You Make the Call – A fall or not a fall?

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.

Agree? Disagree? Have something to add? Why not leave a comment or subscribe to the RSS feed to have future articles delivered to your feed reader?

70 thoughts on “You Make the Call – A fall or not a fall?”

  1. In our service we have two categorisations for a fall – fall from greater, or less than, own height. Keeps it simple. :) In this case, fall > own height.

    As for C-spine, whilst I’m aware that there are efforts to reduce the amount of unnecessary immobilisations, our protocol is simple – if there is a suspicion of C-spine injury, then until the spine is cleared, they’re boarded and collared. So, yeah, in my book, they get immobilised as best as we can.

  2. In our service we have two categorisations for a fall – fall from greater, or less than, own height. Keeps it simple. :) In this case, fall > own height.

    As for C-spine, whilst I'm aware that there are efforts to reduce the amount of unnecessary immobilisations, our protocol is simple – if there is a suspicion of C-spine injury, then until the spine is cleared, they're boarded and collared. So, yeah, in my book, they get immobilised as best as we can.

  3. Unless he complained of head neck or back pain, I felt confident I didn’t feel any step offs, and there was no LOC or AMS, then I wouldn’t board and collar him.

  4. In our service we have two categorisations for a fall – fall from greater, or less than, own height. Keeps it simple. :) In this case, fall > own height.

    As for C-spine, whilst I'm aware that there are efforts to reduce the amount of unnecessary immobilisations, our protocol is simple – if there is a suspicion of C-spine injury, then until the spine is cleared, they're boarded and collared. So, yeah, in my book, they get immobilised as best as we can.

  5. Unless he complained of head neck or back pain, I felt confident I didn't feel any step offs, and there was no LOC or AMS, then I wouldn't board and collar him.

  6. I’d say fall… To me it sounds like he fell through, and grabbed the edges of the sky light (right?) The scrapes on his face indicate he hit his head on something (although maybe they were caused when he was being dragged out). Rather then worry as much about compression injuries, I would worry about over extension… Did anything dislocate/ tear as he caught himself and stopped the forces of gravity from pulling him down? I would make sure he had no LOC, and no pain in his neck/ back, and palp it real good, check for neuro deficits, and if everything came back fine, then I wouldn’t back board

  7. I'd say fall… To me it sounds like he fell through, and grabbed the edges of the sky light (right?) The scrapes on his face indicate he hit his head on something (although maybe they were caused when he was being dragged out). Rather then worry as much about compression injuries, I would worry about over extension… Did anything dislocate/ tear as he caught himself and stopped the forces of gravity from pulling him down? I would make sure he had no LOC, and no pain in his neck/ back, and palp it real good, check for neuro deficits, and if everything came back fine, then I wouldn't back board

  8. It’s not the fall that kills you, it’s how fast you stop. In this case, there’s no impact. I would worry about possible torn ligaments of arms and shoulders. But no C-spine.

  9. It's not the fall that kills you, it's how fast you stop. In this case, there's no impact. I would worry about possible torn ligaments of arms and shoulders. But no C-spine.

  10. I'd say fall… To me it sounds like he fell through, and grabbed the edges of the sky light (right?) The scrapes on his face indicate he hit his head on something (although maybe they were caused when he was being dragged out). Rather then worry as much about compression injuries, I would worry about over extension… Did anything dislocate/ tear as he caught himself and stopped the forces of gravity from pulling him down? I would make sure he had no LOC, and no pain in his neck/ back, and palp it real good, check for neuro deficits, and if everything came back fine, then I wouldn't back board

  11. We still haven’t proven that “spinal precautions” as we use them do anything good to our patients in the field. In fact we have seen quite the contrary in the only medical research available on the topic. I’m not of the opinion that we should be strapping people to things unless they try to hurt us.

    It sounds to me like a short fall, essentially the same as ground level, since he fell to the level of his feet. Let’s not triage based on what a frantic 911 caller said several minutes ago, but on patient presentation. We’ve even seen in research that mechanism only validates an increased index of suspicion for injuries, but does not justify over-triage. Does the assessment make it seem like he has a broken neck? If not, he probably doesn’t.

  12. It's not the fall that kills you, it's how fast you stop. In this case, there's no impact. I would worry about possible torn ligaments of arms and shoulders. But no C-spine.

