While on vacation outside of the US a few days ago, I had two chances to intervene in medical situations. I'm curious what you would have done if you had been in my situation.
Case 1: In a southern coastal city in the UK, an elderly woman reportedly "just fainted and fell" while crossing a street. No one there knew her. Several bystanders were trying to help, including a man who identified himself as a "medic" and woman who worked at a pharmacy. The injured woman was obese, lying awkwardly on her right hip with her torso twisted, her upper chest on the pavement and her head twisted toward her left shoulder. Her head was lower than her body, and she was bleeding from a scalp laceration. The medic knelt beside her and held pressure on the scalp wound. She denied any pain and tried to get up several times, but they held her down even when she vomited, insisting that she should not move. Her breathing was heavy. EMS had been called, and I could hear a distant siren.
Case 2: Halfway between Amsterdam and New York, they paged overhead for a doctor to come to the back of the plane. No one moved. I went back and told the flight attendant I was an ER RN, not a doctor. Apparently, I was their best option.
He took me to an elderly man who was worried about moderate swelling and mild redness in his right lower leg and ankle. With his daughter translating, I learned the swelling had started during our flight, but he'd been on a plane for three hours prior to ours. He had a large scab on his lower right lower shin from a scrape three days ago but denied any pain. He was sitting on a jump seat with his leg propped up on a window well, straight and level with his hip. They were applying cool compresses.
I've second guessed myself a bit on one of these two. What would you have done?
I assisted a doc on a transatlantic flight after I saw passengers interfering with incorrect advice and contradicting the doc, made it to landing and ems took over, for the mess I was hands covered in secretions,they shut down plane before I could wash, so no never again...unless it is my family. ugh
So I read both of the links and what they are talking about is total spine immobilization not cervical spine immobilization or motion restriction. This is a frequently misunderstood concept. Protecting the c-spine has not fallen out of favor in blunt force trauma care. It has, however, with penetrating neck injuries.
"SMR, when indicated, should apply to the entire spine due to the risk of noncontiguous injuries (3American College of Surgeons Committee on Trauma. Advanced Trauma Life Support Course Manual, Chapter 7, Spine and spinal cord injuries. 9th ed. Chicago (IL): American College of Surgeons; 2012. [Google Scholar]). An appropriately-sized cervical collar is a critical component of SMR and should be used to limit movement of the cervical spine whenever SMR is employed. The remainder of the spine should be stabilized by keeping the head, neck, and torso in alignment. This can be accomplished by placing the patient on a long backboard, a scoop stretcher, a vacuum mattress, or an ambulance cot. If elevation of the head is required, the device used to stabilize the spine should be elevated at the head while maintaining alignment of the neck and torso. SMR cannot be properly performed with a patient in a sitting position."
"Indications for SMR following blunt trauma include:
Acutely altered level of consciousness (e.g., GCS <15, evidence of intoxication)
Midline neck or back pain and/or tenderness
Focal neurologic signs and/or symptoms (e.g., numbness or motor weakness)
Anatomic deformity of the spine
Distracting circumstances or injury (e.g., long bone fracture, degloving, or crush injuries, large burns, emotional distress, communication barrier, etc.) or any similar injury that impairs the patient’s ability to contribute to a reliable examination"
This patient was vomiting, had a scalp lac and may have been altered in that she was fighting the people trying to help her. There is no way to determine whether that was because she was fine or because she wasn't. All of these indicate the possibility of a head injury. I would not be willing to risk making an assumption and being wrong. In the field a suspected head injury gets cervical-spine precautions. The medic on the scene was not incorrect and the use of quotation marks around his title was pejorative. I would have done exactly as he did with the exception of log-rolling her while she was puking. As nurses we are not trained in what to do outside of the hospital. It is a different world and we are in the wrong to sit in judgement of things we do not know.
Wuzzie, my sincere understanding is that they are collectively calling all forms (or any form) of restriction "SMR" and saying that SMR is not always indicated but if it is, then x, y, z. That's exactly what it says even in the portion you quoted above. Yes, an appropriately-sized c-collar is a critical component, when SMR of some type is indicated to begin with.
Although we were not there to assess this patient personally, it appears (based on our limited info) that the appropriately qualified person could clear a c-spine in a situation with the basic elements of this one, based on NEXUS criteria as well. [The vacationing passer-by RN may not be that "qualified person," but the fact still remains].
Hopefully you know I would not presume to know any medic's or EMT's role better than they do, or have their particular expertise - which is exactly why I wouldn't have asserted myself much in this situation.
EMS and health systems have been working together to process the various lit reviews/reviews of evidence, etc., and I sincerely think thoughts are changing on this.
