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PostPosted: Thu Oct 27, 2011 11:59 am 
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I had a guy with a ground level fall due to a diabetic event and was wondering your opinions on the choice to maintain c-spine stablization. I entered the scene (I'm an EMT but I was not there in a professional capacity) and saw a male laying on the ground moaning in pain, with an obvious dislocated shoulder. He told me he had blacked out and fallen. I did not see any other issues apart from the very painful shoulder, but then he started saying his back was hurting very badly. I chose to hold C-spine until the medics arrived, and they sort of seemed confused at why I was doing so.

I was taught that ground level falls aren't a serious risk for spinal injury, but that if you have indicators to immobilize c-spine. To me, he had loss of consciousness and back pain, so I was concerned enough to do it, even though I was willing to bet there was no major injury there. Either way, I'd love to hear what you guys think. Overzealous or prudent precaution?


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PostPosted: Thu Oct 27, 2011 12:30 pm 
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I probably would have done the asme thing. I'm no longer a medic, but the side of caution always previals.


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PostPosted: Thu Oct 27, 2011 12:54 pm 
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Please describe the pt
Tall, short, obese, young, old - what? How did you determine this was a diabetic event?

A dislocated shoulder from a standing fall indicates (to me anyway) an underlying condition past diabetes. What kind, if any, history did you get?

thx

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PostPosted: Thu Oct 27, 2011 2:12 pm 
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When it comes to any fall from any height, you can never go wrong with holding c-spine, especially if the dude said he blacked out.

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PostPosted: Thu Oct 27, 2011 2:25 pm 
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Cspine. Pt had LOC then fell. Risk is 5% for injury. Also he dislocated his should from the fall. It isn't much harder to damage the neck. Cspine no questions asked. It takes 5 minutes.

Ya did the right thing by taking cspine

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PostPosted: Thu Oct 27, 2011 3:26 pm 
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TacAir wrote:
Please describe the pt
Tall, short, obese, young, old - what? How did you determine this was a diabetic event?

A dislocated shoulder from a standing fall indicates (to me anyway) an underlying condition past diabetes. What kind, if any, history did you get?

thx


47 year old male, appx 6'2, thin, history of diabetes and prior shoulder dislocation which would probably be why it popped out so easily. I didn't know at the time it was low blood sugar (though I was guessing that's what it was), but when EMS arrived they checked him and it was really low. It was in the restroom so another possibility, I suppose, is that he went vagal and/or had orthostatic hypotension when he got off the throne.


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PostPosted: Thu Oct 27, 2011 3:39 pm 
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You aren't going to do any harm by holding C-Spine. I would have in that situation, due to the nature of the injury as well as the complaint of back pain.

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PostPosted: Thu Oct 27, 2011 8:55 pm 
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You absolutely did the right thing. He had an MOI, so always assume c-spine precautions until you can rule it out, especially considering that he had back pain. Ruling it out would require him to have a normal LOC, which he didn't.

Were the medics confused before or after you gave them your size-up? If you shared with them the same information you put on here, it should have been a no-brainer.


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PostPosted: Thu Oct 27, 2011 10:14 pm 
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Listen to TacAir........He has valid pertinent questions.


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PostPosted: Fri Oct 28, 2011 7:56 am 
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I was going to post this earlier, but I wanted to wait the "pros" had a chance to chime in (I'm not a medic/EMT/etc).

I'm glad to know that my instinct to do the same thing seems to be validated here. Maybe it's all the ER/House medical type shows, but I have this thing that when it comes to the spine - esp. C-spine - that one can never be TOO careful. I'm having a hard time picturing a scenario where keeping it stable would be a bad thing (pros, if you know of one, please share), but I can think of many scenarios where NOT stabilizing it could be a very bad thing.

Again, you pros out there, PLEASE correct any part of that statement that needs to be.

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PostPosted: Fri Oct 28, 2011 12:03 pm 
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macandcheese wrote:
Were the medics confused before or after you gave them your size-up?


It was after, but it wasn't really them overtly saying "Why are you doing that?" It was more the overall casual attitude about the C-Spine. For instance, I had to get my keys out to give them to someone else to let them get a stretcher through another door and needed to go hands off to do so. I looked over at the EMT next to me and said "You want to hold..." and she just shrugged and told the patient not to move while I took my hands off. In addition there was just a sense of reluctance to get the backboard, as if they would have just walked the guy out if it weren't for me holding c-spine. Maybe I was just imagining it, or maybe they were just sloppy, it's hard to tell. I just had the sense that they felt it was unnecessary at the time. I'm glad to hear you guys all think it was prudent and I wasn't going over the top.


