Are you allowed to release c-spine, and when?

[patzyboi]

Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.)

Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?

 

[DesertMedic66]

1.) if the patient tells you to stop or refuses you have to listen to them unless they are altered.

2.) so protocols allow it and other protocols do not allow clearance.

 

[J B]

Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.)

Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?

Main thing to keep in mind is cover your ***.

1)
I would make damn sure I inform them of the risks involved with refusing treatment, try to make sure there is no altered mental status, and get the refusal signed first.

If they are getting combative and thrashing around, you might be doing more harm than good by holding c-spine, so that's worth considering.

2)
Again, it's your ***... 99% of the time they're fine, but if there was a significant MOI (ie MVC) and you release c-spine because "pt reported that his pain went away"... Well, that's not going to look good in court when the guy ends up paralyzed and sues you.

I think clinically clearing c-spine actually isn't a terribly complicated thing - there are even youtube tutorials about it. I think medics can do it in some places. The big thing is not the difficulty of doing it, but that you're really sticking your neck out to do it. If you make a mistake, take off the collar and the pt ends up paralyzed... bad situation. Let the doctor who pays 100k/year in malpractice insurance deal with it. Not worth the risk to me.

As a basic, if there was an unwitnessed trauma and I can't rule out spine/neck injury, they get collared and boarded.

At least that's what I was taught, and it makes sense to me though it's a PITA. If you deviate from protocols you're putting your career/bank account on the line to make the pt's ambulance ride a little more comfortable. Meh.


I'm a newbie so take with grain of salt...

 

[Handsome Robb]

Spinal Motion Restriction is grossly over taught in U.S. EMS education. There are plenty of documented cases of SMR cause more harm than help.

I clear people's c-spine in the field every day. Sometimes multiple times a day. Sometimes multiple times on a call. I'd honest prefer to clear them then board them if I can do it safely.

Google NEXUS or Canadian C-Spine Rule.

We use NEXUS or close to it.

Even if you can't use one of the above tools to "clear" their c-spine if they're A&O and refusing you have to let them go unless you want to deal with assault, battery and kidnapping charges...

 

[cprted]

Any complaints of neck or spine pain? No> Palpate neck and spine for deformities or tenderness. None found> Any neurological deficits, numbness or tingling? No> Rotate head slowly left and right, now flex and extend slowly. Any pain, stiffness, crepitus? No> Spinal cleared.

This obviously assumes a patient that is A/O x3 and GCS of 15.

 

[J B]

Spinal Motion Restriction is grossly over taught in U.S. EMS education. There are plenty of documented cases of SMR cause more harm than help.

I clear people's c-spine in the field every day. Sometimes multiple times a day. Sometimes multiple times on a call. I'd honest prefer to clear them then board them if I can do it safely.

I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?

Any complaints of neck or spine pain? No> Palpate neck and spine for deformities or tenderness. None found> Any neurological deficits, numbness or tingling? No> Rotate head slowly left and right, now flex and extend slowly. Any pain, stiffness, crepitus? No. Spinal cleared.

This obviously assumes a patient that is A/O x3 and GCS of 15.

I could be wrong but I'm pretty sure that, at least as a basic, this gets you fired in my area.

I think the short answer to the OP is: consult your protocols / supervisor / medical direction?

 

[Handsome Robb]

I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?

Yes, you're correct.

With that said, with the current evidence many agencies are enacting a spinal clearance protocol if they don't already have one. Most based off of NEXUS or the CCSR. My ILS partner can use this protocol, they don't need me.

So to truly answer the OP's question. Yes their are tools you can use. No you can't just use them you need to follow your agency's protocol for clearing c-spine in the field.

 

[jrm818]

I have no doubt that this is true, but you're pretty much stuck with your protocols aren't you?



I could be wrong but I'm pretty sure that, at least as a basic, this gets you fired in my area.

I think the short answer to the OP is: consult your protocols / supervisor / medical direction?

If I'm right in guessing your from MA from the other thread - you're right, this isn't ready for prime-time in MA yet, don't do it. Unfortunately sometimes bad medicine has to continue due to local standards, this isn't worth risking your job over. In Mass it does seem like there's a certain lag behind other places sometimes...but less backwards c-spine practices may be coming. I know UMass had started some sort of "NEXUS in the field" study with Worcester EMS at some point at least....

