# C-Collars On Their Way Out?



## Noodle (Mar 11, 2010)

> Applying a brace to the neck of a trauma patient, standard procedure for many decades, can worsen the injury and lead to severe paralysis or death, according to a new study by Houston researchers.



http://www.seattlepi.com/health/414631_Neck25.html

Every time I've seen a spinal immob, it seems impossible to apply the collar without moving the head. Doesn't that kind of defeat the purpose?


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## Aprz (Mar 11, 2010)

I think c-collars are made to _minimze_ movement in the head, but _preferably_ you don't want to move the head at all. I think the problem is that if you don't put on a c-collar on a pt., it is more likely the head is going to move a lot more than what it would have compared to as you're putting it on. So... it's like the lesser of two evils, you either move a lot (w/o c-collar), or you move a little (w/ c-collar), or hopefully you don't even need to move it at all when you put on a c-collar.


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## JPINFV (Mar 11, 2010)

Of course does anyone have a study that even begins to suggest that spinal immobilization protects against secondary spinal cord damage?


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## Aprz (Mar 11, 2010)

Spinal immobolization seems a little bit logical (like treating for shock/trendelenburg position) and also just another CYA method, but probably something under studied (like the trendelenburg position) , yeh?


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## Noodle (Mar 11, 2010)

I agree that c-collars help more than they hurt, but I was wondering if you guys might have any alternatives.

For example, with the big Ferno blocks, you can also wedge them between the patient's hips and the cot rail to keep the body from flopping around.

Nice to meet you all, by the way!


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## Lifeguards For Life (Mar 11, 2010)

Noodle said:


> http://www.seattlepi.com/health/414631_Neck25.html
> 
> Every time I've seen a spinal immob, it seems impossible to apply the collar without moving the head. Doesn't that kind of defeat the purpose?



The debate of risk versus benefit has been going on for some time. Attached is a brief summary detailing one study. There is another study that claims prehospital application of such devices were not applied correctly in most cases.



> The University of New Mexico (UNM) School of Medicine has an excellent Department of Emergency Medicine. In this study, one of their faculty members, Mark Hauswald, performed an interesting study. Dr. Hauswald retrospectively reviewed all cases of prehospital spinal immobilization brought to the UNM Medical Center over a five-year period. Then, these were compared with cases from a similar hospital in Malaysia for the same five-year period.
> 
> Interestingly, spinal immobilization is very rarely, if ever, used in Malaysia. In fact, most nurses and physicians in Malaysia could not recall ever seeing a patient with spinal immobilization applied. Surprisingly, the researchers found there was less neurological injury in the Malaysian patients (who were not immobilized) when compared with the patients in Albuquerque (who received state-of-the-art immobilization).
> 
> They concluded there was less than a 2% chance that prehospital spinal immobilization had any beneficial effect.


Hauswald M, Ong G, Tandberg D, et al: "Out-of-hospital spinal immobilization: Its effect on neurologic injury." Academic Emergency Medicine. 5(3):214–219, 1998.

http://www3.interscience.wiley.com/journal/120143495/abstract


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## lightsandsirens5 (Mar 11, 2010)

Excellent info lifeguard.

I have been taught that a person is their own best spinal immobilizer and the collar is an aid to both the pt and the board/headblocks. I would think, in theory at least, that is securing to a longboard is done properly, a collar is not really needed. It merely aids with getting the pt onto the board with minimal movement. 

I think there really needs to be a in-depth, long-term study of the benefits of full spinal immobilization.


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## JPINFV (Mar 11, 2010)

Aprz said:


> Spinal immobolization seems a little bit logical (like treating for shock/trendelenburg position) and also just another CYA method, but probably something under studied (like the trendelenburg position) , yeh?



Ah... Trendelenburg. Another fine medical myth.


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## Lifeguards For Life (Mar 11, 2010)

JPINFV said:


> Ah... Trendelenburg. Another fine medical myth.



this particular issue has long since been a favorite of mine, especially since it (among other "interventions") are still all but preached in schools across the U.S

http://www.aapsus.org/ajcm/2009/summer/pdf/ajcm-summer2009-trendelenburg.pdf

http://www.jems.com/news_and_articles/columns/Wesley/the_myth_of_the_trendelenburg_position.html

http://www.caep.ca/CMS/temp/pg48(1).pdf


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## terrible one (Mar 11, 2010)

JPINFV said:


> Of course does anyone have a study that even begins to suggest that spinal immobilization protects against secondary spinal cord damage?



I would love to see this as well. I fail to see much if any benefit from applying a C-Collar


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## Aprz (Mar 12, 2010)

Yeh, that's why I mentioned it.  I read the whole thing on these forums about the trendelenburg position and I figured that the c-collar could almost be in the same situation where not very much studies have gone into it, but it is still widely accepted. *shrugs*


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## Aidey (Mar 12, 2010)

What is really nuts is that people are so set in this idea of boarding and collaring every trauma patient they refuse to believe that it may not really help, and that in some patients it may hurt them more. 

Case in point. 18 yo girl crashes her ATV without a helmet on. Reported several minute LOC on scene. Dad loads her up into the back seat of the car with her boyfriend and drives to the nearest fire station, nearly an hour away. 

