Obtaining consent for C-spine

[Brandon O]

Hi all,

I wanted to put an idea out for discussion and comments -- good, bad, or otherwise.

Does anybody currently try to obtain informed consent from conscious and capable patients prior to C-spine immobilization? I know that in most cases, we're not huge on explicitly consenting in EMS -- usually defaulting to the "do stuff until they say stop" approach most of us discovered in the backseat sometime around high school -- and maybe there's a reason for that. Obviously in acute emergencies there's often no time for anything more elaborate.

But for the stable patient after a fall or MVA, with minor symptoms, who we're considering giving the ol' board-and-collar (due to explicit protocol requirements, butt-covering, or a genuine perception of possible need), why not let the patient decide? This doesn't mean: "Hey, want us to tie you up?" It means a sincere attempt to illustrate the relative risks, benefits, and alternatives. Something like:

"So you have two options here. One is that you step out of the car, sit on our stretcher, and we bring you over to the hospital. The other is that we'll put a collar around your neck, lift you onto a hard board, secure you with some straps and tape, and you'll go to the ER that way. Either way they may end up taking some x-rays or other images to make sure there's no fractures or other injury to your neck or back, but if there is, the collar and board might help prevent that injury from getting worse. What's the chance of that? Probably in the ballpark of 1% (adjust if you'd like for risk factors or meeting a decision rule) that you have some injury, something like half that for an injury that might matter. In how many of those injuries will the collar and board make a difference? We're not sure; maybe none, but it's usually considered the safest approach. The downsides are it's uncomfortable, it can make it harder to breathe, you may be there for a while, and they're probably more likely to give you scans that can result in more radiation exposure and some other risks. What do you want to do?"

Or something vaguely like that.

Is this feasible? Is it ethical? Are there practical objections? Do you already do this? What do you think?

 

[Aidey]

I think it is ethical. We are discussing a treatment that has been shown to do more harm than good. Is it practical? Depends on the system. In my system if I gave a patient that speech it would result in medics arguing with me on scene and complaints to my clinical department.

 

[RocketMedic]

Hi all,

I wanted to put an idea out for discussion and comments -- good, bad, or otherwise.

Does anybody currently try to obtain informed consent from conscious and capable patients prior to C-spine immobilization? I know that in most cases, we're not huge on explicitly consenting in EMS -- usually defaulting to the "do stuff until they say stop" approach most of us discovered in the backseat sometime around high school -- and maybe there's a reason for that. Obviously in acute emergencies there's often no time for anything more elaborate.

But for the stable patient after a fall or MVA, with minor symptoms, who we're considering giving the ol' board-and-collar (due to explicit protocol requirements, butt-covering, or a genuine perception of possible need), why not let the patient decide? This doesn't mean: "Hey, want us to tie you up?" It means a sincere attempt to illustrate the relative risks, benefits, and alternatives. Something like:

"So you have two options here. One is that you step out of the car, sit on our stretcher, and we bring you over to the hospital. The other is that we'll put a collar around your neck, lift you onto a hard board, secure you with some straps and tape, and you'll go to the ER that way. Either way they may end up taking some x-rays or other images to make sure there's no fractures or other injury to your neck or back, but if there is, the collar and board might help prevent that injury from getting worse. What's the chance of that? Probably in the ballpark of 1% (adjust if you'd like for risk factors or meeting a decision rule) that you have some injury, something like half that for an injury that might matter. In how many of those injuries will the collar and board make a difference? We're not sure; maybe none, but it's usually considered the safest approach. The downsides are it's uncomfortable, it can make it harder to breathe, you may be there for a while, and they're probably more likely to give you scans that can result in more radiation exposure and some other risks. What do you want to do?"

Or something vaguely like that.

Is this feasible? Is it ethical? Are there practical objections? Do you already do this? What do you think?

I do this every time I run into this exact situation. Generally happens with falls (Fire boards most people before we arrive at MVAs). If they're alert and oriented, I essentially repeat what you said, Brandon, and offer them the scoop as an alternative.

Yes, it got me looked at already by QI, but I have them sign that they refuse the board and collar and note it in the ePCR.

The scoop stretcher is a reasonable tool and I use mine a lot more than most EMSA medics. The backboard is essentially useless for anything other than extrication.

