You Make the Call – Stairway

ymtk

The call was simple when it came in, a man has fallen and is bleeding.

As you climb the granite steps, they are narrow and steep and so far each one is covered in spots of bright red blood.  As you step carefully around the spots and up to the third switch back you find your patient standing in the corner, head laceration over the right eye, slurred speech and a wicked flail chest.  He’s 83.

He’s grasping onto the railings at a turn in the stairs, barely enough room for you to pass by and survey from above.

Similar to this photo from a hotel somewhere, the fellow with the red spot on his face is your patient, just imagine him standing straight up in the corner.  The stairs down around the corner are just as steep and narrow as the stairs here.

How will you deal with C-Spine precautions, if at all?

You make the call.

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47 thoughts on “You Make the Call – Stairway”

  1. I hate when this happens.
    One you could “clear the c-spine if possible and walk him down, the question is he likley to pass out and or fall again even with assistance?
    Two you could clear the c-spine and put him in a stair chair and carry him down.
    Three you could do a standing take down with a ankle hitch and webbing seat to keep him from sliding down the board if you think you have enough room and he will let you lie him flat with that flail chest.
    Four you could place him in a KED while standing and then carry him down in a stair chair.
    Five you could call for a ladder and place him in a stokes with LSB and take him out the window but again he would need to lie flat for that.
    No real Good and eazy options exist.

  2. I'd take normal c-spine precautions but I'd opt to use spider straps in this incident and take the bottom straps and use them to support the bottom of the feet. Slide the board on the stairs and stand it upright (slowly) when we get to a tight corner and can't continue sliding. In this case I think C-spine precautions are not an option to lax on. Imobolizing him will also help stabilize that flail chest in the time it takes to get up the stairs.

  3. I hate when this happens.
    One you could “clear the c-spine if possible and walk him down, the question is he likley to pass out and or fall again even with assistance?
    Two you could clear the c-spine and put him in a stair chair and carry him down.
    Three you could do a standing take down with a ankle hitch and webbing seat to keep him from sliding down the board if you think you have enough room and he will let you lie him flat with that flail chest.
    Four you could place him in a KED while standing and then carry him down in a stair chair.
    Five you could call for a ladder and place him in a stokes with LSB and take him out the window but again he would need to lie flat for that.
    No real Good and eazy options exist.

  4. I hate when this happens.
    One you could “clear the c-spine if possible and walk him down, the question is he likley to pass out and or fall again even with assistance?
    Two you could clear the c-spine and put him in a stair chair and carry him down.
    Three you could do a standing take down with a ankle hitch and webbing seat to keep him from sliding down the board if you think you have enough room and he will let you lie him flat with that flail chest.
    Four you could place him in a KED while standing and then carry him down in a stair chair.
    Five you could call for a ladder and place him in a stokes with LSB and take him out the window but again he would need to lie flat for that.
    No real Good and eazy options exist.

  5. I’d take normal c-spine precautions but I’d opt to use spider straps in this incident and take the bottom straps and use them to support the bottom of the feet. Slide the board on the stairs and stand it upright (slowly) when we get to a tight corner and can’t continue sliding. In this case I think C-spine precautions are not an option to lax on. Imobolizing him will also help stabilize that flail chest in the time it takes to get up the stairs.

  6. I’d take normal c-spine precautions but I’d opt to use spider straps in this incident and take the bottom straps and use them to support the bottom of the feet. Slide the board on the stairs and stand it upright (slowly) when we get to a tight corner and can’t continue sliding. In this case I think C-spine precautions are not an option to lax on. Imobolizing him will also help stabilize that flail chest in the time it takes to get up the stairs.

  7. I hate when this happens.
    One you could “clear the c-spine if possible and walk him down, the question is he likley to pass out and or fall again even with assistance?
    Two you could clear the c-spine and put him in a stair chair and carry him down.
    Three you could do a standing take down with a ankle hitch and webbing seat to keep him from sliding down the board if you think you have enough room and he will let you lie him flat with that flail chest.
    Four you could place him in a KED while standing and then carry him down in a stair chair.
    Five you could call for a ladder and place him in a stokes with LSB and take him out the window but again he would need to lie flat for that.
    No real Good and eazy options exist.

