Log Roll Pelvic Injury

[usalsfyre]

Right, but we don't know that the force was applied solely to the hip, and I guess I'm just using the MOI to state not the assessment (which, I would still do anyway), but to show that a large amount of force has been applied to the patient regardless, and though my assessment may find no broken spine or neck, I am not an x-ray machine, and if someone fell out of a car and broke their hip couldn't I assume that (even if my assessment didn't physically feel it upon palpation) enough force was applied that there is still a risk, and precautions can be taken? I'd rather take the precaution than have to explain why I didn't take precautions, right?

You might want to review the NEXUS study and look at radiography accuracy vs physical exam accuracy for C-Spine injuries (hint, the X-ray machine doesn't win). The "not an x-ray" excuse doesn't work when you look at the data.

I'd rather not put the patient through an uncomfortable, painful, needless and potentially harmful procedure "just in case". I could intubate everyone "just in case" but it's not called for, harmful and would get my card pulled. If more medical directors would start looking at spinal immobilization as an intervention that needs to be justified (which it is) rather than a something we do "just in case" I'm betting the number of times a spine board is used pointlessly (most of the time) would go down drasticly.

 

[Pittma]

You might want to review the NEXUS study and look at radiography accuracy vs physical exam accuracy for C-Spine injuries (hint, the X-ray machine doesn't win). The "not an x-ray" excuse doesn't work when you look at the data.

I'd rather not put the patient through an uncomfortable, painful, needless and potentially harmful procedure "just in case". I could intubate everyone "just in case" but it's not called for, harmful and would get my card pulled. If more medical directors would start looking at spinal immobilization as an intervention that needs to be justified (which it is) rather than a something we do "just in case" I'm betting the number of times a spine board is used pointlessly (most of the time) would go down drasticly.

Well, I understand your point then, and I also agree that it seems a little overboard to immobilize every time.

However, the nexus criteria state:

C-spine imaging is recommended for patients with trauma unless they meet all of the following criteria:
Absence of posterior midline cervical-spine tenderness
No evidence of intoxication
Normal level of alertness
Absence of focal neurological deficit
No clinically apparent painful injuries that might distract from pain of a cervical spine injury


The patient was supposedly intoxicated and there was apparently a strong suspicion of alcohol, so C-Spine imaging using nexus would be recommended, and therefore I would take c-spine precautions. I wouldn't say the procedure is needless, and comparing C-Spine to intubation is a bit of a hyperbole.

 

[usalsfyre]

I appologize, it is hyperboyle, which I can be prone to at times. But it can be useful to get the point across.

However, if the patient is able to actively participate in the exam, and is alert to person, place, time and event, does the fact they have consumed alcohol really make a difference? I'm not saying we should clear the really sloshed (but then, in the absence of good history I probably should suspect something besides alcohol) but a few drinks does not make you incompetent to participate in an exam.

 

[VirginiaEMT]

Id use a scoop stretcher.

THANK YOU, THANK YOU, THANK YOU!!!!! Now please help with this:

I took a elderly lady in from a nursing home that had an obvious deformity of the hip. She was in a bad position, on the bathroom floor, and I used a scoop to get her up and to the cot. I packaged her on the scoop with pillows, straps, blankets, etc. to make her as immobile as possible during the 5-6 minute ride to the E.D. No medic on the call, only BLS, so no pain meds. were administered.

The charge nurse said " I hate those things, they are cold and uncomfortable, and she she have been removed from the scoop and simply placed on the cot for transport(which means we would have had to move her again from the cot to the bed). This patient was in tremendous pain.

It appears that many in our EMS hates the scoop.

What is your opinion on the patient transport?

 

[Aidey]

We have break away stretchers, so when we use the scoop we put that on the gurney, put the pt on that, and then remove the scoop. That way they can be moved on the break away stretcher without having to stay on the scoop.

My opinion is why the heck wasn't ALS called for pain control?

 

[TransportJockey]

Just ran a call today where I made the basics use a scoop They'd never taken the thing out of the truck except to mark that it's there and intact. Worked great

 

[MrBrown]

We have not carried longboards in ages and now only carry the scoop although we are replacing them on a new vehicle basis with something called the CombiCarrier II.

Also no headblocks here.

 

[Shishkabob]

I made the basics use a scoop

You Intermed-god. Jeez, that blue patch with red lettering really got to your head

 

[TransportJockey]

You Intermed-god. Jeez, that blue patch with red lettering really got to your head

Nah, being third on a truck with two Basics for the first part of my shift did Although I wish at least one of the basics had been younger than me I'm still the baby of a service.

 

[jrm818]

We have not carried longboards in ages and now only carry the scoop although we are replacing them on a new vehicle basis with something called the CombiCarrier II.

Also no headblocks here.

