I follow a few EMS forums on various social media sites, but lately I've been commenting less frequently because the signal-to-noise ratio leaves me in despair of the future of our profession. I have to wade through far too many comments from adrenaline junkies, protocol monkeys, booger-eating cretins and fervent disciples of EMS mythology to find the comments of the few people who actually have something relevant and insightful to add to the discussion.
But recently, on the Book of Faces, I read this post on from an anonymous poster:
One of the Doctors Told the local hospital he wants this patient in FULL CSpine Precautions. Our local hospital told us to do it, and the upon asking the doctor why he needs to be CSpined, the doctor said "I don't know, that's what they want"
Needless to say, I refused to put my patient through the discomfort of full Cspine Precautions when to me and my partner was completely unnecessary.
Read the whole thing. If you can, try to slog through a few of the 435 (and counting) comments without succumbing to despair and ending the pain by ritual suicide. The comment thread is divided about 4:1 between "You should have been fired! How dare you defy a doctor?" and "Good for you, intrepid patient care advocate! Spinal immobilization is harmful and unnecessary!"
Problem is, they're both right.
No matter how much science you throw at them, a sizeable portion of the EMS workforce is going to ignore best practices and cling to the dogma they were fed in class all those years ago because ZOMG! We don't have X-ray eyes! Mechanism of injury! I had a dude with an internal decapitation with absolutely no outward signs of injury and we immobilized him anyway and SAVED HIS LIFE! Eleventy!
You're never going to convince these people, and I've learned to stop trying. Twenty years from now, they'll still be practicing 1990's medicine, and still utterly convinced that they know what they're doing.
But engaging in a pissing contest with two ED physicians isn't the way to be a patient advocate, either. Being right won't pay your bills after one of the aforementioned booger-eating cretins fires you because you don't believe in Bigfoot, aliens and occult spinal injury. Many of these types also believe in the predictive value of mechanism of injury as an article of faith. And that's what it is, really – faith – because the science shows that MOI sucks great big rocks off the sea floor when it comes to predicting actual injury. We treat people, not car bumpers.
What distresses me is the sheer volume of commenters who apparently believe that protocols are immutable things, and that we absolutely must follow any orders given to us by a physician, no matter how half-assed and asinine.
Neither of these is true, people.
"I was just following orders," will not afford you one shred of protection in court if you do something obviously harmful to a patient just because a doctor told you to do it. YOu have a moral, ethical, and legal responsibility to question orders you believe are inappropriate, and if necessary, refuse to carry them out if you believe they may cause the patient serious harm.
Now, does a couple of hours of pain and discomfort qualify as serious harm? I guess that depends on whether you're the person undergoing the pain and discomfort. Certainly, outright defiance of doctor's orders was not the best option in this case, but neither is subjecting your patient to an unnecessary and painful procedure just because some trauma center's protocols require it.
I've been in this situation. Years ago, one of my medics got into an ugly pissing contest with an old country doc, and things escalated to the point that he jumped up onto the running board of the ambulance and tried to jerk the keys out of the ignition as they drove away with the patient. I had the unpleasant task of investigating the incident, and meting out whatever discipline was required.
The medic was right, and the doctor was wrong. But the way she handled it was totally unprofessional, and she got suspended for three days as a result. Like I told her then, "You should have just smiled and said, 'Yes, sir' and drove away. Then, once you're out of sight, pull over and do what the patient needs. The doctor you were transferring to would have been much more approving of your changes in treatment than the one you were arguing with."
And after it was over with, I overhauled our protocols to reduce the likelihood of some doctor overriding our treatment decisions in the future. It is one thing to overrule a medic, but it is another thing entirely to bully a medic who is following the treatment protocols approved by the medical society to which you belong.
As I said in that comment thread, there's a simple way out of that sticky situation, and one that covers your ass as well. All it would have taken is a conversation like this:
"Sir, the doctor at the receiving hospital has requested that I strap you to a hard plastic board for the duration of this trip in order to protect your spine. The doctor who treated you is unsure of why he wants this, since he personally read the x-rays that show your neck is not broken. I am legally and ethically bound to inform you of the proposed risks and benefits of this procedure, so that you may make an informed decision on whether you will consent to it or not."
The risks of the procedure include pain and anxiety, particularly soreness to the back of the head, neck, lower back and buttocks, and in studies on healthy volunteers who have undergone this procedure, 100% of them suffered significant pain, and many of them reported that the pain lingered for days or weeks afterward. You will also be more likely to drown on your own vomit should you become nauseated during the trip and I am unable to suction you quickly enough. Since you are overweight, lying on this board may make is more difficult to breathe. Since you are overweight, it is less likely that you will develop a pressure sore from this procedure, but studies have shown that as little as fifteen minutes on a board can induce these sores, and they may require specialized wound care to heal properly.
On the benefits side, there is no scientific evidence that you will benefit in any way from the procedure, even assuming that your neck is broken and we do the procedure perfectly. Both the ED doctor here and the radiologist who read your neck film saw no evidence of fracture, and as such the procedure is not even clinically indicated. However, it will keep your receiving doctor happy if we do it. Do you consent to this procedure, knowing the facts as I have presented them to you?
Sign here, Sir."
Document the hell out of the encounter, and let the receiving physician try to explain why the patient's right to informed consent was unimportant, and why you were wrong in respecting that right.
Following orders without question is what is expected of robots and protocol monkeys. EMS needs more from you than that, and our patients deserve it.
When I trained retrievers professionally, I used to get a steady stream of business from members of the By Gosh and By Gum Club, whose club motto went something like, “By gosh, it seemed like a good ideer, so by gum, that’s the way I done it.”
They were the guys who thought the way to introduce their Lab pup to gunfire was to take him out to the gun range and tie him to the truck bumper while everyone shot, or throw their pups in the lake to teach them to swim.
God bless those guys, because I made a fair bit of money teaching their traumatized pups not to fear gunfire or water.
It was pretty rough on the poor dogs, though. And sometimes, the damage was too great to repair.
In those cases, a few of the club members dropped their memberships and looked for better ways to do things, but many just blamed the failure on their dogs or the trainer they hired to clean up their mess, and went on to traumatize other dogs and plague other pro trainers.
It occurs to me that the By Gosh and By Gum Club has chapters in every EMS system in the country.
By gosh, that’s what was in the textbook, so by gum it must be right.”
What they never realize is that a whole bunch of that textbook was written by an earlier generation of the By Gosh and By Gum Club.
“By gosh, it stands to figger that a feller with a broke neck ought not to move it, so by gum we’ll strap ‘em to a board to make shore that don’t happen.”
Some of them learn better and drop their club membership, but others will continue to do things the same way the rest of their careers, ignoring every piece of evidence that shows theirs was the wrong way.
Still just as rough on the patients as it was on the dogs, though.
My writing partner Gene Gandy and I are planning a new series of monthly articles in EMS World Magazine.
Each month, Gene and I are going to take on a particular piece of EMS dogma, myth or obsolete clinical practice, and subject it to the withering scrutiny of current research.
We're still working on the series title, and we're compiling a list of topics now.
That's where you guys come in.
What EMS practices do you think belong in the dustbin of history, next to the discarded Chokesavers, rotating tourniquets and PASG? What is the prophylactic lidocaine, sublingual Procardia or coma cocktail of today? What dogma do you see perpetuated even now, despite all evidence to the contrary?
WHAT PRECIOUSLY HELD SUPERSTITION, MYTH, CLINCIAL OR ADMINISTRATIVE PRACTICE, OR EMS URBAN LEGEND SHALL WE SLAUGHTER FOR YOU, DISMEMBER, AND FESTOON OUR BEDCHAMBERS WITH ITS BLOODY ENTRAILS?
All you have to do is, um, you know, chime in with your comments.
We'll get right on it.
A friend sent me this a while back as an argument in favor of voting against political incumbents:
A group of psychologists performed an experiment years ago, in which they started with a cage containing five monkeys. Inside the cage, they hung a banana on a string with a set of stairs placed under it. Before long, a monkey went to the stairs and started to climb towards the banana. As soon as he started up the stairs, the psychologists sprayed all of the other monkeys with ice cold water. After a while, another monkey made an attempt to obtain the banana. As soon as his foot touched the stairs, all of the other monkeys were sprayed with ice cold water. It's wasn't long before all of the other monkeys would physically prevent any monkey from climbing the stairs.
Now, the psychologists shut off the cold water, removed one monkey from the cage and replaced it with a new one. The new monkey saw the banana and started to climb the stairs. To his surprise and horror, all of the other monkeys attacked him. After another attempt and attack, he discovered that if he tried to climb the stairs, he would be assaulted. Next they removed another of the original five monkeys and replaced it with a new one. The newcomer went to the stairs and was attacked. The previous newcomer took part in the punishment with enthusiasm!
Likewise, they replaced a third original monkey with a new one, then a fourth, then the fifth. Every time the newest monkey tried to climb the stairs, he was attacked. The monkeys had no idea why they were not permitted to climb the stairs or why they were beating any monkey that tried.
After replacing all the original monkeys, none of the remaining monkeys had ever been sprayed with cold water. Nevertheless, no monkey ever again approached the stairs to try for the banana. Why not? Because as far as they know that's the way it's always been around here.
And that, my friend said, is why occasionally all the monkeys should be replaced at once, the monkeys being incumbent politicians.
Now, the original research has been lost to history, if indeed it ever existed. Most sources consider it a parable and a thought experiment demonstrating organizational inertia and resistance to change.
But it provides an excellent explanation as to why bad ideas and outdated concepts persist in EMS organizational culture; because that's the way we've always done it.
I was reminded of this email by this comment thread on Paramedics on Facebook, in which I was reminded yet again that we still have plenty of monkeys who discourage the newcomer from reaching for the bananas, without really knowing why.
The motivation behind why we do a great many things in EMS has been long forgotten, but still enforced by new generations of unquestioning monkeys.
That's why every
monkey EMT should actively seek out bananas ideas and and concepts from monkeys EMT's from other cages organizations.
Because if your justification for doing something is "That's the way we've always done it," or you reject contrary ideas because "That's not the way we learned it in school," you're just another unquestioning EMS monkey, and you'll always have to settle for working for bananas.
According to TOTWTYTR, that should have been the title to my latest article in EMS World Magazine.
Unfortunately, I had already submitted it to my editor by the time my buddy weighed in. Pity, that. I cribbed many of my best lines from him, including the original title of my book.
Go, read. Enjoy.
… nitroglycerin isn't for chest pain. Nitroglycerin is for vasodilation.
It just so happens that coronary artery vasodilation often happens to relieve chest pain in patients with stable angina. In the genuine acute coronary syndromes, not so much.
I have to agree with Kaiser, and it's just this sort of unmitigated horse shit that gives me the pink leg* whenever I read it. "Administer 3 nitroglycerin and contact medical control" is one of the sillier rules that persist in modern EMS protocols, implemented by those absentee medical directors Rogue Medic likes to rail about so much. Folks, the 3 nitro rule doesn't apply to us.
It has never applied to us.
Three nitros was simply the trigger for the patient to call 911. It was something the cardiologists told their patients: "Here, put one of these little white pills under your tongue when your chest hurts. Take one every five minutes, and if you take three of them and your chest is still hurting, call 911."
That's all it was – a threshold for summoning the medical professionals to render further care. Yet in many EMS systems, it's also the set of protocol handcuffs that force those same medical professionals to limit their treatment to no more than what the patient can do himself.
The only legitimate endpoints for nitroglycerin administration are relief of symptoms, and hypotension.
And heck, even that's a matter of some debate. Some sources consider a BP of 100 systolic to be the endpoint, while others say it's 90 systolic. For my purposes, I'm not real concerned with a BP hovering between 90 and 100 systolic, unless they start out that way.
The folks that screech about an EMT-B assisting a patient with their prescribed nitroglycerin love to use the Right Ventricular Infarction Bogeyman to support their argument that no one but a paramedic with a 12 lead EKG machine should be fooling around with nitroglycerin, despite the fact that many of those same medics don't even bother to do the right-sided chest leads to diagnose that right ventricular infarction.
They also ignore the fact that an RVI patient who is preload dependent, usually looks that way. They have, like, clinical signs and stuff like orthostatic syncope or dizziness, Kussmaul's Sign, or the really big clue: they're borderline hypotensive to begin with. You're not gonna run into many of them that have a BP of 150/90 and then go into the toilet with one dose of nitro. More likely, they're gonna be hovering in the "Hmmm, I wonder if I oughta be giving nitro with a BP in that range," territory. If your paramedic spider sense is tingling that way, it doesn't necessarily mean don't give the nitro; it just means you should have a means of dealing with potential hypotension before it occurs. Get your line first.
For the most part, the problem with nitroglycerin isn't that we're giving too much of it, it's that we're not giving enough. Rather than futz around with Lasix on our acute pulmonary edema patients, filling their bladder when we ought to be emptying their lungs (because contrary to popular belief, most of these patients are not volume overloaded), we ought to be fogging the nitro to them like there's no tomorrow.
To hell with the 3 nitro rule, let's figure out a way to give nitro via in-line nebulizer attached to our CPAP masks.
And just in case I didn't make my point earlier, I'll repeat it: Nitro isn't for pain relief, it's for vasodilation.
If it relieves their pain, fine, there's no need for narcotics. But if it doesn't relieve their pain, you ought to be dispensing the opiate candy toute suite, with a goal of zero pain, while still maintaining an adequate respiratory rate and blood pressure. Less pain equals less catecholamines equals less myocardial workload equals smaller infarct size equals better outcomes.
But still keep giving the nitro anyway, because like I said before, nitro isn't for pain relief.
Nitro is for vasodilation.
* Pink leg is when the red ass has gotten so extensive that it has spread into the surrounding tissues.
With apologies to Happy Medic for borrowing one of his regular themes, allow me to present an exercise in distinguishing Doing What Is Right from Doing What Is In The Protocol:
It's a balmy late summer night, and you respond to lovely, pastoral Decubitus Manor Convalescent Home for a patient injured in a fall. Upon your arrival, you find a charming and alert elderly male complaining of neck pain. He fell 24 hours before, went to the local ED that night and had staples put in his scalp. Skull and C-spine x-rays revealed no obvious fractures, and patient was discharged back to the nursing home.
He complained of neck pain throughout the day today, and finally the doctor ordered him sent back to the ED for a CT scan of the cervical spine. The gentleman had been back at the nursing home today until 9:00 pm, when the radiologist finally interpreted the CT scan. The unofficial, verbal interpretation relayed to the rad tech was "odontoid fracture, and comminuted fracture of C-1."
Our charming little old man is neurologically intact, and has been doddering around the nursing home for 24 hours with no ill effects. The nursing home doc wants him to go somewhere with an on-staff neurosurgeon, which the local ED says is a facility 70 miles away. They call an ambulance to make the transport.
Enter your intrepid hero, Ambulance Driver.
Now here's the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.
My protocols are pretty clear on this issue: Gramps gets the full spinal package. Not only is he over 65 with an "injury above the clavicles" (two of our sillier criteria, based on the Canadian C-spine rules), but he has the cervical spine tenderness, not to mention the friggin' CT scan that reveals a potentially unstable high C-spine fracture.
Now, an 80+ minute trip strapped to a spine board isn't the cruelest thing I can think of doing to this man, but the other two possibilities involve nipple clamps and a live ferret. He weighs less than his age, and his chart already includes orders for a Fentanyl patch PRN and gel seat pads for his wheelchair. I don't like the idea of boarding him if I can help it.
But we're not talking about what I would do. What would you do?
Do you shrug your shoulders and say, "Protocols are protocols," and tell him to suck it up for the 80+ minute trip to the hospital with neurosurgery, or do you explore other options? If so, what are those options? You tell me what you'd do in my place, and I'll post what I actually did in a few days.
You make the call.
Caretic [noun; care-i-tik]*
Def: One who unapologetically defies dogma, conventional wisdom and poorly written protocols to provide quality patient care. Often confused with heretic, by the same people who unquestioningly propagate dogma, blindly accept conventional wisdom, and write stupid protocols.
The dictionary defines heretic as "a professed believer who maintains religious opinions contrary to those accepted by his or her church or rejects doctrines prescribed by that church."
There was a time when the same was said of Jesus Christ: "Say, what has gotten into that nice young, Nazarene carpenter? He used to be such a good boy, and now he's spouting crazy talk!"
Not that I put myself in the same category as Jesus Christ, but I'm a believer in EMS, and I believe firmly in the worth of what we do. I love this profession.
Love it so much, in fact, that I'm willing to point out when we're full of shit. We've got a lot of doctrine in EMS that begs questioning.
Bryan Bledsoe, another EMS caretic, has been a good friend and a professional mentor for many years. And because of his willingness to state some unpleasant truths about our profession, some people in EMS hate his guts. I figure if I can piss off half as many of the same people, and for the same reasons, my career will have been a rousing success.
So yeah, I'm good with being a caretic.
*Word coined by Raquel "Rocky" Digati, a Facebook friend and reader. Here's hoping her word becomes part of the EMS lexicon.
Rogue Medic weighs in with his opinion on evaluating vehicle intrusion as a predictor of injury, which was the subject of a recent episode of the excellent EMS Research Podcast. In his post, he states:
"We want EMS to pay attention to the assessment of the actual patient, rather than the assessment of the possible cost of repair of the vehicle."
Word to your mutha, RM. In fact, I'm stealing that line. Next time one of my co-workers makes a silly decision based solely on what the vehicle looked like, I'm going to ask him, "Are you an EMT, or an auto insurance adjuster?"
I've opined before on the irrational degree of faith EMS places in mechanism of injury criteria. For some, it's a belief system bordering on culthood. MOI criteria were developed as a conceptual tool to give us an idea of where and what to assess, and a rough means of predicting what injuries may be present.
It is not the assessment itself.
The proper use of MOI is to guide assessment, not to dictate treatment and transport decisions.
Further in, Rogue Medic points out:
Why do we treat STEMIs (ST segment Elevation Myocardial Infarctions) with the opposite approach?
The dichotomy is that with trauma triage, we accept a 1,000% to 2,000% overtriage rate, while with STEMI triage, we consider a 5% overtriage rate to be unacceptably high.
The reason is because we're activating trauma centers based on what the car looked like, and we're doing STEMI alerts based on what the patient looked like.
While their pack/day cigarette habit, the number of cheeseburgers they routinely scarf down, and whether their daddy died of a heart attack may be pertinent history, we're activating the cath lab based on presentation.
We should be using the same approach to triage our trauma patients.
In comments to my last EMS Newbie post, reader 40Lizard commented on the discussion Ron Davis and I had on this episode of Confessions of an EMS Newbie:
Funny you should mention starting an IV before giving NTG- we’ve been having that discussion in class this week- and the general consensus is that unless we are SuperMedic and can have divine intuition on how the pt is going to react to the NTG- we’d better have a line in place before giving it!
Um, no offense to you, 40Lizard, but… horse shit.
Allow me to tell you a little tale about a patient I had some years back. We were called to the local nursing home for a patient with respiratory distress. We get there, and find a lady who weighs about three hundred pounds, parked on a chair in front of the air conditioner, oxygen mask strapped to her face at – unusual for a nursing home – an appropriate flow rate of 8 liters per minute.
Now, the lady has really exaggerated air hunger, and from across the room she sounded like a washing machine with the top left open. She’s diaphoretic as hell, and I don’t know who had the more desperate look on her face; the patient, or the LPN attending her.
Now, for you experienced medics out there, this presentation is probably just screaming “CHF! CHF!” in big red, flashing letters, and you’d be right. That’s exactly what was wrong.
She had decided to celebrate her recent discharge from the hospital (for CHF exacerbation, oddly enough), by treating herself to a pound of salted pistachios.
Obviously, this did not prove to be a good idea.
Her heart rate was 140, blood pressure 240/120, and respirations of 40, all with an oxygen saturation of 78% on 8 LPM oxygen. She was obviously tiring, and had that, “I’m about to pass out and you’re going to be picking my large butt off the floor” look about her, so the first thing I did was get her on our cot.
My partner, being the quick-thinking type, was already setting me up an albuterol nebulizer. Unfortunately, she was quickly thing the wrong things, but she can’t really be faulted for doing what she was taught. Lots of EMTs (and nurses and ER docs, I might add) think that albuterol cures all respiratory ailments.
I shook my head and ordered, “Nitro.”
She gave me a quizzical look, but gave me the spray bottle of Nitro anyway. The nurse gave me a nervous look and said, “Um, she hasn’t complained of chest pain…”
I ignored them both, lifted the lady’s face mask and told her to lift her tongue… and promptly delivered a triple squirt of sublingual nitroglycerin spray.
Both the LPN and my partner nearly fainted dead away. But they recovered, and managed to help me load the patient in the rig. I repeated that triple dose of Nitro three more times on the way to the ED. After the last dose, I noticed was getting close to our destination, and decided an IV might be in order, you know, to keep the nurses happy. So I managed to get a 22 gauge in her hand (and it pains me to admit I stuck something that small), and I was still taping it down when my partner opened the rear doors of the rig.
Inside, the receiving ER doc turned out to be none other than our service medical director, a man with whom I’ve taught many an ACLS class. We’ve got that whole absolute trust thing going on, but it really wouldn’t have mattered if it had been another doctor.
So I give him the basic rundown, “CHFer, just got out of the hospital today, celebrated by eating a big salty bag of pistachios. Looks like flash pulmonary edema. Initial BP was 240/120 and sat was 78% on 8 liters, but I’ve been hitting her with the Nitro all the way in, and her BP is down to 160/90, and her sats are 100% now. Breathing a lot easier, too.”
“Any Lasix?” he wanted to know.
“Nope,” I shook my head, “didn’t figure it was a priority, and I just got my line as we pulled up anyway.”
“I agree,” he nodded. “How much Nitro did you give her?”
And that’s when I hesitated.
“Um,” I hedged, “how much Nitro did I give her, or how many times did I give her Nitro?”
He cocked an eyebrow at me quizzically, put on his Medical Director Face, and said, “How about you tell me both.”
So I swallowed hard, and admitted, “I gave her four rounds of Nitro… 1.2 mg at a time.”
He kept that same quizzical expression on his face and said, “You know that’s not in the protocol. And you felt comfortable triple-dosing her with Nitro, without an IV?”
Oh well, if I go down, might as well go down swinging.
“Very comfortable,” I affirmed. “She didn’t need Lasix or fluids, she needed vasodilation. And if a certain medical director I know would push the company to adopt a CPAP protocol, she’d have had that, too.”
He laughed and said, “Well, she’ll have BiPAP as soon as respiratory gets down here, and if that medical director had any pull with the corporate bean counters, a certain ‘I’d rather beg for forgiveness than ask for permission’ medic I know would have had it to play with. Now get your ass back to work.”
The previous anecdote was merely intended to demonstrate that, indeed, lots of Nitro can be safely administered without an IV, and you need not be Supermedic to know when it can be done. All you need do is assess your patient.
I know of medics who devoutly believe that an EMT-B should never assist a patient in taking prescribed nitroglycerin tablets. I don’t know if it’s just protecting medic turf or some baseless superstition about precipitously dropping BP with one or two doses of Nitro, but it’s probably a little of both. And it’s just as wrong as the notion that EMS personnel should never administer more than three doses of Nitro before consulting with medical control.
First of all, the three dose limit on Nitro is something that cardiologists instruct their patients. It doesn’t apply to us. It is simply a trigger for calling 911, in the event that the patient’s chest pain turns out to be more than stable angina.
The end point of Nitro dosing for EMS personnel should be relief of symptoms, or a systolic BP approaching 90 systolic. Period. That applies whether you’re an EMT-B assisting a patient with their Nitro, or a medic administering it yourself. And honestly, if you’re a medic, you probably still need to be giving it to your MI patients, even if you’ve achieved adequate pain relief with opiates. I know the Mayo Clinic studies suggest that Nitro mainly makes us feel better, not the patient, but they are not yet the standard of care.
Secondly, cardiologists apparently believe it is safe to prescribe to their patients who presumably will not have an IV when they take it. Heck, it’s rare enough that they even know their blood pressure before that pop that little white pill under their tongue.
The only time you need be concerned with obtaining an IV before you give Nitro is when the BP is low or borderline, or the patient is suffering from a right ventricular infarction.
A 12-lead EKG takes about 30 seconds to obtain. If it indicates an inferior wall infarction, do a 15-lead EKG (or a second 12-lead with lead V4R). That’s another 30 seconds to determine if your patient is having an RVI or not. If that happens to be the case, you might need to start an IV before you administer Nitro.
I emphasize the word might, because RVI is not an absolute guarantee of preload dependency. If the patient is truly preload dependent, and thus prone to a precipitous drop in BP from relatively small doses of vasodilators like Nitro, there will generally be other clinical signs that point to that fact.
Look for things like orthostatic weakness, syncope or hypotension, and look for Kussmaul’s Sign.
Normally, when you see significant jugular venous distension in a heart patient, you’d expect to hear wet lungs to some degree. Also, JVD usually decreases with the negative intrathoracic pressure of inspiration.
The jugular venous distension in Kussmaul’s Sign does just the opposite: it worsens (or stays the same) with inspiration, and it’s usually present with dry lungs. This is a hallmark sign of impaired reight ventricular filling, and a big clue that vasodilation with Nitro may result in you having your patient flat on his back with his legs in the air, cursing the fact that you didn’t get an IV while they still had a blood pressure.
But it doesn’t take Supermedic to figure that out, it just takes assessing your patient. And it ain’t really all that common anyway.
I know paramedics who can tell you chapter and verse about their patients, and hand off a thoroughly assessed, neatly packaged, NEARLY DEAD patient. There’s a time and place for a thorough history and physical exam.
That time and place is not when your patient is circling the drain.
The ambulance has wheels for a reason, people.
And the answer to that question is, “Hell yes, most of them.”
A great many ground EMS crews are infected with advanced rotoriasis, but the problem is not limited to the EMS profession. Quite a few rural ER docs are ate up with it, too.
I weary of refuting this foolish notion we’ve developed over the years that mechanism of injury is not simply a part of the assessment criteria, but the assessment itself, We need to stop triaging patients to trauma centers, and flying them on helicopters, based solely on that criteria, because of it.
It’s stupid, dangerous and irresponsible, and doesn’t speak well of our ability to accurately assess patients. Most of the arguments to defend helicopter EMS abuse are easily refuted.
Next time you consider calling for the bird, think of our brethren dying in a helicopter crash, ask yourself if that flight is really necessary.
And if your primary justification for the flight is mechanism of injury, or the helicopter is the quickest way to clear an ER bed, or to allow your ground EMS crew to go back into service sooner, you’re part of the problem.
Question: What do the above things all have in common?
Answer: All of them are things in which some people desperately wish to believe, despite the utter lack of credible evidence of their existence.
Now, before you roll your eyes and say, “There goes AD again, making unsupported blanket statements just to make his point,” I will cop to just a little hyperbole:
Bigfoot may actually exist.
I’ve seen plaster casts of his feet, after all, and that Patterson film looked pretty convincing to me.
But one thing that I’ve never seen, never treated, never even heard of in fifteen years of EMS, is a spinal injury not accompanied by readily detectable signs and symptoms.
That’s what occult means, after all. Hidden, as in “never had a clue until we looked at the x-rays.”
Yeah, I know every EMT has a colleague who dates an ER nurse in another city who works with the nurse who treated the guy that walked into the ER under his own power with an unstable hangman’s fracture who, had he even turned his head this much (fingers held about an inch apart for dramatic emphasis), would have been paralyzed for life!
Just like the guy who was painting his house in the nude, and somehow fell off the ladder and wound up lodging a paintbrush handle in his rectum, just about every EMT has heard some variation of the occult spinal injury story.
Hell, I’ve even told that story to my students, back when I actually believed there was some benefit to spinal immobilization.
Now, I’m not so sure.
Few EMTs understand the rationale behind spinal immobilization, or since immobilization is rarely possible, more accurately referred to as spinal motion restriction. When you’re trying to convince the belligerent drunk behemoth that he’s strapped to a rigid board for his own good, and he continues to demand that you “Get this Goddamn thing offa mah neck!” while writhing beneath your three straps and your flimsy cardboard or styrofoam head blocks, true immobilization is an academic exercise at best.
What we do instead is document our steps to restrict spinal motion, including everything we did to convince the belligerent drunk behemoth that strapping him to a board isn’t our idea of fun either, but still necessary.
First, spinal cord injury can basically be divided into two broad categories: primary and secondary.
Primary cord injury occurs at the time of the accident. It’s done. Nervous tissue is contused, destroyed, what have you, and it happens when the accident occurs. Immobilization is a moot point for such injuries. Keeping them still is not going to reverse or even limit that damage.
What spinal motion restriction proposes to limit is something we call secondary cord injury, which occurs after the fact. It may result from post-injury cord inflammation and ischemia, or bony fragments impinging on previously undamaged sections of cord, or worsening an existing primary cord lesion. Restricting movement in patients with spinal cord injury limits the potential for further damage.
At least, that’s the theory.
And that’s all it is really, a theory. Peruse all the medical literature out there, and you will find little, if any, evidence that restricting spinal motion actually accomplishes what it proposes. In fact, the best information you will find merely confirms that, at best, it does no harm.
Moreover, we have just about zero evidence that restricting movement for patients with spinal fractures and no cord injury – the patients who are neurologically intact – does any good at all. The vast majority of those patients have stable fractures, and thus gain no benefit from being strapped to a rigid board.
What you will find, however, is an increasing body of evidence that the practice is not a benign, precautionary procedure at all. It does indeed cause harm, and all for the theoretical benefit of reducing secondary cord injury.
Pain and anxiety.
Vomiting and aspiration.
15% reduction in respiratory capacity, and that’s in healthy, non-obese people.
Increases in intracranial pressure.
Pressure necrosis to occiput, sacrum and heels.
All of these things are possibilities when we strap someone to a spine board, and all for a clinical benefit more theoretical than proven.
Here at The Borg, we have a spinal clearance algorithm of sorts. Like all spinal clearance algorithms, it relies on the presence of a very reliable indicator of serious injury: pain. Sure, there are other indicators of neurological compromise that we assess, but the big one is pain.
If someone breaks their neck, pain will result. Not just the diffuse “Man, my neck kinda hurts,” pain that you commonly see in cases of acute insurance-itis, but specific, midline posterior cervical spine tenderness above the area in question.
Of course, there are other elements that point toward spinal cord injury that need be assessed as well – focal neurological deficits, for example. Just the other night I boarded a male motorcyclist who straightened out a curve, based on nothing more than his complaint of numbness and tingling in his hands. It could have been nothing more than cold weather and crappy riding gloves, but it could also have been the telltale signs of a cord lesion.
He swore his neck didn’t hurt, and I found no signs of injury at all – thank God for muddy, grassy fields! – but I boarded him anyway. Of course, after a two-hour wait on the board in a busy ED, it was determined that he didn’t have any spinal injury, and he was taken off the board.
The presence of pain is what makes an occult spinal injury not occult at all, and in all my years in EMS, I have never encountered a single reliable patient with an unstable spinal fracture that didn’t have it.
Now, not every patient is reliable, hence the other elements of the spinal clearance algorithms that assess mental status and potential distracting injuries. If the patient is deemed to be unreliable due to organic or chemical impairment, or the fact that he seems to be focusing all his attention on his broken leg rather than your fingers walking down the back of his neck, we restrict spinal motion anyway, just as a precaution. It’s the prudent thing to do.
Well, that is, if you believe that boarding and collaring someone is actually beneficial for a patient with spinal cord injury. There is at least one well-constructed study out there that shows otherwise, in which spinal injury patients who were immobilized had significantly worse neurological outcomes than those who were not. I wrote about it a couple of years ago. Go read that post, and then come back.
For patients with penetrating trauma like knife or gunshot wounds, there is no reason to immobilize if the patient is neurologically intact. Nonetheless, it’s common practice in many EMS systems to collar and board shooting victims, even if the time spent immobilizing in the field doubles the patient’s chances of dying.
By God, we’re gonna save you from being paralyzed, even if it kills you!
The National Emergency X-radiography Utilization Study was designed to develop a specific set of clinical assessment criteria that would help cut down on the number of unnecessary cervical spine x-rays in Emergency Departments around the country. It has been validated in many thousands of patients, and generally speaking, those clinical assessment criteria are more accurate than x-rays in ruling out cervical spine fractures.
Of course, NEXUS is rarely used as it was designed. It’s been my observation that the Emergency Department physicians use it to clear patients off our board, but the patient still gets the x-rays anyway. Now you may ask, why do they remove patients from our boards, when we obviously boarded them for a reason, using the same set of criteria?
The reason is that many EMS spinal clearance algorithms, including the one used by The Borg, do not use NEXUS, but instead are modeled after the Canadian C-Spine Rules, which note a higher incidence of spinal injury in patients over age 65, and patients who have sustained significant injury above the clavicles.
Of course, these two additional criteria don’t mean that the patient has a spinal injury, they just suggest that we look at these patients a little more carefully. EMS often adds an additional criterion, the nebulous and subjective “significant mechanism of injury.”
Rather than use MOI as it was intended – as a conceptual tool to tell us where to focus our assessments – EMS tends to use it as the assessment. We place all of our faith in the mechanism, and precious little in our actual assessment findings. We’ve built an entire belief system around it.
This misplaced faith in mechanism of injury is what transforms a useful clinical tool like a spinal clearance algorithm into just another poorly written protocol, where we shoehorn patients into a set of unnecessary treatment steps that offer no benefit.
The state of Maine, pioneers in the use of a statewide field spinal clearance algorithm, has been using NEXUS criteria for ten years now. Everyone from the newest EMT to the most seasoned medic can apply it. Several years ago, they dropped mechanism of injury from the list of assessment criteria because MOI was too unreliable an indicator of injury.
