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 identified myself as a neuro ICU nurse, and the man identified himself as a paramedic. The girl who fell was on her back, face up during her seizure and her airway was patent. The paramedic went to hold her neck to stabilize her cspine, and as he was about to do it, the women who had approached grabbed her forcefully and turned her on her side. We both protested loudly and told her not to move the patient, but she essentially screamed at us that she knew what she was doing and refused to listen. At that point I stepped back, and I have not identified myself as a RN in any situation like that since. It's crappy, but we're not licensed to practice independently in situations like that. It was a rude awakening to realize that the actions of a bystander who was 'helping' the wrong way would affect me and my license/livelihood.
A couple of others have noted the danger of trying to help when several people with various levels of ability are jockeying for position. That was the other reason I bowed out of the first situation. Along with the medic and the pharmacy employee, there were several others already trying to help. On the plane, I was the only one who responded, which made it prudent and easy for me to intervene.
I ran the scenario of the lady who fell in the street by three different paramedics who are currently working on local EMS crews as they passed through our ER today. Each of them quickly responded they would let her sit up. In her case, the significant factors were that she was alert, oriented, denied pain, and wanted to sit up. They stated they would apply a collar after she sat up due to the head injury prior to transporting her, but they would not put her on a backboard.
Moot point because there was no c-collar available at the particular time of the event described in your post. The only way to protect her cervical spine was to have her be still which is what the medic on scene was trying to do albeit a bit too aggressively it sounds. I too would have let her sit up if she had insisted but the collar goes on first. Here's what I would have done if I was on scene and in charge. I would have, with help-see below, stabilized her cervical spine and gotten her positioned more comfortably and in alignment which probably would have negated her resistance to lying still. Getting patients who have knocked their noggins to cooperate can be a challenge at times but there are ways to accomplish this without being an aggressive richard. If I was close to my car and my kit I might have put a c-collar on if that's what it took to get the patient to cooperate but that's it. Then I would have waited the 3-5 minutes it was going to take for the squad to get there at which point I would have immediately relinquished care, let them know she had puked and been on my way. They don't want a full report...trust me on that.
6 hours ago, RobbiRN said:
A couple of others have noted the danger of trying to help when several people with various levels of ability are jockeying for position. That was the other reason I bowed out of the first situation. Along with the medic and the pharmacy employee, there were several others already trying to help. On the plane, I was the only one who responded, which made it prudent and easy for me to intervene.
I stop at any scene that does not have folks in turn-out gear present. I ask if anybody has taken charge, if they have emergency care experience and if they would like my help. If someone identifies themselves as experienced in field care and they do not want help I peace out. If they ask for my help then I stay. Usually that stops the position jockeying and allows for decent team work. I am fortunate that certain factors of my first-responder experience has exposed me to situations and training where patient position presented issues (we call it "Jams & Pretzels" training and it is extremely helpful in situations like this). I am also accustomed to having to use bystanders to assist me when I have no other option so I would have been more comfortable in this situation than the people who were there. Still, I am a minimalist when it comes to off-duty scene response. I do what I need to do to protect from further injury and wait for the people who ARE on duty to take it from there. Really as nurses that's pretty much all we can do. In this scenario if the medic was resistant to suggestions and did not want help I would have walked...it's on him and I'm not going to get in a pissing match.
The dude in the second situation needed medical care that I would not be able to provide on a plane even with their medical kit and a doctor on the phone. Depending on the flight time I would have let the crew know he needs a doctor, on the ground and in a reasonable time frame. Keep the leg up until we land and that's about it.
Backboards are merely for transportation, period. No real immobilization benefit.
Thank you! Thank you! Thank you! A point I have tried to make but done so badly. You can effectively stabilize the cervical spine without a backboard and as far as I can tell from my research C-spine stabilization, in the absence of penetrating neck injuries, is still SOP for certain situations and head injury is one of them.
I thought that was the case, but I asked the attendant if they used a service or had any doctor they could contact for direction if they failed to get help on board. He said no.
