Rep Giffords was shot in the head, and seeing this picture I ask: Why the C-collar?

[JPINFV]

Is it really clearing c-spine? What other interventions are considered an "automatic" unless the patient's condition tells you otherwise? Aren't we supposed to only provide interventions when they are indiciated, not just when they aren't contraindicated?

 

[firecoins]

Is it really clearing c-spine? What other interventions are considered an "automatic" unless the patient's condition tells you otherwise? Aren't we supposed to only provide interventions when they are indiciated, not just when they aren't contraindicated?

gunshots to the head indicate a possibility of a c-spine problem. some shots more than others may be more indicative of c-spine injuries than others. Putting them on a board helps move them quickly and the doctors want the collar. So be it.

 

[Veneficus]

gunshots to the head indicate a possibility of a c-spine problem. some shots more than others may be more indicative of c-spine injuries than others. Putting them on a board helps move them quickly and the doctors want the collar. So be it.

considering the structures of the brain and spine that would be damaged from a head shot, if there was damage it would be readily apparent and irreversible.

You would lose most if not all of your vegatative functions.

 

[usalsfyre]

In this case the cord's been damaged or it hasn't. Remember the purpose of c-spine control is to prevent further injury in the event of spinal fracture. If the the cord (or more likely the hind brain itself in this case) is scrambled, it's a little like closing the barn door after the whole freakin stable has run off.

The only thing that might, maybe, posibly help is an ultra-rapid trip to a surgeon. Screwing around with a board and collar interferes with this, so I've gotta go with no on the board and collar.

 

[reaper]

I agree with use of the board. Not for c-spine, but for movement. Not only easier movement of pt, but to minimize movement of the head. You have brain trauma. Reducing further jarring of the head, can only help.

Makes it easier movement to stretcher and carrying to HEMS if needed.

 

[lightsandsirens5]

Understandable, which is why I keep at least two flat sheets folded on my cot, so I won't have to run back and forth and I can cover up while I'm cutting off.

I'm sorry, but if I have a GSW to the head, unless there are enough hands to cover the pt, your privacy is my third concern, after both of our safety and your life.

As for why the collar and why remove the clothes, That bullet has an unknown path no matter where the entrance and exit wounds are. It could have bounced around inside before exiting. I read about I guy who was shot in the side of his chest and the bullet came out the top of his head. You never know. Our protocol is any GSW to the head or core gets fully c-spined. Plus, if you have an expert marksman with an automatic weapon, there may be two bullets, one came out, one stayed in, but both entered the same hole.

Removing the clothes? There could be hidden bullet wounds. I am amazed how well some bullet wounds hide. Expose, expose, expose. There may be more holes. Can't take the chance of missing one.

That's my take.

 

[JPINFV]

So, the hypothetical bullet won't have enough energy to penetrate the skull a second time (to make the exit) the first time it hits the inside of the skull, but after several bounces (each of which will transfer energy away from the bullet into the surrounding tissue), it will be able to penetrate the skull?

Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.

 

[usalsfyre]

Y'all do understand that considering where the bullet entered, it would have to pass THROUGH the area of the brain that controls all of the functions your trying to protect with c-spine precautions right? And that the bullet passing through there would DESTROY said areas and functions, before the impulses ever entered the cord? And finally that survival depends on these areas not being disrupted, and swift, successful surgical management of the areas that are?

If anyone can give a convincing argument as to why boarding and collaring is needed that doesn't involve blind adherence to protocol or QA managers, please post it here.

 

[Shishkabob]

If anyone can give a convincing argument as to why boarding and collaring is needed that doesn't involve blind adherence to protocol or QA managers, please post it here.

Board: Easier movement

Collar: Better airway control with a tube





Where's my cookie?


(Granted, they don't have her tubed, but still!)

 

[Veneficus]

In fairness, I cannot think of any surgical intervention that would help with a GSW that destroyed the structures in question.

Even if they were not damaged directly, there is still temporary cavitation and force transfer, as well as blood being toxic to neurons.

I think such a trajectory would have been an undisputable kill shot, of course then there actually would be a reason to cover the patient with a sheet.

 

[usalsfyre]

Plus, if you have an expert marksman with an automatic weapon, there may be two bullets, one came out, one stayed in, but both entered the same hole.

Did he come out of the celing on wires too? Because outside of Hollywood this is probably impossible.

 

[Journey]

Collar: Better airway control with a tube

Where's my cookie?

(Granted, they don't have her tubed, but still!)

The presence of a C-collar will not make intubation easy especially for an inexperienced Paramedic.

So, the hypothetical bullet won't have enough energy to penetrate the skull a second time (to make the exit) the first time it hits the inside of the skull, but after several bounces (each of which will transfer energy away from the bullet into the surrounding tissue), it will be able to penetrate the skull?

Personally, I'd love to see a video of an expert marksman who can, with a pistol, put two bullets into the same hole of a person who is falling to the ground.

With 20 people shot, who's to say there was not more than one shooter or what type of weapon was used? Head injuries also bleed a heck of alot and in this type of situation, it may not always be able to clean off all the blood to see the full extent of the injuries.

