MVC Spinal, Yay or Nay.

[bungus]

Call the other day 6 pt MCI, just one guy was my patient. 35 y/o male in MVC, his vehicle, one of those old vans that you expect to see shag carpeting in, was moving at 50km/hr, wearing seatbelt, sitting in the rear seat. They t-boned a mid size SUV going unknown speed on a icy oilfield road. No ejection, no rollover, some pain in his left wrist and left lower leg. No obvious trauma or deformity, no deficits throughout, no numbness/tingling in extremities, pt able to rotate his head with no resistance or pain, no c-spine tenderness or pain on palp, CMSx4 = and strong. All vitals in the acceptable range for his age. No altered LOC, no ETOH, A&Ox4/4, PERL, GCS15. 2 small 1cmx1cm abrasions on the front of his head.

My question is - would you have put this pt on a spineboard?

 

[Shishkabob]

Sounds like you cleared his spine already... so why would you?


I had a 3 patient mvc the other day... I cleared each of their spines, asked if they wanted to be backboarded and each said no. I documented as such and went on with my job.

 

[M3dicDO]

....moving at 50km/hr.....some pain in his left wrist and left lower leg....2 small 1cmx1cm abrasions on the front of his head.

My question is - would you have put this pt on a spineboard?

Great neurological assessment bungus. You bring up a good case because I've seen EMTs and Medics put patients in any form of an accident on a spineboard. I personally think that spinal immobilization is over-used quite a bit. I quoted some of the things you said that would indicate any form of immobilization. The speed is 50km/hr (~30 mph) which isn't too fast rate of speed. Based on the guidelines of the trauma system you operate in, does this speed automatically indicate spinal immobilization? I say this because one of the EMS systems around here requires a spineboard on all collisions over 40 mph (i.e. mechanism of injury). Do your guidelines say anything about speed of impact?

How bad was the pain in left wrist and lower leg? If it's just an ache, then it helps you lower your suspicion of spinal injuries.

The abrasions on the head are probably the most significant of your findings, merely based on the location of injury. Since you pointed out that he had no neck pathology and full ROM, I would would probably not place the patient in a cervical collar. What about the head? Did you palpate the head to assess for pain? Perhaps a fracture? Patients may initially not complain of pain (due to endorphin release) despite significant injury.

The only other two assessments I would perform to further clear spinal immobilization would be a cranial nerve assessment II - XII, and cerebellar testing (e.g. walking gait, finger-to-nose, heel-to-shin). These tests may be seen as being a bit too extensive for a pre-hospital setting, but documenting negative findings on these tests will help reduce your liability.

I summary, based on the information you provided, I would not place the patient on a spinal back board.

 

[usalsfyre]

Call the other day 6 pt MCI, just one guy was my patient. 35 y/o male in MVC, his vehicle, one of those old vans that you expect to see shag carpeting in, was moving at 50km/hr, wearing seatbelt, sitting in the rear seat. They t-boned a mid size SUV going unknown speed on a icy oilfield road. No ejection, no rollover, some pain in his left wrist and left lower leg. No obvious trauma or deformity, no deficits throughout, no numbness/tingling in extremities, pt able to rotate his head with no resistance or pain, no c-spine tenderness or pain on palp, CMSx4 = and strong. All vitals in the acceptable range for his age. No altered LOC, no ETOH, A&Ox4/4, PERL, GCS15. 2 small 1cmx1cm abrasions on the front of his head.

My question is - would you have put this pt on a spineboard?

Nope, but my protocols allow me not to. If yours don't send your medical director a copy of NEXUS.

 

[M3dicDO]

send your medical director a copy of NEXUS.

What's "NEXUS"?

 

[bungus]

Great neurological assessment bungus. You bring up a good case because I've seen EMTs and Medics put patients in any form of an accident on a spineboard. I personally think that spinal immobilization is over-used quite a bit. I quoted some of the things you said that would indicate any form of immobilization. The speed is 50km/hr (~30 mph) which isn't too fast rate of speed. Based on the guidelines of the trauma system you operate in, does this speed automatically indicate spinal immobilization? I say this because one of the EMS systems around here requires a spineboard on all collisions over 40 mph (i.e. mechanism of injury). Do your guidelines anything about speed of impact?