Wuzzie, my sincere understanding is that they are collectively calling all forms (or any form) of restriction "SMR" and saying that SMR is not always indicated but if it is, then x, y, z. That's exactly what it says even in the portion you quoted above. Yes, an appropriately-sized c-collar is a critical component, when SMR of some type is indicated to begin with.
Yes, that is my understanding as well but in this situation SMR was appropriate.
I don't stop if someone else is helping, simply because I don't treat my patient by committee. It's my license, and I'm willing to take the rap for my own mistakes, but I'm not willing to discuss things at the roadside with five people that just want to feel important. Done it, hated it, never again.
We use an algorithm pre-hospital to determine if SMR is required. I can understand why a medic would be reluctant to relinquish c-spine as the elderly can often sustain c-spine fractures from ground-level falls. However, if you are concerned about a brain injury, restraining a person is going to raise ICP too. If a patient is altered (not sure what the mentation status was with patient 1), they rule in for SMR. Age is also a consideration. As I wasn't there to assess the pt as far as midline tenderness or neuro issues, it's tough to say.
Yes, the Canadian rule automatically qualifies this lady as someone who will require radiology c/s clearance due to age alone. Personally, I would need more information to be compelled to put my hands on her to restrain her movements. Probably would have just let them do their thing.
While on vacation outside of the US a few days ago, I had two chances to intervene in medical situations. I'm curious what you would have done if you had been in my situation.
Case 1: In a southern coastal city in the UK, an elderly woman reportedly "just fainted and fell" while crossing a street. No one there knew her. Several bystanders were trying to help, including a man who identified himself as a "medic" and woman who worked at a pharmacy. The injured woman was obese, lying awkwardly on her right hip with her torso twisted, her upper chest on the pavement and her head twisted toward her left shoulder. Her head was lower than her body, and she was bleeding from a scalp laceration. The medic knelt beside her and held pressure on the scalp wound. She denied any pain and tried to get up several times, but they held her down even when she vomited, insisting that she should not move. Her breathing was heavy. EMS had been called, and I could hear a distant siren.
Case 2: Halfway between Amsterdam and New York, they paged overhead for a doctor to come to the back of the plane. No one moved. I went back and told the flight attendant I was an ER RN, not a doctor. Apparently, I was their best option.
He took me to an elderly man who was worried about moderate swelling and mild redness in his right lower leg and ankle. With his daughter translating, I learned the swelling had started during our flight, but he'd been on a plane for three hours prior to ours. He had a large scab on his lower right lower shin from a scrape three days ago but denied any pain. He was sitting on a jump seat with his leg propped up on a window well, straight and level with his hip. They were applying cool compresses.
I've second guessed myself a bit on one of these two. What would you have done?
No.
The road to hell is paved with the best intentions.
In the second situation, it sounds like you didn't know what the situation was when you said "yes", so watching to see if it was enough of an emergency to warrant the risk of identifying yourself as an RN wasn't an option, is that right?
I feel as though once you've ID'd yourself as an RN, then whatever you say carries some risk. If you say "Oh, that's not worth my input, carry on", you're still in some way approving of their actions.
I think personally, I'd ID myself because I'd worry about it being a much more serious situation, and then once I've done that, I feel as though I'd be stuck and need to follow through.
The medic on the scene was not incorrect and the use of quotation marks around his title was pejorative. I would have done exactly as he did with the exception of log-rolling her while she was puking. As nurses we are not trained in what to do outside of the hospital. It is a different world and we are in the wrong to sit in judgement of things we do not know.
The quotation marks around medic were not intended to be diminutive or pejorative. I emphasized his stated title because I'm not sure what "medic" means in the UK. I've heard "medic" used in the armed forces, but in the US we have EMTs and Paramedics in our EMS systems. My uncertainty about his level of expertise was one reason I chose not to assert myself further.
It's true that my descriptions were general, but his version of maintaining c-spine was forcing the patient to remain in the awkward position I described with her head lower than her torso (please read it again) despite her denying pain, asking to sit up, and trying to sit up. She was alert and clearly moving all extremities in her attempts to sit up during which she was physically restrained. Log rolling was not option because she was not on her back.
EMS maintains c-spine after aligning the head and the body. They do not maintain the tortuous and unnatural position in which the patient is discovered.
There's a strong current of reluctance to get involved running through many of the responses here. Has our litigious society trumped all moral imperative to help when we are confident of our skill and knowledge? The irony is that if we turn away, the vacuum will be filled by those more willing but less capable.
What if the person needing help is you, or someone you love, instead of some stranger? Wouldn't you want the most capable person available to step forward?
kp2016
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