# new WMS research : c  spine protocols



## kaisardog (Sep 24, 2013)

The  Wilderness  Medicine Society  has  just  published  some  very  interesting  consensus  research  on preventing   C  spine  injuries in  prehospital  care. what  interested  me  most  was  the  discussion  on  logrolling  vs. a  trap  slide,  and  the  importance  of  padding  the  occiput to minimize  motion.... 

although a  full  WMS subscription  costs  money,  this  article  is  free:

http://www.wemjournal.org/article/S1080-6032(13)00071-9/fulltext


----------



## Christopher (Sep 24, 2013)

I don't know...they seem too logical and level headed for EMS 


			
				WMS said:
			
		

> For the purpose of developing proper guidelines for spinal immobilization in a dangerous environment, it is important to recognize and attempt to differentiate 5 types of spinal injury scenarios:
> 
> 1) an uninjured spine,
> 2) a stable spine injury without existing or potential neurologic compromise,
> ...



5 years ago when I took my first wilderness EMS class, many of these issues were already being discussed and points like skipping log-roll in favor of lift/slide. Granted, the instructors were incredible and in retrospect they've contributed quite a bit towards how I practice "civilized" EMS.


----------



## NBFFD2433 (Oct 15, 2013)

Christopher said:


> I don't know...they seem too logical and level headed for EMS
> 
> 
> 5 years ago when I took my first wilderness EMS class, many of these issues were already being discussed and points like skipping log-roll in favor of lift/slide. Granted, the instructors were incredible and in retrospect they've contributed quite a bit towards how I practice "civilized" EMS.



That's what I was taught.


----------



## Handsome Robb (Oct 15, 2013)

I know that there's a service in the U.S. Who's protocols actually discourage the use of long spine boards. 

We're moving in the right direction!


----------



## EMT B (Oct 16, 2013)

what is the problem with log rolling?


----------



## Christopher (Oct 16, 2013)

EMT B said:


> what is the problem with log rolling?



It doesn't work?


----------



## EMT B (Oct 16, 2013)

apparently not...why doesn't it work?


----------



## Christopher (Oct 16, 2013)

EMT B said:


> apparently not...why doesn't it work?



It allows for a lot of spinal motion. If you believe in the fairy tale that any motion in the spinal column causes further injury, this is obviously A Bad Thing(TM).


----------



## EMT B (Oct 16, 2013)

how would you move a patient onto a longboard then? i was taught that lateral movement of the spine was ok..would you just slide them up onto the board? could you use a scoop to get them up and onto a board?


----------



## Christopher (Oct 16, 2013)

EMT B said:


> how would you move a patient onto a longboard then? i was taught that lateral movement of the spine was ok..would you just slide them up onto the board? could you use a scoop to get them up and onto a board?



Nobody knows what movements in the spine are Ok (in all likelihood any movement within the normal range of motion is Ok). It really does show the failure in EMS education in the US when you're given only one means to move somebody.

I can think of three others:

1. Scoop stretcher
2. Lift and slide
3. Straddle-lift and slide


----------



## EMT B (Oct 16, 2013)

ive been taught scoop strecher, ked, lift, straddle-lift, and all the emergency moves. i was taught the only way to backboard somebody was to use the ked, or the log roll technique because lifting patients without anything under them is bad. im not trying to say that im right...im just trying to say what i was taught


----------



## Christopher (Oct 16, 2013)

EMT B said:


> ive been taught scoop strecher, ked, lift, straddle-lift, and all the emergency moves. i was taught the only way to backboard somebody was to use the ked, or the log roll technique because lifting patients without anything under them is bad. im not trying to say that im right...im just trying to say what i was taught



Good news, the KED actually does not immobilize the C-spine either because it lacks shoulder straps.

"Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which." -Dr. Charles Sidney Burwell in an address to Harvard medical school students.


----------



## ZombieEMT (Nov 9, 2013)

*Scoop for Spinal Precautions*

I find this topic very interesting, as it has been something I have been doing a lot of research on. Has anyone heard of a scoop stretcher being used in spinal immobilization? At my volunteer department, we have recently received approval by New Jersey OEMS (under the circumstane that proper training is provided to users) to use a scoop in spinal immobilization. My chief has performed extensive research and followed the research of others showing how a scoop can be just as good, if not better, than a longboard. It potentially eliminates the effects of log rolling a patient.

