Spinal Immobilization: Are we doing more harm than good ?

[AnthonyM83]

I stopped reading after you guys started posting those two-hour posts, but Dustdevil was making pretty logical sense to me. It seemed people were replying to things he didn't say and then making him defend himself on stuff he shouldn't have to be in the first place.

These kinds of responses seem to be common on these types of boards...someone will mention an ox meter and someone always somehow pops in to accuse the person of relying solely on the ox meter and not the overall patient (when I'm sure he knew that, but that wasn't his question). Or a personal example, when I posted that searching patient would technically be assault, just as fyi, but one should do what they have to in order to keep safe...people replied by saying I was going to get hurt with that type thinking...even though I had just said advocated doing what you need to to stay safe.

It's like people don't read sometimes...they just start up another argument that they can easily win. It seems to happen a lot so maybe it's just human nature...I dunno. It's fine if you're doing it to just point something out, but when you make it seem like it's a fault in the other person, the other person will get defensive, of course.

[Ridryder 911]

Anthony I respect your opinion and like everyone else is entitled to one. But in educated debates, reciting personal anecdotes never really solves an educated question. When citations has been provided and one refuses to acknowledge and to question is okay, but to continually debate is frivolous. This has been an re-current response whenever someone disagree or tries asks for more specifics on the thread question. In most of the EMS forums there are of us that are aware of those that perform client care and those that talk about it, and our up to current standards. Over-all as a member of several forums it is usually the same members.. and we have become professionally close. Yes, we may criticize and praise each other ;this is what makes forums work.... other wise they become VERY boring. Don't believe me look at other EMS websites... without debates.. they get gooey and no educational debates occur.

As I again state, I respect his opinion not the "attitude" or belittling. Which is a direct violation of this forum, in which he likes to direct to others. When all the dust .. settles ( no pun intended) I hope we still respect each other... I do. I know I have thick skin from bigger & more important tomcats..lol

oh... another thing is it is a pulse- oximeter ...not ox-meter... :wink:

Respectfully,

R/R 911

[medik8]

:roll:

Wow.....guys....if u need me, I'll be taking my nap due to mental exhaustion...

There were good points made here....everywhere....

Personally, I'm claustrophobic as hell on one of those things, and unless you can pretty much assure me my back is broken, you are NOT going to board me.....plain and simple. I know that sounds stupid....but tis the way it is with moi.

In addition, like I'm sure all of you can say as well, I have had patients (like I would be) absolutely refuse to be boarded. Some of them had back problems already (when I thought the boarding was most important), some absolutely refused to lay flat with all that garb on because they felt out of control and too confined (again like myself)...

I've had to talk a few into it because it was for their own good, and at least a few times, fractures were proven later and was glad we decided on the board. But, have upset some, as well, by advising that the board was the right thing to do, only to get to the ER and then watching the doc remove it right before my eyes without any x-rays or confirmation of injury (which really pissed me off) :x .

Let me think on this one for a bit...

[vs-eh?]

I don't think any services in Ontario have specific spinal "protocols". And if there is it is news to me. For us it is based on clinical judgment, pure and simple.

I honestly don't understand how it could be based on anything else. I mean using basic assessment skills and observation, it is pretty easy to see if someone needs a board or not. Simply following "protocols" blindly because they say so is foriegn to me.

It's analogus to treating all chest pains as ischemic, all SOB as CHF or broncoconstriction, all alerted mental status as hypoglycemia/narcotic OD. I could go on...

This is a basic assessment. If you can't do that, I'd hate to see that same person on a chest pain patient (especially one that speaks minimal english) or an NYD abdo pain. Good luck.

And anecdotes are irrelevant imho. You can't win 'em all.

:joker:

[History Nut]

I take keyboard under fingers somewhat hesitantly on this subject because I know I am going to come across as a grumpy old dinosaur but so be it. I reserve the right to express my opinion based on my experience. After all, I wasn't 'brain dead' during most of those 25,000 plus EMS runs I did in my career.

