I must be cruel, only to be kind: Thus bad begins and worse remains behind.
Hamlet Act 3 Scene 4, Shakespeare
Let me tell you two true stories.
A long time ago when I was a rural doctor in a rural hospital, one night I was called to see a a group of teenagers who had been in a car rollover. One of them had been asleep in the back, without a seatbelt. He was complaining of neck pain and the ambulance folks had brought him in a stretcher with a well fitted cervical neck collar on.
His examination was only remarkable for tenderness of his cervical spinous processes
I could take my own plain film xrays so did a cervical spine lateral and AP ( which was crap quality). I couldnt see anything abnormal but could not get a shot of the C7/T1 junction. I decided to send him to the city hospital for a CT given his pain and the mechanism of injury.
He got transported by RFDS aircraft ( I was not a RFDS doctor back then!) to the city where he was seen at THE major trauma hospital in the ED. He had a CT spine study which was reviewed by the ED registrar who cleared it and discharged the teenager home with his mum. They drove back to our town and did the best they could as he had ongoing neck pain. I believe he got a soft neck collar to wear and some ibufrofen analgesia.
Anyway 3 days later we get a call from a nervous ED reg who asks how the patient is doing and if there are any symptoms of limb paraesthesia or weakness. Luckily he had developed none, but still had moderately severe neck pain. The CT scan was eventually reported by a radiologist who detected an undisplaced cervical spine fracture. Anyway the patient did ok and spent a few months in a Philadelphia collar.
Lessons learnt :
– respect the mechanism of injury and the patients symptoms
– Awake cooperative patients protect their own injured cervical spine better than anything we do!
– Dont try to report xrays at night by yourself !
Okay second story. Fast forward quite a few years and I am now a Flying Doctor. I get called to fly a woman involved in a car rollover ( sound familiar?) who self extricated and walked around then got picked up by passers by and taken to a nearby rural hospital. The local doctor had assessed her and she had a fractured clavicle but no other obvious injuries. Anyway he could not clear her cervical spine without xrays so wanted her flown to a regional hospital for this. By the time I got to her, she had been supine on a spinal board with a rigid cervical neck collar for 4 hrs. She had been bladder catheterised as they did not want to let her sit up. But she had no neck pain nor limb signs nor symptoms. She certainly had no neck tenderness. I put her into our vacuum spinal mattress and removed the collar. She felt better off the board and without the collar and was awake and cooperative since the rollover. Her CT scan was normal and she was discharged from ED.
-awake patients who can self extricate do a better job at protecting their spine than we do!
-we need to be more selective in our use of spinal immobilisation techniques, rather than dogmatic
-hard spinal boards are cruel for anything more than extrication of unconscious patients
By the way did you know that a major Brisbane hospital and ED for the last 5 years have used soft neck collars instead of rigid ones?
CHECK THIS OUT