It always seems to happen in 3’s. This time it started as I was doing an interfacility transport. I had a patient with a significant head injury. Her C-spine was cleared and I had strict instructions to keep her head elevated about 30 degrees.

During the transport I considered how we are always taught to take C-spine with a head injury. But what about elevation of the head for the head injury? Yes, I know, I can put a pillow under the long board to elevate it. What if that is not enough? How many pillows can I use to elevate the head of the board and still secure the patient safely?

I ruminated on this for a couple of weeks. I had been thinking could we just KED someone, if they needed C-spine and needed their head up? After all, once the KED is on, manual C-spine is let go and the patient is moved to the long board. Does the patient have to be on a long board?

Then my husband came home to tell me about a tree cutter who fell 60 feet with his chainsaw. There were no chainsaw injuries but the man landed on his face. Now he had C-spine, head injury and facial issues. The patient had bleeding on his face and in his mouth. Airway was a concern, especially with the patient on his back on the long board. So we discussed how to put a supine patient into a KED. We only use it for the seated patient so we talked about the possibility of sliding the patient onto a KED then securing it.

Then the third instance came when I went into the ED to work. An EMT came to me and asked me if I ever heard of putting a patient in a KED but not on a long board. Talk about déjà vu! I chuckled as I related the thoughts I had been having over the past few weeks. We looked at our protocols and they clearly state that once the patient is secured in the KED they are to be positioned on a long board. Yet there may be instances when we need to deviate from protocols. If airway is a major concern and the patient can only breathe if he/she is upright, maybe using a KED without a long board is adequate spinal immobilization. If the patient has significant head trauma, maybe this is another time to deviate from protocols. Check with your medical director. Be sure to document why you deviated from protocol.

What do you think?

Julie Brady, RN, NREMT-P, is an EMS instructor/coordinator at Waukesha County Technical College (WCTC) which is located in southeastern Wisconsin.

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Emergency Medicine at the Breaking Point….

The following guest blog was written by Matthew Bassett, an Emergency Response Manager for a company located in Maryland, and an EMT-B. The viewpoints below are Matthew’s, and not of Emergency Medical Products.

We all have a horror story. Most of us have more than one. The triage nurse who simply refused to process our patient. A full-scale resuscitation effort that happened in an emergency department corridor because all the beds were full. The two-hour waiting times, the EMS supervisors called to the facility, the patients, sick of waiting, who tried to get off the cot and just go home.

And we all know that it’s getting worse. Relationships between hospital staff and EMS providers, once jovial and fraternal, have soured in many places. Emergency departments struggle to find beds and providers in the face of a never-ending stream of patients, and often, they take their frustration out on us. In turn, EMS providers grow increasingly restless in the emergency department hallways, sometimes with critical patients. More often, however, we wait with Priority 3s tying us down at the hospital while our colleagues run themselves ragged across large jurisdictions.

As both a volunteer EMS provider in a major urban area and an emergency management professional, I’ve seen the problem of overcrowded emergency departments from the top and the bottom. I’ve sat in meetings with fire chiefs and hospital administrators who floated grand schemes and focused on silver bullets, and I’ve stood in fluorescent hallways for hours, out of service and waiting for beds.

While there are many theories, I have encountered general consensus on one pivotal issue. EMS and the emergency department have become the new primary care providers, for the enormous (and growing) number of Americans who cannot afford “normal” health insurance. Regardless of your political views or your explanation for the problem, we all agree that it’s not going away. And federal law requires that no hospital turn any patient away based on their ability to pay (or just about anything else, for that matter. Yet the modern system of HMOs and hospital management is based on generating revenue.

In short, we have emergency departments who can’t afford patients being flooded with patients who can’t afford anything else. But this flood of primary-care patients, with rashes, colds and sprains, engulfs the beds EMS providers need for real emergencies. Cardiac, stroke, and trauma patients face longer transport times to hospitals which might be so clogged that their care could be unacceptably delayed.

The current situation is clearly untenable for us, as EMS providers. Lengthy ED waits strain response times, patient care, and morale. What may not be obvious to the general public, however, is the danger such overcrowding presents them- even if they’ve never been to the hospital and are in perfect health. To say that 9/11 changed everything is to restate the painfully obvious, but terrorist attacks and natural disasters like Katrina have reshaped our perception of the world beyond our ambulance doors. Tunnel vision on one particular threat, such as terrorist attacks or hurricanes, will not help us to prepare for the next “big one.” Instead, we have to adopt an “all-hazards” approach- ensuring our emergency response infrastructure is flexible and coordinated enough to approach any incident.

But in preparing for all hazards, we must acknowledge that our emergency medical system is at the brink. With overcrowded emergency departments, lengthy transport times, and thinly-stretched EMS coverage, a major disaster like Katrina, 9/11, or the Northridge earthquake of 1994 could cripple our ability to help.

We can’t ditch a call to the Priority 3 patient across town when, a few moments later, the dispatcher calls for mutual aid for the Priority 1 down the street. We can’t dump patients in the waiting rooms at a hospital and then leave- they have to be seen by someone. We can’t, in good conscience, encourage people who want transport to sign refusals instead.

To be blunt, the American emergency medical system finds itself in crisis because of the poor. Whether they are elderly Americans warehoused in cut-rate nursing homes, minimum-wage Wal-Mart employees in America’s rural areas, or illegal immigrants living on the fringes of society, their access to healthcare exists only through the door of an emergency department. Short of sweeping federal legislation (and a shocking drought of American compassion) these people will remain legally entitled to one avenue of healthcare- ours.

