Question from a novice

[E229Lt]

Well, semi-novice. I was an A-EMT, when there was such a thing back in 1977. Now I'm a simple CFR-D Firefighter.

At a fire incident last weekend, as we were taking up, one of the members reported that someone (civilian)had just been shot in front of the rig. As it turns out, the person had been shot in the right side of the face, just above the lip. The entry wound looked to be somewhere between a 25 cal. and a .380. No exit wound was noted and I instructed the members to apply a "C" collar.

I got some pretty strange looks from the brothers and just repeated myself and it was done, along with the remaining patient care.

My question: Should I have bothered? My thinking was, with no exit wound, there was a possibility the bullet could have been in or near the C-spine and any movement could endanger the patient. Is this common practice? Should it be? Or was I overdoing it?

[twocuts]

Interesting that you ask that. This is a hot topic right now. Typically I always C-spined anyone who was shot from the femur to the head if I did not see an exit wound (except the arm etc). The thought was always that if I didn't know where the bullet was then I was going to protect the spine. However, new studies have shown us that this may be overkill (so to speak). If the person is neurologically stable, is awake and alert, doesn't have any alcohol or drugs on board etc, then it is probably acceptable not to. I think of it like this though. What would happen if you didn;t immobilize and they suffered a deficit because of it, vs. what would happen if you immobilized and the bullet was no where close to the spine?

Our system has a spinal algorithm. I like it, but, do what you are comfortable with. no one will ding you for erring on the side of the patient.

Corey

[hageremtp]

As a comfort to myself, I would take full c-spine on anyone that was shot in the head. Like the alst post stated, its your call to make...and if you make the wrong one- its you that has to sleep at night knowing it. Overkill maybe, but I can still sleep at night without knowing that I caused un-due harm.

[Nemiko]

Ooh, tough call. I think you did the right thing. I'd C-spine them, too, seeing as it is head trauma, and let's face it- with no exit wound, you don't know where that bullet is or where it's going to go if they move. I'd honestly rather get yelled at for wasting a c-collar and the time to hold good c-spine than to live with the knowledge that I could have done something to prevent further harm.

Nemiko

[Weruj1]

E229..........welcome to flip side brother ! I would immobilize this person for the reasons you just stated......certainly you have no idea where the bullet is so I say I would do the same thing .........

oh ya ,,,,,,,he called himself a NOVICE .........LOL >.......Cmon Lou !@

[DaSharkie]

Not a whole lot of thought process involved in this.

Guy gets shot, if it is anywhere in the torso I'll board them. We have no C-spine clearing protocol, so they get it, no discussion. Especially if it is in the upper torso. We board people for less, so they're getting the works.

I also don't have X-Ray vision so I have no idea which way the round traveled so, again, they're getting a collar.

Finally, you made the guess at a 0.25 calibre or a little larger. Well if it looks like a 0.25 calibre then taht is a nasty round. It is only marginally larger than 0.22 which fragments and rattles around the body. In the head it is extremely dangerous because it has a tendency to rattle around and shred the brain. There are also numerous documented cases where the round travels around the circumference of the skull inside causing nasty cavitation damage. With a high tendency to fragment, it is too easy for a fragment to land in a vertebral disk so I say you did well.

As for the guys looking at you funny, well just explain it to them.

[fre156]

Always, always, always err on the side of caution. Putting on a collar will never hurt the patient. Not putting on a collar might.

You have no way of knowing where the bullet might be lodged. Rule of thumb; protect the patient, cover your behind. If this is a shooting, chances are you'll be called into court. Do you want to explain to a judge or jury why you didn't protect the patient's cervical spine? I sure wouldn't want to! :eek:

[IAMedic]

I would C-Collar and board for this simple fact; do you know how much force happens to the spinal column from a gunshot?? I have seen some reports that it is like driving head on into a tree at 50 mph. We would board that person, correct?? You did the right thing and think you'd be hard pressed to find anyone who would not back you up.

Good Job and you by no means are a novice, Sir. You've been doing this since 1977, but just don't have the credentials or certificates. I would take your experience and knowledge over some Paramedics I know, anyday!!

