3 ft fall spinal immobolization

[zeektheman]

I have a scenario I want to run by everyone. I work in a region that has a fairly liberal spinal immobilization protocol with a few exceptions (those being age restrictions and certain high risk MOIs).

I responded the other day for a 30 year old male who had fallen off of a ladder about 3 ft. The patient was CAOX4 and denied any LOC. Patient stated that he lost his footing and fell. His only complaints where his lower right arm which appeared to be broken and a 1 inch laceration on his fore head. I did a through assessment and found no numbness and tingling, no neck/back pain, palpation of the spine was normal and no pain upon ROM. I made the decision to defer spinal immobilization and transport in a postilion of comfort. Off course though once I got to the ED the nurse practically killed me for not taking spinal precautions. What are your thoughts on this?

[island emt]

We must paint the ER staff a very clear picture of the how, why and why not of mechanism of the injuries sustained.

We also have to clearly explain that we followed the spinal protocol to rule out the need to collar and board this pt and show that the Pt did NOT need to be immobilized by our protocols.

Many hospital staff have no clue that there is plenty of evidence based medicine studies to show that when done properly following the NEXUS protocol EMS can safely rule out the need to immobilize a pt that passes the clearance protocol.

[ERDoc]

Many non-board certified hospital staff have no clue that there is plenty of evidence based medicine studies to show that when done properly following the NEXUS protocol EMS can safely rule out the need to immobilize a pt that passes the clearance protocol.

Fixed it for you. The way you handle the nurse who does stupid shit like this is up to you. You could simply say, "It's my protocols. If you have a problem with it, take it up with my medical director. Here is Dr. X's number. He'd love to tell you why you are wrong."

As for the pt, let's define spinal precautions. A back board is total worthless so let's get rid of that. As for the cervical collar, well, we all know how useless they are. However, the way I think of these cases is that if I need to image them, then they should be in a collar. So, does the pt need a collar. That depends on which criteria you use. If you use the NEXUS criteria, the answer is, it depends. Is the arm fracture a distracting injury? There is no clear cut answer from NEXUS. You could argue for or against a collar in this case. Next, let's use the Canadian C-spine rules (CCSR). Step 1, any high-risk factors? Age over 65? No. Paresthesias in extremities? No. Dangerous mechanism? Yes. The CCSR define a fall of greater than or equal to 3' to be a dangerous mechanism. So, according to the Canadians this pt should be imaged and therefore should have a collar.

Now, if you were to bring the pt in to my ER without a collar, I'd have no problems with it. If you put a collar on, I'd have no problems with it. Some people just get so uptight, much like this nurse.

[island emt]

Your correct Doc:

We've had a spinal rule out protocol going back into the early 90's that came from the wilderness medicine folks up here.

It was updated with the NEXUS study as our state medical director was heavily involved in the study and again after the Canadian study.

[ERDoc]

Your You're correct Doc:

There, fixed it for. Sorry Island, I couldn't resist.

[island emt]

TABBOMA Doc

Couldn't resist :-}

[scubanurse]

It's silly that an ER nurse doesn't know about NEXUS. Makes me pissed that I don't have enough "experience" to work in an ER.

[ERDoc]

I find that there is a difference in appreciation for the literature betweens the ASNs and BSNs.

[Just Plain Ruff]

Why not have post-it notes or little business cards printed up with a link to your protocols and the studies supporting your protocols. Then when a bitchy nurse who doesnt' have a clue yells at you, you can pull out the card, tell her to stop yammering and go to these websites and then if she still wants to yell at you to come back and yell.

More than likely she'll go to her manager complaining about how rude you were to her.

But yeah, just retort back to her and say "I followed my protocols so call my service if you have an issue with it, you know the number, 911"

Edited January 17, 2014 by Ruffmeister Paramedic

[scubanurse]

I find that there is a difference in appreciation for the literature betweens the ASNs and BSNs.

I know it's not this way everywhere, but around here you'll be hard-pressed to find an ADN in ER's, and very rare in other units of the hospital since most won't hire new grads unless they are BSN and if they are hired, it's because they were already working at the facility.