Your patients should thank you...both choices much more comfortable than LSB, at least to me.

Do you do ever do anything to secure the head? I'm on-board with the criticism of the current system of rampaging backboards that storm through scenes strapping themselves on the backs of every patient they find. Still, there really are patients with unstable spines who may even end up in a halo...do you do anything to try to restrict movement in high-risk cohorts?

 

[MrBrown]

Your patients should thank you...both choices much more comfortable than LSB, at least to me.

Do you do ever do anything to secure the head? I'm on-board with the criticism of the current system of rampaging backboards that storm through scenes strapping themselves on the backs of every patient they find. Still, there really are patients with unstable spines who may even end up in a halo...do you do anything to try to restrict movement in high-risk cohorts?

The only thing I can think of is rolled up towels and tape or letting the patient rest in POC so they dont move around ... last pair of blocks I saw was in the lego bucket, seriously we haven't had them in a few years.

 

[jrm818]

It's always interesting to me to learn about how things are done in other systems. I'd love to see a outcome comparison between your system and a high performing US system. Could give some more specific data about the benefit/lack of benefit of immobilization techniques than comparing with Malaysian pickup trucks (or wherever the comparision was in the "homeboy ambulance" c-spine study).

Do you tend to do any assessment of the spine? NEXUS/Canadian C-spine criteria or the like? Is there any change in your treatment of trauma/fall/whatever patients if you suspect a spinal injury?

It might be the remnants of our c-spine brainwashing over here, but I would be a little hesitant about completely abandoning any attempt to keep high risk patients from moving their head.

 

[MrBrown]

Consider the possibility of cervical spine injury in all patients suffering from trauma. Patients with injury secondary to road crash or significant fall (especially head first fall), and patients with preexisting cervical spine abnormalities (e.g. ankylosing spondylitis or rheumatoid arthritis) are particularly at risk. Life threatening abnormalities within the primary survey take priority over the cervical spine.

Patients who meet all of the following criteria (regardless of mechanism of injury) do not need cervical spine immobilisation:
• GCS 15, alert, cooperative and
• No neck or upper back tenderness on palpation or active movement and
• Normal peripheral sensation and movement and
• No significant painful or emotional distractions.

These criteria may be used for children provided the child is old enough to understand and cooperate with taking a history and performing an examination. If all of the above criteria are not met then the patient must have their cervical spine immobilised.

Immobilising the cervical spine
• Life threatening abnormalities within the primary survey take priority over the cervical spine and immobilisation must never impair maintaining adequate airway, breathing and circulation.

• Place the patient supine in a well-fitted hard collar with the head and neck in an anatomically neutral position (3-4 cm of flat pillow or folded towel behind the head). If the patient is placed on their side then maintain this anatomically neutral position if possible.There is usually no role for the ‘recovery position’ in this group of patients.

• Lateral padding (or head blocks) at the side of the head is not required as a routine for all immobilised patients. Lateral padding should be considered if significant movement is anticipated (e.g. over rough terrain), or the patient is unconscious but has normal airway and breathing, or if there are clinical signs of cervical spine injury. Lateral padding must not be used if it interferes with the ability to look after the airway.

• The head and shoulders must not be independently immobilised unless the entire body is also immobilised.This is to avoid creating
a fulcrum effect on the spine. Entire body immobilisation is not required as a routine for all immobilised patients, but should be considered when significant movement is anticipated (e.g. over rough terrain).

• Spine boards and other rigid flat boards are to be used as sliding or extrication devices only. Patients must not be transported on such boards. Scoop stretchers are preferred as they allow stretcher removal at hospital without having to roll or lift the patient.Devices such as the KED should not be used as a spinal immobilisation device in their own right. The primary function of the KED is to keep alignment of the spine during extrication. Once in place, a KED should remain on until the patient is in hospital, but with the strap tension released to enable the patient to be in a supine position.

• Clinical judgement must be used for uncooperative patients. If cervical spine immobilisation results in the patient ‘fighting’ to remove it, then it is appropriate not to formally provide immobilisation if this approach minimises cervical spine movement. All patients with suspected spinal injury should be transported supine, but if forcing the patient to lie supine results in them ‘fighting’ to sit up, then it is appropriate to allow them to adopt a position that minimises cervical spine movement.

• If significant respiratory distress is present it is appropriate to gently sit the patient to 45 degrees, with a cervical collar in place and the spine in alignment.

• Patients requiring intubation should have the front of their hard collar undone during intubation. In line stabilisation (not traction) of the cervical spine should be performed during intubation if there is a spare trained person to perform this.

 

[jrm818]

Got it (and like it).

I hope you didn't type that all out on my account

 

[Aidey]

We have not carried longboards in ages and now only carry the scoop although we are replacing them on a new vehicle basis with something called the CombiCarrier II.

