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

[Melclin]

http://www.youtube.com/watch?v=YzYxz_uvtSI

God, that made my day.

One thousands internets for you sir.

 

[lightsandsirens5]

So I'm really not convinced the GSW makes it more likely the person would sustain a spinal injury when falling.

I agree.

However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.

I know from calls I have run that you have no idea whatsoever where that projectile went while inside the body. You have to be a firearms and forensic ballistics expert to even begin to understand it, in my opinion. But my opinion is not worth much.

I agree with Vene, or was it JP.....I dunno.......when they said that if the projectile has already severed the spinal column all the c-spine in the world won't help. But there is that slight chance that the projectile has fractured a vertebra and not severed the spinal cord. I know the benefits of c-spine are debated, but my protocols say that a suspected spine injury gets c-spined, so that is what I will do for now.

 

[usafmedic45]

pass generally around the brain by ricocheting around the inside of the skull and re-emerging almost directly opposite the entrance

I wouldn't call a bullet that rides around the inner table of the skull like a bobsleder in the chute "ricocheting". It's well documented as having happened (not to mention that I have seen it personally) but it's not a "ricochet" which would imply an uncontrolled careening of the round inside the skull which would result in the brain being damaged. Also keep in mind that even if the round does ride the curve of the skull around, it doesn't mean that it's not doing a tremendous amount of damage in the process. The shockwave can inflict a significant contusion to the cerebrum or damage to the blood vessels supplying the brain (most notably the bridging veins).

 

[Aidey]

I agree.

However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.

I know from calls I have run that you have no idea whatsoever where that projectile went while inside the body. You have to be a firearms and forensic ballistics expert to even begin to understand it, in my opinion. But my opinion is not worth much.

I agree with Vene, or was it JP.....I dunno.......when they said that if the projectile has already severed the spinal column all the c-spine in the world won't help. But there is that slight chance that the projectile has fractured a vertebra and not severed the spinal cord. I know the benefits of c-spine are debated, but my protocols say that a suspected spine injury gets c-spined, so that is what I will do for now.

*shrug* My medical director has said it is not necessary to c-spine isolated GSWs to the head with a trajectory that does not involve the spinal area. The specific patient he was talking about was unconscious, so we weren't even able to assess for deficits.

 

[JPINFV]

Discussing scenarios are a great learning tool. But, criticizing those in a very stressful situation for applying a backboard and c-collar is a little over the top. You don't know what they assessed at scene. A patient can still be talking and show neuro defiicts.

Criticizing? Who is doing that? There's a lively discussion on the merits of c-spine in patients suffering a gun shot to the head, but I don't see anyone saying that what these EMTs and paramedics did was tantamount to malpractice. There's a huge gray zone between perfection and malpractice and our (collective as health care providers) is to be closer to perfection than malpractice. The second any of us begin to believe that our care is not worthy of discussion or debate because we're perfect is the second that that individual needs to get out of health care. This is doubly true for a field such as EMS that too often relies on blanket rules, such as anyone with a mechanism gets a back board regardless of assessment.

Personally, I welcome people questioning any care that I provide. If I cannot justify it with a reasonable medical assessment on why a patient needs a specific treatment, than it's very likely that I shouldn't have administered or ordered that treatment. No health care professional, paraprofessional, or technician should ever be beyond question or reproach regardless of the combination of the letters behind his or her name.

What's especially troublesome is that you are questioning the need to have a discussion on the care provided on a discussion board. If all this board was supposed to be was mindlessly patting each other on the butt for being in health care, then I could just as easily get that fix watching football. Thankfully, there's more to discussions than that.

Considering the magnitude of this situation, maybe sarcasm and the cutesy humor might not be appropriate for this discussion. Yes, laughter is great medicine but there is a time and place. Jokes, sarcasm and criticisms directed at the providers in this situation is distasteful at all levels. Maybe another thread would be more appropriate for sarcasm and jokes.

If you're so uptight, why be involved with a discussion at all regarding it. After all, what sort of discussion is there if everyone has the same opinion?

In regard to the distastfulness of discussing the incident and, in some cases (I take it a reference to the Mechanism of Injury video), sometimes the best way to expose the insanity of a concept is with parody. If that's too much, then...

 

[lightsandsirens5]

*shrug* My medical director has said it is not necessary to c-spine isolated GSWs to the head with a trajectory that does not involve the spinal area. The specific patient he was talking about was unconscious, so we weren't even able to assess for deficits.

Well, you may have a better med director than I do! I see you reasoning believe me.

