Monhae

Brudzinski's neck sign is a neurological reflex associated with inflamation of the meninges. It is one of many indicators to the "possibility" of Meningitis and occurs in less than 50% of pediatric Meningitis cases and less than 10% of Adult cases. Like any sign, it is part of a list of indicators to guide you on your quest for the proper diagnosis or working diagnosis. A bread crumb if you will. The more signs present, the better, but a lack of signs doesn't negate their usefullness. Also remember that this is a reflexive sign. Like any reflex test, it's accuracy is dependant on you illiciting the reflex, not the patient "providing" the reflex. For those not familiar, it is tested by you manipulating the patient's head forward, flexing the neck and observing the patients lower extremities. There should be flexion of the hips and knees in an attempt to raise the lower extremities. Remember were looking for a reflexive response, not an intentional response from the patient.

Wow! A portable ambulance. Now we just neet a pop up stretcher to make it all complete. Or did I miss that part.

I see. My apologies for misunderstanding. We have a very liberal and very active medical director. We too have many of the same issues. Limited radio or phone contact, when further orders are needed sometimes, but he trust us to make the right call and tell him about it later. I've rarely seen him not willing to back one of us up. Very rarely.

The NIMS ICS design is becoming a standard in many states. It depends on the level of emergency. Some emergencies fall under federal regulations and whatever structure designated by the feds applies. Some emergencies fall under state regulations and whatever structure designated by the state applies. To keep it simple, most situations fall under county or city juristictions and therefore local policies apply. Every county and city """Should""" have a pre-designated plan and chain of command structure drawn up and implimented. Should being the operative word. Check local ordinance and be familiar with it. Since you asked that question, I'm assuming you might need to do that. Here's the funny part. In Texas, the highest authority in an emergency, in a county or city, is the county Judge. Usually someone with no emergency training whatsoever. Rarely is that authority abdicated to the judge, but it is there for the taking, should you get a judge with control issues. If my understanding of the law is incorrect, please let me know. jimmy

Must be interesting to not work under a doctor. That would be something worth trying. Please, don't assume that were simply trained monkeys. We must make working diagnosis and treatment decisions as well, and I never have trouble stepping out and making the hard calls. I just feel that when I'm making a decision that might put my medical director at risk, that he be included in the decision. Even if it is after I've already made the call and done the treatment. It's a common curtesy, which allows the continued level of trust he shows us with his liscense.

If you need a Texas patch, let me know. jfutrelle@scurrycountyems.com

Remember a big rule in interpreting 12 leads. The machine never interprets. The machine has a series of algorythms it follows based on calculated averages and limited perameters, to make it's interpretations. You have human eyes, common sense and the ability to think outside the box. The reliability of the 12 lead printout is decided on a case by case basis. What you see is the same physical representation of electrical activity as a standard single lead, just less filtered. It uses the same basic electronics to display the waveform. The waveform representation effects the interpretation, but the interpretation algorythms do not effect the waveform displayed. Your evaluation is always the valid one. If you believe that the waveforms printed are to noisy, than run it again. Your the final judge and the final level of validity for the printed strip. jimmy Excuse me. A correction. I meant to add that AVL, AVF and AVR are calculated leads and not actual measurements. Those leads should be considered unreliable if there is too much noise or interference.

A scoop scretcher is a tool. One of many in a limited arsenal of tools available on an ambulance. Spinal immobilization can be done with a scoop, a long board, a short board, and KED, a Vacuum board, a set of board splints and a few other creative things, in conjunction with a C-collar or CID or other neck and head stabilizing devices. There is not a definitive answer to your question. From the limited information to create a mental imsge, several of the aforementioned devices could be used and all be appropriate. Only the medical professionals onscene could determine what the "best" device of choice is/was. the rest of us can give conjecture and opinion, but nothing concrete. Each device having it's pros and cons, limit our opinions even more. Considering the mental picture I developed from your story, I would say a scoop is acceptable, but no more or less acceptable that a long board. The term "best" is and always will be a subjective term and again falls to the primary care giver's impression of the scene to make that determination. The short of it is, we can't answer that question. Jimmy

You are correct. Perhaps I should have put "hurts" in quotes. In truth backboards suck big time. I am a strong advocate to selective spinal immobilization. Truly.

