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

[JPINFV]

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.

I think there's another way to look at this. Before a spinal clearance protocol can be put into place, spinal immobilization needs to be indicated first. Is spinal immobilization indicated in a patient with a gun shot wound? If it's not indicated, like a patient with a significant mechanism (again, do we routinely consider immobilizing children who slip and fall?), then there's no reason to rule it out with a clinical decision making tool like NEXUS.

 

[usafmedic45]

Linuss's hackles are up. h34r:

I'll get the popcorn.

 

[reaper]

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.

I think there's another way to look at this. Before a spinal clearance protocol can be put into place, spinal immobilization needs to be indicated first. Is spinal immobilization indicated in a patient with a gun shot wound? If it's not indicated, like a patient with a significant mechanism (again, do we routinely consider immobilizing children who slip and fall?), then there's no reason to rule it out with a clinical decision making tool like NEXUS.

Well, the problem there is most medical directors are still including full immobilization for any GSW to head or trunk, in there protocols. Until a significant study produces evidence to the contrary, most will continue to do so.

So then you are looking at a clearance issue.

 

[abckidsmom]

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.

Absolutely. I've not done more than a 5 patient shooting, but there was a whole lot of LET'S GET THESE PEOPLE OFF THE SCENE RIGHT NOW. And none of those scenes lasted more than 15 minutes once we made patient contact.

Best thing or not the best thing, getting a patient boarded takes as long as stripping them completely and looking for more holes. Giving yourself 1.5 -2 full minutes to really look the patient all over and get them immobilized is completely a fair game.

 

[Aidey]

Just because the protocol says it is so, is it really so? Going with the less-is-more school of medicine where are the studies saying spinal immobilization is indicated in those patients? To me to makes more sense to prove that an intervention is necessary than prove that it is not.

 

[lightsandsirens5]

I'll get the popcorn.

I got soda pop!

/end of hijack

 

[ParaPrincess904]

The congress woman was talking on scene and prior to surgery.

The article quoted the intern, who said she was not talking. Alert, but unable to talk, so the possibility for injury is there, is it not?

 

[Aidey]

What kind of injury are you talking about?

A brain injury, definitely. A spinal cord injury, not so much. She was shot on the left side of the head. In most people the language areas are lateralized to the left side of the brain, making it very likely one or both of the main language areas were damaged.

 

[usalsfyre]

Another thought is it is impossible to elevate the head of the bed to 30 degrees, which can help reduce ICP, if the patient is on a spine board.
(Don't have references right now, let me get coffee)

 

[CAOX3]

I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area, I understand and even agree with the research, however we work in systems designed by others more educated, so as I may disagree with some decisions they really are not mine to make. I don't have a problem with these providers decision and I certainly am not second guessing their actions.

Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury. So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.

If you have a problem with a protocol or SOP then gather the information and present your case to medical direction. Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope. A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.

 

[usalsfyre]

I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area

Of course

I understand and even agree with the research, however we work in systems designed by others more educated,

HIGHLY debatable. Even if someone holds a medical degree if they haven't kept up with current research and practice I'd be hard pressed to consider them "more educated" in our area of specialty.

so as I may disagree with some decisions they really are not mine to make. I don't have a problem with these providers decision and I certainly am not second guessing their actions.

I don't think anyone has a "problem" per say, just pointing out that the LSB may have been pointless.

Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury. So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.

Define distracintg injury (which very few people are able to do BTW). Is she able to participate in an exam calmly? Just because it's distracing to us doesn't mean it is to her. Is CQI interested in why a descion was made and correcting flaws, or just hammering people because they "broke protocol"? The former is real quality improvment, unfortunately the latter is standard EMS QI/QA

If you have a problem with a protocol or SOP then gather the information and present your case to medical direction. Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope. A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.

Good advice.

 

[JPINFV]

I have read most of the posts in this thread, my opinion is, it comes down to what is going to be acceptable treatment option for your area,

I completely disagree. The ideal treatment is the ideal treatment. The question is, does your system recognize and allow for the ideal treatment. Just because a system is behind in the times does not mean that what they mandate is automatically ideal. So the question still remains, does the ideal treatment plan for this patient include spinal immobilization?

I understand and even agree with the research, however we work in systems designed by others more educated, so as I may disagree with some decisions they really are not mine to make.