Attendant was being lazy or just didn't know. Next time, try to go over his head.
First case - protect the airway
2nd case - there doesn't seem to be anything immediate required
Backboards are merely for transportation, period. No real immobilization benefit.
Yes. Thank you. This has been a source of grief on our end for decades. Patients who from minor fender-benders who were ambulatory at the scene were back-boarded after complaining of neck pain. Their complaints multiplied en route due to the backboard, and they arrived angry and sometimes outright hostile until we could get them off it--which used to require someone higher than RN. EMS is using them less often, and our lives are better.
Pixie, you mentioned previously that log rolling is no longer indicated? Can you elaborate on that?
Pixie, you mentioned previously that log rolling is no longer indicated? Can you elaborate on that?
Log rolling is discouraged if you have not ruled out an unstable spine or pelvis. Even in the new edition of TNCC, you would defer rolling the patient to inspect the posterior side if you have a suspicion of an unstable spine or pelvis. Total practice change, right?
Log rolling is discouraged if you have not ruled out an unstable spine or pelvis. Even in the new edition of TNCC, you would defer rolling the patient to inspect the posterior side if you have a suspicion of an unstable spine or pelvis. Total practice change, right?
Okay that makes no sense. If you need to board a patient to transfer from ground to cot or cot to cot how are you to get the dang thing under them?
Yes, it's a bridge lift. I've used it for years but it's not that easy to do and requires a bunch of people. Also not possible for obese patients. What a nightmare.
I am confused how all of this lines up with the consensus statement posted earlier. Can anyone humor me (or have pity ?)?
Does the term SMR not intend to reference or include the cervical spine (the c-collar)?
I suppose the consensus statement could be, in part, an attempt to clarify that a long board should be used extremely judiciously and that a c-collar is needed if a long board is also being used, but that interpretation of the statement seems problematic as I have never noticed that being an issue (rampant use of long board w/o c-collar) - - so my reading of the statement is that it is saying something different.
Does anyone take it to mean that wide use of c-collar is still recommended (thus the r/o factors mentioned are only meant to apply to long board and not c-collar)? Is it just meant to clarify that wide use of long board is not recommend (something that hasn't been being practiced anyway for quite awhile now)?
Possible interpretations of the statement:
1. SMR refers to restriction of parts of the spine not including cervical. Statement is confirming that long board should be used very judiciously. Its necessity in a situation can be ruled out by the factors mentioned (intoxication, ALOC, neuro deficit, distracting injury etc., etc.), but if it is deemed necessary, a c-collar should also be used. This interpretation is problematic as already described above, and by other issues, such as the fact that c-spine motion can't be considered adequately restricted if you allow the entire rest of the spine below it to move freely. Then there is also the thought that the danger involved in not restricting c-spine movement is in a subsequent forceful impact - not just movement itself, which we know occurs to some degree regardless of "immobilization".
2. SMR refers to any portion/method of restriction, including c-collar. If you are concerned about part of the spine, you are concerned about all of it. The need for SMR can be ruled out by the aforementioned factors. [I think this is the more likely interpretation d/t the increasing criticisms of c-collars, but this interpretation also doesn't make complete sense because it theoretically allows rule-out of some patients who otherwise would require imaging to r/o injury - such as the elderly].
I am confused how all of this lines up with the consensus statement posted earlier. Can anyone humor me (or have pity ?)?
I mentioned that log rolling is becoming verboten, Wuzzie asked about alternatives that are suggested, so I posted the link to the ENA position paper that references alternative methods to move patients instead of log rolling. Is that what you mean? Sorry, brainy no worky today. ?
RobbiRN, RN
8 Articles; 205 Posts
A couple of others have noted the danger of trying to help when several people with various levels of ability are jockeying for position. That was the other reason I bowed out of the first situation. Along with the medic and the pharmacy employee, there were several others already trying to help. On the plane, I was the only one who responded, which made it prudent and easy for me to intervene.