ER C-Spine

[mikie]

Have you ever transfered a fully immobilized pt on a LSB, and once at the hospital, they (RNs usually) just takes the pt out of it all (remove head blocks, collar, straps & board), without even checking C-Spine? As if we just put them on the board for fun...

Just curious...

Thanks!

 

[colafdp]

absolutely..this unfortunately has happened many many times. I remember going to a rollover MVA one day, with two patients trapped. Long story short, we get the driver to the ER (fully boarded and immobilized) and we put her on the bed, and the nurse takes off the collar and headblocks, and undid the straps because "they were bugging her".

The driver ended up having a C2, and C3 fracture. Trust me, i feel the same way about it that you do....we put them on the board, just cause we're jerks and we want to make their ride as miserable as possible...

Maybe someone can chime in here, but I remember hearing something about a study that stated our c-spine precautions aren't worth diddly....is this true, or was i just imagining it?

 

[certguy]

One of the worst fellings I ever had was when we were working a HS football standby , had a player go down , and the team DR. ( an orthopedist who had assumed care on our 15 y/o head injury with decreasing LOC ) broke every protocal we had and removed the pt. from c - spine while we were running code 3 to the trauma center . The pt. was free flopping on the board ! The trauma team met us outside the door and the surgeon went ballistic . You better believe I documented the h___ out of that call . That DR. got called on the carpet by county EMS . I had visions of this kid in a w/c and my cert going bye - bye . The pt. had a concussion , but recovered fully , surprisingly , I wasn't involved with the investigation , though I was our pt. man , and the DR continued to practice .


Stuff like this makes you wonder if a higher level of care is always the best level of care ?

 

[teammedic]

most ER nurses think what we do in the field is worthless. i dont know why maybe its they go to school longer. i think all ER nurses should have some experience in the field as a third crew member. this would show them the role we play in pt care. maybe then we would get respect. i also like when giving report they role their eyes and dont hear a word of what you said. some ER nurses are good and some i could shoot.

 

[Ridryder911]

most ER nurses think what we do in the field is worthless. i dont know why maybe its they go to school longer. i think all ER nurses should have some experience in the field as a third crew member. this would show them the role we play in pt care. maybe then we would get respect. i also like when giving report they role their eyes and dont hear a word of what you said. some ER nurses are good and some i could shoot.

Okay, let's be clear before we start stating all nurses. What is incredible is the number of "ground level" falls that are C-collared, LSB etc. for a fall < 2-3 feet without any pain, or hx of osteopenia, osteoporosis, etc. Many not using any common sense at all. Remember, nurses have to deal with a patient on a LSB for minutes to hours all patients complaining that the "ambulance drivers" placed them on this for what? Want to be urinary cathed, all because the EMT"s placed you onto a LSB with CID? Remember, there is more to the story after you leave.

There is more and more research documenting that immobilizing many non true spinal patients is actually causing more harm than good. Protocols should be reviewed upon really whom should warrant immobilization instead of a everyone gets immobilization guideline. Even the discussion of serious trauma patients may not need all the crap we place onto patients is being studied. It is has been found many of the injuries occur during the event and not afterwards. I believe we will see a drastic change within the next few years.

R/r 911

 

[Zanerd]

absolutely..this unfortunately has happened many many times. I remember going to a rollover MVA one day, with two patients trapped. Long story short, we get the driver to the ER (fully boarded and immobilized) and we put her on the bed, and the nurse takes off the collar and headblocks, and undid the straps because "they were bugging her".

The driver ended up having a C2, and C3 fracture. Trust me, i feel the same way about it that you do....we put them on the board, just cause we're jerks and we want to make their ride as miserable as possible...

Maybe someone can chime in here, but I remember hearing something about a study that stated our c-spine precautions aren't worth diddly....is this true, or was i just imagining it?

I mentioned a conversation I had with a Doc/PA. There was also another post with part of an article about this subject by JPINFV.

Perhaps I will search the web to find some more info...

 

[Ops Paramedic]

I feel for you, when it appears that someone does not appreciate the work and effort you put in. We also experience it out this side, often, more so in some of the government facilities. But beware the day you don't immobolise and should have, you will end up in a world of trouble...