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PostPosted: Fri Oct 28, 2011 1:22 pm 
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kbilly84 wrote:
I'm having a hard time picturing a scenario where keeping it stable would be a bad thing...


C-Spine stabilization will rule out the standard "head-tilt chin lift" taught as part of BLS. In this case, the jaw thrust is advised, although that method is presumably practiced less and might not be as effective.


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PostPosted: Fri Oct 28, 2011 6:51 pm 
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johndoe wrote:
macandcheese wrote:
Were the medics confused before or after you gave them your size-up?


It was after, but it wasn't really them overtly saying "Why are you doing that?" It was more the overall casual attitude about the C-Spine. For instance, I had to get my keys out to give them to someone else to let them get a stretcher through another door and needed to go hands off to do so. I looked over at the EMT next to me and said "You want to hold..." and she just shrugged and told the patient not to move while I took my hands off. In addition there was just a sense of reluctance to get the backboard, as if they would have just walked the guy out if it weren't for me holding c-spine. Maybe I was just imagining it, or maybe they were just sloppy, it's hard to tell. I just had the sense that they felt it was unnecessary at the time. I'm glad to hear you guys all think it was prudent and I wasn't going over the top.

That's just a team of medics who don't care. Your actions were just and correct 100%.

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PostPosted: Sun Oct 30, 2011 5:24 pm 
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Altered LOC with significant mechanism (as evidenced by the shoulder dislocation--also counts as a distracting injury) and c/o back pain absolutely needs spinal immobilization. Someone with all of those won't get the collar off in the ED until they have had bony injury ruled out radiologically.

NEXUS C-spine criteria--you cannot rule out spinal injury by physical exam alone in a patient who has any of the following:
Midline tenderness
Focal neurological deficit
Decreased level of alertness
Intoxication
Distracting injury

Canadian C-spine rule is also worth reviewing. Most of the rules are aimed toward emergency department practice, but when I was still practicing prehospital we used a version of the NEXUS criteria for avoiding immobilization.

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PostPosted: Sun Oct 30, 2011 5:43 pm 
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PotatoMuncher wrote:
johndoe wrote:
macandcheese wrote:
Were the medics confused before or after you gave them your size-up?


It was after, but it wasn't really them overtly saying "Why are you doing that?" It was more the overall casual attitude about the C-Spine. For instance, I had to get my keys out to give them to someone else to let them get a stretcher through another door and needed to go hands off to do so. I looked over at the EMT next to me and said "You want to hold..." and she just shrugged and told the patient not to move while I took my hands off. In addition there was just a sense of reluctance to get the backboard, as if they would have just walked the guy out if it weren't for me holding c-spine. Maybe I was just imagining it, or maybe they were just sloppy, it's hard to tell. I just had the sense that they felt it was unnecessary at the time. I'm glad to hear you guys all think it was prudent and I wasn't going over the top.

That's just a team of medics who don't care. Your actions were just and correct 100%.


Agreed.


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PostPosted: Mon Oct 31, 2011 12:40 am 
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you all make good points from both sides of it and for one if you are a medic off duty it is always good to react and do what your trained to do but when you dont have the proper equipment to handle certain things it is best to hear on the side of caution and wait till medics arrive OS but you should always do your assessment and do what you can until they get here cause that makes there part easier and faster i agree with what you did and how you acted in the situation.

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PostPosted: Mon Oct 31, 2011 11:32 pm 
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TacAir wrote:
Please describe the pt
Tall, short, obese, young, old - what? How did you determine this was a diabetic event?

A dislocated shoulder from a standing fall indicates (to me anyway) an underlying condition past diabetes. What kind, if any, history did you get?

thx

Tac, how does the answer to any of those questions have any bearing on whether or not to take c-spine precautions?

OP, c-spine no-brainer, at least in my AO. I think the consensus is that EMS generally over reacts with regard to c-spine precuations, but as a lowly EMT-B that's not my decision to make... :wink:

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PostPosted: Tue Nov 01, 2011 1:26 am 
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kbilly84 wrote:
I'm having a hard time picturing a scenario where keeping it stable would be a bad thing (pros, if you know of one, please share)

I am no pro, but if you don't know how to clear c-spine, you are stuck holding it. There are plenty of scenarios which could require the use of your hands, which you can't do if you are holding c-spine.


