Position found in indicated head trauma. We'll move past the moi.
While I've been told by medical directors past that if I bring in an intoxicated patient with altered LOC and photogenic head trauma, and there's a c-spine issue, they'll hang me out to dry -- I'm not sure that the location the patient is found in gives us the MOI here.
Did anyone reliable witness the traumatic event? Did he just roll out of bed (if so / no c-spine needed), or did he get beat up by four guys in a parking lot after doing a bunch of coke, crawl home and pass out on the floor? Are we able to distinguish these two events based on the information present?
Because if he's just rolled out of bed, the c-spine isn't indicated. But if you're planning on doing a 1,000 calls / year for the next 20-30 years, you want to be pretty sure when you're making decisions that you're going to be held accountable for.
Spinal exam is unobtainable due the pt's mental status.
Well, strictly speaking, the physical examination is still present, it's just limited by the ability of the patient to describe their neurological function. Likewise the history is compromised by the patients LOC, but might be provided by bystanders.
It seems like this is going around in circles. Here's some quick opinions:
* Clinical practice guidelines may vary by location, by country, county / state / province, and even by city, or ambulance service.
* The overwhelming majority of patients receiving c-spine precautions in North America do not have unstable c-spine fractures, nor are they at risk for unstable c-spine fractures.
* C-spine precautions are routinely overapplied in situations where they're not clinical indicated with detriment to the patients involved.
* While NEXUS and Canadian C-spine Rule attempt to provide evidence-based criteria for rule out in conscious, sober, alert, adults with minor mechanisms, there are no evidence based guidlines for situations like the one you describe.
* This is a grey area. Protocols are written on the assumption that the world is black-and-white. It's not. This is why the provider should be sufficiently educated and experienced to apply them as guidelines.
* A lot of systems and a lot of medical directors would rather just avoid the ethical and legal consequences of someone poorly trained, or having a bad day, applying judgment inappropriately, so they accept a small degree of harm to a large number of patients to avoid a large degree of harm to a small number of patients. This in itself should define why this situation is a grey area.