The fire station was a BLS station, and when the FFs contacted the patient she has a diminished LOC, was very combative, and wouldn't let anyone near her but her dad and boyfriend. They attempted to put on O2 and a c-collar and she freaked out. Per an EMT on scene she was yelling at them and "swatting" at them. She pulled on the c-collar and thrashed around, and yanked the O2 mask and then the cannula off and threw them. They took off the c-collar, and left her alone and she laid still in the boyfriend's lap. So they decided that since she is moving less they would just leave her alone and monitor her as best as they could while waiting for the ALS ambulance.

The medic on the ambulance FLIPPED OUT. Seriously flipped out. He is still furious about it. She ended up having a skull fracture, intracranial bleed and serious concussion, but no spinal cord injury. The medic can not be convinced that leaving the girl alone was the best thing they could do for her since she moved more when they tried to do anything. I've discussed it with him, and the fact that if she did have a spinal cord injury her moving would have made it much worse than lying still without a c-collar on. I've pointed out that agitating someone with a bleed jacks up their pulse and BP thus encouraging bleeding. 

He is still in the mindset that she was a serious trauma and she should have been immobilized immediately, damn the circumstances.


I personally am a fan of Canada's system, using the full body vacuum splints rather than a hard spine board. I feel they are much more versatile, comfortable, adaptable, and they actually mold to the patient offering some support and stabilization. That crap we do on the long spine board with 4 straps is NOT stabilizing at all.


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## CAOX3 (Mar 12, 2010)

Aidey said:


> What is really nuts is that people are so set in this idea of boarding and collaring every trauma patient they refuse to believe that it may not really help, and that in some patients it may hurt them more.
> .




It isn't about what I believe, its about what my medical director assumes responsibility for.  

Its his job to stay current on evidence based medicine and publish his treatment guidelines to echo those findings.  We operate under his lic.  he makes the rules, he wants me to immobilize every patient I come in contact with thats his decision regardless of my beliefs and opinions.

I agree with you completely, however you doc better be on board with your decision especially in such an extreme example you presented, because if he isnt you will be the one blowing in the wind to catch the poop storm thats a coming.


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## viccitylifeguard (Mar 12, 2010)

i was told in class that  97% of the people we board  and collar are  put through unessary discomfort and procedures.  the only other thing i was told was  the  c-collar  is not for immobalization but only a reminder not to more  your  head .
makes  sence  to me   since  any  semi consious person can more  there head easily  
just my thoughts


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## firetender (Mar 12, 2010)

I'm not clear if this thread is about soft or hard C-collars, boarding and immobilizing the head/neck or full spinal immobilization, so I'll comment on most.

I don't even know if soft C-collars (maybe with a "rib" of flat plastic) are in use anymore, but when they were, we called them "reminders". The rigid, adjustables were second-generation reminders, but very limited and easy to cause more damage for the truly injured patient because of it really only being a half-step and with much adjustment needed to seat well.

As far as immobilization goes, the name of the game is cause no further harm. Translated in real terms, if the patient arrives at the hospital, is not immobilized and is found to have a spinal fracture, YOU, Sir or Madam, are screwed! I don't know that there is much choice with this one.

Yet, what the study shows is...and I'm picturing here...a Malaysian is knocking coconuts off a tree, he loses his grip, falls, lands on his head, hyperflexing his neck and loses sensation and movement below his shoulders. One of his Buddies grabs his arms, the other his legs, and head flopping, they run him to a truck, throw him in the back and speed off to the hospital. This guy does better than our guys who we fully immobilize?

He does and I'll tell you why; In the process of immobilization, untrained/unpracticed Responders while trying to immobilize, rearrange much more than the patient's body can handle. 

Spinal immobilization (an EMT function, by the way), is an art. It takes a tremendous amount of practice under many different circumstances. *The idea is to produce as little movement as possible WHILE you are moving, positioning and supporting the person and putting them into an anatomically balanced package where NOTHING moves. 

And the hardest part, if you think about it, is getting every one around you to slow down and coordinate.* 

In an ideal world, somebody would develop a "Cocoon Spray"! 

My point is, there IS a way (or many ways) to do that, but so often speed and expediency take the place of meticulous action. And that's what it takes; slow, deliberate, well-planned (without being micro-managed), and technically precise actions, coordinated with others *IF it is clear ONE person is Director* or alone if you get an inkling that your "help" are more likely to harm your patient.

It's all about "Proper" immobilization, which means a highly technique sensitive approach to all aspects of immediate intervention. This is not something you practice a couple times in class before testing. This is something worth mastering, and it's also fun to do with others, taking turns, twisting bodies and really, really evaluating. Six people, in pairs and triads with a seventh as Coach/Observer (alternating) in a room with a lot of junk (and rescue equipment and NO equipment) makes a very pleasurable afternoon.


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## firetender (Mar 12, 2010)

*Hippocrates Replies*

I'm not clear if this thread is about soft or hard C-collars, boarding and immobilizing the head/neck or full spinal immobilization, so I'll comment on most.

