No C-Spine... Right call?

[BOS 101]

Obviously follow your guidelines.....But protocols and what is right for your pt can be at odds with one another. EMS is riddled with bro science, anecdote and tradition. Thankfully the tide is shifting towards evidence based medicine and science based medicine.
It is very difficult for many to accept change or accept the fact that what they have been doing for years... And told was saving lives...... Actually doesn't.... And can make it worse.
Because we have always done it that way is one of the scariest phrases you can hear.
It doesn't help that our training is skills focused ... And many have no idea why we do certain things let alone the science behind it. Many thankfully take their education into their own hands and fill the gap.

But unfortunately it puts you in the spot of, do I follow protocol or put my butt in harms way
An unfortunate dilemma, I just dont want to test what I can get away with either

 

[Medic Tim]

But unfortunately it puts you in the spot of, do I follow protocol or put my butt in harms way
An unfortunate dilemma, I just dont want to test what I can get away with either

I have a lot of leeway where I work. We also have a great medical director who encourages .... Expects us to deviate as our guidelines are just that... Guidelines.

As for c-collars.... I am not a fan. I would like to see the soft collars come back.... Assuming they will have benefit.
I am in my phone so k can't post studies but there are many out there showing c-collars are frequent applied wrong, not sized right and like lsb just don't do what they are hyped to do. There is a great video somewhere showing a c-collar being applied to a cadaver under x-ray of fluoroscopy. The amount of cervical manipulation and traction was unreal.

 

[NomadicMedic]

Fair enough and when it comes to LSB i have a gripe
But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
As far as Collars, what is your opinion?

I'll bet everyone is happy that YOU view collars as useful, because you've seen doctors use them.

SMH

 

[Tigger]

Fair enough and when it comes to LSB i have a gripe
But collars I view as helpful, if physicians use them to stabilize patients with possible\confirmed neck injuries, so will I
Until evidence proves that collars are not useful, then I will use them, and I mean legit studies, no circumstantial statistics bs
As far as Collars, what is your opinion?

I use them on low risk patients because I am told to. Most c-collar applications I see are done with poorly fitted collars, which we know do nothing, and possibly hyperextend the patient, which is potentially detrimental. There is also some research showing that cervical collars may increase ICP, which can be detrimental as well.

The body does a pretty good job of self splinting after injury and a few pieces of soft plastic are not likely to improve that.

Here's a recent Dr. Bledsoe article with a variety of studies included.
http://www.jems.com/articles/print/.../why-ems-should-limit-use-rigid-cervical.html

As and aside, "circumstantial statistics bs" probably beats the rationale of "a doctor uses one so therefore so do I."

 

[BOS 101]

I have a lot of leeway where I work. We also have a great medical director who encourages .... Expects us to deviate as our guidelines are just that... Guidelines.

As for c-collars.... I am not a fan. I would like to see the soft collars come back.... Assuming they will have benefit.
I am in my phone so k can't post studies but there are many out there showing c-collars are frequent applied wrong, not sized right and like lsb just don't do what they are hyped to do. There is a great video somewhere showing a c-collar being applied to a cadaver under x-ray of fluoroscopy. The amount of cervical manipulation and traction was unreal.

I just read up on that thanks to our friend, i had heard some stuff but i dont like to jump into anything without some proper sources
I too would like to see the soft collars put to the test and hopefully they could be of more use
cspine also gets more negative reaction due to human error in application, not defending all of it but its a fair point

 

[BOS 101]

I'll bet everyone is happy that YOU view collars as useful, because you've seen doctors use them.

SMH

I mean doctors tend to be decently trained, and its something i'm using as reasoning not forcing anything on you so no need to be spiteful

 

[BOS 101]

I use them on low risk patients because I am told to. Most c-collar applications I see are done with poorly fitted collars, which we know do nothing, and possibly hyperextend the patient, which is potentially detrimental. There is also some research showing that cervical collars may increase ICP, which can be detrimental as well.

The body does a pretty good job of self splinting after injury and a few pieces of soft plastic are not likely to improve that.

Here's a recent Dr. Bledsoe article with a variety of studies included.
http://www.jems.com/articles/print/.../why-ems-should-limit-use-rigid-cervical.html

As and aside, "circumstantial statistics bs" probably beats the rationale of "a doctor uses one so therefore so do I."

