The C-Spine / Helmet Issue

The good news in the world of head trauma and brain injury is that we’re seeing a lot more folks putting on helmets before they go out and do potentially dangerous, head crushing stuff. The good/bad news is that we’re encountering more patients who are wearing helmets and need to be placed in full spinal immobilization. This brings up a controversial decision. Should we remove the helmet or leave it in place?

The leave it or remove it controversy has been around for as long as I’ve been in EMS and, like most controversies that remain unresolved for years, there are merits to both options. In these instances, it’s easy to create blanket rules and then follow them mindlessly.

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Medicine Between The Frames

One of my favorite bloggers, Seth Godin, recently introduced me to the work of Scott McCloud, an author who’s written several classic books on understanding comic books. Scott dissects the comic medium and explains the ongoing allure of the comic book to the uninitiated.

One of Scott’s observations is that comic books require imagination on the part of the reader because, in all great comic books, the action occurs between the frames. The artist only shows you snapshots of action and dialogue. Most of the story takes place in our heads. The real story is the stuff that we invent that happened in-between the frames.

Medicine works in much the same way. We assess, we ask our questions, we do our head-to-toe and we make a guess (educated) about what’s going on. Then we make a change, and the medicine begins, after we make the change, not before.

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The Art of The Pulse Check

   Fast or Slow, Strong or Weak, Regular or Irregular

I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.

I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.

In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.

The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.

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Test For Unconsciousness: The Sternal Rub

Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.

In other words … it’s a great subject for The Spot.

Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.

Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.

If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.

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Atypical Cardiac Chest Pain

We taught you what cardiac chest pain looked like, right? You remember.

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

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Seven Flawless Physical Restraint Tips

Physical restraint techniques and procedures are a subject of debate and controversy in EMS. Few agencies have taken the time and energy to research and develop a comprehensive restraint guideline for field providers to follow.

When violent or aggressive patients show up (and they always do) EMT’s are left to fend for themselves. In these situations we take on a great deal of risk, both personal and legal, to bring the patient safely to the hospital.

I’ve had my share of both good and bad take-downs. When things go well the call transitions smoothly from the street to the hospital. The patient stays protected, the prehospital personnel stay safe and everyone goes back in service happy.

When things go badly people get hurt, patient care gets compromised and everyone ends up writing a lot of paperwork. In the worst cases you may end up sitting across from your patient in a courtroom explaining why you made the decisions that you made.

Here are some tips to help make your next patient restraint scenario go smoothly. Follow these guidelines and you’ll reduce the possibility of ever having to explain your actions. If you do end up needing to justify your decisions, you can take comfort in the fact that these gudeliness give you a rock solid foundation of compassionate, patient centered care. 

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Understanding OPQRST

After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.

For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.

This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.

Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.

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Test For Unconsciousness: The Hand Drop

After I wrote a recent article on the benefits of the face flick for assessing level of consciousness, I received a string of questions and commentary on the effectiveness of another, more well known assessment for unconsiousness - the hand drop test.

The hand drop test is considerably more well known than its cousin the face flick and it remains a fairly reliable, though somewhat controversial test.

There’s a reason why the hand drop test is so well known. It tends to work. It’s a clever and reliable way to force a patient to make a decision and reveal their true mental status.

When done properly it’s harmless and does not require forcing pain or noxious stimuli on the patient. It also has the advantage of  being appropriate to perform in front of family and loved ones. Unlike the face flick which is a bit to obnoxious for public consumption, the hand drop can be performed anywhere and looks like a fairly standard neurological test. If you don’t have this one in your tool box yet, it’s time to add it. If you do know it, let’s review it. There are some subtle elements to doing the hand drop test accurately and safely.

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Test For Unconsciousness: The Face Flick

Sometimes, when we get on that outer boundary of established medical practices we start running in to controversy. As an author, and a bit of a non-conformist, I love controversy. One area that falls in the gray realm of medical assessment is testing for unconsciousness. This is a concept familiar to all who work in emergency services and rarely considered by the lay public. I’ll explain.

When we encounter a person who is not responding to us there are several possibilities.

1.) They may be unconscious

2.) They may be semi-conscious

3.) The person may be sleeping

4.) They may be fully conscious and feigning unconsciousness (for various reasons)

We treat all patieint who refuse or are unable to respond to us with a high index of suspicion for injury or illness, but it’s helpful to try to get an idea where the patient actually is mentally. Are they here and not responding to us, or are they just not here?

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What Is Nystagmus?

When we think of testing for nystagmus, medical personnel and lay people alike, we tend to think of the horizontal gaze nystagmus test performed by police officers as part of the standard field sobriety test (SFST). It’s true that the police have taken this useful neurological exam and put it to good use to identify folks who may have had to much to drink. There are other good uses for the nystagmus test as well.

I use the horizontal gaze nystagmus test as a part of the basic neurological exam that I do any time I’m uncertain of how well a patients brain is talking with their body. Head injuries, altered mentation, syncope, dizziness and headaches are some of the common complaints that make me want to check out how well the patients brain is doing its job. So this test gets pulled out of the tool box frequently. But what is nystagmus anyway? How do you really test for it and what does it tell you when you find it?

What is nystagmus?

Imagine that I took a large drum and I painted it white with black stripes running evenly down it. Then I set the drum on an axis and spun it slowly in one direction. As you watched the drum your eyes would focus on a black stripe and follow it across the surface of the drum until the stripe moved out of visual range. Then your eyes would jump backward to acquire a new stripe and follow it. This repetitive cycle of smooth eye pursuit interrupted by fast twitches (saccadic movement) is what we call nystagmus.

This peculiar tracking of the eye can be induced by spinning in a chair, riding on a roller coaster or observing a spinning object like in the example above (AKA Opticokinetic nystagmus). It can also be caused by a wide variety of medical and pharmocological conditions. Most causes of nystagmus point to an abnormal condition within the nervous system. It is a physical finding that calls us to pay attention and look deeper.

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