C-spine injury or cause of brain cancer?

emt58

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We had a patient tonight who has brain cancer and her daughter said she had been in the bathroom all day and didn't want to come out. She finally agreed to let us in. I did my assessment and she was alert and oriented x4, got vitals, she seemed normal but couldn't really tell me why she was in the bathroom for that long, she just kept saying she fell asleep woke up every now and then but didn't want to get up (although now I know the real reason why). No head trauma and patient had pms in all extremities. She said she didn't fall and neither did her family that was there claimed she had fallen but when I came back after getting the stretcher with my driver, my partner was assisting her getting out of the floor and had moved her to the hallway because she couldn't walk! So that threw me for a loop. I then asked if she had any neck or back pain and she denied. Well got her to the hospital and she started not being oriented x 4 when the doctor asked her what year it was and stated her youngest son was in school (it's sunday)... she answered my questions accurately earlier and was even able to tell me her social security number and birthdate. Should this patient have been backboarded? I felt c-spine was compromised after my partner had moved her. If I had known she couldn't walk I probably would have immobilized right then and there. Do you think this was a cause of brain cancer of not being able to balance or a possible floor level fall resulting in damage? Her family stated she had an operation on the tumor last week but it wasn't completely removed and she has been missing treatments along with medication dosages. I'm sort of freaking out, and with good reason... my *** is no longer covered.
 
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DesertMedic66

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Alert and orientated x4, with no neck/back pain, denies fall, distals/neruo intact, would get no backboard from me.

Why couldn't she walk? (too weak, unable to balance, etc).
 
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emt58

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Alert and orientated x4, with no neck/back pain, denies fall, distals/neruo intact, would get no backboard from me.

Why couldn't she walk? (too weak, unable to balance, etc).
I'm really unsure. She could move her legs when standing with assistance but just couldn't balance herself to be able to take steps. She could squeeze my hands and push on my hands with good strength. I've researched that brain cancer can cause motor function to diminish but that's all I can think. It was just a very odd call.
 

Anjel

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No backboard from me. No mechanism of injury, no pain, no distracting injuries, no drugs/alcohol.

Say someone is having a stroke and can't move their arm. Are you going to splint it? Nope.
 

Medic Tim

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No board . Even if she fell and hit her head or had neck and back pain. Placing a person on a backboard does not prevent further injury or protect the spine like they preach in school. The evidence they use to support it is very old and flawed. There is a ton of research out there on this. Hopefully you will read some of it.
 
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emt58

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No board . Even if she fell and hit her head or had neck and back pain. Placing a person on a backboard does not prevent further injury or protect the spine like they preach in school. The evidence they use to support it is very old and flawed. There is a ton of research out there on this. Hopefully you will read some of it.
Yeah I've read up on it and have read about new research that many times it's way too precautionary and sometimes only hurts the patient, and I do agree. But I'm concerned because the patient could not walk and normally could according to her and family. She was oriented to my questions but just seemed 'off' at the same time, hard to explain but with brain cancer I'm sure it can affect limb movement/balance and even mental status... she was oriented under my care but at the hospital was a different story. Like I said, she could not explain what really happened or why she was in that bathroom for so long "asleep". Family didn't seem to care and neither did the patient which is why I say it just seemed like an odd call...
 

VFlutter

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Is it primary brain cancer or metastatic? Spinal metastasis is a possibility. But depending on type and location or the tumor it very well could cause all of it.
 

WolfmanHarris

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No board.

The effects of brain CA can be wide ranging and extremely variable as the disease worsens. The eventual cause of death in brain CA is the effects of the large amounts of edema caused by the mass and the resulting interruption of brain functions. Furthermore the most commonn type of malignant brain CA is Glioblastoma Multiforme (GBM) which forms in the glial cells and thus has a high likelihood of infiltrating other parts of the brain.
 
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emt58

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Is it primary brain cancer or metastatic? Spinal metastasis is a possibility. But depending on type and location or the tumor it very well could cause all of it.
As far as I know just primary brain cancer. She had a spot directly on her upper forehead right above the hairline where they operated last week so I assume that's where the tumor was and where the brain was primarily affected.
 

Christopher

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The answer to the question "should I have immobilized this patient?" is always No. Rigid immobilization is not helpful and most likely harmful. (if you're asking about a behavioral patient the term is "restrained")

The correct question is, "should I have ensured motion restriction of the patient's cervical and/or thoracic spine?"

Anyways...

She said she didn't fall and neither did her family that was there claimed she had fallen but when I came back after getting the stretcher with my driver, my partner was assisting her getting out of the floor and had moved her to the hallway because she couldn't walk!
Skin, tissue, and bone sits between the spinal cord and the outside environment in all humans with normal anatomy.

Were there significant findings to anything between the spinal cord and the outside environment?

So that threw me for a loop.
Look at it this way: She's been sitting on that floor for a while because for whatever reason she couldn't walk. The #1 treatment for this patient is moving them to a position of comfort, which is likely your stretcher's mattress.

Moreover, if you have paralysis due to a traumatic cord injury you're going to have some outward sign of an injury.

I then asked if she had any neck or back pain and she denied.
Patients with true neck/back pain will tell you about it without prompting. This goes for just about any complaint a patient may have. Very few are actively seeking to withhold vital information. Very few.

Should this patient have been backboarded? I felt c-spine was compromised after my partner had moved her.
You would have seen the compromise immediately. Immediately. Injuries to the spinal column are broken down into primary or secondary. Primary insults, such as moving your patient inappropriately, will have immediate results. Secondary insults have a gradual onset due to inflammatory processes.

