Spinal Immobilization: Are we doing more harm than good ?

[Dustdevil]

So were working off the "wear a rubber just in case" theory in spinal immobilization?

Not even remotely analogous. Rubbers don't cause disease (unless you're allergic to latex, of course). However, the failure to immobilize somebody with a delicate spinal injury can cause catastrophic morbidity.

There has to be another way....

Absolutely. And when we find it, I'm all for it. But I am not for practicing scientifically unsound theories on my patients in the meantime. Are you?

[PRPGfirerescuetech]

It is analgous....just not in the way you chose to look at it...

Regarding practicing unsound theories? I agree. But is their any other way besides "field X-Rays or MRI's" to be completely sound in judgement?

Realistically, MD's remove spinal immobilization soon after a short assessment. If MD's are doing that, and its sound for them....why isnt it sound for us?

[EMS-Cat]

My personal spine board horror story which actually has very little to do with the fact I was on the board, but what happened when I got to the ER.

Fairly aggressive full speed rear-end coll. P/U truck vs our 3/4 camper van. Hit hard enough to pop the refer out of it's frame and launch a 40 qt Gott cooler the length of the van [my lower back had an imprint of 'ott' for a week], broke my captain's chair free of it's frame and shoved it under the dash. We slid across two lanes of traffic and hit a guard rail at a 45 degree angle.

Would have been a *lot* worse if husband hadn't been a really good driver and shed impact speed like crazy before we hit. Documented LOC, the whole bit. The EMS team on arrival did everything right and I deff. warranted a collar and backboard out of the deal.

Then problem was out county protocols, at that time, set transport to the nearest facility ER. Said nearest ER was one that pretty much no one would take a dead cat to at that time - it's cleaned up a bit since then because it no longer has any delusions about being a real hospital and understands it's pretty much a basic gen med/surg/day surg stop-over.

Got to the ER, was checked in by an RN, had vitals taken and then left alone in a room with no view of the nurse's desk and, here's a biggie, no buzzer, call bell, nothing, for over 20 minutes [remember the whole c-collar, secured to a back board thing]. After about half an hour a PA comes in. [Here I state I have nothing against PA - I good one is a dream come true. A bad one is BAD]. He pretty much says nothing, reads the chart, and then his physical is comprised of removing the c-collar, shoving a hand behind my neck and asking if that hurt, shoving another under my lower back, asking the same and then removing the straps and tape and rolling me off the board and onto the gurney.

Did anyone notice absolutely no x-rays or labs or anything between admit and removal from the board? I certainly did. I was then discharged home with a bottle of Percodan.

Right ...

On followup with my real doc the next day, I demonstrated some pretty aggressive back muscle strain and a moderate whiplash with hyper extension/flexion of the neck on x-ray. Husband, who wasn't even seen by the ER PA, showed a hairline crack of the vertebral body on C-4 from a flying object in the vehicle.

FWIW: The lawsuit took a couple of years to settle, the guy who hit us had no insurance [in a mandatory insurance state, btw], his daughter, who was in the back seat at the time, was admitted for observation for abd pain [he failed to tell anyone she was in the truck at the time - the State Patrolman saw he when he check out the truck sitting there holding her belly] and the hospital got off scott free by showing they had beefed up ER policies since then and had fired the PA and his supervising doc lost privileges there.

And a fun time was hand by none.

[Dustdevil]

It is analgous....just not in the way you chose to look at it...

I'm open to new ways of looking at it.

Regarding practicing unsound theories? I agree. But is their any other way besides "field X-Rays or MRI's" to be completely sound in judgement?

Yep. Wait til you get to the hospital and let them decide.

Realistically, MD's remove spinal immobilization soon after a short assessment. If MD's are doing that, and its sound for them....why isnt it sound for us?

Because they've had half an hour to calm down and actually start to feel where they hurt by then. In the first half hour after an accident, people simply don't feel everything yet. I have had several patients with c-spinal fractures who were ambulatory at the scene and denying any injury only to feel it later. You don't care about those patients?

[actualparamedic]

Anyone from an EMS system here that has a c-spine field clearance protocol? What have your experiences been so far?

I heard Central DuPage EMSS (half hour west of Chicago, busy urban-suburban system) has had a c-spine field clearance protocol in use for several years. Markers include mechanism, pain, neuromotor scoring, neuro (GCS) deficits, etc. It doesn't mean they escape spinal immobilization, it means they escape riding the backboard.

Dustdevil's point about a patient's post-accident frame of mind by the time a MD performs an ED c-spine clearance is rooted in absolute truth: they're just unwinding enough to finally focus on themselves (not their car, motorcycle, cellphone, purse, children, missed job interview, etc.).

I'd also like to hear how often anyone here still applies a KED for high speed trauma, or if anyone applies it regularly for MVC victims as part of policy/protocol.

