Study questions the standard of C-Collars

Baylor study doubts neck brace standard
In some cases, device might hurt accident victims

By TODD ACKERMAN
HOUSTON CHRONICLE

1/25/10

   Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.

   Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive, a finding that could upturn the way emergency medical personnel and doctors act to stabilize and protect the upper spine in potentially fatal neck injuries, such as those that commonly occur in bad automobile accidents.

   "This study is a proof of concept that in cases of severely unstable neck injuries, cervical collars are not only not helpful, but harmful in many situations," said Dr. Peleg Ben-Galim, a professor of orthopedic surgery and the study's lead author. "More research needs to be done, but it might be that we can prevent some of the deaths and quadriplegia that occur in these injuries."

   The study appeared this week in the Journal of Trauma.

   Dr. David Persse, medical director of Houston's Emergency Management Services, called the study "compelling" and "concerning" and said it will come up for discussion at the annual meeting of the nation's 30 largest EMS departments in Dallas next month. But he also said he doesn't want to overreact.

   "We need to look at this thoughtfully before we change the standard of care," said Persse. "It concerned a particular kind of injury. It may apply to other injuries as well, but we don't know that yet."

   But Persse added that he understands the need to act quickly, that "it's not like a lot of areas where there's not as serious downside to waiting for the next study."

Car-crash victims

   Ben-Galim said cervical spine injuries are found in the autopsies of up to 94 percent of people who die in car crashes, which claim about 44,000 U.S. lives annually. There are about 11,000 people annually who survive spinal cord injuries.

   There is no obvious alternative to cervical collars, though hospitals often place sandbags under the back of the patient's head and, less commonly, some EMS teams at the scene of the crash wedge the head of the patient between foam bolsters on the backboard.

   The injuries in question involve the area where the brain connects to the spinal cord. Doctors treating such injuries work to stabilize the ligaments, muscle and bone to prevent secondary injury and to protect the brain stem and cord.
  
   Baylor researchers undertook the study after a case in which a broken jaw precluded the use of a cervical collar on the survivor of a car wreck brought to Ben Taub. When the doctors started to put a collar on the patient, fluoroscopy showed two of the patient's vertebrae separate, causing doctors to immediately remove the collar. The treated patient ultimately walked out of the hospital on his own.

   Ben-Galim noted that there are other such case histories in medical literature.

   To study the phenomenon, Baylor researchers made an incision in cadaver neck ligaments based on patient X-rays, then simulated clinical scenarios by applying cervical collars and putting the bodies in ambulances and driving a distance.

   In all of the cadavers, imaging technologies found that the collar increased the rupture.

   In effect, the collars pushed the head away from the shoulders, Ben-Galim said.

   He said the rupture stretching occurs because of both the application of the collars and their continued use.

   One national expert called the study interesting but said he wasn't sure it would one day change the standard of care.

   "There are certain cases, like the ones in this study, that can be dangerous, but they're rare -- most people who suffer high neck injuries die immediately," said Dr. Tom Scaletta, the past president of the American Academy of Emergency Medicine. "I think the study's importance will be to raise awareness about the special care that must be taken -- preserving patients' normal head position, making sure they're not having difficulty breathing."

Anecdotal cases

   Dr. Walter Lowe, director of the Memorial Hermann Sports Medicine Institute and team physician for the Houston Texans football team, said the study wouldn't change the care of injured football players removed from the field in collars and on stretchers because those injuries tend to involve lower areas of the spine.

   Ben-Galim said that since the study was undertaken, Ben Taub doctors have saved patients with severe neck injuries by loosening or removing cervical collars early and rushing them to the operating room, but he acknowledged such cases are anecdotal.

   He said the research team looked at 400 articles and found no scientific evidence that cervical collars can stabilize severely unstabilized spine injuries.

Original source: http://www.seattlepi.com/health/414631_Neck25.html

Pain Scale - "Zero to Ten"...!

In this business of ER/EMS/Healthcare, we have been tasked with an attempt to objectify a patient's "pain".  Apparently many bean-counters and doctoral candidates have done research on how to do this, and as such the "Zero to Ten" scale was born.

Now most of you reading this are undoubtedly of the ER/EMS genre' and are all too familiar with this "scale".  Our instructors, mentors, preceptors, managers, educators (ad nauseum); pound it into us to use this scale.  It's pretty easy for them to say that because on paper it looks good, but as most of you, my readers know, it is haphazard at best to apply effectively...  Oh, wait, let me also throw in what they told us in feel-good-nursing-school, "pain is whatever your patient says it is".   So, we are asked to unquestioningly document "whatever" the patient says about their pain.

By itself, this is not too bad, however, it is when the patient is savvy to this whole pain scale thing that they begin to manipulate it to suit their own needs and wants.  We are left to unquestioningly just "write it down" with no practical attempt to help the patient understand what we are trying to measure.