The agruement that was brought to OEMS was that our state protocols state to follow manufactures guidlines on equipment. Well in short terms, Ferno states that the Ferno Scoop EXL is adequate for spinal immobilization and even has specialty head immobilizers. See below. This shows the head immobilizers on their site.

http://www.fernoems.com/products/immobilization/scoop-stretchers

Just to help support my statement, I want to add some links.

Ferno Scoop EXL
Comparison of Scoop Ferno Stretcher with the Long Board for Spinal Immobilization


----------



## Christopher (Nov 9, 2013)

ZombieEMT said:


> I find this topic very interesting, as it has been something I have been doing a lot of research on. Has anyone heard of a scoop stretcher being used in spinal immobilization? At my volunteer department, we have recently received approval by New Jersey OEMS (under the circumstane that proper training is provided to users) to use a scoop in spinal immobilization. My chief has performed extensive research and followed the research of others showing how a scoop can be just as good, if not better, than a longboard. It potentially eliminates the effects of log rolling a patient.



There is no evidence in favor of a longboard, so it doesn't take much to beat it!

A padded scoop stretcher is more likely to actually help limit energy deposition on the spine due to the gap in the back than a backboard. (Note: I didn't say movement, I said energy deposition)



ZombieEMT said:


> The agruement that was brought to OEMS was that our state protocols state to follow manufactures guidlines on equipment. Well in short terms, Ferno states that the Ferno Scoop EXL is adequate for spinal immobilization and even has specialty head immobilizers. See below. This shows the head immobilizers on their site.
> 
> http://www.fernoems.com/products/immobilization/scoop-stretchers
> 
> ...



Also:

Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? American Journal of Emergency Medicine; 2010 Sep 1;28(7):751–6. Available from: http://dx.doi.org/10.1016/j.ajem.2009.03.014

Hachen HJ. Emergency transportation in the event of acute spinal cord lesion. Spinal Cord 1974 May;12(1):33–7. Available from: http://www.nature.com/doifinder/10.1038/sc.1974.6


----------



## TransportJockey (Nov 9, 2013)

Robb said:


> I know that there's a service in the U.S. Who's protocols actually discourage the use of long spine boards.
> 
> We're moving in the right direction!



We are a non wilderness service and it's likely our next protocol revision will do away with lsb immobilization all together. Thank god.


----------



## EpiEMS (Nov 10, 2013)

TransportJockey said:


> We are a non wilderness service and it's likely our next protocol revision will do away with lsb immobilization all together. Thank god.



Will you still have C-collars?


----------



## TransportJockey (Nov 10, 2013)

EpiEMS said:


> Will you still have C-collars?



Yep. But no strapping to backboards.


----------



## mycrofft (Nov 10, 2013)

I love this, but I read this:

 "Although the expert panel was unable to identify a single well-documented case in the literature of prehospital neurologic deterioration as a direct consequence of improper or inadequate immobilization, many cases have documented severe morbidity, and even mortality, secondary to immobilization itself".

By logic and the absence of, say, Nazi camp experiments, this would not be able to be proven in any event except where a radiological exam was done on scene, then the immobilization was really botched.

I'm going to keep on reading, especially looking for citation about struggling patients.

BTW: in the responses above I keep seeing the EMT insistence that there is "*A Right Way*" to address a potentially complex situation like "spinal injury". I'm also seeing people arguing against immobilization but citing how a certain type of movement or immobilization is bad, when their premise is that it is all bad.

(Of course, my premise is know how to do it right, have the tools, only use it when it is proper).

EDIT: I am already seeing nearly absolute lack of specific consideration of the patient needing extrication , not just given a hand to climb out of the situation. THIS is an example of the EMT "all or nothing" thinking when these results are applied to different situations (cutting patient out of a car, patient stuck in a culvert down a slope, etc). THIS way lies "cook booking".


----------



## mycrofft (Nov 10, 2013)

Christopher said:


> Good news, the KED actually does not immobilize the C-spine either because it lacks shoulder straps.
> 
> "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which." -Dr. Charles Sidney Burwell in an address to Harvard medical school students.



I was KED'ed and it held MY head pretty darn immobile. And that was without a C-collar. It was a brand-name KED and the user knew what he was doing, too.


----------



## NomadicMedic (Nov 10, 2013)

mycrofft said:


> I was KED'ed and it held MY head pretty darn immobile. And that was without a C-collar. It was a brand-name KED and the user knew what he was doing, too.




"If you are basing your claims on anecdotal experience, then any treatment will seem to work for anything and everything."
—Steven Novella, MD

Next.


