Trauma C-Spine This essay is not intended to criticize any emergency medical or hospital staff. I am writing this essay out of concern for patients who come into the emergency room that may have a jeopardized spinal cord resulting from an injury or suspected injury to their cervical spine. I am a certified emergency medical technician, farm-medic instructor and currently a medical diagnostic student doing clinical’s. In the United States each year there are approximately 10, 000 reported cervical spine injuries that come into emergency rooms. Motor vehicle accidents account for approximately 45%, falls approximately 30%, the remaining 25% from sports and miscellaneous. Although only a small amount of these spinal injuries are life threatening, they all need to be treated as such.
Survival of these patients depends on pre-hospital care, emergency room care and quality diagnostic radiographs, all done at times under extreme time restraints and pressure. The number one goal in patient care is not to make any situation worse than it already is. Most pre-hospital care is usually done by emergency medical technicians. Their main concern is to assess, stabilize and transport the patient to a facility that can give additional care and treatment. The emergency room staff is the second step to the patient’s survival.
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Their duties include further stabilization, evaluation and treatment of the patients’ injuries. Radiographers are to supply ER doctors with quality diagnostic X-rays so they can make informed decisions about further patient care. Each of these groups need to be aware of what is involved with the other’s job, so that the patient will receive the best of care. Emergency medical personnel are trained in the proper pre-hospital care of patients in the field. Pre-hospital care of patients suffering from suspected cervical spine injury involves making sure the patient has a patent airway. Placing a properly sized C-collar on the patient to stabilize the neck.
Packaging the patient for transport to the emergency room, which involves proper placement and securing of patient on backboard, and making sure to secure the head and shoulders so there is no movement of these areas by the patient. While en route to the hospital emergency room further assessment of patient can be done. Upon arrival at the emergency room there needs to be good communication between EMT’s and ER staff. The radiographer’s job is to deliverer quality X-rays that have been ordered by the medical staff. Basic radiographs required to exclude a cervical spine fracture include lateral view, view, and an open-mouth odontoid view. The lateral view must include all seven cervical vertebrae as well as the joint space between C 7-T 1.
If this is not possible because of patient size or condition then a swimmers view will be needed. The view should show all cervical vertebrae, while the dens and joint space should be visible on the odontoid view. These exams need to be completed in a timely matter while continuing to maintain cervical immobilization. The importance of obtaining quality X-rays cannot be overemphasized as the most frequent cause of missed cervical fractures is the result of inadequate films. The medical staff role in the care of trauma c-spine injuries is to make sure that proper exams are done so that a proper diagnosis can be made. This is achieved by a good physical assessment as well as proper communication with the EMT’s about mode of injury, and evaluation of radiographs that have been ordered.
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If the radiographs are inadequate to rule out a fracture, then the need for repeated or additional X-rays or a CT scan should be obtained, until all vertebrae are visible and the possibility of fracture can be ruled out. This is how it is supposed to work. Let’s take a look at a real life situation. EMS is called to the scene of a motor vehicle accident in which two cars have collided and the drivers of both vehicles are to be transported to the hospital for treatment. Both patients are treated according to local protocol by being fitted with a c-collar and placed on a backboard for transportation to the local ER. Patient #1 complains of a headache and a sore shoulder.
Patient #2 appears fine and has no complaints of pain. The ambulance arrives at the emergency room; both patients are put into rooms, and evaluated by the ER staff. X-rays are ordered so that the cervical spine can be cleared, the C-collar removed, and the patient taken off of the backboard. The x-ray technician arrives and decides to do the exams in the ER X-ray room because the films are so much better than the ones taken with the portable. Things are busy in the department and if someone has a chance they will come down and help him but until then he is on his own. The emergency room has become busy and there is no help around, so the technician moves patient #1 into the X-ray room since patient #1 is triage d as the most critical.
The patient is left on the ER cot and the proper X-ray’s are taken and developed. The lateral was not quite dark enough and without help it was hard to get the shoulders relaxed enough to see C 6-7. The lateral was repeated and a swimmers view was taken to see C 6-7. The AP view turned out all right, but on the odontoid view the dens was not visible, so it was repeated two more times.
It finally turned out. The X-rays were viewed by the ER physician and cleared so that the c-collar could be removed and the patient taken off the backboard. The technician is tired and it’s almost quitting time so he had better hurry and get this exam done. Evidently everyone is still busy in the department because no one has come to help him out. Patient #2 was not hurt as bad, and you don’t know why those EMS people have to put the c-collar on every patient that stubs their toe. The technician takes the patient to the X-ray room and decides that since he had so much trouble getting his shots on the cot with the last patient he will move this patient to the exam table.
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He had difficulty sliding the backboard so he unstrap ed the patient and had them slide themselves over to the exam table. Once the patient is in place he noticed that she is wearing a necklace and has earrings in. He can get the earrings off but has trouble with the necklace so he undoes the c-collar and tells the patient not to move their head while he removes the necklace. The technician gets the necklace off and before you reapply the c-collar you decide to take the open mouth odontoid as that way the collar will not get in the way.
The ER clerk calls and says that there are three more patients who need X-rays. The technician takes the pictures and his open mouth turns out great, but the lateral is a little light… C 7 is not quite visible but the AP shot is good; things are busy so he goes ahead and decides these films are good enough. He take the patient back to their room and proceeds to do the other exams that are needed.
Could this happen? Does this happen? Maybe someday the world could be like this! EMS responds to a motor vehicle accident and have to place a patient on backboard with a c-collar applied. The EMS crew just had a continuing education program presented by an X-ray technician that showed them what they could do to help speed up c-spine exam time and also help reduce patient risk, so the EMS crew removed the patients jewelry before they applied the c-collar. Upon arrival at the hospital the proper X-rays were ordered to evaluate the patient for cervical spine injury. The radiographer arrived with help to do the necessary exam. The patient was taken into the exam room and since the radiographers had just completed a continuing education program on patient care, where cervical spine injuries were involved, they were very careful when moving the patient. They kept the patient on the backboard and did not attempt to move the patient’s head or neck.
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The radiographers made sure that the films they showed to the doctors were of diagnostic quality. Could this happen? Yes, if everyone involved was properly trained, took pride in their work and departments were adequately staffed. Does this happen? I hope so.
