A fall that the hospital gave me grief about

[KyleG]

70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved.

My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.

On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.

Just wondering if I was in the wrong or right here.

 

[DesertMedic66]

What are your protocol for spinal immobilization?

 

[firecoins]

Was a RN questioning it or an MD?

 

[Ackmaui]

70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved.

My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.

On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.

Just wondering if I was in the wrong or right here.

You are completely in the right. Unwitnessed fall, who knows what could have happened. Doesn't matter what the hospital staff says...it's your cert, not theirs. Good job

 

[Aidey]

70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved.

My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.

On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.

Just wondering if I was in the wrong or right here.

I can't tell from your post if the pt was complaining of hip, neck and back pain or not.

You are completely in the right. Unwitnessed fall, who knows what could have happened. Doesn't matter what the hospital staff says...it's your cert, not theirs. Good job

WRONG! An unwitnessed fall is NOT a good enough reason to do anything to anybody. If the pt is reliable, and lacks the signs and/or symptoms of a spinal injury they do not need to be backboarded. I see you are still a student, have you taken PHTLS yet?

Hell, they don't need to be backbaorded either way, but we're taking baby steps here.

 

[JakeEMTP]

On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.

Since the patient was claiming no pain, the hospital staff may just have be asking what you saw in your assessment that warranted spinal immobilization. It might even be seen as a show of respect for your opinion before they remove the backboard. Of course if you just say "that's what my protocols say to do" you could lose the chance to shine.

 

[Anonymous]

What are your protocol for spinal immobilization?

That is what I am wondering... Were Medics on scene? Can they clear C-Spine?

 

[DesertMedic66]

That is what I am wondering... Were Medics on scene? Can they clear C-Spine?

Even if their medics can't clear C-spine, I still want to find out what made them take the precautions.

 

[KyleG]

She did complain of pain onc. RN and MD were questioning it.

In my opinion she really had the pain but once she knew how we reacted to that pain she flipped it around.

 

[Handsome Robb]

She did complain of pain onc. RN and MD were questioning it.

In my opinion she really had the pain but once she knew how we reacted to that pain she flipped it around.

So she had midline cervical/thoracic pain on scene? Or she didn't? Positive LOC? Altered?

Like Aidey said unwitnessed fall =/= spinal motion restriction. Just like any other treatment there are indications as well as contraindications. Not saying it was contraindicated but it's one of the most overused tools in our toolbox IMO.

It might just be me but I hate backboarding people, it makes everything more difficult except for moving people.

 

[Anonymous]

Even if their medics can't clear C-spine, I still want to find out what made them take the precautions.

I hope I am not hijacking but I thought some agencies allow medics to transport without immobilization if certain criteria are met? I am still very new to EMS so I apologize if I am mistaken... Example:

Assessment of spinal injury–Answer yes or no to each of the following clinical criteria:

– Is patient reliable (calm, cooperative, awake, fully alert, oriented to person, place, time and situation?
– Is there suspicion of ingestion or use of alcohol or drugs?
– Is there a language barrier?
– Is the patient < 12 years or > 55 years of age?
– Is the patient experiencing an acute stress reaction?
– Does the patient have an abnormal mental status?
– Does the patient have any distracting injuries?
– Is there a communications barrier?
– Does the patient have spine pain? Spine tenderness?
– Is the motor exam normal?
– Is the sensory exam normal?

If the patient is reliable and all other assessments have been answered “no”, the spine may be cleared and the patient transported without spinal immobilization

 

[DesertMedic66]

Yes systems do let medics clear C-spine. As to what all criteria needs to be met is agency/region specific.

 

[Anonymous]

Yes systems do let medics clear C-spine. As to what all criteria needs to be met is agency/region specific.

I am an idiot. I read your "even if their medics" as "even if they're medics"

 

[Arovetli]

As for clearance of cspine, check out NEXUS and the Canadian C-Spine Rule on pubmed. Lots of good stuff on there.

 

[Ackmaui]

I can't tell from your post if the pt was complaining of hip, neck and back pain or not.



WRONG! An unwitnessed fall is NOT a good enough reason to do anything to anybody. If the pt is reliable, and lacks the signs and/or symptoms of a spinal injury they do not need to be backboarded. I see you are still a student, have you taken PHTLS yet?

Hell, they don't need to be backbaorded either way, but we're taking baby steps here.

An unwitnessed fall is absolutely a good enough reason. Yes I am a student, a paramedic student, I have been an EMT-b for 12 years. I am an on call EMT with my fire department for 12 years and I have been an ER tech for 11 years. Yes I have taken PHTLS.... So don't throw the student angle in my face.
It is not hurting them to be on the board and do you want to be the one to tell their family that their loved one is hurt because you didn't take the time to put a collar on and board them? You don't know what they hit on the way down. Take the time to do the right thing and shame on the hospital staff who would have certainly complained if it were their family member on the call and you didn't do everything to insure their health.

