When to immobilize when not to?

[62_derick]

In the Pa state Protocols it states to immobilize the spine when there is any mvc!

Now do you immobilize when there is a mva and the patient does not have any complaints of neck or back pain? and there is no severe MOI (ie rollover intrustion and so on)

Or do you just immobilize at every mva with or with out good MOI and with or with out complaints?

The reason this is being brought up was due to being called out on a single mva moderate front end damage and rear. Pt states vehicle rolled over but there was no damage to back that up. PT had no complaints of neck or back pain and refused to placed on a back board and collar. Took pt to a local hospital and was asked by the staff why no collar and back board, explained pt refused. Later that week I got pulled into my sups office and had to explain why pt was not immobilized and that pt told staff at hospital that she did not deny this at all.

What I should have done was got pt to sign a refusal stating did not want the immobilation but was not told that they needed to sign something if there rufusing that.

So anyways do you immobilze no matter what or do you go on the complaints?

 

[LondonMedic]

Now do you immobilize when there is a mva and the patient does not have any complaints of neck or back pain? and there is no severe MOI (ie rollover intrustion and so on)

You can have a high energy impact without rollover or intrusion, and especially in modern vehicles with crumple zones and rigid passenger compartments, external damage is not always indicative of energy.

Although spinal injury and spinal cord injury is relatively rare, I would always suggest spinal immobilisation unless you can positively clear a spine clinically (which I find difficult to do inside a vehicle).

 

[the_negro_puppy]

In the Pa state Protocols it states to immobilize the spine when there is any mvc!

Now do you immobilize when there is a mva and the patient does not have any complaints of neck or back pain? and there is no severe MOI (ie rollover intrustion and so on)

Or do you just immobilize at every mva with or with out good MOI and with or with out complaints?

The reason this is being brought up was due to being called out on a single mva moderate front end damage and rear. Pt states vehicle rolled over but there was no damage to back that up. PT had no complaints of neck or back pain and refused to placed on a back board and collar. Took pt to a local hospital and was asked by the staff why no collar and back board, explained pt refused. Later that week I got pulled into my sups office and had to explain why pt was not immobilized and that pt told staff at hospital that she did not deny this at all.

What I should have done was got pt to sign a refusal stating did not want the immobilation but was not told that they needed to sign something if there rufusing that.

So anyways do you immobilze no matter what or do you go on the complaints?

Sounds stupid that you have to immobilise with every MVA/RTC. No pain (also on papation), no loss of power, movement or sensation, no numbness, are pretty good indicators that there is no c-spine injury, however I guess you never know.

My partner and I got chewed out by this idiot triage nurse (whom everyone at the hospital-even other nurses despise) for not collaring a 17 y.o male who had been punched in the face and unconcious for a short period of time. When we arrived he was walking around fine, no complaints of pain, no loss of sensation of function etc, GCS 14 due to some confusion i.e short term memory loss- asking the same questions.

The nurse at the hospital said "why isnt he collared", and told other nurses to do it. When the other nurses went to do it they turned to her and asked her if it was neccessary due to no pain on palpation etc and she was ranting about the MOI. When we took him to his bed the other nurse took the collar straight off.

Just because there is a slight posibility (MOI) doesnt mean there is an injury. We shoul be able to use our clinical judgement to avoid unneccesary procedures on patients. I say treat the patient not the MOI

 

[LucidResq]

Although spinal injury and spinal cord injury is relatively rare, I would always suggest spinal immobilisation unless you can positively clear a spine clinically (which I find difficult to do inside a vehicle).

This is a very good point.

Things to consider:

1) Unreliable patients should probably be boarded. This includes intoxicated, any AMS, too young to communicate effectively, unconscious, instances of language barriers, apparent cognitive disorders.... etc. Even if they are not complaining of any neck or back pain.

2) Any loss of consciousness = consider boarding

3) Physical exam of neck and back = any tenderness, deformity, spasm, etc = board

4) Any sensory or motor deficits, tingling, visual disturbances, gait abnormalities, etc = board.

5) Distracting injuries = probably gonna board.

6) Hx of neck/spine injury = board.