Be carefull of generilastion, but I do agree with you that in hospital staff should book some shifts on the road, so that if we tell them for example "The patient refused to be immobilsed", they understand it. But it would be unfair not to return a favour and pull some shifts in the er, so that when they do something that you don't think is right, that there may well be a good reason (Not saying that there is a good reason for just ripping the immobolisation off the patient without an examination of some kind).

Remember the documention aspect with regards to these kind of situations. It is tricky sometimes, but if you feel that the patient is being mismanaged, try diplomatically to resolve the differences, you tend to get a lot futher than just kicking up a fight. The well documented patient record (Make specific mention of your treatment as well as your examination regarding the power of movement, any fall out on - vascular Fx, Neuro Fx and Motor Fx, etc. of all the limbs for: on arival, during transport, and at handover) form with a hand over signature is worth GOLD, it could save your behind when someone decides to try and get some money for the patient who is now in a wheelchair!!

Hence my thread regarding c-spine clearence pre hospital...

 

[MSDeltaFlt]

Let's all bare in mind, people, that even your significant spinal cord injuries won't stay on the LSB for their entire hospital stay. Sometimes they'll even be pulled off before their interventions are performed.

This is the voice of experience.

Do you think I stayed on the LSB for the week after my wreck, through my two surgeries (one of them prone), up to my halo placement for my C2 Fx? I'll give you 3 guesses and the first 2 don't count. My Pulse/Motor/Sensory was never compromised, and I'll be back online in a 1 1/2 weeks with no weight restrictions.

Pulling someone off the board is usually going to be OK as long as they follow their SOP's. I have no problem clearing someone in the field - following protocol. If I can't with my limited protocol ranges, and they still seem grossly intact according to my assessment, I will also tell the ER in my radio report that they can probably be cleared clinically.

Blanket statements can be very dangerous. Remember that we're just following protocol. They also might be following protocol as well. Some nurses just might be having a bad day and/or bad attitude; not unlike some of us EMS'ers.

Just my humble thoughts

 

[fma08]

we have a protocol in which if the pt. meets certain criteria, we can opt out of placing them in a c-collar and on a back board, but our med director made it clear in which instances it is necessary for spinal precautions such as significan MOI, head/neck/back pain, distracting injuries, etc. as for getting to the er, one of the first things the doctors do around here is take the head blocks and collar off to inspect the neck, some put it back on till they get an xray or ct scan, and some just take it off completely if they feel ok with it. here the doctors at least are good about not blowing off our report if they come in on a long board. i have come to trust their decisions. i have run into some nurses yes that just kinda roll their eyes, or ignore us or whatever. just document that report was given and transfer of care was given to... whoever. nothin you can do for pt care after that point.

 

[skyemt]

we have a protocol in which if the pt. meets certain criteria, we can opt out of placing them in a c-collar and on a back board, but our med director made it clear in which instances it is necessary for spinal precautions such as significan MOI, head/neck/back pain, distracting injuries, etc. as for getting to the er, one of the first things the doctors do around here is take the head blocks and collar off to inspect the neck, some put it back on till they get an xray or ct scan, and some just take it off completely if they feel ok with it. here the doctors at least are good about not blowing off our report if they come in on a long board. i have come to trust their decisions. i have run into some nurses yes that just kinda roll their eyes, or ignore us or whatever. just document that report was given and transfer of care was given to... whoever. nothin you can do for pt care after that point.

i hope no one takes this personally, but in my experiences, the ER staff will take reports from those EMT's that give good ones...

as for all the rest that don't... well, you know how they are received.

 

[BossyCow]

If we bring in a backboarded pt, the doc is the only one who can let them out of C-spine.

 

[firecoins]

yeah, nurses are not allowed to clear patients. Doctors and PAs do. I find the doctors and PAs often remove patients rather quickly anyway.

 

[KEVD18]

it happens. i don't let it bother me. i wouldn't say i don't care what happens to the pt after i transfer care, but after the pt is signed over, its no longer my responsibility. a person with a higher level of licensure made a clinical decision that happens to override mine. who am i to argue.

