would you c-spine?

[NYMedic828]

Has anyone mentioned how much the process of spinal immobilizing actually hinders an efficient auto extrication?

Half the time we can get someone out through the back seat or the trunk of a minivan or they could just climb out on their own but we insist that for the sake of their survival they must remain still and wait for us to rip their vehicle apart and/or try and slide them out in an extremely uncomfortable manor.

I wonder how many patients involved in major MVAs may actually have survived had we yanked them from the car in a more rapid manor and just gotten them to a surgeon that much faster? (Not many I'm sure, but still an interesting thought)

 

[Veneficus]

So your arguing against the use of a backboard for any spinal immobilization procedures?

I would, except as an extrication device.

I know there are some neuro studies from the 70s and 80s that state it is useful, but there were too many unaccounted for variables in my opinion.

 

[ExpatMedic0]

I have read some rather discouraging study's regarding back boarding patients. I would like to read more study's about it before I completely cast it aside as a tool. I would agree that most patients are back boarded with out spinal injury's, but what about those with spinal injury's? You could argue against it, however for the time being it would appear its still expected of us since its written in all modern paramedic text books I am aware of, still a national practical exam required for certification and still written into protocols which Medical Doctors continue to approve and publish in various forms.

 

[rmabrey]

And I thought my service was halfway progressive by allowing us a rule out protocol.........then I read it and changed my mind

 

[Christopher]

I have read some rather discouraging study's regarding back boarding patients. I would like to read more study's about it before I completely cast it aside as a tool. I would agree that most patients are back boarded with out spinal injury's, but what about those with spinal injury's? You could argue against it, however for the time being it would appear its still expected of us since its written in all modern paramedic text books I am aware of, still a national practical exam required for certification and still written into protocols which Medical Doctors continue to approve and publish in various forms.

Modern paramedic text books and protocols written by medical directors still support Esophageal Detector Devices and don't require waveform end-tidal capnography...they state/require LOTS of things which would be negligent if lawyers had half a clue (apologies in advance Gene if you read this page). If your protocols aren't updated at least biannually they probably support treatments that are no longer the standard of care.

There is no physical or mechanical basis for the assumption that strapping someone down to a level, rigid board decreases spinal motion and reduces sequelae from spinal trauma. The spine is not level for starters...

You're responsible for knowing how to appropriately treat your patients in spite of what your textbook said, what NREMT tests on, and what your protocols say.

 

[ExpatMedic0]

You're responsible for knowing how to appropriately treat your patients in spite of what your textbook said, what NREMT tests on, and what your protocols say.

That is a quite a dangerous statement to make for someone with what is often 1 year of vocational training don't you think? Just because your read some study's in a professional journal or formed a hypothesis does not give you the right to deviate from what is the current national standard of care.

I am not saying I am a strong advocate of back boarding, in fact I am advocate of clearing C spine in the field if permissible in your area. However to imply if we DO suspect a possible spinal injury and intentionally refuse to backboard based on your own personal standard of care and opinion, that is not the way this works man.

What if I disagree with the efficiency of amiodarone in cardiac arrests? Does that give me the right to deviate from ACLS (which we are all required to certify in) and protocols?

What if I decide 1 day that all those articles we have been reading on the in efficiency of pre hospital intubation is true, so I refuse to intubate anyone from now on as a result.

Yes you can deviate from protocols and use good clinical skills to make decisions. If you can explain why you did what you did more power to you, so long as a jury of your peers and your medical director will concur.

It does not give you the right to do whatever you want because you disagree with your scope of practice, the education system, your medical director, and the whole system.

If you decide not to backboard someone because you DO NOT suspect a spinal injury and you can justify it or justify why the spinal immobilization was unnecessary based on the injury... that is great. I am not saying to blindly follow our protocols and avoid clinical judgments.

If you want things to change speak to your medical director about changing the spinal immobilization protocols, speak to the American College of Surgeons about changing there current guidelines for us, your state EMS office, the National Registry or emergency medical technicians, act to change textbooks, go back to college and earn a degree which can further the progression of these ideas, conduct EMS research study's and become involved with epidemiology, join professional organizations which create change.

