RE: SSI

[Guest guest]

FYI

I Sponsored a Wilderness EMT class in Amarillo in June of 2002. In that

class we were taught Spinal Clearance with specific criteria.

Listed are the criteria:

1. Totally alert, not intoxicated

2. no painful " distracting " injury (the one that most don't comprehend, or

should I say " have the most trouble with " )

3. no neck pain

4. no neck tenderness

5. no numbness, tingling, or weakness

6. normal motor/sensory exam of extremities

7. painless full range of motion of neck

These were taught by a physician who helped instruct the class. The protocol

was developed through the Wilderness Emergency Medical Services Institute in

Pennsylvania. I must state that if ANY of the above criteria are not met

Spinal Immobilization, or if you prefer Spinal Restriction; MUST be performed.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

Have there been any studies on the number of non-immobilized/non-xrayed

patients who present to the ER several hours post-incident with neck

pain and stiffness? Having seen and experienced that many times, I

would bet the number is significant. And I would bet that they all get

x-rayed.

Rob

[Guest guest]

Give it up!!!!

[Guest guest]

Some anonymous smartass named " R.K. " who hasn't the integrity to sign

his e-mails wrote:

> Give it up!!!!

Wassamatter? Backboarding too much work for you? In a hurry to get

back to your recliner and football game?

Far be it for me to believe that something should actually be adequately

studied before it is given gospel status.

Rob

[Guest guest]

Any one know an email address for a good ce on line program like genesis or

what. If you do I need it.

thanks

[Guest guest]

Actually I was against not backboarding patients until the Wilderness EMT

class. There was a week that we actually discussed everyday the significance and

research. It is not so much laziness, it is better patient care. If the

criteria are followed there is little if any chance that an injury will slip by.

The stories we have heard of fractures to the C-spine and such can be avoided

by proper assessment and treatment. As I mentioned before the one criteria

that I have seen give the biggest problem is: Distracting Injuries. This

could be any injury that would distract from a good assessment i.e. fractured

leg,

arm, blunt force trauma, or any injury that keeps the patients attention

centered on that, rather than being able to state for certain that they do not

have pain in their back or neck.

A complete assessment and confidence in your skills is the only way to be

sure of proper care. ANY physician will tell you that if in doubt FULLY

IMMOBILIZE, Or restrict movement; which ever terminology you prefer.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

Pain and stiffness? Can you please elaborate a little? I am getting over a

bout of the flu (second one this season) and had I gone to the ED, I would

definitely present with neck pain and stiffness. Not all etiologies of neck

pain and stiffness are related to CSI, or any trauma for that matter.

Mike

Re: SSI

Have there been any studies on the number of non-immobilized/non-xrayed

patients who present to the ER several hours post-incident with neck

pain and stiffness? Having seen and experienced that many times, I

would bet the number is significant. And I would bet that they all get

x-rayed.

Rob

[Guest guest]

Mike Schadone wrote:

> Pain and stiffness? Can you please elaborate a little?

Thanks for asking. I am speaking of the large number of MVA victims who

say (and believe) that they are fine until about 6 to 8 hours

post-accident when their neck stiffens up and gets painful. I am not

suggesting that these people have a significant CSI. The large majority

will have only simple " whiplash " muscle spasms, requiring muscle

relaxants and a moderate pain reliever for a week.

Having seen and experienced this many times, I know that the symptoms do

not appear until several hours after the incident. Once they do, a lot

of those victims are headed for the E.R. where they will be x-rayed.

Some will even call an ambulance. Right or wrong, I suspect that there

WILL be questions about why they weren't x-rayed on their first trip to

the E.R. since they obviously had an MOI conducive to CSI.

Rob

[Guest guest]

> > Pain and stiffness? Can you please elaborate a little?

>

> Thanks for asking. I am speaking of the large number of MVA

victims who

> say (and believe) that they are fine until about 6 to 8 hours

> post-accident when their neck stiffens up and gets painful. I am

not

> suggesting that these people have a significant CSI. The large

majority

> will have only simple " whiplash " muscle spasms, requiring muscle

> relaxants and a moderate pain reliever for a week.

>

> Having seen and experienced this many times, I know that the

symptoms do

> not appear until several hours after the incident. Once they do,

a lot

> of those victims are headed for the E.R. where they will be x-

rayed.

> Some will even call an ambulance. Right or wrong, I suspect that

there

> WILL be questions about why they weren't x-rayed on their first

trip to

> the E.R. since they obviously had an MOI conducive to CSI.

>

> Rob

You're living in a " What If? " world.

[Guest guest]

R.K. wrote:

>

> You're living in a " What If? " world.

Correct. It works. In fact, it is the very basis of every scientific

study ever done. If you are not living in a " what if " world, you are a

fool.