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PostPosted: Tue Nov 01, 2011 4:03 am 
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In reality "C-spine control" done in pre-hospital is a joke. I'd say, the only reason, well, that's not entirely correct, the MAIN reason we do it is for litagation purposes (that's how pathetic our society is)..................Yea, all you EMT-B's can scream now, but they only truly give you the correct statistics about the effectiveness of C-spine control via C-collar and back board with head bed or head blocks until you get higher on the food chain, for instance the CCEMTP class.................then they let you in on the secrets.........Pre-hospital C-spine performed by BLS crews is very, very rarely done correctly..............and EVEN if it's done correctly, it will cause the individual supposedly immobilized patient to move due to the pain of bing placed on a hard cold back board with a torture device strapped to their neck in the form of an overpriced C-collar...........The only time IN MY OPINION NOW BOYS, C-spine should be pushed on the patient is if when the initial R1 arrives, during their assessment, they find a deficit.....................THEN the circus can come to town with the C-collar and B-board and head blocks or head-bed.......................litigation is the fear, not C-spine injury..........and that ladies and gentleman is one of the reasons I vomit when I see how some crews treat patients..........BTW, dude, Tac Air is asking those questions because he's showing you that their are more fators that need to be known before you attack someone with a c-collar.


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PostPosted: Tue Nov 01, 2011 6:15 am 
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IANMCDEVITT wrote:
BTW, dude, Tac Air is asking those questions because he's showing you that their are more fators that need to be known before you attack someone with a c-collar.

Not according to the cookbook written by my medical director, dude. Trauma from falls = this EMT controls C-spine. Whether or not a person is fat, short, diabetic, or what age they are has 0 bearing on whether or not I'm taking c-spine precautions. It may change the way I'm going to attempt to maintain neutral c-spine alignment, but not the fact that I am supposed to attempt it. You'll remember the OP said he/she manually held c-spine, not that he/she did the whole song and dance. Holding manual or using a towel roll or any host of other things can be done to address the factors that TacAir mentioned, but that's a technique issue, not a control c-spine or not issue.

Maybe a person farther up the food chain will make a different call, but we're all about following protocol and adhering to scope of practice here on the ZS first aid forums, right? I'll let the parmedics that show up tell me to stop doing what I'm doing if they want to, at that point patient care is pretty much on them. Trust me, I'm HAPPY to wander back to my big red truck without ever having to unleash the hounds of c-spine control on some unsuspecting patient... :wink:

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PostPosted: Tue Nov 01, 2011 8:58 am 
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Then can you wander back to your big red truck right now and let the medical folks handle the medical and trauma calls? When I need some water sprayed on something, I'll call you ?


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PostPosted: Tue Nov 01, 2011 11:47 am 
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IANMCDEVITT wrote:
Then can you wander back to your big red truck right now and let the medical folks handle the medical and trauma calls? When I need some water sprayed on something, I'll call you ?

Ah, clever. Rude, but clever. I don't have all the fancy certs you do Ian, but I've been an EMT for 15 years, career firefighter for 12, and we've been doing medical and trauma response for decades on my department. Lots of good EMT's, paras, prior service combat medics, etc. on my department. Hate to break it to you, but in practically all parts of the nation today firefighters = 'the medical folks'. Maybe you've had bad experiences with that, we happen to have a pretty great relationship with the transport and ALS guys/gals in our area, and our Medical Director (he's another guy with a few pretty impressive letters after his name) is likewise well respected.

My question was directed to TacAir, a guy who generally gives good scoop. I still can't see how the questions he asked have any bearing on whether or not a street level EMT needs to take c-spine precautions, only the techniques they might use to take those precautions. Feel free to enlighten me on that yourself, if you can. I'm all ears. Seriously. If there's something or somebody out there that says a short person or old person doesn't need their c-spine held in a neutral position after a fall with resulting musculoskeletal injuries, I would love to know it.

Anyhoo, getting talked down to is one of the reasons, methinks, that the First Aid forums are so lightly populated and traveled. If a guy/gal with my credentials and street experience is told to 'go away' by those with higher credentials like yourself (those who are supposed to be both the real and de facto educators in the EMS field, IMHO), I imagine it's even more hostile for a person with no training or experience. Love to stay and visit, but I've gotta go find something to spray water on. Wouldn't want to bother 'the medical folks' anymore...

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PostPosted: Tue Nov 01, 2011 2:19 pm 
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Took a second, thought about it, and now here we go:
I think the why (diabetic or otherwise) in this situation is irrelevant, as are the patient stats. You've got one, arguably two distracting injuries, a positive loss of consciousness, and a suggestive mechanism. As far as more knowledge up the hierarchy goes, even the most liberal docs I work with would keep this guy in a collar until they imaged his neck, and that's not anti-litigation, that's good medicine. The reason I came to this conclusion is that I can not imagine a normalized EMS scenario (non-wilderness, non-TEMS) where it would be appropriate to clear this man's c-spine in the field. No matter what his size, age, or history.


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PostPosted: Tue Nov 01, 2011 4:31 pm 
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You absolutely did the right thing.


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