 

[mcdonl]

Your state doesnt have a spinal protocol? Or are you saying they fail the rule out but you still dont think they need it?

Rule outs are pretty easy... they either pass or fail. And, if they refuse AMA's are pretty cut and dry too... at least in our protocols.

 

[medicdan]

I do this, albeit with a slightly different speech... In general, we suck at informed consent in EMS, and I've made it a goal to improve this in my patient interactions. I didn't realize this, but one of the companies i work for has a explicit place for patients to sign indicating consent to treatment... I've also been talking about it a lot when I teach...

 

[NomadicMedic]

Brandon, I think if you actually give the speech as you wrote it, you're setting yourself up.

"So here's the thing. You can either have ice cream and cake which is really pretty good. I'll give you a ride over there my minivan and after the cake and ice cream we can go swimming over at my house. Or I can put you in a cardboard box, sealed up with masking tape, throw a bunch of ping-pong balls and then take you over to my house and feed you roasted beets and brussels sprouts. They say that brussels sprouts are a lot more healthy than cake, but they taste like crap and you're probably not gonna like them. So, which one will it be?"

I think if you explain it without the negative bias, you'd be much more apt to be able to withstand any legal or QI issues that may arise out of your C-spine deferral.

 

[Aidey]

Where is the line between negative bias and blunt truth? Except for the 1% thing, nothing he said was conjecture.

I really, really wish I could get away with a speech like that. I actually do try and inform my patients of what I am doing, but even hinting that c-spine isn't necessary results in too much negative backlash already.

 

[Christopher]

Brandon, I think if you actually give the speech as you wrote it, you're setting yourself up.

"So here's the thing. You can either have ice cream and cake which is really pretty good. I'll give you a ride over there my minivan and after the cake and ice cream we can go swimming over at my house. Or I can put you in a cardboard box, sealed up with masking tape, throw a bunch of ping-pong balls and then take you over to my house and feed you roasted beets and brussels sprouts. They say that brussels sprouts are a lot more healthy than cake, but they taste like crap and you're probably not gonna like them. So, which one will it be?"

I think if you explain it without the negative bias, you'd be much more apt to be able to withstand any legal or QI issues that may arise out of your C-spine deferral.

I had a doctor refuse spinal precautions after an MVC that the fire first responders were a bit miffed about. So I did my evidentiary review spiel for the fire guys as to why it is A-Ok that somebody would refuse this, and the MD wrote on our lil refusal form under reasons I am refusing care: "Not supported by Cochrane" (if I recall he didn't spell it right, but he apparently was listening when I gave my speech).

 

[JPINFV]

"Not supported by Cochrane" (if I recall he didn't spell it right, but he apparently was listening when I gave my speech).

I bet the fire guys were wondering what OJ's lawyer had to do with this.

 

[Christopher]

I bet the fire guys were wondering what OJ's lawyer had to do with this.

If the board or collar does not fit...you must continue to strap them down to it.

 

[hogdweeb]

Honestly, the fire department and ambulance squad I run with dont really "Consent". we tell the patient "we are going to do this, dont move. any movement needed will be done by us. Its for your safety and well being. Have we gotten the "no"? of course. but we keep trying, explaining that we do not know the extent of their spinal injuries and have to do this until the Doctors remove it. still no, we dont, but we document. Same goes for anything needing immobilization.

 

[RocketMedic]

Honestly, the fire department and ambulance squad I run with dont really "Consent". we tell the patient "we are going to do this, dont move. any movement needed will be done by us. Its for your safety and well being. Have we gotten the "no"? of course. but we keep trying, explaining that we do not know the extent of their spinal injuries and have to do this until the Doctors remove it. still no, we dont, but we document. Same goes for anything needing immobilization.

Thats a horrible policy that begs for a lawsuit.

 

[Summit]

Great thread and great points Oto

Thats a horrible policy that begs for a lawsuit.

Indeed

 

[JPINFV]

The consent issues in this thread is why I prefer to refer to EMS consent as "tacit consent" instead of "informed consent"

 

[medicdan]

The consent issues in this thread is why I prefer to refer to EMS consent as "tacit consent" instead of "informed consent"

Semantics, but sure. Informed consent IS rare, even in hospital, or among physicians.