Rob

[Guest guest]

Perhaps the question should be asked why they were not

treated for/educated about their soon to be

painfull/stiff muscle spasms the first visit. However

as you stated once they return to the ER with pain

they no longer meet the SSI criteria, they have pain.

Here is an interesting question? Does everyone who

presents to an ER's triage with complaints of neck

pain 2ndary to trauma get/need Spinal

Immobilization/restriction? It's an ER question

rather than a pre-hospital question but one I've asked

myself many times before.

F. Lockridge

--- Rob wrote:

> Mike Schadone wrote:

> > Pain and stiffness? Can you please elaborate a

> little?

>

> Thanks for asking. I am speaking of the large

> number of MVA victims who

> say (and believe) that they are fine until about 6

> to 8 hours

> post-accident when their neck stiffens up and gets

> painful. I am not

> suggesting that these people have a significant CSI.

> The large majority

> will have only simple " whiplash " muscle spasms,

> requiring muscle

> relaxants and a moderate pain reliever for a week.

>

[Guest guest]

It is a clinical decision. If they come back with paravertebral spasm (i.e,

whiplash) and don't have point tenderness or neuro deficit, I start them on

an opiate (LorTab and a muscle relaxant Skelaxin) and change to a NSAID in 2

days. No x-rays are ordered unless the index of suspicion is elevated.

BEE

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

Re: SSI

Perhaps the question should be asked why they were not

treated for/educated about their soon to be

painfull/stiff muscle spasms the first visit. However

as you stated once they return to the ER with pain

they no longer meet the SSI criteria, they have pain.

Here is an interesting question? Does everyone who

presents to an ER's triage with complaints of neck

pain 2ndary to trauma get/need Spinal

Immobilization/restriction? It's an ER question

rather than a pre-hospital question but one I've asked

myself many times before.

F. Lockridge

--- Rob wrote:

> Mike Schadone wrote:

> > Pain and stiffness? Can you please elaborate a

> little?

>

> Thanks for asking. I am speaking of the large

> number of MVA victims who

> say (and believe) that they are fine until about 6

> to 8 hours

> post-accident when their neck stiffens up and gets

> painful. I am not

> suggesting that these people have a significant CSI.

> The large majority

> will have only simple " whiplash " muscle spasms,

> requiring muscle

> relaxants and a moderate pain reliever for a week.

>

[Guest guest]

Rob,

Does " whiplash " rate a c-collar and longboard? Would these tools be helpful

or detrimental? Can you tell me (of your experience " having seen and

experienced this many times " ) of any person involved in a traumatic incident

whose SSI indications were originally negative that presented back at the ED

with a c-spine fracture directly resulting from the original traumatic

incident?

I am sorry, but neck pain and soreness just does not cut it with me. Give

me an appropriate-acting person with the ability to communicate openly and

without distracting injury, and allow me to assess their spine. Given no

mid-line spinal pain or point tenderness and no neurological deficit, this

patient (I can firmly say) has no unstable fracture of the c-spine (if any

fracture at all), and thus, no risk of further injury from movement.

Mike

Re: SSI

Mike Schadone wrote:

> Pain and stiffness? Can you please elaborate a little?

Thanks for asking. I am speaking of the large number of MVA victims who

say (and believe) that they are fine until about 6 to 8 hours

post-accident when their neck stiffens up and gets painful. I am not

suggesting that these people have a significant CSI. The large majority

will have only simple " whiplash " muscle spasms, requiring muscle

relaxants and a moderate pain reliever for a week.

Having seen and experienced this many times, I know that the symptoms do

not appear until several hours after the incident. Once they do, a lot

of those victims are headed for the E.R. where they will be x-rayed.

Some will even call an ambulance. Right or wrong, I suspect that there

WILL be questions about why they weren't x-rayed on their first trip to

the E.R. since they obviously had an MOI conducive to CSI.

Rob

[Guest guest]

In a message dated 12/3/2003 8:38:49 AM Central Standard Time,

mreed_911@... writes:

> He's that 1 in a million that Rob worries about. Good point though - we

> didn't immobilize him in the ER... until we got the films. And even then,

> just lying on a bed with a collar.

>

The sad thing is that it only takes that one person in over a million to sue

the medics and take them for everything they have. All I know to do is to

make sure my assessment is thorough and document, document, document. Even so if

the patient finds the right slick-talking attorney it still may not be enough.

I guess this all goes back to the philosophical in that there are no

guarantees in life except for death, and yadda, yadda, yadda....

, tossing in her $02.

[Guest guest]

>I guess this all goes back to the philosophical in that there are no

>guarantees in life except for death, and yadda, yadda, yadda....

>

>, tossing in her $02.

