Atypical Spinal Immobilization

[WAS967 97]

I'm not going to bore people with a war story, just know that my question is rooted in experience and that my question does not seem to have a definative answer. (At least not that I have been able to find. This goes along well with the other post about mechanism.

You arrive on the scene of a 2 car MVA - head on. Both cars, single occupant. Both drivers ambulatory (walking) at scene. One patient has complaint of neck pain. Your EMT knowledge tells you the patient needs immobilization. A helper holds manual C-Spine stabilization while you do a quikc head to toe assessment which yields no additional findings. Fire department is there with additional help so you decide to perform a standing takedown. As you explain the procedure to the patient, he tells you that he has a congenital problem that prevents him from being lay flat or else he passes out because of loss of blood flow to the brain. (This is a very real syndrome, I don't recall the name at this time).

My question(s) is/are this: How do you immobilize this patient? NYS BLS protocols state "Immobilize patient with appropriate immobilization device." What is appropriate in this instance or in similar instances? Do you NOT immobilize this patient and risk C-Spine injury? How do you transport this patient to the hospital?

[x635 4,066]

Interesting Situation.

I wonder if this would be postural hypotension? I wonder how legit this patients story actually is? Does he actually pass out,or feel like he is going to pass out because of an inner ear thing, etc?

I'd probaly do a standing takedown, see how the patient felt or reacted, and take a set of vital signs.

If this condition proved itself, I'd probaly, after consulting medical control for further information or advice, KED or shortboard the patient and transport with head elevated.

[Guest alsfirefighter]

Answer: Good spinal assessment with good documentation period. I wouldn't even attempt the standing take down any further because of what you told him and he may end up saying screw all of it or become very anxietic because he is counting on having all the symptoms of a near or full syncopal episode.

If he is complaining about neck pain, that's fine. But what kind? Because of the ability to clear c-spine and constant training my agency has become very good at assessing the spine and associated anatomy. If the spine is ok with no pain on palp, and no deformity, the pain is 99.9% muscular. If you have a broken vertabrae you will almost certainly have pain on palp, it is the strongest indicator, only certain instances of compression fractions doesn't follow the pattern but they are generally seen from vertical impacts to the top of the head.

TREATMENT: C-collar, with patient semi-fowlers or fowlers (90 degree head up) secured to a short board on the stretcher. As long as the head, neck and shoulder area is isolated you won't run into a huge problem with keeping the neck immobilized. Keep constant MNF checks and as I said document the condition and what the patient said and that is all that is needed.

www.foops.org - fraternal order of paramedics soceity-Contributing Editor

IACOJ Bureau of EMS Chairman

[WAS967 97]

x625: Bottom Line: You can't lay the patient down. How do you immobilize? The "Call Medical Control" option is always there sure, but I'm looking for opinions on how you would proceed as a provider in this given situation.

alsfirefighter: Good answer. That was my route of thinking. Problem is there is a plague out there called "all or nothing" thinking. People are trained to immobilize with whatever, but in the end they MUST be on a long board. If they come out on a KED, them aren't fully immobilized unless they are on a longboard, they say. (And the manufacturer supports this way of thinking.) But I wonder what the alternative it. If you can't go to longboard, what do you do? They say you do nothing. I have to disagree.

Long story short, I had a similar situation where the BLS organization I was with refused to have even a collar on the patient if he wasn't on a longboard. It made me think long and hard about who is right, what is right, and how I would proceed if faced with the same problem again in the future.

Some people say they wish they could do C-Spine clearance in the field. Funny thing about that. I was told recently that statistics show, that in agencies that started doing C-Spine clearance protocols in the field, actually immobilized MORE patients than LESS. Food for thought.

[Oswegowind 17]

Get him to sign the RMA and document that you are unable to fully immobilize the patient secondary to the situation. That way the patient confirms your documentation with a signature...be sure to advise him of all appropriate actions you are supposed to take!!! Later on in a lawsuit you will have back-up and not have to hit your 10-13 button!!!!

RMA = refusing spinal immobilization (treatment) not just refusing assistance...way to CYA!!!

[mikeinet 37]

If a patient signs an RMA... they (by the PCR) are waiving any medical attention... can you as a EMT still provide care after the patient signed their right away??? It feels that this would be an even bigger legal issue that the origional issue (providing care after an RMA)

[tbendick 27]

Treating a patient after the RMA??

Well why not???

If we look at what is done, we perform a assessment and the patient can give us informed consent.

If the patient would like to refuse treatment, they should be able to refuse one treatment but not another. I had patients sign RMA's all the time and still treat and transport.

NYC ACR report (PCR) has a section for RMA that states to list what the patient signed the RMA for. However I don't think anyone should encourage an RMA

"I have been advised and I understand that medical assistance

on my behalf is necessary and that refusal to accept prehospital

care and transportation to a designated ambulance

destination may imperil my health or result in death.

Having read the above, I refuse to accept:

o Pre-hospital care (Specify): _______________________

o Transportation to the hospital_________________"

[WAS967 97]

Absoultely you can continue to treat a patient after an RMA. It is a very common misconception that you only get a patient to sign an RMA if they don't want to go to the hospital. Not true! If the patient say, refuses to have an IV inserted, then they can sign off saying they refused IV access. RMAs are not necessarily all inclusive.

In the case of the patient who requires the immobilization but cannot because of whatever reason (the one i stated is just one of several I can think of), then having them sign an RMA is inappropriate. They aren;t REFUSING treatment, they are UNABLE to recieve treatment because of certain contraindications. If you had a patient that was allergic to an active ingredient in albuterol and thus you could not give them a nubulizer treatment for thier asthma, would you have the sign an RMA? Absolutely not! Becuase they aren't refusing, they are unable. Regardless, the option to call medical control is under utilized (it's not just for medics you know), and talking to a receptive doctor about the situation (we'll discuss unreceptive MC MDs later on) is probably a good route to take when faced with an unusual situation. Especially when you have a patient that is refusing treatment yet you think thier refusal will have a negative impact on thier health. Talk to the doctor, and go so far as have the PATIENT talk to the doctor. You'd be amazed how quickly they change thier mind sometimes.

[WAS967 97]

Just as a follow up, I still have no definite answer to this problem. I posed my question to my PHTLS instructor this past weekend and he was as stumped as everyone else, offering only the PC answer that for proper immobilization, the patient must be supine on a longboard so that inline stabilization is maintained. The quest continues.