Who's still routinely c-spining?

mycrofft said:
Yeah, that's what I want. Someone subject to vomiting or becoming combative or claustrophobic, strapped down prone on a hard board on my ambulance litter.
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I think you were looking for supine ;)

I'm sure you're right as to what their response would be but ETOH =/= automatically remove a patient's ability to consent. If they're drunk but able to follow what's going on, reiterate risks and other things they're told I'd say they have every right to refuse but that's just me.

You're also talking to the Medic who had a Physician complaint because I refused to backboard a patient with a confirmed lumbar fracture who ambulated into the Urgent Care two days after the injury.

The patient wrote a letter thanking my agency for the care I provided so that got squashed pretty quickly.
 
DEmedic said:
I find that BLS people still routinely C-spine, because it's what they know. When paramedics arrive on the scene of a traumatic injury, we don't routinely C-spine patients, instead we use selective spinal immobilization criteria.

I also find that if it's a chaotic scene, a backboard and c-collar is more likely to be applied… Because somebody with a white helmet is running around willy-nilly yelling, "get a board"
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We were taught to cspine everyone until we knew definitively that they didn't need it..even then they said..put a collar on them. most of the medics that i talk to all say..''when you are out in the real world, forget that :censored::censored::censored::censored:."
 
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Tigger said:
Yesterday we went to the urgent care for a girl who had fallen while hiking and through x-ray was determined to have an L1 fracture. No CT so the doc would not rule out a c-spine injury despite having no related complaint and meeting Nexus criteria (yes she had a fractured L1 that was painful but she was still answering questions calmly and appropriately so I don't see that as a distracting injury).

I said I would take her with no c-spine precautions and position of comfort, or maybe a collar if it made everyone feel better. The only concession I ended up with was using a scoop not a board. Reason given: if she vomits, I can't control her airway since I can't move her without hurting her. Position of comfort was prone, with head on a pillow. So we put her on the scoops and dramatically increased her pain level despite copious padding and an eventual of 4 of morphine. Yea, we definitely helped her. :glare:
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I don't quite follow. What type of L1 fracture was it? I figure maybe burst? Regardless of what you might feel about SMR, its still indicated in one form or another for unstable injury. You haven't mentioned whether this was an unstable type fracture.

Also, my understanding is that the literatire supports the idea that 1) Xrays are less than perfect and 2) once an xray shows a fracture, the likelihood of other fractures becomes vastly higher and a CT scan is pretty much mandated.

You couldn't control her pain with morphine? Are you limited dose wise? Was 4 the only pain relief she got?


GoldcrossEMTbasic said:
The agencies, around MN, even while in route when dispatcher states rear end minor fender bender. The protocol is C-spine precautions and backboard even if the patient is alert and oriented x3 and GCS is 15. In class we had to go by the book of course. But I think the protocol is that even if we go on call where a patient fell, we collar the pt and backboard too. And the patient usually will state that this is not necessary. And some patients don't realize how quick the spinal cord can be severed even if the cervical part of the body moves even by a millimeter. Depending on the type of trauma they encountered.:excl:
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As others have said, this sort of story is largely mythical. I can certainly point you in the direction of some relevant literature if you would like. Please forgive me if I'm wrong or English isn't your first language or something, but Goldcross, level with us mate, are you sure you aren't just having us on with that sort of example and one or two other thing you've said? You might have noticed by now that you've referenced a few issues that are commonly used to troll prehospital providers and if thats just because you're starting out, then great, we've all been there and I am happy to correspond with you and help you with a ton of great resources because you're obviously keen. But common mate, if you're having a laugh, now is the time to tell us.


Tigger said:
Did a standing take down just now. I feel dirty, need a shower right quick.

Slowly I work for change but obviously it takes a long while.
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I honestly didn't know that was still a thing. Out of interest, is there a justification document laying around or some guidance for your clinical department on why they require you to do that? I don't suppose you have an electronic copy of your guidelines do you? I'd be interested to see them.

