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Consider this Case Study

Jeff Brosius trauma-list@trauma.org
Fri, 21 Jun 2002 13:03:36 -0400


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I once had a link to the State of Maine's Field Spinal clearance =
protocols.  Lost in the cyber world, I'm afraid.  Pret?  Help me out?

Regardless, I do not believe that they included Mechanism of Injury.  =
Many providers seem to forget that a vertebral fracture is a bone =
fracture, and broken bones HURT! =20

Best,

Jeff Brosius
Paramedic, etc.
Atlanta, GA
www.prehospital-perspective.com
medic245@mindspring.com
"The fate of the wounded rest=20
in the hands of the one that=20
applies the first dressing."
-- Nicholas Senn, 1896
  ----- Original Message -----=20
  From: John L. Meade=20
  To: trauma-list@trauma.org=20
  Sent: Friday, June 21, 2002 10:35 AM
  Subject: RE: Consider this Case Study


  Perhaps "field criteria" have been published that are different from =
the ED criteria for clinical clearance of cervical spines. The published =
ED criteria do not mention mechanism of injury as a criterion. There are =
5 criteria that must be met to clinically clear: no midline cervical =
tenderness, no focal neurologic deficit, normal alertness, no =
intoxication, and no painful, distracting injury.





  Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a =
set of clinical criteria to rule out injury to the cervical spine in =
patients with blunt trauma. National Emergency X-Radiography Utilization =
Study Group. [see comments.] [erratum appears in N Engl J Med 2001 Feb =
8;344(6):464.]. [Journal Article. Multicenter Study] New England Journal =
of Medicine. 343(2):94-9, 2000 Jul 13.





  JM=20

   =20

  John L. Meade, MD, FACEP=20

  Emergency Medicine Specialist

  Emerald Healthcare Group, P.A.=20

  http://www.statdoc.com/ =20



  When you dream in color, it's a pigment of your imagination.



  -----Original Message-----
  From: trauma-list-admin@trauma.org =
[mailto:trauma-list-admin@trauma.org] On Behalf Of Krin135@aol.com
  Sent: Friday, June 21, 2002 08:59
  To: trauma-list@trauma.org
  Subject: Re: Consider this Case Study



  In a message dated 05-Jun-02 13:58:26 Central Daylight Time, =
dinerman@computron.net writes:




  Case in point regarding vascular Doppler in the field:

  On my last shift I attended a 34 y/o male bicyclist who, while on his =
customary pre-dawn ride,  hit a hard to see gate and fell on his =
extended right arm. He was rewarded with a severely angulated, fractured =
/ dislocated right elbow. (Probably snapped the humeral head off).  He =
was wearing his helmet tho.  (Said he bikes for his health!) =20

  Cleared C-spine according to our protocol, discovered no other notable =
injuries during the full exam,(some minor road rash / lacs) splinted the =
arm from shoulder to fingertips (no radial pulse was noted before or =
after splinting), moved him to the rig, started IV NS for analgesia, =
administered 4 mg Morphine for pain, obtained vascular Doppler of distal =
fingertips indicating circulation present, transported to local ED.  =
Local ED MD confirmed Doppler, and diagnosis via x-ray. Local ortho and =
vascular specialists were contacted and Pt was transferred from local ED =
to Houston (75 miles) for open reduction at a specialist ortho hospital. =
=20



  Catching up with the list after a long spell of not being able to read =
in detail...

  Just out of curiosity, how did you clear this patient's C spine =
clinically, since he had a significant distracting injury as well as a =
significant mechanism of injury? Any scuff marks on the helmet? IIRC, =
all of the current protocols specify that patients with both of those =
factors (mechanism and distracting injury) should *not* be cleared in =
the field.

  Got bit on that one a long time ago, with a gal who had a dislocated =
shoulder from a 4 wheeler wreck. Turned out that the pain in the =
shoulder was masking neck pain, and follow up films were suspicious for =
a posterior fracture.