I don't even know if soft C-collars (maybe with a "rib" of flat plastic) are in use anymore, but when they were, we called them "reminders". The rigid, adjustables were second-generation reminders, but very limited and easy to cause more damage for the truly injured patient because of it really only being a half-step and with much adjustment needed to seat well.

As far as immobilization goes, the name of the game is cause no further harm. Translated in real terms, if the patient arrives at the hospital, is not immobilized and is found to have a spinal fracture, YOU, Sir or Madam, are screwed! I don't know that there is much choice with this one.

Yet, what the study shows is...and I'm picturing here...a Malaysian is knocking coconuts off a tree, he loses his grip, falls, lands on his head, hyperflexing his neck and loses sensation and movement below his shoulders. One of his Buddies grabs his arms, the other his legs, and head flopping, they run him to a truck, throw him in the back and speed off to the hospital. This guy does better than our guys who we fully immobilize?

He does and I'll tell you why; In the process of immobilization, untrained/unpracticed Responders while trying to immobilize, rearrange much more than the patient's body can handle. 

Spinal immobilization (an EMT function, by the way), is an art. It takes a tremendous amount of practice under many different circumstances. *The idea is to produce as little movement as possible WHILE you are moving, positioning and supporting the person and putting them into an anatomically balanced package where NOTHING moves. 

And the hardest part, if you think about it, is getting every one around you to slow down and coordinate.* 

In an ideal world, somebody would develop a "Cocoon Spray"! 

My point is, there IS a way (or many ways) to do that, but so often speed and expediency take the place of meticulous action. And that's what it takes; slow, deliberate, well-planned (without being micro-managed), and technically precise actions, coordinated with others *IF it is clear ONE person is Director* or alone if you get an inkling that your "help" are more likely to harm your patient.

It's all about "Proper" immobilization, which means a highly technique sensitive approach to all aspects of immediate intervention. This is not something you practice a couple times in class before testing. This is something worth mastering, and it's also fun to do with others, taking turns, twisting bodies and really, really evaluating. Six people, in pairs and triads with a seventh as Coach/Observer (alternating) in a room with a lot of junk (and rescue equipment and NO equipment) makes a very pleasurable afternoon.


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## JPINFV (Mar 12, 2010)

firetender said:


> As far as immobilization goes, the name of the game is cause no further harm. Translated in real terms, if the patient arrives at the hospital, is not immobilized and is found to have a spinal fracture, YOU, Sir or Madam, are screwed! I don't know that there is much choice with this one.


So we shouldn't follow things like NEXUS because the person in the 10 mph simple rear end traffic accident might possibly have a spinal fracture despite displaying absolutely no clinical indication of a spinal fracture? 



> Yet, what the study shows is...and I'm picturing here...a Malaysian is knocking coconuts off a tree, he loses his grip, falls, lands on his head, hyperflexing his neck and loses sensation and movement below his shoulders. One of his Buddies grabs his arms, the other his legs, and head flopping, they run him to a truck, throw him in the back and speed off to the hospital. This guy does better than our guys who we fully immobilize?


According to one study, yes he does better or just as well as patients who are immobilized. In cases like that, the damage is done and spinal immobilization isn't going to change or reverse that. Immobilization does not prevent or treat primary spinal cord injury and there's zero evidence that it protects against secondary spinal cord injury. After all, there's a reason why you sleep on a mattress at home and not a piece of plywood. However, EMS seems to think that the natural spinal position is flat. 



> Spinal immobilization (an EMT function, by the way), is an art. It takes a tremendous amount of practice under many different circumstances. *The idea is to produce as little movement as possible WHILE you are moving, positioning and supporting the person and putting them into an anatomically balanced package where NOTHING moves. *


*
How do you plan on making it so that nothing moves when the object immobilizing the majority of the body isn't contoured to shape the natural curves? The only possible way is by tightening down the straps which will cause motion in the spine as the spine flattens out.*


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## firetender (Mar 12, 2010)

JPINFV said:


> How do you plan on making it so that nothing moves when the object immobilizing the majority of the body isn't contoured to shape the natural curves? *The only possible way *is by tightening down the straps which will cause motion in the spine as the spine flattens out.



I suppose this is my very point. Work it, work it again and again and you'll find many ways to do the job. This is where simple scenario practice is invaluable. 

You use towels, pillows, clothes, sheets, (what ever happened to sand bags?); anything you can fold and mold to stabilize the gaps and support the body in position. If common sense tells you the equipment you're given is not quite up to the task, prepare yourself to figure out your own "supplements" to make it work and make sure you have them on board.


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## firetender (Mar 12, 2010)

JPINFV said:


> So we shouldn't follow things like NEXUS because the person in the 10 mph simple rear end traffic accident might possibly have a spinal fracture despite displaying absolutely no clinical indication of a spinal fracture?



Well, to medics oriented toward worrying about their liability in the field (of whom there are many here on this site), NEXUS (under the  circumstances of the incident) may not appear adequate for their comfort.  

(I try not to say "shouldn't" to anything, to avoid having a shouldy attitude.)


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## JPINFV (Mar 12, 2010)

firetender said:


> Well, to medics oriented toward worrying about their liability in the field (of whom there are many here on this site), NEXUS (under the  circumstances of the incident) may not appear adequate for their comfort.
> 
> (I try not to say "shouldn't" to anything, to avoid having a shouldy attitude.)