  13. I’d say if you did a thorough assessment and found pertinent negatives like no neck or back pain with/without palpation and a fall less than own height AND the patient was considered reliable (not intoxicated, no change in LOC, etc.) then C-Spine would be unnecessary. However, if the C-Collar is already on him and he’s halfway on the board I wouldn’t stop until a physician cleared him and told me to remove the C-Spine precautions. I’ve learned how to apply and when to apply. And in a wilderness setting when to remove. But as far as urban EMT-Basic scope of practice is concerned, once the C-Spine precautions are done and done well, I’m going to leave them in place until I reach the hospital. I could be wrong but that’s my best shot.

  14. I'd say if you did a thorough assessment and found pertinent negatives like no neck or back pain with/without palpation and a fall less than own height AND the patient was considered reliable (not intoxicated, no change in LOC, etc.) then C-Spine would be unnecessary. However, if the C-Collar is already on him and he's halfway on the board I wouldn't stop until a physician cleared him and told me to remove the C-Spine precautions. I've learned how to apply and when to apply. And in a wilderness setting when to remove. But as far as urban EMT-Basic scope of practice is concerned, once the C-Spine precautions are done and done well, I'm going to leave them in place until I reach the hospital. I could be wrong but that's my best shot.

  15. We still haven't proven that “spinal precautions” as we use them do anything good to our patients in the field. In fact we have seen quite the contrary in the only medical research available on the topic. I'm not of the opinion that we should be strapping people to things unless they try to hurt us.

    It sounds to me like a short fall, essentially the same as ground level, since he fell to the level of his feet. Let's not triage based on what a frantic 911 caller said several minutes ago, but on patient presentation. We've even seen in research that mechanism only validates an increased index of suspicion for injuries, but does not justify over-triage. Does the assessment make it seem like he has a broken neck? If not, he probably doesn't.

  16. I'd say if you did a thorough assessment and found pertinent negatives like no neck or back pain with/without palpation and a fall less than own height AND the patient was considered reliable (not intoxicated, no change in LOC, etc.) then C-Spine would be unnecessary. However, if the C-Collar is already on him and he's halfway on the board I wouldn't stop until a physician cleared him and told me to remove the C-Spine precautions. I've learned how to apply and when to apply. And in a wilderness setting when to remove. But as far as urban EMT-Basic scope of practice is concerned, once the C-Spine precautions are done and done well, I'm going to leave them in place until I reach the hospital. I could be wrong but that's my best shot.

  17. I’m going to say fall from standing position, with a sudden awkward decelaration/stop. He has lacerations to his face, arms and legs (how did they get on his face?) That says to me that they are possibly distracting injuries. Although there is a push to reduce the amount of c-spine interventions in the prehospital setting, I absolutely would feel that this patient warrants full C-Spine immobilization.

    Keep in mind that we are dealing with a different sort of fall here. The forces would suggest a compression injury rather than some sort of lateral or Anterior to Posterior force.

  18. Our Medical Control protocols allows us to clear c-spine in the field. I haven’t met anyone stupid or arrogant enough to do it. I’ll board and collar simple syncope. Can’t hurt and it might help.

    1. Our Medical Control protocols allows us to clear c-spine in the field. I haven’t met anyone stupid or arrogant enough to do it.

      There are no words…..

    2. WOW! Thats all I had for a long time but then again… The cookbook (protocol) most likely allows you to omit spinal motion restrictions and not “clear” c-spine in the field. It seems that your doctor has more confidence in the level of education and ability to appropriately assess a patient than the field crews do in your service. I would think that you might want to check out the local PHTLS class or do some small amount of research, or even- i dont know make the statement “cant hurt and might help” to your medical director and see what their reaction is… most likely the doc wont be pleased with the application of potentially harmful treatment without appropriate assessment.

    3. Your Medical Control sees it fit to give you an expanded scope of practice that many systems would love to have… There’s nothing stupid or arrogant about that.

    4. The ability to properly assess the potential for spinal injury in the field and potentially clear the c-spine is not stupid or arrogant; it’s simply good medicine. The State of Maine examination is industry standard and has the research-based evidence to back it up. Current research actually shows that placing patients in spinal precautions who don’t need it may potentially be harmful.

      Please fight the urge to become a “cookbook” medic who simply performs procedures to “cover your own ass”. EMS is a new field and it’s up to us to make sure that our scopes continue to expand and we are given more autonomy. By treating without thinking you are part of an appallingly large group in EMS who are going to relegate us back to a time when ambulances were glorified taxi cabs. Please be a better care provider than that.