So we write what the patient says, then we spend the next 5-10 minutes charting all those "little things" that we observe about the patient's behaviors - those things that seem to make the patient's self-assessment inconsistent at best....

"patient talking/texting/IM'ing on cell phone..."

"patient laughing, joking with friends..."

"patient walks to room with steady, coordinated gait..."

"patient smiling..."

"patient resting (sleeping) on stretcher spooning with boyfriend...!"

...and on and on

Sometimes we go further to note more objective findings such as the vital signs:

-reported pain score "10"

-Pulse rate: 56....???

However, in an attempt to further quantify this pain scale, and maybe to help the patient understand what we're looking for, I came across this table (see below) which strives to put some defining characteristics to the different pain levels....

Comparative Pain Scale
	0	No pain. Feeling perfectly normal.
Minor Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.	1 Very Mild	Very light barely noticable pain, like a mosquito bite or a poison ivy itch.
	2 Discomforting	Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails.
	3 Tolerable	Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection.
Moderate Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.	4 Distressing	Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard
	5 Very Distressing	Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed.
	6 Intense	Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. Comparable to a bad non-migriane headache combined with several bee stings, or a bad back pain.
Severe Unable to engage in normal activities. Patient is disabled and unable to function independently.	7 Very Intense	Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. Comparable to an average migraine headache.
	8 Utterly Horrible	Pain so intense you can no longer think clearly at all.. Comparable to childbirth or a real bad migraine headache.
	9 Excruciating Unbearable	Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. Comparable to throat cancer.
	10 Unimaginable Unspeakable	Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.

So, now, here's your clinical story to illustrate the use of this scale...

Dr: "Between zero, being no pain and 10 being the worst you can imagine, how would you rate your pain?"

Pt: (calmly)..."a 10"....

Dr: "Okay, at 10 would be you getting hit in the face with a 15 pound sledgehammer, and unconscious from the pain, not the head injury.  Most people have never and will never experience this pain level ~ and if they do, will undoubtedly be unconscious..."

Pt: (again calmly)..."okay, 9-and-a-half..."

Twas' the Night Before Christmas - Nurse Style

Twas the Night Before Christmas -A Nursing Version

Twas the night before Christmas, and all through the floor
Lasix was given, filling foleys galore.
Stockings were worn to prevent emboli,
they came in two sizes, knee and thigh high.

The patients were nestled half-@$$ed in their beds,
while visions of stool softeners danced in their heads.
We in our scrubs, and they in their gowns,
Fashion created to hide extra pounds.

When down in the ER it became such a zoo,
they called with admissions for me and you.
They're coming, they're going, and they're all looking the same.
My patience for patients is starting to wane.

Now call lights are ringing, the patient 400 pounds,
says "Didnt get my pericare, send my nurse now".
And now delegation seems the best plan,
We try to send others, for the needs of this man.

When what to my wondering eyes should appear,
But Santa himself and 8 tiny reindeer.
Hey says he comes from Central Supply.
To bring us LR, NS, & D5.

The doctors then scribbled what no one could read.
Orders on patients, to measure their pee.
We try to decipher illegible words,
orders for patients, to guaiac their turds.

The new shift arriving, our day is now through,
How did stool & emesis get in my shoe?
We give them report and pass on the facts,
and tell them of duoderm lining the cracks.

And the nurses exclaim as they limp out of sight,
"Ativan to all, and to all a good night".

Nurses' Perks For Working on Christmas

There truly are advantages to working on Christmas and other holidays.  If you are scheduled to work a holiday, don't despair!  Look at the bright side.

OVERTIME PAY:  This is one perk that most nurses appreciate when working a holiday like Christmas.  The extra money can help with holiday expenses.  If you are really on the ball, you can start paying off your bills quicker – get a jump on your New Year's resolution.  If your loved ones are upset that you are not going to be there part of the day on Christmas, plan something special with them later in the week!  Let them know in advance what you will be doing.

YOU DON'T HAVE TO COOK:  Health care facilities go full scale on Christmas to make a fantastic meal for patients and family members.  Staff members working Christmas reap the benefit of a great holiday meal without the cooking and clean-up!

YOU GET TO WITNESS SPECIAL MOMENTS BETWEEN PATIENTS AND FAMILY MEMBERS:  You get a front row seat to those special holiday moments shared between patients and their family members.  You see the hugs from grandkids, the gifts exchanged, and hear the resolutions and hopes for the New Year.  This is a gift you can't and won't want to exchange!

YOU ARE REMINDED HOW LUCKY YOU ARE:  By seeing those special moments, you are reminded of how lucky you are and all of the great gifts in your own life.  After all, you get to leave the health care facility after your shift – conversely the patients have to stay!

