Selective Spinal Immobilization

[Icarus]

Hey guys, just joined - great site you have here.

I was hoping you could help me with something. I'm trying to find other county or state EMS agencies that allow EMT-B's to utilize a selective spinal immobilization protocol (based on NEXUS criteria or otherwise).

I don't want to argue the merits of allowing basics to use these protocols or anything. Basically, my department's medical director already approved the policy, but wants me to find other policies (from EMS Agencies, not individual departments) that allow basics to use a selective spinal immobilization protocol to bring to our county director.

So far I've found Maine state EMS, but haven't had much luck otherwise. If you know of any, I would greatly appreciate it.

Thanks.

 

[firecoins]

NYC will do it eventually. who knows when!

 

[AZFF/EMT]

Our neighboring department chooses to do this at times. A run is in litigation now. A call came out around 1pm for a fall injury.the examined the guy and got a refusal. A couple hours later they got another call fromthe same guy. He wasnt feeling right and had painful tingling in his extremities. They called for a rescue (my department) placed a ccollar and and walked the patient to our gurney. We didnt like what we saw and took full c-spine precautions and documented the hell out of it. well upon exam athe arriving hospital the patient had a c-2 and 3 fracture, was flown to a neuro hospital and died 2 hours later. I always elect to Cover my ***.

 

[ffemt8978]

Here's a summary of our protocols

I know I've posted this a couple of times before, but our protocols state that we are NOT to board and collar a patient based upon mechanism of injury alone. I would change this to allow c-spine precautions based upon mechanism of injury or medic gut-feeling.

Our protocols state that we are not to board and collar a patient if communication is possible and all of the following conditions are met:

1. Patient is CAOx3
2. Patient not under influence of drugs or alcohol
3. Patient has no complaints of neck pain
4. Patient has no complaints of arm or leg numbness
5. External exam reveals non-tenderness
6. NO distracting injury

 

[skyemt]

Our neighboring department chooses to do this at times. A run is in litigation now. A call came out around 1pm for a fall injury.the examined the guy and got a refusal. A couple hours later they got another call fromthe same guy. He wasnt feeling right and had painful tingling in his extremities. They called for a rescue (my department) placed a ccollar and and walked the patient to our gurney. We didnt like what we saw and took full c-spine precautions and documented the hell out of it. well upon exam athe arriving hospital the patient had a c-2 and 3 fracture, was flown to a neuro hospital and died 2 hours later. I always elect to Cover my ***.

totally off the point...

many studies have shown spinal immobilization to provide little benefit, and the risk of causing injury when none existed... do no harm? if the patient meets certain criteria (even assuming MOI), he may be transported without being immobilized on an LSB, the theory being a low risk of secondary injury, which is what the LSB is designed to prevent. after all, whatever injury occurred do to the initial insult is already present.

you are talking about a patient who had a c-2,3 fracture, AND WAS RELEASED rather than transported. this act of possible negligence has nothing to do with selective spinal immobilization.

 

[skyemt]

Here's a summary of our protocols

Maine uses this type of protocol, and New York State is in the process of adopting it.

it is important to note also that usually, this selectivity does not apply to the elderly. they will need a high index of suspicion, and will be immobilized based on mechanism alone. research papers put out by emergency physicians, in favor of selective immobilization, specific warn against using it in patients over 70.

 

[Outbac1]

Our province wide protocol is available here
http://emergency.medicine.dal.ca/ehsprotocols/Protocols/flowcharts/CSpine.cfm?ProtID=6294.01

It is similar to ffemt8978.

 

[Icarus]

Awesome! Thanks everyone for your replies.

Here's a summary of our protocols

Is there any chance you could link me to an official version of that policy? Or perhaps PM it to me? I've been instructed to get official copies or corrospondance if possible.

it is important to note also that usually, this selectivity does not apply to the elderly. they will need a high index of suspicion, and will be immobilized based on mechanism alone. research papers put out by emergency physicians, in favor of selective immobilization, specific warn against using it in patients over 70.

Definitely - this will be one of our criteria to be ruled out (<65 yrs and >18 mths)

 

[Icarus]

Also, skyemt, do you know if there is a copy of the (proposed) policy for New York state anywhere? I was looking through the minutes of their medical board meetings from several years ago and they mentioned that the policy had been approved and were looking at an implimentation date of Dec 05 - so you're saying that this hasn't exactly happened I take it

 

[Ridryder911]

Our neighboring department chooses to do this at times. A run is in litigation now. A call came out around 1pm for a fall injury.the examined the guy and got a refusal. A couple hours later they got another call fromthe same guy. He wasnt feeling right and had painful tingling in his extremities. They called for a rescue (my department) placed a ccollar and and walked the patient to our gurney. We didnt like what we saw and took full c-spine precautions and documented the hell out of it. well upon exam athe arriving hospital the patient had a c-2 and 3 fracture, was flown to a neuro hospital and died 2 hours later. I always elect to Cover my ***.

Man there is sooo many wrongs in that statement. First, your department is just as much in the wrong as the other EMS. They called for rescue, and placed a C-collar (recognizing the potential complications) then they walked the patient to the stretcher, (if they assisted they are just associated with the outcome). Then recognizing the problems they covered their arse and then took full spinal precautions and documented it.