I just don't agree totally with my med dir or totally with you. That's all. Hope you don't mind.

~~~~~~~~~~

uasf: I stand corrected. My choice of words was inappropriate.

 

[usafmedic45]

Criticizing? Who is doing that?

I read his response as "You don't agree with me, so you are criticizing _____". It seems to be a matter of perspective and whether one believes in constructive criticism or not.

 

[usafmedic45]

uasf: I stand corrected. My choice of words was inappropriate.

No worries. Just figured I would clarify what actually happens in the circumstance you were describing since I have seen it firsthand.

 

[JPINFV]

I agree.

However, with the things I have stated above and the fact that several hundred foot pounds has been suddenly transferred to the pt's head, I see a high index of suspicion for spinal injury.

However, not all energy transferred is the same. A pick axe delivering and a sledge hammer is going to transfer the energy differently. Similarly, a bullet which pierces a bone is going to transfer much less energy than one that lodges in a bone. Especially with a through and through where the bullet distributes the remaining energy elsewhere after leaving.

 

[JPINFV]

I wouldn't call a bullet that rides around the inner table of the skull like a bobsleder in the chute "ricocheting". It's well documented as having happened (not to mention that I have seen it personally) but it's not a "ricochet" which would imply an uncontrolled careening of the round inside the skull which would result in the brain being damaged. Also keep in mind that even if the round does ride the curve of the skull around, it doesn't mean that it's not doing a tremendous amount of damage in the process. The shockwave can inflict a significant contusion to the cerebrum or damage to the blood vessels supplying the brain (most notably the bridging veins).

However does any of those scenarios (the richochet, the bobsled, or the in and out) change the need for spinal immobilization. Just because the damage is great or minor to the brain doesn't change how immobilization works.

 

[JPINFV]

I read his response as "You don't agree with me, so you are criticizing _____". It seems to be a matter of perspective and whether one believes in constructive criticism or not.

Alternatively, maybe medicine isn't as straight forward as we (collective "we") would like it to be.

 

[usafmedic45]

However does any of those scenarios (the richochet, the bobsled, or the in and out) change the need for spinal immobilization. Just because the damage is great or minor to the brain doesn't change how immobilization works.

Effectively, it does not. Personally, my main concern would be with the collar being applied too tight and compressing the superficial veins that drain the head. Other than that, I see no harm in putting a C-collar on this patient.

 

[lightsandsirens5]

However, not all energy transferred is the same. A pick axe delivering and a sledge hammer is going to transfer the energy differently. Similarly, a bullet which pierces a bone is going to transfer much less energy than one that lodges in a bone. Especially with a through and through where the bullet distributes the remaining energy elsewhere after leaving.

Exactly. I did not say that very well. I am not saying the impact with the head itself is enough to cause spinal injury. Just stating that there is a lot of energy behind that projectile and it will do unexpected things.

I am by no means an expert in ballistics and firearms, so I am wide open to any correction on things I say. I appreciate it actually.

 

[usafmedic45]

Alternatively, maybe medicine isn't as straight forward as we (collective "we") would like it to be.

Of course it's not. I was just commenting on the vibe I picked up from the posts you were responding to.

 

[reaper]

Ok ladies and gentlemen,
There are valid points all the way around.

I do not agree with boarding every pt. A pt should be assessed and determined to have a factor for spinal immobilzation.

Now, there are maybe a handful of providers here that have ever worked a MCI shooting. I myself have worked 3 in 22 years. When you are in a situation like this, you do not have the luxury of being able to perform a full neuro assessment. The time is not there for this to happen. So you do the next best thing. You expect the worst and package them fully for transport and get them en route to a trauma center. If this was a single shooting. You may have more leeway on this option.

Next, most services that have a spinal clearance protocol all follow the same standards for field clearance. In that standard is one little catch! "No distracting injuries". A GSW to the head is a very distracting injury. So, that kinda takes the clearance out of the equation.

So let's be objective to all sides of the argument and not let personal feelings towards a poster, get in the way of a good discussion.

 

[JPINFV]

Of course it's not. I was just commenting on the vibe I picked up from the posts you were responding to.

I was agreeing with you and offering another alternative. I'll offer that immobilizing this patient would not be wrong (in the sense of malpractice "wrong"), just not the best treatment. Essentially good care, just not ideal care.

 

[ffemt8978]

I was agreeing with you and offering another alternative. I'll offer that immobilizing this patient would not be wrong (in the sense of malpractice "wrong"), just not the best treatment. Essentially good care, just not ideal care.

And therein is the crux of this discussion.

 

[Shishkabob]

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

A) I never said, or implied, the first part.

B ) Where does the second part even come from?

 

[lightsandsirens5]

So let's be objective to all sides of the argument and not let personal feelings towards a poster, get in the way of a good discussion.

No personal feelings here. ^_^

You make some excellent points that completely escaped me earlier. Thanks.

I have never worked a scene with more than one GSW pt. So I am sorely lacking in the multiple-critical-GSW-pt-adrenaline-rush-general-chaos-and-triage-scene-experience department.

(In addition to multiple other departments. )

 

[lightsandsirens5]

A) I never said, or implied, the first part.

B ) Where does the second part even come from?

Linuss's hackles are up. h34r: