Rep Giffords was shot in the head, and seeing this picture I ask: Why the C-collar?

[frdude1000]

If you were the aid that first treated her, with no equipment, what would you have done? Would you have lifted her head like he did?

 

[Veneficus]

I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute. I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.

If I could speak on a situation of potential spinal damage that was clearly not the case in this incident??

You arrive on scene of a mass shooting, there are wounded and blood in large quantity.

The triage officer sets you upon a patient deemed "red" for immediate transport.

You move over to the patient who is vocered in blood, witnesses tell you she was shot in the head.

With a patient whose head and in all likelyhood upper torso is covered in blood, how do you decide the only wound is to the head?

Do you take the word of the bystander?

Would your treatment change if there was also a wound to the thorax?

Multiple wounds to the face and neck which could further complicate your treatment of airway and bleeding control?

How do you clear away enough dried or still wet blood to properly assess?

Do you decide the wound looks grevious and forgo a more detailed assessment?

Once boarded and collared, in the back of the moving rig, how to you perform a significant enough exam on the posterior?

From your posts, I would be quite sure you have experience with penetrating wounds. From either a knife or a gun, it is sometimes very difficult to detect or identify small surface wounds caused by them I no doubt think you have experienced. Especially with any quantity of blood.

I don't think that the extent of the injuries cold be assessed even enough for life saving treatment in the back of an ambulance, on an already boarded patient. Privacy or not. (Which is not a concern of mine in a life threatening injury)

As for bullet splinters, it is entirely possible such an event could take place. But the fragments cannot damage a structure without damaging everything in it's path. In the case of a head wound from the posterior, the cerebellum, and entire brain stem would be subject to damage. It the wound was truly a through and through,the midbrain would be destroyed as well.

Similarly if the projectile entered through the front, the damage would be in reverse order and to enter the spine in addition to the many other critical structures the projectile or even fragment would likely cause massive damage to the basilar artery.

I don't think it would be likely to have such an injury without obviously apparent findings.

I agree with you that finding all injuries is not important, but finding the lifethreatening ones or ones that would define your treatment certainly would be important, which cannot be done with accuracy or precision on a immobilized patient, in the back of an ambulance.

It would be quite tragic for a responder to be distracted by a spectacular wound to the head, and miss the potential wound to the neck or upper thorax which led to among other complications too numerous to list, things like an open pneumo, carotid dissection, expanding hematoma that comprimises the airway or cerebral circulation, etc, etc.

What's more, how do you reassess over time the neck region or signs like JVD, flattening veins, early tracheal deviation, etc? Those are findings that may develop over time and not be readily apparent on scene.

As I often say and only partially in jest, you might find yourself with a perfectly protected spine on a dead person.

Do you think the risk of missing a managable life threatening wound is lesser than the possibility of an occult spinal injury? (given the index of suspicion of the structures most likely involved for such a spinal injury to exist?)

I wouldn't call it wrong to immobilize this type of patient, I just don't think it would help.

If I had to choose between taking time to immobilize or doing a more complete exam, I would choose exam. But that is the decision of the individual provider.

 

[Veneficus]

If you were the aid that first treated her, with no equipment, what would you have done? Would you have lifted her head like he did?

Absolutely, it sounds as if it was done to protect the airway.

 

[Probi]

im honestly so newb. But..
Fall = Collar. Even if fall is from a GSW

AND

Who knows how Fox News would have anally penetrated them if they did not look like they were being as professional as possible. Collar looks pro to the average person, no collar... kinda sounds like a law suit :S but im so newb so who knows.

 

[abckidsmom]

As I often say and only partially in jest, you might find yourself with a perfectly protected spine on a dead person.

Do you think the risk of missing a managable life threatening wound is lesser than the possibility of an occult spinal injury? (given the index of suspicion of the structures most likely involved for such a spinal injury to exist?)

I wouldn't call it wrong to immobilize this type of patient, I just don't think it would help.

If I had to choose between taking time to immobilize or doing a more complete exam, I would choose exam. But that is the decision of the individual provider.

How long does it take you to do an exam? I really am able to put a high priority on examining while immobilizing. I completely agree in this case that a single shot to the head with a mentating patient looks pretty unlikely for a c-spine injury, but I bet that board was pretty convenient from the er bed to the ct scanner to the or table.

I groaned when I saw it happen, but there were times when patients were still on backboards when they arrived in our trauma ICU after stops here and there on the radiology floor of the hospital up to 6 hours. If they were actually sick, sometimes they just weren't stable enough for the turns, and it completely made it easier to move them from place to place.