So why is it that paramedics are more concerned about liability than physicians in the ER?


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## firetender (Mar 13, 2010)

JPINFV said:


> So why is it that paramedics are more concerned about liability than physicians in the ER?



I never was, myself, but I hear that concern run through a lot of threads here.


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## reaper (Mar 13, 2010)

firetender said:


> I never was, myself, but I hear that concern run through a lot of threads here.



 I see it from a lot of new people. I think these schools are trying to scare them with it. I do my job, the way it needs to be done. I never even think about being sued. Haven't had to worry in 20 years, not gonna start now.


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## Veneficus (Mar 13, 2010)

Spinal immobilization. It seems I have written volumes on it.

Where to start, how about with the injury itself? A force great enough to disrupt the Lamina or pedicle of a vertebrae causing partial transection of the cord is not going to have the damage mitigated by immobilizing somebody.

Different parts of a vertebrae can be fractured. A fracture of a spinous or transverse process is not going to pose a threat to the CNS. There is extensive musculature and other structures that stabilize a spine.

Complete disruption of all the structures protecting the spine would be very obvious and most likely not compatible with life.  (my law of anatomy is the deeper in the body, the more important the structure) Even major blood vessels are superficial to the cord. 

A blunt impact that could destroy a lamina or pedicle which would cause secondary cord injury would have to be a force great enough to not be absorbed through all the preceding layers of the body. It is these layers that I would like to talk about for a moment.

As a normal reaction to injury, swelling takes place. The aforementioned musculature and other structures surrounding the spine that is damaged is not immune to this phenomenon. While this musculature (including ligaments) does not contact the cord directly, it does restrict the compartment the spine is in. It is this compartment restriction that occludes the anterior and posterior spinal arteries and their predecessors, effectively shutting off circulation to the cord. 

The ganglia and relatively more superficial arteries outside of the cord can be impacted in addition to sympathetic trucks outside the cord proper all causing nervous deficits.

Along comes the long spine board. A wonderful extrication device, not so useful as an immobilization device. Taking an “S” shaped spine, and putting it on a flat board creates pressure points. (Anyone who has ever slept on a mattress  can tell you the effect of these pressure points) The pressure exerted on focal parts of the spinal column causes distribution of such across the whole, reducing the body’s natural protections and increasing spinal displacement. Especially when the supporting structures are already damaged. The idea a board will help defies the laws of physics. 

How significant is this compression? It depends on the injury. On several occasions I have seen patients decompensate when a spine board was removed in the trauma bay. A treatment popular in Germany is to pack the retroperitoneal space to create compression to stop and intraperitoneal bleed. Could that direct pressure be externally produce by the weight of the body against the surface of a board?  If so it stands to reason the board can create enough pressure to occlude major vessels. Might be good to stop bleeding, certainly not good for the spine. There is considerable literature devoted to cutaneous effects of spine board compression. 

Those hospital people couldn't be very smart if a board actually worked, they never use a board. Have you ever seen a patient laying in a neuro intensive care unit on a spine board? How about on a trauma ward? Why is there criteria for removing a board in as little as 10 minutes of arrival to the ED?

Does “do no harm” only apply when it doesn’t upset an EMS tradition? Why do new procedures or techniques require a higher level of evidence than old ones? That is another thread.

The c-collar. A device designed to limit flexion and reduce vertical compression of the cervical spine.  That was all it was ever supposed to do. It assumes the patient fits snuggly into it. Rarely the case in the cheap ones used Prehospital. Look at all the adjustments and padding included with a Miami J collar patients are discharged in.

Doing things on the cheap. All over the world the spine board is only used as an extrication device. The giant vacuum mattresses for immobilization. It is time consuming and expensive. But it is better for the patient. A flat board that doesn’t work is better for EMS system budgets and requires less care and training. It can be abandoned at the hospital to go back in service instead of waiting for it to be removed. Especially useful when you have less units than call volume. 

Sadly, the fallacy of the spine board will persist. Perpetuated by people who lack the male anatomy to stand up and say “enough” and those who boarding people makes them feel like they are doing something positive.


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## mycrofft (Mar 13, 2010)

*Search. NHTSA invented EMT's (A and P types) to protect spines.*

Since EMT's were invented by DOT to address MVA's, it is a cultural bias leaning on spinal immobilization by the means most cost-effective to disseminate swiftly at the turn of the Sixties-Seventies. This still leads to blind rote application of boards etc. Immob is see as a treatment and not as a packaging to extricate and transport.

C collars, spine boards, Trendelenberg...tourniquets....CPR...do them unthinkingly and without considering the pt at hand, and you can do damage. THINK. Thoughtfully challenge old protocols. Be an "informed data consuimer", watch out for sensational studies whose main bent is to attract readers and maybe grant money.

PS: Case in point, if you  boarded me and placed me supine my airway would shut off. Many people including myself would ave to battle claustrophobia when strapped down, and strapping too tight itself can cause asphyxia. Use your tools, and use them wisely and with constant feedback.


