C-Collars on their way out?

[JPINFV]

However, this quote somewhat limits the application of the study. Is it reasonable to change practice for an injury that few patients actually survive?

Alternative question, is it reasonable to engage in a practice with questionable effectiveness in patients with the condition we're trying to stabilize when the majority of the patients with that condition die immediately anyways or have already suffered irreversible injury? After all, spinal injury are a small fraction of all traumas and unstable spinal injuries are a small fraction of spinal injuries and spinal immobilization has never been shown to prevent secondary injury. So we're subjecting trauma patients to a questionable intervention that may help a small fraction of a small fraction of our patients.

[fireflymedic]

One thing I would venture to question though is if you look at a patient on a backboard, especially if the patient is heavier, they aren't truly kept "in line" which is the goal. Padding really should be put under the head to raise it up to an in line position - part of the reason they say don't remove helmets unless absolutely neccessary - they actually put the head in a better position. Also, there are a lot of people (as another person said with the "no neck club") that don't receive appropriately sized collars in the first place. If you look an immobilized person has a pretty steep curve to their c-spine. Perhaps a shorter collar or padding under the head would be more effective - just a thought? Along with poor immobilization (especially with the three strap boards) patients slide all over.

As to the foam blocks, we utilize the "head beds". For those that aren't familiar, they are a foam piece attached to the backboard and then two foam blocks velcro to the sides next to the patient's head. Much more stable than the giant foam blocks and tape that many (at least in this area due to cheaper cost) are still utilizing. Though some are using blanket/towel rolls instead. Also, I have utilized a blanket roll for a large patient that couldn't fit a c collar. Wrap the blanket around the patient's neck, then fold the sides down next to the head to form "headblocks". Similar to the general round foam neckbraces seen worn sometimes by patients.

I agree that the study does bring about some questions to be investigated, and the preliminary information is something to consider, but I have difficulty believing that unrestrained movement in any direction with a potential or proven c-spine injury is better than restricting movement in some fashion. Just like any injured part - excessive moment does increase the risk for bleeding, inflammation and damage to nerves and surrounding tissue. I think we need to look into what the stress points in the c collar are, and find a way to eliminate those, as opposed to completely doing away with immobilization because from what I'm understanding of the study, it's not the actual limiting of movement that is potentially affecting these patients negatively, it's the stretching of the ligaments in the neck that are causing the greater potential for injury.

[Chief1C]

I'm still very meticulous about spinal immobilization and try not to apply something that in effect, stretches the head upward. Nearly every patient, a 'neckless' collar fits perfectly. I cringe when I see people fitting a 'regular' collar onto patients, b/c they assume it's the standard size.

We use a the vinyl/foam blocks for patients being flown, and these

for patients going by ground. I actually like these better, b/c there is significantly less Velcro for blood, vomit and hair to get trapped in. I have to wonder what would replace the cervical collar.

[Richard B the EMT]

FDNY "standard" is the head-bed.

At least we don't use sandbags, and haven't for roughly 2 decades.

Also, within this last decade, we had the rolled blanket horseshoe method removed from protocols. I don't agree with that one, but until my instructors tell me otherwise, I'll live with it.

[Chief1C]

We have a stack of 5lb Ferno sand bags in the closet.. Like ten pairs.

[NickD]

>>Baylor College of Medicine doctors used cadavers to confirm that so-called cervical collars can be counterproductive<<

A couple of observations from my very limited experience:

- All I've ever seen doctors do with cervical collars is remove them.

- A properly sized collar shouldn't stretch the neck at all.

- Despite the one case they cited where's beef? How many people not already neurologically compromised became so after the application of a collar?

- Did these doctors take into account the situations we find our patients in? Let's see what happens if we drop the use of collars and start extricating patients from wrecks, moving them from floors to gurneys, going up and down stairs, and transporting them in ambulances with suspensions that belong in the scrap heap over roads built a hundred years ago.

- Some doctors, especially the ones entrenched in academia, follow the theory of publish or perish in terms of career advancement. And EMS is easy prey for them because the street cred of medics can't push back against a group of doctors with a bunch of letters after their names.

- Another counter study will appear soon (funded by an association representing the manufacturers of c-collars) with hired guns to refute the whole notion of the first study.

[JPINFV]

- A properly sized collar shouldn't stretch the neck at all.

Key word= properly. Additionally, it should be expected that there is some movement, however limited, as the collar is put into place. Given the current design of collars, there isn't any avoiding this.

- Despite the one case they cited where's beef? How many people not already neurologically compromised became so after the application of a collar?

The opposite should be a better question. How many people not neurologically compromised would become neurologically compromised if no immobilization occurred? The reality is that showing lack of harm isn't enough. What should be shown is benefit of use.

- Did these doctors take into account the situations we find our patients in? Let's see what happens if we drop the use of collars and start extricating patients from wrecks, moving them from floors to gurneys, going up and down stairs, and transporting them in ambulances with suspensions that belong in the scrap heap over roads built a hundred years ago.

For the majority of patients, probably nothing will change in terms of outcome. Why aren't medical patients who need to go through all of those cases routinely placed into c-collars? In addition, even an ambulance with 300k miles on it can give a smooth ride if the driver knows what s/he is doing. Unfortunately, a lot of ambulance drivers are more concerned about how high they can peg their speedometer than how smooth of a ride they can give.

- Some doctors, especially the ones entrenched in academia, follow the theory of publish or perish in terms of career advancement. And EMS is easy prey for them because the street cred of medics can't push back against a group of doctors with a bunch of letters after their names.

Then why not push for more paramedics to be involved with research? Medics can push back, they just choose not to because it's too hard. After all, nothing is stopping paramedics from getting all of those letters (BS, MS, etc) behind their names and looking for research jobs or approaching agencies (state EMS, county EMS, etc) looking to start projects or research registries.

Edited January 28, 2010 by JPINFV

[joesph]

Has any one seen a c-collar system using vacuum splint technology. If you think about it wouldn't elongate the neck, allow movement, it would conform to the patient and could be built to bridge out to the shoulders and give a better base to the c-collar. Fore that matter it could be formed in such a manner as to support the head as well so the weight would not be suspended by a neck that is immobilized. One of you guys develop that and become a millionaire.

[Dustdevil]

- Did these doctors take into account the situations we find our patients in? Let's see what happens if we drop the use of collars and start extricating patients from wrecks, moving them from floors to gurneys, going up and down stairs, and transporting them in ambulances with suspensions that belong in the scrap heap over roads built a hundred years ago.

Very interesting point. It is true that this study takes into account only the manipulation necessary to apply the collar itself, while ignoring the manipulation necessary for extrication. Extrication -- even simple manoeuvring from a supine position -- is a whole 'nother dimension of factors that is not addressed.

[treaux]

Many good points in this thread and as someone already said, initial studies like this are going to be put through the washer several times before any type of conclusion can really be made.

I agree that the current options for c-collars make it very difficult to size properly for many of our patients and I have been known to either forgo the collar and use manual stabilization or create some type of modified c-spine protection in cases where I feel the collar would be detrimental. The same can be said for long boards in many cases. I also agree that the extrication factor makes collars worth their weight in gold when it comes to messy situations.

firefly, I find it odd that you said the STA blocks to work better than the big Ferno blocks. We use the STA blocks as well (to clarify, they have the blue pad that sticks to the board and two triangle like wedges that velcro to it) and I think they do a terrible job. In my experience the Ferno blocks do a much better job of staying put and reminding the patients not to turn their head, where the STA blocks just seem to twist away (yes, even with the blue "mean" tape).