C-Spine after a fight

Rebelw/oaGauze

Rebelw/oaGauze

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Long time reader, first time post. Big fan of the website and everyone here has provided so much great information. My question is whats everyones feelings on C-Spine precautions on a patient after a fight? They are most often intoxicated and have facial/head trauma so they are instant candidates for C-Spine. Aside from obvious trauma and extreme intoxication, does a collar go on everytime? Just wanted some opinions from all you lords of the streets:)
 
It all depends on the patients presentation. If they are alteredyes or have neck pain then yes, but if its a fat lip, ect then no. Unfortunately in most cases we have to c-spine them even if they do not need it based solely on protocol.
 
Yeah thats what usually happens. I dont care about burning through collars but I want to exercise some discretion. Unfortunately like you stated protocol usually dictates they get the collar.
 
If he isn't unconscious, isn't complaining of head or neck pain, is CA&O x 4, has no neurological deficits, nothing abnormal upon palpation, or refuses spinal precautions, there is no reason to immobilize him.
 
EMTinNEPA said:
If he isn't unconscious, isn't complaining of head or neck pain, is CA&O x 4, has no neurological deficits, nothing abnormal upon palpation, or refuses spinal precautions, there is no reason to immobilize him.
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Alcohol can mask the pain, so to speak.

With significant facial or head trauma, if the patient will tolerate it, I'd backboard them.
 
Sasha said:
Alcohol can mask the pain, so to speak.

With significant facial or head trauma, if the patient will tolerate it, I'd backboard them.
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Alcohol won't mask unconsciousness, neurological deficits, or abnormal findings in palpation of the c-spine. I see no reason for immobilization, but everyone is free to follow their discretion.
 
EMTinNEPA said:
Alcohol won't mask unconsciousness, neurological deficits, or abnormal findings in palpation of the c-spine. I see no reason for immobilization, but everyone is free to follow their discretion.
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No, but it can mask neck or back pain. If someone has neck pain, they get a C-Collar and board, so it should be one of your assesment points. Move wrong and that neck pain can become neck pain and neuro defict.

Btw rebel love your username.
 
Depends on local protocol.

I think its always better to do something thats not needed that will not cause any further damage than to face any disciplinary consequences.

Not to the Op but there alot of EMTS out there that try to apply there "street smarts" in the wrong places. If its protocol so what if its stupid its your job. If you want to change it go back to school and become the EMD.

Use your "street smarts" in decisive decisions that are going to make a difference in the positive outcome of a patient.

I really get peeved by people (not the op) who constantly question protocols that even I might consider "stupid" it is not our job to decide what to follow and what to omit, at the end of the day we are just worker bees.

If its even questionable to c-spine I would say do it just to cover your own ***. (Unless it was a pillow fight) :P
 
FFMckenzie said:
Depends on local protocol.

I think its always better to do something thats not needed that will not cause any further damage than to face any disciplinary consequences.

Not to the Op but there alot of EMTS out there that try to apply there "street smarts" in the wrong places. If its protocol so what if its stupid its your job. If you want to change it go back to school and become the EMD.

Use your "street smarts" in decisive decisions that are going to make a difference in the positive outcome of a patient.

I really get peeved by people (not the op) who constantly question protocols that even I might consider "stupid" it is not our job to decide what to follow and what to omit, at the end of the day we are just worker bees.

If its even questionable to c-spine I would say do it just to cover your own ***. (Unless it was a pillow fight) :P
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Studies have shown that spinal immobilization is beneficial less than 2% of the time. In fact, spinal immobilization can have negative effects. Backboards, cervical collars, and CIDs are not the most comfortable things in the world. What happens if you board the patient in the OP's scenario and he did not need immobilization, but while immobilized he develops a stiff neck or back pain? Even a drunk can put two and two together and realize that he didn't have this pain before he was boarded. It may be post hoc ergo propter hoc, but then again, this is a drunk we're talking about.

Following protocols to the letter, while it may be beneficial to you covering your assets, it may not always be in the best interest of the patient. And if it isn't, but you follow the protocol to the letter anyway, you may not get fired, but you sure aren't fulfilling the patient advocacy part of your job.
 
Rebelw/oaGauze said:
Long time reader, first time post. Big fan of the website and everyone here has provided so much great information. My question is
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this isn't talk radio
 
EMTinNEPA said:
Studies have shown that spinal immobilization is beneficial less than 2% of the time. In fact, spinal immobilization can have negative effects. Backboards, cervical collars, and CIDs are not the most comfortable things in the world. What happens if you board the patient in the OP's scenario and he did not need immobilization, but while immobilized he develops a stiff neck or back pain? Even a drunk can put two and two together and realize that he didn't have this pain before he was boarded. It may be post hoc ergo propter hoc, but then again, this is a drunk we're talking about.

Following protocols to the letter, while it may be beneficial to you covering your assets, it may not always be in the best interest of the patient. And if it isn't, but you follow the protocol to the letter anyway, you may not get fired, but you sure aren't fulfilling the patient advocacy part of your job.
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Yeah yeah. You read my post about the evils of backboarding a long time ago, BUT what if your patient is in that 2%?? Are you going to risk his mobility because you read a study? Major facial or head trauma, backboard.

It's not following protocol, it's being smart and thinking about what could have happened to your patient.
 
My vote is for selective spinal procedures. I think that c-spine precautions or sinal motion restriction or whatever it is call now in days is plain over used, but I am also no willing to toss the equipment off the truck because some studies show that it is rarely effective. Moderation is key here.
 
