tag:blogger.com,1999:blog-4266294048567663301.post9050512865205445285..comments2024-03-27T21:50:14.333-07:00Comments on Mill Hill Ave Command: Can you "GLASS" the patient to clear the c-spine?Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.comBlogger6125tag:blogger.com,1999:blog-4266294048567663301.post-47473514500514312172013-01-30T16:44:27.162-08:002013-01-30T16:44:27.162-08:00All auto glass is not created equal. The windshiel...All auto glass is not created equal. The windshield in modern vehicles will break far more easily than the side or rear windows. You can whack you head on the side glass pretty hard and the glass will not break. <br /><br />If the glass is broken for reasons other than a patient's head contacting it, it does signify a pretty good amount of force was applied. Think roll over. <br /><br />Still, if mechanism is a poor prognosticator of injury, it's an equal poor prognosticator of lack of same. <br /><br />I think that examining the patient, or rather teaching EMTs and paramedics how to properly examine a patient for injury is the way to go. TOTWTYTRhttps://www.blogger.com/profile/17221321904364051792noreply@blogger.comtag:blogger.com,1999:blog-4266294048567663301.post-20575561311667622312013-01-21T19:31:25.423-08:002013-01-21T19:31:25.423-08:00Of course my whole discussion above is looming und...Of course my whole discussion above is looming under shadow of the bigger question, which is "Do any non-obtunded, neurologically intact patients even need C-spine immobilization?" Obvs we don't know the answer, but I meant to throw that in...Vince Dhttps://www.blogger.com/profile/10636259293820649555noreply@blogger.comtag:blogger.com,1999:blog-4266294048567663301.post-46366348204201361992013-01-21T19:28:04.153-08:002013-01-21T19:28:04.153-08:00Gah I'm a week behind on my reading - it might...Gah I'm a week behind on my reading - it might as well be a year in FOAMed time.<br /><br />I tore into, in my opinion, an overly-glowing review of the study on JEMS (http://www.jems.com/article/patient-care/analysis-supports-limiting-spinal-immobi), but I've really been trying to like it over the past couple weeks. There's still two things I can't get over:<br /><br />1) Like Brandon said, the focus on the mechanism involved in the collision at the expense of patient assessment. I don't know if I would ever feel comfortable clearing a NEXUS-positive patient in the field, even if they were GLASS negative. On the other hand, if they are GLASS negative and NEXUS negative, you really haven't gained anything over just using NEXUS. The only real utility I see would be in the altered patient for whom NEXUS does not apply, but that's going to require a lot more evidence of safety, which leads nicely in #2...<br /><br />2) One of the things that makes NEXUS so special is the pains that researchers went to achieve good follow-up when it was being validated. Being retrospective registry data, that kind of follow-up is just not assured and worries me when we're talking about rare-but-devastating consequences. I've looked through the registry they cited, and although a lot of the collision info is detailed and well documented, the medical follow-up is a bit less trustworthy. There could have been six bad outcomes or there could have been sixty - it's a classic "unknown-unknown" per Rumsfeld.<br /><br />I give the authors kudos for diving into the data to find a novel and objective demonstration of a low-risk mechanism, but until there's prospective validation done I think this paper has gotten all the attention it needs. Hopefully it won't affect my practice, but I have a feeling I'm going to be paying extra attention to vehicle windows when I'm in the field - pretty well matching your summary.Vince Dhttps://www.blogger.com/profile/10636259293820649555noreply@blogger.comtag:blogger.com,1999:blog-4266294048567663301.post-25588834036703521272013-01-20T14:15:37.005-08:002013-01-20T14:15:37.005-08:00Well, no doubt. But we can probably all agree that...Well, no doubt. But we can probably all agree that vehicle damage is, at best, a somewhat indirect and poorly-predictive indicator of patient injury. My point is, the prevalence of this disease is going to be so low that it's probably not hard to find criteria which yield a pretty good predictive value, and in the end I suspect that clinical criteria are a better choice than mechanism-based criteria -- even if they tend to be more subjective and hence with less interrater agreement.<br /><br />I mean, what's our goal here? To come up with something that's so easy to use, a caveman could do it? Are the other criteria really so subjective that it's a problem?Brandon Ohttps://www.blogger.com/profile/11678802535068489022noreply@blogger.comtag:blogger.com,1999:blog-4266294048567663301.post-9185186764438411992013-01-18T12:10:21.905-08:002013-01-18T12:10:21.905-08:00I wouldn't take lack of airbag deployment as a...I wouldn't take lack of airbag deployment as arbitrary, since there is a quantifiable force associated with activation - or at least there is supposed to be! As for the windows, glass tends to break if sufficient force is transmitted to it. <br /><br />Spare change, on the other hand, is only associated with mild, and disproportionate, feelings of victory. <br /><br />Cervical trauma requires, well, trauma. If there are not signs of significant trauma to the vehicle, do we still need to immobilize? <br /><br />(Well evidently, some British EMS officers believe so... http://www.bbc.co.uk/news/uk-england-sussex-20944339)Brooks Walshhttps://www.blogger.com/profile/16108633682893762401noreply@blogger.comtag:blogger.com,1999:blog-4266294048567663301.post-87043779313528084822013-01-15T15:32:31.792-08:002013-01-15T15:32:31.792-08:00I am of several minds about this. Although I love ...I am of several minds about this. Although I love to see more research on spinal immobilization -- especially ways to avoid doing it -- and it's interesting that they tried to use objective criteria, I can't help but feel like further glorifying mechanism is not a positive step, and the criteria seem a little arbitrary.<br /><br />What I think this reveals more than anything is that almost nobody with a stupid (technical term) MVA mechanism has a significant spinal fracture, so just about any criteria to rule them out will have pretty good specificity. I wonder what the numbers would've been if they'd used, say, the presence of over $1.00 in change in the seats.<br /><br />My other complaint is my standard one, which is that the entire game is predicated upon assumptions which may not have a basis in reality. If those are "significant" spinal injuries (in the chart), we're meant to view them as the misses, but by what lights are we calling them "unstable"? The fact that they would eventually require operative fixation? Because what we instinctively read is that these people were at risk of deteriorating prior to hospital arrival without spinal immobilization, and that's probably a huge leap.Brandon Ohttps://www.blogger.com/profile/11678802535068489022noreply@blogger.com