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

[Christopher]

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.

If you follow the protocol you are fine. If you do not follow the protocol, you're opening yourself up to liability.

I hope lawyers get smart and start suing agencies that immobilize patients needlessly.

 

[Medic Tim]

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.

So much fail

You are opening yourself up to trouble by not following you policies.
This kind of attitude is what keeps EMS from progressing.(among others)

 

[EpiEMS]

I hope lawyers get smart and start suing agencies that immobilize patients needlessly.

This would be truly beautiful.

 

[lanceavil]

I live in Central CA, our local protocals say that c-spine (and backboard) can only be removed by a physician after they determine if it's needed or not. But if patient is refusing treatment, and is A&O x4, it just depends on the situation. It's easier to explain why you did something than why you didn't. If they don't want treatment, and you already c-spined, just make sure they sign a refusal.

 

[Christopher]

I live in Central CA, our local protocals say that c-spine (and backboard) can only be removed by a physician after they determine if it's needed or not. But if patient is refusing treatment, and is A&O x4, it just depends on the situation. It's easier to explain why you did something than why you didn't. If they don't want treatment, and you already c-spined, just make sure they sign a refusal.

At our organization you will receive verbal coaching, followed by a remedial training plan, and if that doesn't fix it disciplinary measures for excessive/unnecessary procedures. So no, it is not easier to just do something.

Then again, we're not in CA (the land before time apparently).

 

[medicnick83]

In South Africa, basics and intermediates are not allowed to clear C-Spine - Even if we could, I wouldn't, I'd rather let a doctor or a x-ray clear it.

 

[Hwnorth]

interesting

 

[Carlos Danger]

There is a big difference between "clearing" a c-spine, and simply choosing not to immobilize someone because it isn't indicated.

"Clearing" implies that there is in fact a significant potential for needing cervical immobilization, but that I'm using assessment skills to determine that such an injury doesn't exist. That's dicey considering that in the hospital, anyone with a significant chance of having a cervical injury is only "cleared" by a combination of clinical exam and imaging, and only by an MD.

"Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different.

We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria.

When you pick up a patient with chest pain and you don't cardiovert them because they are in NSR at 90, would you say you "cleared" their rhythm from needing cardioversion? No - you wouldn't say anything at all about cardioversion, because it would have never even entered your mind because it's just not called for.

That's how we should view the person who fell from standing and has no neck pain and almost zero chance of an unstable cervical fracture. We aren't "clearing" those people's c-spines; we just aren't implementing a procedure because it isn't indicated.

 

[TransportJockey]

If they refuse then I let them go and document the crap out of it.

As for 'clearing c-spine' we technically can't do it... but if it's not indicated I don't do it. Hell, I've brought in rollovers just sitting on my cot w/out boarding.

 

[jefftherealmccoy]

We have a 5 step procedure to clear c-spine in the field-

1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
3. If pt is glasgow 15, A&O x 4, step 4, if not IMMOBILIZE
4. If pain or deformity at any point of spine, IMMOBILIZE, if not, 5
5. If circulation, motor and sensory is normal, spine is clear, if not, IMMOBILZE
When in doubt, IMMOBILIZE.

Our medical control doc is actually pretty cool on this. He has told us that our cot is pretty much as effective as the backboard.

 

[chaz90]

We have a 5 step procedure to clear c-spine in the field-

1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
3. If pt is glasgow 15, A&O x 4, step 4, if not IMMOBILIZE
4. If pain or deformity at any point of spine, IMMOBILIZE, if not, 5
5. If circulation, motor and sensory is normal, spine is clear, if not, IMMOBILZE
When in doubt, IMMOBILIZE.

Our medical control doc is actually pretty cool on this. He has told us that our cot is pretty much as effective as the backboard.

That actually seems pretty restrictive. Immobilization based on mechanism alone is ridiculous, and by that algorithm, you couldn't even proceed past step two for any "high mechanism." My favorite part of our selective spinal immobilization protocol is "ambulatory at any time." That removes a lot of the nonsense.

 

[Christopher]

There is a big difference between "clearing" a c-spine, and simply choosing not to immobilize someone because it isn't indicated.

It means a lot of things to a lot of people (EMS, ED, radiology, etc).

"Clearing" implies that there is in fact a significant potential for needing cervical immobilization, but that I'm using assessment skills to determine that such an injury doesn't exist. That's dicey considering that in the hospital, anyone with a significant chance of having a cervical injury is only "cleared" by a combination of clinical exam and imaging, and only by an MD.

"Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different.

I think I brought this up either earlier or in another thread, but the language used is "overloaded" (in computer science speak).

NEXUS and CCR "clear" a C-spine w.r.t. imaging need.

Selective spinal motion restriction protocols "clear" a C-spine w.r.t. splinting need.

I frankly do not care if they have an unstable radiological finding.

