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Mon Aug 20 13:05:23 BST 2007

Mike,

JRCALC guidelines were updated last year although I know from
correspondence that not all trusts have updated or rolled out new
training. Preferred journey time on spinal board is now < 30mins but
option of either placing patient on vacuum mattress (and all attendant
issues with that) or continuing on spinal board with longer journey time
having informed receiving A&E of this. No indication in any version of
JRCALC that if spinal board contraindicated due to journey time that
patient should be placed on basic stretcher mattress. Most obvious
problem in this instance is what method to be used in A&E to transfer to
their trolley with minimum delay. 

Original research using real SCI patients 14-55yrs 'immobilised' on
spinal boards showed pressure sores did not achieve significance until
after 6 hours immobility. In UK, majority patients off within 2 hours of
application. Standards on arrival in A&E are not consistent between
hospitals, between staff within A&E departments, between experienced
nurses and junior doctors, between clinicians and managers etc etc. The
vast majority of people experiencing spinal protective devices resulted
from a professional emergency responder making a judgement call at the
scene of the accident, utilising training derived from a national
curriculum. There is a greater consistency and inter-rater reliability
in the application of these devices by UK paramedics than in their
continued use/removal after arrival in A&E. 

Personally, I would say scene-of-incident errors occur due to paramedics
deviating from established national practice guidelines whereas
in-hospital errors occur because of a lack of the same. The rewrite of
SIA's Managing Spinal Cord Injury: The First 48 Hours' (www.spinal.co.uk
<http://www.spinal.co.uk/> ) summarises the ongoing debate on the issue
of applying spinal protective devices from UK perspective, going far
beyond current JRCALC guidelines and offering a completely revised
assessment questionnaire for informing the removal of spinal protective
devices.

Male driver 53, parked at traffic lights. Rear-end shunt at ~ 10mph.
Claims no neurological change or neck pain on examination. Walked to
ambulance for 'precautionary' check-up in A&E. Paramedic failed to note
headrest removed from driver's seat. Sat upright in ambulance during 15
minute journey. On arrival in A&E unable to move legs, hands, arms -
definitive C5/6 tetraplegia.

Male, 43, farmer. Driving tractor with open-back cab towing trailer
stacked with bales of hay. Bale falls from top onto back of neck. Gets
out of cab. Climbs onto trailer carrying bale. Re-secures load. Proceeds
home. Unloads trailer. Enters house, showers, sits down to dinner and
says to wife 'If my neck still hurts tomorrow I'll go to hospital'.
Enters A&E 0930 next day (after completing morning milking etc, explains
accident to triage nurse who walks him to trolley bay asked to undress
and lie on trolley. Taken to x-ray - subluxation of C5-6. noted - no
ensuing neurological impairment.

From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Pond Life
Sent: 17 August 2007 19:00
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Question for the prehospital experts

I have recently been involved in an incident where this happened. Both

myself and another paramedic (both very experienced) identified there
was no

indication to place the patient into a collar (and therefore onto a
board)

as per our JRCALC guidelines here in the UK.

I walked the patient to the ambulance and a doctor (who was on scene)
said

that he felt uncomfortable that we hadn't placed a collar on the patient

because of the MOI.

I respect the doctor concerned within his field in the ER, however he
does

not respond to EMS MVA's and was out of his normal environment.

In an effort to not rock the boat (and not because the patient
clinically

required it), I placed a collar on the patient and a blanket log roll
around

the head and then strapped the patient to the stretcher. In the UK, if

journey times for such patients are greater than 20 minutes the spinal
board

is contraindicated.

Got to the ER and three things happened?

1. We were criticized for not placing the patient on a board - I was

embarrassed for the staff as they were not up to date on our guidelines

(2004).

2. The junior ER doctor in the ER performed a c-spine check which was at

best sub-optimal - didn't even feel the c-spine! Certainly well short of
our

c-spine examination guidelines. The doc was then bullied by a nurse into

writing up an x-ray just to prove a point that the patient required it
and

we should have placed the patient on a board. 

3. and then to top it all... the ER dept ('suspecting a c-spine
injury!!')

only taped the head and neck down of the patient. When I pointed out
that

this did not constitute spinal immobilization and was in fact was
inherently

dangerous we left the dept in disgust.

I learnt a bunch of lessons that day. Most of which related to out dated
and

poor care in the ER.

A bad experience

Mike Bjarkoy.

Paramedic. UK.

-----Original Message-----

From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]

On Behalf Of Ben Reynolds

Sent: 17 August 2007 03:00

To: Trauma &amp, Critical Care mailing list

Subject: Question for the prehospital experts

When, if ever is it acceptable for a patient involved

in an MVA to be made to walk from the car into the

back of the ambulance to be boarded and collared?  Use

the following example from which to springboard your

answer:

21 year old restrained female head on collision with a

stationary vehicle.  Airbags deploy.  Patient has a

large cut on her head but is out and walking around.  

Ben Reynolds, PA-C

Pittsburgh, PA

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Question for the prehospital experts