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Spinal Immobilization: You Make The Call

With apologies to Happy Medic for borrowing one of his regular themes, allow me to present an exercise in distinguishing Doing What Is Right from Doing What Is In The Protocol:

It's a balmy late summer night, and you respond to lovely, pastoral Decubitus Manor Convalescent Home for a patient injured in a fall. Upon your arrival, you find a charming and alert elderly male complaining of neck pain. He fell 24 hours before, went to the local ED that night and had staples put in his scalp. Skull and C-spine x-rays revealed no obvious fractures, and patient was discharged back to the nursing home.

He complained of neck pain throughout the day today, and finally the doctor ordered him sent back to the ED for a CT scan of the cervical spine. The gentleman had been back at the nursing home today until 9:00 pm, when the radiologist finally interpreted the CT scan. The unofficial, verbal interpretation relayed to the rad tech was "odontoid fracture, and comminuted fracture of C-1."

Our charming little old man is neurologically intact, and has been doddering around the nursing home for 24 hours with no ill effects. The nursing home doc wants him to go somewhere with an on-staff neurosurgeon, which the local ED says is a facility 70 miles away. They call an ambulance to make the transport.

Enter your intrepid hero, Ambulance Driver.

Now here's the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.

My protocols are pretty clear on this issue: Gramps gets the full spinal package. Not only is he over 65 with an "injury above the clavicles" (two of our sillier criteria, based on the Canadian C-spine rules), but he has the cervical spine tenderness, not to mention the friggin' CT scan that reveals a potentially unstable high C-spine fracture.

Now, an 80+ minute trip strapped to a spine board isn't the cruelest thing I can think of doing to this man, but the other two possibilities involve nipple clamps and a live ferret. He weighs less than his age, and his chart already includes orders for a Fentanyl patch PRN and gel seat pads for his wheelchair. I don't like the idea of boarding him if I can help it.

But we're not talking about what I would do. What would you do?

Do you shrug your shoulders and say, "Protocols are protocols," and tell him to suck it up for the 80+ minute trip to the hospital with neurosurgery, or do you explore other options? If so, what are those options? You tell me what you'd do in my place, and I'll post what I actually did in a few days.

You make the call.