Immobilize or not?

[Mountain Res-Q]

he was definitely altered, and it was probable that he had a LOC. hmm. i appreciate all the answers to my thread but i'm only about a year experienced and I'm confused as to why you would not backboard him just to be safe?

thanks guys

Because it was not medically reasonable and has a high chance of causing more pain, suffering, injury, resources, and expense than you realize.

 

[NomadicMedic]

I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them. In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours. I still vote for no backboard.

 

[Tigger]

I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them. In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours. I still vote for no backboard.

Your brain = far more superior tool than backboard.

 

[epipusher]

I think you need to realize that not every altered patient needs to be backboarded. That's in the criteria simply because a patient with an altered mental status would not be able to give you a good answer as to the mechanism of injury. So in that case, you would be putting that person on a board simply because they couldn't relate what happened to them. In this case, there was no trauma and the patient didn't hit the floor with a thud. He's altered because he's tired. He has neck pain because he's been dancing for 20 hours. I still vote for no backboard.

How is the provider able to absolutely rule out that the patient is altered only due to being tired? As far as the thud, the provider is putting their full faith and trust in a witness that is essentially a bystander. Too many what if's.

 

[Veneficus]

How is the provider able to absolutely rule out that the patient is altered only due to being tired? As far as the thud, the provider is putting their full faith and trust in a witness that is essentially a bystander. Too many what if's.

There are no absolutes in clinical medicine.

You just have to use your judgement as to the reliability of the information you get.

I am also rather fond of physical exam findings that give credibility to the story.

Backboarding every patient because of "what if..." is just as stupid as giving every patient chemo because "what if..."

 

[HMartinho]

We just immobilize if the height of fall is greater than the height of the victim, or if the neurologic exam shows neurologic deficits, signs of TBI or spinal cord injury.

 

[epipusher]

wow.....just wow.

 

[AMF]

It's important to understand that there are rules for these kinds of things which of course vary from place. The "provider before patient" rhetoric they teach you in school for scene safety applies to treatments as well, and your protocols are (should be) designed to accomodate the practice of an entire career of individuals, not just the basic with one year of experience. If you don't feel comfortable using a rule-out protocol, don't use it. Nevertheless, backboards are absolutely not a benign treatment, and the sooner you become comfortable ruling out patients, the better.

 

[mycrofft]

Where are the retrospective studies linking height of fall to degree of likelihood and insult to C spine (or any spine, or skull)? Where are the studies of iatrogenic insult due to use of LSBoard? (Articles have been cited in EMTLIFE linking airway establishment delays to spineboarding, and studies show outcome of pts with spineboard left on in ED versus taken off upon entering ED, are about the same).

Not to be bad here, and I'm always the guy who tells the new person to follow protocols, but just because the adoption of the use of the spineboard and the creation of EMT's were on the same date and time, and medical controllers have always had some reasons to distrust EMT discretion in the field, there are reasons NOT to use spine boards so widely and arbitrarily.

 

[tnoye1337]

I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.

 

[Aidey]

I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.

What trauma?!

 

[tnoye1337]

What trauma?!

Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.

 

[DPM]

So if I whiteness the death of a family member do I need to be put into spinal restrictions? According to your definition Trauma is an entirely emotional condition... and it clearly doesn't apply here.

I feel like some common sense is needed. Was the mechanism enough that it could cause a spinal injury that would require a back board? I'd say no, but stick to your protocols.

 

[Mountain Res-Q]

I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.

Malpractice much?

Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.

Emotional trauma and physical trauma are two different things. And even when talking about physical trauma, the fact is that trauma does not equal backboarding.

I feel like some common sense is needed. Was the mechanism enough that it could cause a spinal injury that would require a back board? I'd say no, but stick to your protocols.

Cookbook Medicine: the biggest reason why EMS is viewed and treated as a trade and not a profession. Common sense first needs to be common, then it all makes sense. Case in point; the absolutism of this statement:

I would backboard him. Any sort of trauma that isn't clearly visible is a backboard and collar to me.

<_<

 

[tnoye1337]

Emotional trauma and physical trauma are two different things. And even when talking about physical trauma, the fact is that trauma does not equal backboarding.

You're totally swaying away from the topic. If someone is injured from dancing for forty hours, you have absolutely no clue as to what happened, wouldn't you rather be safe? What happens if he has an underlying injury and he had no neuro function to that area... A GCS of 11 is pretty damn low and to not backboard someone to cover your own *** is just stupid.

 

[Mountain Res-Q]

You're totally swaying away from the topic. If someone is injured from dancing for forty hours, you have absolutely no clue as to what happened, wouldn't you rather be safe? What happens if he has an underlying injury and he had no neuro function to that area... A GCS of 11 is pretty damn low and to not backboard someone to cover your own *** is just stupid.