  We weren't able to do CT at that hospital that weekend, so had to ship =
her off...I suspect that there was no significant sequelae, as she was =
lost to follow up, but it did get my pulse to rise for a bit.

  ck


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<BODY lang=3DEN-US vLink=3Dpurple link=3Dblue bgColor=3D#ffffff>
<DIV>I once had a link to the State of Maine's Field Spinal clearance=20
protocols.&nbsp; Lost in the cyber world, I'm afraid.&nbsp; Pret?&nbsp; =
Help me=20
out?</DIV>
<DIV>&nbsp;</DIV>
<DIV>Regardless, I do not believe that they included Mechanism of =
Injury.&nbsp;=20
Many providers seem to forget that a vertebral fracture is a bone =
fracture, and=20
broken bones HURT!&nbsp; </DIV>
<DIV><FONT face=3DArial size=3D2></FONT>&nbsp;</DIV>
<DIV>Best,</DIV>
<DIV>&nbsp;</DIV>
<DIV>Jeff Brosius<BR>Paramedic, etc.<BR>Atlanta, GA<BR><A=20
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/3D"http://www.prehospital-perspective.com">www.prehospital-perspecti=
ve.com</A><BR><A=20
href=3D"mailto:medic245@mindspring.com">medic245@mindspring.com</A><BR>"T=
he fate=20
of the wounded rest <BR>in the hands of the one that <BR>applies the =
first=20
dressing."<BR>-- Nicholas Senn, 1896</DIV>
<BLOCKQUOTE dir=3Dltr=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Djmeade@statdoc.com href=3D"mailto:jmeade@statdoc.com">John =
L. Meade</A>=20
  </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Friday, June 21, 2002 =
10:35=20
AM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> RE: Consider this Case =

  Study</DIV>
  <DIV><BR></DIV>
  <DIV class=3DSection1>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3=20
  FAMILY=3D"SANSSERIF"><SPAN style=3D"FONT-SIZE: 12pt; COLOR: =
black">Perhaps &#8220;field=20
  criteria&#8221; have been published that are different from the =
</SPAN></FONT><FONT=20
  color=3Dblack><SPAN style=3D"COLOR: black">ED</SPAN></FONT><FONT =
color=3Dblack><SPAN=20
  style=3D"COLOR: black"> criteria for clinical clearance of cervical =
spines. The=20
  published </SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black">ED</SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black"> criteria do not mention mechanism of injury as =
a=20
  criterion. There are 5 criteria that must be met to clinically clear: =
no=20
  midline cervical tenderness, no focal neurologic deficit, normal =
alertness, no=20
  intoxication, and no painful, distracting injury.</SPAN></FONT></P>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black"></SPAN></FONT>&nbsp;</P>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black"></SPAN></FONT>&nbsp;</P>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black">Hoffman</SPAN></FONT><FONT=20
  color=3Dblack><SPAN style=3D"COLOR: black"> JR. Mower WR. =
</SPAN></FONT><FONT=20
  color=3Dblack><SPAN style=3D"COLOR: black">Wolfson</SPAN></FONT><FONT=20
  color=3Dblack><SPAN style=3D"COLOR: black"> </SPAN></FONT><FONT =
color=3Dblack><SPAN=20
  style=3D"COLOR: black">AB.</SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black"> </SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black">Todd</SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black"> </SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black">KH</SPAN></FONT><FONT color=3Dblack><SPAN=20
  style=3D"COLOR: black">. Zucker MI. Validity of a set of clinical =
criteria to=20
  rule out injury to the cervical spine in patients with blunt trauma. =
National=20
  Emergency X-Radiography Utilization Study Group. [see comments.] =
[erratum=20
  appears in N Engl J Med 2001 Feb 8;344(6):464.]. [Journal Article. =
Multicenter=20
  Study] </SPAN></FONT><FONT color=3Dblack><SPAN style=3D"COLOR: =
black">New=20
  England</SPAN></FONT><FONT color=3Dblack><SPAN style=3D"COLOR: black"> =
Journal of=20
  Medicine. 343(2):94-9, 2000 Jul 13.</SPAN></FONT></P>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black"></SPAN></FONT>&nbsp;</P>
  <P class=3DMsoNormal><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black"></SPAN></FONT>&nbsp;</P>
  <DIV>
  <P class=3DMsoPlainText><FONT face=3DArial color=3Dblack =
size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">JM=20
</SPAN></FONT></P>
  <P class=3DMsoPlainText><FONT face=3DArial color=3Dblack =
size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">&nbsp;=20
  </SPAN></FONT></P>
  <P class=3DMsoPlainText><FONT face=3DArial color=3Dblack =
size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: =
Arial">John</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial"> =
</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: =
Arial">L.</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial"> =
</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: =
Arial">Meade</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">,=20
  </SPAN></FONT><FONT face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: =
Arial">MD</SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">, FACEP=20
  </SPAN></FONT></P>
  <P class=3DMsoPlainText><I><FONT face=3DArial color=3Dblack =
size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: Arial">Emergency=20
  Medicine Specialist</SPAN></FONT></I></P>
  <P class=3DMsoPlainText><FONT face=3DArial color=3Dblack =
size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">Emerald =
Healthcare=20
  Group, P.A. </SPAN></FONT></P>
  <P class=3DMsoPlainText><FONT face=3D"Courier New" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black"><A =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/3D"http://www.statdoc.com/"><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: =
Arial">http://www.statdoc.com/</SPAN></FONT></A></SPAN></FONT><FONT=20
  face=3DArial color=3Dblack size=3D3><SPAN=20
  style=3D"FONT-SIZE: 12pt; COLOR: black; FONT-FAMILY: Arial">&nbsp;=20
  </SPAN></FONT></P>
  <P class=3DMsoPlainText><FONT face=3D"Courier New" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black"></SPAN></FONT>&nbsp;</P>
  <P class=3DMsoPlainText><EM><B><I><FONT face=3D"Times New Roman" =
color=3Dblack=20
  size=3D2><SPAN style=3D"FONT-WEIGHT: bold; FONT-SIZE: 10pt; COLOR: =
black">When you=20
  dream in color, it's a pigment of your=20
  imagination.</SPAN></FONT></I></B></EM><FONT color=3Dnavy><SPAN=20
  style=3D"COLOR: navy"><BR><BR></SPAN></FONT></P></DIV>
  <P class=3DMsoNormal style=3D"MARGIN-LEFT: 0.5in"><FONT face=3DTahoma =
color=3Dblack=20
  size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: =
Tahoma">-----Original=20
  Message-----<BR><B><SPAN style=3D"FONT-WEIGHT: bold">From:</SPAN></B>=20
  trauma-list-admin@trauma.org [mailto:trauma-list-admin@trauma.org] =
<B><SPAN=20
  style=3D"FONT-WEIGHT: bold">On Behalf Of =
</SPAN></B>Krin135@aol.com<BR><B><SPAN=20
  style=3D"FONT-WEIGHT: bold">Sent:</SPAN></B> </SPAN></FONT><FONT =
face=3DTahoma=20
  color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: Tahoma">Friday, =
June 21,=20
  2002</SPAN></FONT><FONT face=3DTahoma color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: Tahoma">=20
  </SPAN></FONT><FONT face=3DTahoma color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: =
Tahoma">08:59</SPAN></FONT><FONT=20
  face=3DTahoma color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-FAMILY: =
Tahoma"><BR><B><SPAN=20
  style=3D"FONT-WEIGHT: bold">To:</SPAN></B> =
trauma-list@trauma.org<BR><B><SPAN=20
  style=3D"FONT-WEIGHT: bold">Subject:</SPAN></B> Re: Consider this Case =

  Study</SPAN></FONT></P>
  <P class=3DMsoNormal style=3D"MARGIN-LEFT: 0.5in"><FONT face=3DArial =
color=3Dblack=20
  size=3D3><SPAN style=3D"FONT-SIZE: 12pt; COLOR: =
black"></SPAN></FONT>&nbsp;</P>
  <P class=3DMsoNormal style=3D"MARGIN-LEFT: 0.5in"><I><FONT =
face=3D"Arial Black"=20
  color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: 'Arial Black'">In=20
  a message dated </SPAN></FONT></I><I><FONT face=3D"Arial Black" =
color=3Dblack=20
  size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: 'Arial Black'">05-Jun-02</SPAN></FONT></I><I><FONT=20
  face=3D"Arial Black" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: 'Arial Black'">=20
  </SPAN></FONT></I><I><FONT face=3D"Arial Black" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: 'Arial Black'">13:58:26</SPAN></FONT></I><I><FONT=20
  face=3D"Arial Black" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; COLOR: black; FONT-STYLE: italic; =
FONT-FAMILY: 'Arial Black'">=20
  Central Daylight Time, dinerman@computron.net=20
  writes:<BR><BR></SPAN></FONT></I></P>
  <P class=3DMsoNormal style=3D"MARGIN-LEFT: 0.5in"><FONT face=3DArial =
color=3Dblack=20
  size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: =
black"><BR></SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2 FAMILY=3D"SCRIPT"><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">Case=20
  in point regarding vascular </SPAN></FONT><FONT face=3D"Comic Sans MS" =