So because others are more educated, their decisions are automatically beyond question? Especially for interventions with a large psychomotor component and plenty of short cuts (like spinal immobilization), provider buy-in is drastically important. Doing immobilization just for show is useless, and if providers feel that it isn't important, but because the protocol has to be followed regardless of assessment, then they are more likely to take shortcuts. Beware of the system where asking "Why?" is discouraged.

Even if you have a c-spine clearance in place this woman isn't going to meet the criteria, as was stated a GS to the head is going to be considered a distracting injury. So in my area she gets a board and collar or I get a meeting with CQI, the latter isn't any kind of heat I'm looking for.

Again, what is the indication for c-spine? A bullet wound? Now the serious question is, "Is spinal immobilization beneficial (thus indicated) in a gun shot victim?" You can't clear someone from an intervention that was never indicated in the first place.

If you have a problem with a protocol or SOP then gather the information and present your case to medical direction. Flying by the seat of your pants because you read something on an Internet forum is dicey at best, implying that its acceptable providers forgo immobilization on a patient with these injuries is very slippery slope. A high profile mass shooting isn't a situation where your going to want to test your relationship with your medical director.

Who is advocating flying by the seat of their pants? Is suggesting that people make an assessment and form a treatment plan based on assessment and index of suspicion instead of blindly following a protocol the same as advocating flying by the seat of their pants? Finally, if protocols are supposed to be followed without question, are paramedics and EMTs really "professionals" or are they simply technicians?

Does the treatment plan change because of it being high profile? Should medical providers do things just to make it look like they're doing something because cameras are on scene?

 

[terrible one]

I'd love to see the day EMS moves beyond a plastic c-collar, some tape and a rigid board for what it calls 'cervical immobilization'

 

[jrm818]

Of course

Define distracintg injury (which very few people are able to do BTW). Is she able to participate in an exam calmly? Just because it's distracing to us doesn't mean it is to her. Is CQI interested in why a descion was made and correcting flaws, or just hammering people because they "broke protocol"? The former is real quality improvment, unfortunately the latter is standard EMS QI/QA

And NEXUS is explicitly designed to be used as a decision tool (the way you describe) not as a strict protocol.

In the NEXUS criteria, "distracting" was left intentionally undefined for the reason you state. It was decided that there was too much clinical variation to create an all-encompassing list of objectively distracting vs. non-distracting injuries, (not that anyone would realistically remember the entire list if they did), and instead the rule requires that a provider utilize good assessment, clinical judgment, and their gestalt to determine if a patient is eligible.

 

[usalsfyre]

And NEXUS is explicitly designed to be used as a decision tool (the way you describe) not as a strict protocol.

In the NEXUS criteria, "distracting" was left intentionally undefined for the reason you state. It was decided that there was too much clinical variation to create an all-encompassing list of objectively distracting vs. non-distracting injuries, (not that anyone would realistically remember the entire list if they did), and instead the rule requires that a provider utilize good assessment, clinical judgment, and their gestalt to determine if a patient is eligible.

You hit my point exactly. Two of the terms I find providers have the hardest time defining are "distracing injury" and "agitation".

 

[Shishkabob]

You hit my point exactly. Two of the terms I find providers have the hardest time defining are "distracing injury" and "agitation".

Well, if you ask Jimmy E at work, EVERYONE is agitated

 

[usalsfyre]

Well, if you ask Jimmy E at work, EVERYONE is agitated

Yeah, my threshold for treatment of agitation is a bit uhh, lower than some others. Remeber kiddies, lorazepam makes EVERYONE feel better B).

 

[Shishkabob]

Two vials for me, 1 vial for the patient, 1 vial for the random bystander that stops at the scene


I much prefer Versed to Ativan... I can give it IV/IO/IM and IN. Ahh.. IN Benzos... I love you so.

 

[firecoins]

What kind of injury are you talking about?

A brain injury, definitely. A spinal cord injury, not so much. She was shot on the left side of the head. In most people the language areas are lateralized to the left side of the brain, making it very likely one or both of the main language areas were damaged.

how did you rule out a spinal injury?
how do you know that the bullet didn't fragment into her spine? or that it was the only gunshot?
how did you know she did not incure a spinal injury falling to the ground?

we have the hindsight of doctors with the full array of equipment found in a trauma center. None of us responded.

I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute. I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.

 

[Sandog]

Oops posted to wrong thread...