"I did not think a broken arm would distract him from reporting tenderness to his neck." Distracting injuries are subjective and based on the patient's interpretation of pain, not the physician's. If there is any doubt if an injury is distracting, obtain radiographs of the patient's cervical spine. One patient's distracter is not always the same as that of another.
"The initial 3-view radiographs were negative so I cleared the patient from cervical precautions. I thought the midline cervical tenderness was secondary to a muscle strain not fracture." If a patient continues to have significant cervical tenderness after plain films, obtain a CT scan to further evaluate the cervical spine.
"The intoxicated patient had negative cervical radiographs and no cervical tenderness, so I cleared him from spinal precautions. Why is he paralyzed now?" Do not remove an intoxicated patient from cervical precautions until you can perform and document a repeat examination with no midline tenderness in a sober patient.
"I checked sensation during my initial examination but did not record the results." Spinal cord injuries may be easily missed in a busy ED. The patient's lack of movement may be thought to be due to a lack of cooperation or intoxication. It is important to document a full neurologic examination during the initial evaluation and at time of disposition. Write it down. "Negative acute" or "WNL" is not adequate.
"I wanted to see the cervical radiographs before I intubated the patient. I did not know that he would aspirate." The primary survey and necessary interventions to stabilize the patient are ALWAYS preformed before radiographs. If the airway is in jeopardy assume the patient has a spine injury, apply in-line cervical stabilization, and intubate the patient.
"Her mechanism was not consistent with a cervical spine injury, so I removed her from the cervical collar. She just fell from standing at her nursing home." Always take a complete and detailed history before clinically clearing a patient from a cervical collar. Older patients are at increased risk for cervical spine injuries with seemingly minimal mechanisms. Have a high level of suspicion for cervical fractures in the elderly.
"I thought that the radiographs were adequate to clear the patient from the cervical collar even though the cervical thoracic junction was not visualized." Never settle for inadequate films. Significant pathology can be missed if the cervical thoracic junction is not visualized. Order a repeat swimmer's view or a CT scan. Inadequate films provide no legal protection.