  19. Goes either way. Depends on the medic, and either way can be defended. For me, if I hear he caught himself, denies neck/back pain, denies loss of consciousness, is alert and oriented and upon exam I feel no step offs or deformities… I probably wouldn’t package him Even if you called it a fall… I’d call it fall from less then standing w/ negative LOC. The why I’m trained, this typically does not fall under guidelines for cspine requirement. Unless of course something in exam/history tells us otherwise.

    On the other hand, if I wasn’t first on and first responders had him packaged already, I probably would leave him like that. Or at least explain his options to him and let see how he felt.

    1. I dont really agree with explaining his options to him.. We’re not talking about transporting vs non-transporting, we are talking about treatment. Once he decides to go, in my opinion the course of treatment and the burden of the decisions made fall on the Medic and not the Patient, unless they are adimately refusing, informed of the risks OF refusing, but that must be done by their own free will, not by a Medic/EMT asking them if they want treatment A vs treatment B.

      That would be like asking a patient if he wants aspirin, nitro and a line for chest pain. He called you, you’re the professional, and the decision of how he is packaged is up to you.

  20. I'm going to say fall from standing position, with a sudden awkward decelaration/stop. He has lacerations to his face, arms and legs (how did they get on his face?) That says to me that they are possibly distracting injuries. Although there is a push to reduce the amount of c-spine interventions in the prehospital setting, I absolutely would feel that this patient warrants full C-Spine immobilization.

    Keep in mind that we are dealing with a different sort of fall here. The forces would suggest a compression injury rather than some sort of lateral or Anterior to Posterior force.

  21. Yes, it’s a fall. Granted he caught himself (according to one set of witnesses) on the edges of the skylight, he still fell. What kind of contortions did his body go thru during the “catching” himself? Could he have injured his back or neck while trying to catch himself? Could he have hit his head/neck on the edges of the skylight while catching himself? I don’t know, I wasn’t there to witness it so I’m going to package this gentleman in full spinal immobilization until proven otherwise.
    Even if I had protocols to “clear c-spine in the field” I’m not going to take that chance. That is what X-ray machines and CT scans are for and I’m not jumping on the boat that c-spine precautions and spine boards cause more injuries. Not if they are done properly.
    This scenario brings to life some of the problems in EMS~getting two sets of stories of what events actually occurred and whom to believe. If the patient is conscious and alert you can often times get a closer picture of the reality of the event, but keep in mind that their adrenaline was/is high and they sometimes will not feel an injury until later, nor will they accurately remember the exact sequence of events all the time.

  22. I'm going to say fall from standing position, with a sudden awkward decelaration/stop. He has lacerations to his face, arms and legs (how did they get on his face?) That says to me that they are possibly distracting injuries. Although there is a push to reduce the amount of c-spine interventions in the prehospital setting, I absolutely would feel that this patient warrants full C-Spine immobilization.

    Keep in mind that we are dealing with a different sort of fall here. The forces would suggest a compression injury rather than some sort of lateral or Anterior to Posterior force.

  23. Our Medical Control protocols allows us to clear c-spine in the field. I haven't met anyone stupid or arrogant enough to do it. I'll board and collar simple syncope. Can't hurt and it might help.

  24. Our Medical Control protocols allows us to clear c-spine in the field. I haven't met anyone stupid or arrogant enough to do it.

    There are no words…..

  25. Goes either way. Depends on the medic, and either way can be defended. For me, if I hear he caught himself, denies neck/back pain, denies loss of consciousness, is alert and oriented and upon exam I feel no step offs or deformities… I probably wouldn't package him Even if you called it a fall… I'd call it fall from less then standing w/ negative LOC. The why I'm trained, this typically does not fall under guidelines for cspine requirement. Unless of course something in exam/history tells us otherwise.

    On the other hand, if I wasn't first on and first responders had him packaged already, I probably would leave him like that. Or at least explain his options to him and let see how he felt.

  26. I dont really agree with explaining his options to him.. We're not talking about transporting vs non-transporting, we are talking about treatment. Once he decides to go, in my opinion the course of treatment and the burden of the decisions made fall on the Medic and not the Patient, unless they are adimately refusing, informed of the risks OF refusing, but that must be done by their own free will, not by a Medic/EMT asking them if they want treatment A vs treatment B.