FiremanMike said:
Patient had etoh on board.. I'll be honest I wasn't quick enough at the time to try and play the consent angle, but in retrospect the doctor would have just said "her lack of consent is invalid because of the alcohol"...
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That raises an interesting issue. In your area, does intoxication remove a person's right to refuse care? I wouldn't have thought so.


While I'm sure you could argue until blue in the face about who can REALLY make informed consent, the drunk issue has been tested here with consistent findings that drunk idiots have the right to be idiots even when they're potentially head injured as well. Summarized somewhat more appropriately bellow. I would be fairly surprised if it was drastically different in the US. I thought you chaps/chapettes were all about the right to make the wrong choice?

"...if they can understand your advice that they should go to hospital, that they have suffered an injury that needs attention, if they can in fact consider that and weigh it up against their competing desire to keep drinking, or go home, or do whatever else they want to do, and they can make that clear to you, then they retain their competence."
 
rockyfortune said:
We were taught to cspine everyone until we knew definitively that they didn't need it..even then they said..put a collar on them. most of the medics that i talk to all say..''when you are out in the real world, forget that :censored::censored::censored::censored:."
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I really hate this street vs book type thing and always have.

If some reasonable practice is genuinely acceptable, then why is some utterly different 'theoretical' alternative being taught as gospel? Currently one of the local universities is teaching that pts be rigidly interviewed along "AMPLE" lines after an initial complaint is established, because, you know, when your pt has chronic lumbar back pain as a starting point, really nailing down that last meal is super important. Additionally the DOLOR mnemonic has been recently taught as an assessment tool for any and all pain. Obviously everyone, including all (as far as I know) the academics teaching this acknowledge this isn't and shouldn't be what actually happens but I've never actually been able to extract an answer as to why this sort of BS goes on.

Conversely, if real world practice doesn't reflect practice being taught at an academic institution where, theoretically at least, the best evidence should be the corner stone of all the teachings, then far from throwing out the book, the real world needs to get on board with the science.

I don't see that the whole real world vs school BS makes any sense from either perspective. I get that there is, in all fields, a differences between the leading edge academic gold standard and otherwise current or standard practice. Practice & culture will always take a while to catch up with fast paced evidence based change. But that is quite a different notion.
 
I only C-Spine my CHF patients.
 
This is one of the few areas were our standards are grey. It simply states to immobilize the c-spine if trauma is known, suspect, or cannot be ruled out. Soooo....in this world of OMG!OMG!OMG!OMG!OMG!OMG!, out comes the collar and backboard.

Many of my colleagues await the arrival of an algorithm in order to decreased the amount of patients that get collared and boarded, but I say do it yourself. I get many odd looks when someone complains of neck pain and I don't whip out the C&B.
 
Melclin said:
<snip>
If some reasonable practice is genuinely acceptable, then why is some utterly different 'theoretical' alternative being taught as gospel? Currently one of the local universities is teaching that pts be rigidly interviewed along "AMPLE" lines after an initial complaint is established, because, you know, when your pt has chronic lumbar back pain as a starting point, really nailing down that last meal is super important. Additionally the DOLOR mnemonic has been recently taught as an assessment tool for any and all pain. Obviously everyone, including all (as far as I know) the academics teaching this acknowledge this isn't and shouldn't be what actually happens but I've never actually been able to extract an answer as to why this sort of BS goes on.
<snip>
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I think a part of it is ensuring that everyone knows SAMPLE, as a baseboard to spring from. That way when we go into a scene, we have SAMPLE in our mind. But yes, the books teach "always do a full SAMPLE", while real paramedics say "sometimes I skip over certain parts of SAMPLE". There is some disconnect there.
 
My protocols still call for pretty routine c-spine.