 

[Aidey]

No, it is not. Search Pubmed. MOI is NOT a good enough reason to do anything! I don't care how long you have been doing this, things change and backboarding is little more than snake oil. I'm not trying to throw anything in your face, I was trying yo give you the benefit of the doubt. Let me rephrase my question, have you taken PHTLS recently? Within the last year or two?

It does hurt them to be on the board. There are multiple measurable negative effects of being back boarded and having a c-collar on. Do you want to be to the one to explain to their family why they now have bed sores because you didn't bother to assess your patient for actual injuries and not imaginary ones?

I don't care what they hit on the way down. I care what they are complaining of and what my assessment finds. The right thing is to follow evidence based medicine and eliminate the unnecessary use of c-collars and back boards. The right thing is to assess your patient properly. The right thing is the educate yourself about the treatments you provide

1. Motion in the unstable thoracolumbar spine when spine boarding a prone patient.
http://www.ncbi.nlm.nih.gov/pubmed/22330191

2. Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee.
http://www.ncbi.nlm.nih.gov/pubmed/21909006

3. Routine application of cervical collars--what is the evidence?
http://www.ncbi.nlm.nih.gov/pubmed/21752367

4. Effects of spinal immobilization devices on pulmonary function in healthy volunteer individuals.
http://www.ncbi.nlm.nih.gov/pubmed/21644085

5. Removing a patient from the spine board: is the lift and slide safer than the log roll?
http://www.ncbi.nlm.nih.gov/pubmed/21610441

6. Cervical collars are insufficient for immobilizing an unstable cervical spine injury.
http://www.ncbi.nlm.nih.gov/pubmed/21397431

7. Effectiveness of cervical spine stabilization techniques.
http://www.ncbi.nlm.nih.gov/pubmed/21358496

8. Value of a rigid collar in addition to head blocks: a proof of principle study.
http://www.ncbi.nlm.nih.gov/pubmed/21335583

9. Evaluation of the safety of C-spine clearance by paramedics: design and methodology.
http://www.ncbi.nlm.nih.gov/pubmed/21284880

10. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.
http://www.ncbi.nlm.nih.gov/pubmed/21248650

11. Unintentional strangulation by a cervical collar after attempted suicide by hanging.
http://www.ncbi.nlm.nih.gov/pubmed/21183526

12. Are scoop stretchers suitable for use on spine-injured patients?
http://www.ncbi.nlm.nih.gov/pubmed/20837250

13. Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients.
http://www.ncbi.nlm.nih.gov/pubmed/20805776

14. Motion in the unstable cervical spine during hospital bed transfers.
http://www.ncbi.nlm.nih.gov/pubmed/20699754

15. Routine spinal immobilization in trauma patients: what are the advantages and disadvantages?
http://www.ncbi.nlm.nih.gov/pubmed/20569942

16. Implementing traumatic cervical spine clearance clinical practice guidelines.
http://www.ncbi.nlm.nih.gov/pubmed/20539188

17. Assessing the implementation of guidelines for the management of the potentially injured cervical spine in unconscious trauma patients in England.
http://www.ncbi.nlm.nih.gov/pubmed/20539187

18. Clinical examination is insufficient to rule out thoracolumbar spine injuries.
http://www.ncbi.nlm.nih.gov/pubmed/20489662

19. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department.
http://www.ncbi.nlm.nih.gov/pubmed/20457772

20. Pre-hospital care management of a potential spinal cord injured patient: a systematic review of the literature and evidence-based guidelines.
http://www.ncbi.nlm.nih.gov/pubmed/20175667

21. Clearance of the asymptomatic cervical spine: a meta-analysis.
http://www.ncbi.nlm.nih.gov/pubmed/20101134

22. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
http://www.ncbi.nlm.nih.gov/pubmed/20093981

23. Neurologic sequelae of penetrating cervical trauma.
http://www.ncbi.nlm.nih.gov/pubmed/19881402

24. Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso.
http://www.ncbi.nlm.nih.gov/pubmed/19820585

25. Cervical spine motion during extrication: a pilot study.
http://www.ncbi.nlm.nih.gov/pubmed/19561822

26. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma.
http://www.ncbi.nlm.nih.gov/pubmed/19524236

27. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.
http://www.ncbi.nlm.nih.gov/pubmed/19394111

28. Efficacy and compliance of a prehospital spinal immobilization guideline.
http://www.ncbi.nlm.nih.gov/pubmed/19390912

29. Fatal child cervical spine injuries in motor vehicle collisions: Analysis using unique linked national datasets.
http://www.ncbi.nlm.nih.gov/pubmed/19375697

30. A comparison of three cervical immobilization devices.
http://www.ncbi.nlm.nih.gov/pubmed/19291567

31. A biomechanical comparison between the thoracolumbosacral surface contact area (SCA) of a standard backboard with other rigid immobilization surfaces.
http://www.ncbi.nlm.nih.gov/pubmed/19131824

32. Cervical spine clearance: a review and understanding of the concepts.
http://www.ncbi.nlm.nih.gov/pubmed/19079406

33. [Prevention of pressure ulcers--review of the evidence].
http://www.ncbi.nlm.nih.gov/pubmed/19039912

34. Isolated transverse process fractures: spine service management not needed.
http://www.ncbi.nlm.nih.gov/pubmed/18849799

 

[Veneficus]

An unwitnessed fall is absolutely a good enough reason.