So far, no one has seen an inordinate percentage of quadriplegics tooling around Bangor or Portland in their motorized wheelchairs, and we’ve heard no reports of juries awarding record monetary damages for the patients who weren’t collared and boarded. It may just be that they’re on to something up there that other EMS systems around the country would do well to copy.
The Borg have a spinal clearance protocol, but its benefits are diluted because they insist on immobilizing anyone with a significant MOI, or patients over age 65, or patients with an injury above the clavicles. Not “exercise due caution” in these patients, mind you, just “immobilize.”
No ifs, ands or buts, no exercising clinical judgment, no consideration of what’s best for your patient, just immobilize. Strap ‘em all to a board, and let the radiologists sort ‘em out.
Now imagine yourself, say, at a bar. You’re flirting with the waitress, nursing a Coke because you’re drew the short straw for designated driver, when all of a sudden and for no reason, Sumdood clocks you right in the mouth. Splits your lower lip and knocks out a tooth, the bastard.
But you’re pretty badassed yourself, and you didn’t even leave your feet. You’re more pissed than anything, really, and would like nothing more than to exact a little revenge, but Sumdood, as he always does, has vanished like a wisp of smoke. Your buddies cluck sympathetically at your mangled lip and missing tooth.
“Dude,” they say, “you oughta get that checked out. Call an ambulance or something. You’re gonna need stitches and everything.”
So then the ambulance arrives, crewed by Rookie Partner and a burly but nonetheless rakishly handsome and devilishly charming paramedic, namely… me, Ambulance Driver.
“Yep, that’ll need stitches,” I agree as I examine your face. Other than the split lip and missing tooth (carefully stashed by your buddy in his go cup filled with a White Russian because it has milk in it, and everyone knows you’re supposed to put dislodged teeth in milk), there isn’t a mark on you. Your pupils are fine, you didn’t lose consciousness, your neck doesn’t hurt when I palpate it, and you’re moving all your limbs appropriately. I even have you close your mouth and smile, checking for malocclusion of your teeth that may tell me you’ve suffered a fractured jaw.
You’re moderately impressed by my thoroughness, and thankful that The Borg employs such dedicated and skilled medics. They’re a pretty damned impressive outfit, you’re thinking. They’ve got their shit together. I’m in good hands, you’re thinking.
And then I say it.
“Um,” I say apologetically, “to take you to the hospital, we’re gonna have to put a collar around your neck and strap you to a board.”
“But I didn’t hurt my neck!” you protest. “Why is that necessary?”
“We have to,” I repeat, mentally biting my tongue to keep from agreeing with you wholeheartedly. “It’s, um… well, it’s the protocol. It’s for the best, really.”
“So you’re saying that strapping a guy with nothing but a split lip to a board is actually in his best interests?” you ask dubiously. “Dude, what have you been smoking?”
But hey, the guy has an injury above the clavicles, and the protocol clearly states that I’m required to immobilize that guy.
That’s a scene I am forced to repeat, day in and day out, several times a shift. And I am faced with the choice of explaining to my patient that my medical director is not a monosynaptic, booger-eating dullard, just that he writes protocols designed to be used by medics that are, or I can follow the protocol as written and have the patient think I’m the monosynaptic, booger-eating dullard.
Either way, it doesn’t reflect well on The Borg, or EMS in general.
Ironically, the same medics who immobilize everyone in the belief that if it keeps even one patient from being paralyzed… are the same medics who are card-carrying members of the No Neck Fits Everyone Society, and believe that three straps are all that’s necessary to properly secure a patient to the board.
Now, being an ornery type who refuses complete assimilation into the Hive Mind, I rebel at doing unnecessary and potentially harmful things to my patients, and carefully explain to them that they have the right to refuse any medical treatment that we offer *wink wink, nudge nudge*. Sometimes I just refuse to follow the protocol, and I get my pee pee whacked for it fairly regularly.
But a great many of my colleagues don’t even go that far, and simply follow the protocol blindly, never questioning the wisdom (or lack thereof) behind it. Some of them even tell the patient things like, “If you want to go to the hospital on my rig, you have to go on the board.”
That’s a practice that doesn’t just flirt with the legal definition of coercion, it gives it a naked lap dance and slips its cell number and hotel key into Coercion’s pocket. It’s wrong, and we shouldn’t make our patients submit to painful and unnecessary treatments just to get the help they seek.
Every time the FTO Drone whacks me on the pee pee for not immobilizing someone needlessly, he’s almost apologetic about it. “It’s not you, AD,” he’ll say as I’m taking the online spinal immobilization tutorial for the umpteenth time, “it’s all these other yahoos who aren’t using their heads at all. If we’re going to discipline them for it, we can’t let you get away with doing the same thing.”
And he’s right. Discipline needs to be applied uniformly, even if it occasionally requires that a good medic who exercises his brain receive the same punishment as the bad medics who didn’t.
Of course, they could also re-write the protocol to allow more freedom to exercise clinical judgment, and hire medics worthy of that level of trust.
Like, you know, ones that don’t believe in Bigfoot, aliens and occult spinal injury.