First off, I am not citing any 'studies', just my experience so those of you in love with 'studies' in the medical field will be frustrated. Although I worked in a disciplined agency so I followed all the protocols that were required, my opinion of most medical 'studies' is that their greatest value is that they are printed on paper so they might help start a fire in an appropriate situation.

A case in point is the study cited in the original post. Some doctors did chart reviews and came to conclusions about spinal immobilization using spine boards based on hospital outcomes. I am glad they got to publish so they could make a few extra bucks and brag. I am not impressed. They drew a conclusion about one aspect of patient care from cases that have too many variables to make a single conclusion valid. What were the mechanisms of injury in each case? At what point was spinal immobilization begun and was it properly maintained throughout? Was the board padded in the lumbar and cervical region to maintain the natural curve of the spine? Was the body padded properly so the strapping system kept the patient still? What kind of strapping system was used? Upon hospital arrival was the patient kept properly secured or like most cases completely unsecured and left on the board? When sent to X-ray, was the patient escorted so enough people were available to keep the patient immobile during the X-rays? The last originated from a student in one of my first aid classes who was an X-ray tech. He told of patients being brought to him on a backboard and everyone would leave for him to do the X-rays. He had no idea what a long back board was so he would just ask the patient to 'scoot' over onto the X-ray table! He was taking first aid so he could better understand the apparatus that was often on his patients.

The popular thing these days are "statistical blind studies" if I remember the term correctly. They sound neat as they assume (!) that repetition in numbers eliminates errors. That works great in land survey. We would 'tape' a line over and over at the same pull on the 'tape', the same side of the stake, noting temperature for its affect on the 'tape' and after doing it a certain number of times, calculate the accuracy based on 'error canceling error'. It works well because by applying the "scientific method" there is only one variable. For those that have forgotten high school science, "scientific method" allows only one variable in any experiment. Dealing with real humans in multi-caregiver and facility situations involves way too many variables to validate even 'statistical blind studies'. If one wanted to do a real study involving the benefit or lack of benefit of long back board spinal immobilization, it would have to include careful study of all variables. First a study monitor would have to ride with the prehospital unit to score each variable. The monitor would then have to continue into the hospital setting to validate any variations and findings. Hospital charting is far from error proof both accidentally and deliberately. After all the separate records are collected they then can be categorized for variables and only those cases used that have only the LSB, properly used, applied to the experiment. Of course to be ethical, the study monitor would have to get patient consent of those that were not going to get boarded after explaining all the risks. Good chance of that happening! Medical studies, especially in the pre-hospital setting are often applied to a patient without their knowledge or consent. I am surprised that some really sharp lawyers haven't made a fortune off this simple fact.

As far as my experience with using LBBs for spinal immobilization, I believe that they are a useful tool when properly used. The flaws are in standard application of the tool and use protocols dictated more by the latest lawsuit results than true medical needs. While I was still working, we didn't have any protocols for field clearing of C-spine. As far as application protocols, that varied with each facility that received the patient. One thing about medicine, is that there is no consistency between facilities and schools. It is very dogmatic and not very analytical anymore. Thanks to liability, protocols triumph over analysis. I would like to hear the experience of those of you that do work with clearance protocols. I would believe your 'anecdotes' over all the 'medical studies' in the world.

Now that you all have concluded that it is good that I am retired as I am no longer a threat to the human race, I hope you take a moment to think about what I have posted. I believe that 'medical studies' do have some use. They should be used to give us a direction for true analysis and careful experimentation long before changes in the standard of care are made. Unfortunately, the medical profession seems to jump to conclusions based on the latest 'study' and that rolls downhill to land in EMS's lap. In case you are interested, I have seen 'standards of care' totally reverse themselves and some come full circle regarding some procedures/meds in my time on the job. I am just saying we should all remember our anatomy and physiology and use our brains before swallowing whole someones 'paper'. Regardless, since EMTs and Paramedics are at the bottom of the patient-care ladder, you can only follow what your area's protocols require. Maybe someday EMS will be so dogmatic that they can train monkeys to do our work (oh, wait, firemen already work ambulances don't they? :twisted: ) but until then, we should keep using what we know and what we learn through experience to do the best for our patients.