 

[JPINFV]

Semantics, but sure. Informed consent IS rare, even in hospital, or among physicians.

It depends... for medicine outside of procedures (lumbar taps, central lines, etc)? I'll agree to an extent. For surgery and anesthesiology? Every procedure, every time.

 

[Christopher]

It depends... for medicine outside of procedures (lumbar taps, central lines, etc)? I'll agree to an extent. For surgery and anesthesiology? Every procedure, every time.

I think you can break it down by the "type" of the procedure: emergent, urgent, routine, and elective.

Emergent / urgent has some sense of "implied consent" either by a 911 call or the patient's acceptance of help during your initial assessment. Some attempt should be made to obtain consent for urgent procedures, but often in the form of, "I'm going to do X," and wait for them to say "No".

Routine would be something like obtaining a blood pressure / ECG, which unless they expressly say no, it is considered so mundane that you assume it is Ok. I think these do not even fall under a class of consent, because there is often no tangible risk to their application. This does not mean the patient could not refuse them.

Elective would be your procedures which are reasonable to spend the time explaining their indications, contraindications, risks and benefits. I find in EMS this is usually things like pain control, antiemetic administration, IV starts to make the receiving facility happy, etc. Whether or not these actually get Expressed Consent or not is another thing entirely.

Application of a C-collar and long spine board for spinal motion restriction would fall under the Elective procedures. Given this process does not actually treat any sort of acute condition, they can be considered Emergent or Urgent. Utilization of a backboard to move somebody would fall under Routine.

I think this approach is logical and allows patients to make informed decisions about their care when appropriate and applicable.

 

[Summit]

Semantics, but sure. Informed consent IS rare, even in hospital, or among physicians.

What makes you say this? Sometimes it doesn't happen... sometimes it always happens.

 

[JPINFV]

Emergent / urgent has some sense of "implied consent" either by a 911 call or the patient's acceptance of help during your initial assessment. Some attempt should be made to obtain consent for urgent procedures, but often in the form of, "I'm going to do X," and wait for them to say "No".

...and I've seen consent being done to a patient being rushed for an emergency exploratory laparotomy following a trauma. Would it be reasonable to gain consent prior to doing something like RSI?

Routine would be something like obtaining a blood pressure / ECG, which unless they expressly say no, it is considered so mundane that you assume it is Ok. I think these do not even fall under a class of consent, because there is often no tangible risk to their application. This does not mean the patient could not refuse them.

Agreed... and the really minor procedures like that are generally covered by the admission agreement for hospitals.

Elective would be your procedures which are reasonable to spend the time explaining their indications, contraindications, risks and benefits. I find in EMS this is usually things like pain control, antiemetic administration, IV starts to make the receiving facility happy, etc. Whether or not these actually get Expressed Consent or not is another thing entirely.

Agree.

Application of a C-collar and long spine board for spinal motion restriction would fall under the Elective procedures. Given this process does not actually treat any sort of acute condition, they can be considered Emergent or Urgent. Utilization of a backboard to move somebody would fall under Routine.

I don't think using a backboard for the limited need and duration of a move should require consent... just like using a slide board, breakaway, or scoop for the same purpose wouldn't need a consent.

I think this approach is logical and allows patients to make informed decisions about their care when appropriate and applicable.

The legal and ethical argument (i.e. avoiding paternalism) would be that consent should be obtained as often as possible.

 

[Christopher]

...and I've seen consent being done to a patient being rushed for an emergency exploratory laparotomy following a trauma. Would it be reasonable to gain consent prior to doing something like RSI?

Depends on their mental status prior to RSI. I've yet to perform a truly elective RSI, and yet to do one on a patient who could be deemed competent. I could imagine a scenario with a burn patient, and yes we should get consent.

I don't think using a backboard for the limited need and duration of a move should require consent... just like using a slide board, breakaway, or scoop for the same purpose wouldn't need a consent.

Yeah I tried to say that at the end of my paragraph, but I didn't get it out there that well.

The legal and ethical argument (i.e. avoiding paternalism) would be that consent should be obtained as often as possible.

As a whole we could do a better job with consent in EMS ("we" very much includes me). It'd be interesting to see Expressed Consent (or Informed Consent) being a part of the NR psychomotor evaluation (please ignore that giant can of worms I just opened).