    That would be like asking a patient if he wants aspirin, nitro and a line for chest pain. He called you, you're the professional, and the decision of how he is packaged is up to you.

  27. WOW! Thats all I had for a long time but then again… The cookbook (protocol) most likely allows you to omit spinal motion restrictions and not “clear” c-spine in the field. It seems that your doctor has more confidence in the level of education and ability to appropriately assess a patient than the field crews do in your service. I would think that you might want to check out the local PHTLS class or do some small amount of research, or even- i dont know make the statement “cant hurt and might help” to your medical director and see what their reaction is… most likely the doc wont be pleased with the application of potentially harmful treatment without appropriate assessment.

  28. Yes, it's a fall. Granted he caught himself (according to one set of witnesses) on the edges of the skylight, he still fell. What kind of contortions did his body go thru during the “catching” himself? Could he have injured his back or neck while trying to catch himself? Could he have hit his head/neck on the edges of the skylight while catching himself? I don't know, I wasn't there to witness it so I'm going to package this gentleman in full spinal immobilization until proven otherwise.
    Even if I had protocols to “clear c-spine in the field” I'm not going to take that chance. That is what X-ray machines and CT scans are for and I'm not jumping on the boat that c-spine precautions and spine boards cause more injuries. Not if they are done properly.
    This scenario brings to life some of the problems in EMS~getting two sets of stories of what events actually occurred and whom to believe. If the patient is conscious and alert you can often times get a closer picture of the reality of the event, but keep in mind that their adrenaline was/is high and they sometimes will not feel an injury until later, nor will they accurately remember the exact sequence of events all the time.

  29. Your Medical Control sees it fit to give you an expanded scope of practice that many systems would love to have… There's nothing stupid or arrogant about that.

  30. Well it is definitely a fall, but so is a patient tripping over a curb or sliding out of a chair. The important aspect to determine is whether the patient is at risk for spinal injury or not. Based on the fact that he did not fall 20 feet through the skylight to the stairs below (a clear no-brainer for c-spine precautions) I think that the patient would qualify as “questionable mechanism” and as such would warrant a State of Maine examination. The exam consists of:
    – Lack of point tenderness to the spinous processes during direct palpation
    – Ability to abduct and adduct the 2nd/3rd and 3rd/4th digits against force bilaterally
    – Ability to flex and extend the wrists against force bilaterally
    – Ability to differentiate between sharp and dull pressure on both upper extremities (I use the hands)
    – Lack of numbness/tingling bilaterally

    The State of Maine exam is evidence-based and well proven in the field. Please take a moment to looks up some resources on PubMed about it. You’ll be doing your system and your patients a huge service.

    I have a similar post on my blog about trauma activations, another great “You Make the Call” situation: http://510medic.wordpress.com/2010/04/30/why-did-you-bring-this-patient-here/

  31. It’s not a fall. It’s a near fall, and he needs to be evaluated for his lacerations, but that’s it. Unless he tells you he hit his head when he fell through the skylight there is no reason in the world to immobilize him. Medic Jake is absolutely right in his comments. Even the ACS recognizes that MOI is a poor predictor of injuries. Treat the patient before you, not the one in the text books.

  32. The ability to properly assess the potential for spinal injury in the field and potentially clear the c-spine is not stupid or arrogant; it's simply good medicine. The State of Maine examination is industry standard and has the research-based evidence to back it up. Current research actually shows that placing patients in spinal precautions who don't need it may potentially be harmful.

    Please fight the urge to become a “cookbook” medic who simply performs procedures to “cover your own ass”. EMS is a new field and it's up to us to make sure that our scopes continue to expand and we are given more autonomy. By treating without thinking you are part of an appallingly large group in EMS who are going to relegate us back to a time when ambulances were glorified taxi cabs. Please be a better care provider than that.

  33. Well it is definitely a fall, but so is a patient tripping over a curb or sliding out of a chair. The important aspect to determine is whether the patient is at risk for spinal injury or not. Based on the fact that he did not fall 20 feet through the skylight to the stairs below (a clear no-brainer for c-spine precautions) I think that the patient would qualify as “questionable mechanism” and as such would warrant a State of Maine examination. The exam consists of:
    – Lack of point tenderness to the spinous processes during direct palpation
    – Ability to abduct and adduct the 2nd/3rd and 3rd/4th digits against force bilaterally
    – Ability to flex and extend the wrists against force bilaterally
    – Ability to differentiate between sharp and dull pressure on both upper extremities (I use the hands)
    – Lack of numbness/tingling bilaterally

    The State of Maine exam is evidence-based and well proven in the field. Please take a moment to looks up some resources on PubMed about it. You'll be doing your system and your patients a huge service.