[EMS49393]

Being me, and knowing where my loyalty is, I have to add my two cents. One of the people hotly involved in this debate is unable to back any of his opinions up with facts, studies, or documented proof of any sort. The other educated person involved in this debate has not only named sources for reference, but has been involved in at least one research project (probably several more then I know about) that changed a protocol where I practice. I'm more willing to side with a person that has proven himself through practice, research, involvement, and commitment to providing the highest in care then someone that skirts around every issue presented. It seems to me that a certain person here likes to argue for the sake of argument, even if he is unable to support said arguments. He commands the English language, twisting into an oblivion in an attempt to make it seem he is intelligent or has a clue. It's my opinion, and only my opinion that if you no longer practice, you no longer participate. We're no longer living in the "good ole days" and I frankly could care less how good a paramedic you think you were. You feel you need to have an opinion about an issue, be prepared to back it. Studies are done for a reason.

DG - Got my snail mail today. Excellent article this quarter, ironic how part of it shows up here. My interest is not so much with the LBS, but with the cervical collar itself. What I'd like to know is if we can re-invent the egg. A few designs of cervical collars have come across my career, and I have yet to see one I actually think does a good job. In an age where are patients are getting heavier, and necks are getting wider, the design seems outdated. Is there a better way to restrict the c-spine then what we've been using? I'm very interested in the effects of the design we have on suspected brain injury patients. Do you know of any research about it? I'm interested in it, and I'd love to be involved in studying it further.

[Dustdevil]

One of the people hotly involved in this debate is unable to back any of his opinions up with facts, studies, or documented proof of any sort. The other educated person involved in this debate has not only named sources for reference, but has been involved in at least one research project (probably several more then I know about) that changed a protocol where I practice.

In other words, you preferred to be baffled with mass quantities of BS than to be dazzled by brilliance. Lists of studies which do NOT back up your point look awful impressive if you are playing a numbers game. But the point is quality, not quantity. And no studies can be found which scientifically conclude that field clearance safely eliminates unnecessary immobilization AND assures that no spinal injuries are not immobilized. In fact, none of them even attempt to conclude that. That's the problem.

[PRPGfirerescuetech]

do not take offense to this, but Id like to see said studies...

[AnthonyM83]

If someone were moderating this debate, I think they'd say it would now be up to someone to find quality journal articles "scientifically conclude that field clearance safely eliminates unnecessary immobilization AND assures that no spinal injuries are not immobilized" IF they wanted to disprove Dustdevil...not the other way around.

(Sorry...just trying to follow debate w/o head exploding.)

[Ridryder 911]

I understand that Dusts wants scientific proof in the field and this would be nice. But Dusts is quite aware that are very few scientific researches that has been studied in the field setting. There are many reasons and he is quite aware why, with so many variables.

I don't believe there was any persons post that discussed that LSB & cervical immobilization should not occur in true suspected spinal injuries. The difference is that routinely immobilizing, because that has been the usual S.O.P's should be investigated more and maybe eliminated form our teaching. Again, not disregarding MOI, and other significant attributes that has been discussed. My main point was the routine use of LSB on these patients. Again they are used routinely without thought, and application usually has no foresight of the complications.

Yes, I doubt there are any articles that actually describe field clearance... that was performed solely in the field. In comparison there are very true field studies validating medical procedures and medications we administer.

If you want more references here are some... sorry they are from trauma centers, which also actually deal with spinal patients as well.

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

and for studies of pressure sores...

http://emj.bmjjournals.com/cgi/content/full/18/1/51

Yes, I am aware of your opinion of removing the patient ASAP when entering the ER. This would be great if it was practical, but realistically will not occur, for possibly several hours. Thus the inquiry of placing patients to begin with that does not really need to be on one. Not to open a can of worms but sport trainers and sport physicians have been "field clearing" for years, with apparently successful rate (not high school trainers)

This may be one of the cases we have to agree to disagree...

Respectfully,

R/R 911