That was a very good read, thank you, There is all too much to read about and look into in there I will have to do some more studying
I would like to see soft collars and vacuum mattress put to the test, and the natural splinting of your body i wonder how long it lasts
Anyway, I don't mean to seem mindless or "o i just do what the doc says" but its the same as listening to the medic which everyone threw a fit about beforehand so i see it as justifiable when considering Rx
But this link is very cool, thanks

 

[NomadicMedic]

I mean doctors tend to be decently trained, and its something i'm using as reasoning not forcing anything on you so no need to be spiteful

As you gain experience you'll see plenty of doctors do plenty of things that are no where near reasonable.

However, they have a fair amount of education and are licensed to kill. You, on the other hand, have around 120 hours of basic first aid education and really lack the knowledge to make any real decisions as to treatment modality except "mongo put on board".

Not being spiteful, I'm just sayin'.

 

[BOS 101]

As you gain experience you'll see plenty of doctors do plenty of things that are no where near reasonable.

However, they have a fair amount of education and are licensed to kill. You, on the other hand, have around 120 hours of basic first aid education and really lack the knowledge to make any real decisions as to treatment modality except "mongo put on board".

Not being spiteful, I'm just sayin'.

I get that, like i said much earlier in the thread every medical professional is an individual and even a doctor can be a dummy but as a general rule a doctor is a decent person to take tips from, I work in an ER currently and know bad ones and good ones
And im not trying to make all the decisions or do anything other than what i should(if thats what youre getting at\wording threw me off sorry), protocol (even if its outdated) still sides with smr for most occasions
Thanks for the input

 

[Carlos Danger]

I have. If it's not indicated and it's making the patient uncomfortable, why would I keep it in place? From what I've read in this thread, I'm pretty sure I would have c-spined that patient, though.

Well clearly, we are talking about that patient....

 

[Akulahawk]

Yes but because he is altered (well depending on how altered) He isnt necessarily reliable to rule out cspine
And the MOI isnt the only reason i would use precautions, the broken teeth and blood mean he hit his head so now the MOI has a tangible injury on him that i can look at and say, hey that all went straight to his head and neck, he could have something wrong
And i respect what you say about assessing, but even with nothing present beyond the head trauma i would like to use a collar just to immobilize the neck(I agree LSB's are somewhat useless and over used) but on the same token to cover my *** I would go full c spine in reality
You can kinda say You're right, MOI does mean something big here to me cuz its possibly so big and just because he may not have any current deficits, doesnt mean I wanna say forget cspine and then something happen to him enroute
I'm Saying i would prefer to take precautions here, mainly because he is altered and there is obvious trauma with sigMOI, so that I do no harm
This putting the studies about spinal precautions aside for now, until they become protocol and can save my ***, and prove beyond a doubt that precautions arent needed

Is there "obvious trauma" present? Yes, to the teeth/mouth. What's the MOI? If you know that, does the MOI show a transfer of force to the cervical spine? It's easily possible to cause injury to the teeth/mouth without transferring any significant forces to the c-spine while causing a concussion. Ever watch a boxing match?

I'm not saying that you're necessarily wrong, just that you have much to learn, one of which is to discard the idea of "significant MOI" because MOI alone doesn't mean much.

If I walked up to you and slammed your right tibia with a 20# sledge hammer, there's MOI for potential tibial fracture. You fall to the floor in an "unwitnessed" manner because other than you and I, there were no other witnesses, and I'm gone...When you fell, you kind of collapsed toward the right and somehow managed to slow your fall with an outstretched right arm. There's now MOI for wrist/forearm injury. You remain very still on the floor until EMS shows up. They want to put you in c-spine precautions because you're apparently altered (babbling something about a guy with a sledge hammer and otherwise screaming a lot), you're in a setting of trauma, and you might have hit your head when you fell (you didn't and there are no lumps/bumps or c-spine step-offs). Oh, and you somehow managed to bite your tongue while falling and jarred some teeth when you landed so you now have some oral bleeding.

None of this has any significant level of force being transferred to your c-spine. You might be injured pretty painfully, but you don't need SMR and SMR isn't going to easily manage the injuries you're likely to have sustained. Notice that of the above, I have written primarily Mechanism and very little about Assessment?