    I have a similar post on my blog about trauma activations, another great “You Make the Call” situation: http://510medic.wordpress.com/2010/04/30/why-di

  34. We as EMS providers have to remember, what we do in the field cascades into what happens in the ER. If you bring someone in with c-spine precautions, you can bet that they are going to get radiated. If you do a good assessment and determine that the patient isn’t in need of c-spine, you may have saved your patient radiation, pain and discomfort, and thus are a good patient advocate. C-spine precautions are way over rated and are actually being proven to cause harm. Good medics should look for a reason to perform a procedure and not be mindless, spineless robots. With the minimal information provided, I would not immobilize this patient. Sorry for those who disagree, but that may be my 26 years of full time EMS experience talking.

    1. I can agree with you to a point. EXPERIENCE does you no good in a court room, it is what your protocol (s) dictate. I would like to see the evidence or facts that show C-Spine precautions have caused more harm, and when was this study done and where.

      1. http://roguemedic.blogspot.com/2009/11/spinal-immobilization-harm.html

        “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.

        1. Ventilations over compressions, niphedapine, sodium bicarb and calcium as first line code drugs, lasix, 3 stacked shocks, rhythm analysis after shock, etc. My point being without studies and review of “Standard of Care” we sure have been doing more HARM than good for a long time. I think current c-spine practice falls well within that statement.

  35. It's not a fall. It's a near fall, and he needs to be evaluated for his lacerations, but that's it. Unless he tells you he hit his head when he fell through the skylight there is no reason in the world to immobilize him. Medic Jake is absolutely right in his comments. Even the ACS recognizes that MOI is a poor predictor of injuries. Treat the patient before you, not the one in the text books.

  36. We as EMS providers have to remember, what we do in the field cascades into what happens in the ER. If you bring someone in with c-spine precautions, you can bet that they are going to get radiated. If you do a good assessment and determine that the patient isn't in need of c-spine, you may have saved your patient radiation, pain and discomfort, and thus are a good patient advocate. C-spine precautions are way over rated and are actually being proven to cause harm. Good medics should look for a reason to perform a procedure and not be mindless, spineless robots. With the minimal information provided, I would not immobilize this patient. Sorry for those who disagree, but that may be my 26 years of full time EMS experience talking.

  37. It is a fall, for this simple reason he went through a “skylight” maybe not the whole way. There is still a mechanism of injury to the spine. Until proven otherwise: C-SPINE PRECAUTION is a must and a standard of care, we as EMS providers forget this sometime(s) when dealing with patient(s) we are trained to do no further HARM.

    1. It is a questionable mechanism not a positive mechanism. The State of Maine criteria has been proven to be a teachable and appropriate method for clearing the cervical spine in the field. There’s no link to the free article, but the summary fills you in: “Linkage of EMS and hospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers. ” There were no acute spinal fractures missed using the criteria. Check it out: http://www.ncbi.nlm.nih.gov/pubmed/16147480

  38. The ability to properly assess the potential for spinal injury in the field and potentially clear the c-spine is not stupid or arrogant; it's simply good medicine. The State of Maine examination is industry standard and has the research-based evidence to back it up. Current research actually shows that placing patients in spinal precautions who don't need it may potentially be harmful.

    Please fight the urge to become a “cookbook” medic who simply performs procedures to “cover your own ass”. EMS is a new field and it's up to us to make sure that our scopes continue to expand and we are given more autonomy. By treating without thinking you are part of an appallingly large group in EMS who are going to relegate us back to a time when ambulances were glorified taxi cabs. Please be a better care provider than that.