----------



## Christopher (Nov 10, 2013)

mycrofft said:


> I was KED'ed and it held MY head pretty darn immobile. And that was without a C-collar. It was a brand-name KED and the user knew what he was doing, too.



For the KED to have some means of stopping longitudinal movement, it needs something like shoulder straps (this is why quick clips have never sat well with me, unless you cross them over).

The CED, a much nicer KED, actually has shoulder straps.

All I'm asking is that if you're going to play the "near zero movement" game of spinal immobilization, Do It Right! All transverse and longitudinal movement needs to be stopped. No excuse to leave one or the other unsecured.


----------



## mycrofft (Nov 10, 2013)

DEmedic said:


> "If you are basing your claims on anecdotal experience, then any treatment will seem to work for anything and everything."
> —Steven Novella, MD
> 
> Next.



And if I ignore my professional personal experience (qualified observer) at the hands of _competent and thorough practitioners_ ( I am aware of their creds),  then I ignore and withhold what data I have to offer...versus the interminable discussions we get into here once in a while about which order to apply and tighten the straps and if color coding is good or not.

I've seen botched KED applications in true extrications. I've seen excellent applications when it wasn't in my opinion necessary. I'm just saying that I was KED'ed by someone who knew what they were doing and I darn well wasn't turning my head without fighting.

EDIT:
Here's a picture of a KED application:





It does not match my experience, in that I had "KED upside my head", whereas this guy barely has KED to his ears. Is this a new version or something? Maybe they applied mine higher up on me for some reason (I'm five-ten).


----------



## Anomalous (Nov 26, 2013)

I need help settling an argument.  How many straps are REQUIRED on a long spineboard?  Citing your source would be great!


----------



## Medic Tim (Nov 26, 2013)

Anomalous said:


> I need help settling an argument.  How many straps are REQUIRED on a long spineboard?  Citing your source would be great!



That would depend.

this smells of homework.


----------



## Anomalous (Nov 26, 2013)

Nope.  We use 8 or 9 straps now but some want to switch to spider straps and just trying to document our decision.


----------



## NomadicMedic (Nov 26, 2013)

Anomalous said:


> Nope.  We use 8 or 9 straps now but some want to switch to spider straps and just trying to document our decision.



8 or 9? Holy smoke. We use, at most, 5. (If we backboard at all... Which I seldom do)


----------



## Anomalous (Nov 26, 2013)

If I remember right, it all started with some study from Canada.  I think the name of the article was "Fit to be Tied" but I don't remember where or when it was published.


----------



## unleashedfury (Nov 26, 2013)

Anomalous said:


> Nope.  We use 8 or 9 straps now but some want to switch to spider straps and just trying to document our decision.



Spider straps are nice, secure your patient well. but they never seem too fold nicely back in position for storage.



DEmedic said:


> 8 or 9? Holy smoke. We use, at most, 5. (If we backboard at all... Which I seldom do)



I'm a huge advocate of selective C-Spine protocols. I've seem EMTs and Paramedics roll up to an accident and just have a patient who was up and walking around go and lie down on the Long back board. 

Protocol needs to catch up. this C-spine Long Board Immobilize all traumas, Grandma tripped over her carpet and bummed her knee. By protocol she needs to be C-spined and boarded, 

I took some heat the other day from the ER nurses cause I made the choice not to C-spine a fall victim. The guy fell trying to get out of bed, twisted his ankle. Which proved to be broken later, No LOC hell he just fell on his bum after he fell. Did he need c-spine NOPE

The research is here and shows hard evidence of C-spine not required in most instances. But we still have the old school practicioners who still do not welcome change.


----------



## Christopher (Nov 27, 2013)

Anomalous said:


> I need help settling an argument.  How many straps are REQUIRED on a long spineboard?  Citing your source would be great!



I don't have to cite any sources when I say this, "there is no known requirement for how many straps are required when using a long spine board."

Why? Because there isn't any decent literature to support any other statement.

You could reasonably state only that the minimum number of straps required may vary per patient, but something like 3 or 4 serves as a floor. However, this is only "expert" opinion and has no known basis in reality or fact

I would say if you do believe in the magical long spine board immobilization fairy (same evidence base as the Tooth Fairy, Santa Claus, or the Easter Bunny) that if 4 straps is good, 5 straps is better, 8 straps is amazing, and 9+ straps is clearly the best.

Are we suffocating them? Probably. But I'll be damned if I let their spine move even a millimeter! Wouldn't want to make a bunch of quads because I was scared of a little respiratory insufficiency.


----------