Have you read any of the previous research? "Covering your ***"? I thought this was about the patients best interest. I treat patients based on the medicine of what I can do for them that will provide the most benefit, not what a protocol says to do because "all patients are the same" and "all we want you with your pathetic 120 hours or training to do is perform the same 'awesome life saving skill' that actually hurts more people than it helps". Things you are taught as fact at a BLS level (and sometimes at the ALS level) are often relics of 20, 30, plus years ago. While modern medicine and research advances, EMS protocol tends to lag behind. This is why pre-hospital EMS is a trade and not the profession it should be. Instead of EDUCATING people to think, analysis, and treat the patient, they can get away with a few hundred hours of TRAINING by teaching people HOW to do it, but not WHY or when. This goes to the "should EMS degrees be the standard" thread. And the answer is YES, this is why. I just had this situation where some uneducated "shiny new card" First Responders boarded a patient because (correct quote) "we have to, it is in the protocol". ALS shows up and is not happy. They made the choice in 5 seconds of history to board based on MOI. No educated assessment based on medicine? Now this case is my problem because the FR took patient care away from an EMT who didn't want to board but is not part of the county system and thought that he had to hand over care to officially sanctioned responders. The result of the dubious thinking is a lowering in the standard of care and unnecessary pain, suffering, expense, and resource usage in order to "cover your ***". There is a time and place for spinal restriction, but this situation IS NOT one of them. Every attempt MUST be taken to "think and assess you way out of water boarding, I mean back boarding, your patient."

 

[tnoye1337]

Have you read any of the previous research? "Covering your ***"? I thought this was about the patients best interest. I treat patients based on the medicine of what I can do for them that will provide the most benefit, not what a protocol says to do because "all patients are the same" and "all we want you with your pathetic 120 hours or training to do is perform the same 'awesome life saving skill' that actually hurts more people than it helps". Things you are taught as fact at a BLS level (and sometimes at the ALS level) are often relics of 20, 30, plus years ago. While modern medicine and research advances, EMS protocol tends to lag behind. This is why pre-hospital EMS is a trade and not the profession it should be. Instead of EDUCATING people to think, analysis, and treat the patient, they can get away with a few hundred hours of TRAINING by teaching people HOW to do it, but not WHY or when. This goes to the "should EMS degrees be the standard" thread. And the answer is YES, this is why. I just had this situation where some uneducated "shiny new card" First Responders boarded a patient because (correct quote) "we have to, it is in the protocol". ALS shows up and is not happy. They made the choice in 5 seconds of history to board based on MOI. No educated assessment based on medicine? Now this case is my problem because the FR took patient care away from an EMT who didn't want to board but is not part of the county system and thought that he had to hand over care to officially sanctioned responders. The result of the dubious thinking is a lowering in the standard of care and unnecessary pain, suffering, expense, and resource usage in order to "cover your ***". There is a time and place for spinal restriction, but this situation IS NOT one of them. Every attempt MUST be taken to "think and assess you way out of water boarding, I mean back boarding, your patient."

Okay, well I clearly don't have half the experience as you do, so you have to see my side. I'm going by what I was taught in my class. I'm still a virgin to this field just looking to pop my cherry.

 

[Aidey]

Well I went to Google for this one. Trauma defined by Google is, "Emotional shock following a stressful event or a physical injury, which may be associated with physical shock and sometimes leads to long-term neurosis" The mere fact that the patient had fallen or whatever was due to the physical strain of the dancing. By that definition, it's trauma.

The next time you trip and fall I hope someone calls 911 and they backboard you. After all, that is trauma isn't it?

*facepalm*

Go to pubmed.com and search for things like c-spine, backboard and c-collar and start reading. Don't stop until you understand why we are all telling you that you are wrong.

 

[tnoye1337]

Well, I guess I'm wrong, but in my defense I didn't read the part where they said it was CLEARLY muscle pain.

 

[mycrofft]

It's OK to be wrong. I'm a walking example.*

Revisit the event.

On feet 45 hrs, no mech of injury, I assume normal vital signs (???...), LOC on feet and fell to floor. No obvious external s/s. When regains consciousness after lying supine, then c/o neck pain. Another possible cause: did the pt just finish a long, long delayed toilet break?

1. What were vital signs? Most likely causes of LOC in this event would be: what? (I'm thinking dehydration, orthostatic hypotension, hypoglycemia, sheer fatigue, or fell asleep...pun unintended). Vital signs would hopefully reveal if there was a cardiac component. Get pt hx.

2. How bad is neck pain? Is it self-relieved by repositioning? (Holding that 6 lb melon we call a head up on that pencil we call a neck for 45 hrs alone could be the cause).

3. If I had the pt calm and on the litter, I might sandbag the head and be careful in movement, but otherwise don't additionally move the pt unless there are other signs; drive carefully, and don't wake him up.


(*Ask Mom)