As well, C1 C2 (atlas/axis) fractures are common. It is a rarity that the spinal injury caused the death, if there was not an immediate cord injury. Don't know the MOI or care too, but there may be other factors that lead to the death.

R/r 911

 

[AZFF/EMT]

I agree R/r. It was a pretty ridiculous call. I am involved in QA/QI on the charts and I am glad I was not involved in this. It's not our medic who is involved in the litigation. The suit is about the first responding agency not taking cspine precaution.

My point is that even though there are protocols and some agencies use selective c-spine it is still your *** on the line and who will be in court defending your actions, even if you fel you followed your protocols correctly. Its your cert and your life, be sure.

 

[skyemt]

My point is that even though there are protocols and some agencies use selective c-spine it is still your *** on the line and who will be in court defending your actions, even if you fel you followed your protocols correctly. Its your cert and your life, be sure.

you are missing the point again...

Rid's point, and my point, is that there is no way you could even dream that the protocols were followed correctly. as in any area of what we do, if you do not follow protocols correctly, you are exposed to potential litigation. you had better have a very defensible position for not following them. if not, well then....

 

[skyemt]

Also, skyemt, do you know if there is a copy of the (proposed) policy for New York state anywhere? I was looking through the minutes of their medical board meetings from several years ago and they mentioned that the policy had been approved and were looking at an implimentation date of Dec 05 - so you're saying that this hasn't exactly happened I take it

i have not seen it. my information comes from the county level. and no, it hasn't happened yet, but is in the works. however, protocol changes take a long time to make it through the system.

 

[Ops Paramedic]

We use a guideline which is based on Nexus and adopted from hospital. However, in one or two patient scenario, we will not apply them. If there is any indication, the patient gets immobolised. We will only clear c-spine clinically on a multiple casualty incident and resources are scares. As for the protocol being published in our protocol and guidelines booklet, it is not. Now the question is, can you do it or not. The booklet does not say you can't, nor does it say you can...

Walking a patient to the ambo for spinal immobolisation, with a c-collar on... What is the point?? I think it might be due to lazyness as it involves work to get the kit out. I see it all the time and try to stop it when i can. Should you commit to any form of c-spine immobolisation, you need to carry it through in the correct fashion, otherwise you are contradicting yourself.

 

[paramedix]

Everyone gets trained to perform proper SMR. Thus this should be performed as well as possible. As ops paramedic mentioned, we do not have a set protocol out here, but we are regulated by the HPCSA.

If in doubt, immobilize the patient and do it correctly. We do get MCI often and unfortunately we are tasked to clear patient's in order to treat and transport everyone to hospital.

Again, walking with a collar....unless you're a dog... you don't walk around with a collar, neither should your patients.

 

[skyemt]

it is important to understand exactly what you are saying when you put a collar on someone...

you are saying that based upon your protocols, assessment, etc, you believe that there may be an unstable spinal situation present, or possible due to secondary injury. that's why you put the collar on...that's why when you put a collar on, they get boarded as well... it would therefore make no sense to have someone walk over to the rig...

not to go back to education, but many problems like this come from EMT class... memorizing "steps", rather than understand what you are doing and why...

"c-collar", check... "got that step done, now let's walk over to the rig!"

i have never seen an emt who truly understood what the purpose of immobization was tell a pt to walk anywhere.

 

[AZFF/EMT]

and that lack of education and lack of really being able to rule out c-spine injury in the field, is where the selective c-spining can possibly become dangerous for ems. I picture many many more cases in litigation, even when protocols are followed, because :censored::censored::censored::censored: happens and when ypou think that you correctly ruled out an injury only to find out later that there was an injury (not talking about the call earlier) and a lawyer gets involved.

I agree with the theory and wish that it could be used widely, but I do not like lawyers and after seeing the things they can do, I would always start with covering my *** completely.

 

[skyemt]

and that lack of education and lack of really being able to rule out c-spine injury in the field, is where the selective c-spining can possibly become dangerous for ems. I picture many many more cases in litigation, even when protocols are followed, because :censored::censored::censored::censored: happens and when ypou think that you correctly ruled out an injury only to find out later that there was an injury (not talking about the call earlier) and a lawyer gets involved.

I agree with the theory and wish that it could be used widely, but I do not like lawyers and after seeing the things they can do, I would always start with covering my *** completely.

if the protocols for clearing c-spine are followed accurately, there is a 99+% probability that there is no injury requiring stabilization. of course, there is always a chance of something crazy...

you are so hung up on lawyers... one reason for the new protocols is precisely BECAUSE of the lawyers... patients were brought into the ER's developing back injures from unnecessary immobilization, injuring a patient where no injury existed previously.

think about what you are saying, and why things develop the way they do... there are usually good reasons...

 

[AZFF/EMT]

sometimes there are, and sometimes 1 year later things are back to the way they were. I am not against it, it just believe a total re-education needs to happen at all levels of ems or it to work properly, and I hope there is. I believe in change, hell I came from the army. The place where most of the new trends come from and are tried well before civilian ems. There are many great things coming out of iraq right now that we will do on the streets in the years to come.