Admission to hospital with spinal cord injury is for most a hazy memory of frantic doctors and nurses testing one thing or another. Whether you’ve been through the process or are interested in what’s happening to a loved one, we take a closer look at primary and secondary clinical examinations. From a quadriplegic patient point of view I share my thoughts and feelings experienced at the time.
On average 350 people require hospitalization and treatment for spinal cord injury in a specialized spinal unit in Australia each year. That is 15 per million of the population (aged 15 years and older). Ongoing costs associated with long-term care are estimated to be more than $500 million AUD per year. International incidence rates for spinal cord injury range from 10 to 40 cases per million population.
AUSTRALIAN SPINAL INJURY UNITS
Australia has six hospitals with specialized spinal units that care for SCI patients. They are located in the following five States:
- Queensland (Princess Alexandra Hospital)
- NSW (Royal North Shore Hospital & St James Hospital)
- Victoria (Austin Hospital)
- South Australia (Royal Adelaide Hospital)
- Western Australia (Royal Perth Rehabilitation Hospital)
Tasmania, Northern Territory and the A.C.T. do not have Spinal Units and SCI patients are sent to the closest interstate Spinal Unit.
PRIMARY EXAMINATION AND TREATMENT
When a spinal cord injury patient arrives at the nearest major emergency department, a detailed history is sought from paramedics, witnesses, and if conscious the patient while transferring quickly and smoothly to a trauma trolley. A spinal board is an ideal transfer device as resuscitation can continue with little interruption. A scoop stretcher is also adequate but a slower process. In the absence of either device, trained personnel can perform a coordinated spinal lift. Correct lifting and transfer techniques are essential to avoid further damage to the spinal cord and greater paralysis.
Spinal Board for patient transport and transfer
Full general and neurological assessments are undertaken in accordance with the principles of Advanced Trauma Life Support (ATLS). The examination must be quick yet thorough because spinal cord injury is frequently associated with multiple injuries. The patient’s airway, breathing and circulation – ABC n that order — are the first priorities as the spinal injury itself can directly affect the airway (for example by producing a retropharyngeal haematoma or tracheal deviation) as well as the respiratory and circulatory systems. The cervical spine (C1-C7 neck) is then secured in the neutral position, a central nervous system assessment is undertaken, and any clothing removed.
Spinal Cord Injury can be accompanied by:
- Head injury (coma of more than 6 hours duration, brain contusion or skull fracture) 12%
- Chest injury (requiring active treatment, or rib fractures) 19%
- Abdominal injury (requiring laparotomy) 3%
- Limb injury 20%
SECONDARY EXAMINATION AND TREATMENT
Having addressed any immediate life-threatening injuries, a secondary examination (head to toe) aims to identify and treat other serious injuries. The patient should be kept covered as much as possible and body temperature monitored while conducting the secondary examination. In the supine (face up) position, cervical and lumbar abnormalities of the spine may be detected by gently sliding a hand under the patient. If neurological symptoms present, a senior doctor or spinal specialist may direct a partial log roll to examine the back for specific signs of injury. Signs include local bruising or deformity of the spine (e.g. increased interspinous gap) and vertebral tenderness.
The entire length of the spine must be inspected, as about 10% of patients with an unstable spinal injury have another secondary spinal injury at a different level. Priapism (an erect penis or clitoris not returning to flaccid state within four hours) and diaphragmatic breathing (abdominal breathing) are signs of a high spinal cord lesion. Warm limbs are indicative of good circulation but should not negate the possibility of neurogenic shock attributable to spinal cord injury. A good secondary examination includes a thorough assessment of the peripheral nervous system.
Diagnosis of intra-abdominal trauma is made difficult amongst those with high spinal cord lesions (above T7). Lack of abdominal sensation together with diaphragmatic breathing can mask the classic symptoms of abdominal swelling, bruising and pain. Signs of peritoneal irritation do not develop however the pain may be referred to the shoulder from the diaphragm and this is an important symptom. When blunt abdominal trauma causing internal bleeding is suspected a peritoneal lavage (flexible plastic tube inserted into abdomen) or computed tomography may be performed unless clinical concern justifies an immediate laparotomy. Abdominal bruising from seat belts, especially isolated lap belts in children, is associated with injuries to the bowel, pancreas and lumbar spine.
The log roll during secondary examination provides ideal opportunity to remove the spinal board. While necessary to restrict any flexion or rotation of the spine, these rigid boards create pressure points on the occiput, scapulae, sacrum, and heels. Abnormal spinal column alignment and broken bones are also highly susceptible to pressure area marks, poor circulation and skin degradation. It is generally recommended the spinal board be removed within 30 minutes of its application whenever possible. Should a spinal board be required for longer than 30 minutes use of a pressure relieving mattress is recommended. In the field these typically include memory foam (tempura) and vacuum bead types. Interface pressures are much lower when a vacuum mattress is used and patients report the device is much more comfortable than a spinal board.
EMOTIONAL CATHARSIS
If you are still awake having covered the clinical primary and secondary assessment key points above, let me tell you as someone who has endured this process, this is where I experienced sheer heartbreak. My life was over. All those swarming around me connecting monitors, delivering injections, setting cannula’s and installing catheters, essentially placing me on life support, faded into the background. I crawled so far inside myself I sometimes wonder if I will ever truly return. Anxiety subsided, fear evaporated and with a single cold tear trickling past my temple I slipped into the darkness.