[N2DFire]

I agree 100% that this Pt gets a C-collar.
As all the others have said (in various ways) A C-collar ain't gonna kill em - not having a C-collar might. It's your job to be the Pt's advocate and do anything in your power that works to their favor (well being & safety)


Originally posted by IAMedic
Good Job and you by no means are a novice, Sir. You've been doing this since 1977, but just don't have the credentials or certificates. I would take your experience and knowledge over some Paramedics I know, anyday!!

Ditto - every last bit of it.

[ff7134]

LT you are no Novice...actually you have been doing the job longer than I have been alive.


But yes I would C-spine them. Best to CYA on this, and not like its going to really hurt the patient in any major way. If the docs don't thik it is necessary they'll take it off.

Good Job;)

[twocuts]

[QUOTE]Originally posted by IAMedic
[B]I would C-Collar and board for this simple fact; do you know how much force happens to the spinal column from a gunshot?? I have seen some reports that it is like driving head on into a tree at 50 mph. We would board that person, correct??

Not necessarily. The literature out there takes mechanism of injury out of the picture. I have the liberty of clearing c-spine on a patient that rolled until there car was a 12"box as long as certain criteria are met. You should see this trend catch on nationwide because it makes sense scientifically.

If you have the following:

A reliable patient
no spinal or paraspinal pain on palpation
no distracting injury (this is subjective)
A neurologically intact patient

No spinal movement restriction required, regardless of mechanism.

BTW, I agree with boarding the patient in this case.

[Ohiovolffemtp]

From your friendly neighborhood EMT Instructor:

Person shot from pelvis to top of head gets full C-spine precautions: C-collar, long board, head blocks. He also gets high-flow O2 - via non-rebreather if breathing OK, BVM if not and rapid transport. Airway ajuncts (oral or nasal if needed). Don't wait for medics - there's nothing we can do for this guy unless he doesn't have an airway. He needs rapid surgery.

Lt:
You did perfect. You can ride in the back of my box anytime.

[smurfe]

Best to CYA on this,

I gotta say their isn't any "CYA" on this one. Bullet in the head get full spinal and if you aren't doing it, you need to re-consider. As IAMedic stated, the "G" force of the bullet hitting the skull itself could cause spinal injury and if you don't have an exit, you just don't know where it is hiding. Now do I advocate every "head Injury" getting full spinal? NO, if granny falls and bumps her head, I will R/O spinal injury and they will get it if I have any doubts at all. A ground level fall won't have the "g" force a bullet will. I always spinal when in doubt, but a bullet in the head always gets it. I would say "good call" on this one, but you were actually just doing your job correctly LOL

Smurfe:D

[twocuts]

Originally posted by Ohiovolffemtp
From your friendly neighborhood EMT Instructor:

Person shot from pelvis to top of head gets full C-spine precautions: C-collar, long board, head blocks. He also gets high-flow O2 - via non-rebreather if breathing OK, BVM if not and rapid transport. Airway ajuncts (oral or nasal if needed). Don't wait for medics - there's nothing we can do for this guy unless he doesn't have an airway. He needs rapid surgery.

Lt:
You did perfect. You can ride in the back of my box anytime.

I am not disagreeing with the treatment here, however, lets step outside of the box and think about what we are saying. There is no recipe for treatment. There are concepts. To say that every person shot from pelvis to head gets a c-collar, long board and head blocks is to practice from the recipe. Sometimes the concept leads you in the direction of putting a collar on someone and they sit on your stretcher with a suction yankeur in their mouth. The goal is to restrict movement. Put me flat on my back on a board when the front half of my face is blown off? I don't think so. I know what you mean, but, too many people practice the recipe, and, I have the hardest time teaching them how to think for themselves and practice medicine. That is one of the main reasons people do not make it in my system.

[DrParasite]

C-collar and full spinal precations. PHTLS teaches that any major trauma to the Central Nervous system (with the exception of a stab wound to the neck with no neuro deficits) gets boarded and collared. good call Lt

[bigJ164019]

Full spinal precautions is a must here.