Hmmm...new marketing gimmick: Backboards- pallets for people.

Just watch the pressure ulcers start forming now.

 

[Aidey]

Fall = Collar. Even if fall is from a GSW

Why?

 

[JPINFV]

I didn't realize that the most important thing about providing good medical care was to make it look like you were doing something.

I didn't realize that Fox News, or any other MSM derermined how we were to practice medicine.

Have you ever fell down? Did you remember to take c-spine precautions when you did?

 

[JPINFV]

how did you rule out a spinal injury?
how do you know that the bullet didn't fragment into her spine? or that it was the only gunshot?
how did you know she did not incure a spinal injury falling to the ground?

I still don't get why anyone has anything buy a low index of suspicion for a spinal injury.

I still have not seen a valid argument where you arrive on the scene of mass gunshooting, you assume a spinal injury and backboard them. This can always be downgraded as you fiurther assess enroute. I don't know who is staying on scene long enough to find all injuries occurred by each patient when this could be done enroute in t e privacy of the ambulance enroute to a trauma center.

You take spinal precautions because you have a high index of suspicion that a spinal injury occurred. As such, why would you remove the precautions in side an ambulance bumping down the road?

 

[Veneficus]

How long does it take you to do an exam?

Depends on what I am examining for, but I am pretty quick and very detailed when it comes to trauma. But it requires things like total exposure and more than the cursory pat down I often see.

but I bet that board was pretty convenient from the er bed to the ct scanner to the or table.?

I don't see any problem with this at all, but if a provider does not suspect a cspine inujry, and is going to se the LSB for ease of pt. transfer, what is the point securing the head? It forces the constant control and reassessment of the airway, since the pt cannot move to protect it.

Backboard, slideboard, whatever yo need to move a pt. But if that is the motive, call a spade a spade, and don't try to hide it with some wild "suspicion" of a spinal injury.

I groaned when I saw it happen, but there were times when patients were still on backboards when they arrived in our trauma ICU after stops here and there on the radiology floor of the hospital up to 6 hours. If they were actually sick, sometimes they just weren't stable enough for the turns, and it completely made it easier to move them from place to place.

I once worked for an EMS service that had custom slideboards that fit on the middle 1/3 of the stretcher under the sheet and above the matress, a bit more forgiving than a spineboard, and really made moving easier. I thought it was brilliant.

 

[Probi]

well because in a chaotic situation like that theres no way to tell what happened to your patient on the way down, or since she was alert but not verbal, theres no way to quickly and effeciently check for nero defecits... so why not play it safe for both parties and just collar? I mean im a newb though so Im more looking for enlightenment not to challenge an epic pool of knowledge

And I have fallen before, But never from a GSW to the skull Have you?
and Fox news seems to do what they want for ratings, not for the moralistic presentation of information to the masses. But this Fox news tid bit is TOTALLY irrelevant to the post, and i apologise for that

 

[Smash]

I'm confused. Not that that is anything new. I could have sworn that the Launoix and Kaups studies were posted way back on page 2.

So we have some pretty compelling evidence that c-spine injuries do not occur from gunshot wounds to the head (unless, as has been pointed out, ad nauseam) the bullet transects the spinal column, in which case it's lights out anyway.

Would anybody in the "Yay Spineboard!" camp like to put forward some evidence that a c-collar and spine board are anything other than detrimental in this subset of patients? (hell, in any subset of patients for that matter)

 

[CAOX3]

It isn't about if we believe that the action its fruitless, its about who you answer too. Trust me I understand we backboard way to many people yada, yada, yada I can't make it any more simple then that. Its about whet the medical control physician expects of us. We don't get to change the rules because a study its published there are channels, it takes time it doesn't happen over night.

My point is implying a provider forgo immobilization in this scenario is dangerous, maybe it isn't an exit would, maybe she has multiple lacerations from the fall. I don't have sixty minutes, I'm not in a controlled environment where I can study every opening this woman has.

I pull the bull :censored::censored::censored::censored: card on the majority who say they wouldn't immobilize this patient, its easy to practice google medicine but when it comes down to it and your in that situation I'm guessing most providers here are going to immobilize them and monday morning quarterback later.

 

[usalsfyre]

It isn't about if we believe that the action its fruitless, its about who you answer too. Trust me I understand we backboard way to many people yada, yada, yada I can't make it any more simple then that. Its about whet the medical control physician expects of us. We don't get to change the rules because a study its published there are channels, it takes time it doesn't happen over night.

