Fall from 3 ft

[zeektheman]

I work in a region with a fairly liberal spinal immobilization protocol. The protocol does have some restrictions though ( age greater than 65 and significant MOIs). I have a scenario I want to run by you guys.

I responded for a 50 year old male who fell about 3 ft off of a ladder. The male stated that he lost his footing resulting in the fall. The patient was CAOX4 and denied any LOC. The patient presented with a possible break to his lower right arm as well as a one inch laceration to his head. I conducted a thorough assessment and found that the patient did not complain of any neck/back pain, numbness and tingling, palpation of spine was normal and no pain upon ROM of the neck. I deferred spinal immobilization. But when I got to the ED the nurse practically died when she saw that the patient did not have spinal precautions in place. She stated that a "fall from 3 ft that involves any head trauma should be immobilized!" What do you guys think about immobilizing this patient?

 

[NomadicMedic]

No. I would not have put him on a board.

 

[mycrofft]

Another story featuring a nurse yelling at someone.

Report her, that is not professional behavior.

 

[MrJones]

If your treatment of the patient was appropriate and in accordance with your service's protocols (and it appears that it was), ignore her. Or do as I do in such situations; stare at her w/ a blank look on your face while she scolds you, then turn around and leave without saying a word in response.

 

[Fire51]

I wouldn't c-spine this patient either. My grandpa slipped of a ladder, He had a broken rib. We had a paramedic, nurse and AEMT that were all in our family. We didn't c-spine him, we actually walked him to car and drove him to the hospital. C-spine is not for every patient with some sort of trauma. Some believe you need to c-spine these patients, so you will but heads with them, don't worry about it if you followed your protocols and did a good assessment.

 

[medicsb]

Going by NEXUS criteria, some might argue that the arm fracture could be a distracting injury.

Going by the Canadian C-spine Rule, you're patient would rule in for imaging of the c-spine via "dangerous mechanism": fall from height of "≥3 ft/5stairs".

The Canadian C-spine rule has been shown to have a better sensitivity, so I'd prefer it over NEXUS. (http://www.ncbi.nlm.nih.gov/pubmed/23048086)

Be that as it may, in the ED the patient would get a c-collar and imaging. I think it would be appropriate to only place a C-collar if he was already ambulating.

 

[CentralCalEMT]

Many nurses are so used to paramedics placing everyone who has more than a paper cut on a board, so when a thinking medic, in accordance with protocol, does not use a board they flip out. In my system, no we would not c-spine and we do not c-spine nearly as much as surrounding counties tho due to our protocols leaving a lot of it up to physical assessment and paramedic discretion rather than a black and white protocol.

 

[TheLocalMedic]

I don't like to board people unless it's warranted, so I run into this kind of crap all the time. Just explain your findings (no neck pain, no pain on ROM, no paresthesia, no injury) and then ask the nurse if they could justify strapping that patient to a board. Do it calmly and respectfully, and with all the authority you can muster.

And you get bonus points for explaining this in front of a doctor, because they'll generally tell the nurse, "Duh, why would you ever backboard someone like this?"

 

[ZombieEMT]

No board or collar.

 

[johnrsemt]

Look at how many people that fall off ladders, get up and drive themselves and their broken arm to the ED. None of them are c-spined, few of them get yelled at by the nurses.

We had a gentleman walk into the ED after falling off a 2nd story roof, onto a pile of trash lumber. picked himself and the 2X4 that he had stuck himself to with 3 nails walked over to a saw cut it short enough so that he could get in a truck and was driven to the ED. Triage freaked out but he was calm about it. "I knew that I wasn't supposed to remove impaled objects".

 

[RebelAngel]

My Captain told that unless they deny, immbolize. She said if you do not the ED will chew you out.

Sent from my XT557 using Tapatalk 2

 

[usalsfyre]

My Captain told that unless they deny, immbolize. She said if you do not the ED will chew you out.

Sent from my XT557 using Tapatalk 2

The ED chewing you out is not a valid reason to do or not do anything.

 

[RocketMedic]

My Captain told that unless they deny, immbolize. She said if you do not the ED will chew you out.

Sent from my XT557 using Tapatalk 2

The ***-chewing you will receive for treating inappropriately far exceeds the ***-chewing you'll get from a nurse with a wrong idea.

 

[RebelAngel]

The ***-chewing you will receive for treating inappropriately far exceeds the ***-chewing you'll get from a nurse with a wrong idea.

