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Spinal Injuries - Extrication and Transport

One of the most serious type of casualty is those who suffer spinal injury.

And these injuries are difficult to diagnose at the scene and often improperly transported and evaluated at the receiving facility. This is despite the fact that protocols for the diagnos, treatment and evaluation for such casualties have been established for over a half-century.

Sadly, many EMT,  paramedic, and physician texts and training programs do not properly address the problems associated with such patients.

In order, these problems are as follows:

(1) Identification of a possible cervical injury. The big question. Does this patient have a fracture or break in the cervical veterbra. This is difficult, if not impossible to determine at the scene. One of the biggest errors is to ask the patient to move his/her neck or move their toes and extremities and then conclude "there is no injury" if there is no resultant complaint of numbess or tingling. Time after time, circa 2010, I see a young physician or R.N. evaluate a patient brought in on a backboard, ask them to "wiggle their toes", "move your hands and feet" and (gasp) "move your head". If there is no numbness or tingling they rip off the cervical collar and release the backboard. This procedure is absolutly positively wrong. Only a radiological film can determine whether or not there is a cervical injury. Period. Worsem yet, the EMT at the scene conducts similar questioning and, if there are no complaints of tingling or numbness, walks the patient to the bus and sits them on a bench for transport. Argh!!!!

(2) This brings us to the criterion for stabilization. That is: If there is any evidence of sudden neck flexure, assume that there is spinal injury and a cervical break. Has the patient's head hit the windshield? Assume cervical fracture. Has the patient slipped on the ice, fell backward and struck their head? A difficult call. Was it a hard strike of the head? Hmmmm. How hard does such a blow have to be to cause an injury. In one case, a heavyset fifty year old parking lot attendant slipped on grease, fell backward, and fell, blocking the exit to the garage. He tried to get up. His partner complained that he had to get the attendant out of the way because there were cars waiting to get out. All honking their horns.  A helpful police officer explained to me that he had "helped" the man to a bench to await the ambulance. "He could move his hands and feet," explained the officer, who had some first aid training. In the process of moving twenty foot without stabilization, the patient's spine was injured. He became a quadraplegic. Assume cervical fracture. When in doubt STABILIZE. The whole drill. Collar, sandbags, or use one of the modern stabilization systems.

(3) When you get to the hospital, don't be in a hurry to retrieve the backboard or collar. One of the problems with expensive stabilization systems is that the EMT's are reluctant to leave the hospital without them. In many ways, the old disposable wooden backboard and inexpensive sandbags were superior in they were expendable.

(4) In a suspected cervical fracture: Cut the upper clothing off at the scene. Yup. Get that bandage scissor out and zip up the arms and jacket. Don't ask. Do this quickly. DO NOT REMOVE CLOTHING ANY OTHER WAY. The longer you wait, the more difficult this will be to do. The patient will protest about how much his/her leather jacket costs. Don't ask. CUT. Fib and tell them you'll get fired if you don't do this. Tell them the insurance company will pay for it. Maybe yes, maybe no, but it sounds reasonable.

(5) As soon as possible TELL THE PATIENT NOT TO MOVE OR FLEX THEIR HEAD! This is probably the most important thing to do, and it is not mentioned in any EMT training program. Tell them they have a suspected cervical fracture and may become a paraplegic if they move their head. There is a school of thought that says "never upset the patient". In this case they are WRONG. The patient will accept this stoicly and rationally. Read (5) again. Now read (5) a third time.

(6) If you leave them at the hospital tell them to inform the staff not to remove the collar until they are set up for an x-ray. This will not endear you to the ER staff.

(7) I used to use a two-inch strip of adhesive tape and place it on their foreheads and write in magic marker: "DO NOT REMOVE COLLAR TILL X-RAY". This will probably be ignored.

(8) At an incident there is a tremendous "rush" to get the patient on the way to the hospital. This is expecially true if the accident is holding up a railroad, subway, ferry, airplane or light-rail line. Try hard to resist this pressure. If everything else is stable TAKE YOUR TIME.

(9) Upon arrival assign one person to apply axial traction and to maintain that traction until the head is stabilized. That person must have no other duties.

(10) If you see a physician or nurse start to rip off stabilization before the patient is evaluated and x-rayed stop them. This is something to throw yourself over the railroad tracks for. The last hospital I got thrown out of was due to me telling the patient in front of the attending who was about to remove a collar (I had witnessed the patient get hit by a car and thrown in the air and land on his head in front of the hospital) was "This physician may paralyze you. If so, I will testify against him in a court of law and have him prosecuted". "Get him out of my emergency room" the physician ordered hospital security. P.S. The patient was x-rayed and indeed had a fracture.

An informative case involving a cervical spine injury was decided in Cook County, Illinois (Ross v. Silver Cross Hospital, Ill. Cir. Ct. Cook Co. Docket No. 73L-10351. On May 6, 1971, Pamela, a fifteen year old and four friends were involved in an intersection automobile collision on July 9, 1971. The four friends were thrown out of the automobile leaving Pamela in the back seat complaining of tingling in her legs. EMT's used a spine board to remove Pamela and noted on the call report the had full use or hands, legs and could move her feet and wiggle her toes. She was transported to the Silver Cross Hospital Emergency Department. While the EMT's were filling out paperwork an emergency department R.N. questioned Pamels, noted she could wiggle her toes and move her legs, removed the collar and Pamela's shell blouse by pulling her arms upwards. When the upward motion occurred Pamela screamed, fainted, and awoke to find she was totally paralyzed from the neck down. X-rays of the verterbral column revealed Pamela had a fracture dislocation of C-6 and a shattered C-7. As a result of this injury Pamela spend four months in a hospital followed by a longer period at a rehabilitation center.

She became a paraplegic with limited use of her arms requiring a full-time attendant.

Why did this happen?

Apparently the nurse was not impressed by EMT's provisional diagnosis of possible cervical spine injury. In many instances EMT's dramatically transport "gift-wrapped" patients with cervical collars and spine boards only to reveal they have only "whiplash" injuries. Her unwillingness to accept the impression of the EMT's caused serious permanent harm to the patient.

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