I would have to agree with those that say it depends upon the presentation of the patient. As a medic, where I work, I am allowed to selectively c-spine based upon predetermined criteria. (Most of which have already been mentioned - no neuro deficits, no neck pain, not altered, is A&Ox3, etc.) If the patient meets the criteria for opting not to collar/board them, then they do not get it. Along with various physical findings, we can use "paramedic discretion" when determining if a patient is getting boarded. In otherwords, if they meet all the criteria to not be boarded, but my gut/mechanism/something on scene tells me to go ahead and do it, I can opt to board the patient anyway.

I am all for opting to not board a patient, when appropriate. No only is that thing uncomfortable, there are also other things to consider, depending upon your patient and any pre-existing conditions that may exist. For example, the little old lady with kyphosis of the spine, or the little old man that fell at the ECF and has bedsores on his backside. How long is the transport? If it is a very long transport, it is possible that pressure points while lying on the board have begun to do some damage to the skin, even if it is not yet visible.

Lots of factors go into my decision on whether or not I board a patient. I am not advocating not boarding patients that may need it. However, I believe as a whole that EMS providers board to many patients, and for alot of them there is no benefit. If properly educated, there is no reason why one should not board those that meet the criteria to fore go it.
 
Forget about only losing your job, it only takes ONE incident for you to lose a lawsuit, your cert, and your livelihood. If it's in your protocol, do it. Some places do allow the techs to clear C-spine in the field, at the "provider's discretion". That terminology places the onus of that decision entirely on the provider.

If your protocol mandates SMR, then do it. Protect yourself. If it makes the pt uncomfortable, or produces some stiffness/tightness, it really isn't your problem. The only way I would clear C-spine if there was a clearly defined protocol in regards. As in "see A, do B". Know what I mean? If the pt suffers damage as a result of not performing SMR, the blame is off of you as the protocol dictated your actions based on your findings.

Once I treated a pt that was experiencing neck pain secondary to an MVA. Supine positioning was out of the question, as it worsened the dyspnea (active wheezing), and caused further stress for the pt. We did a KED and a nearly fowler's positioning with satisfactory results. We documented well. My point is, if you neglect SMR, be prepared to document a pretty substantial reason such as a kyphotic elderly female, for example, who screams in pain and flails around when placed supine on a LSB.

When It comes down to it, I'll follow the cookbook if the potential for liability is unacceptable otherwise.

Remember, we're not MD's. If and when you go to court, you'll find out. For example, the attorney asks you what the diagnosis of your pt was. Say the pt had S/Sx of APE and dyspnea. The correct answer would be "I am not at liberty to diagnose, as I'm not an MD. My pt assessment revealed dyspnea and bibasilar rales, with a Hx of CHF. I treated the pt for rales and dyspnea per dept protocol". Or, "the pt C/O retrosternal Cx pain with ischemic anterolateral changes on the 12 lead. We treated for that complaint and that finding per protocol". If you deviate from protocol, which is acceptable, as we should all strive to be more than "cookbook" providers, be ready to validate your decisions.

My understanding of deciding on guilt of malpractice and such is that your actions or lack thereof will be compared to what other competent providers of similar training would do under the same circumstances.

Protect ya neck!
 
Sasha said:
Yeah yeah. You read my post about the evils of backboarding a long time ago, BUT what if your patient is in that 2%?? Are you going to risk his mobility because you read a study? Major facial or head trauma, backboard.

It's not following protocol, it's being smart and thinking about what could have happened to your patient.
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A couple of watery drunks coming to fisticuffs is major facial or head trauma? As I said, it depends on the patient's presentation. All the OP said was "a fight", nothing in regards to physical findings, chief complaint, anything. And since when do we base medical care on "what ifs"? Call me crazy, but I thought medical care was supposed to be based on evidence (*cough*studies*cough*). In my experience and the experience of many others, spinal immobilization is rarely needed for somebody who got clocked in the kisser by somebody who isn't a professional boxer. And just because I agree with you that most backboarding is unnecessary, then I stole your opinion?
 
Call me crazy, but I thought medical care was supposed to be based on evidence (*cough*studies*cough
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Medicine is full of studies that say whatever the researcher wanted them to. I can find studies for backboarding, as much as I can find against it. Same with every other procedure medical professionals do. The key is to not take them as the gold standard. I am quickly learning not to depend on studies for your teatment modalities but to evaluate each patient and form their treatment plan from there.

I said IF there was serious facial trauma. He DID mention head/face trauma.
 
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Sasha said:
Medicine is full of studies that say whatever the researcher wanted them to. I can find studies for backboarding, as much as I can find against it. Same with every other procedure medical professionals do. The key is to not take them as the gold standard. I am quickly learning not to depend on studies for your teatment modalities but to evaluate each patient and form their treatment plan from there.

I said IF there was serious facial trauma. He DID mention head/face trauma.
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We're dealing with a lot of "ifs" here, as well as your definition of facial trauma. If somebody punches me and I get a bloody nose, it is facial trauma, but is it considered MAJOR facial trauma. And yes, he DID mention facial trauma, but that goes hand-in-hand with "fight".

And if we don't look to evidence to determine the best course of action, what else do we have to look to? Patient assessment, yes, but that's physical evidence. Patient presentation along with what has been proven to work is all we have to go off of, otherwise we would still be using patchouli and chants to heal others.
 
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