C-spine immobilization criteria

[EMS49393]

Well, I'm lucking out this month. We are having a lecture in a few weeks from one of our ER residents on c-spine immobilization criteria, techniques, etc., at our monthly audit review meeting. There has been a lot of discussion and change in the thought process behind this skill, and it will be nice to have a review of what we've learned so far and where we're going.

I plan on taking some fantastic notes (of course I always do) and I might be willing to post the information gained from this Doctor's research for discussion.

[DwayneEMTP]

Unless you attributed the 'tired feeling' to a neurological deficit, which it certainly sounds that you didn't, I wouldn't have immobilized this pt.

I just had a like conversation with my medical director after clearing several pts via NEXIS and then having the ER freak out and immobilize based simply on, in my opinion, "key words." As you mention, bicycle/auto, auto/telephone pole, ped/auto, etc. In EMS you certainly can't judge a book by it's cover.

I asked my Medical director, "Does there come a point where getting along with our rural hospital is better for my pt than attempting to do more progressive medicine?" His reply was, "No, there doesn't. You explain your reasons for your choices, if they don't understand then educate them, if they still have issues they can complain to me. You, in no case, choose regressive medicine to make someone, anyone else happy." I wanted to kiss him on the mouth.

Assuming this pt had no drugs/alcohol on board, was mentating properly, then I don't see any indication for immobilization. The words bike/automobile in the same sentence do not trump intelligent assessment. Not ever.

Awesome question, and responses.

Dwayne

[streetMD]

I also would not have boarded this pt based on your assessment findings. C-spine is quite evident as the head represents a significant mass than can easily shift fractured vertebrae. As for T-spine injuries, particularly near the lumbar, one would need a significant extrinsic force to cause further damage. Unless one is actively attempting to further damage to the area, it's quite difficult to move your T-12 when sitting or supine.

[FireMedic3982]

You stated that he had obvious redness to the lower thoracic spine, but you only note that he had no tenderness to the c-spine. To exclude a patient from spinal immoblization you must palpate the entire spine, not just the c-spine. Any complaint to the spinal column requires spinal immobilization. Plain and simple.

[stcommodore]

How about this situation...20s male sitting outside asumed intoxicated. Police called for "man screaming" they call us. Patient has a small abrasion to the forehead, but no other signs of injury. Patient being intoxicated isnt speaking clear but states no injuries. There are no signs of othet trauma, no cspine pain,etc...

Thoughts

[EMS49393]

You stated that he had obvious redness to the lower thoracic spine, but you only note that he had no tenderness to the c-spine. To exclude a patient from spinal immoblization you must palpate the entire spine, not just the c-spine. Any complaint to the spinal column requires spinal immobilization. Plain and simple.

If you would have understood the post you would have seen where I noted that the redness resembled his mesh undershirt. He had several layers of clothing on and I'm sure was a little chaffed in more than one area after sweating all day. Also, he never complained of pain, only of a "tired" feeling he noted was more than likely a result of riding his bicycle all day. I did palpate the entire spine. The medical director has since found that I did not err in my care of this patient.

Nothing is "plain and simple." I wouldn't immobilize a nursing home patient with a compression fracture when it's been treated and I'm there for another reason such as a routine transport. Perhaps it's all cut and dry in your world, but in my world all my patient's are different, and I treat them all differently.

Thanks to everyone who had valuable input.

Edited November 29, 2009 by EMS49393

[Biker911]

I feel you did the right thing. Why was the Pt even transported? Legal issues in the USA or common company practice? If he has no complaints, does not want to or need to tie up the ER, why not have him sign a release and let the lawyers fight it out later.

Nurses and Dr.'s are great at second guessing when they are not at the scene. They have all the equipment to use and are trained to make decisions after results.

My Canadian 2 cents worth.

[FireMedic3982]

If you would have understood the post you would have seen where I noted that the redness resembled his mesh undershirt. He had several layers of clothing on and I'm sure was a little chaffed in more than one area after sweating all day. Also, he never complained of pain, only of a "tired" feeling he noted was more than likely a result of riding his bicycle all day. I did palpate the entire spine. The medical director has since found that I did not err in my care of this patient.

Nothing is "plain and simple." I wouldn't immobilize a nursing home patient with a compression fracture when it's been treated and I'm there for another reason such as a routine transport. Perhaps it's all cut and dry in your world, but in my world all my patient's are different, and I treat them all differently.

Thanks to everyone who had valuable input.

Even if the redness resembled his mesh shirt something compressed it against the skin to make the imprint. Therefore, that indicates blunt force to the back. I did read your post. You only mentioned palpating the c-cpine. Thanks for clarifying.

Some things are cut and dry. When they fall within a very specific protocol. However, the appliation of the protocol falls to our judgement. It's hard to sit a say it was right or wrong from a written scenario. I have had the same problem with the ER for the same reason, expecially when we first started the criteria based immoblization. We don't do c-spine "clearance" in this area.

A nursing home patient with a diagnosed compression fracture that is being treated doesn't compare to a pre-hospital patient hit by a car. Two entirely different scenarios there.

I apoligize if my post seemed rude. It seriously was not intended that way, verbal vs. written communication.