Immobilize or not?

[adamjh3]

As has been said it will depend on your local protocols. A lot of EMTs here in California would hear "back pain" and immediately jump to putting the patient in spinal restrictions. If the pain was not mid-line (along the spine) and the patient displayed no neuro deficits I likely would not have placed him in spinal restrictions.

You did fine, spinal immobilization was probably beat into your head in EMT school, and we always fall back to our training.

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[Tigger]

Back pain or any kind of pain in the back possibly caused by trauma = C-spine. I would have been ripped to shreads if I arrived at the hospital without C-spine.

Out of curiosity, who does the ripping? I've definitely brought in patients with similar presentations and had nurses thank me for not boarding them. I hardly ever see a doc during handoffs but I imagine they would feel similar. Plus if a nurse makes noise about not spinaling someone I am happy to explain my reasoning. Usually an explanation is all it takes for cool heads to emerge. If you I can't justify my lack of treatment then maybe I have a problem, but that is not going to happen.

Somewhat related: my job in Sports Medicine has given me the opportunity to learn a much better neuro exam than in basic class. Is performing a neuro exam out of scope for me as a basic for anything beyond poops and giggles? Can I use that info to help guide my treatment?

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[Handsome Robb]

Tigger it's gonna come down to your protocols. Are you allowed to clear c-spine in the field? As a basic, my first guess is no. If they meet the criteria per your protocols your hands are tied unless you have a really good reason to justify your actions such as having to fight a patient onto a board.

 

[mycrofft]

Parsing:

1. Follow local protocol.
2. If he wants to get out of it, have the AMA ready to sign.

 

[Tigger]

Tigger it's gonna come down to your protocols. Are you allowed to clear c-spine in the field? As a basic, my first guess is no. If they meet the criteria per your protocols your hands are tied unless you have a really good reason to justify your actions such as having to fight a patient onto a board.

I can't clear c-spine in the field as I am a basic, as you note. I'm not really talking about clearing c-spine though. I'm thinking more along the lines of a typical unnecessary c-spine situation, where someone ends up on the board based purely on mechanism and not any complaints. A neuro exam seems like a good way to "talk my partner off the ledge" when it comes to a ground level fall with no complaint of neck or back pain. I hate when someone ends up on the board just because some misguided EMT was told by a misguided instructor that every fall patient should be boarded as a CYA measure. If a patient has neck or mid line back pain secondary to a traumatic event, they are going on a board because that is the standard of care in the area and we lack a better immobilization technique presently. Nowhere do the protocols state that someone should be boarded based on mechanism, so I could do a neuro exam to "prove" that someone does not need a board.

Would doing such a thing constitute clearing c-spine, even though c-spine precautions were probably not indicated to begin with?

 

[DesertMedic66]

Out of curiosity, who does the ripping? I've definitely brought in patients with similar presentations and had nurses thank me for not boarding them. I hardly ever see a doc during handoffs but I imagine they would feel similar. Plus if a nurse makes noise about not spinaling someone I am happy to explain my reasoning. Usually an explanation is all it takes for cool heads to emerge. If you I can't justify my lack of treatment then maybe I have a problem, but that is not going to happen.

that would be the nurses at the recieving facility who in turn would contact my sup and my treatment choice. If I can explain why I had a good reason not to do something then they are fine with that. But I'm not going to try to talk my way out from not using C-spine when they have back pain. Defiantly not as a Basic.

 

[Handsome Robb]

Is it midline back pain or generalized back pain? There's a big difference. In all honesty a pt complaining of generalized back pain will more times than not be in more pain by the time you get to the ED if you put them on a board than if you left them alone and transported in a POC.

There's a huge difference between "back pain" and "midline back pain". You can discern the difference with a proper assessment.

 

[JPINFV]

I hate the term "clearing c-spine." Simply saying that there is no indication for immobilization is not clearing anything. Do you clear emergency transport and downgrade to non-emergent transport because of the vital signs?

What other intervention is considered to always be indicated unless certain conditions are met? Shouldn't all interventions be considered to not be necessary until history and physical findings indicates them to be necessary?

 

[Tigger]

I hate the term "clearing c-spine." Simply saying that there is no indication for immobilization is not clearing anything. Do you clear emergency transport and downgrade to non-emergent transport because of the vital signs?