 

[VFlutter]

So your arguing against the use of a backboard for any spinal immobilization procedures, or just for this scenario?

IMO, spinal immobilization is greatly over used based based off blind obedience to protocol and fear of "what if". We have all been force fed the stories of that one time some guy that fell from standing height, had a step off injury, and was paraylzed, and sued and use it as justification to backboard every remotely related MOI. Also when it is used it has been shown to be poorly done and not all that effective (if it all)

 

[ExpatMedic0]

IMO, spinal immobilization is greatly over used based based off blind obedience to protocol and fear of "what if".

I agree completely.
However, what I am saying is... what if YOU DO suspect a spinal injury? Would you not backboard?

 

[Christopher]

That is a quite a dangerous statement to make for someone with what is often 1 year of vocational training don't you think? Just because your read some study's in a professional journal or formed a hypothesis does not give you the right to deviate from what is the current national standard of care.

I've had a few years outside of vocational training, but that wouldn't change what I'm saying.

My point is you are ultimately responsible for doing what is right/best for your patient. It doesn't matter whether that came from a guideline, protocol, medical control, NREMT, a textbook, latest research, etc.

If we're not actively critical of standards, well they aren't really useful to anyone. Does your system even know what evidence supports its standards? Thankfully our local protocols go beyond old standards (NREMT is the low end).

I am not saying I am a strong advocate of back boarding, in fact I am advocate of clearing C spine in the field if permissible in your area, but to imply if we DO suspect a possible spinal injury and intentionally refuse to backboard based on your own personal standard of care and opinion, that is not the way this works man.

It is not my personal standard but rather an accepted standard. Perhaps you're right that NREMT doesn't agree.

What if I disagree with the efficiency of amiodarone in cardiac arrests? Does that give me the right to deviate from ACLS (which we are all required to certify in) and protocols?

You're free to deviate from ACLS whenever you please. ACLS is not a protocol, it is instead a guideline that is often used when creating protocols. As you note though, you're probably not as free to deviate from your protocols.

Due to many issues with the drug, when given the option I avoid using amiodarone altogether in favor of procainamide. In cardiac arrest it doesn't really matter, they're similar in efficacy to a saline flush.

What if I decide 1 day that all those articles we have been reading on the in efficiency of pre hospital intubation is true, so I refuse to intubate anyone from now on as a result.

I'm not sure where electing not to intubate a patient becomes bad clinical judgement. Good clinical judgement quite often means making the decision to not intubate a patient, you learn that well in an RSI system.

Yes you can deviate from protocols and use good clinical skills to make decisions. If you can explain why you did what you did more power to you, so long as a jury of your peers and your medical director will concur.

Protocols form the foundations of care, they are not intended to be the limits.

It does not give you the right to do whatever you want because you disagree with your scope of practice, the education system, your medical director, and the whole system.

I don't disagree with my scope and I've not exceeded it with my statements on C-spine.

As an educator I teach the standard and teach students to evaluate the statements critically.

I disagree with my medical director on occasion and he disagrees with me on occasion...seems par for the course. I'm not actually in disagreement with my system, I think it runs pretty well for C-spine issues.

I removed the rest of it as it strays off topic

 

[ExpatMedic0]

Ah ok, so YOU ARE following some kind of standard in place. I misunderstood you and thought you as an individual where choosing not to backboard people because of your own personal vendetta. Its been a while, but I have spoke to people following the Canadian C-spine rule and I have herd good things. Here is a question for you then, If you have a high index of suspension for a spinal injury with altered Pulse Motor Sensation and significant Mechinsm, how do you manage it in your system with out a backboard?

We use a modified Canadian C-Spine rule that the state office put in place. It works pretty well.

Cool, I am working on finishing my undergraduate degree as we speak.

My BSc is in computer science and I work outside EMS in a field with active engineering research. I skipped a masters to get into EMS.

 

[Anonymous]

Okay now in this case, you pull up on scene after fire. As you walk up they say grab the flat. Their assessment is already done and they have decided they are going to flat her out. Family is around and patient is in excruciating pain. Just from what you have gathered in the little time you have been on scene you agree flat would cause least discomfort (not necessarily saying is best for treating pt)

Would you say "hold up, we need to c-spine this person?" if you thought that was the case.