I'll be sure to discuss that with my Captain.

 

[CentralCalEMT]

Remember, just do not do anything that blatantly violates local protocol. I am fortunate enough to have lenient c-spine rules. However if you have a restrictive protocol, your options are limited. As others have said, follow protocol, act in the patient's best interest, and do not do something simply because the ER will yell at you.

 

[unleashedfury]

I work in a region with a fairly liberal spinal immobilization protocol. The protocol does have some restrictions though ( age greater than 65 and significant MOIs). I have a scenario I want to run by you guys.

I responded for a 50 year old male who fell about 3 ft off of a ladder. The male stated that he lost his footing resulting in the fall. The patient was CAOX4 and denied any LOC. The patient presented with a possible break to his lower right arm as well as a one inch laceration to his head. I conducted a thorough assessment and found that the patient did not complain of any neck/back pain, numbness and tingling, palpation of spine was normal and no pain upon ROM of the neck. I deferred spinal immobilization. But when I got to the ED the nurse practically died when she saw that the patient did not have spinal precautions in place. She stated that a "fall from 3 ft that involves any head trauma should be immobilized!" What do you guys think about immobilizing this patient?

You performed a thorough assessment and proved that C-Spine can be deferred based upon your findings.

How was the patient presenting when you arrived? Was he Sitting UP? Was he lying supine or was he up and walking around probably holding his injured arm or applying pressure to the head.

I can easily see justifying deferring C-Spine I presume the arm injury was a defensive injury since he may have placed his arms out to break his fall.

Unfortunately a lot of nurses can"t understand the "thinking Pre-hospital provider" where you perform a assessment find relevant findings and treat/transport accordingly. Most are used to he fell on his own two feet. bruised up his hands and needs to be C-spined cause I can't think for myself I need a Nurse to do that for me.

 

[medicsb]

So, what do your protocols actually say, OP? Those of you voting to defer c-spine precautions, what do your protocols say? Most protocols for C-spine clearance that I have seen are either based on the Canadian C-spine rule or NEXUS criteria.

Just as an example, Delaware BLS protocols use NEXUS criteria plus some additional and then Canadian C-spine Rule as "modifiers" for immobilization (http://statefireschool.delaware.gov/pdfs/BLSStandingOrders2013.pdf).

Maine uses NEXUS (http://www.maine.gov/ems/documents/2013_Maine_EMS_Protocols.pdf).

Wake Co. NC basically uses NEXUS.

Generally, EM physicians will use the criteria or rule that I have mentioned. They have been tested and validated. Deviating from those should be done very cautiously. It seems many are using general gestault or only using some of the criteria.

Anyhow, my point is that you could argue that the patient in the scenario warrented immobilization. Definitely by the Canadian C-spine rule and maybe by NEXUS (if one argues he had a distracting injury). The nurse was not definitively wrong.

 

[zzyzx]

"Be that as it may, in the ED the patient would get a c-collar and imaging. "

Not in the ED that I work in. Not for a 50 y/o. That would be madness.

 

[Handsome Robb]

So, what do your protocols actually say, OP? Those of you voting to defer c-spine precautions, what do your protocols say? Most protocols for C-spine clearance that I have seen are either based on the Canadian C-spine rule or NEXUS criteria.



Just as an example, Delaware BLS protocols use NEXUS criteria plus some additional and then Canadian C-spine Rule as "modifiers" for immobilization (http://statefireschool.delaware.gov/pdfs/BLSStandingOrders2013.pdf).



Maine uses NEXUS (http://www.maine.gov/ems/documents/2013_Maine_EMS_Protocols.pdf).



Wake Co. NC basically uses NEXUS.



Generally, EM physicians will use the criteria or rule that I have mentioned. They have been tested and validated. Deviating from those should be done very cautiously. It seems many are using general gestault or only using some of the criteria.



Anyhow, my point is that you could argue that the patient in the scenario warrented immobilization. Definitely by the Canadian C-spine rule and maybe by NEXUS (if one argues he had a distracting injury). The nurse was not definitively wrong.

We use NEXUS.

I didn't see anything glaring that would make him fail it. The arm could be argued as distracting but if he's calm and cooperating with my assessment and not freaking out about that arm it's not a distracting injury.

 

[Brevi]

The ED chewing you out is not a valid reason to do or not do anything.

This is a great quote