YOU ARE NOT WORKING THE ENTIRE 24 HOUR PERIOD:  You still have about 12 hours of the day to spare.  Make plans to do something special on the holiday before or after your shift.  Create a unique and new tradition for your holiday this year!


Credit for this essay goes to Sue Heacock, RN

Some Pearls for EMS/ER to live by...

Credit for this goes to Thom Dick as publised in his JEMS article...

Following is a list of 30 Pearls for EMS/ER practice.... 

1. People don’t change. 
2. Some of the most beautiful people in the world come wrapped in the plainest packages .
3. You can stir up as much trouble as you need to. Just make sure you do it only to make things better, your care is always top-notch and your certs are always up to date.
4. You may be a medical genius. But sometimes it’s your job to just take people to the hospital.
5. Never plan anything until after noon on the day after a 24-hour shift.
6. People make stuff up, sometimes.
7. This is medicine we’re doing here.
8. There are two kinds of leaders in EMS: good ones, and those who spend just enough time in the field to realize they hate it—then presume that qualifies them to lead those who don’t.
9. It’s not enough to be nice. You have to be competent and nice. 
10. There’s a very good reason why you’ve never met a dual-role surgeon. 
11. The genius who first presumed that one person could do two full-time jobs at once was an administrator who meant some other person.
12. Liars lie—that’s why we call ’em liars.
13. A whole lot of stuff is funnier than you think.
14. Paramedics/ER Nurses get lied to for a living. There’s only one thing dumber (sic) than lying to one, and that’s lying to a whole room full of them at once.
15. Anybody can be a former Paramedic/ER Nurse. All you have to do is quit.
16. Never do anything you know is stupid (especially if the person who tells you to do it is stupid).
17. You can break bad rules, especially if you’re funny.
18. Your life insurance company wants you to be in perfect health, because that means you can keep on paying premiums. They don’t care if you’re happy.
19. The concept of fear is not discussed in any EMS/Nursing text. That’s too bad, because fear is a component of all suffering.
20. What’s right is not always popular; what’s popular is not always right.
21. People who cut corners eventually find themselves running around in circles.
22. If most people were smart, we would be unemployed.
23. Be nice to people on your way up. You may meet them again on your way back down.
24. If the patient tells you they’re about to die, they’re probably right.
25. Nothing in the EMS/Nursing curriculum makes us judges.
26. We should probably listen about twice as much as we talk.
27. People don’t care how much you know until they know how much you care.
28. If you’re tired of taking care of poor, old, dirty, naked sick people, take a rest. Do something else.
29. Your ambulance is a machine that can either earn you a living or kill you on any day of your career. It probably deserves your respect.
30. A partner who tells you not to worry about their driving because they "can handle it" most likely isn’t so sure. Maybe you’d better take the keys.

US Panflu Update - 11/12/09 "Are we in the clear yet???"

US Pandemic Situation Report- Nov 12th

The overall national trend is now one of declining impact. Reporting nationwide continues to be highly variable from location to location. Some locations are reporting decreases in case loads while others are reporting dramatic surge. The below information pertains to those locations within the US reporting challenges related to pH1N1.

School Absenteeism

Student absenteeism rate (elementary and high school): 10-40% (10-20% usual range reported)
Teacher absenteeism rate (elementary and high school): not specified but still documented

Local Medical Infrastructure

EDs and outpatient clinics continue to be overwhelmed by anxious well and truly ill patients.

EMS and first responders report no appreciable impairment in operations reported.

Hospital ward level inundations have been reported. Excession of capacity was not noted since last report. Healthcare worker absenteeism has contributed to strain.

ICU capacity has been reported to approach near- to at-capacity. Demand for ECMO or HFOV continues to be observed.

San Joaquin County, California declared a local state of emergency due to broad medical infrastructure strain.

Mortuary services have not reported strain.

Fewer people are donating blood in the United States due to the pandemic. In addition, some blood centers nationwide have had to throw out blood donations after learning that the donor had influenza-like symptoms. Although the centers claim that they have sufficient blood supplies now, a further decrease in blood donations, particularly during the Christmas season, is a concern.

General Infrastructure Strain

Main sectors affected this week include primarily education, public health, and medical care. Government and corporate sectors have not reported strain since last report.

A pork producer from Clinton, North Carolina filed for bankruptcy after owing about USD three million to various vendors. The company, Coharie Farms, blames the loss on an increase in grain prices, a decrease in hog prices, and pandemic (H1N1) 2009 "fears". The owner of Coharie Farms plans to liquidate the company and "some" of the 170 employees will be laid off. The company lost about 17 million dollars this year. Coharie Farms is the largest independent pork supplier to Smithfield Foods Company. North Carolina has the second largest pork industry in the United States.