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## Buzz (Mar 13, 2010)

I was chewed out by an ER doc relatively recently for boarding and collaring a patient that he felt didn't really need the backboard. Unwitnessed fall, dementiated patient didn't remember falling, and she was complaining of pain in her arm (there was swelling, but we couldn't determine if there was deformity). Based on protocol, we boarded her. We taped a folded blanket down to the board to try and make it a bit more comfortable. After I finished writing my report, the nurse let me know the doctor wanted to talk to us. He wanted to rant at (to?) us about torturing old ladies and unnecessarily back boarding people. We ended up giving the only explanation we had; it's our protocol--it doesn't matter what we think about it. He did bring up some pretty good points, though I wish he'd had a more personable way of conveying it.


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## Shishkabob (Mar 13, 2010)

Here's what I don't like about this debate:  You can't prove the opposite of what has already happened.  You'll hear opponents of C-collar/spinal RESTRICTION state "Show me a study that proves it's effectiveness".. you simply can't prove something would have happened if done differently.


I personally saw someone brought in, full restriction, after an MVC, complaining of neck and back pain.  Fx of C5, T7 and L1.  Can we prove that putting him on the backboard kept his peripherals neurologically intact?  No.   But there's also no evidence to the contrary.



If backboards _are_ linked to an increase in morbidity/mortality/increased injury, then we need to figure out why, and correct that, do we not?  Why throw something out as being useless having only PART of the information needed to determine what's best?



I don't have a personal view on this yet, but personally, if I'm complaining of neck and back pain I'd prefer to be restricted until deemed safe.


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## Aidey (Mar 13, 2010)

JPINFV said:


> However, EMS seems to think that the natural spinal position is flat.



No kidding. I really need to find a good diagram of the spine and why the pt putting their knees up is not going to compromise their spine, and is probably going to help. That way I can show it to the FFs on scene and they will stop arguing with the poor uncomfortable patients.

I'm a small person, and lying with my legs flat over arches _my_ lumbar spine, let alone someone who is carrying extra weight in their butt and hips.


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## Shishkabob (Mar 13, 2010)

Whatever happened to the foam mat that people were touting a while ago?


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## JPINFV (Mar 13, 2010)

Linuss said:


> Here's what I don't like about this debate:  You can't prove the opposite of what has already happened.  You'll hear opponents of C-collar/spinal RESTRICTION state "Show me a study that proves it's effectiveness".. you simply can't prove something would have happened if done differently.



Yes, in an individual patient, you can't. That's why studies don't use just one person to make a determination. That take a lot of people, divide them up into a treatment group and a control group, match subjects based on several criteria and control for variables that can't be matched, and then compare the outcomes as a group. If you just think of studying individual subjects, then most research is impossible and we're back to junk like homeopathy.


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## Veneficus (Mar 13, 2010)

Linuss said:


> Here's what I don't like about this debate:  You can't prove the opposite of what has already happened.  You'll hear opponents of C-collar/spinal RESTRICTION state "Show me a study that proves it's effectiveness".. you simply can't prove something would have happened if done differently.





Hauswald M, Ong G, Tandberg D, et al: "Out-of-hospital spinal immobilization: Its effect on neurologic injury." Academic Emergency Medicine. 5(3):214–219, 1998. 


http://www.jems.com/news_and_articles/columns/Bledsoe/bledsoe_top_10_ems_studies.html

"Interestingly, spinal immobilization is very rarely, if ever, used in Malaysia. In fact, most nurses and physicians in Malaysia could not recall ever seeing a patient with spinal immobilization applied. *Surprisingly, the researchers found there was less neurological injury in the Malaysian patients (who were not immobilized)* when compared with the patients in Albuquerque (who received state-of-the-art immobilization)."  




Linuss said:


> I personally saw someone brought in, full restriction, after an MVC, complaining of neck and back pain.  Fx of C5, T7 and L1.  Can we prove that putting him on the backboard kept his peripherals neurologically intact?  No.   But there's also no evidence to the contrary..



Did this patient receive any treatment for these injuries? If so, what? were they taken to surgery? discharged? Externally fixated or splinted? What kind of fracture was it? Was it effectively self splinted? Was it an unstable fracture? While it sounds impressive to have occult fx found, doesn't mean there is significant risk of secondary injury. What was the damage to the surrounding tissue like? Significant swelling? Necrosis? Disruption? None visible on CT? Was an MRI even performed? 



Linuss said:


> If backboards _are_ linked to an increase in morbidity/mortality/increased injury, then we need to figure out why, and correct that, do we not?  Why throw something out as being useless having only PART of the information needed to determine what's best?



Flat board, contoured body. Most babies have a toy so they can learn the square block doesn't fit in the round hole. Why can't EMS "professionals" accept the human body doesn't fit well on a flat surface?

Generally the body responds to painful stimuli be retracting away from it. Pain is a response to cellular injury. So if being on a board is "painful" the natural response to withdraw. Is it simply tough love that they are forced to it? That is the same logic as "I only hit you because I love you." The risk/benefit equation was lost when everyone started getting immobilized instead of the very few people that it _might_. have any benefit for.



Linuss said:


> I don't have a personal view on this yet, but personally, if I'm complaining of neck and back pain I'd prefer to be restricted until deemed safe.