  8. I'd take normal c-spine precautions but I'd opt to use spider straps in this incident and take the bottom straps and use them to support the bottom of the feet. Slide the board on the stairs and stand it upright (slowly) when we get to a tight corner and can't continue sliding. In this case I think C-spine precautions are not an option to lax on. Imobolizing him will also help stabilize that flail chest in the time it takes to get up the stairs.

  9. Slurred speech? Hmm…could indicate badness, along with the flail chest, so let’s not rule out c-spine. I would take him out on a LBB. Secure via criss-crossed chest straps, along with straps across pelvis area and knee area. A fifth strap would be used to create a ‘stirrup’, and then the ankles secured to the LBB with 2″ tape. Before that, a neck roll fashioned from a blanket, since the regular c-collars are terribly uncomfortable for the elderly. Then fashion soft head rolls from a pair of blankets or towels. Secure the head. Then run a piece of rope in and on the bottom to serve as hand holds. This allows the board to be lifted in a vertical position from step to step without ‘bumping’ it, while it is supported at the top. I would also apply a section of rope at the top, which would aid in moveing the board down the stairs in a close-to-horizontal position until you got to the turns. The ropes would also help since it does not look like a very wide stairway.

  10. Slurred speech? Hmm…could indicate badness, along with the flail chest, so let’s not rule out c-spine. I would take him out on a LBB. Secure via criss-crossed chest straps, along with straps across pelvis area and knee area. A fifth strap would be used to create a ‘stirrup’, and then the ankles secured to the LBB with 2″ tape. Before that, a neck roll fashioned from a blanket, since the regular c-collars are terribly uncomfortable for the elderly. Then fashion soft head rolls from a pair of blankets or towels. Secure the head. Then run a piece of rope in and on the bottom to serve as hand holds. This allows the board to be lifted in a vertical position from step to step without ‘bumping’ it, while it is supported at the top. I would also apply a section of rope at the top, which would aid in moveing the board down the stairs in a close-to-horizontal position until you got to the turns. The ropes would also help since it does not look like a very wide stairway.

  11. Slurred speech? Hmm…could indicate badness, along with the flail chest, so let's not rule out c-spine. I would take him out on a LBB. Secure via criss-crossed chest straps, along with straps across pelvis area and knee area. A fifth strap would be used to create a 'stirrup', and then the ankles secured to the LBB with 2″ tape. Before that, a neck roll fashioned from a blanket, since the regular c-collars are terribly uncomfortable for the elderly. Then fashion soft head rolls from a pair of blankets or towels. Secure the head. Then run a piece of rope in and on the bottom to serve as hand holds. This allows the board to be lifted in a vertical position from step to step without 'bumping' it, while it is supported at the top. I would also apply a section of rope at the top, which would aid in moveing the board down the stairs in a close-to-horizontal position until you got to the turns. The ropes would also help since it does not look like a very wide stairway.

  12. OK for once I’ve gotten in here early enough to offer something different.I’m also gonna take a chance at looking stupid here.
    First, you need full c-spine and in my opionon you are not really gettting it from the KED/Stair chair, plus the KED is gonna cause a LOT of discomfort for that chest and possibly compromise breathing.
    So I’m thinking we get him on a board on the stairs and then into SKED (if you are not familiar, Just google SKED). These put lots of handles on the patient, accommodate the board, collar, headblock setup, and hold the patinet snugly in. You can do a vertical lift, stand him straight up if you need to, or lower him out a window. We carry these on our rescue. Hazmat team use the hazmat version for bragging a patients out to the decon area. Ours is a rescue variety which could be the perfect choice for this call because it gives the best protection for the patient and keeps him totally stable no matter what position. Before the final lacing up, I’d try getting a pillow in on the patients chest to see if that helps with the breathing.
    Main medical concerns here are his breathing (proper end tidal CO, and O2 sats?), his altered mental status and when it started (possible CVA prior to the fall?), possible head injury (the head lac is just a distraction, cover it when you have time and move on).
    I am staying away from the stair chair because it is very difficult to make those turns with all the handles and tracks sticking out. I am also not liking the idea of sliding the board because of the additional trauma that could be induced to the spine.. Remember, even though he is tied down, the bones still rub and scrape with each start and stop or thump on the stairs.
    This is a challenging one. I think any of the solutions might work if executed carefully. I’m not suggesting others made bad choices, I’m just trying to share what is in my mind as I think it through. I’m wondering what all of you are thinking about the priority of injuries?
    Justin you didn’t say if this is an open type stairwell? If it is, this becomes much easier. Go up one floor and anchor your line to drop right down the center of the stairwell. Set the SKED up to hang the patient horizontally and get him at waist height then just walk him down suspended. One firefighter lets out the belay as you descend and all the rescuers do is guide him as he floats down. The photograh does not look like the written description. An open stairwell would be easier.
    OK, so now do I look stupid, or did I get you thinking?

