Spinal precautions

[cosgrojo]

I am conflicted on this issue. As a "seasoned" provider (as my much younger co-workers call me), I know that there is not much harm in when you perform the application of the collar. In fact doing it a bit later in the process provides you with more assessment data. As an instructor of BLS practical stations, the criteria is to apply collar immediately after you have determined that trauma is involved, or suffer from critical criteria fail. It is not often that a student will think about this issue long enough to even think about questioning this philosophical difference between criteria and assessment... so I rarely have to defend myself or explain the dichotomy.

I also think that we overuse the board and collar. I cringe to myself every time someone meets the criteria for getting one, and I know that it is going to cause harm/discomfort/pain. I hate the fact that I sometimes put these things on patients just because that is what the hospital expects of me, and what the State DOT standards blindly tell me to do. If I don't put them on, I get an earful from the hospital staff (depends who's on... some Docs' in my local are more willing to accept divergent behavior than others), and when I do put them on... 50% of the time the hospital has discontinued the whole thing even before they get to x-ray.

[P_Instructor]

.....I know that there is not much harm in when you perform the application of the collar. In fact doing it a bit later in the process provides you with more assessment data. As an instructor of BLS practical stations, the criteria is to apply collar immediately after you have determined that trauma is involved, or suffer from critical criteria fail.

You do as you feel fit. Concerning when the application of the collar is performed, as long as the c-spine is being adequately maintained, the c-collar may be applied after the initial head-to-toe. This will afford the opportunity to discover any injury to the neck with palpation. As an evaluator, this being performed after the first exam does not constitute a critical criteria fail. However, the collar does need to be applied for trauma prior to LSB immobilization. A cervical collar does not provide immobilization, the care giver provides this with proper technique and securing.

[cosgrojo]

You do as you feel fit. Concerning when the application of the collar is performed, as long as the c-spine is being adequately maintained, the c-collar may be applied after the initial head-to-toe. This will afford the opportunity to discover any injury to the neck with palpation. As an evaluator, this being performed after the first exam does not constitute a critical criteria fail. However, the collar does need to be applied for trauma prior to LSB immobilization. A cervical collar does not provide immobilization, the care giver provides this with proper technique and securing.

I am sorry I was not more specific... My comment was based on the criteria for LSB station, not PA... and this is kind of the issue. We send mixed signals to the students. We tell them to collar immediately after manual c-spine being held in long board, and then give them an option during PA. The students do not always understand or even identify this gap in instructing. Sometimes they do, and then I have to explain (ineffectively, I might add) why PA and LSB are different and we are teaching to do it one way over there, but telling them you will fail if you do it like that over here. While trying to simply teach them a "skill" we sometimes make it harder on the students to get the "whole picture." Ideally they would all get the fact that in the field, they are going to need to integrate all of these skills together, but far too often they do not. We try and hammer that point into their heads, but they are too focused on breaking everything down into it's own segment because it is easier to remember that way.

[P_Instructor]

I am sorry I was not more specific... We try and hammer that point into their heads.....,

I understand now, and sorry as I was depicting the Registry Paramedic Trauma Assessment (which I do also use for the basic to tie the whole picture together)....Maybe if we keep 'hammering' their heads, they will put the collar on themselves.....

[scubanurse]

Fair question. And perhaps I've simply been misapplying them all this time, but I've never really seen them prevent an uncooperative pt from doing anything except perhaps touch their chin to their chest. Other than that, without additional support pts have near full range of motion.

The additional support would be the head blocks and proper technique for securing them to the backboard... When the combination of the c-collar, head blocks, backboard, and securing the patient properly to the backboard, I have seen even combative patients not able to move around much. But again as you said... anecdotal evidence

[DwayneEMTP]

The additional support would be the head blocks and proper technique for securing them to the backboard... When the combination of the c-collar, head blocks, backboard, and securing the patient properly to the backboard, I have seen even combative patients not able to move around much. But again as you said... anecdotal evidence

Yeah, but your word's good enough for me. And I agree at that point that things might possibly be improved for a cervical spine injury. But what has come before that? In the group of patients we're talking about, look at the manipulation that's taken place. And now, not just against the weight of the head, but against the force of another person attempting to hold it still.

So after all of that manipulation, unless you have a way to from combative to immobilized without movement, by the time we've immobilized are we still really doing any good?

I'm not so sure...

Anyone have that study that compared New Zealand, with almost no immobilization of any kind, to a New Mexico service that immobilized nearly everyone, that showed the NZ system showing significantly reduced morbidity where spinal injury is concerned? (Again, taken from my head, I could be misremembering) I was just talking to our medical director the other day about this, but I can't remember where I saw it, though he was familiar with it.

Though my thoughts are not likely to change anything, I sure find the discussion interesting...

Dwayne

[scubanurse]

So after all of that manipulation, unless you have a way to from combative to immobilized without movement, by the time we've immobilized are we still really doing any good?

Dwayne

Let's knock them all out with RSI... backboard them...tube em...and be done with it! Problem solved. No more combative patients! Just kidding. I think.

The movement, when say extricating a patient when we didn't need to pop the door or cut the roof, should be minimized as much as possible by going slow, talking it through before you move, etc. But when the roof is cut and a KED is not contraindicated...why not use a KED? I know this is opening another can of worms here, but why not do all that we can do minimized further trauma?

I may be living in my own perfect universe where we have plenty of time and resources and everyone is a 4-year college educated paramedic (I wish!), but why not do more inservice on how to apply spinal immobilization with the least amount of collateral damage. Why not put providers through a series of scenarios and practice extricating and moving someone with a suspected cord injury? Again another can of worms, but I think this problem stems deeper than just do you apply the collar and if so when.

[DwayneEMTP]

Agreed. But the collar was the point of the discussion put forth by the OP.

And I agree, if a large percentage of your patients aren't fighting the collar, then we do in fact live in different worlds.

In the subdued pt, I agree with all of your arguments. Man, many of mine are not subdued or in a state of mind to become so. See what I mean?

Dwayne

[chbare]

Fairly new evidence based thoughts out of the UK where many concepts are discussed:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2751736

Much of the immobilization hysteria in the United States boils down essentially to the following broad concepts:

1) Defensive medicine

2) Protocols

3) Ease of Movement

Take care,

chbare.

[scubanurse]

Still reading the article, but thank you very much for the link!!