Replies to This Discussion

Permalink Reply by DUST on August 28, 2009 at 6:28am

Jeff, I agree with you on the cell phones. The last mva I was on a car had slid off the road into a ditch. As I was walking toward the vehicle, I saw the driver chatting on the her cell phone. I told her not to move, with some authority, as I started walking toward her. She briefly glanced at me with very little interest, continued chatting, and then exited the vehicle! I command a lot of respect I guess!

Permalink Reply by Cory on August 28, 2009 at 6:45am

Hey Michael I think alot of us agree that on trauma calls the C-collar needs to be put on just in case, I think Jim's story is the best example why it needs to be done but you also need to remember that you can tell the in coming ambulance no they don't need it but if they think they do, then they can do it, its not your choice anymore they are in control of the pt.s care. So unless they are doing something life threatening they probably won't get in trouble. To your last question on is this depends on their departmental SOP" I think it probably has more to do with their Hospital Protocols. But then again I could be wrong.
Be safe Brother and take care!
Cory

Permalink Reply by Mick Mayers on August 28, 2009 at 7:29am

We have a spinal immobilization protocol that includes the ability to rule out c-spine injury, if applicable. However, back when I was on the bus, I had a woman who stated that she had slipped off the second to the bottom step onto the carpeted floor of her condo. She was conscious, alert, ambulatory, etc. She was refusing treatment and transport, except that I had a gut feeling there was more to it. Although we ruled her out, she walked to the rig and while en route to the ER, she complained of a little stiffness in her neck. Suspicions aroused, I convinced her to allow me to immobilize her, albeit it wasn't the best job I've ever done because we were already transporting.

Long story short, she had a basilar skull fracture and fractured C2-C3 which was detected AFTER the ER cleared her as well, removed the C-collar, and wheeled her to x-ray upright, where she lapsed into unconsciousness.

Moral of the story: Trust your gut, consider the mechanism of injury, and it never hurts to be TOO cautious when you are talking about someone else's life. Treat the patient how you would want yourself or a family member treated, and you'll never go wrong.

Permalink Reply by FETC on August 28, 2009 at 8:07am

Michael,

We for the most part package everybody full LBB w/ C-Spine Precautions with a MOI from trauma. Our state has a governing "clearing the c-spine protocol" which can be administered in the field to eliminate the need for spinal immobilization during transports.

I usually see this used more often in the "I am not hurt and don't want to go to the hospital type patient". We use the clearing the c-spine protocol as an addition to our medical evaluation for the no transport documentation.

Now with that said, we do package alot of people who never complain of head, neck or back pain. Quick story here: We package this girl involved in a minor MVA, transport her to our local ER, place is swamped, and the doc triages her while she is still on our cot and orders the nurse to remove all the c-spine immobilization after we transfer her to their bed. The nurse does, 30 mins later the girl tells the nurse her neck is starting to hurt.... the nurse puts just a c-collar back on while she is sitting on the gurney awaiting to go to x-ray.

In the x-ray room the tech calls the ER doc to the room to view the picture (even before they develop the film) and do not move the girl becasue she has a C2 fx. About 40 minutes after we clear the hospital, we get toned to respond back and assist the ER, thinking this was a weird request we respond and wonder what we are going to...

We arrive and the ER requests us to RE-PACKAGE the girl with full LBB and C-Spine for the MED-EVAC flight to a trauma facility. I ask why and they say they are not "trained" to package a subject as well as we are.

You can never over board a patient.... besides if they are transporting the patient, regardless if your chief is a senior EMT, he is not in charge of the patient care once it is transferred to them. They can do essentially anything they want so you should drop the "bullied" mentality and realize that they are liable for the care and just performing the best care possible to reduce future spinal injury.

TCSS
FETC

Permalink Reply by Gregory R Bailey on August 28, 2009 at 12:13pm

Mike,
Unfortantly it is an abused treatment. But the standard of care requires such things be manatory. Our state/county protocls require this in those type injuries MVA, Falls, injuries above the clavical ect. In our state you never know when DHEC is around, also we do not care portable xray equipment. I have seen minor injuries result in spinal truama. These injuries are not allways noticable right a way. And I have heard of lawsuits be files on all involed. We do not have deep pockets. So what do you do. Err on the side of the patient. We tried in our system to have a standing order for not using FSI it was abused so now we can not just do what we want. But on the other hand a patient can refuse and sign a liabilty release form and FSI not performed, this done by EMS in our system. Trust me I know how you feel brother. But you got to do what you got to do. Hang in there I sure you guys do and outstanding job.

