It's a simple little rule really, one that I learnt in training school. 'If they are drunk and have fallen a long way, collar and board them'.
It sounds simple, but there is a world of difference between what should be done and what can be done.
My current chappie was drunk which, to be honest, was probably a normal state of affairs for him. He'd taken some imagined offence at the person living upstairs from him (for this was the classic Newham housing scheme where a landowner converts a perfectly nice house into eight or nine one bedroom flats). He'd staggered upstairs and been banging on the other person's door – then when the door was answered had become aggressive. The flat owner had given him a push and our drunken patient had stumbled backwards and fallen down the stairs.
The person who'd pushed him was the one who'd called the ambulance.
The police were in attendance as the drunk was acting aggressive, again called by the person who'd pushed my patient.
We arrived to find a couple of drunks, one of which was our patient. He was verbally aggressive – but not physically violent, although I had the suspicion that it wouldn't take much before he started waving his fists around.
Topless, like many of our drunks, he sat on the end of his bed. Because he was topless you could see the obvious fracture of his clavicle (although to be fair I thought it was a dislocated AC joint, but then, that is what x-rays are for).
Restless and agitated, although more likely due to the drink rather than any suspected head injury, it took me quite some time to persuade the patient that it was in his own best interests to come to hospital. It was only when I told him that the bone he had broken could cause fatal bleeding (the truth, although not in this case) that he agreed to come to hospital.
He refused to be collared and boarded, and besides, he was much too agitated to lay still for any amount of time.
It's here that judgement comes into play. You balance up the need to 'collar him' because he fell down a complete flight of stairs and is so drunk he could be walking around with a broken neck and not realise it with the realisation that if you try to strap him down to a board he's going to struggle and put his neck through more contortions than if he were to just sit quietly in the back of the ambulance.
I remember one study that said that if someone is walking around on scene and hasn't got any signs of spinal cord damage, then it's incredibly unlikely that they have damaged their spine.
So, on balance, trying to force someone into being immobilised is probably going to do more harm than good.
And so I sat him in the ambulance checked him out and at the end of my journey walked him into the hospital – and after telling my tale they sent him to the minor injury department.
I also made sure that I documented everything on my patient report form, just in case…
In the past, when I was less wise, I'd struggled with drunk patient's to get them collared and boarded – and each time I'd thought that the struggle had done more harm than good. The same with the person agitated from a head injury, where the only way to safely transport them is to sedate them – something that we cannot do and instead have to call out a HEMS or BASICS doctor.
So while it would be nice to have the option to sedate patients, i think that it would be more important to have a less dogmatic approach to our immobilisation of patients.