 

[Medic Tim]

In Maine basics can clear c spine. I believe it is nexus or very similar. Where I work in Canada we use ccsr.

 

[Christopher]

Lets say you're holding c-spine on a person, and suddenly they refuse any treatment after that, and asks you to let go. Are there any "tests" you can do in order to "clear" c-spine ('clear' would not be the best word, but I can't find another word for it.)

Another example is that you're holding c-spine as a precaution (kind of like the beginning of your national trauma assessment) and patient doesn't feel any pain and/or condition improves. Can you just let go or are there some specific tests you can do?

Clear is the correct terminology. Although we've overloaded the meaning.

And certainly you can do it. You do it every day. How do you know your medical patient isn't lying to you and didn't fling themselves down the stairs? You don't. They could die of a horrific spinal trauma because you were too lazy to board and collar them.

Yes I know only their belly hurt, but nobody cares about your belly if you have a spinal injury!

I know what you're thinking, "But Christopher, that sounds ridiculous."

Yes, but that is our mode of spinal care.

So let's get back to the more important issues:

(1) Can you "clear" a C-spine in the field?
(2) What does "clear" actually mean?
(3) What tools are available to help me "clear" a C-spine in the field?
(4) So I've cleared the C-spine...what now?!

1. Can you "clear" a C-spine in the field?
Yes, most modern EMS systems have been doing this for at least the last 5 years.

2. What does "clear" actually mean?
To you? It means not using Spinal Motion Restriction procedures.

To the hospital? It means not imaging the spine.

To the radiologist? It means no significant findings during imaging studies.

It means very different things to different people. Keep in mind none of these are the same thing!

3. What tools are available to help me "clear" a C-spine in the field?
NEXUS and the Canadian C-Spine Rule are the two most commonly talked about. However, these two rules are not intended to inform YOUR decision about whether to apply SMR procedures, instead they were validated to inform THE HOSPITAL'S decision about whether or not to send the patient for imaging.

This is a huge distinction. But does it matter?

Yes and no. You need to take away from this that the NEXUS and CCR were not designed to inform your opinion about the appropriateness of SMR. It will result in a large about of overtriage from a field perspective because they deal with radiologically significant findings. Note that I did not say clinically significant.

The ideal EMS tool would inform your opinion about the appropriateness of SMR such that 0 clinically significant spinal injuries were missed. Many retrospective and prospective studies exist which have validated the appropriateness of NEXUS and CCR for prehospital use, however, you should understand the difference.

Also note that these studies say nothing of what is appropriate SMR!

4. So I've cleared the C-spine...what now?!
Don't be weirded out when you hear that somebody who had a "cleared" C-spine had a "significant spinal injury". Everything is working as expected.

Because clinically significant is not the same as radiologically significant.

 

[Mariemt]

Sure I can clear it all I want, but I better be clear and gone when my MD and squad director find out. Our protocol has specific "rules " for immobilization, once we immobilize, we can't clear. We have certain guidelines to follow, certain moi etc. However, we can let an unaltered patient refuse and can do manual c spine for comfort reasons.

We also hate hard backboards, but must use them for certain things per protocol. So to limit discomfort we use back rafts which believe it or not make a big difference.

 

[augustHorch]

Clear is the correct terminology. Although we've overloaded the meaning.

And certainly you can do it. You do it every day. How do you know your medical patient isn't lying to you and didn't fling themselves down the stairs? You don't. They could die of a horrific spinal trauma because you were too lazy to board and collar them.

Yes I know only their belly hurt, but nobody cares about your belly if you have a spinal injury!

I know what you're thinking, "But Christopher, that sounds ridiculous."

Yes, but that is our mode of spinal care.

So let's get back to the more important issues:

(1) Can you "clear" a C-spine in the field?
(2) What does "clear" actually mean?
(3) What tools are available to help me "clear" a C-spine in the field?
(4) So I've cleared the C-spine...what now?!

1. Can you "clear" a C-spine in the field?
Yes, most modern EMS systems have been doing this for at least the last 5 years.

2. What does "clear" actually mean?
To you? It means not using Spinal Motion Restriction procedures.

To the hospital? It means not imaging the spine.

To the radiologist? It means no significant findings during imaging studies.

It means very different things to different people. Keep in mind none of these are the same thing!