My point is implying a provider forgo immobilization in this scenario is dangerous, maybe it isn't an exit would, maybe she has multiple lacerations from the fall. I don't have sixty minutes, I'm not in a controlled environment where I can study every opening this woman has.

I pull the bull :censored::censored::censored::censored: card on the majority who say they wouldn't immobilize this patient, its easy to practice google medicine but when it comes down to it and your in that situation I'm guessing most providers here are going to immobilize them and monday morning quarterback later.

You can call BS on me all you want. My last GSW to the head didn't get a board or collar, so yes I put my money where my mouth is.

If you disagree with the current protocol, why not work on getting it changed? There's a crapload of evidence on this thread alone to help you with that goal. Or have you bothered to present this evidence to medical director? NEXUS is over 10 years old now, Maine has been using it with out ill effects for the same amount of time. Maybe the impetus is on the providers to affect the change, not the medical director who's shown he's not going to change without a push.

 

[SunnyEMT]

In no way qualified to contribute to the discussion from experience or training (I start EMT-B next week ) but there's a very strong likelihood that the school I'm attending trained some of the EMTs on scene. When an appropriate time presents itself, I'll put it to them and pass on the response.

On a side note, it was reported in local news that she and her Director, Ron Barber (who was the second person shot and standing right next to her) were both found slumped against the glass window of the store. Wouldn't this indicate that they had been thrown backwards from the force of the shot/s and therefore possible they sustained some kind of injury that would make a c-collar/ board advisable? Again, a totally ignorant question! lol

And if at all relevant, she was transported by chopper.

 

[DrewCox]

In years of experience with gsw's that involves the head....as stated, you never know the genuine path of the bullet until xray. I may see an entrance wound and an exit, but it may not be the direct path of the bullet. Many times partial fragments from the round can be found near or in the spinal cord, vertabrae, or elsewhere. Secondary use of the c-collar could simply be they are limited by basic protocol by the OMD to c-collar any and all gsw's to the head. In addition the c-collar is a great tool to have in place for an airway issue. It has become the standard to c-collar pts for traumatic intubation. Stay safe

 

[usafmedic45]

as stated, you never know the genuine path of the bullet until xray

Even then, plain radiographs are a miserable way of determining that.

It has become the standard to c-collar pts for traumatic intubation.

Honestly, I know a lot of people who c-collar anyone intubation in the field to minimize tube movement.

 

[spike91]

In this case as long as there was no airway issues created or exacerbated by the collar, I'd sure as hell do it. Like it has been said several times, its not what you see. Its what you do NOT see. Its a trauma involving the head, most likely an unconscious patient or an AMS patient (fair guess considering the hole in her head). Also, given the violent nature of the injury, how do you know the perp didn't kick her a** a bit before he put the bullet through her head? Its called spinal immobilization precautions for a reason.

 

[Aidey]

Putting someone in a c-collar and on a back board is not a benign procedure. What many of us are talking about is proving an intervention is necessary before it is done, and whether or not that intervention is even useful in this case.

 

[Fish]

First their is the unknown path of the bullet. Than and immediate jerking and fall to the ground. Why would you not put a c collar on?

The person pictured is bleeding from her head. board and collar seems automatic.

Agreed, all this picture tells me is GSW to the head(without knowing where the bullet ended up). Automatically gets board and collar, there is no board and no collar in c-spine precautions with GSW it is all or nothing.

 

[firecoins]

Putting someone in a c-collar and on a back board is not a benign procedure. What many of us are talking about is proving an intervention is necessary before it is done, and whether or not that intervention is even useful in this case.

The c-collar does prevent movement of the neck which is what I am trying to do. The backboard keeping things still is another question but it does make moving the patient easier. I am not an expert at determining bullet trajectory or bullet fragmentation and I do not have x-ray vision. Patients shot in the head usually fall on top of being shot, have AMS and may or may not have neurological deficits. Maintaining C-Spine precautions does indeed cover my ash in case some ambulance chasing attorney wants to sue if the patient had incurred any c-spine damage.

With any major trauma, I am doing a rapid assessment on scene and a full one enroute to a trauma center. I put but them on the board and collar on scene based on a rapid assment and MOI. It remains on until we get to the hospital, even if my full assessment indicates it may not be necessary. If the trauma team doesn't like the board and collar, they can remove it. On every major trauma I have had, the MDs kept the collar on until x-ray comes. That at least indicates they want it on until they can see the x-rays.