Identifying Spinal Injuries

Stolen from BT, thought it was a good post and would be good to share.

Mike
----------------
This is really a 2-part medical scenario, the first being the
ability to field assess for the presence or absence of a spinal
injury, and then being able to stabilize the person if they do have a
potential spine injury until EMS folks can arrive on scene, (who
then, depending on their training, may contribute more to problems
than solutions, but that's another topic for another day ... :{)

Determining the presence or absence of spine injury in the field
given positive or uncertain mechanisms of injury (which includes
scenarios like jumping waterfalls), is one of the cornerstone
concepts of wilderness first aid training that you learn in a WFR
(Wilderness First Responder) course. Though each training company has
their own system for it, some being based more on 'mechanism of
liability'(MOL) than mechanism of injury (MOI), all of the 'spine
rule out protocols' as they are formally called involve a detailed
and systematic assessment of spinal motor and nerve functions,
through a series of very specific extremity and central spinal column
exam checks. These assume the patient is 'reliable' in their mental
status to assess an accurate pain response, as the presence of
distractions such as acute stress responses, other
distractingmusculoskeletal injuries, and the influences of
intoxicants and even moderate hypothermia can mask normal
pain responses. This takes a good bit of time while you sit with the
patient (keeping their head and spine from moving), to get them out
of their 'fight or flight' adrenalin response they normally
experience after most scenarios that precipitate potential spine
injury mechanisms (like jumping 25' waterfalls!). I've seen people up
and walking around after horrendous car wrecks, initially complaining
of no injuries, only to later find a laundry list of life threatening
problems as their acute stress response (or more likely their acute
alcohol intoxication)abated, and they were only then able to begin to
localize pain more appropriately. So just because the victim says
they're OK, or they are walking or paddling around, doesn't
necessarily mean their spine is OK. A scary trauma stat out there is
that up to 25% of cord injured victims (quadra- or paraplegics) were
caused by the subsequent uncontrolled movement and/or progressive
swelling after the initial injury-causing mechanism.

With the use of this 'spine rule out protocol', field providers
can very often (but not always), differentiate a soft tissue injury
(damage to the connective muscle or ligament tissue) from a spinal
column or spinal cord injury (damage to the bony vertebrae and/or the
'al-dente' nervous system tissue that comprises the spinal cord).
This could have been a critical medical assessment for Seanie, where
landing hard or too flat off a waterfall jump could have caused
either soft tissue and/or potential compression force fractures to
the spinal column, usually the lower lumbar area. I know at least a
half-dozen kayakers and c-boaters who have been seriously spine
injured as a result of this MOI.

The decision should be a red/green flag - they either are or are
not spine injured, based on the MOI and the resulting spine
assessment. Some wilderness medicine training companies teach that
it's OK to put a cervical/neck collar on someone "just in case", then
let them walk out, which is analogous to being "kind of pregnant". At
Wilderness Medical Associates we teach that victims either are or are
not spine injured, and if you're not confidant with the spine
assessment of the patient you need to get somebody to the scene with
the training who is. Which again, unfortunately isn't always
the 'patch and polyester boys' who show up from the local rescue
service, well intentioned, but often times under-trained and under-
prepared for a wilderness evacuation.

The decision on whether you leave the victim in the position
they are found in while you wait for outside rescue help to arrive
depends on the victims likelihood for further deterioration from
environmental factors such as hypothermia if they are in the water,
or the inability to adequately keep them from further motion or
increased pain/discomfort if they stay in their boat. There is no
clear recipe for these situations, so you need to be a 'thinking
cook'. There needs to be a clear 'risk/benefit' assessment of the
risks of moving a potentially injured spine with the benefits of more
spine stability and patient comfort once they are out of the boat
lying down in a position of comfort. If they are reasonably
comfortable/dry/supported in their boat, I would leave them there,
with a rescuer holding 'hands-on-stable' to their head and cervical
spine. If they are potentially going to deteriorate from hypothermia
and/or muscle spasms from the position they're in (generally the case
these days with the boat's you have to get 'poured' and/or 'shoe-
horned' into), then you may be better to have 3 or 4 people assist in
getting the person out of the boat. This involves stabilizing each of
the body weight centers (head, chest and pelvis) supported with a set
of rescuer's hands, and providing gentle in-line traction while you
systematically 'un-pretzel' one weight center at a time, generally
moving the body in an axial (in-line with the spine) plane. Moving in
small axial increments at a time, getting them out of their boat onto
a bed of PFD's and under a tarp may be the best position to have them
in until EMS arrives with the necessary backboard/litter equipment,
and hopefully the hypothermia packaging to prevent inevitable heat
loss from a patient generating zero body heat during the subsequent
backboard or litter evacuation. If you can medically 'rule out' spine
injury to a patient, doing all the proper exam checks under the
proper training/certification guidelines, there is no reasonable
chance that the person has a spine injury, and they can safely walk
or even boat out. This saves significant risk to both the patient and
the rescuers of difficult and perhaps unnecessary protracted
litter evacuations.

So Charlene, Seanie has already learned the most important part
of this scenario, that "*#$!^ happens" out there and at some point
she or someone boating with her will need to have, medically
speaking, "their bacon pulled out of the fire". So, to make a 'short
story long', what "pulled my bacon out of the fire" was taking a WFR
course. Along with swift water rescue training, it was probably the
best investment I could make in the safety and well-being of me and
my paddling buddies. The WFR course I took clearly changed my life
and the way I look at 'what is acceptable risk' for me and those I am
responsible to on a trip. I learned more in my 72 hour WFR course on
how to think on my feet, problem solve and creatively improvise than
I did in my 1000+ hour paramedic training, and I use skills I learned
in that WFR on every 'streets' ambulance call and wilderness response
I run. It's a pricey course in some people's eyes (but less than the
cost of a boat). But what price can one put on having the skills and
confidence to save someone's life (or their spinal cord), so that we
can continue to enjoy this life-giving activity of whitewater boating-
an activity that also has the potential to snatch a life away from
us just as quickly.

Feel free to contact me if you have questions, or go to the
Wilderness Medical Associates website at www.wildmed.com for further
info on wilderness medicine training courses.

Dennis Kerrigan,

Registered EMT-Paramedic, Wilderness EMT-Paramedic
Instructor Preceptor, Rescue 3 International
Instructor Trainer, American Canoe Association
Senior Faculty, Wilderness Medical Associates
Former Head Guide, NOC Chattooga Outpost

brendan.leslie's picture

Hey there.
I'm currently a WFR after sitting my course at Camp Carolina, NC,with Hank. However that was a few years ago and it's about to run out. Now that I live in Christchurch, New Zealand I'm not sure as to where I can do a resit.
Can you help us out on this front?
Cheers.