C-Spine clearence in the field

[Trauma_Dog]

We are currently using a c-spine clearence protocol in the field, which requires a consultation with the on-duty supervisor. After approval for clearence, the supervisor is required to do an immediate follow up with the hospital to see if there were cervical x-rays taken and the outcome ect. This has been so successful that there is talk from our medical director about being able to do this without a supervisor consultation........Your thoughts........

[pompanofd]

HAPPY NEW YEAR , MEDICS SHOULD BE ABLE TO CALL THE SHOTS! IF YOU THINK SOMEONE NEEDS C-SPINE THEN DO IT. IF IT'S A MINOR CAR ACCIDENT & THEY ARE WALKING AROUND , THEY USUALLY DON'T NEED C-SPINE! EVEN IF I CALL A SUPERVISOR , IT'S MY LICENSE ON THE LINE , NOT HIS!!! BE SAFE.......

[Pamela Baber]

Prior to commenting on this issue, I would be curious to know what basis you or your supervisor are using for C-spine clearance
and if you have had any cases where it was discovered on follow-up that C-spine immobilization should have been done.

[Ed]

This debate is beginning to happen a little in the system I'm with. The paramedic instructor has been teaching the new medics c-spine clearing when certain conditions have been met. I.E. able to make informed decision (not drunk), no midline tenderness.
I am not completely sure on the whole procedure but then the pt. is asked to turn head right - left then touch chin to chest.
I have been in EMS for 15 years and I can't count how many times people are "Fine" initially at the scene and develop neck and back pain after 10 or 15 minutes.
We have no idea which way they were thrown around in a car or how hard they fell to the ground. In my opinion everyone in an MVA goes to the hospital on a board. Until I get a portable X-ray machine that I can tow behind my rolling emergency room thats the way I feel. The Docs in the E.R. would take an X-ray of this patient if he walks in the front door of the hospital so why are we giving them less of a standard of care. I know its a pain to board them all but thats my job.

[BURNSEMS]

Well, I guess I am all for progression but whats next clearing Hip Fx,, We just had a case where a Medic on one of Our Scenes cleared a Spine w/ his modified version of the Protocol and guess what oooopps this 90 y/r old woman had a Lumbar Fx, I can see the Good and The Bad but I am not a M.D. nor do I have a dozen Lawers as a M.D does so I am going to Error on the side of my Patient until a Better way comes along, or we implant X-Ray vision.

[morriss]

Call me crazy, but all of my patients get c-spine control for all MVAs, falls, etc. I don't have X-ray eyes and have seen the advanatges of this method. Err on the side of conservatism.

[benson911]

In my EMS system medics can clear a c-spine in the field as long as the pt meets these criteria and they are documented on the run sheet.
1. No neck pain
2. No back pain
3. No numbness, tingling or weakness in the extremities
4. No POP to neck or back
5. No POM to neck or back

It is essentially the system used by the ER personnel before they rip all the immobilization equipment off your neatly packaged patient. The medic is allowed and encouraged to package anyone he/she suspects may have an injury that's not apparent. This is where the mechanism of injury kicks in, if it was a bad crash, high fall or they landed on cement it's a different story.

Good judgement and following the protocol has produced excellent results and more comfortable patients and so far no one has had a "hidden" problem found later.

[Romania]

We were just given a copy of our proposed standard for clearing c-spine. I am not all that thrilled about it, I for one will be on the extremly cautious side for this one.

------------------
Alan Romania, CEP
romania@uswest.net
IAFF Local 3449

My Opinions do not reflect the opnions of the IAFF or Local 3449.

[Boothby]

We don't have a protocal for clearing c-spine in the field, and I don't think it will happen any time soon. This City is swarming with attornies who would love to see us do that. One of the TV adds even says "Been in a wreck? Got your check? Call .....". I believe that the city attornies would pass little green apples if we tried to clear c-spines in the field.

------------------
Larry Boothby
Firefighter/Paramedic
Truck 3 A-shift
Local 1784
Memphis.

[Resq14]

In Maine, we have been using a spinal injury protocol for several years now. This is basically what it consists of:

Entry in to this protocol is based on whether a person has a positive, negative, or uncertain mechanism of injury. First, consider the mechanism of injury. A positive MOI (high speed crash, big fall, etc.) REQUIRES, as usual, spinal immobilization. A negative MOI (or, nature of illness) such as a cut finger, chest pain, etc, does not require spinal immobilization (as usual).

Where the fun begins is for the "uncertain" MOI patients. These are the low speed crash patients, the patients who've tripped and fallen, etc. Prior to beginning the detailed assessment, the following must hold true.

- Patient is competent and able to answer questions. Patient must be CAO, with no history of loss of consciousness. Patients with distracting injuries, acute stress reaction, alcohol on breath, altered LOC, or who are mentally incompetent AUTOMATICALLY become immobilized.

- When asked, patient must not have any spine discomfort or pain. If they do, they're immobilized.

WIth these things out of the way, we then palpate the entire spine, checking for point tenderness. If there is any, the patient is immobilized.