[canuckEMT]

I was wondering, taking a quick look at some of the replies here, it sounds like some of the stories of being on a board too long are hospital related. Now given we are the ones to make that decision if the person needed it or not. I have heard of services in my area that have c-spine clearance protocols, and I bellieve they are based on the CCR(CanadIan C spine Rule).

My question is, for this to be proper in the field, what kind of criteria should be included in the clearance protocol? This has been disputed in many forums that I have read. If we don't have mobile xray capability in the unit (which isn't always good enough) then what should be added to the algorhythm?

And should there not be better protocols in place in the hospital to get these Pt's off the board quicker and lessen the added pain involved from being on the board for extended periods of time? The hospitals in the city near me are now starting to take Pt's off the long board and put them into a bed via a transfer board( thinner plastic) and then keeping them still on the matress of the cot until they have been cleared.

[PRPGfirerescuetech]

[Ridryder 911]

I agree, that the days of LSB routinely are over. This procedure is way overdone and really causes more damage and pain than the protection is set for. Mainly, we have not educated our medics to when there is really a risk versus CYA. Grandma falling in the floor onto her butt versus the high speed MVC. As well as clearing C-spine manually. We have specific C-spine clearance protocols and with the specific of "suspicion of c-spine, one can immobilize".. the only difference I have seen is the B.S. low impact fender bender calls no-longer get boarded as often, and the knee pain, no longer get CID etc... more focus on the C/C . When potential c-spine injuries the medics still perform LB etc.. as usual..

Cook book medicine and unwarranted procedures need to be curtailed. The same as EKG monitoring and I.V. .. for patients that do not warrant them...

Be safe,

R/R 911

[Dustdevil]

This same thing happens everytime we have this discussion. Somebody accuses me of clinging to "cookbook" practice of spineboarding everybody. Any intelligent person who has read what I have written and still makes that accusation is being intentionally dishonest, because there is no way that could be inferred from my writings. I have NEVER said anywhere that I thought everybody in an accident ought to be boarded. In fact, I am on record multiple times -- even in this very thread -- agreeing that too many patients are boarded and that an appropriate limiting protocol should be developed.

For the slow people out there, let me make this clear again:

Although seeking to limit unnecessary spinal immobilization procedures is certainly a worthwhile goal that I fully support, NONE OF THE CURRENT PROTOCOLS, NOR THE SO-CALLED STUDIES SUPPORTING THOSE PROTOCOLS, ARE SAFE FOR EXTRAPOLATION TO FIELD USE. Read them. They were not even developed for field use. They are for hospital practice. Give me a protocol that is validated in the field and takes into account the differences between field and clinical practice, and does not completely discount asymptomatic spinal injuries as "insignificant" and I will readily embrace it.

Having a healthy index of suspicion for spinal injury after seeing a significant MOI on scene is not cookbook medicine. It is using your head. If somebody takes a significant hit to the right upper quadrant, don't you suspect a liver injury? Do you need a protocol to tell you that this is a very real possibility? Of course not. It's common sense.

I'll tell you what cookbook medicine is. It is asking five questions and then determining that your patient's chances of a spinal injury are insignificant without taking other factors into consideration. THAT, my friends, is cookbook medicine! If you haven't seen an accident victim with an asymptomatic (on scene) spinal injury, then you simply haven't been in the field long enough. Or else you don't have adequate followup with your patients. It happens. It happens all the time. NONE of the current spinal clearance protocols address those patients.

If the ER docs want to kill those patients at the hospital just to show everybody how they can follow a five question protocol without using their intelligence, then good for them. That's their business. That's their insurance. That's their license. As for myself, I am looking for some scientific validation of my practice which shows it to be in the best interest of my patients. So far, we have not been given that.

Oh, and by the way, where are all the studies that show us all these pressure ulcers that are allegedly occurring everywhere? Ha! Good luck finding that! You won't. Nuff said. More lies. The whole concept is smoke, mirrors, extrapolation and semantics. Not a lick of science involved. Screw that.

[pmedic623]

If you haven't seen an accident victim with an asymptomatic (on scene) spinal injury, then you simply haven't been in the field long enough. Or else you don't have adequate followup with your patients. It happens. It happens all the time. NONE of the current spinal clearance protocols address those patients.

.

Good point, reminds me of the guy that was ambulatory at scene of rollover with no c/o pain and turned to talk to the trooper and fell to the ground and hasn't walked since, we pick him up all the time for various complaints usually resulting from his pressure sores due to sitting in his wheelchair all the time. My regular partner worked this wreck and hadn't arrived on scene but fire/rescue was in the process of assessing and thought this guy was just lucky with no apparent injuries. Guess not!! I think I'll just keep immobilizing!