Case Study 31

The Answer

Assessment

  • Patient has a mechanism for a spine injury.
  • Possible closed head injury.
  • Bruised and abraded left shoulder.

The Plan

  • We will control the spine, monitor the patient for a developing head injury, and RICE the shoulder.
  • We will perform a focused spine assessment (FSA) and make a decision on the need for further spine immobilization. Our evacuation plan depends on the results of this assessment and decision.

Anticipated Problems

  • The patient does not pass the FSA and we need to maintain spine immobilization and arrange for evacuation.
  • Patient may develop signs of increasing intracranial pressure and need a rapid evacuation.

Pause: You are about to make an important medical decision. Think about how you are making the decision. What information are you considering? What is influencing your decision?

Comments

This is a common WFR course scenario. There is a mechanism for a spine injury (the fall onto the head and shoulder) but there is no sign of spine injury. Your sense of the situation is that the patient is a candidate for a focused spine assessment and a decision on whether spine immobilization is warranted.

Let’s focus the discussion on how we make this decision.   

What information are you considering?  Where did you get it?  How accurate is it?

You saw the MOI and you learned in your WFR that landing on your head is a mechanism for a spine injury. This MOI makes sense to you, and the conservative approach you learned about spine injuries makes sense as well even though you know spine injury mechanisms are more educated guess than hard science. Your companion was not impressed by the MOI but follows your lead and controls the spine.   

You used your PAS, a logical and widely used assessment scheme, to determine that the only injury appears to be the hematoma (goose egg) on the head. You’re comfortable with your assessment. The patient seems reliable, your assessment skills sound. Knowing about perception and confirmation biases--our tendency to see what we want to be there--you had your companion double check the patient’s LOR and vital sign measurements.

You plan to make your decision based on a protocol for selective spine immobilization, the FSA. Where does this come from? Is it accurate? It’s based on a large study1 identifying criteria for evaluating a spine for injury (reliability, CSM, spine pain/tenderness).* A number of wilderness and urban emergency medicine experts say it’s a good decision tool to use in the field. 2,3,4 You have a memory aid to remind you how to do it. You understand that it is double checking your observations and findings from your initial PAS. 

 What might be influencing your decision?

Are you eager to release spine immobilization because you really don’t want to deal with a spine injury right now or because the patient is hammering you about letting him get up and wrangle the horses? He says, “It wasn’t a fall. I just kinda slipped off the back of the horse. I’ve had worse crashes in the rodeo.”  You wonder if you are overreacting by doing the entire PAS/FSA drill you learned in your WFR course. 

Are you skeptical about the FSA because of the emotional influence of a tale you heard, which you can’t substantiate and only vaguely remember, about someone who fell from a horse, got up to walk, and was paralyzed?

Are you tentative because this is the first time you are actually performing this assessment and making the decision on your own?  

Are you feeling time pressure to make a decision because of the cowboy’s insistence he take care of his horses?  

These thoughts are real. It’s good that you are aware of how you are making this decision and that you are evaluating the quality of the information you have available, the protocols you are using (PAS and FSA), and the influence of your emotions on this decision. It’s called mindful practice--thinking about your thinking. It supports the important and often underappreciated wilderness medicine skill of decision-making.  

This brief case study is only the tip of the iceberg of the study of decision-making. 

End of the Tale

You use the FSA protocol to confirm the findings in your PAS that there are no signs or symptoms of spine or spinal cord injury in this patient--the patient is reliable, sober, and not distracted; his CSMs are normal in all extremities; and there is no pain or tenderness when the spine is palpated. You report this to the patient who quickly agrees with your conclusion that you can release spine control. The patient sits up, carefully dons his cowboy hat, then heads off to gather his pack string. 

You are still worried about a possible head injury and follow the horses to the trailhead.  The goose egg on the head has become a bit smaller while it begins to turn a nice shade of purple. The cowboy denies a headache, says he is fine, thanks you for the help, and heads into the sunset. You take some time to reflect on your experience and the decision you made. You are proud of your work, yet wise enough to know your experience is now one real patient. There is much still to learn. 

 * The devil can be in the details when we evaluate science. This study was hospital- and physician-based. There are several follow-up studies that show that EMTs and paramedics can perform the protocol correctly.5,6 There are none we are aware of on WFRs or other laypeople performing the skill, and one that shows that WFA-trained people7 are inconsistent with their performance of the protocol.

1. Hoffman JR et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med.  2000;343:94-9

2. Domeier RM, Indications For PreHospital Spinal Immobilization: National Association of EMS Physicians Standards and Clinical Practice Committee Position Paper. Prehosp Emerg Care. 1999;3(3):251-3.

3. Forgey, W.W.  (2006) Wilderness Medical Society Practice Guidelines For Wilderness Emergency Care. 5th Ed. Guiford, CT: Falcon Press

4. Johnson, D. et al. (2010, September 21)  Wilderness First Responder Scope of Practice.  Retrieved from http://www.outdoored.com/Community/blogs/wildmed/archive/2010/05/21/wfr-scope-of-practice-draft.aspx

5. Stroh G. Braude D.  Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization.  Ann Emerg Med. 2001; 37(6):609-15.

6. Dunn T, Dorfman T, Dalton A. Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol? A preliminary report.  Prehosp Emer Care. 2004;8(2): 207-11.

7. Schumann SA, Schimelpfenig T, Sibthorp J, Collins RH. An examination of wilderness first aid knowledge, self-efficacy, and skill retention. Wilderness Environ Med. 2012;23:281–287


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