    1. The KED immobilizes the entire head, neck and back, no? So the ‘c-spine’ is covered. Any version of immobilizing this guy will be uncomfortable. Putting him in a chair will simplify the extrication. He did manage to walk to where he was found, does this change your attitude about treatment, or the severity of his injuries?

      1. The KED will do as you say and if it were normal c-spine considerations I would go that way too. But I have have patients with breathings issues in a KED and this gent has a flail chest. I would shy away from trying to do the KED route because of the possibility that it might compromise his breathing even further. Of course, you go with what you have and it depends on what you see and feel in the moment. As I said, all of the other options would work. Mostly it depands on how you see it working for that patient. Also, I was a bit anxious to present some new possibilities. SKEDS are pretty neat and do have their place. They are under used IMHO.
        Capt. Tom

      2. The KED will do as you say and if it were normal c-spine considerations I would go that way too. But I have have patients with breathings issues in a KED and this gent has a flail chest. I would shy away from trying to do the KED route because of the possibility that it might compromise his breathing even further. Of course, you go with what you have and it depends on what you see and feel in the moment. As I said, all of the other options would work. Mostly it depands on how you see it working for that patient. Also, I was a bit anxious to present some new possibilities. SKEDS are pretty neat and do have their place. They are under used IMHO.
        Capt. Tom

    2. The KED immobilizes the entire head, neck and back, no? So the ‘c-spine’ is covered. Any version of immobilizing this guy will be uncomfortable. Putting him in a chair will simplify the extrication. He did manage to walk to where he was found, does this change your attitude about treatment, or the severity of his injuries?

  13. OK for once I’ve gotten in here early enough to offer something different.I’m also gonna take a chance at looking stupid here.
    First, you need full c-spine and in my opionon you are not really gettting it from the KED/Stair chair, plus the KED is gonna cause a LOT of discomfort for that chest and possibly compromise breathing.
    So I’m thinking we get him on a board on the stairs and then into SKED (if you are not familiar, Just google SKED). These put lots of handles on the patient, accommodate the board, collar, headblock setup, and hold the patinet snugly in. You can do a vertical lift, stand him straight up if you need to, or lower him out a window. We carry these on our rescue. Hazmat team use the hazmat version for bragging a patients out to the decon area. Ours is a rescue variety which could be the perfect choice for this call because it gives the best protection for the patient and keeps him totally stable no matter what position. Before the final lacing up, I’d try getting a pillow in on the patients chest to see if that helps with the breathing.
    Main medical concerns here are his breathing (proper end tidal CO, and O2 sats?), his altered mental status and when it started (possible CVA prior to the fall?), possible head injury (the head lac is just a distraction, cover it when you have time and move on).
    I am staying away from the stair chair because it is very difficult to make those turns with all the handles and tracks sticking out. I am also not liking the idea of sliding the board because of the additional trauma that could be induced to the spine.. Remember, even though he is tied down, the bones still rub and scrape with each start and stop or thump on the stairs.
    This is a challenging one. I think any of the solutions might work if executed carefully. I’m not suggesting others made bad choices, I’m just trying to share what is in my mind as I think it through. I’m wondering what all of you are thinking about the priority of injuries?
    Justin you didn’t say if this is an open type stairwell? If it is, this becomes much easier. Go up one floor and anchor your line to drop right down the center of the stairwell. Set the SKED up to hang the patient horizontally and get him at waist height then just walk him down suspended. One firefighter lets out the belay as you descend and all the rescuers do is guide him as he floats down. The photograh does not look like the written description. An open stairwell would be easier.
    OK, so now do I look stupid, or did I get you thinking?