An example of a time I think it would be inappropriate to board:
My boyfriend was working as an EMT at a water park. A drunk guy took a swan dive in to some shallow water and had a decent head lac, so the lifeguards went to help and called him over. The poor little lifeguard tried to get c-spine going but couldn't because he was so combative. My boyfriend came on and tried to calm the guy down, and he was pretty much ok until they started trying to hold c-spine or immobilize him in any way. Then he'd start thrashing around and screaming... the whole bit. So he gave up on the immobilization and focused on continuing his assessment while keeping him as calm and still as possible.

Yes, based on MOI alone you'd want to board this guy, and maybe this could have been accomplished with some muscle on scene or some haldol... but without that available is it really worth it to try to hold this guy down which just causes him to thrash around and risk him further injuring himself or injuring you?

Just an example to consider. I think we should be focusing on good decision-making skills rather than "I'm going to board every pt. from an MVA."

 

[Veneficus]

as usual, it is all about perspective

In the effort to have state wide protocols, they hae to be written for the lowest common denominator.

In PA, an EMS certificate never expires. You just have to get a medical director to sign you are current. While such lax oversight cuts down on paperwork and is beneficial for rural providers to keep "certification," it is not in the best interest of the patient or the art of medicine.

PA also has a lot of rural and volunteer providers. I don't have official numbers but I would bet it is second only to NJ. The same thing happened to us in Ohio, there was apush for statewide protocols, and when it went through it left a lot of more advanced/progressive services and providers wanting.

Statewide protocols in my experience do more harm than good. Not to say local ones can't be just as bad, I was at a service that still used high dose epi in arrests well into the 2000s. But once something gets carved in stone over at the statehouse, it takes nothing less than a coming of a messiah to alter it. Locally all you have to do is change the med director.

But let me expand on mechanism of injury. MOI was never supposed to dictate treatment. It was supposed to clue in a provider on what injuries (index of suspicion) were possible and would have to be assessed for. The use of MOI in US EMS actually predates the ATLS course as a memory aid in deciding "how" bad somebody is based on the very minimum provider education.

As Londonmedic pointed out, this all came about in an era of steel vehicles without seatbelts. When a person was in an MVA (MVC, RTA, RTC or whatever you like) because of the nature of the metal the force of n impact was transferred mostly to the occupants. They also hd a tendency to impact windshields and bounce around the inside of the vehicle. Speed and therefore damage were extrapolated to injury based on the fact of the day most cars didn't have seatbelts, and if they did, nobody wore them. So you would expect, and it was probably provable to a degree that if there was damage to the car, there was definately damage to the people.

Trauma trivia from ATLS: In order to brace yourself against a frontal impact without a restraint in a car traveling 35MPH in the year 2003, you would have to be able to benchpress 17,000 lbs.

Since no human can do that, it lends to the conclusion that there was probably a compression injury and/or an extension injury, depending on the site of impact and the speed involved. Spinal injury was therefore likely and assumed until ruled out. Based on this forces that caused these injuries were extrapolated to non vehicle injuries like falls. The wisdom of the day was if the measured forces were the same, the injuries were the same.

Today, cars are built a little differently. you can easily total one and walk away. with all the construction features you can't see/don't think about, like frames, cages, crumplezones, etc. and the ones you do notice like seatbelts and airbags, the exact opposite from those days are true, you will probably escape major injury. With the decrease in force transfer to a human, the injuries are lesser. (Now and again we come upon people not wearing seatbelts, or struck by forces the car cannot absorb, but they are considerably less and declining un number)

So what about falls and other mechanisms? They are very complex, how the patient fell, from what hight? What did they land on? kinetics of impact absorbtion of body surface, health conditions, etc.

Bottom line: The old mechanisms are no longer reliable. But if you actually understand how those rules about mechanism came about, your index of suspicion is much more accurate now.