Permalink Reply by Ben Waller on August 28, 2009 at 8:25pm

Remember that spinal packaging is not the benign event that we've alway been taught it is.
Studies have shown that between 1/3 and 1/2 of all uninjured test subjects placed in a spinal package will develop neck and/or back pain, hypertension, and other problems. That's people with no mechanism and no injury prior to the package!

The Maine spinal clearance protocol has been around for over a decade, and if applied with a proper physical exam, it works well. (It's the one Hilton Head's is modeled upon) Maine has had no serious problems documented with their spinal clearance protocol use.

I'm not a fan of CYA medicine...a lot of what we used to do based on "doing something just HAS to be better than doing nothing" has been proven either useless or even harmful.

Folks, we're supposed to be practicing Primum Non Nocere...First, Do No Harm.
Spinal packaging everyone with the slightest mechanism for CYA is a violation of that rule.

Spinal packaging someone based on a big mechanism and a positive physical finding like neck stiffness, on the other hand, is using your experience and instincts to do the right thing...but it was a size-up and assessment-based "right thing", not just CYA. Good job.

Permalink Reply by Ben Waller on August 28, 2009 at 8:29pm

CYA medicine is poor medicine, and spinal packaging has never been shown to do anything for the patient's well-being. It's accepted practice, but not a single study shows that spinal packaging is efficacious.

We have a well-written spinal packaging clearance protocol, and it's worked well for us for three years or so.
Total bad outcomes - zero. Total better spinal assessments - virtually all of them.

And...spinal packaging isn't harmless. There are studies that show that uninjured test victims develop neck pain, back pain, hypertension, and other real medical problems including distal paraesthesias in high percentages when placed in a spinal package for as little as 20 minutes.

Permalink Reply by Ben Waller on August 28, 2009 at 8:31pm

Never is a long, long time, and there are studies that show that spinal packing itself can be harmful to patients, and even to uninjured test subjects. Further, there's no study that proves that any spinal packaging is actually good for a patient or that it actually protects the spine. There's a theory that says so, but until science proves it, basically we're following 30 years of urban legend every time we put a patient into a spinal package.

And, while tragic, there's nothing you could have done for a patient with a hangman fracture that died before you could even get a c-collar out.

Permalink Reply by blair4630 on August 29, 2009 at 2:00am

1) there are spinal clearance protocols followed in most states, however they vary from state to state, and you're not even in our country. You cannot legally be protected by using protocols that we use here in the states, although if there truly is no laws pertaining to EMS whatsoever, then I guess you can use whatever you wish.

2) Once the ambulance crew arrives on scene and makes patient contact, that is their patient and their responsibility. You cannot tell them "no" if you simply don't agree with what they wish to do regarding immobilizing the pt.

3)it seems a little presumptuous that you would tell the ambulance "no" they don't need immobilized because they don't have a spine injury, yet you are on here looking for spinal clearance protocols to follow. Think about it.

Permalink Reply by Michael Vito on August 30, 2009 at 3:42am

Guys, one thing to clarify. Team leader of the ambulance unit in question is a "first responder level only" meaning he is not certified as an EMT-B even their supervisor. My chief is EMT-I certified by the Americans and UK.

FYI, Believe or not by statistics only three certified EMT-Paramedic throughout the Philippines. Their certification came from elsewhere (US or UK).

And I say it again.... NO NATIONAL EMS CERTIFICATION YET. THERE IS NO NATIONAL EMS LAW Here..... sad to say.....

The ambulance unit in question is ironic, they got the ambulance because of their gov't funding. For us, vollie... we are not. We got technical knowledge but lack the resources. That's why we got bullied.

Second, they have a so called "medic" that has video camera with them and that guy is allegedly paid by the TV network. Other units on the surrounding area thought alsoand so they like package the pt. a lot because it looks cool on TV. So even the law is not written, I believe they have crossed the ethical and moral line of the EMS service.

Permalink Reply by Michael Vito on August 30, 2009 at 3:56am

I know blair. we are thinking about it, we appreciate you guys for the feed back and opinions.

That's really sad truth for us here and we and the rest of the Fire / EMS units especially volunteers that comprise the 85 % active throughout the Philippines have tried or frustrated to push for the national EMS law for the past more than 10 years. And still we are waiting and push.

Permalink Reply by Michael Vito on August 30, 2009 at 4:12am

Thanks Gregory, Ben Waller, FETC and the rest of FFN for your contribution.

I have printed the first two pages of this thread two days ago and that night. Showed to the rest of the members involved including our chief. Consolidated the facts on what we know and we had a very good discussion about this.

I know most of you is cultured shocked about the different world we are in. We have always dreamed that somebody that all in the EMS community here will be put in order. We prayed this coming May 2010 national election will brought about change and hopefully include EMS. We hope the congressman wannabe is Pro EMS.

We keep you posted guys. Again. Thank you so much.

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