 

[Doctor B]

As someone who transports alot of critical trauma patients to Level 1 trauma centers we see the same thing. Regardless of the initial pt. presentation they are immediately log rolled off the backboard. Keep in mind though that they are in NO WAY clearing their spine when they do this. The pt. may remain in the c-collar but neutral alignment is always maintained until they are either cleared clinically or radiologically. In my opinion the term "backboard" is a misused label that should actually be called an extrication board (except for the departments using the spine mattress/ vacuum splint). The method to my madness is simple. Are you really immobilizing the pt's spine to the board keep in mind that the board is flat and the spine is not. Unless you heavily pad the board the downward compression forces of the ambulance driving down the road over bumps, potholes, etc... are still able to act upon the spine (just ask my wife who is in the healing stages of an anterior compression fracture of her thoracic spine). The reason they remove the patient from the board so quickly is that studies have shown that decubitus ulcers can develop in as little as 90 minutes. Just a suggestion to protect yourself though is to make sure you document the patient's SMV's is all extremities upon transferring care to the ER staff. Additionally, document the first and LAST name of the nurse you are transferring care to. That way if the pt. deteriorates in the ER they will be unsuccessful in trying to blame it on you!

 

[mikie]

just an aside, a got a weird vibe from some earlier posts...

I'm NOT in anyway 'bashing' nurses or docs or anyone in the ER. I trust their abilities and I'm sure know what they're doing (I want to be a nurse down the road possibly). And perhaps it does have to do with us sometimes giving a poor report.

Just clarifying my first thought.

...Carry on!

 

[skyemt]

As someone who transports alot of critical trauma patients to Level 1 trauma centers we see the same thing. Regardless of the initial pt. presentation they are immediately log rolled off the backboard. Keep in mind though that they are in NO WAY clearing their spine when they do this. The pt. may remain in the c-collar but neutral alignment is always maintained until they are either cleared clinically or radiologically. In my opinion the term "backboard" is a misused label that should actually be called an extrication board (except for the departments using the spine mattress/ vacuum splint). The method to my madness is simple. Are you really immobilizing the pt's spine to the board keep in mind that the board is flat and the spine is not. Unless you heavily pad the board the downward compression forces of the ambulance driving down the road over bumps, potholes, etc... are still able to act upon the spine (just ask my wife who is in the healing stages of an anterior compression fracture of her thoracic spine). The reason they remove the patient from the board so quickly is that studies have shown that decubitus ulcers can develop in as little as 90 minutes. Just a suggestion to protect yourself though is to make sure you document the patient's SMV's is all extremities upon transferring care to the ER staff. Additionally, document the first and LAST name of the nurse you are transferring care to. That way if the pt. deteriorates in the ER they will be unsuccessful in trying to blame it on you!

if you feel that way, there are products you should be using with your long board, such as the Back Raft. pads the voids, protects from ulcers.
simple solution to your issues, which are valid.

 

[Doctor B]

skyemt,

I agree with you wholeheartedly!! Fortunately our agency is one of the very few utilizing the evac-u-splint system. Unfortunately not everyone has the budget to support this though. The Back Raft is another great tool. I'm sure most of providers out working on the streets would love to purchase these for their boards. Unfortunately, as we are all painfully aware, EMS is seemingly driven more and more by the financial aspect as opposed to the pt. care aspect.

 

[skyemt]

skyemt,

I agree with you wholeheartedly!! Fortunately our agency is one of the very few utilizing the evac-u-splint system. Unfortunately not everyone has the budget to support this though. The Back Raft is another great tool. I'm sure most of providers out working on the streets would love to purchase these for their boards. Unfortunately, as we are all painfully aware, EMS is seemingly driven more and more by the financial aspect as opposed to the pt. care aspect.

well, many systems have protocol problems with the evacu-splints, if used in place of an LSB... they can develop small leaks, and then you lose the rigidity of the evacusplint, and can end up with no immobilization. i have seen it happen.

as for the Back Raft, if it should fail, you are no worse off than if you never used it at all, as it lays over the LSB. it is a $15 item... would hardly put a strain on the budget. one only has to seek solutions to issues... they are out there.

 

[paramedix]

"Oh that's fine honey, we will re-immobilize him if there is something wrong, you can take your toys off now".... have you ever had that statement.

Like mentioned earlier in the thread, this happens and our "toys" get removed quickly without consideration, especially government institution. I might add in the same breath, it's not all of the government institutions.

I really hate it when the "toys" are removed especially whilst I'm busy handing the patient over. It is at that point when you mention he has c-spine tenderness and everything goes quiet...