Vaughan,
Your post raises many important points.
I think it is vital that clinical practice remains patient centred and is
not medico-legally driven. The decision to immobilise is a judgement call
that in my view is best made by those at the incident scene. Clearly the
threshold to immobilise will also be influenced by clinical experience but
at the end of the day the "Bolam" test will be applied by a judge in a
negligence claim when deciding whether a defendant can show that he acted in
a accordance with a body of competent professional opinion. The level of
training and experience as well as the contents of existing local
(ambulance) protocols and, whether or not there has been compliance with
such, will also be considered, as well as establishing that any harm that
has occurred is a consequence of such actions......
The decision not to immobilise a patient, at least not initially, will also
have to be frequently made particularly when extricating patients from
challenging environments - e.g. confined space, from height etc. and have to
be balanced against other non-clinical variables such as on-going hazard.
The benefits of prompt evacuation versus the risks of potentially lengthy
entrapment time have to be balanced at the time and are rarely considered by
those (based in hospitals) not experienced in having to make such
decisions. This would also have to be considered in any negligence claim.
I would share Matt's hope that the practice of transferring patients on to
longboards within the ED has been long abandoned. This was based on the
incorrect assumption that ED trolleys did not provide adequate
thoraco-lumbar support for patients with unstable spinal fractures.
I therefore strongly contest your view that the decision to remove a patient
from a longboard is the sole remit of doctors and rest my case!
John Black
Emergency Department
John Radcliffe Hospital
Oxford
-----Original Message-----
From: Vaughan Knight [mailto:[log in to unmask]]
Sent: 12 September 2002 12:40
To: [log in to unmask]
Subject: removal from spinal boards/ clearing of 'C-spine'/ longboard
packaging.
I have been reading these threads with obvious interest, and the three seem
to be linked by the same medical/legal argument.
The decision to utilise the spinal long board is not always based on the
needs of the patient, but the protection of the ambulance crew. The
mechanisms involved in an RTA for example, may create an index of suspicion
even though the patient has walked at the scene, and is not overly keen to
be strapped to a board for transport. But based on the fact that 'absence
of neurological indicators does not rule out cervical spine damage', few
paramedics would, I suspect, be willing to take the risk of missing the
statistical 1% of 'c-spine' fractures.
Another situation often faced by crews is that of the simple rear end shunt,
where those involved insist on hospitalisation. In some cases demands for
collars and immobilisation are made, as well as those who refuse to get out
of a vehicle because they've got neck pain. It is not a case for using a
board for every neck pain, but we are sometimes put under pressure by the
patients themselves, and at times it is the hospital staff that provide the
pressure:
A couple of years ago I took a patient into A&E who had fallen 10ft. from a
ladder and sustained a femoral fracture. To cut a long story short, I
managed him with a scoop and a splint with gas for pain. In A&E the nursing
staff insisted that the patient was transferred to a spinal board, which he
was on for about 30mins prior to removal without x-ray.
The decision to remove a spinal board once in place I believe is the sole
remit of doctors. This is based on the increasingly developing culture of
'no win, no fee'. The fact is, that medical decisions have to be justified
legally. Who but a doctor is willing to stand up in court and justify a
decision that has left somebody paralysed?
For reference: http://www.traume.org/spine/cspine-stab.html
Vaughan Knight
Paramedic, Manchester.
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