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

[lightsandsirens5]

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.

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.

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

Lol. No. See above.

 

[Aidey]

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.

 

[Journey]

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.

 

[Journey]

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.

 

[JPINFV]

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]

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]

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.

 

[Veneficus]

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.

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.

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.

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.

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.

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]

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.

 

[Aidey]

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.

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.

 

[Veneficus]

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.

 

[Aidey]

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.

 

[Journey]

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.

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.

 

[lightsandsirens5]

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)

 

[ffemt8978]

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]

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.

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.

 

[Journey]

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.

 

[jjesusfreak01]

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.

 

[ffemt8978]

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]

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:

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.