No it is not. That is what is taught to EMTs because they are not given enough formal education to make decisions.

They have simple instructions that do not allow deviation due to their limits. That is very different than being medically a good reason.

Yes I am a student, a paramedic student, I have been an EMT-b for 12 years. I am an on call EMT with my fire department for 12 years and I have been an ER tech for 11 years. Yes I have taken PHTLS.... So don't throw the student angle in my face..

None of this conerns me. A student who is right in a particular case is greater than any provider who is wrong.

I do not think you are right in this case though. Not because you are a student, but because you have a very limited perspective that was a reinforced behavior for more than a decade.

It is not hurting them to be on the board and do you want to be the one to tell their family that their loved one is hurt because you didn't take the time to put a collar on and board them?.

I respectfully disagree. Elderly people have decreased chest wall expansion and decreased ability to compensate for it even without pathology. Even worse if they do have something like CHF.

Additionally, compression that can result in skin breakdown can occur in less than an hour. Again which can be worsened by underlying pathology.

I don't want to tell a family I gave them a painful nonhealing wound either.

A stress response from being painfully strapped to a board or restricted in an unfamiliar environment can cause a host of deletorious effects. Increasing HR, BP, etc in a patient with various underlying conditions could be a problem.

Furthermore, if you take a patient with an actual spinal pathology from their self splinted position of comfort and manipulte them to a flat position, you may worsen inflammation which may occlude spinal arteries resulting in secondary paralysis.

Moreover, if you cause pain in said injured patient, they will move around so much trying to find a position of comfort, you restriction attempt actually increases motion. (which is not nearly as problematic as the inflammatory response above.)

If the patient is osteoporitic, kyphotic, and has osteomalacia with remodeling, you may actually cause an injury where none existed prior to your "treatment."

You don't know what they hit on the way down

Maybe Voldemort got them with a spinal injury curse...

Sorry, but examine the patient. If they are capable of answering and reliable, ask. Rather than play "What if?" be a sound clinical provider.

Take the time to do the right thing

Examine your patient and make a decision where the benefit outweighs the risks.

and shame on the hospital staff who would have certainly complained if it were their family member on the call and you didn't do everything to insure their health.

They may have been complaining because they worry you might erroneously put their relative on a board because you didn't know it could result in harm?

 

[FourLoko]

I just think back to 2010 when I was T-Boned on the driver side of my little two door car. Passenger space intrusion was present but not terribly excessive. My only complaint at the time was a numb right hand which was from the airbag.

Now that I think back I don't recall if the FF put a C-Collar on but they did break out the backboard. They stuck it in the passenger door so I climbed over the center console and pushed either the door or console with my feet to get onto the thing.

That's my not so scientific tale about backboard usage and how they do it just to do it.

 

[Veneficus]

I just think back to 2010 when I was T-Boned on the driver side of my little two door car. Passenger space intrusion was present but not terribly excessive. My only complaint at the time was a numb right hand which was from the airbag.

Now that I think back I don't recall if the FF put a C-Collar on but they did break out the backboard. They stuck it in the passenger door so I climbed over the center console and pushed either the door or console with my feet to get onto the thing.

That's my not so scientific tale about backboard usage and how they do it just to do it.

A backboard can be a very useful extrication device. Nobody disputes its role in that.

The problem is it is not benign as once thought, so it can cause injury when used as a motion restriction device inappropriately.

I also seriously doubt that it actually prevents secondary spinal injury. Unless there is a mechanism I am not aware of, I would wager a lot it may actually worsen spinal injury.

 

[CCNRMedic1982]

I am fairly new to all of these post but like a lot of what I read. A lot of very intelligent and dedicated people in this profession. With that being said here is my two cents. I think that with the given information it was appropriate to restrict spinal movement. There are a lot of things that could cause potential harm or discomfort to certain pt. types. But when spinal motion restriction is indicated based on a good strong assessment and unfortunately what some services protocols will allow you to do. I think it is in yours and your pts best interest to do so. From what I recall paralyzed pt. can have pressure sores as well. The service I work for has very short transport times. So the pts we have on backboards aren't on them for very long. But if someone works in a place where they have longer transports that is some to think about operationally to advocate for your pt. and provide the best care possible.