To BB or not to BB

[Arovetli]

As much as I would prefer that we were thoroughly trained in physical assessment, evaluating risk factors, and able to use judgement there doesn't seem to be much room for that with the CCSR.

Right. Im not talking about paramedics, Im talking about physicians, who are trained and educated and bear the responsibility to make clinical judgements. The OP seemed inquisitive as to why there may have been some consternation from the attending as to his treatment. Not a comment on what paramedics can or cant do, or how the canadian rule should or shouldn't be applied by EMS.

 

[Melclin]

It sounds like this individual had very localized injuries, and was able to fully participate in his assessment. If both his legs were crushed, and when you asked his past history all he would say is "It hurts too much to think" I would agree that he has distracting injuries.



No, it doesn't. At least not according to all of the full text versions of the CCSR validation studies I have copies of. They specify previous cervical surgery, not any spinal surgery at all.

The point of the OP's question seemed to be getting at why the doctor took the approach that he did.

You stated categorically that the pt could be cleared under nexus and CCR. All I was saying was that I can see how it might be a bit more grey than that. I suggested the grey area because it might be useful to the OP in determining why the dr disagreed with the management. Thats all.

 

[Arovetli]

im really not in the mood to get an internet argument, but you seem hell bent on it.

What do you think vertebral disease is, and does it not occur to you that a spinal fusion may be a process by which to treat said disease? Not that it really matters, its just something to throw into the mix when you are thinking, especially if you subscribe to a conservative approach. In assessing this patient I want to know why he had the procedure and how, if at all, it effects anything. That to me is of more value that simply knowing he went under a knife. I get it that it may be lumbar vs. cervical, i get that it is a minor splash of grey...but its still an item we want to explore.

Your right, when they designed the methodology, they picked 65, because thats a commonly used number. They could have analyzed the data out to age 64, 4 months, and 3 days. It really doesn't mean anything more than that. Do you really think that between the morning of your 65th birthday and the time you blow your cake candles out that magic sauce sprinkles from heaven, drips in your ear, and undermines the strength of your cervical spine? Its a freaking number to aid the data analysis. Again, something to think about when deciding on a treatment plan.

The "rule" is just a tool. Its not a be all end all to ruling in or out injuries. Nothing is. No tool we have is perfect. No data, no machine, no diagnostic. We use clinical judgement and the best of science, and a little artistry to treat our patients. One paper, one flow chart, does not necessarily become the gold standard in all things treatment, and allow you to send your brain out to lunch because your MDCalc app on your iphone can just make decisions for you. (As an interesting aside, MDCalc includes the hx of vertebral disease as exclusionary critera.... damn conservatives)

This is why EMS cant have nice things....

I was a little cranky. Rereading, I came off like a jerk. Apologies.

 

[KellyBracket]

... He complained that his pain intensified on the BB. I opted to remove him from the BB to avoid exacerbation of his pain and potential injury to his fusion. His pain resolved to a 0/10 in a supine position on the softer surface of the stretcher. ...

An ER physician's perspective:

You started a therapy on the patient, and it hurt them. You changed the therapy, and the pain stopped. You continued this second therapy. This is wise medicine.

Look, you did the right thing, but you have to make sure you document your findings, document the patient's wishes, and be proactive. Probably the doctor forgot about this 10 minutes later, but you never know. Approach your service chief/EMS coordinator/EMS medical director first, lay out your rationale. Be confident, but receptive.

Good for you for doing the right thing - keep at it!

 

[Handsome Robb]

Look, you did the right thing, but you have to make sure you document your findings, document the patient's wishes, and be proactive. Probably the doctor forgot about this 10 minutes later, but you never know. Approach your service chief/EMS coordinator/EMS medical director first, lay out your rationale. Be confident, but receptive

Very good point. If you ever have an issue with a coworker/co-responder/hospital staff or any sort of deviation from protocol it's in your best interest to bring it to the proper party's attention. If you wait for them to find out on their own it can be misconstrued that you were trying to hide something...then your integrity comes into question, it's not something you want to deal with.

 

[Medico]

Sorry for this late reply. I'm located in Virginia and lost my power due to a string of storms.

I appreciate all the feedback and rational provided.

To answer a previous question, I did not give any Fent. as his pain was a 0/10 when off the backboard, and remained a 0 throughout transport.

I've attempted to follow up on this patient, but have not yet received anything further.

 

[MountainMedic]

It's these damn rural ER docs. Half of 'em are family practitioners playing around. Going to med school does not an ER physician make. You were 100% right. Just wait 5-10 years, when reasons NOT to backboard are taken more seriously than reasons to throw a pt on a piece of plastic with few proven benefits.

Here's a little rural ED story. Hopefully an extreme:

MD: He's in cardiac arrest. Should we intubate?
Medic: Maybe you should start CPR first.
MD: Right. How about some Versed?
Medic: Why?
MD: CPR's really traumatic, he shouldn't have to remember that. Can someone draw me up some sux? What's the dose?

Swear to god. Saw it with my own eyes (won't say where).

 

[Handsome Robb]

All I can say is wow.

 

[Medico]

It's these damn rural ER docs. Half of 'em are family practitioners playing around. Going to med school does not an ER physician make. You were 100% right. Just wait 5-10 years, when reasons NOT to backboard are taken more seriously than reasons to throw a pt on a piece of plastic with few proven benefits.

Here's a little rural ED story. Hopefully an extreme:

MD: He's in cardiac arrest. Should we intubate?
Medic: Maybe you should start CPR first.
MD: Right. How about some Versed?
Medic: Why?
MD: CPR's really traumatic, he shouldn't have to remember that. Can someone draw me up some sux? What's the dose?

Swear to god. Saw it with my own eyes (won't say where).

Unbelievable.

I do hope that those says come sooner rather than later. The BB has such a tight grip in the minds of many.

 

[Codiaque]

It is obviously protocol driven. Our Nexus is for over 75 years old in Pueblo County here in Colorado. We also have a new protocol that allows for c-collar only immobilization due to new studies that are showing LBBs are doing more harm than good to the elderly.