Spinal immobilization?

[Stealth83]

I am currently an newbie EMT-A (Similar to EMT-I or PCP). While doing some work for a local ski area (not under medical direction) I was presented with an interesting situation...

A 13 year old male snowboarder decides he wants to try out a large jump in the terrain park. He takes the jump too fast and at a bad angle. Witnesses say he went to the top of the jump (approx 10ft.) and went another few feet above it, landed hard, awkward, and screamed out in pain.

Upon arrival (approx 5 minutes after the accident) the young boy was in obvious pain and supine on his back. (Friends had removed his helmet.) Assessment revealed localized back pain - 7/10 - (approx T7) with and without palpation and "tingling" in his lower legs. No other trauma or pain, no other neurological deficit, and he was CAOx4.

At the time I was working with another patroller, an EMR (similar to EMT-B).

I made the call to immobilize due to the back pain and tingling in the feet, which also means EMS must be called, and we packaged him up and brought him into the Patrol Hut.

His mother was in the chalet and met us in the hut.

Secondary assessment showed the back pain reduced to 3/10 and the tingling in his feet gone. At this time the mother proceeded to question me on the necessity of the immob. and the Ambulance.

Shortly after assuring the mother it was necessary, the Medics showed up and took the boy to the hospital. (They are not permitted to clear C-Spine on scene).

Talking with my partner after the accident she told me that she also believed that the pt. did not require immob. and that it was probably nothing.

I stand by my judgment and see no reason to not have immobilized the pt.

What do you think? Does tingling in the feet suddenly disappear? Would he have just been scared for some reason and said there was no tingling when there really was?

Thanks


Based on studies of the clinical criteria to determine the need for spinal x-rays, there is a presumption that without symptoms and physical findings associated with spinal injury, no significant spinal injury exists. Therefore spine immobilization is indicated in prehospital trauma patients who sustain an injury by a mechanism of injury having the potential for causing spinal injury and who have at least one of the following clinical criteria

altered mental status,
evidence of intoxication,
a distracting painful injury,
neurological deficit,
spinal pain or tenderness

[Weruj1]

good call................had to do it ........I say good job. The mechanism of injury warranted it for sure plus he may have had a some neuro impairment with hte whole tingling thing ........if nothing was found then he endured some bit uncomfortableness but he can walk away from it !

[mcaldwell]

I am the Safety Manager for a large Ski Resort where we often handle a half-dozen of these a day, and in my opinion you did it right.

You had mechanism (10+ ft jump with poor landing), spinal/back pain, and initial nuero indicators (tingling in lower extremities).

I am certainly no advocate of "cover-your-***" procedures, but around here and based on those findings, he's definitely getting the whole package regardless of whether or not it goes away in the PC.

The tingling does sometimes go away after immobilization. It may not have been actual spinal pressure that caused it, but rather a simple contusion in proximity to a nerve, but you have no way of determining that in the mtn clinic. It could have simply been caused by minor swelling complicated by his physical position on the slope, and alleviated by the support that the board provided.

If he had only one or two minor indicators (say height and very minor localized pain), and you have a field C-spine protocol, you "might" have been able to rule it out in the clinic, but with three indicators and one of them a possible nuero deficit you definitely needed to board and transport him.

Good Job! :)

[DaSharkie]

You did the right thing. Here our protocols would call for a trauma workup at the level one center should we decide so based upon further assessment. He was 13 so he was probably about 5 feet or so the fall was twice his height. This puts a tremendous amount of force upon the body especially when it is unexpected.

No LOC which is good, but still could have a head injury, many are very slow in presentation. He cried in pain, meaning something hurt him when he landed, back or something else. You do not have X-ray vision so how are you supposed to know what was injured?

Even if you could clear C-Spine in the field, this guy had signs adn symptoms of a possible spinal chord injury, ergo you bought the board and collar, and a trip to the ED. I am not losing my ticket because I offended your sensibility. I work for the best interest of my patient, not your well being. (sorry for the ranting there.)

Now this guys tingling was probably because he got the wind knocked right the heck out of him when he landed. Then he began hyperventilating, further enhancing the numbness and tingling sensation. The problem with this is that it masks any potentially underlying injury the boy may have had.

As stated here, the muscle twitching, sensation, and movement can deteeriorate rapidly or not at all after a possible spinal chord injury and I, like many others here, are not exactly willing to take the chance that this poor guy will move wrong because I did not board them and end up paralised below the nipples at 13.

All in all, I think you did the right thing. You can't change the past anyway. Expalin your logic to your partners / co workers. THis is one of the best learning experiences you can get in EMS, the simple bantering about that we do.

[EMTSteve]

We always C-spine when trauma is suspected. Pretty much every time we transport an MVC patient - no matter how bad the pain is or even if there is none in the back and/or neck - we C-spine. It's better to do it and not need it than need it and not do it. When I do my ambulance inventory, the first thing I check is the compartment where we keep the backboards. We're always supposed to have two on board. Because I don't want to go to an MVC and not have backboards if we need them.

If you hadn't applied C-spine to the patient, the mother might be suing you for not doing it.

[kghemtp]

I was headed down the same thought process as Sharkie on the tingling, but the conditions found, the eyewitness accounts, and mechanism of injury would indicate every treatment you offered. I'd be very much against signing this kid off in the care of a parent just because they paid $35 for the day and want their money's worth! Ya know, 3/10 is still something, especially given the situation. Yeah, we've ALL had experiences as kids or adults where we land on our @sses or heads & walk away with considerable pain, but this one does have some great potential for seriousness. Good call with boarding, regardless of what anyone else chose to do afterward.

[EMTfarmer]

I heartily agree with the above assessments and would have taken c-spine precautions. In this vein, has anyone here heard Dave Gurchiek from Montana State University speak on "All clear: No backboard needed"? He spoke at our state conference this fall. What he says makes a lot of sense but some of it flys in the face of much of our training. Interested to hear other opinions.

[lieutenant109]

Good call on your part. It is easier to explain why you did c-spine then why you didn't and he suffered complications! With this country being sue happy it is always best to CYA.

[EMTSteve]

If the mother was upset about C-spine, imagine how she would have felt if you had to check for a priapism. :)

[Catrina]

I would definitely concur with the above posters. It is by far better to be cautious and provide too much care than it is to provide too little care. From my limited knowledge, it definitely seems like this kid was a good candidate for spinal injury. In lifeguarding, if a person fell from height greater than his own, we were instructed to package him up as a possible spinal injury. If ever the slightest bit concerned about the possibilty of such an injury, then of course you should take the necessary precautions. And this isn't a CYA thing, this is in the best interests of the patient. So good job, good call, and stick to your guns; you were right.

[smurfe]

I say good call also. I have found with kids that when you interview them they either totally exaggerate their pain and symptoms or rate the pain low as they don't wanna appear as a weenie. Like others have said, I am not a fan of boarding everybody but I to probably would of this patient also.

All I can say is never question yourself for doing something, only question yourself if you didn't and thought you should :D

Smurfe:D