I care about clinically unstable spines.

We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria.

Amen.

That's how we should view the person who fell from standing and has no neck pain and almost zero chance of an unstable cervical fracture. We aren't "clearing" those people's c-spines; we just aren't implementing a procedure because it isn't indicated.

"You wouldn't put a traction splint on due to mechanism alone?"

 

[firecoins]

Only allowed to release during definite positive spinal injury.

 

[Bullets]

We have a 5 step procedure to clear c-spine in the field-

1. Assess MOI. (slow speeds, seatbelts, no airbag, no ALOC, no drug/alcohol, no distracting injuries, no hx of bone disease)
2. If pt is high risk due to MOI IMMOBILIZE, if not, step 3
3. If pt is glasgow 15, A&O x 4, step 4, if not IMMOBILIZE
4. If pain or deformity at any point of spine, IMMOBILIZE, if not, 5
5. If circulation, motor and sensory is normal, spine is clear, if not, IMMOBILZE
When in doubt, IMMOBILIZE.

Our medical control doc is actually pretty cool on this. He has told us that our cot is pretty much as effective as the backboard.

LOC, Drugs and Alcohol, distracting injuries and bone disease have nothing to do with MOI

MOI should not determine your treatment EVER. MOI is a clue to inform you of POSSIBLE injuries, and requires a basic understanding of physics that you dont get in EMT class to fully evaluate. If you see a rolled car, you should realize what forces were placed on the body and how that COULD cause injury

We had a patient yesterday fall 20 feet onto a wood floor. had some lumbar pain. Walked out of the hospital that night with 4 fractured carpals in a cast. MOI says trauma alert, his injuries did not

"Selective spinal immobilization", however, is where you simply don't immobilize someone unless they appear to need it, per your protocol. Very different.

We need to think of placing a patient in spinal precautions as a procedure, which, like all other procedures, is only indicated in limited, specified situations. We only give fluid boluses to people who meet certain physiologic criteria. We only cardiovert people who meet certain physiologic criteria. We should only immbolize people who meet certain physiologic criteria.

When you pick up a patient with chest pain and you don't cardiovert them because they are in NSR at 90, would you say you "cleared" their rhythm from needing cardioversion? No - you wouldn't say anything at all about cardioversion, because it would have never even entered your mind because it's just not called for.

That's how we should view the person who fell from standing and has no neck pain and almost zero chance of an unstable cervical fracture. We aren't "clearing" those people's c-spines; we just aren't implementing a procedure because it isn't indicated.

Now if i can just get Medics, Nurses and Doctors to understand this and STOP GIVING ME A HARD TIME AT THE HOSPITAL

sorry

 

[Carlos Danger]

NEXUS and CCR "clear" a C-spine w.r.t. imaging need.

Selective spinal motion restriction protocols "clear" a C-spine w.r.t. splinting need.

Well, here's the thing......

When does a patient need to be "cleared" of an injury? Only when there was significant suspicion that the injury may exist in the first place.

And if there was significant suspicion in the first place, I'm not sure that I as a paramedic want to be the one to state, definitively, that such an injury doesn't exist. Which is exactly what you are doing when you say "I cleared the c-spine".

On the other hand, simply choosing not to apply cervical spinal precautions because your patient doesn't meet the criteria for that procedure (neuro deficit, neck pain, etc.), while seemingly the same in practice, is a very different approach medico-legally.

In the first approach you are basically saying "This patient suffered trauma that made a c-spine injury a possibility, but my clinical exam finds that he does not in fact have such an injury". In the second approach, you are saying "I didn't place him in c-spine precautions because he had no clinical evidence of a cervical injury". Again, they are very different things to the risk-managment folks.

The authors of the NEXUS study may have used the terminology "cleared", because they are physicians and that's what physicians do. Paramedics don't typically "clear" patients of injuries.

If someone has an MOI that indicates the potential for a femur injury, but you choose not to put a traction splint on because their is no evidence of trauma to their leg, do you chart that you "cleared" their femur? No. You just chart that there was no indication for a traction splint.

It may seem like semantics, but in the legal sense, there is a BIG difference between "clearing" a patient, and simply choosing not to perform a procedure because it isn't indicated. This was explained to me years ago by a lawyer who is also a paramedic.

Of course, one could argue that all of that only matters IF you ever get sued for not applying cervical precautions. And that is a really decent point. However, that's placing a lot of faith in the criteria, and in your ability to always implement it without error.

I'm not sure if NEXUS will ever catch on widely. There are several studies that dispute it's validity, and x-rays are relatively easy and cheap.

I frankly do not care if they have an unstable radiological finding.

I care about clinically unstable spines.

Is there such thing as an unstable radiological finding vs. and unstable clinical finding?

 

[Christopher]

Well, here's the thing......

