Spinal Immobilization: Are we doing more harm than good ?

[Ridryder 911]

Oh the stories... the one of turning their head in x-ray ..yadda, yadda.. I could go on about patients that angiogram was clear and enzymes negative and walked out the hospital and went into v-fib... so poop happens, and we will never solve everything.

I believe the main point is to use good common sense, and rational judgment. I am definitely not against immobilizing, but when needed. So many times I have seen clients brought in with no rationale of LSB & CID, except it is our protocols and tat is the way I was taught. I have the same feeling with any medical procedure or medications administered to the client.

I feel like any other medical procedure and medication there should be an indication and rationale for it as much as not using it. Blanket treatment does cover your ass, but does not always represent the best for the patient...

Be safe,

R/R 911

[AnthonyM83]

Do you think EMTs' "rationale" and "common sense" is sufficient for them to make the determination?

[reaper]

Like I said before, MOI!!! We must use common sense when treating any pt! :shock:

[pmedic623]

I feel like any other medical procedure and medication there should be an indication and rationale for it as much as not using it. Blanket treatment does cover your ass, but does not always represent the best for the patient...

Since I have no choice but not to deviate from protocol............ Anyway I definately see your point that a number of people get immobilized that don't need it but what, if any, adverse effects does this have on anyone, speaking of course of people who really don't need it.

[dgmedic]

I'm actually surprised that this is a subject of such debate -

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.

Well, that’s odd, not to be argumentitive, but that would mean that all that disagree are not intelligent (or something other than intelligent) and you are able to accurately predict their intentions every time. When you read the studies, you do know one is to look for validity right? And you do know what the term validity means right? I ask because your above interpretation of the discussion up to this point. Perhaps you are just not communicating well. If you could point us in the direction of studies that show that field medics are unable to clear the spine or why the studies that have shown we are able to selectively immobilize, be invalid studies.

Now let me say that I completely agree with you that studies that are conducted in hospital should not be extrapolated to the out-of-hospital setting (though this is no-brainer logic). But with this said, it is completely appropriate to implement procedures in the prehospital environment from the hospital setting that have been studied (and resulted in favorable, valid results) in the prehospital setting. This has been done with spine clearance…in the prehospital setting…with valid prehospital studies.

Perhaps you can differentiate between field and clinical practice for me? These are quite subjective terms; with your definition perhaps we may be able to address your concern. Also, I don’t understand what you mean by the “discount[ing of] asymptomatic spinal injuries as insignificant.†Do you mean in reporting methods, evaluation methods, or inclusion for statistical analysis? Or just point me to the study and I can read it for myself.

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 agree on suspect injury, but according to your above logic, you should “expect†every person that has upper right injury automatically has a liver injury. I would say no if a 3 year old hit his father in the gut, I would say yes if the 3 year old shot the father there.

But if this is your argument for spinal immobilization I would suggest you look at the study by Domeier et. al (PEC 1999 Oct-Dec; 3(4):332-7) regarding MOI – MOI has no reliability regarding prehospital clinical evaluation for spinal injury – ie it’s not predictive - doesn’t really matter. If you need more valid studies, I can give them.

Also, if you suggest that even the suspicion of injury we should board, even if there is no injury, even with the documented drawbacks of spinal immobilization – I would suggest that we should start defibrillating every one of our patients because early defibrillation is key. So, we defib all, no matter what their complaint or status. I know it’s asinine, but it is parallel reasoning.

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.

Scientific validation? In the American medical community, peer-reviewed studies are the essence of scientific validation. I will amend that the studies need to be published in reputable journals, but…well, I guess I just don’t know where you get “your†scientific validation if not from valid studies or by conducting your own valid (and peer-reviewed) research.

As for a “5 question†cookbook style: hhhhmmmm, how about the thrombolytic screening list? I would like to see you make a decision purely based on your “practice†for the administration of thrombolytics. I can say that you probably wouldn’t be in medicine for very long. I do believe that this screening everyone does – even those stupid, monkey cardiologists – those idiots, freaking cookbook cardiologists!

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.

Yeah, considering all the other evidence, we do need to see those pressure ulcers don’t we? Come on, be serious man, that truly is not your sole evidence for selective immobilization is it? How about evaluation purposes (even for the physician)?

And down to the last point, if everyone is still stuck on godsend of immobilization, let me ask you this – where are the studies that show that immobilization prevents FURTHER neurological damage (although there are studies that show that they do not…just want a few that show that they do). And lastly….for a bit of trivia…can anyone tell us how the use of the LSB came into use in the prehospital setting? What was the LSB designed for…what was it’s original purpose? I think that would answer a lot too.

If you really haven't found valid prehospital studies on this subject, let me know and I will post...but I'm a little tired now. I would suggest looking a little harder.

-dg

[Dustdevil]

Well' date=' that’s odd, not to be argumentitive, but that would mean that all that disagree are not intelligent (or something other than intelligent) and you are able to accurately predict their intentions every time.[/quote']

Ummm... my statement about intelligent people was regarding those who misinterpret what I have written (as you have), not about those who disagree with my viewpoint on the topic.

There is no study that validates that they CAN. The burden of proof is on the experimental protocol, not on me.

In the ambulance vs. in the hospital.

There is no study. And that is my very point! NO study addresses those victims who suffer SCI but were not boarded because only boarded patients are figured into the study. Without statistics addressing those who were NOT boarded, you have an incomplete and myopic study. Why would you readily accept a study which specifically avoided any statistics which might contradict their theory?