I had always said, the scariest place to leave me is alone in my own head, and here I was, at the gates of my own demons residence. Curled up in a ball my life flashed before my eyes. Like so many old projector slideshows on a fibro wall in Brighton, my boyhood memories from pedal cars to last sweet kiss flickered by all scratched and torn, then faded away.
A voice was calling my name, I was reluctant to look. My eyes cracked open to see a huge surgical steel hammer pass within inches of my face, You may feel a bump here the doctor said, as a spike was driven into my skull just above my right ear. The left was just as bone crunching loud but also painless.
The drugs had kicked in clawing me back from the abyss. My fight had just begun. Exaltation to deep depression would persist over the next three months but drawing on this emotional catharsis gave me great peace despite the gravity of my situation and in time would come to fast-track my acceptance of quadriplegia.
Wow….you know that Tasha is helping me, but perhaps you won’t mind giving me a hand as well….can you tell me why they drove a spike into your head? Is this standard? What does it do?
Hi Jane, Most are familiar with the halo often applied to spinal cord injury patients. Gardner Wells tongs or calipers are often used for unstable incomplete high cervical spine fractures to serve the same purpose, relieve any compression and restrict movement to prevent further damage the spinal cord. Traction is the surest way of stabilizing an incomplete unstable fracture or fracture dislocation, though it’s almost useless in the case of complete permanent quadriplegia.
You can see the pins they hammer into the skull about a finger width above each ear, and the tongs, pulley and weight suspended over the end of the bed in the following images (click to enlarge). I talk a little more about my experience as a patient with tongs here…
Quadriplegia – A View From The Chair.
Sweet holy hell…your vivid description of your initial medical experiences jerked my insides into knots. I’m new to this site, so forgive me for my lack of familiarity of procedure, but what was the thought process of medical staff for leaving you in a solitary state for extended periods? You noted that the scariest place was in your head (isn’t that true for most of us who find ourselves on the business end of those in white jackets) but extended periods without the benefit of attention borders on neglect.
Hi Deb, thanks for dropping by. I have kept candid those early dark days and isolation for too long. Negligence on behalf of the hospital was far from my mind at the time. I had people stiicking things where you don’t want to know. I empathsize with the 48 currently in the spinal unit I was in. Can still see the dots on the ceiling 16 years after my injury. In one way I am glad I jerked your guts so you have an understanding and on the other hand I would never wish those dark days on anyone. No matter how good the protocol bad nurses will happen.
Graham…I thank you deeply from my “jerked guts” and all. Your candor throughout this site does take us all back to our individual dark days and those times when hospital staff played the delightful game of “Orfice Tag”. But I think that revisiting painful events can help us put our present difficulties into perspective. Ahhh…but that’s me babbling on. All babbling aside and at the risk of sounding like an idiot, I would also like to compliment you on your way with words. It is a relief at times to read your raw expressions…I actually catch myself shouting at my laptop “that’s exactly what I’ve been trying to say!” What a dork! haha
Aww.. that’s very sweet of you to say Deb thank-you. You made my day. I have many sayings, one of them is, “I almost enjoy my darkest days as tomorrow can only be brighter.” And by that I agree sometimes we have to revisit a painful place before we can let it go and find new perspective.
I’ve long been fascinated with raw expressions and enjoy delving into others human psyche having done a little counseling and mentoring over the years. Body language is another intriguing study to me.
People talk of life changing events, acute spinal cord injury is one near top of the list. How perspectives, values, mannerisms and physical abilities change. That’s not to say everything changes. Another of my sayings is “If a wheelie is an asshole, chances are, they were an asshole before their accident.”
I’ve been trying to publish at least one article per week (any help is welcome). I think you will enjoy the next one Deb. It’s raw and I hope bound to have some screaming and others teary at their laptop. It literally embodies what you and I are discussing here. It’s scheduled for the 27th, here’s a sneak peak.
Priceless! Your comment re “If a wheelie is an asshole, chances are, they were an asshole before their accident.” Thank you! There is this perception out there that when an individual survives a “life-changing event” they grow a halo, unfurl lush wings, and expound profound nuggets of wisdom afterward. Well…ok…a few folks do…but as a rule…a stinker remains a stinker and a sweetie remains a sweetie.
Do you catch yourself just people watching sometimes? Fade into the background and watch human behavior? I have learned more about human behavior this way than in university class rooms. Although this has gotten me into some “interesting” situations….uhhhh, like the time five of the biggest police officers I have ever seen assisted me in making a citizen’s arrest! Long story for another time!
Am very much looking forward to your next article. (would also be interested in helping) Keep the raw emotions coming, you are an excellent writer. I have a question for you? Have you considered writing a book? Maybe including the articles you have already published here and then building on them? Not sure if you would like to talk about it here or off-line or if you would rather tell me to mind my own business. haha!
I come from a very conventional family, 4th born of 5 siblings our parents are still happily married and all 23 in our immediate family are very close. Pretty rare these days. I like people watching, even in my own family. Being a quadriplegic I’m keenly aware of how people move their hands, where and how they sit, their mannerisims and how over time they change. Next time you see people hug take notice if they pat on the back or not. A pat means it’s platonic, a ritual without alot of emotion attached. No pat means it’s sincere and intimate.
Many have suggested and I have considered writing a book or two. I may a bit later in life. I would need a hand in organising. It’s just not a big priority to me at the moment. I’m very excited to hear you are interested in helping me with articles Deb, that could be great fun! Up on the right here you’ll see a Register link, create a profile, I’ll give you the ability to publish, and we’ll go from there.