After two wonderful years in Hawaii, I’m returning to New York to take up new clinical and educational challenges. Before I do, I thought it was appropriate to send one last “postcard from the ED”. This one comes from a case that reminded me that when it comes to decision rules, “there are more things in heaven and earth…than are dreamt of in your philosophy.” Here it is:
A 38 year old surfer comes into the ED by private vehicle. He was driven by a friend to get some pain medication for “spraining my neck”. After being hit by a large wave and tossed around he felt a pop and began to notice severe pain in his neck. At first he tried to paddle back out, but the pain forced him to come to the beach. After about an hour the pain had not improved and he decided he needed some stronger pain medication.
He had no other injuries, no focal neurologic deficits, and had not been drinking. On examination he had no change in his level of consciousness, he had a normal neurologic exam. The location of his pain was para-spinal located in the upper cervical muscles by the occiput, and he said “his throat hurt”. He was unable and unwilling to rotate his neck in any direction.
Based on NEXUS this patient could have potentially been cleared clinically. However, having lived in Hawaii for some time, I have learned to respect the power of the ocean. For me any surf related injury is a high risk mechanism until proven otherwise. If you were not to treat this as a high-risk mechanism and were using the Canadian c-spine rule, you would have gotten to the “able to rotate neck” part before slapping that cervical collar back in place, which is what I did. Below you can see the reformatted image of a C1 fracture. The patient was accepted for transfer to the trauma center, where he was treated and released with no neurologic deficits.
In hindsight I believe the absence of midline tenderness was due to the extreme amount of soft tissue pain he was in, and the muscular splinting of his unstable C1 fracture. To me it could have counted as a distracting injury however I’m not sure I’ve ever considered para-spinal strain as a distracting injury. Maybe it is a flaw in the language, since the word distracting means “taking your attention elsewhere”. This implies that the pain should be somewhere other than the neck.
Other than mechanism, the real red flag for me was his unwillingness to move his neck. In my experience the alert patient with an unstable c-spine fracture DOES NOT want to move!!! I’ve also come to realize, working in rural community hospitals here in Hawaii, you paradoxically see more of the isolated serious walk in traumas than you do in a major trauma center. Often the rules of tertiary care practice do not translate. Here are some of the key take away points for me in this case.
- A patient with a mechanism that is unfamiliar to the physician may be overlooked as high risk due to lack of experience with that type of injury.
- For obvious reasons clinical decision rules in trauma are designed using a patient pool which is skewed towards common injury patterns. Unusual mechanisms or patterns of injury unique to your clinical environment (in this case surfing) should be treated as potentially outside the scope of these rules.
There has been some recent trauma literature suggesting that these rules don’t apply to trauma activation criteria patients, This was a reminder that they do not always apply to non-trauma activation patients either. We teach these clinical decision rules, but it is imperative that we also teach the inclusion and exclusion criteria used in the studies, the potential flaws in the human application of these rules, and the limitations of all studies to be generalizable to all patients, so that we can better decide if they apply to the patient in our ED at any given moment.
Finally, if you do use the rules I would consider the combination of NEXUS and Canadian algorithm. Dr Scott Weingart has a compelling argument and a nice diagram showing how the two can work in synergy. In this case my patient would have also failed to be cleared clinically based on the combined rule.
The EMBER is a small bundle of free open access resources to deepen your knowledge. Thanks to all the educators out there putting time and energy into teaching others.