How bad was the pain in left wrist and lower leg? If it's just an ache, then it helps you lower your suspicion of spinal injuries.

The abrasions on the head are probably the most significant of your findings, merely based on the location of injury. Since you pointed out that he had no neck pathology and full ROM, I would would probably not place the patient in a cervical collar. What about the head? Did you palpate the head to assess for pain? Perhaps a fracture? Patients may initially not complain of pain (due to endorphin release) despite significant injury.

The only other two assessments I would perform to help clear spinal immobilization would be a cranial nerve assessment II - XII, and cerebellar testing (e.g. walking gait, finger-to-nose, heel-to-shin).

I summary, based on the information you provided, I would not place the patient on a spinal back board.

Well, our high risk factors here in Alberta for spinal immobilization include rollover, ejection, 100km/hr+, 65y/o+, paresthesia in extremities, ATV/bicycle trauma. So I ended up ruling out a high risk MOI.

Palpated the entire head, just a bit tender around the abrasions, no signs of any fractures on palp.

Pain in the left extremities was caused by the MVC, ache in the wrist, a bit worse in the lower ext. Just banged up.

In the end the patient was discharged from emerg and sent home about 60 minutes after transfer of care.

 

[JPINFV]

What's "NEXUS"?

It's the criteria based on the National Emergency X-ray Utilization Study.

Here's a study comparing NEXUS criteria with the Canadian C-Spine rule (the other big rule in/rule out criteria).

http://www.sciencedirect.com/scienc...394838d2afce9b8e136b9775a006ed4b&searchtype=a

 

[bungus]

I did choose to not spinal this patient based on the said above findings, however, a complaint was filed against me by a firefighter that was on scene at the time for not placing this patient on a spineboard. Firefighter had no patient contact nor did he do an assessment of his own. He is medically trained to the EMR level here, I think that equivalent EMT-B in the states.

My supervisor spoke to me today about it and said this will stay on my "file" for when the big lawsuit comes and to make sure to spinal everyone in situations like this to cover your ***.

Irritation and stress brought on this thread lol.

 

[Shishkabob]

And 'tis why I ask patients when I plan to clear them from it. If from my assessment they don't require it, and I ask the patient if they want to be backboarded and they state no, that's the end of it.

Full patient treatment consent.

 

[M3dicDO]

I did choose to not spinal this patient based on the said above findings, however, a complaint was filed against me by a firefighter that was on scene at the time for not placing this patient on a spineboard. Firefighter had no patient contact nor did he do an assessment of his own. He is medically trained to the EMR level here, I think that equivalent EMT-B in the states.

My supervisor spoke to me today about it and said this will stay on my "file" for when the big lawsuit comes and to make sure to spinal everyone in situations like this to cover your ***.

Irritation and stress brought on this thread lol.

Welcome to the medical practice in the 21st century. I see practitioners do more to "cover their ***" than anything else. It's sad, very sad. No wonder the costs of health care keeps rising.

I hope nothing more comes of this incident. It's tough having something stupid like this go into your "file." Let me share with you something I have learned from my experiences in EMS. The only person that will look out for you is you! Never depend on your colleagues or supervisors to help you out if something goes wrong. They won't jeopardize their medical licenses to cover your butt. Stay safe out there....

 

[Veneficus]

I did choose to not spinal this patient based on the said above findings, however, a complaint was filed against me by a firefighter that was on scene at the time for not placing this patient on a spineboard. Firefighter had no patient contact nor did he do an assessment of his own. He is medically trained to the EMR level here, I think that equivalent EMT-B in the states.

My supervisor spoke to me today about it and said this will stay on my "file" for when the big lawsuit comes and to make sure to spinal everyone in situations like this to cover your ***.

Irritation and stress brought on this thread lol.

Part of the problem with basic level providers is that they are taught as absolutes.

A doctor I respect very highly shakes her head and says "the poor creatures, they don't know any better."

 

[MrBrown]

A doctor I respect very highly shakes her head and says "the poor creatures, they don't know any better."

Thats right, Mrs Brown did not know any better

Nah Brown would not put this dude on a spine board

Welcome to our Canadian friend

*Brown hands bungus a Tim's

 

[tao]

I would not have c-spined this patient. I know of many EMTs who would just to cover their rumps, though.