I understand your argument. I do. I'm a firm believer in improving our assessment skills. Our medical director is big on Differential Diagnosis. I'm happy we have someone who wants us to think. I'm considered the slow old guy. The "pup medics," no offense intended, around think in hyper-terms. Load and go. Short scene times. Jump on those ALS skills ASAP. There in too big a hurry for the "good stuff" to slow down and really dig into a patient's situation. Too many or the "old guys" are into the "hell this is the same old crap again" mode and overlook the small clues and take too long sometimes or don't give enough treatment. We have a gap in quality patient care. Don't misunderstand me. I'm not saying that those mentioned don't give QPC, but that there are gaps and the occasional patient falls through those gaps. We consider this acceptable and we should not. We think too often, well I really should have done more for that guy, but on another call, identical, we do the same old thing again. Anyone watch House. I love House. I know that he is a fictional character, but I strive to be that type of diagnostician. To find the deeper clues. To look at medical and trauma from outside the box. I base my treatments on the patient and the assessment, not some pre-determined guideline. That is all a protocol is. A guideline. I deviate or combine protocols on occasion. I call medical control adn say, "hey, this is what I have, can I do this instead." But I make sure that any deviation or alteration is backed with a strong assessment of the patient and the situation. We need to be more than the sum of our cirtifications and the minimum standards of care set down by our state. We need to be the life line and the voice of reason for our patients. We have the best picture. We see the environment. The ER does not. We are a liason for care. I rambled a bit.....sorry. I also support the idea of treatment and not transporting, but it must be weighed carefully with what is best for the patient. That is opening up a can of liability worms you should be careful about opening. I forsee much discussion and experimentation before that concept ever sees real consideration. Jimmy

Confidence is a time consuming process. It is aided by second guessing yourself. That is a good reflex. Only as long as it doesn't impeed your final decision. Second guessing makes you rethink and be sure you did not miss anything. No amount of sage wisdom can give you confidence. Only repeated contact with the unknown can prepare you for the constant confrontation with it. You sound as if your on the right track. Just give yourself the time needed to allow the things you do to become second nature. Then you find that you calm down and can take in more of the situation naturally. This is my 23 year and I still have butterflys in my stomach on every call, but you'll never see that. Here's my sage advice. I always told my students, when you step out of an ambulance, you're Superman and the lone Ranger rolled into one. If you can't fill those shoes.......Don't get out. The patient must have almost instant confidence in you for you to do your job correctly. Confidence in yourself takes time, so you have to be a duck. Calm above the water, paddling 90 miles an hour underneath and never let the patient see you sweat. That and 50 cents will get you a drink from our fridge. Have a good day.

I would say yes. The patient had a possible LOC (Unverifiable) and you can't rule out hypoglycemia, completely as the cause of altered LOC, because of mechanism of injury. All selective spinal immobilization protocols require a more thorough physical (palpation, ROM and neurological) assessment to make the final call though. The bigger question here is who's call is it. If the fire department says no and they are the primary care giver, then let them say no. If you are the person in charge of the transport of that patient to the hospital, and you want them boarded and collared then you also have the call. Unless that first primary care giver is transporting and accepting full responsibility for the patient, then they are transfering care to you. That makes you the liable one as well and the main liability for how that patient is turned over falls in your lap. The last time I checked spinal immobilization is a BLS skill in all 50 states. You now become the primary care giver and you can treat the patient as you deem proper. Even if it means applying the backboard or a KED and collar after they are placed on the cot. We have all made decisions, then circumstances changed before arrival at the ER and we changed or add to our treatment. Realizing that more needs to be done and doing what is necessary is the sign of a good EMT. Realizing more needs to be done but sticking to the original decisions, being inflexible, gets patients hurt or killed at some point. Know your chain of command and don't be afraid to do what I do. "Excuse me, but this is my patient and this is how I want to treat my patient. If you do not agree, then it is your patient. What can I do to assist you?" and smile and politely turn care over to them. Ive ruled out C-spine before, and half way to the hospital, the patient goes. "My neck is really starting to hurt." You shift gears and immobilize. Tha laws reguarding chain of command and continuity of care should support what I've just said in almost every state. Your patient, so do what you believe is right. You're the one who has to answer for it. If not your patient, then make suggestions, and support, if possible, the decisions of the person making them. It also never hurts to err on the side of caution.