Friday, February 27

You Make the Call...C-Spine Precautions

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.


firefighter / paramedic said...

no c spine. How long has he been walking around without a collar since the incident? Besides I am not buying the bat story. Not too many bouncers are employed to swing basebal bats. If nurse crotchet has anything to say it is only because now she has to do something.

Anonymous said...

Our guidelines state that if there is significant trauma above the clavicles and with consideration to MOI, then collar and board. However in this case I would argue that this wasn't significant trauma, and as long as he didnt have any central C-spine, back pain or LOC then I wouldn't have boarded him.
Even if he ended up having a C-spine injury as long as my PRF (patient report form) recorded my findings accurately, I'm pretty confident I would be absolutely fine if a complaint came in.

Anonymous said...

I would explain to the pt. that we would really like to board and collar him as a precaution. If he refuses, it is HIS call and it would be so noted on the PCR (PRF). If he is conscious and alert and competent to make decisions, he is able to refuse any treatment. No need to go through the thrashing scene. His lack of recollection concerns me, you may have a sleeper injury here.
We had a "refused but then returned later" about 2 months ago, and we did the full immobilization. I later learned the pt. had a slight spinal compression injury. You never know.
Capt. Tom

chris said...

Don't you just hate those calls. With no signs of intoxication, A & O X 4, and fully understands the risks and complications, AMA is granted. That is what we hear every day from Medical control when we punt. Our training and better judgement tells us, when in doubt, whip it out. But your always going to have that difficult patient. Since we don't diagnose patients (even though 80% of MI's are diagnosed by Paramedics), I will give it my best effort to talk my patient into the C-spine, but if negotiations fail, I punt.

Big Show said...

Honestly, as an EMT who got there and has no real way of knowing what happened, and being presented with a large head laceration, I'd go for the board and collar, because "you never know" Better safe than sorry...I'd just explain the risks of not getting a board and collar "Sir, its for your own protection, we don't have an X-ray etc". If he doesn't want it, he doesn't want it, not much we can do. My agency allows a PT. to sign a refusal for a board and collar, so the liability issue is non existent.

2 wheel terror said...

Damn cops, always making the call to you guys, to make the call.