Edit: I did want to clarify. SMR can be as little as just a C collar and be within protocols. However, everyone in my area seems to think that SMR means full spinal immobilization. I've only seen it omitted completely once, a collar maybe a half dozen times and the rest of the time it is full backboard.
 
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Bearamedic said:
These 5 criteria put it on par with an xray clearing. add in female over 65? 80?and you have surpassed xray clearing

Link is just what i found, cant find a list that includes the elderly female tidbit.
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Where did you get the female component? That's not part of NEXUS.

9D4 said:
My protocols still call for pretty routine c-spine.
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Interesting. Looks like they've combined the Canadian C-spine rule and the NEXUS criteria so you have to pass both.
 
In PA we still use what is basically NEXUS, per protocol. In Maryland there was a recent switch to clinical judgement (Protocols state "the provider shall determine the appropriate immobilization device for the patient").

Hopefully that trickles north to PA by next year...
 
Brandon O said:
Where did you get the female component? That's not part of NEXUS.
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I dont know, i think it might have been in a slide show during a ce class.

The elderly female reasoning was osteoporosis increased the chances of fx which may be completely asymptomatic, and the common subtle neurological diminishment masked symptoms or positive criteria as well. Those two things together seemed to be significant enough in a prehospital setting to not safely "field clear"

I tried to find a citation that would be useful for a physician assistant student in a hospital setting, but could find none. :sad:
 
Bearamedic said:
The elderly female reasoning was osteoporosis increased the chances of fx which may be completely asymptomatic, and the common subtle neurological diminishment masked symptoms or positive criteria as well. Those two things together seemed to be significant enough in a prehospital setting to not safely "field clear"
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I can sort of see where you're coming from. I don't think osteoporosis is associated with neurological impairment, but it is associated with fracture risk.

However, it's worth remembering that in the NEXUS validation studies, this was not one of the components and there were still essentially no significant misses. So if you start adding more caveats just because they make some physiological sense, you're creating a new rule and there may not be any need for it. (Where does it end? Should we rule out diabetics, macho men with high pain tolerance, and folks with big heads?) After all, the whole notion of prophylactic immobilization is based on the idea that it "makes sense," and that's what we're trying to move away from using the evidence we have available now.

I understand the urge to fret, but I think the best way to find reassurance is to look back at the validation studies and really wrap your head around them. If you'd personally seen hundreds and hundreds of patients and cleared them using the defined NEXUS criteria (or the Canadian rule), even in cases where you might have been uncertain, then eventually you'd probably start to believe in it. That hasn't happened to you -- not yet anyway -- but it has happened in the studies. So believe!
 
I wasnt meaning to imply that osteoporosis caused neurological deficit, only the increased fx risk for females. And then combined with old age neurological changes, explained the false negatives. It was mentioned that the nexus didnt have enough in the age range to be conclusive (over 65 or 80?)

Im not really in a position to safely clear, as my protocols dont allow it. Nor do i get the chance to followup.

But i understand your more rules point, this may have been targeted at prehospital setting where attention to detail can be diminished or misinterpreted as patient distractions.
 
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Hm.

Well, it's fair to say that the validity of NEXUS hasn't been demonstrated AS STRONGLY in patients over 75 or 85 or wherever you want to draw the line. That's just a statistical inevitability; most of the studies took patients of all ages, and the average age was much younger (30s or 40s usually), so focusing on a subset of the age range means the study size goes from thousands down to much less. That would be equally true if you asked about validity for patients "age 26-29," but I realize there's a better reason to think that the oldest group may actually have a different risk.

It's hard to see exactly how many old folks it's been validated in. Neither the original NEXUS derivation (Hoffman 1992) nor the validation (Hoffman 2000) give full age breakdowns, although the range does go up past 100, so there were SOME patients in that older group. Similar story in a retrospective chart application using NEXUS (****inson 2004), and in a study that compared NEXUS with the Canadian rule (Stiell 2003). These are all studies with thousands enrolled, so even in the subsets the numbers should have some weight.

