Uncooperative c-spine patients?

[zappa26]

How do you guys deal with patients who possibly have a c-spine injury but don't want to be collared and boarded? Patients who are drunk/high or have a more distracting injury and don't believe they need to be immobilized?

The reason I ask is I had a 6yo boy dive into about two feet of water while I was working as a lifeguard. He was rubbing his neck and crying, and his friend said he hit his head on the bottom of the pool. I alerted other lifeguards to come help me, then ran up to him and began holding manual stabilization (he was standing) while asking him questions. As soon as he saw the backboard however, he started running away to his parents. We ended up assessing him on his mom's lap and he ended up being fine.

Thanks all!

 

[atropine]

Well, you can't force anyone to do anything they don't want, just document the hell out of the incident.

 

[marineman]

don't know how but it double posted

 

[Shishkabob]

They get what they ask for. They get reminded of the risks, and possible death, associated with treatment or lack there of, and they make a decision. They live with it, and you document the crap out of it.

 

[marineman]

documentation

Yes we all know we should immobilize patients with those conditions however I'm not going to fight you over it.

 

[rescue99]

Let's see....this is a good reason for having those sign and release forms. Mom and Dad are not skilled providers and should have been explained the possibilities as a measure of informed consent prior to a refusal of care/transport. EMS is the best resource for this kind of situation. Transport is not a requirement for EMS response but it is a great way to cover all your bases.

 

[Fireguy]

How do you guys deal with patients who possibly have a c-spine injury but don't want to be collared and boarded? Patients who are drunk/high or have a more distracting injury and don't believe they need to be immobilized

Violent drunk with head trauma after crash. Two state troopers and a roll of 3in tape later and they were on the way to the ER. By the way, no need to lecture me on this one. I was with the FD and had nothing to do with it.

 

[rescue99]

Lifeguards don't have the same capabilities as EMS. My advise, follow policy!

 

[BLSBoy]

Lifeguards don't have the same capabilities as EMS. My advise, follow policy!

And if policy says LBB and collar, and its against the patients wishes, its called battery.

 

[Hockey]

And if policy says LBB and collar, and its against the patients wishes, its called battery.

Not if they're drunk

 

[Fir Na Au Saol]

Lots of variables in each situation...

What are the risks/benefits of fighting with them to get them collared and boarded? Do you have protocols for sedation? Is this an appropriate patient for sedation? What about RSI in an severe trauma case?

If they have an occult spinal injury, wrestling with them could be the thing that exacerbates the injury to a permanently disabling or even fatal one. Keep them calm, make them comfortable and get them to a higher level of care ASAP. Then DOCUMENT the beejeebers out of what you did and why. I've "been there, done that" more than once with ETOH patients who were walking and talking on scene. The ED staff were very understanding once the full circumstances were explained. So was my service's medical director.

 

[Mountain Res-Q]

Document the hell out of it!!!

Two years ago we had a man with neckpain post tubbing accident at the Snow Park who waved off all help until the pain got worse 30 minutes latter. We backboarded him and call an Ambo. About 5 minutes post backboarding he got real combative... the claustraphobic kind of "I'm fine... I can't be strapped down like this." I have no authority to detaine him, nor do I have the ability to remove c-spine/backboard precautions once I put them on... what to do? Ambo is 25 minutes out (at least) and this guy is trying to rip himself out of the collar/straps. So, I calmed him down a little, gave him a great speach, and told him that it was a bad idea. He said, " I don't give a ****, get me out now or I will rip it off." Okay. Helped him out so that he didn't hurt himself. He agreed to stay seated again a wall with the collar on until Ambo arrived. When they did, we agreed to put him in a KED so that he could stay seated and "in control" and transported him that way. Not a great solution, but what are you going to do. I documented that one to the Nth degree, had family (in his name) sign my AMA paperwork, and wrote a seperate Incident Report soon after. Never heard anything on that, but never felt comfortable with the situation. Removing the board isn't something I believe I should be doing... but what choice did I have?

 

[berkeman]

Another related incident -- guess I need to learn more EMS-related Spanish...