As for spinal fractures, there is a difference in clinically significant fx vs. any spinal fx. As an example I would point out the incidence of missed findings on portable trauma room spinal x-rays compared to CT. The X-ray misses a lot of fx. but does point out the gross ones. The CT shows more, but often care is not changed. (litigating of a undiagnosed spinal fx is an ambulance chasers' dream come true) "My client has debilitating pain and loss of function from a 3mm crack in the body of a vertabrae that you didn't find or treat." (even though the "treatment" wouldn't be any different than what was already done)

If your protocols don't permit you to select who is immobilized or not, then you have 2 options, 1. immobilize them. 2. Call online med control and ask somebody who has a license to practice medicine to grant you permission and accept responsibility to not immobilize them. To do otherwise could get you in big trouble.

If you have a protocol that allows you to selectively immobilize or clinically clear a patient, the steps you need to take should be clearly detailed in that document and you should follow it.

I know it sucks when you work under a protocol where you know a patient doesn't need immobilized or you can't take it off once it is in place. (had a kid (10 year old) immobilized by BLS responders prior to my arrival that was hit in the stomach by a large red rubber ball. I was not permitted to remove such a device once placed. So off to the hospital we went. I explained to the doc on the phone what an utter waste this was. The kid was discharged before my report was finished. (his older sister was kind impressed enough to leave me her phone number on a vomit bag, no i never called) Can you imagine how hard you have to kick a rubber ball into somebody's stomach to break their spine?

 

[LucidResq]

I know it sucks when you work under a protocol where you know a patient doesn't need immobilized or you can't take it off once it is in place. (had a kid (10 year old) immobilized by BLS responders prior to my arrival that was hit in the stomach by a large red rubber ball. I was not permitted to remove such a device once placed. So off to the hospital we went. I explained to the doc on the phone what an utter waste this was. The kid was discharged before my report was finished. (his older sister was kind impressed enough to leave me her phone number on a vomit bag, no i never called) Can you imagine how hard you have to kick a rubber ball into somebody's stomach to break their spine?

LOL! Our protocols are pretty good about letting us decide "to board or not to board," but they do say that once someone is boarded they are not to be removed and must be transported.

 

[JPINFV]

Today, cars are built a little differently. you can easily total one and walk away. with all the construction features you can't see/don't think about, like frames, cages, crumplezones, etc. and the ones you do notice like seatbelts and airbags, the exact opposite from those days are true, you will probably escape major injury. With the decrease in force transfer to a human, the injuries are lesser. (Now and again we come upon people not wearing seatbelts, or struck by forces the car cannot absorb, but they are considerably less and declining un number)

To add to that, generally the worse the accident looks (within specific limits), the better the occupants are. Crumple zones are meant to... well.. crumple. In doing so, energy is dispersed. If you need any better example, look at just about any NASCAR accident and, say, the accident that killed Dale Earnhardt.

 

[mycrofft]

A few of us were active in the field as the newer cars took over.

Modern cars are 'way safer at the same speeds and type accidents as before.
Now with rice rockets tearing up and down local streeets at over 100 mph, nothing short of a NASA fix will save you when the front end shears off at the firewall or you roll about twelve times at 1/5 the speed of sound. Or don't wear your seatbelt.

Go ahead and board a refusing pt. I did my share. They fight the board, which in my opinion is worse than having them lie quietly. They can experience positional asphysxia (some folks cannot lie flat). And without a signed refusal, they might fight you in court.

 

[Veneficus]

Modern cars are 'way safer at the same speeds and type accidents as before.
Now with rice rockets tearing up and down local streeets at over 100 mph, nothing short of a NASA fix will save you when the front end shears off at the firewall or you roll about twelve times at 1/5 the speed of sound. Or don't wear your seatbelt.

You don't have to try and make me feel old, I am doing quite well on my own.

Go ahead and board a refusing pt. I did my share. They fight the board, which in my opinion is worse than having them lie quietly. They can experience positional asphysxia (some folks cannot lie flat). And without a signed refusal, they might fight you in court.

I don't suggest fighting anyone to put them on a board, infact I doubt very much a board helps at all. More than one study I have seen shows they do damage. But more than that, a competant patient has the right to refuse any part of treatment, so if they refuse I am not sure why anyone would try to fight it. Of course like you said, best to document the very well and have them sign you advisedthem of the risks, because if they refuse and do end up hurt because of it, I would bet my last $ the story would be they didn't refuse, you just didn't do it.