What if restrictng you would do harm or increase the complications of your injuries? What if you restrict swelling and create hypoxia in neural tissue that is not only extremely sensitive to it, but may not recover from it? Why risk creating a compartment syndrome in a compartment that contains your CNS?

Consider the difference in CNS damage compared to PNS damage and regeneration. Microglial phagocytosis actually inhibits regeneration of the CNS.


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## Shishkabob (Mar 13, 2010)

Ok, are we talking restriction here, or backboards?  I know that the spine is curved, I'm not saying that a flat board is the best / a good restriction device... ever.  I'm saying we need to find ways to minimize movement, hence 'restriction', correct?  



> Did this patient receive any treatment for these injuries? If so, what? were they taken to surgery? discharged? Externally fixated or splinted? What kind of fracture was it? Was it effectively self splinted? Was it an unstable fracture? While it sounds impressive to have occult fx found, doesn't mean there is significant risk of secondary injury. What was the damage to the surrounding tissue like? Significant swelling? Necrosis? Disruption? None visible on CT? Was an MRI even performed?



Pt was flown the Parkland (level 1 trauma) when I was there.  Pt complained of slight tingling in both legs, but still had motion and sensation. Swelling around T and L. Spoke with doctor the next shift I was there, stated that surgery was performed on the Tspine andLTspine fractures.  Therapeutic hypothermia was initiated at the hospital I was at. 



I have read the Malaysian report a bunch of times already, as it is brought up in every single one of these threads.  Until a much more comprehensive, and controlled, study comes out, there will always be debate.  If doctors can't even agree on the facts, how does anyone expect a decision to be made?  But as you know, using Americans as guinea pigs doesn't sit too well for prospective patients...





> What if restrictng you would do harm or increase the complications of your injuries? What if you restrict swelling and create hypoxia in neural tissue that is not only extremely sensitive to it, but may not recover from it? Why risk creating a compartment syndrome in a compartment that contains your CNS?



And what if it causes more good then harm? Again, you can't prove what hasn't been done.  

Doesn't matter anyhow... I have horrible luck and I'll end up getting paralyzed no matter what choice I make :blush:


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## JPINFV (Mar 13, 2010)

Linuss said:


> I'm saying we need to find ways to minimize movement, hence 'restriction', correct?


...but that's the issue. Do we need to find some way to minimize restriction to begin with? A priori, yes. Of course A priori trendelenburg works and massive fluid resuscitation in trauma patients works as well. We need to determine if there is any benefit at all and I propose that as long as the only indication for spinal immobilization is "trauma" we won't. To use an example, it's like trying to determine if Narcan works if you only studied patients receiving a coma cocktail. Unfortunately, if we can't get field providers to buy into not immobilizing everyone (because, regardless of the protocols, if a provider doesn't buy into it they won't implement it), then there will never be a proven benefit because the number of patients who do not need immobilization will crowd out the few who *might* benefit. Even still, there has to be a better way to immobilize than an unpadded or makeshift padded board. A few blankets over a piece of plywood is more comfortable than plywood alone, but I'm willing to bet that you still wouldn't want to sleep on it. 



> Doesn't matter anyhow... I have horrible luck and I'll end up getting paralyzed no matter what choice I make :blush:



From my understanding of trauma, it's luck to go the other way around. It's a narrow window of force to break the vertebral column and not hurt the spinal cord. Take a pencil. Now break the wood of the pencil without damaging the graphite core. That window of force is what spinal immobilization is truly concerned about.


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## Veneficus (Mar 13, 2010)

The problem is that most EMS systems across the US regard the spineboard as an adequete immobilization device.

My point is that the known anatomy, physiology, and pathophysiology of vertebrae and the spine minimize the benefit of spinal immbolization. It seems logical to me that if actual immobilization (as an example by the use of a full body vacuum splint) is minimally effective, then the logical conclusion is that ineffective immobilization (a spineboard) does nothing or is iatrogenic. (of which there is a growing body of evidence)

I conceed that part of that may come from over use of spinal immobilization protocols. Which is directly the fault of medical direction not the field provider. (aka backboarding) But the incidence of spinal injury in EMS education is grossly overstated. The environment of fear of not immobilizing somebody is counter productive to sound clinical judgement and as an extension good medical practice. 



Linuss said:


> I have read the Malaysian report a bunch of times already, as it is brought up in every single one of these threads.  Until a much more comprehensive, and controlled, study comes out, there will always be debate.  If doctors can't even agree on the facts, how does anyone expect a decision to be made?  But as you know, using Americans as guinea pigs doesn't sit too well for prospective patients...:



The reason that study keeps coming up is because it is likely the only one that will ever hae a control group of no spinal immobilization. Having a control group lends considerable weight to any experiment. 




Linuss said:


> And what if it causes more good then harm? Again, you can't prove what hasn't been done.



The same could be said for many medical treatments both in EMS and in medicine in general. But I take issue with the fact that new practices and procedures have to demonstrate benefit to be adopted and old procedures are not held to the same level of scrutiny. Especially when the current level of medical knowledge demonstrates flaws in the theories which led to those treatments. 

Demonstrating flaws in the theories of ingrained practices may be the only evidence we ever have to justify the initiation or discontinuation of specific practices. 