3. What tools are available to help me "clear" a C-spine in the field?
NEXUS and the Canadian C-Spine Rule are the two most commonly talked about. However, these two rules are not intended to inform YOUR decision about whether to apply SMR procedures, instead they were validated to inform THE HOSPITAL'S decision about whether or not to send the patient for imaging.

This is a huge distinction. But does it matter?

Yes and no. You need to take away from this that the NEXUS and CCR were not designed to inform your opinion about the appropriateness of SMR. It will result in a large about of overtriage from a field perspective because they deal with radiologically significant findings. Note that I did not say clinically significant.

The ideal EMS tool would inform your opinion about the appropriateness of SMR such that 0 clinically significant spinal injuries were missed. Many retrospective and prospective studies exist which have validated the appropriateness of NEXUS and CCR for prehospital use, however, you should understand the difference.

Also note that these studies say nothing of what is appropriate SMR!

4. So I've cleared the C-spine...what now?!
Don't be weirded out when you hear that somebody who had a "cleared" C-spine had a "significant spinal injury". Everything is working as expected.

Because clinically significant is not the same as radiologically significant.

Im glad you posted this...

I hate the word "clear" when talking about C-spine because it means TOTALLY different things to different people...

I never clear a c-spine because to me, the definition involves imaging and i dont have the ability to do that in the field.

I do a C-Spine algorithm that is outlined in my protocol... if they fail, they get boarded. If they pass, i will ask them if they want to be boarded as a precaution, and i will let them know all the risks associated.

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made. Unless they refuse, then inform them of risks, let go, and document everything.

 

[Christopher]

Im glad you posted this...

I hate the word "clear" when talking about C-spine because it means TOTALLY different things to different people...

I never clear a c-spine because to me, the definition involves imaging and i dont have the ability to do that in the field.

I think it is an Ok term to use when talking among similar providers. Re-use of words is the natural course of any Language. It is when we are not aware of these differences that we run into trouble.

Whether you say "clear", "optional immobilization", "field clearance", or "selective spinal immobilization", does not really matter. So long as you're consistent.

Part of the problem is nobody is willing to stand up and say, "YES! I cleared this patient of needing SMR and YES they had a radiologically significant finding during imaging. And YES this was still the right call."

Not needing SMR and not having an injury are also not the same thing...we're just wussies.

I do a C-Spine algorithm that is outlined in my protocol... if they fail, they get boarded. If they pass, i will ask them if they want to be boarded as a precaution, and i will let them know all the risks associated.

I'm making a big push for people to change the way they talk about this topic in general. Instead "if they fail X Y and Z, they get boarded." I'd rather people say, "if they meet criteria X, Y, and Z they receive spinal motion restriction".

This tiny change allows us to talk about the two separately, as they are not the same issue. You're also not talking about what device is used to achieve SMR, which is the most important part.

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made. Unless they refuse, then inform them of risks, let go, and document everything.

I don't understand this last bit. Just because somebody else starts down the path does not mean I have to.

Besides, there is no more of a risk to the refusal of C-collar/LSB than there is to the application of C-collar/LSB. In fact, it is easier to show the risk of application than the risk of refusal.

I really really wish an entrepreneurial lawyer would start suing the pants off EMS agencies for our spinal practices...since that seems to be the only way to get it to change.

 

[augustHorch]

I don't understand this last bit. Just because somebody else starts down the path does not mean I have to.

I somewhat misspoke here...

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made unless they fail something then the rest of the algorithm doesn’t necessarily need to be completed.. Unless they refuse, then inform them of risks, let go, and document everything.

Basically... if I’m going down this path, I’m not going to stop halfway through and say "i have reason to believe you shouldn’t need any SMR"... I’m going to finish my assessment. And i think someone manually holding c-spine and letting go, even for just a second, is irresponsible c-spine immobilization...

Part of that algorithm includes mechanism of injury and patient reliability. If they fail PT reliability and have mechanism... we don’t do any more of the algorithm. They get boarded

EDIT: I am an EMT-B

 

[chaz90]

And i think someone manually holding c-spine and letting go, even for just a second, is irresponsible c-spine immobilization...

Why? People self splint quite well. No one was "holding C-Spine" before you got there, and the patient didn't spontaneously become paralyzed. Also, stopping once you begin some part of spinal immobilization (and believe me, I use that term loosely) is perfectly reasonable. I can't tell you the number of times I've come up to a scene and found someone holding C-Spine before I told them to let go.

