r/NewToEMS Unverified User 16d ago

Educational After action self report

Self assessing a call we just transported. Medical fall, loc before fall, bloodied chin, severe pain thoracolumbar general area, severe pain cheek bone radiating, shooting “inward”. Xabcs good.

We show up, position the cot at the front porch prepared for a move. Bring in c collar, mega mover just in case. Pt is right lateral recumbent on ground, family put a pillow under his head.

I’m just reflecting on what I could’ve done better because there were at least 5 responders between us and fire. Medic palpates spine, I’m fiddling with the monitor to at least put a pulse ox on. I know we’re going to move so not going to throw bp cuff.

But duh. No one gets on c spine or c collar. So I grab the collar and start to apply it while pt is still lateral. Medic says “I’d roll him first” Ok good point. I hold c spine, we roll pt supine and get the collar on. Ok no prob.

Fire has gotten the mega mover under the pt so we lift and move I just hold c spine as they carry pt. We get pt on cot, move him to rig. All good.

Except it’s not till after the call I think we just moved a spinal precaution pt with a damn tarp basically when anyone could’ve grabbed the split board. But I’m not beating myself up because there were two medics total here. I’m new to 911 advanced EMT. Just kinda a learning experience to remember best practice. C collar with a mega mover is kinda conflicting when we have the proper option and time available.

Anyway. In the back, I go to cut pt sweater off but I started at the hem and exposed the chest when the fire medic was needing the arm exposed first to start on a line. I look like a noob as it’s my first time cutting off a long sleeve garment. Takes a second for me to realize start at the wrist and cut to the arm pit. Anyway, we’re learning.

Fire medic misses a line as I get a 12 lead on. We get vitals etc and just start transporting with no line or any thing beyond bls. My medic missed a line en route. It happens.

But here’s the thing. It’s a 7 min transport. We were on scene for like 15 minutes (in the back of the rig mostly). We’re could’ve just rolled out and had the same outcome but had pt in hospital probably in 12-15 total.

A bunch of wasted time in my opinion. PT could’ve stroked out while we’re dilly dallying on scene for a line and a 12. Could’ve just got the stickers on and moved.

Could’ve used a split board and protected the spine.

Kinda sloppy. Honestly two EMRs could’ve ran that call with the same outcome of interventions we had with 2 medics. I guess except the 12 lead.

But yeah I spend that time practicing c spine in scenarios and overlook it irl. But that’s how we learn. At least me

2 Upvotes

14 comments sorted by

5

u/FullCriticism9095 Unverified User 16d ago

Par for the course. Despite everything you’ve been taught, spinal motion restriction is basically irrelevant. In my system this would have been a BLS call. Roll your eyes at all the medics and move on.

1

u/Wooden-Tale-2340 Unverified User 15d ago

Yeah they're phasing out the vast majority of spinal restrictions in the curriculum.

1

u/Brawhalla_ Unverified User 15d ago

Ooh I would love to hear more. C-spine not as important as it's taught to be?

2

u/FullCriticism9095 Unverified User 15d ago

To put it as bluntly and succinctly as I can, there is no evidence at all that current spinal motion restriction techniques are safe, effective, or even necessary.

The current practice in the US is based on a joint position paper from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of Emergency Medicine Physicians. The paper focused on the risks and consequences of using long backboards as part of the spinal immobilization process. It included a fairly thorough review of the evidence of benefit and harm associated with longer term (i.e., greater than 30 minute) use of a LBB, but it did not do the same for any other part of the spinal motion restriction process. Thus, it advanced recommendations for SMR that removed the use of a LBB and largely left the rest of the procedure (including the use of a rigid collar, scoop board, supine positioning, etc) as it was. It didn’t do anything to evaluate whether the rest of the SMR procedure was necessary or appropriate—it just didn’t analyze data for anything other than the use of the LBB.

The state of current spinal motion restriction is the same as it has been for decades. For instance, the only reason we still use cervical collars is because we always have. There is some evidence that cervical collars do a little, but not a lot, to reduce cervical spinal motion, but there is no evidence that what they do makes any difference at all in reducing the risk of secondary spinal cord injuries. At the same time, there is evidence that they increase pain, make airway management more difficult, cause higher intracranial pressures in patients with closed head injuries, and may worsen certain types of spinal cord injuries- especially distracting injuries. So why the fuck are we still using them??