Next, the patient's neuromotor responses are tested. This involves comparing motor function bilaterally in all extremities utilizing several tests per extremity (more on these if anyone is interested). Any discrepancies, or the inability to conduct these exams (post CVA patient, for example) means the patient must be immobilized.

Finally, the patient's neurosensory responses are tested bilaterally in all extremities, again using several specific tests per extremitiy. Any discrepancies, or the inability to conduct these exams (post CVA patient, for example) means the patient must be immobilized.

To my knowledge, no patient who has been entered in to this protocol has been incorrectly diagnosed as not having a spine injury.

However, problems do arise. The main problem I have is that everyone has different definitions of what are positive, negative, and questionable MOI's. To me, a low speed rollover (for instance, vehicle simply slipped off an icy road and tipped over) is usually a questionable MOI, whereas many people around here would consider it to be a positive MOI. But this spcific issue is about the only problem I have with it. I think all-in-all, it's been a great program.

One of the doc's who spear-headed this project described his goal wonderfully by stating, "The point here is not to cut down on the number of patients you backboard. You may end up boarding MORE patients as a result of this. The point is to give patients the appropriate care that is needed."

[This message has been edited by Resq14 (edited January 09, 2000).]

[This message has been edited by Resq14 (edited January 09, 2000).]

[Michael Day]

Orange County EMS protocols allow for clearance of c-spine in the field by medics. The procedure requires the pt to be CAO x 3, no significant MOI, no evidence of other injury to distract the pt's awareness to pain, no ETOH or mental impairment, no pain on palp. to spinous processes of cervical, thoracic, lumbo-sacral spine, and no pain in patient's ROM. If any of this has a positive or "yes" answer, then the pt is immobilized. All of this assessment must be completely documented, and QA / QI monitors this procedure closely.
By the way, our C-Spine protocol is being featured on "Spinal Impact" airing 2-1-00 @ 22:00 on The Learning Channel. We're not sure what the entire show will be about but our Assistant Medical Director was interviewed as well as 2 of our medics reacting an MVA. This may help with explaining our protocol...
Good Luck.

[This message has been edited by Michael Day (edited January 18, 2000).]

[grymreeper]

The clearing of C-Spine in the field is coming like it or not. My Assistant Training Officer just returned from the West Virginia BTLS conference and a protocol to clear c-spine was adopted. Yes I do see lawsuits increasing but as long as protocol is followed EMS personnel should be in the clear.

[rapaho]

There is alot of great ideas and discussion on this and it would be time and effort saving if we all could clear 'obvious' non-traumatic c-spine in the field, but...the almighty BUT, I don't trust people enough to respond to the questions correctly, and like one responder already mentioned, how many times have you seen no pain or no obvious def/crep/tend. and it ends up painful 15-30 minutes later with a Fx. to one or more vertabrae. I just feel we are all safer and better covered if we always assume the worst,treat for that possibility, and hope for the best.
I realize that people are very quick to complain and judge us when they say they are fine but if they are not fine, they will thank us in the long run.

[This message has been edited by rapaho (edited February 03, 2000).]

[benson911]

rapaho - According to my Medical Director and his associate (A doc with a law degree) there have been cases of patients injured and suing the EMS agency for immobilizing them unnecessarily. And for EMS agencies causing injury by their unnecessary immobilization.

C-Spine clearance in the field, following an approved protocol, is appropriate and in the best interest of your patient. It also puts the onus of a lawsuit on your Medical Director and their legal advisors(not that you can't be sued, this is America.)

Basically, we ask the same questions and complete the same exam as the Doc's in the er before they rip off all of our well-placed packaging. It works, accept change, it won't hurt.

[LuxRes907]

I personally run in the same EMS system that ED runs in and would agree with him in this situation. Until I have a magical X-Ray machine in my squad, I'm gonna collar and board every pt. that's been involved in a trauma unless there refusing care. I personally have seen pt. who haven't presented without any significant problems turn out to have significant spinal fx. I used to work in our local ER as a Tech. and have seen a few pt. arrive at our trauma center that have been "cleared" by a quick tenderness assesement and shown to have major Fx of the cervical spine. Personally I'm not willing to put my license on the line with a quick "field test."

[Resq14]

I guess I don't follow some people's logic. I think this is a prime example of how infrequently our treatments are based on sound, comprehensive research.

The Maine Spinal Injury Protocol was developed by Maine EMS after conducting extensive research on its own, as well as evaluating research from many other locations. The resulting protocol is based on solid facts...and we have an MD (many, actually) who stands behind this protocol.

So, while I have no problem at all with erring on the side of caution, I don't think it behooves us to base our treatments too much on fear, tradition, and instinct. A little of these are good and necessary, but let's base our treatments on tested protocols. Treatments which are justified and supported by facts are a good thing, in my opinion.

We need more outcome based studies which examine the logic of what we do (or don't do) and the effects it may have on our patients. In the end, it can only improve the care we provide to our customers.

(I haven't seen anyone describe a spinal evaluation protocol which is even close to what we do in Maine...see my post above for general description of the Maine protocol. I think it is much more than a "quick field test")