We need to get away from this mindset of taking SMR meaning C-Collar, head blocks, and long spine board. In my ideal world, we would put a C-Collar alone (or yellow sticker to the forehead for all I care) on a narrow subset of patients determined to have a high risk of spinal injury from clinical finding. Even these people would be transported in a position of comfort and simply handled carefully, as all patients should be. The C-Collar would simply be used as a visual reminder that the patient is considered to have a risk of a spinal injury. If the patient complains about discomfort or access is needed to the neck, the collar comes off.

 

[Aidey]

I somewhat misspoke here...

But once C-Spine has been started (head stabilization), the entire algorithm needs to be completed before the decision is made unless they fail something then the rest of the algorithm doesn’t necessarily need to be completed.. Unless they refuse, then inform them of risks, let go, and document everything.

Basically... if I’m going down this path, I’m not going to stop halfway through and say "i have reason to believe you shouldn’t need any SMR"... I’m going to finish my assessment. And i think someone manually holding c-spine and letting go, even for just a second, is irresponsible c-spine immobilization...

Part of that algorithm includes mechanism of injury and patient reliability. If they fail PT reliability and have mechanism... we don’t do any more of the algorithm. They get boarded

EDIT: I am an EMT-B

That still doesn't make any sense. I've responded to all sorts of calls where someone, either a bystander or first responder, has inappropriately "taken c-spine". I am not going to run through the entire algorithm on a patient that doesn't even meet the criteria for SMR just because someone else is paranoid.

 

[augustHorch]

Why? People self splint quite well. No one was "holding C-Spine" before you got there, and the patient didn't spontaneously become paralyzed. Also, stopping once you begin some part of spinal immobilization (and believe me, I use that term loosely) is perfectly reasonable. I can't tell you the number of times I've come up to a scene and found someone holding C-Spine before I told them to let go.

We need to get away from this mindset of taking SMR meaning C-Collar, head blocks, and long spine board. In my ideal world, we would put a C-Collar alone (or yellow sticker to the forehead for all I care) on a narrow subset of patients determined to have a high risk of spinal injury from clinical finding. Even these people would be transported in a position of comfort and simply handled carefully, as all patients should be. The C-Collar would simply be used as a visual reminder that the patient is considered to have a risk of a spinal injury. If the patient complains about discomfort or access is needed to the neck, the collar comes off.

I think you are probably correct...

Its just the protocols that have been drilled into me

 

[highglyder]

We have no specific standard on SMR. Many standard do require us to consider c-spine injuries and immobilisation is indicated if it is obvious, suspect, or cannot be ruled put. The problem is that there is no standard manner in which to rule it out. It boils down to a good assessment and experience, something which makes many uncomfortable.

Many also think that collars and boards can only be applied together. I've often used only a board when the injury is isolated to the thoracic or inferior regions. I've also used collars for comfort when I determined that their neck pain is muscular in origin.

I am a minimalist. I do things that are clinically required rather than because the book says so. I document my rational and that's usually the end of it. I have been questioned about certain things in the past and successfully defended my actions. Perhaps such experiences have allowed me to forgo certain typical concerns in matters of CYA.

 

[Bullets]

2)
Again, it's your ***... 99% of the time they're fine, but if there was a significant MOI (ie MVC) and you release c-spine because "pt reported that his pain went away"... Well, that's not going to look good in court when the guy ends up paralyzed and sues you.



As a basic, if there was an unwitnessed trauma and I can't rule out spine/neck injury, they get collared and boarded.

Significant MOI isnt enough to apply SMR

Unwitnessed trauma is just that, unwitnessed and not enough evidence to apply SMR

Do they have cervical pain? Do they have neuro deficits? Do they have a distracting injury and wouldnt be able to tell you they have pain?

Just because a car flips isnt a reason to apply SMR, ive had patients roll their cars, take 30 minutes to extricate and they crawl out and walk away. If and when you take an extrication course and you see the technology in cars, you understand that they can take a beating will litle damage to the cab.

 

[medic741]

Just do it. We have Selective Spinal Immobilization protocols in the region I work in, but don't know a provider that 'clears' spines. It's not worth my card, my liability, or my job.