When does a patient need to be "cleared" of an injury? Only when there was significant suspicion that the injury may exist in the first place.

And if there was significant suspicion in the first place, I'm not sure that I as a paramedic want to be the one to state, definitively, that such an injury doesn't exist. Which is exactly what you are doing when you say "I cleared the c-spine".

On the other hand, simply choosing not to apply cervical spinal precautions because your patient doesn't meet the criteria for that procedure (neuro deficit, neck pain, etc.), while seemingly the same in practice, is a very different approach medico-legally.

In the first approach you are basically saying "This patient suffered trauma that made a c-spine injury a possibility, but my clinical exam finds that he does not in fact have such an injury". In the second approach, you are saying "I didn't place him in c-spine precautions because he had no clinical evidence of a cervical injury". Again, they are very different things to the risk-managment folks.

I think we're on the same page, as I'm not looking to "clear" a patient of injuries. I'm looking to answer: Do they need restriction?

The authors of the NEXUS study may have used the terminology "cleared", because they are physicians and that's what physicians do. Paramedics don't typically "clear" patients of injuries.

NEXUS and CCR identify patients for imaging studies. Cleared meant no imaging, not no injury.

If someone has an MOI that indicates the potential for a femur injury, but you choose not to put a traction splint on because their is no evidence of trauma to their leg, do you chart that you "cleared" their femur? No. You just chart that there was no indication for a traction splint.

I don't know if I would even chart that much. No closed Fx, no traction splint.

It may seem like semantics, but in the legal sense, there is a BIG difference between "clearing" a patient, and simply choosing not to perform a procedure because it isn't indicated. This was explained to me years ago by a lawyer who is also a paramedic.

Which is why I think the terminology isn't useful. My concern is not with clear or not clear. My concern is with a clinically unstable fracture that requires splinting.

Of course, one could argue that all of that only matters IF you ever get sued for not applying cervical precautions. And that is a really decent point. However, that's placing a lot of faith in the criteria, and in your ability to always implement it without error.

Many of the CCR/NEXUS trials look at these "misses" and they always boil down to: radiologically significant vs clinically significant.

I'm not sure if NEXUS will ever catch on widely. There are several studies that dispute it's validity, and x-rays are relatively easy and cheap.

CCR seems to supplanting NEXUS around here.

Is there such thing as an unstable radiological finding vs. and unstable clinical finding?

Yep. Radiologists will note "unstable cervical spinal injuries" with nasty case reports about this "big miss", which were patients walking around for days, etc. Came in due to something vague like "neck pain" or "neck stiffness", "finally" get "appropriate" imaging and are found to have something requiring intervention.

My point is, if you can walk around with it for days, it is not "unstable" clinically and it did not need stabilization/splinting. The patient perhaps should have received earlier imaging, but an imaging finding does not mean splinting was necessary.

By adopting NEXUS/CCR in the field for "clearance" or "selective immobilization" (whatever you want to call it), you're effectively using "predicted need for imaging" as a surrogate. My point is this is a poor surrogate for true need.

What we do not want to miss are patients with unstable fractures which are clinically significant. These are the real patients who benefit from spinal motion restriction.

 

[jefftherealmccoy]

I don't see why people say MOI isn't enough to board someone. I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.

My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.

If a pt is in a significant wreck and completly denies injury but wants to be evaluated, there are times that I won't backboard. But for the most part, they're going on a board.

And @ bullets-
No crap LOC, Drugs and Alcohol, distracting injuries and bone disease have nothing to do with MOI. The protocol is like a page long and I was paraphrasing.

 

[Carlos Danger]

My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.

Do you not see how that story is actually a perfect example of why backboarding isn't necessary, even when cervical injuries do exist.....?

 

[Christopher]

I don't see why people say MOI isn't enough to board someone. I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.

Because backboards are not helpful, that is why.

My own sister CRUSHED her C2 in a wreck, was ambulatory, had- what she called- muscular pain in her neck, and didn't realize she had spinal pain until she started having neuro deficits a few hours later.

A backboard would not have stopped those deficits. Those are from secondary cord injuries, usually inflammation or hypoxia to the cord.

If a pt is in a significant wreck and completly denies injury but wants to be evaluated, there are times that I won't backboard. But for the most part, they're going on a board.

If that is your protocol go ahead, but don't kid yourself into thinking you're actually helping them.

 

[TransportJockey]

I don't see why people say MOI isn't enough to board someone. I've been on plenty of patients (in my very short career) that have had significant MOI but their adrenaline is so high because they were just in a roll over, or bad crash, or fell off a building, they don't feel a thing, even on palpation, and they've got significant trauma to the spinal column.

.

Because studies show little to no benefit, increased risk and detriment to the patient, not to mention they are overused. More and more protocols are pulling backboarding all together. Look at the news release from Maine earlier this year