Domeier 2005 studied a modified NEXUS for prehospital use, and they do give an age breakdown; eyeballing the chart it looks like about 1900 enrolled age 75+. Their sensitivity was a little lower than in the other studies, about 92%, and it's true that a fair number of their injuries were in the older cohort, but none of the missed injuries mattered (no clinical sequelae).

Goode 2014 just came out and seems to be the only study specifically addressing this. They concluded that NEXUS wasn't very sensitive with age >65, with sensitivity only 65.6%. However, the sensitivity BELOW 65 was only 84.2%, which is dramatically less than in the other studies, so I have to wonder what they're doing differently; if we trust these numbers we shouldn't be using NEXUS for anybody.

So with all that said, I think that it may be overreaching to say that older patients don't qualify for NEXUS. Although they may be at higher risk for fracture, that isn't quite the issue; the issue is whether the rule can detect those fractures, and I don't think there's any good reason to say that all old patients can't reliably report pain or neuro deficits. Obviously selected patients (e.g. with dementia or diabetic neuropathy or MS or something) may be a different story, but hopefully your clinical judgment would already tell you that you may not be able to clinically clear those people anyway.

I'll grant that there isn't much evidence specifically addressing this question, except the aforementioned study by Goode. The easiest way to get a bit more data would be to write to the NEXUS authors (Hoffman et al) and ask for the specific age breakdown in their studies; then you could get those exact numbers. I'll also grant you that the Canadian rule does use age >65 as a rule-out; I suppose if you're worried you could just start using their rule, which has also been validated for EMS use.

(Most of the cited studies are available at the DRL if you want to read up.)
 
Reading into the Goode study a bit more, their difference is probably explained by enrolling a different population; they're looking at HIGH RISK injury, not just all blunt trauma. Meaning: "... associated injuries from high-energy mechanisms (e.g., pelvic/long bone fractures), ejection from a vehicle, death in same compartment vehicle, fall from greater than 20 feet, vehicle speed greater than 40 mph, major vehicle deformity/significant intrusion, and pedestrian struck with speed greater than 5 to 20 mph."

Now that's risky! Which helps explain why their rate of C-spine fracture is 7.4% in the young and 12.8% in the old, both of which are waaaaay higher than in any other studies (like 5-10x higher). This was based on a previous study by the same folks which found similar results in all-age severe trauma.

I think this has very little relevance to the topic at hand. Most providers are not trying to clear an 80-year-old (or in many cases a 30-year-old) who just got ejected from a vehicle without some imaging, and most EMS personnel are probably giving that guy a collar. NEXUS is for the little old lady who fell.
 
C-Spine

I agree with DEmedic. I find that EMT-B's are more likely to routinely C-spine because that is what is drilled into their head. In my situation it usually depends on how many hands I have. If its just my partner and myself, I have far more important things I need them doing other than c-spine because once you are on it, you are stuck on it.

I do monitor though to make sure the PT understands not to move, or I will place towels on either side of their head for light support. But unless I have the manpower, Which is usually not the case, I don't
 
Here's LA County's new SMR guidelines, what do y'all think?

http://ems.dhs.lacounty.gov/policies/Ref1300/1334.pdf

Potential for unstable spinal injury?

Strongly consider SMR in patients at high risk:
  • Age greater than or equal to 65 years old
  • Meets trauma criteria for mechanism of injury
  • Axial load injury

Perform careful assessment on all patients:
  • Unreliable Patient?
    • Altered
    • Uncooperative/Limited evaluation
    • Intoxicated
  • Abnormal Spine exam?
  • Abnormal sensory or motor exam?

If YES: SMR REQUIRED

If NO:
Consider forgoing SMR with low-risk features:
  • Simple rear-end MVC or other low energy mechanism?
  • Ambulatory on scene?
  • No neck pain?
If YES: SMR Not Needed
If NO: Use Judgement, Consider less invasive SMR
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