, 2010)

redbull said:


> What would you have done? Just curious.



That depends on the totality of the assessment.


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## adamjh3 (Nov 3, 2010)

JPINFV said:


> That depends on the totality of the assessment.



Exactly. Because my system doesn't allow basics to clear c-spine in the field I would have either gotten on the phone with my base hospital physician to present my findings and ask  to clear c-spine for Tx, or upon finding neurological deficencies (sp? no dictionary on hand) or midline pain modified c-spine for the pt, which probably would not involve a backboard, maybe a KED but that entirely depends on the patient. The purpose of c-spine restriction (immobilization is impossible in the field) is to keep the patient from moving, but you also do not want to create pressure points or pain. I would have to see the patient, and be able to assess what is comfortable for them.


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## Handsome Robb (Nov 3, 2010)

Was anyone taught to put a rolled towel/pillow under the Pt's knees on a LSB to promote comfort? Thats how I was taught and when on a ride-along recently I asked the medic if she wanted me to do this and she looked at me like I was a certifiable nutcase. Sorry to go OT, it kinda pertains to the pressure points and pain statement above.


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## Aidey (Nov 3, 2010)

Before I guess what I would have done, why was the patient backboarded?


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## adamjh3 (Nov 3, 2010)

NVRob said:


> Was anyone taught to put a rolled towel/pillow under the Pt's knees on a LSB to promote comfort? Thats how I was taught and when on a ride-along recently I asked the medic if she wanted me to do this and she looked at me like I was a certifiable nutcase. Sorry to go OT, it kinda pertains to the pressure points and pain statement above.



Yes, I was. Lay on some concrete somewhere and put a rolled towel under your back. More comfortable than the flat hard ground, but still uncomfortable.


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