" There are only two things certain in life--death & taxes. " The difference

between them is that death doesn't get worse every time Congress meets.

Conley Harmon

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[Guest guest]

There is one other thing that is certin, and that is change.

Nac. County EMS

Conley Harmon wrote:

> >I guess this all goes back to the philosophical in that there are no

> >guarantees in life except for death, and yadda, yadda, yadda....

> >

> >, tossing in her $02.

>

> " There are only two things certain in life--death & taxes. " The difference

> between them is that death doesn't get worse every time Congress meets.

>

> Conley Harmon

>

> ----------

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> Checked by AVG anti-virus system (http://www.grisoft.com).

> Version: 6.0.542 / Virus Database: 336 - Release Date: 11/18/03

>

>

[Guest guest]

The problem that I have with this is that the patient (the husband) refused

care. I'll stipulate that he had a C2 fx and was halo-ed, etc. My issue is

that many times that a spouse is injured, the other usually worries more

about them then they do their selves. This may count towards a distracting

injury (no one ever said that it had to be their own). Once they know that

their spouse is being taken care of and they get to that " Okay, I've been

sitting in the waiting room for a few, now " mentality, they start worrying

about themselves, again.

Significant factor: How long after arrival at the ED did the husband voice

concern for himself?

I am not discounting this story. Does this patient fall into the

" Distracting injury " group as I have stated? Is this a patient population

that we need to be aware of? Did this patient actually have NO pain when

assessed by EMS, only to have it initiate after arrival at the ED? Did the

patient actually have pain, but dismissed it until arrival at the ED?

These are questions that are very difficult because the extraneous factors

are hard to duplicate and may very well be never seen in a study group. It

is these types of patients that have papers written about them to add to the

documentation of anecdotal cases (i.e. stories of limited significance).

A patient that I had the pleasure of seeing recently had the same sort of

issue. A pediatric who was involved in a playground type accident (supine,

sliding head-first into a soft, but reinforced pole) presented to me with

only localized head pain (right tempero-parietal area). He complained of no

other pain. He denied LOC, dizziness, nausea, etc. SSI criteria were all

negative. As the story continues, neither the patient nor the grandmother

wishes him to be transported if he just bumped his head. I agreed. Kids

bump their heads a lot and rarely need to be evaluated at a hospital, but I

cannot just dismiss this patient. The mechanism was just not typical. I

further investigated and again palpated his spine. process by bony process.

No tenderness at all. His grandmother, again, stated that he seemed to be

fine and didn't want to burden him with an ambulance transport. Well, at

this point, I couldn't find anything except for the headache which seemed to

be going away, now. But, I still wasn't comfortable. Something was just

not right. Deciding that this patient was very cooperative, I decided that

if he could move his neck without pain, then I would let him go. I told him

to s-l-o-w-l-y look down towards the ground, but if he felt any pain at all,

to stop immediately. I was going to check flexion, extension, and finally,

lateral and rotational movement. Well, he stopped after only moving his

head about 5 degrees or so (read: minimally) and stated that he felt

something in his neck, but it wasn't pain. I palpated his neck again and he

winced at C2. Still no neuro deficit, there was a pronounced midline spinal

tenderness. Patient was boarded and collared and transported to the local

hospital for evaluation (unknown how he made out. I was not on the

transporting unit).

This is inline with the literature suggesting these types of injuries in

pediatrics often reduce and are not radiographically evident. (E Belaval, S

Roy, et al. Article: " Fractures, Cervical Spine " eMedicine.com 04.29.02) I

have to wonder if that was the case.

So, finally, I have to wonder if more questions need to be asked, but maybe

enough can be asked onscene to delineate these patients. I guess we'll see.

Mike

[Guest guest]

Mike Schadone wrote:

>

> Does " whiplash " rate a c-collar and longboard? Would these tools be helpful

> or detrimental? Can you tell me (of your experience " having seen and

> experienced this many times " ) of any person involved in a traumatic incident

> whose SSI indications were originally negative that presented back at the ED

> with a c-spine fracture directly resulting from the original traumatic

> incident?

I have never worked in the field utilizing the SSI protocols, so I have

experiences to offer in that specific regard. However, yes, I have

indeed had patients in the field whom my ONLY reason for CSI suspicion

was MOI who turned out to have CSI. In one case, I immobilized an

ambulatory, CAO patient from a serious MOI MVA and took him to the E.R.

where x-rays were suspicious. He was then taken by CareFlite to

in Fort Worth (an hour away) where he was found to have a C-spinal

fracture. My index of suspicion earned me a letter of commendation from

CareFlite to my department. And that was certainly not the only time in

twenty-five years that I have had low-suspicion patients turn up with CSI.

