By
now you've most likely heard about the revised Maine Spine
Assessment Protocol. This article will look at the differences
between old and new, and emphasize some key points to remember
when using the Protocol.
The
biggest change from the old Protocol to the new is the change in
focus on mechanism of injury as the primary factor in determining
whether or not to immobilize a patient. In the original Protocol,
mechanisms were defined and treated as follows:
§
"Positive" — high potential for injury,
automatically immobilized
§
"Negative" — no possibility of spinal cord injury,
no need for immobilization
§
"Uncertain" — the Protocol was utilized to
determine need for immobilization.
Research
has called this approach into question. As a result, "mechanism"
is no longer being used to make the determination about immobilization.
It is now being used to alert EMS providers to the need for spinal
injury screening. Thus EMS providers are being called upon to
depend on their assessment skills rather than just to follow
black and white criteria. Mechanisms that suggest the need for
screening include axial load (e.g. diving into a body of water),
blunt trauma, motor vehicle collisions, bicycle collisions, falls
from a height greater than three feet, and falls (by adults) from
a standing height. The list is not exhaustive, and other
mechanisms might also be considered trigger points for further
assessment.
Another
change is that the new Protocol moves the question of reliability
from the end of the process to the beginning, where it really
should be. Any patient, in order to be acceptable for assessment
by the Protocol, must be calm, cooperative, sober, and alert, and
must not suffer from any significant distracting injury. A two-year
old child, an intoxicated adult, a person experiencing an acute
stress reaction, a person with a fractured tibia/fibula, a
patient who does not speak or understand English when that's the
only language the provider speaks — these are not "reliable
patients," and therefore cannot be adequately
assessed using the Protocol. If there is any doubt at all
with these patients, they must be fully immobilized.
The
questions of abnormal sensory/motor exam and spine pain/tenderness
remain in the protocol, although the order of these (we used to
assess for spine pain and tenderness before we performed
the sensory/motor exam) has been reversed. Also, the new Protocol
has eliminated specific instructions as to how to perform a
sensory/motor exam, leaving it up to the individual clinician. No
longer do we have clear instructions about finger ab/adduction,
hand flexion/extension, sharp/dull discrimination and so on like
we used to. Instead we get the following very unclear
instructions: "This examination should include commonly
accepted [emphasis added] assessment means for consideration
of motor or sensory deficits from spine injury." This change
is discussed in Dr. Burton's article in this issue of the Journal
(see page ____).
While
not a change, another clarification that is worth mentioning is
documentation. It is simply not enough for the EMT to state that
he or she used the Protocol. He or she must spell out
the findings.
The
documentation needs to clearly demonstrate every item in the
Protocol, including the first, the patient's reliability. Merely
circling the items in the Glascow Coma Scale is not sufficient
for this purpose. The fact that the patient is alert and oriented
to person, place, time, and event must be spelled out. The fact
that the patient is calm and cooperative, and does not have any
distracting injuries must also be spelled out. It must be clear
from the narrative that the patient does not have any signs of
intoxication. These might not all be documented in a single place
in the narrative, but must be documented somewhere.
The
findings of the sensory and motor exams also need to be clearly
stated, along with the method used for performing those exams. If
sharp/dull discrimination is tested, then that must be documented.
If the motor exam is tested with a comparison of hand grasp
strength or finger ab/adduction, then hand grasp strength or
finger ab/abduction must be documented. The fact that the patient
denies any spine pain needs to be clear, as does the fact that
there was no tenderness to palpation along the entire length of
the spine.
While
this sounds like a lot to write in the very small space given for
the narrative, it can be concisely done. An example might be:
S
— 34 y,o. male, seat-belted driver of mid-sized sedan
reports hitting patch of black ice and sliding off road into
ditch at low speed, estimates approx. 15mph. States airbags did
not deploy. Denies injury. [Allergies and medications would be
listed as appropriate in the box.] PMHx: denies. Last oral intake:
regular lunch two hours ago.
O
— Male pt. pacing with steady gait outside vehicle, calmly
talking on cell phone upon EMS arrival, no visible injury.
A&Ox4. ABCs okay with resps. even, non-labored, skin pink,
warm and dry. Exam reveals head/neck: no injury, no bleeding
noted, PERRL. Chest: equal expansion, no injury noted, breath
sounds equal and clear throughout. Abdomen: soft, non-tender, no
bruising or injury noted. Pelvis: non-tender. Extremities: no
injury noted. Hand grasps strong and equal bilateral, equal
finger ab/adduction and hand flexion/extension, foot plantar/dorsi-flexion
strong and equal bilateral, reports equal sensation to touch with
paper clip tip and fingertip to bilateral hands and feet.
Posterior: spine without deformity, non-tender to palpation along
entire length.
In
the above example, all of the key points of the Protocol were
addressed: reliability, presence or absence of distracting
injury, normal or abnormal sensory/motor exam, and presence or
absence of spine pain/tenderness. It was clear and defensible
that this patient did not need immobilization.
In
the past, EMTs have filled in the "Maine Spine Assessment
Protocol Used" check box on the run report form only
when the Protocol was used for the purpose of helping them
determine whether or not to immobilize the patient. Now, however,
they are to fill in the box whenever there is any possibility
whatsoever that there might have been a spinal injury,
because that is when they'll be using the Protocol. That means
the rollover motor vehicle crash, the fall down a flight of
stairs, the trip-and-fall on a flat surface, possibly even the
fall out of bed or a wheelchair. EMTs will be using the
assessment on all of these patients and therefore will need to
indicate this on the run sheet. In summary, on all potentially
spine-injured patients, they will use the Protocol, fill in the
box on the run sheet, and do the QA form. (This statewide QA
study on the Protocol is expected to last about a year, about as
long the state anticipates it will take to collect the data it
needs to assess the Protocol's changes.)
While
the MSAP is, and has been, a required component in Maine EMT-B
licensure classes since the adoption of the National Standard
Curriculum for EMT-Basics in 1995, not all teachers have been
teaching it in their Basic classes, so not all EMTs have been
trained. Now is the perfect opportunity for all providers of all
levels, whether they've had the initial training or not, to study
this Protocol, so they can be providing "standard of care"
for all of their patients. Anyone who has not been offered a
program on the MSAP, should speak with his or her training
officer, who can contact the regional office to arrange one.
The
MEMS web site has four resources for viewing or downloading
related to this new protocol, and anyone can access them. One is
a full PowerPoint presentation, complete with x-rays and other
illustrations for instructors to use when teaching the program,
and for attendees to use to review it afterwards. Also available
is the new "booklet" about the protocol, so readers can
print off their own copy if it wasn't distributed during class,
or even before class to review ahead of time. There's also a
listing of the program objectives and a copy of the state QA form.
All these MSAP documents are located at <http://www.state.me.us/dps/ems/docs/spinal.html>,
or can be obtained from your regional office or Maine EMS.
The
goal of the MSAP is to identify and immobilize all
patients at risk for unstable spinal injuries, as well as to
identify and not immobilize those patients with no risk.
Taking an MSAP class, studying the resources available,
thoroughly assessing and treating all potentially spine injury
patients, and documenting all findings are the ways in which EMTs
at all levels are able to achieve that goal.
© 2003 by
Jacqueline B. Vaniotis