Linuss said:


> Doesn't matter anyhow... I have horrible luck and I'll end up getting paralyzed no matter what choice I make :blush:



You and me both.


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## Shishkabob (Mar 13, 2010)

> Even still, there has to be a better way to immobilize than an unpadded or makeshift padded board




We're all in agreement then... problem is how do we get to a better way? 


Another thing is, how do we know that any/all patients who were peripherally intact on arrival, and degraded later, weren't caused by the hospital movement as well.. much like the possibility of esophageal intubation?


I need to go to bed... I'm getting sick.  That's what I get for sufficing off McDonalds fries and tequila for the past week.


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## Veneficus (Mar 13, 2010)

Linuss said:


> We're all in agreement then... problem is how do we get to a better way?



stop perpetuating fear and myth.




Linuss said:


> Another thing is, how do we know that any/all patients who were peripherally intact on arrival, and degraded later, weren't caused by the hospital movement as well?  Why are inadvertent spinal injures blamed on us, just like inadvertent esophageal intubation?



One better: How do we know that the reason the pt was intact and later impaired wasn't because of evolving injury over time?

If the current popular theory of cord injury secondary to infammatory response is correct, EMS immobilization may have absolutely no effect on the progression to disability. (though as I stated, based on my observations I think the spineboard may be accelerating the progression) 





Linuss said:


> I need to go to bed... I'm getting sick.  That's what I get for sufficing off McDonalds fries and tequila for the past week.



The breakfast of champions.


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## Lifeguards For Life (Mar 13, 2010)

Linuss said:


> I need to go to bed... I'm getting sick.  That's what I get for sufficing off McDonalds fries and tequila for the past week.



you enjoyed Panama City then?


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## Two-Timer (Mar 15, 2010)

There seem to be two points yet to be addressed in this thread (or maybe I missed them reading through.)

First, selection of patients for boarding can be as much a factor as the boarding itself. One system in my area utilizes a process allowing c-spine clearance at all levels from EMT-B to Medic. Numbers of boardings has declined while no increase in negative patient outcomes has occurrred and far fewer patients suffer from the boarding's collateral damage. This was done through a protocol so Medical Control drives and monitors the change.

Second, the Malaysian study does not allow patient to "flop all over" but presumes manual stabilization where one rescuer devotes full attention to spinal stabilization throughout transport. That is likely the key difference- too often people put patient's on a board, breath a sigh of relief and move on to other things thinking the problem of spinal immobilization is solved. The patients body, however, can still move about applying forces to the spine. It is the illusion that c-collars and boards provide true immobilization that leads to injury.  I have used vacumn blankets a great deal and while they are much better than boards, neither is as good as an attentive care provider.


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## downunderwunda (Mar 15, 2010)

Two-Timer said:


> One system in my area utilizes a process allowing c-spine clearance at all levels from EMT-B to Medic. Numbers of boardings has declined while no increase in negative patient outcomes has occurrred and far fewer patients suffer from the boarding's collateral damage. This was done through a protocol so Medical Control drives and monitors the change.



Full marks to this area for forward, progressive thinking.



Two-Timer said:


> It is the illusion that c-collars and boards provide true immobilization that leads to injury.



C-Collars provide up to 35% reduction in movment. Extrication deviceds such as the KED will increase that to about 95%. Back boards are an axtrication device, not for the patient to be strapped to & left on for all eternity. We need to move past the mentality that a C-collar & back board are enough for spinal immobilisation. If the person is genuinly spinal damagaed, then they need what i have mentioned above, and rapid transport to a trauma centre & spinal unit.


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## Two-Timer (Mar 15, 2010)

Absolutely- boards are extrication devices. A further complication with managing the spine injured patient in our area is transport time. It is not unusual to have the closest hospital up to 45 minutes removed from the incident.  We have to go to the closest hospital where further diagnoses occurs. A facility capable of actually treating a spinal injury is a minimum of another hour of transport. This translates into a spine-injured patient being in need of immobilization at least 2 hours before definitive care. No wonder boards create problems of their own. We have to find a better way. (If nothing else a good Protocol for by-passing spine injuries in a manner similar to what we do for STEMI's.)

While I have had good success with vacumn blankets, I have also found that they can become obstacles in the treatment of multi-system trauma. Probably 25% of the time a leak develops somewhere and a lot of the time they are deflated during the initial work-up at the first hospital the patient arrives at. Is there a segmented, or compartmentalized blanket out there?


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## MedicSparky (Mar 15, 2010)

I may be misunderstanding someone, perhaps when "padded boards" were mentioned this is what was meant.

In school I was taught that you fill any void space between the pt and the board. This may not be the best possible practice for stabilizing spines/preventing further injury, but I can see this providing somewhat more stabilization than a plain board with void spaces.

A thought I had was perhaps a thinish memory foam layer over a hard board. This would conform to the pt's spine, while providing a solid structure to keep the whole thing from bending. 

While we probably cannot forgo stabilization for legal issues, we can still experiment with new ideas. I think the best way to continue here is discuss new ideas, speak to our Med Directors, and eventually try to experiment with these new possibilities.