  color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">Doppler</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">=20
  in the field:<BR><BR>On my last shift I attended a 34 y/o male =
bicyclist who,=20
  while on his customary pre-dawn ride,&nbsp; hit a hard to see gate and =
fell on=20
  his extended right arm. He was rewarded with a severely angulated, =
fractured /=20
  dislocated right elbow. (Probably snapped the humeral head off).&nbsp; =
He was=20
  wearing his helmet tho.&nbsp; (Said he bikes for his health!)&nbsp;=20
  <BR><BR>Cleared C-spine according to our protocol, discovered no other =
notable=20
  injuries during the full exam,(some minor road rash / lacs) splinted =
the arm=20
  from shoulder to fingertips (no radial pulse was noted before or after =

  splinting), moved him to the rig, started IV NS for analgesia, =
administered 4=20
  mg Morphine for pain, obtained vascular Doppler of distal fingertips=20
  indicating circulation present, transported to local ED.&nbsp; Local=20
  </SPAN></FONT><FONT face=3D"Comic Sans MS" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">ED</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">=20
  </SPAN></FONT><FONT face=3D"Comic Sans MS" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">MD</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">=20
  confirmed </SPAN></FONT><FONT face=3D"Comic Sans MS" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">Doppler</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">,=20
  and diagnosis via x-ray. Local ortho and vascular specialists were =
contacted=20
  and Pt was transferred from local </SPAN></FONT><FONT face=3D"Comic =
Sans MS"=20
  color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">ED</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">=20
  to </SPAN></FONT><FONT face=3D"Comic Sans MS" color=3Dblack =
size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">Houston</SPAN></FONT><FONT=20
  face=3D"Comic Sans MS" color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'">=20
  (75 miles) for open reduction at a specialist ortho hospital.&nbsp;=20
  </SPAN></FONT></P>
  <P class=3DMsoNormal style=3D"MARGIN-LEFT: 0.5in"><FONT face=3D"Comic =
Sans MS"=20
  color=3Dblack size=3D2><SPAN=20
  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; =
FONT-FAMILY: 'Comic Sans MS'"><BR></SPAN></FONT><I><FONT=20
  face=3D"Arial Black" color=3Dblack size=3D2 FAMILY=3D"SANSSERIF"><SPAN =

  style=3D"FONT-SIZE: 10pt; BACKGROUND: white; COLOR: black; FONT-STYLE: =
italic; FONT-FAMILY: 'Arial Black'"><BR>Catching=20
  up with the list after a long spell of not being able to read in=20
  detail...<BR><BR>Just out of curiosity, how did you clear this =
patient's C=20
  spine clinically, since he had a significant distracting injury as =
well as a=20
  significant mechanism of injury? Any scuff marks on the helmet? IIRC, =
all of=20
  the current protocols specify that patients with both of those factors =

  (mechanism and distracting injury) should *not* be cleared in the=20
  field.<BR><BR>Got bit on that one a long time ago, with a gal who had =
a=20
  dislocated shoulder from a 4 wheeler wreck. Turned out that the pain =
in the=20
  shoulder was masking neck pain, and follow up films were suspicious =
for a=20
  posterior fracture.<BR><BR>We weren't able to do CT at that hospital =
that=20
  weekend, so had to ship her off...I suspect that there was no =
significant=20
  sequelae, as she was lost to follow up, but it did get my pulse to =
rise for a=20
  bit.<BR><BR>ck</SPAN></FONT></I></P></DIV></BLOCKQUOTE></BODY></HTML>

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