30 y/o intoxicated Hispanic male does a hard face plant on concrete at an event I'm working. I take manual C-spine while my partner starts the exam and vitals, but neither of us are fluent in Spanish, so we could only ask basic questions, etc. PD shows up before Fire/Ambu, and he's fluent in Spanish, so starts asking lots of questions. Pt starts nodding his head Yes and shaking his head No to the questions, while I'm trying to hold C-spine on him! Normally I would have advised the Pt initially to only answer questions verbally, without moving their head, but I wasn't able to do that with this guy, and PD didn't bother to mention it before starting the questions. I wasn't able to interrupt the LEO initially to point this out, so about all I could do was hold the C-spine as firmly as I could. I need to add that initial advisory to my limited Spanish capabilities...

 

[Sasha]

Not if they're drunk

No, but if they are drunk and combative you are going to be causing more damage by wrestling thme onto a backboard and have them struggle against it then you would just to allow them to rest comfortably.

We had one patient, kind of. It wa the weekend of the citrus bowl at my old IFT job. We saw an accident, contacted dispatch and went and assisted. One guy starred the windshield with his forhead and had quite a bit of blood running down.

He allowed me to hold C-Spine and get a basic assesment for pain, if he had loss conciousness, what happened, etcetc. however as soon as the fire guys got there he flipped, stood up and wouldn't allow them to touch them. They recognized the risk/benefit and did not force him on the backboard.

 

[ericg533]

I have had two patients fight us after being longboarded. One was postictal, started fighting, was restrained, and got 10mg valium (per medical control). The other patient fell down a full flight of stairs and hit his head on a small table conveniently placed at the bottom of the stairs. He fought and was also restrained.

 

[HotelCo]

Document document document.

 

[EMT11KDL]

has anyone said DOCUMENT!!! everyone has...

make sure you write everything, everything you told the patient, use quotes. document what the pt says also. who was all on scene. if you don't think its relevant still write it! cause if you don't put it into your report, than it never happened! Depending on your area, Contact Med Control and tell them what is also going on, and document that conversation!

You have to cover your azz, cause people now will take you to court over stupid :censored:

 

[MendoEMT]

A couple of points:

1. Was there a medic at scene at the pool to clear c-spine? How do you know that the kid was "fine" without x-ray glasses?

2. Minors or people under the influence are not legally competent to refuse care. Period.

3. If someone doesn't want to be backboarded, even when you ask nicely and explain why you are doing it (and they are not competent to make care decisions on their own i.e. intox or minor) then don't be afraid to man up and call law in or use restraints. If someone is altered I often use restraints and it's my butt on the line if I didn't c-spine them when they needed it.

Sometimes you just need to assert your authority to get it done.
B)

 

[mycrofft]

Did anyone say document? Oh, yeah!

Sometimes I wish I had a "shouldercam", most times I don't.
If an EMS class lets their class end without getting their instructors' thoughts on this, they are negligent students.B)

We provide care and sevice, not enforcement. It is a privilige with responsibilities, not license to coerce. If the pt has a medical or psychiatri condition rendering them unable to make rational decisions about their own care and safety, follow local guidelines.

I've rassled some folks and the outcome was always dicey once we went hands-on. Ths is an other reason never to respond alone, you have a partner to witness if a pt won't sign a release or won't comply with care.

 

[Fir Na Au Saol]

I have to disagree strongly with some of this...

A couple of points:

1. Was there a medic at scene at the pool to clear c-spine? How do you know that the kid was "fine" without x-ray glasses?

2. Minors or people under the influence are not legally competent to refuse care. Period.

3. If someone doesn't want to be backboarded, even when you ask nicely and explain why you are doing it (and they are not competent to make care decisions on their own i.e. intox or minor) then don't be afraid to man up and call law in or use restraints. If someone is altered I often use restraints and it's my butt on the line if I didn't c-spine them when they needed it.

Sometimes you just need to assert your authority to get it done.
B)

And if you have to break their arms? Or if while you're "manning up" on them you turn a minor injury into a major one? Or they dislocate their shoulder fighting the restraints? Then it's also your butt on the line in the malpractice suit too. I'd strongly suggest that you get personal malpractice insurance if you don't already have it. Better yet, re-evaluate your absolutist attitude before you get yourself in trouble.

There are times when you have to think outside the box and bend protocols to special situations in the best interest of the patient. Sure, there ARE times when you need to get down to business and strap them down, but you have to keep THINKING at all times.