What other intervention is considered to always be indicated unless certain conditions are met? Shouldn't all interventions be considered to not be necessary until history and physical findings indicates them to be necessary?

That's my line of thinking, but I can think of only one partner who agreed with me.

Everyone (generalized) else is of the opinion that every fall/MVC patient has a c-spine injury until proven otherwise. I think that's a reasonable line of thought until an assessment is done. That said, an assessment needs to dictate treatment, not an assumption. If you assume c-spine injury but your assessment reveals no compromise, the patient should not be spinaled. Yet I keep seeing patients with no signs or symptoms brought in on a board. Many cite fear of ER RNs where I work as well, but I don't think that theory is warranted. At least where I am, no RN is going to say anything for not providing a treatment that is not indicated.

Sorry to belabor the point, I guess I'm just having trouble trying to get my partners to look at things and think critically about what needs to be done instead of basing treatments off misguided and archaic assumptions.

 

[JPINFV]

I've never gotten the fear of random ED RNs to begin with. "Oh noes, the big bad nurse will yell at me." Fornicate that. If you can justify your treatment, justify it and move on. I've gone toe to toe with ED RNs more than once when I was an EMT, and if I can justify my treatment decisions, I'll do it every time. For example, I'm not going to call 911 for paramedics when I'm a minute away from the ED just because some RN got her panties in a bunch that she had to start an IV.

 

[usalsfyre]

So revealing some biases here but, let's face it, a long spine board is a pseudo-treatment, and as such can't have any REAL indications. As such, it gets used when that other voodoo that's taught to EMS (mechanism) suggest it.

 

[HMartinho]

Just to clarify a few things, in Portugal, the EMT's-B have little autonomy. If I go to the hospital with a patient who was beaten multiple times in the back, chest and belly, with back pain on palpation, without a full spine immobilization, probably the ER triage nurse and Attending physician, will "crushing me against the wall".

I who am EMT-B and I can not make diagnoses. We do not have paramedics (who can do a more thorough clinical evaluation, and make a diagnosis). We only have emergency critical care nurses and physicians, which in this case were not dispatched to the scene.

This does not mean I do not know how to do a neurological examination, as I did with my colleague, and as we found it, I decided to "play it safe", and make a full spine immobilization.

 

[Handsome Robb]

I'm not doubting you or your treatment. I'm still wondering what everyone is referring to as back pain? Generalized? Midline? Scapular? My point is "back pain" is a very generalized statement.

 

[JPINFV]

I who am EMT-B and I can not make diagnoses.

Do you perform a history and physical exam?

Do you use that history and physical exam to come to some sort of conclusion about what's going on?

Do you you that conclusion to help guide your treatment, even if it's simply to pick a protocol?

If you answered "yes" to the above questions, then you make a diagnosis, regardless of what you want to call it.

 

[BrushBunny91]

When in doubt? c-spine. unconscious? Unknown moi? c-spine.

 

[STXmedic]

When in doubt? c-spine. unconscious? Unknown moi? c-spine.

Sadly, I'm pretty sure this one IS serious

 

[adamjh3]

When in doubt? c-spine. unconscious? Unknown moi? c-spine.

Why?

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[BrushBunny91]

Why?

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Its been beaten into my head that When faced with a unconscious patient and unknown moi, you expect the worst and c-spine. It's better to be safe then sorry.
How would you handle that?

 

[JPINFV]

Depends on the physical exam.


Oh, noticing you're still a student, ask your instructor why, if you're trying to stabilize a fracture, you'd strap a curved group of bones to a flat board. Just something to think about.

 

[Handsome Robb]

Is there any signs of a traumatic MOI? Situational awareness is worth its weight in gold. Pinpoint pupils or other signs of OD ie empty pill containers, suicide note, history of suicide attempts? Kussmaul's Respirations? Medic alert tag indicating a medical condition such as Diabetes? There are a decent amount medical conditions that can cause unresponsiveness that have no need for c-spine unless the onset lead the patient to experience a traumatic event. Now if the pt is at the bottom of a set of stairs all scraped and bruised that's a different story.

Per NREMT, sadly you are correct, in the real world its not the case.