What can we do about this situation? The answer is, not much. As EMS providers, we show up for our shifts, transport our patients to the hospital specified by protocol, and generally do the best we can for these people. But as informed citizens of a free and open society, it behooves us to advocate for change in the environment of modern healthcare. To improve our capabilities in responding to true emergencies, and to prepare ourselves for a strong and flexible response to a major disaster, we must advocate for broad-reaching healthcare reform.

It sounds extreme. Our job begins at the scene and should theoretically end at the hospital door. But what happens after we arrive at the receiving facility- and more importantly, what happens before we are dispatched- is crucial to healing our emergency response system and alleviating the crushing load of low-priority, “primary care” calls.

Access to free clinics, neighborhood health outreach programs, and “urgent care” centers are working like a Band-Aid across a lacerated artery. Federal, state, and local governments must work together with health departments, community organizations, and public schools. The common goal should be comprehensive health education and access to primary care for those too poor to afford it, even illegal immigrants. We can have primary care systems in place, or we can take them to the ED.

A lot of American taxpayers would (understandably) balk at such a plan. It sounds like the national healthcare system that’s become the third rail of American politics. And it’s true. Such an effort would not be cheap. Nor should it be one-size-fits-all. Communities should decide for themselves how to implement it. But taxpayers would see significant savings at all levels, as government subsidies of overcrowded hospitals and ambulance transport for indigents would decrease drastically.

But this is not, and never has been, about money. Hospital overcrowding lays an intolerable burden on our ability to care for others. Overloaded emergency departments slow down everyday responses, and in doing so, could cripple our ability to manage a large-scale disaster like 9/11 or Katrina.

You might not agree with the solution I propose, or might have a better one. I’d be very interested to hear opinions in either case. But I think EMS providers can all acknowledge that we cannot meet this challenge alone. We need to advocate for ourselves and for our patients when it comes to this issue. In doing so, on a local or national level, we strengthen our country’s ability to stand ready.

As a friend and fellow EMS provider always tells me, I’ll see you at the Big One.

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I often think back to a motor vehicle crash that I responded to about 15 years ago. It was a low impact crash with minimal vehicle damage. I was directed to one of the drivers who was standing on the sidewalk. She really wasn’t injured but wanted to be checked at the hospital.

I was dutifully following protocols and attempting to provide standard spinal stabilization. The patient had severe kyphosis and was adamant that she did not want to be placed on the long board. She insisted that her doctor had told her not to ever be placed on a board and that we would do more damage by stabilizing her on a long board. After much talking and padding, we were able to provide spinal stabilization on the long board to this patient. My duty was done but she was not happy.

As time passed I often would think about why I insisted on spinal stabilization for that patient. I truly didn’t think she needed it. The easy answers are that was what the DOT curriculum taught and that was our department protocol. Therefore, it was the right thing to do. It was what was expected – by my department, my co-workers, my medical director, the ED staff and the State. It was our standard of care.

But was it the right thing? Does every patient involved in a motor vehicle crash need spinal stabilization? It is well documented that spinal stabilization has multiple adverse effects which include: restricted ventilation, increased skin pressure and pain. Adding the patient’s kyphosis into the mix, I’m sure it was even worse for her. So what could be done? Working with our medical director, our department changed our protocols to allow for selective spinal stabilization. It is not always easy to change how it “has always been done” (at least for the 20 years I’ve been in EMS). There has to be some foundations for change. Selective spinal stabilization has been controversial for at least 10 years. There have been studies showing that with training, assessment and following well-defined protocols, selective stabilization can be performed with accuracy in the prehospital setting. In the State of Maine, EMS has been doing selective stabilization for many years. Despite the studies that have been done and the success of selective stabilization in multiple states, the standard of immobilizing every patient after a motor vehicle crash persists. Why?First of all we do not clear C-spine in the field. We evaluate the patient and determine if they are truly at risk for spinal injury (cervical, thoracic or lumbar) and really need spinal stabilization. With selective stabilization protocols then number of patients requiring spinal stabilization is cut by about 40%.Initially, only paramedics were allowed to perform selective spinal stabilization. In time the ED staff became receptive to selective stabilization. Yes, the same staff who would take off our stabilization devices as soon as a patient was turned over, did not like that we no longer brought every patient in on a long board.

Then after a couple years protocols were expanded to allow Basic EMTs to perform selective stabilization. Another uproar! How could a Basic be allowed to do that? With the same well-written protocol and good assessment skills, a Basic should also be able to determine the appropriateness of stabilization in a given situation. After all they are following protocols to perform spinal stabilization.

All the protocols that I have seen follow the ED algorithm for choosing the need for spinal stabilization. First, the mechanism of injury must be considered. This is the vaguest part of protocols. What makes it significant MOI? Does that vary by age and general health of the patient? The patient must be alert and oriented without intoxication or distracting injuries. Then the patient exam needs to be done. Does the patient have any complaints of neck or back pain? Are there any deformities found on palpation. Is there any numbness, tingling or funny feeling in their extremities? Aren’t Basic EMTs able to ask these questions and perform these evaluations?

However, the controversy still rages. Should the standard of care be changed to allow for selective stabilization in the field? Who should be allowed to perform the skill? Do we need more research to change the standard of care?

Julie Brady, RN, NREMT-P, is an EMS instructor/coordinator at Waukesha County Technical College (WCTC) which is located in southeastern Wisconsin

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My name is Julie Brady, RN, NREMT-P, and I am an EMS insturctor/coordinator at Waukesha County Technical College (WCTC) which is located in southeast Wisconsin. I have been asked by Emergency Medical Products (EMP) to contribute to the exchange of ideas and stories on challenges that are encountered everyday in our practice and the EMS field. I encourage you to participate, provide feedback and post your stories.

This is not a personal endorsement of EMP or their products, but I do hope that the opportunity they have provided will be a good forum to discuss the current issues EMS providers face in todays environment.

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