 

[rescue1]

Another question, this one for the LSB haters.
Say you get called for a fall off a roof. Your patient is complaining of severe back pain and has some deficit in both his legs. Your partner is all like "Bro, this is totally a spinal fracture".
How do you this patient from the lawn to the cot, then from the cot to the hospital bed? Carrying him unsupported is likely to exacerbate the injury as he bends in the middle. If you log roll and board him, its a pain to take the board out from the under him once he's on the cot, same with a scoop.
What would be your way of transporting him from ground to cot to bed without boarding him? And is the technique you suggest used anywhere else?

 

[Christopher]

Another question, this one for the LSB haters.
Say you get called for a fall off a roof. Your patient is complaining of severe back pain and has some deficit in both his legs. Your partner is all like "Bro, this is totally a spinal fracture".
How do you this patient from the lawn to the cot, then from the cot to the hospital bed? Carrying him unsupported is likely to exacerbate the injury as he bends in the middle. If you log roll and board him, its a pain to take the board out from the under him once he's on the cot, same with a scoop.
What would be your way of transporting him from ground to cot to bed without boarding him? And is the technique you suggest used anywhere else?

Scoop stretcher. Funny enough, scoop stretcher at least has SOME evidence.

 

[Christopher]

...Here is a question for you then, If you have a high index of suspension for a spinal injury with altered Pulse Motor Sensation and significant Mechinsm, how do you manage it in your system with out a backboard

The honest answer is I usually have no choice as my first responders will have them packaged prior to my arrival probably 60-70% of the time. When I have my druthers out will come a scoop stretcher or a reeves sleeve and padding.

 

[rescue1]

Scoop stretcher. Funny enough, scoop stretcher at least has SOME evidence.

That makes sense. Do you have the big plastic ones or the smaller metal ones?

 

[Handsome Robb]

Okay now in this case, you pull up on scene after fire. As you walk up they say grab the flat. Their assessment is already done and they have decided they are going to flat her out. Family is around and patient is in excruciating pain. Just from what you have gathered in the little time you have been on scene you agree flat would cause least discomfort (not necessarily saying is best for treating pt)

Would you say "hold up, we need to c-spine this person?" if you thought that was the case.

If they need to be spinaled, absolutely.

"Get a line and monitor, I'm going to draw some fent then once it starts working we will roll her onto the board."

 

[Anonymous]

If they need to be spinaled, absolutely.

"Get a line and monitor, I'm going to draw some fent then once it starts working we will roll her onto the board."

ALS was cancelled by fire prior to arrival. No pain management for this pt other than the vicodin taken an hour beforehand.

If it clears up any confusion the system here uses a private company for transport. ALS and Fire are separate....

 

[ExpatMedic0]

Patient is in there 70's correct? Does the physical exam reveal anything abnormal at the location of injury site or anywhere along the spine or pelvis? What was your general impression and did you suspect a fracture of any kind?

 

[Handsome Robb]

ALS was cancelled by fire prior to arrival. No pain management for this pt other than the vicodin taken an hour beforehand.

If it clears up any confusion the system here uses a private company for transport. ALS and Fire are separate....

If she's uncomfortable enough to have to worry about how you are going to cause the least amount of harm during transport she needs pain management.

I'll add another to my original response, first responders don't tell me what they need, they give me a report and I make the decisions unless there's extenuating circumstances such as an confined space or high-angle rescue. In that case it's their sandbox and I don't want to intrude on that.

 

[AnthonyM83]

So for those patients who were ambulatory do you think it would be better to backboard them over transporting them in position of comfort? What did they do when they got to the ER? Full immobilization?

Ah, you're drawing me into a different argument. Does immobilization work, etc?
I replied to your original statement "I love when people C spine after the patient has already been ambulatory for an extended period of time."

Your quote implies that you DO agree with "C spine". You disparage C spine AFTER the patient has been ambulatory for an extended period of time, making the implication that it SHOULD be done if that patient has NOT been ambulatory.

Then, why are you asking me about "full immobilization" in general? I wasn't addressing useful not of full immobilization in general. I was addressing your implication that if that patient has been ambulatory, the we shouldn't C spine (in a situation in which you otherwise would have).