Let's place a game of You make the call...
You can comment here and/or read other comments at my home blog, linkable from my profile page.

This call was one of the ones I look back on as a perfect example of why a blanket C-Spine protocol is never a good idea. Paramedics need the training and authority to "clear" C-Spine in the field based on proven assessment techniques.

I'm assigned to an ALS ambulance dispatched to a PD eval late on a Saturday night to a nightclub famous for trouble.
On scene PD advises that they responded to a call for a fight, but the defending party fled the scene 30 minutes ago, then suddenly returned.

Our patient is in his late 20's, conscious and alert, no alcohol or elicit drug use admitted or evidenced on assessment. He states the bouncer came at him with a "baseball bat" which the bouncer denies.
The patient has a small, non suturable laceration, approx 2 cm to his right parietal skull, bleeding controlled, and there is some blood in his long unkempt hair.

He is initially refusing treatment, but after talking him into the back of the ambulance where there is better light he decides to go with us simply to escape the situation.

He has no pain, no complaint and makes no indications that the laceration is bothering him. He also states he does not recall the bat hitting him and that he may have scraped his head on a wall as he ducked out of the way of the bat.

From my experience, and the fact I had to talk him into the ambulance, if I break out a cervical collar this guy will freak and fight, twisting his neck this way and that to avoid my cervical immobilization device.

My protocol states that full C-Spine precautions are to be taken on any person with trauma noted above the clavicles.

Do I C-spine this patient? Just collar? Based on your protocols...You make the call.

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Comment by FETC on March 1, 2009 at 7:14pm
We are allowed to clear the c-spine based on our protocols and that is for all levels EMT-B/I and P.

I used to do it before the protocols were changed...
Comment by the Happy Medic on March 1, 2009 at 2:08pm
I think I'll print that out and hang it on the door at HQ.
Comment by Tom Bouthillet on March 1, 2009 at 1:45pm
It's not about us, and what we're allowed to do, it's about what's good for patients. I'd rather be brought to the hospital by a taxi driver than subjected to potentially dangerous treatments with no proven clinical value. The RSI discussion comes to mind.

Just because most prehospital ALS interventions have not been proven to change 30 day mortality or improve survival to hospital discharge does not mean that patients would be better off if they were treated by technicians with a 30 day crash course in medicine!

Wake County EMS has one of the best EMS systems in the country, with some of the best survival rates for cardiac arrest (37% for the entire system and 49% in the City of Raleigh). They use a King LT as the primary airway about 80% of the time. Does that mean they don't need paramedics? Or is the truth more complicated than that?

Part of our job is educating our patients as to the risk they are taking when they refuse care and any alternatives available to them. Who do you want explaining that to your mother or father?

Nothing will advance the EMS profession more than a commitment to evidence based solutions to our communities problems. The best way to stop being regarded as technicians is to start acting like professionals.

Comment by the Happy Medic on March 1, 2009 at 1:07pm
Excellent comments! Too often they conform to the weakest instead of expanding wit hthe strongest, as you say.
As far as peer reviewed literature, I can't find that phrase in my protocols. I am not a protocol robot, far from it, but if we based our actions on proven techniques we'd be back to glorified taxi drivers, jsut what my budget strapped department wants to hear.

Great comments, I look forward to following your comments in the future.
Comment by Tom Bouthillet on March 1, 2009 at 1:01pm
Why "based on my protocols"? What difference does that make? The relevant question is, does the peer reviewed literature suggest this patient's C-spine can be cleared by a competent caregiver? There's a big difference! Whether it's advanced airway, 12 lead ECG interpretation, or prehospital spinal clearance, it's wrong to make the assumption that "an EMS system is an EMS system and a paramedic is a paramedic." There are good EMS systems and there are poor EMS systems. What an excellent EMS system is allowed to do does not mean that all EMS systems should follow suit. When you see a blanket statement like "all injuries from the clavicles up require spinal immobilization" it means that the EMS administrators or physician controllers are worried that your lowest common denominator either has no common sense or may not be able to safely perform a medical screening exam. Whether spinal immobilization is indicated or not, it's always a mistake to throw someone down on a backboard kicking and screaming.

Comment by the Happy Medic on March 1, 2009 at 12:26pm
3 arms that is.
Comment by the Happy Medic on March 1, 2009 at 12:25pm
Argue or discuss? I've found quite a difference in protocols around the country and this is a fun way to find our differences and see what works and what doesn't.

As far as continuing ed credits, they're only available for those with 4 arms or less. Sorry.
Comment by lutan1 on February 28, 2009 at 8:57pm
The text book answer is if the protocols say to do it, then going against them may open up a can of whupp-ass that you don't want.

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