Significant MOI is sort of like pornography. We can't concretely define it, but we know it when we see it. That is why the medic must maintain a high index of suspicion and not blindly follow a five-question screening protocol without also using his brain to determine other probabilities. I can think of no other instance in medicine where we completely discount the possibility of something so cavalierly.

You are -- as the post you are quoting stated -- misrepresenting my case. If you truly care what I actually said, then re-read the part in bold letters. If you are only interested in putting words in my mouth that I never said, then please continue to do so.

Again, you completely miss the point. There are multiple problems with the studies. All have been previously mentioned here. And some even agreed to by you. First, they do not state what those who are trying to extrapolate them to field use are claiming they say. Second, they are incomplete since they omit relevant statistics. And third, they were never meant for field use.

The difference is, those patients still get treated for their injury, which was already diagnosed. The patients we are refusing to immobilize never get diagnosed or treated at all. See the difference?

Uhhh... YES! If the "experts" are claiming that this happens frequently, does it not make you the least bit suspicious that they cannot offer a single statistic regarding the occurrence of pressure ulcers in backboarded patients? You don't want evidence?

Dunno. Never looked. However, since even the proponents of spinal clearance protocols maintain that it MUST be done in those meeting the criteria, it remains a given until proven otherwise. If there is conclusive evidence that spinal immobilization is of absolutely no therapeutic benefit, then I'll be the first to kick my heels when we throw it out the door. I have no stock in a backboard company. I couldn't care less. All I care about is my patient.

I would be interested in reading both. My mind is open.

[dgmedic]

Well, if so many are “misinterpreting†what you are saying, perhaps there are some communication problems and you should be clearer in YOUR viewpoint and not broad explanations.

[Ridryder 911]

Very good points... just like those that believe cervical collars provide immobilization. Laying a person on a solid piece of plastic really provide immobilization?.. and whom to say laying them on a padded firm bed would not do the same thing?... as long as the patient maintains neutral alignment.

From what I have recently seen in a lot of EMS there is very poor immobilization. How many out there actually place blanket rolls between the straps and curvature of the patients?.. The last time I seen a KED used on a adult has been years... The same being of truly immobilization of patients in major trauma.. due to most of the cases need rapid extrication they are rapidly placed onto a LSB and "pulled" out. These are the ones that need spinal immobilization the most. But understanding, spinal injuries is usually the last priority and worry of these patients, one's attention is usually geared to keep them alive.

I agree with DG.. there has been research for several years showing the B.S. of most LSB & CID. Dust your a big fan of Brian Bledsoe, I suggest reading some of his articles on debunking spinal immobilization.

As far as pressure sores, it does not take a rocket scientist to understand ... if one laying immobile on a nicely padded bed, for a couple of hours in a surgical suite can cause nerve and decreased tissue perfusion. Surely an educated person can deduct laying on a hard plastic board immobile would cause the same, maybe worse damage

Why does one think hospitals spend several of thousands of bends on rotating and air beds. Surely an educated medical person understands decreased capillary pressure in tissue perfusion even in a short period of time. The same is true when immobile or restrained clients, damage can occur. Since the clients cannot move or adjust , roll-over which the normal person does to prevernt injuries. Although the studies was not for pre-hospital clinical prat-ice, immobile and restrained is immobile and restrained no matter what type of room the client is in.

Dust, I usually agree about 95% of your post and respect your opinion and knowledge with experience. However, this like the CCEMT/P post; I believe you are not clearly presenting your question or thoughts.

Be safe,

R/R 911

[Dustdevil]

You guys have absolutely got to be kidding me. Not being clear? I could not possibly make it any simpler. If you continue to completely misunderstand my views after restating them in three different ways, it is clearly a comprehension problem on your end. Or else you are intentionally misrepresenting my views for the sake of debate. Either way, I'm out. I find myself not even debating the issue, but simply spending my entire time correcting what you say I said. If I wanted to teach elementary English, I would have gone to school for that.

This whole argument is retarded. You aren't even debating the points I made, dg. You're simply skirting the issues with diversions. Sounds kinda like this:

• Me: My cat has fleas.

You: Well my poodle doesn't have fleas, so you're stupid for saying all dogs suck!

• It is a complete non-sequitor.

As for the board being used for immobilization as opposed to extrication, I have already addressed that when it came up in previous discussion. I agree that the board is not necessary for immobilization and should be avoided. I am a proponent of dumping the patient onto the hospital gurney and taking my board with me. I don't care how they are immobilized, so long as it gets done. But the board is still required for extrication in most cases. My argument is not defending the practice of leaving patients on boards for long periods. My argument is merely defending the practice of initial immobilization. If the ER doc decides the patient needs to immediately come off the board, great. I have no problem with that. But in order to get the patient safely onto and off of my cot, they need to be on it.

[Ridryder 911]

Dust I take offense of what you said and described. I consider myself and others VERY educated and maybe it is you that should reconsider on learning on how to improve your communication skills. Obviously, this is a re-current problem as reference to other posts. (CCEMT/P debate etc...)

Forums are just a way to voice personal ideas, suggestions to others and references. Like anything here really changes anything in EMS, especially from ex-EMS personal and those not involved in State and National policy making. Hopefully, we spark interest to make others aware of situations or to be able to get involved to change things.

Like I said I respect your opinion due to your knowledge and past experience.

Respectfully,

R/R 911