C-Spine rearing its ugly head

thegreypilgrim

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Here in wonderful SoCal we are in love with c-spine. It's like our main form of treatment in EMS. Even though we have a spinal clearance protocol in pretty much every county, it's just one of those things that hasn't quite entered the realm of cultural acceptance. Oddly, and perhaps ironically, in my experience this is actually more on the hospital's end of things. Most providers I've responded with try to find ways to implement the spinal clearance protocol, often only to be chided about doing so by hospitals. Yesterday, I kind of got my first taste of that.

Anyway, I give you the following rather routine scenario and tell me what you think:

HPI: 83 year old female presenting to urgent care facility status post unwitnessed fall at home. Patient is amnestic to event and cannot definitively help you rule out syncope vs. mechanical fall. Currently patient is alert and oriented complaining only of tenderness to right temporal skull. Family is bedside and states that the fall took place about 2 and a half hours ago.
Vitals: BP 144/98, P 112, RR 18, SpO2 98% RA, BGL 263 mg/dL.
General: Well developed, appears comfortable. Seated in wheel chair.
HEENT: Approximately 2" laceration to right temporal skull which has not been closed. No other trauma. Pupils PERRLA. No dysarthria. Equal facial symmetry.
Neck: Trachea midline. No JVD. No tenderness on palpation. No vertebral step-offs.
Chest: Denies chest pain. No accessory muscle use. Clear and equal to auscultation bilaterally.
Abdomen: Denies tenderness. No rigidity, distention, or guarding.
Extremities: No edema, clubbing, or trauma noted. Equal grips/pushes. Positive circulation and sensory-motor function x 4.
Skin: Warm and dry.

PMHx: Diabetes, Atrial Fibrillation, HTN
Allergies: Penicillin, Morphine
Medications: Diltiazem, Coumadin, Diovan, Glyburide.



ECG looks something like this except a bit slower:
afib_2a.jpg





So, do you c-spine this patient or not? In case anyone asks, the urgent care has not performed any radiographic imaging, labwork, or provided any other interventions other than requesting your code 2 (no lights and sirens) response.
 
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I would also not board this patient.

Though with the coumadin, she certainly would get a ct.
 
Nope, I wouldn't board.
 
Shame on all three of you!

As soon as care was transferred in the ED the resident ordered her to be placed in a c-collar.

I hope you learned your lesson.
 
Shame on all three of you!

As soon as care was transferred in the ED the resident ordered her to be placed in a c-collar.

I hope you learned your lesson.

Really? That's ridiculous. Why why why!? Did you get reprimanded?

I wouldn't have boarded her either. Amnestic to the event doesn't prove LOC. it's not uncommon that people won't remember what happened to them. Not saying she didn't syncope but I don't see spinal motion restriction indicated at all by this case.
 
Why did the urgent care call?
 
Really? That's ridiculous. Why why why!? Did you get reprimanded?
Not really. They asked me why I didn't do it, and after I answered proceeded to do it anyway. Pretty standard fair.

I wouldn't have boarded her either. Amnestic to the event doesn't prove LOC. it's not uncommon that people won't remember what happened to them. Not saying she didn't syncope but I don't see spinal motion restriction indicated at all by this case.
Agreed. Problem is everyone around here interprets that part of NEXUS rather conservatively.
 
I agree with you about the hospitals. I was told by an MICN that if you bring someone in as a trauma resource they must be c-spined, regardless of assessment findings. I smiled and nodded to get him to stop talking so I could walk away.
 
TheGreyPilgrim, the way you respond to that is, "I cleared the patient per cspine protocol". That basically forces them to refer to the protocol, which the residents might not even be aware of. Don't try to explain the specifics, just say you used the protocol (that your medical director wants you to follow).

I don't know what your specific protocol states, but the head laceration could be considered a distracting injury by whoever tries to judge you. I will say I'd be cautious with an 83 y/o...
 