If I had known she couldn't walk I probably would have immobilized right then and there.
Zero indication for spinal motion restriction. Even with this patient's signs of neurological compromise, we still have zero indications.

Only oxygen gets more overuse in EMS than the rigid extrication board (incorrectly called a "long spine board" as placing a patient on it cannot possibly confer any benefit to the spine; although if the term is used to mean 'causes unnecessary and harmful pressure to the spine' then I will agree it is used appropriately).

Do you think this was a cause of brain cancer of not being able to balance or a possible floor level fall resulting in damage? Her family stated she had an operation on the tumor last week but it wasn't completely removed and she has been missing treatments along with medication dosages.
This is most assuredly due to her brain cancer. Unless your assessment found some nasty ecchymosis or step-offs.

Injuries to the spinal column do not cause altered mental status on their own, they'd need a contributory finding to support it as a cause of a loss of CPP (cerebral perfusion pressure), like neurogenic or hypovolemic shock.

I've seen some nasty ground level falls, so I don't want you to think I don't believe this patient could have sustained a grievous injury. But all of these patients had significant physical findings.

To suggest this patient suffered a clinically significant fracture of her cervical or thoracic spine producing neurological deficits without any outward indications to the overlying structures is truly a Zebra medical case!

I'm sort of freaking out, and with good reason... my *** is no longer covered.
I'm going to remove the use of personal pronouns because this is not directed just to you:

I take a dim view of folks who perform procedures to CYA. Providers should perform procedures based on patient-centric outcomes. This means providers need at the very least an indication prior to performing any intervention or procedure...and they had better back it up with an assessment.

"My ***" is not an indication for anything.

Our crews who do these sorts of unnecessary procedures get remediation.

I don't want you to read this thinking I'm placing any special blame on you for worrying about your partner killing somebody over simple patient movement. We've all been sold war stories as literature in EMT and paramedic school, many times over (good news, we're not alone in our misunderstandings in medicine). I have been pretty bad at parroting them over the years and actively seek to remove them from my teaching.

I'm very happy to see you challenge your assumptions in an open forum!
 

mycrofft

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Isn't it a weird visual when one thinks about covering one's backside with a spineboard? I'd use pants.

There are many reasons for needing help to ambulate besides spinal insult. Try sitting on a toilet seat for an hour then rapidly stand up; numb legs, vasovagal, etc. Not even mentioning illness (infection, meningitis), possible side effete of possible meds, fatigue, electrolyte imbalances.
 

Brandon O

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Dear Christopher is putting it a bit strongly, but I think the key takeaway is that if the question is "could this patient have been harmed by not immobilizing his spine?" the answer is basically always "no." Whether it's always "no" or almost always "no" is not 100% settled, but it's a pretty academic distinction.

If the question is "could *I* have been harmed by not immobilizing his spine?" the answer may be yes. That's why, as observed, immobilization is more about your butt than any part of the patient's anatomy. But at least you can stop worrying about the other thing.

(Can we start calling backboards "ischial precautions"?)
 

Anonymous

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I sit down to use the toilet for more than 5 minutes and I cannot walk right after. I think your question has been thoroughly answered but I will add one more "No" for good measure.
 

unleashedfury

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We had a patient tonight who has brain cancer and her daughter said she had been in the bathroom all day and didn't want to come out. She finally agreed to let us in.I did my assessment and she was alert and oriented x4, got vitals, she seemed normal but couldn't really tell me why she was in the bathroom for that long, she just kept saying she fell asleep woke up every now and then but didn't want to get up (although now I know the real reason why). No head trauma and patient had pms in all extremities. She said she didn't fall and neither did her family that was there claimed she had fallen but when I came back after getting the stretcher with my driver, my partner was assisting her getting out of the floor and had moved her to the hallway because she couldn't walk! So that threw me for a loop. I then asked if she had any neck or back pain and she denied. Well got her to the hospital and she started not being oriented x 4 when the doctor asked her what year it was and stated her youngest son was in school (it's sunday)... she answered my questions accurately earlier ...


I just stole part of your Original Post to use for my response.

1.You were dispatched drive over to the house and find a patient who wouldn't let you in the bathroom. She has been in their ALL DAY.

So how does the family know she "fell" if she locked herself in the bathroom all day?

2. You performed a thorough Physical assessment of the patient. She denies any injuries, She was Alert & Oriented answering questions appropriately. Vital signs WNL.

3. You stated the patient has Brain Cancer with a surgical procedure performed recently with a healing wound.

Is this her only medical history? what about medications? How has she been acting for the last few days prior to this incident?

Various things can cause "weakness and altered mental status" Infections, Medication side effects, Dehydration, Low Blood Sugar, electrolyte imbalances. you name it.

In my honest opinion this patient didn't need C-Spine Precautions she offered no complaints of injury and your physical assessment did not show any justification to perform said actions.

my *** is no longer covered


This....
encourages me to keep my Pimp hand strong

Covering your *** is all about justifying your treatment actions, what you have performed,what you have not performed. and why.

If the ED Doc asked me why this patient was C-Spined, Placed on a long hard board of plastic, and secured to be bounced off of every bump in the road to the ED I would simply state. Pt. presented CAOx3, answered all questions appropriately, offered no complaints of pain, Physical exam showed no injuries, pt. denies fall, and scene did not show any mechanisms warranting a fall.
 

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