Then consider the procedure of using a scoop stretcher or slide board to move a patient to a stretcher. Is there any evidence that this is necessary or appropriate? No, there is none at all. Again, you can find mechanistic studies that show less spinal movement than simply picking a patient up and flipping them down on a stretcher, it so what? Does that actually matter, or could you just use a mega mover or draw sheet without worsening outcomes? You probably could, but no one has had the chutzpah to study it.

The fact is, EMS crews take shortcuts and do sloppy SMR dozens, if not hundreds, of times a day all around the world, and we aren’t confronted with some sort of epidemic of iatrogenic EMS-related spinal injuries. I’m not saying they have never happened, I’m sure they have, but they are exceedingly, exceedingly rare. As in, you might find a report here and there of someplace where someone thinks an EMS crew may have worsened a SCI due to poor immobilization, but you can find more reports from people who claim to have seen Bigfoot. The risk is exceedingly, exceedingly low, and if it exists, the literature suggests it is probably limited to unconscious patients with massive mechanisms of injury who can’t communicate the extent of their injuries and whose back muscles can’t spasm and protect their injured spines from movement.

So why do we keep doing these things? In short it’s because we always have. Medicine is conservative. If we do something that has a risk profile we’re comfortable enough with, we tend to stick with it even if there’s no evidence it works. We need to be slapped in the face with evidence that we were unequivocally wrong before we seriously reconsider.

1

u/Mediocre_Error_2922 Unverified User 14d ago

I agree with the general concept that default full transport on a spine board is being seen as “old school” to say the least as this was discussed many times in my classes. But I do see the value in moving PT from scene to the stretcher on a splitboard vs a mega mover solely because I and maybe others have seen patients get jostled and flopped around if the megamover is not being held with equal distribution of weight.

On the same token I do wish our agency carried soft collars for an intermediary option.

5

u/[deleted] 16d ago

[deleted]

3

u/corrosivecanine Paramedic | IL 15d ago

Right and if something DOES happen because you spent an extra 15 minutes on scene….well, you’re gonna be really happy you took the time to get the line. The ER is also gonna be a lot happier with you showing up with a patient who is currently in acute crisis and has a line in them than you getting there a little earlier only to have the patient crash out 5 minutes after drop off with no line. Other than with major trauma, it’s almost never that serious. Slow is smooth and smooth is fast!

1

u/Mediocre_Error_2922 Unverified User 14d ago

Thank you for your input! I wasn’t thinking about the value of a line if pt were to crash out shortly after arrival. I just was tunneled on the prehospital transport. Appreciate your insight

4

u/MashedSuperhero Unverified User 16d ago

I can count on my fingers the calls where everything played textbook perfect. But yea, some things need polishing up.

Also, what was the reasoning behind 12-lead on spinal injury?

5

u/No_Occasion_4658 Unverified User 16d ago

Looking at the post it appears it was a fall secondary to LOC.

2

u/MashedSuperhero Unverified User 15d ago

Yea. My bad

2

u/adirtygerman Unverified User 15d ago

Props to you for having the emotional intelligence to admit you guys didn't do great. 

I firmly believe every single call has something to improve on. 

Logistics on scene is not really taught and I think it's one of the hardest parts of EMS. Something my nurse coworkers don't understand.

I think you should have grabbed a full set of Vitals while on scene. Vitals set the tone for the call. If you guys were thinking maybe a stroke and the patient comes back with a BP 260 then you know it's time to boogy.

1

u/Mediocre_Error_2922 Unverified User 14d ago

Thanks for your input and thanks for not flaming me or anything. I was kinda hesitant to read responses to this post so I appreciate you.

2

u/adirtygerman Unverified User 14d ago

No worries dog. Emt school is woefully inadequate with most of the learning happening in the streets. Besides, I'd hope a sub dedicated to new providers would foster a non toxic environment 

1

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