  39. Well it is definitely a fall, but so is a patient tripping over a curb or sliding out of a chair. The important aspect to determine is whether the patient is at risk for spinal injury or not. Based on the fact that he did not fall 20 feet through the skylight to the stairs below (a clear no-brainer for c-spine precautions) I think that the patient would qualify as “questionable mechanism” and as such would warrant a State of Maine examination. The exam consists of:
    – Lack of point tenderness to the spinous processes during direct palpation
    – Ability to abduct and adduct the 2nd/3rd and 3rd/4th digits against force bilaterally
    – Ability to flex and extend the wrists against force bilaterally
    – Ability to differentiate between sharp and dull pressure on both upper extremities (I use the hands)
    – Lack of numbness/tingling bilaterally

    The State of Maine exam is evidence-based and well proven in the field. Please take a moment to looks up some resources on PubMed about it. You'll be doing your system and your patients a huge service.

    I have a similar post on my blog about trauma activations, another great “You Make the Call” situation: http://510medic.wordpress.com/2010/04/30/why-di

  40. It's not a fall. It's a near fall, and he needs to be evaluated for his lacerations, but that's it. Unless he tells you he hit his head when he fell through the skylight there is no reason in the world to immobilize him. Medic Jake is absolutely right in his comments. Even the ACS recognizes that MOI is a poor predictor of injuries. Treat the patient before you, not the one in the text books.

  41. We as EMS providers have to remember, what we do in the field cascades into what happens in the ER. If you bring someone in with c-spine precautions, you can bet that they are going to get radiated. If you do a good assessment and determine that the patient isn't in need of c-spine, you may have saved your patient radiation, pain and discomfort, and thus are a good patient advocate. C-spine precautions are way over rated and are actually being proven to cause harm. Good medics should look for a reason to perform a procedure and not be mindless, spineless robots. With the minimal information provided, I would not immobilize this patient. Sorry for those who disagree, but that may be my 26 years of full time EMS experience talking.

  42. It is a fall, for this simple reason he went through a “skylight” maybe not the whole way. There is still a mechanism of injury to the spine. Until proven otherwise: C-SPINE PRECAUTION is a must and a standard of care, we as EMS providers forget this sometime(s) when dealing with patient(s) we are trained to do no further HARM.

  43. I can agree with you to a point. EXPERIENCE does you no good in a court room, it is what your protocol (s) dictate. I would like to see the evidence or facts that show C-Spine precautions have caused more harm, and when was this study done and where.

  44. http://roguemedic.blogspot.com/2009/11/spinal-i

    “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.

  45. Ventilations over compressions, niphedapine, sodium bicarb and calcium as first line code drugs, lasix, 3 stacked shocks, rhythm analysis after shock, etc. My point being without studies and review of “Standard of Care” we sure have been doing more HARM than good for a long time. I think current c-spine practice falls well within that statement.

  46. It is a questionable mechanism not a positive mechanism. The State of Maine criteria has been proven to be a teachable and appropriate method for clearing the cervical spine in the field. There's no link to the free article, but the summary fills you in: “Linkage of EMS and hospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers. ” There were no acute spinal fractures missed using the criteria. Check it out: http://www.ncbi.nlm.nih.gov/pubmed/16147480

  47. Primum non nocere: First, do no harm . . . THE most fundamental guiding principle of medical care, field or hospital. Nowhere in my training did I ever come across any texts or reference that stated my fundamental guiding principle was ‘First, cover my own ass.’ Protocols or guidelines are meant to be paired with common sense and professional knowledge – at all times! Experience and growth as an EMT (ALS or BLS) should be taking us outside our box, not sealing us inside.

    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.

  48. Primum non nocere: First, do no harm . . . THE most fundamental guiding principle of medical care, field or hospital. Nowhere in my training did I ever come across any texts or reference that stated my fundamental guiding principle was 'First, cover my own ass.' Protocols or guidelines are meant to be paired with common sense and professional knowledge – at all times! Experience and growth as an EMT (ALS or BLS) should be taking us outside our box, not sealing us inside.

    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.

  49. Primum non nocere: First, do no harm . . . THE most fundamental guiding principle of medical care, field or hospital. Nowhere in my training did I ever come across any texts or reference that stated my fundamental guiding principle was 'First, cover my own ass.' Protocols or guidelines are meant to be paired with common sense and professional knowledge – at all times! Experience and growth as an EMT (ALS or BLS) should be taking us outside our box, not sealing us inside.

    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.

  50. 9 reasons to c-spine…
    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)……
    -
    -If a patient presents with ANY of these you must perform c-spine precautions. No matter what the MOI is.

  51. 9 reasons to c-spine…
    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)……
    -
    -If a patient presents with ANY of these you must perform c-spine precautions. No matter what the MOI is.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>