A injury to the head will more than likely present with neuro deficits along with being a distracting injury. How long are you going to screw around on scene trying to figure out whether it is just the head injury or if the fall or a bullet had also caused a spinal injury?

The fact that they were able to stabilize the c-spine, place the patient on the board and get the patient out of the scene should be noted rather than criticizing their choice of using a c-collar. You were not there and you did not do the assessment on this patient. There is a good chance many here will never even see one gunshot patient up close and here they had 20 to deal with. C-collar or not, the first responders on this scene deserve respect for a tough day and the decisions made based on their assessment rather then criticism from some arm chair EMTs.

As far as the patient not being covered, there is a good possibility their extra sheets went to others waiting for another ambulance or the medical examiner.

My deepest condolences to the victims and their families as well as all of those present on this horrific scene. This was a senseless act and no amount of training may adequately prepare you for a situation like this. All you can do is what you believe is in the best interest of the patient at that time with safety for everyone a concern.

 

[Aidey]

I had a self-inflicted GSW, 9mm, through and through at the temples. Unconscious, pulse, still breathing (with a gag reflex). We boarded and collared him. My MDs first question on reviewing the run with me was "Why on earth was he put on a back board?". He said there is no point in back boarding or collaring an isolated GSW to the head.

Now, as much as it pains me to agree with Linuss being a cheeky twit , it is true she may have ended up on a back board for movement.

Journey, are you keeping up with field practice? It is becoming more common for us to put a c-collar on a patient AFTER they are intubated. It minimizes movement and helps keep the neck midline, reducing the chance of dislodgement. That is what Linuss was talking about.

 

[mc400]

It was a semi auto pistol with a large capacity magazine. The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.

 

[mc400]

Uh and I forgot. Expose , tape to the board and drive fast. All interventions done en route unless the were critically needed right away. If I was on an engine I would hop in the ambo with thier medic and go. IV/IO en route, etc. Wouldnt be too worried about the collar. Time is what will save the patient in this scenario.

 

[Veneficus]

A injury to the head will more than likely present with neuro deficits along with being a distracting injury. How long are you going to screw around on scene trying to figure out whether it is just the head injury or if the fall or a bullet had also caused a spinal injury?

I think the point being made is that if the bullet did cause a spinal injury, not only would it be readily apparent since the plethora of structures I am too lazy to type out control everything from your breathing, to BP, to HR, voluntary movement and inhibitaory stimulous to name a few.

The patient would be dead, or an organ donor.

Spinal injury from a fall from standing in a 40 y/o female? I don't believe it for a second.

Maybe I could accept potentially a flexion or extension injury. But that being the case you are still left with a vent dependant quad if things go well.

 

[Journey]

The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.

How much is not much? That all depends on what area of the brain was affected, what vessels were disrupted, the amount of swelling and the chance of infection. Surviving and returning to a normal life can be two very different outcomes.

 

[Veneficus]

It was a semi auto pistol with a large capacity magazine. The congress woman was talking on scene and prior to surgery. I would think that it was mostly skull damage that was done and the bullet didnt directly effect too much brain tissue. I have seen a few gsw's to the head a lot like it and people survive just fine, and most were with AK rounds not slow moving pistol rounds.

This is the only info I have seen on the wounds, please post the source that states she was talking on scene.

http://news.yahoo.com/s/ap/us_med_congresswoman_brain_injury

 

[Journey]

I think the point being made is that if the bullet did cause a spinal injury, not only would it be readily apparent since the plethora of structures I am too lazy to type out control everything from your breathing, to BP, to HR, voluntary movement and inhibitaory stimulous to name a few.

The patient would be dead, or an organ donor.

Spinal injury from a fall front standing in a 40 y/o female? I don't believe it for a second.

Maybe I could accept potentially a flexion or extension injury. But that being the case you are still left with a vent dependant quad if things go well.

So you are saying the EMTs and Paramedics treated this woman all wrong?

I've seen several spinal injuries in patients a lot younger and with what seemed like minor falls. It all depends on their body position and what they hit on landing. I've also seen irreversible damage done from just bending an picking up a pick of paper. Just because you think the patient might be a vent dependent quad is no reason to blow off doing a thorough assessment and packaging per your protocols to still try to preserve some function. There is a vast difference in function with what an incomplete vs a complete quad can be rehabilitated to.

Blanket statements like yours could cause someone to get lax on an assessment and do the wrong thing.

You might also consider how a patient with a pontine injury or stroke might present. Locked in does not mean they are dead or an organ donor.

 

[Aidey]

Spinal injury from a fall from standing in a 40 y/o female? I don't believe it for a second.

Can that be amended to "healthy 40 y/o female?" I know horses vs zebras, but wouldn't there be a remote chance of injury in someone with a severe osteoporosis process such as OI, poorly managed ESRD, or an eating disorder?

This is the only info I have seen on the wounds, please post the source that states she was talking on scene.

http://news.yahoo.com/s/ap/us_med_congresswoman_brain_injury

The CNN interview I'm watching currently is with a MD was at the event who says she was alert and conscious but unable to speak, so she was communicating by squeezing his hand. He said she was responsive and interactive the whole time he was with her. The guys name is Dr. Steven Rayle.