Melclin
Forum Deputy Chief
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The age old debate in EMS.
Consider the following three jobs I've been to in the past 2 weeks:
1. A modern SUV involved in a single car role at 110km/h with significant cabin intrusion on drivers side. Driver GCS 6, cushings triad, RSI'd flown to level 1. Pt, usually healthy 27YOF, was rear passenger side occupant, wearing a seatbelt, self extricated, ambulating after accident. Reports being uninjured, pain free, doesn't look sick, nil evident injuries, strong radial pulse, warm hands. A quick GCS and bare bones neuro exam/nexus criteria assessment = GCS 15, but reduced sensation reported in L leg, otherwise NAD. Stood her up, sat her on the board, collared her, moved to the truck for further exam. All NAD except HR of between 100 and 130, apparently rising with waves of anxiety about the condition of the driver. Now not complaining of altered sensation in L left leg and more thorough neuro exam is spotless. I elected to keep her immobilised based on mechanism, the original question of altered sensation and some system specific technicalities that aren't relevant to my question.
2. Mid 90's hatch back, rolled down ~2m ditch onto roof after sliding off gravel road at approx 40km/h. Nil cabin intrusion. Pt 19YOF, self extricated, ambulating normally at the scene. O/E: GCS 15, neuro exam NAD, NEXUS all negative, nil complaints other than small lacerations on hands, which I cleaned and dressed. Borderline tachy reduced to 80 with some calming influences. Sent pt home with someone to observe her, gave her minor head injury advice just in case.
3. 60YOF cyclist travelling approx 30km/h, was clipped by another cyclist travelling the opposite direction. Pt pushed sideways onto grass, landing on L arm and shoulder, is unsure about 2ndry head strike. Pt is collared and sitting on the side of the road on our arrival (first crew on scene is treating her more seriously injured cycling partner, but had briefly assessed and collared our pt). Pt is GCS 15, neg NEXUS criteria, nil neuro deficits. Stood pt up & boarded her, moved to truck for further exam. C/O Pain in R scapula around the area of an older injury, pain radiating up R side of neck and into occiput, with generalised minor headache. Nil trauma evident anywhere. Rest of exam NAD. Pt has nil medical hx and is on no medications. I elected to remove the collar and board. Pt complained approx 1 hour after initial exam of aching around C-2, not changing with palpation and radiation of pain in scapula to thoracic vertebrae, again not changing with palpation. I didn’t change my treatment plan.
Considering these cases in retrospect, there does seem to be a little inconsistency in my decision making and I was wondering what you all thought of these decisions. I’m not at all interested in “I wud board them all coz protocol says” or “Just follow your protocols”. That’s fine if you have to do that, but I’m more interested in what you thought I should have done with each of these pts individually outside of guideline/protocol specific discussion and if you think there is some inconsistency in the way I’ve applied spinal precaution overall.
I will give you all some outcome info after I’ve heard a few people pipe up.
Consider the following three jobs I've been to in the past 2 weeks:
1. A modern SUV involved in a single car role at 110km/h with significant cabin intrusion on drivers side. Driver GCS 6, cushings triad, RSI'd flown to level 1. Pt, usually healthy 27YOF, was rear passenger side occupant, wearing a seatbelt, self extricated, ambulating after accident. Reports being uninjured, pain free, doesn't look sick, nil evident injuries, strong radial pulse, warm hands. A quick GCS and bare bones neuro exam/nexus criteria assessment = GCS 15, but reduced sensation reported in L leg, otherwise NAD. Stood her up, sat her on the board, collared her, moved to the truck for further exam. All NAD except HR of between 100 and 130, apparently rising with waves of anxiety about the condition of the driver. Now not complaining of altered sensation in L left leg and more thorough neuro exam is spotless. I elected to keep her immobilised based on mechanism, the original question of altered sensation and some system specific technicalities that aren't relevant to my question.
2. Mid 90's hatch back, rolled down ~2m ditch onto roof after sliding off gravel road at approx 40km/h. Nil cabin intrusion. Pt 19YOF, self extricated, ambulating normally at the scene. O/E: GCS 15, neuro exam NAD, NEXUS all negative, nil complaints other than small lacerations on hands, which I cleaned and dressed. Borderline tachy reduced to 80 with some calming influences. Sent pt home with someone to observe her, gave her minor head injury advice just in case.
3. 60YOF cyclist travelling approx 30km/h, was clipped by another cyclist travelling the opposite direction. Pt pushed sideways onto grass, landing on L arm and shoulder, is unsure about 2ndry head strike. Pt is collared and sitting on the side of the road on our arrival (first crew on scene is treating her more seriously injured cycling partner, but had briefly assessed and collared our pt). Pt is GCS 15, neg NEXUS criteria, nil neuro deficits. Stood pt up & boarded her, moved to truck for further exam. C/O Pain in R scapula around the area of an older injury, pain radiating up R side of neck and into occiput, with generalised minor headache. Nil trauma evident anywhere. Rest of exam NAD. Pt has nil medical hx and is on no medications. I elected to remove the collar and board. Pt complained approx 1 hour after initial exam of aching around C-2, not changing with palpation and radiation of pain in scapula to thoracic vertebrae, again not changing with palpation. I didn’t change my treatment plan.
Considering these cases in retrospect, there does seem to be a little inconsistency in my decision making and I was wondering what you all thought of these decisions. I’m not at all interested in “I wud board them all coz protocol says” or “Just follow your protocols”. That’s fine if you have to do that, but I’m more interested in what you thought I should have done with each of these pts individually outside of guideline/protocol specific discussion and if you think there is some inconsistency in the way I’ve applied spinal precaution overall.
I will give you all some outcome info after I’ve heard a few people pipe up.