I agree with you about the hospitals. I was told by an MICN that if you bring someone in as a trauma resource they must be c-spined, regardless of assessment findings. I smiled and nodded to get him to stop talking so I could walk away.
Yeah I don't get it man. This is like a universal Southern California thing to have hospitals be kind of unofficially at odds with random EMS protocols - even the rare progressive ones. I suppose that isn't all that unusual, but the near universal rejection of EMS c-spine clearance by hospitals around here is something I cannot wrap my mind around.
 
If C spine is working how can it rear its ugly head?
Sorry couldn't resist.
 
TheGreyPilgrim, the way you respond to that is, "I cleared the patient per cspine protocol". That basically forces them to refer to the protocol, which the residents might not even be aware of. Don't try to explain the specifics, just say you used the protocol (that your medical director wants you to follow).
They ought to know what NEXUS/CCR is. It's basically a standard of practice now, but I'm sure you know the fact that it's in the protocol doesn't mean much around here. I'm not in LA anymore, but the whole even-though-it's-in-the-protocols-I-don't-think-you-should-have-done-it thing still happens even out here.

I don't know what your specific protocol states, but the head laceration could be considered a distracting injury by whoever tries to judge you. I will say I'd be cautious with an 83 y/o...
I hate c-spining the elderly. I feel like I'm causing them more problems by doing it, and by all available evidence that appears to be the case.
 
I'm on a BLS unit right now. Most of our falls are elderly people in SNFs. If its a fall that the patient possibly hit their head then honestly I don't have a choice but to C-spine. The supervisors want it, our protocol person at work wants it, and the doctors/nurses at the hospitals want it.

We do have spinal clearence protocols on BLS and ALS units. Everytime I have followed that protocol I get "talked to".

So I go C-spine on most SNF falls. Why? Because I'm an EMT who has a job where there are a million EMTs who have in applications. I work at an at will state meaning I can be fired for nothing really. So I'm not going to give my employer something to fire me over because I need a paycheck.
 
I'm ganna throw a spanner in the works.

I'd probably collar her.

She's over 65 with what sounds like a decent whack to the head. I'd think she was ganna get a collar per CCR.

Maybe I'm picturing the wrong thing. But she doesn't sound that reliable to me when we're talking about NEXUS. NEXUS required pristine mental status. Doesn't really sound too pristine to me.

That said I can totally see how actually sitting in front of this pt might change things. Has she been ambulating with no deficits since? Maybe her mental status is perfect. Maybe the lac makes you think she graze a lamp shade on the way down rather than collecting a solid metal bench or something. You know...all that actually seeing the pt type stuff.

I've had similar pts and not collared. Perfect mental status, perfect neuro, nil tenderness and ambulating since. Even then I explained that there was a risk and said I wanted to, and then allowed her to refuse.
 
Per my protocols, anybody that has been ambulatory after an event and has no neck/back pain or altered mental status does not require a collar or board (although I can use one if I feel it is warrented).

So since it sounds like none of these things fit in this pt- I would not board or collar this PT.

(obviously i am not there to see the pt for myself- so this is my opinion based on the information at hand.)
 
I'm ganna throw a spanner in the works.

I'd probably collar her.

She's over 65 with what sounds like a decent whack to the head. I'd think she was ganna get a collar per CCR.

Maybe I'm picturing the wrong thing. But she doesn't sound that reliable to me when we're talking about NEXUS. NEXUS required pristine mental status. Doesn't really sound too pristine to me.
Ah, you're killing me Melcin!

I'll grant you she's probably not pristine in terms of mental status, but for 83 it's hard to do better I imagine. She was completely alert and oriented to time/place/person/event. She understood what was happening, why she was in urgent care, remembered events prior to fall. Just couldn't say how she fell.

Neuro exam is perfect. No nausea/vomiting. No paresthesias. Nothing of concern.

She ambulates with assistance even in normal circumstances. Family were the ones who brought her there to begin with, meaning she had to get up and walk back in the house, out to the car, sit in the car upright on the bouncy road, get out the car, and get herself back in her wheelchair all without spinal restriction.
 
Had almost the exact same scenario the other day. Protocol in this county states that because the patient was over 55 they should be c-spined.

In your case my answer to the hospital staff would be the patient would not tolerate it.
 
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