 

[ERDoc]

Speaking from the physician side of things, I would like to see this pt with a cervical collar. LSB is optional, but coming off upon arrival at the ER. You cannot clear the c-spine in this pt with either NEXUS or CCS rule, which means they need imaging. If they need imagining, then they need a cervical collar. Is there evidence that it will do anything? No, but it will remind them not to move (sometimes) until we can clear them.

 

[BOS 101]

Is there "obvious trauma" present? Yes, to the teeth/mouth. What's the MOI? If you know that, does the MOI show a transfer of force to the cervical spine? It's easily possible to cause injury to the teeth/mouth without transferring any significant forces to the c-spine while causing a concussion. Ever watch a boxing match?

I'm not saying that you're necessarily wrong, just that you have much to learn, one of which is to discard the idea of "significant MOI" because MOI alone doesn't mean much.

If I walked up to you and slammed your right tibia with a 20# sledge hammer, there's MOI for potential tibial fracture. You fall to the floor in an "unwitnessed" manner because other than you and I, there were no other witnesses, and I'm gone...When you fell, you kind of collapsed toward the right and somehow managed to slow your fall with an outstretched right arm. There's now MOI for wrist/forearm injury. You remain very still on the floor until EMS shows up. They want to put you in c-spine precautions because you're apparently altered (babbling something about a guy with a sledge hammer and otherwise screaming a lot), you're in a setting of trauma, and you might have hit your head when you fell (you didn't and there are no lumps/bumps or c-spine step-offs). Oh, and you somehow managed to bite your tongue while falling and jarred some teeth when you landed so you now have some oral bleeding.

None of this has any significant level of force being transferred to your c-spine. You might be injured pretty painfully, but you don't need SMR and SMR isn't going to easily manage the injuries you're likely to have sustained. Notice that of the above, I have written primarily Mechanism and very little about Assessment?

I totally get that you're right, moi doesn't prove spinal injury and it matters just as much hire the mechanism injured the person etc
But it's in this scenario fairly possible for spinal injury if not likely, so as a precaution I would do it (the collar mainly)
this of course not taking into account recent studies about effectiveness, just that it is protocol and for an altered patient who may not be careful with their neck and may harm themself further

 

[Tigger]

I totally get that you're right, moi doesn't prove spinal injury and it matters just as much hire the mechanism injured the person etc
But it's in this scenario fairly possible for spinal injury if not likely, so as a precaution I would do it (the collar mainly)
this of course not taking into account recent studies about effectiveness, just that it is protocol and for an altered patient who may not be careful with their neck and may harm themself further

It has been shown that this is a very, very unlikely occurrence.

 

[Akulahawk]

Speaking from the physician side of things, I would like to see this pt with a cervical collar. LSB is optional, but coming off upon arrival at the ER. You cannot clear the c-spine in this pt with either NEXUS or CCS rule, which means they need imaging. If they need imagining, then they need a cervical collar. Is there evidence that it will do anything? No, but it will remind them not to move (sometimes) until we can clear them.

Bingo! If the scene (and patient) is how I imagine that it was, I would have likely put a collar on the patient. If the patient still has good muscular control about the cervical region, then the patient should be able to provide greater c-spine stability than a simple collar is capable of providing on its own. My point is that the OP shouldn't rely on MOI alone to make these decisions.

 

[Bullets]

You say you see doctor's use a collar in the EW, are they using the same stiff neck select EMS collar? Or are they using a Philadelphia collar or a soft wrap collar?

 

[BOS 101]

You say you see doctor's use a collar in the EW, are they using the same stiff neck select EMS collar? Or are they using a Philadelphia collar or a soft wrap collar?

"Pro Care Patriot adult" appears to be the same stiff neck stuff I've used on the amb
But im speaking for one ER in AZ so others are varied I'm sure

 

[RocketMedic]

You might make an argument against placing a c-collar to begin with, but why on earth would you remove one that someone else already placed?

That medic sounds like one of those paramedics that gives EMS a bad image.

I've done it plenty of times. No reason to continue something that is incorrectly, improperly or no longer functionally placed. Do you leave collars on every single one of your patients regardless of circumstance?

 

[RocketMedic]

With that being said, I'd likely scoop this patient to the cot with an aporopriately sized collar or towel roll. Probable TBI.

 

[EMTinCT]

Collar yes, board no. Boards are only for moving a patient, not for transport.