  14. OK for once I've gotten in here early enough to offer something different.I'm also gonna take a chance at looking stupid here.
    First, you need full c-spine and in my opionon you are not really gettting it from the KED/Stair chair, plus the KED is gonna cause a LOT of discomfort for that chest and possibly compromise breathing.
    So I'm thinking we get him on a board on the stairs and then into SKED (if you are not familiar, Just google SKED). These put lots of handles on the patient, accommodate the board, collar, headblock setup, and hold the patinet snugly in. You can do a vertical lift, stand him straight up if you need to, or lower him out a window. We carry these on our rescue. Hazmat team use the hazmat version for bragging a patients out to the decon area. Ours is a rescue variety which could be the perfect choice for this call because it gives the best protection for the patient and keeps him totally stable no matter what position. Before the final lacing up, I'd try getting a pillow in on the patients chest to see if that helps with the breathing.
    Main medical concerns here are his breathing (proper end tidal CO, and O2 sats?), his altered mental status and when it started (possible CVA prior to the fall?), possible head injury (the head lac is just a distraction, cover it when you have time and move on).
    I am staying away from the stair chair because it is very difficult to make those turns with all the handles and tracks sticking out. I am also not liking the idea of sliding the board because of the additional trauma that could be induced to the spine.. Remember, even though he is tied down, the bones still rub and scrape with each start and stop or thump on the stairs.
    This is a challenging one. I think any of the solutions might work if executed carefully. I'm not suggesting others made bad choices, I'm just trying to share what is in my mind as I think it through. I'm wondering what all of you are thinking about the priority of injuries?
    Justin you didn't say if this is an open type stairwell? If it is, this becomes much easier. Go up one floor and anchor your line to drop right down the center of the stairwell. Set the SKED up to hang the patient horizontally and get him at waist height then just walk him down suspended. One firefighter lets out the belay as you descend and all the rescuers do is guide him as he floats down. The photograh does not look like the written description. An open stairwell would be easier.
    OK, so now do I look stupid, or did I get you thinking?

  15. The KED immobilizes the entire head, neck and back, no? So the 'c-spine' is covered. Any version of immobilizing this guy will be uncomfortable. Putting him in a chair will simplify the extrication. He did manage to walk to where he was found, does this change your attitude about treatment, or the severity of his injuries?

  16. How do you clear the cspine? Do you have an xray machine in the bus? No! Board him, take all c spine precautions and stand the board up, just as you would in a city elevator, or call for fire to take him out of the window.(which would actually be my first choice. Either way…its gonna call for some muscle power to take care of this pt properly.

  17. How do you clear the cspine? Do you have an xray machine in the bus? No! Board him, take all c spine precautions and stand the board up, just as you would in a city elevator, or call for fire to take him out of the window.(which would actually be my first choice. Either way…its gonna call for some muscle power to take care of this pt properly.

  18. Although he was able to walk, that doesn’t mean that he didn’t suffer a trauma (flail chest, remember?). Also, making him walk would only exacerbate any trauma he had, so full spinal immobilization would be the only option, preventing any potential further complications that may occur by slight movements. I completely agree with the previous post in the options so I am not going to back over them. I think it has covered almost any and all of the evacuation strategies pertinent. I think it’s appropriate to say with his injuries, whether internal or external, make him a load and go situation and the pre-existing factors like potential CVA make it all the more important, meaning the quickest and safest way to get him out would be the best. Remember the ABCD’s and get his butt to the ER as quick and safe as possible!

  19. Although he was able to walk, that doesn’t mean that he didn’t suffer a trauma (flail chest, remember?). Also, making him walk would only exacerbate any trauma he had, so full spinal immobilization would be the only option, preventing any potential further complications that may occur by slight movements. I completely agree with the previous post in the options so I am not going to back over them. I think it has covered almost any and all of the evacuation strategies pertinent. I think it’s appropriate to say with his injuries, whether internal or external, make him a load and go situation and the pre-existing factors like potential CVA make it all the more important, meaning the quickest and safest way to get him out would be the best. Remember the ABCD’s and get his butt to the ER as quick and safe as possible!

  20. The KED immobilizes the entire head, neck and back, no? So the 'c-spine' is covered. Any version of immobilizing this guy will be uncomfortable. Putting him in a chair will simplify the extrication. He did manage to walk to where he was found, does this change your attitude about treatment, or the severity of his injuries?

