When we hear a person has had a fall, there are a series of questions to be asked to find out more about the fall. Most of these establish mechanism, or the likelihood an injury has resulted. Most of the time there are factors in play that remove all of our normal indicators and put us back at square one. Other times it is obvious what we need to be concerned about.But what about when the story evolves into a grey area?
A cable TV installer was working on a rooftop when he stepped through a plastic skylight. The opening is approx 3 foot by 3 foot and he was brought down to the street by residents of the apartment building.
As units arrive you hear he has fallen through a skylight 20 feet over a staircase and is bleeding from the legs, arms and face. C-Spine precautions are taken as you learn he caught himself on the edges of the skylight and was raised back up through the opening by residents.
Is it a fall? From how high? Do we need to maintain C-spine precautions?
You make the call.
Comments
"Is there any evidence that those with spinal fractures are not harmed by immobilization?
Is there any evidence that those with spinal fractures receive any benefit from spinal immobilization? As far as I know, the answer to both questions is No."
I am not an absolutist. I don't do a BGL on every patient, don't put the cardiac monitor on every patient, I don't c-spine every fall and don't start IV's on every patient. I like to think that paramedics can use their mind. We cannot be driven solely on fear of litigation with our treatments, and need to be confident and justified in our decisions. Who would have thought that we would do CPR without ventilation (CCR), or use CPAP in the field. I am sure c-spine is and will be studied and modified from current standards.
C-spine clearance protocols are becoming more common place because studies are showing C-spine/full body immobilization CAN cause harm, primarily because of the lack of identifying and compensating for spinal curvature. We are taught to 'pad for void spaces' when boarding . . . but how often have you seen anyone do this? Because EVERYONE's spine is curved! Every single person place on a backboard should have padding. In most cases, up until about age 10 or so, every child should have padding under their torso, and all adults should have minimum padding under the head. That's for patient's with a standard spine curvature. An elderly patient with advanced kyphosis needs a large amount of padding to maintain their head and neck in neutral position. With high indices of suspicion for osteoarthritis, spinal stenosis, and osteopenia/-porosis, these patients are especially susceptible to injury from backboarding while at the same time being highly prone to spinal injuries from minor falls.
I'm a paramedic with pronounced C-, T-, and L-spine curvature because of a broken L1 vertebra I experienced as a teenager in a MVC. If I am ever in another MVC or other accident with potential spinal implications, I hope that I remain conscious long enough to refuse to be boarded supine on a long board. The curvature of my back is so severe that 'padding' appropriately would be almost impossible, and placing/securing my curved spine on a long straight board would only serve to exacerbate any potential injury.
When teaching ITLS, I stress to students the importance of proper evaluation and packaging of trauma patients with regards to spinal precautions, stressing that when it comes to the spine, we need to conform our equipment to the patient, not conform the patient to our equipment!
In the same way the SMR can prevent further injury and paralysis, it can also CAUSE injury and paralysis. If local protocols allow for ruling out C-spine, learn it and use it when applicable. And on those grey areas, use common sense and good judgement. Live and learn outside the box.
1. unconscious
2. altered/disoriented
3. loss of consciousness
4. suspicion of ETOH/drug intoxication
5. Cervical spine/back pain
6. cervical spine/back tenderness, or deformity
7. cervical spine/back pain with motion
8. neurological deficit (-PMS in any extremity)
9. other painful or distracting injuries (such as open femur fracture which could potentially cause more pain than spinal injury)......
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-If a patient presents with ANY of these you must perform c-spine precautions. No matter what the MOI is.