But no, whiplash does not rate full-immobilization. Unfortunately,

whiplash cannot usually be differentiated from CSI without radiography.

> I am sorry, but neck pain and soreness just does not cut it with me. Give

> me an appropriate-acting person with the ability to communicate openly and

> without distracting injury, and allow me to assess their spine. Given no

> mid-line spinal pain or point tenderness and no neurological deficit, this

> patient (I can firmly say) has no unstable fracture of the c-spine (if any

> fracture at all), and thus, no risk of further injury from movement.

That is all well and good a few hours after the incident. But

immediately post injury, it is a gamble. The protocol does not take

into account the symptom-numbing endorphins and adrenalin that flood the

system in an MVA. Once all of that wears off and the victim is away

from all of the distracting stimuli, he realizes, " damn, this hurts! "

Rob

[Guest guest]

Mike Schadone wrote:

> My issue is

> that many times that a spouse is injured, the other usually worries more

> about them then they do their selves. This may count towards a distracting

> injury (no one ever said that it had to be their own). Once they know that

> their spouse is being taken care of and they get to that " Okay, I've been

> sitting in the waiting room for a few, now " mentality, they start worrying

> about themselves, again.

That is an excellent point. One does not have to have a painful injury

to be otherwise distracted in a situational crisis. In that regard, the

protocol seems to focus too much on the objective patient criteria.

Rob

[Guest guest]

For what it's worth, we have been following a c-spine clearance protocol

since the summer of 1999. Since that time we have cleared more than

2,000 c-spines without a single complication. We do have a system that

requires our field paramedics to contact a supervisor to confirm the

appropriateness of the c-spine clearance. Distracting injuries do become

an issue, but if in doubt we immobilize.

In my opinion, the patients we now immobilize are better and more safely

secured because the medics see a " real " reason to immobilize rather than

just because we are supposed to.

Anyone interested in our protocol is welcome to contact me off the list.

Barton

MCHD EMS

[Guest guest]

Actually... this does raise a good question for the group. How many have

protocols in place which allow SSI?

We changed our protocol about 5 years ago to follow the Maine model. For

the first 2 years, our Medical Management Committee followed each patient

for complications/outcome through their hospital stay until discharge.

We charted over 600 patients which SSI was practiced, with no complications

or errors. As with MCHD, if there is any doubt, we'll go ahead and

immobilize.

Jack Pitcock

EMS Division Manager

Baytown Health Dept EMS

RE: SSI

For what it's worth, we have been following a c-spine clearance protocol

since the summer of 1999. Since that time we have cleared more than

2,000 c-spines without a single complication. We do have a system that

requires our field paramedics to contact a supervisor to confirm the

appropriateness of the c-spine clearance. Distracting injuries do become

an issue, but if in doubt we immobilize.

In my opinion, the patients we now immobilize are better and more safely

secured because the medics see a " real " reason to immobilize rather than

just because we are supposed to.

Anyone interested in our protocol is welcome to contact me off the list.

Barton

MCHD EMS

[Guest guest]

Jack and the guy from MCGD (sorry, message on different computer) are

showing objective (not anecdotal) data that SSI is effective and save. We

should continue to monitor this and all EMS practices and react accordingly.

BEB

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

RE: SSI

For what it's worth, we have been following a c-spine clearance protocol

since the summer of 1999. Since that time we have cleared more than

2,000 c-spines without a single complication. We do have a system that

requires our field paramedics to contact a supervisor to confirm the

appropriateness of the c-spine clearance. Distracting injuries do become

an issue, but if in doubt we immobilize.

In my opinion, the patients we now immobilize are better and more safely

secured because the medics see a " real " reason to immobilize rather than

just because we are supposed to.

Anyone interested in our protocol is welcome to contact me off the list.

Barton

MCHD EMS

[Guest guest]

Terry,

Most lawyers are ignorant of emergency prehospital care. Hence, there

aren't that many lawsuits against medics. However, after seeing some of the

posts

on this list, I think the premiums should be increased. There's too great of

a risk pool.

-Wes Ogilvie

[Guest guest]

Bledsoe wrote:

> Jack and the guy from MCGD (sorry, message on different computer) are

> showing objective (not anecdotal) data that SSI is effective and save.

How many anectdotes does it take to be called " objective? " When that

4000th patient dies, will he still be an anectdote?

Rob

[Guest guest]

Stay where you are at. I am driving over to CHOKE YOU. Red Honda Accord. Be

looking out the front window!!!!

BEB

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

Re: SSI

Bledsoe wrote:

> Jack and the guy from MCGD (sorry, message on different computer) are

> showing objective (not anecdotal) data that SSI is effective and save.

How many anectdotes does it take to be called " objective? " When that

4000th patient dies, will he still be an anectdote?

Rob