  21. How do you clear the cspine? Do you have an xray machine in the bus? No! Board him, take all c spine precautions and stand the board up, just as you would in a city elevator, or call for fire to take him out of the window.(which would actually be my first choice. Either way…its gonna call for some muscle power to take care of this pt properly.

  22. Although he was able to walk, that doesn't mean that he didn't suffer a trauma (flail chest, remember?). Also, making him walk would only exacerbate any trauma he had, so full spinal immobilization would be the only option, preventing any potential further complications that may occur by slight movements. I completely agree with the previous post in the options so I am not going to back over them. I think it has covered almost any and all of the evacuation strategies pertinent. I think it's appropriate to say with his injuries, whether internal or external, make him a load and go situation and the pre-existing factors like potential CVA make it all the more important, meaning the quickest and safest way to get him out would be the best. Remember the ABCD's and get his butt to the ER as quick and safe as possible!

  23. Ahhh and my best friend the Reeves comes into play again. C-collar him, put him on the reeves and maneuver down the stairs where you will have more room to work to do what you need to do. Never under-estimate how a Reeves can come in handy!

  24. Ahhh and my best friend the Reeves comes into play again. C-collar him, put him on the reeves and maneuver down the stairs where you will have more room to work to do what you need to do. Never under-estimate how a Reeves can come in handy!

  25. Ahhh and my best friend the Reeves comes into play again. C-collar him, put him on the reeves and maneuver down the stairs where you will have more room to work to do what you need to do. Never under-estimate how a Reeves can come in handy!

  26. c-spine with ked and stair chair his 83 years old worry more for the head and less about the spine til you get him out and with the flail chest he does not need to be walking,the board is a no go tink it would hurt him more laying flat.The chair can make the turns were the LSB wont.

  27. The KED will do as you say and if it were normal c-spine considerations I would go that way too. But I have have patients with breathings issues in a KED and this gent has a flail chest. I would shy away from trying to do the KED route because of the possibility that it might compromise his breathing even further. Of course, you go with what you have and it depends on what you see and feel in the moment. As I said, all of the other options would work. Mostly it depands on how you see it working for that patient. Also, I was a bit anxious to present some new possibilities. SKEDS are pretty neat and do have their place. They are under used IMHO.
    Capt. Tom

  28. c-spine with ked and stair chair his 83 years old worry more for the head and less about the spine til you get him out and with the flail chest he does not need to be walking,the board is a no go tink it would hurt him more laying flat.The chair can make the turns were the LSB wont.

  29. c-spine with ked and stair chair his 83 years old worry more for the head and less about the spine til you get him out and with the flail chest he does not need to be walking,the board is a no go tink it would hurt him more laying flat.The chair can make the turns were the LSB wont.

  30. c-spine with ked and stair chair his 83 years old worry more for the head and less about the spine til you get him out and with the flail chest he does not need to be walking,the board is a no go tink it would hurt him more laying flat.The chair can make the turns were the LSB wont.

  31. The KED will do as you say and if it were normal c-spine considerations I would go that way too. But I have have patients with breathings issues in a KED and this gent has a flail chest. I would shy away from trying to do the KED route because of the possibility that it might compromise his breathing even further. Of course, you go with what you have and it depends on what you see and feel in the moment. As I said, all of the other options would work. Mostly it depands on how you see it working for that patient. Also, I was a bit anxious to present some new possibilities. SKEDS are pretty neat and do have their place. They are under used IMHO.
    Capt. Tom

  32. c-spine with ked and stair chair his 83 years old worry more for the head and less about the spine til you get him out and with the flail chest he does not need to be walking,the board is a no go tink it would hurt him more laying flat.The chair can make the turns were the LSB wont.

  33. The KED will do as you say and if it were normal c-spine considerations I would go that way too. But I have have patients with breathings issues in a KED and this gent has a flail chest. I would shy away from trying to do the KED route because of the possibility that it might compromise his breathing even further. Of course, you go with what you have and it depends on what you see and feel in the moment. As I said, all of the other options would work. Mostly it depands on how you see it working for that patient. Also, I was a bit anxious to present some new possibilities. SKEDS are pretty neat and do have their place. They are under used IMHO.
    Capt. Tom

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