Social Anxiety

Frustration and anxiety associated with failure of meeting expected public access to pandemic vaccine and public perception of uneven distribution of vaccine to priority groups has become the primary focus for public anxiety. This relates to public outcry due to a perception of politicians and other non medical-risk groups observed to be vaccinated ahead of those groups identified and publicized by CDC for vaccine priority.

Worried well influx to emergency departments and parents keeping well children home from school continues to be documented. Limited instances of parents refusing vaccination after reports of adverse vaccine reactions (regardless of credible proof the vaccine was the cause of the reaction) continue to be documented.

The current focus for social tension revolves around vaccine availability and uneven distribution.

In addition to strain and anxiety, medical staff are dealing with threats, insults, and bribes from patients. Doctors are compelled to reassure patients that they are waiting their turns for the vaccine and not prescribing Tamiflu for themselves or their families unless necessary. Two vaccine clinics in New York were canceled after parents began to threaten nurses. According to staff members, one parent stated that he would "hunt down" the nurse if anything happened to his child while another parent threatened to sue a nurse if something happened to his child.

Primary triggers for social outcry and anxiety behavior continue to be 1) the death of children or 2) pregnant mothers in a community. Publicly perceived violation of expectation regarding availability (and now) distribution of pandemic vaccine has become a prominent driver of social anxiety.

Environmental Conditions

Environmental conditions are currently moderately optimized for transmission throughout the majority of the US and are projected to optimize fully within the next 3 months.

Expected Progression

While national epidemiological statistics indicate a past peak and decline in cases, high variability in local experience is still observed. Overall national impact is declining.

Pandemic H1N1 is expected to continue to strain local medical capacity, however now at lower levels. Variables in local transmission include herd immunity levels achieved through prior community exposure to the virus, public and healthcare worker uptake of pandemic vaccine, and virus genetic stability.

Veratect's West and East Coast Operations Centers remain vigilant for possible resurgence following mass mixing events such as Thanksgiving and especially the Christmas / New Year's holiday seasons. It is unclear to what degree the pandemic will impact social functioning when environmental conditions are maximally optimized in January-February. Veratect remains vigilant for reporting of virus drift or recombination.

 James M. Wilson V, MD
Chief Technical Officer and Chief Scientist
Veratect Corporation
Kirkland, Washington
571.225.3671
jim@veratect. com

CAMTS Accreditation - Blessing or Curse?

NOTE: This is my commentary/response to the original article which appears at:

VerticleOnline and published Oct 21, 2009

MY COMMENTARY:

CAMTS accreditation has become double edged sword.

On one hand your HEMS program may not be able to live without it (either by regulatory requirement of your state, OR by lost revenue via third party insurers who require accreditation), but on the other it may be hard to live WITH it too! -recurring site visits, 3 year applications for reverification, continually updating standards etc.

One of the big problems with CAMTS accreditation is that in some circles it is legislatively mandated (see the 8 states that require it) and by definition, accreditation conflicts with "mandatory" -- so which is it? Mandatory or voluntary???

Personally I believe the original intent of CAMTS was good for the following reasons:

1) It's not governmental: for those of us who dislike big brother running everything. (This is a HUGE plus in my book)

2) Technically, it's still voluntary (debatable)

3) Nursing/carregivers: involvement with heavy focus on requirements for the medical crews, in my opinion, is good. I believe the industry is moving towards recognizing the medical crews as AIRCREWS. I think there will be needed discussion when/if this happens (I hope it does) because then there is more FAA oversight in that aspect.

4) CAMTS uses widespread representation. Argue if you like about how the pilots are not as strongly represented, but there are a few other "non-specific" seats on the CAMTS board of directors which could be occupied by qualified pilots as well.

---->NOTE: if the HEMS pilots do not feel they are represented adequately by CAMTS, then they should lobby their professional organizations to develop some type of accreditation program as well, OR, get their representative body to work more collaboratively and intertwined with CAMTS

5) In my personal opinion, in what I have read and researched over the years, I feel CAMTS strives to stay "ahead of the curve" in as much as incorporating or leaning towards industry leading "best practices" as well as those practices which may be recommendations by federal investigative/review committees. I have always felt that CAMTS was dynamic and responsive to the HEMS community.

I realize there are more problems and concerns with CAMTS which I have not listed here; I will look for part two of this article to help stimulate more discussion.

My bottom line however, is directed towards the skeptics and nay-sayers.. and I say to those that are (1) unhappy, (2) dis-enfranchised or (3) mis-represented by CAMTS - "sorry", CAMTS has ONLY become so influential and powerful by the VOLUNTARY submission to it's program requirements and accreditation processes by programs across the US... The more programs that seek the CAMTS "Merit Badge", give the CAMTS machine more influence, power and presence....