Also no headblocks here.

That's it, I'm moving. I can get used to the weather.

 

[LucidResq]

Really had to dig to find this ol' post of mine

EMS Responder article about the Cochrane Review

The readership is referred to the brief evidence-based emergency medicine report by Baez and Schiebel entitled, "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" which appeared in the Annals of Emergency Medicine in January 2006. The objective of this study was to quantify the effect of different methods of spinal immobilization (including immobilization versus no immobilization) on mortality, neurologic disability, spinal stability and adverse effects in trauma patients

The authors searched all databases where peer-reviewed medical journal articles would be found, along with the Cochrane Controlled Trial Register for evidence of scientific trials. Then they contacted experts in the field and eight manufacturers of spinal immobilization devices to determine whether they were aware of any sound evidence for use of these devices that would not otherwise appear in the on-line search. The authors were unable to find a single randomized controlled trial of actual injured patients to support the efficacy and effectiveness of spinal immobilization strategies and spinal immobilization techniques. In other words, there has never been a study in the medical literature that proves that any form of spinal immobilization or any technique or device used during such immobilization actually prevents spinal cord injury or lessens morbidity from spinal column injury.

 

[LucidResq]

And I'm too busy making dinner to dig up the articles right now, but there is also a significant body of evidence that points to the often ignored complications of immobilization via LSB, such as decubitus ulcers, pain and even neuro deficits.

 

[firetender]

Pardon, please, need to catch up!

Why are you so skeptical? What is considered a "valid" (I read "worthy") injury? And I ask again, what are you out if they are seeking?

I can't answer you in terms of the OP's post. Too little info to go on. Let me tell you my truth.

In an overtaxed service, with limited resources and almost non-existent back up you learn to be extremely discerning. In an atmosphere where everybody in ALL allied agencies are having MI's at the THOUGHT that these "kids" are carrying NARCOTICS! you get a little cautious on who you shoot up. At the same time as EMS was getting off the ground, so were scammers attaining a greater level of sophistication.

You do the job. Everyone deserves the best you have. AND don't be made a fool of because of your dilligence more than once by the same person. If you notice patterns, pay attention to them and share what you've learned. You have the right to conserve your own life-force and provide support for your peers in doing so as well.

Once again, this is not about prejudice, this is not about attitude, this is wholly about discernment and the appropriate application of scant, available resources; and that includes good will and your own self-respect.

It took me a good 9 years in the field before I started to recognize that maybe I was overtreating. I began paying more attention to my patients, guaging them for a true sense of urgency and specifificity to determine the DETAILS of what I was really treating. Let's figure out what's the real emergency and then focus on that and that alone.

So when someone talks to me about a call, even on this forum, I guess I kind of expect that the basics will be covered and DETAILS communicated so I can respond adequately.

Please don't distract all of us from what's REALLY going on and don't rag on me when I call you on it!

Fondly,

your local firetender

 

[Aidey]

And I'm too busy making dinner to dig up the articles right now, but there is also a significant body of evidence that points to the often ignored complications of immobilization via LSB, such as decubitus ulcers, pain and even neuro deficits.

What is also interesting are the number of potentially serious injuries that manage to walk themselves into the ER. I've heard of one case of something similar here.

http://swns.com/horse-rider-who-suf...des-again-thanks-to-f1-technology-261212.html

 

[usalsfyre]

I can't answer you in terms of the OP's post. Too little info to go on. Let me tell you my truth.

In an overtaxed service, with limited resources and almost non-existent back up you learn to be extremely discerning. In an atmosphere where everybody in ALL allied agencies are having MI's at the THOUGHT that these "kids" are carrying NARCOTICS! you get a little cautious on who you shoot up. At the same time as EMS was getting off the ground, so were scammers attaining a greater level of sophistication.

You do the job. Everyone deserves the best you have. AND don't be made a fool of because of your dilligence more than once by the same person. If you notice patterns, pay attention to them and share what you've learned. You have the right to conserve your own life-force and provide support for your peers in doing so as well.

Once again, this is not about prejudice, this is not about attitude, this is wholly about discernment and the appropriate application of scant, available resources; and that includes good will and your own self-respect.

It took me a good 9 years in the field before I started to recognize that maybe I was overtreating. I began paying more attention to my patients, guaging them for a true sense of urgency and specifificity to determine the DETAILS of what I was really treating. Let's figure out what's the real emergency and then focus on that and that alone.

So when someone talks to me about a call, even on this forum, I guess I kind of expect that the basics will be covered and DETAILS communicated so I can respond adequately.

Please don't distract all of us from what's REALLY going on and don't rag on me when I call you on it!

Fondly,

your local firetender

I apologize for calling you out, it was wrong of me. That said, I see "drug seeking" used more as an excuse for people NOT to do their jobs more often than not.