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## JPINFV (Mar 15, 2010)

MedicSparky said:


> While we probably cannot forgo stabilization for legal issues,


Really? There's a law that states that you must immobilize trauma patients?


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## MedicSparky (Mar 15, 2010)

JPINFV said:


> Really? There's a law that states that you must immobilize trauma patients?



No, but it's easier for a lawyer to say "My client would be able to walk now if you'd have stabilized him," as opposed to "My client would be able to walk now if you hadn't stabilized him." It makes more sense to a jury and to expert witnesses that stabilization prevents injury.


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## JPINFV (Mar 15, 2010)

...and the defense expert goes, "There is absolutely zero evidence that spinal immobilization would have changed the outcome." Additionally, the evidence for selective spinal immobilization is more than adequate to implement in any system that trusts their prehosptial providers.

Also, that's a liability problem, not a legal problem.


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## MedicSparky (Mar 15, 2010)

JPINFV said:


> Also, that's a liability problem, not a legal problem.



Good point ^^

For purposes of self interest of all people involved in the EMS process it's much easier to establish that stabilization works and therefore it is used. The evidence for selective stabilization is mostly anecdotal. The issue is that it is better to err on the side of caution and make sure that some one isn't hurt due to negligence.


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## JPINFV (Mar 15, 2010)

MedicSparky said:


> The evidence for selective stabilization is mostly anecdotal.


Err... which journals are you looking at? 

Spinal immobilization: Recommendation: C ("There is poor evidence to support procedure or treatment")
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal Immobilization

Selective spinal immobilization: Recommendation: B ("There is fair evidence to support procedure or treatment")

http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=213


The problem with spinal immobilization is that it has never been established to work where as there are at least 2 heavily researched protocols (National Emergency X-ray Utilization Study (NEXUS) criteria and Canadian C-Spine criteria) that have been shown to be useful for clinically clearing patients of spinal injury.


Final edit: Good summary on the difference between NEXUS and Canadian C-Spine:
http://www.aafp.org/afp/2006/0515/p1787.html


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## MedicSparky (Mar 15, 2010)

Its anecdotal because there's no way to know if the pt was injured before their trauma, no way to know the extent of the injury after the incident/before the intervention, and there's no way to measure how stable the pt was during moving to the spine board. 

To measure these things we would need to do a full battery of tests on a pt's head/neck/spine, subject them to injury, test them again without moving them, then test them during or after a move.

A study isn't a scientific test, it's a group of anecdotal cases and can be skewed by selective sampling. As well a study will not show anything close to fact is the sample size is not large enough and not varied enough. Studies are all well and good, but we need to remember there are a lot of variables in every trauma. Without inhumane human testing we'll never be able to conduct a truly scientific test of spinal stabilization. We should pay close heed to the studies available, but we should also remember that there are other possible explanations. The difference between scientific test with study -can- be used in a court against you for negligence charges or a lawsuit.


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## JPINFV (Mar 15, 2010)

Methinks someone needs to look up what a case control and a cohort study is. 

Similarly, are you arguing that unless the physician clears all trauma patients radiologically, that he has committed malpractice? Additionally, yes, scientific studies can very well be used in a court of law. Otherwise the practice of medicine would never change because once a standard of care is set it would never be changed out of fear of liability. 

Quick question. If spinal immobilization was introduced today as a new intervention, would you use it despite no evidence that it works?


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## MedicSparky (Mar 15, 2010)

A physician clearing someone isn't malpractice if done with current acceptable procedures for determining their injury. 

A scientific study can be used in a court of law, and I never said otherwise.  



> The difference between scientific test with study -can- be used in a court against you for negligence charges or a lawsuit.



This means that if you make a determination not to implement a procedure that could help someone, or to implement a possibly dangerous procedure, based on a study a lawyer can easily get you arguing that a study contains many variables. The studies saying that spinal immobilization may be unnecessary cannot know how the pt's spine was before the incident, before the intervention, and how much it moved during transport. A good lawyer would say spinal immobilization was used for decades, these studies do not eliminate all variables, and there is a chance that the pt would have retained full pms with immobilization. 



> If spinal immobilization was introduced today as a new intervention, would you use it despite no evidence that it works?



I will do what Med Control tells me to do, and everything I feel will benefit my patient. It makes sense that when moving anyone with a possible head/neck/spine injury that you want to reduce the further movement of an injured area. Logically a spinal board is better than nothing. What we need now is -not- to keep arguing this on a forum full of people without command decisions. Leave the decision to the Medical Directors in your area. Make your own personal opinion; perhaps come up with ideas for replacing boards if you believe that boards are useful, but need to be changed.


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## JPINFV (Mar 15, 2010)

MedicSparky said:


> A physician clearing someone isn't malpractice if done with current acceptable procedures for determining their injury.



Now I'm confused. You earlier said that selective spinal immobilization is just anecdotal, yet there is significant amount of evidence that this can be safely done by EMS. Why would a prehospital provider face more liability that a physician for utilizing them to prevent unnecessary immobilization? 



> This means that if you make a determination not to implement a procedure that could help someone, or to implement a possibly dangerous procedure, based on a study a lawyer can easily get you arguing that a study contains many variables.


You do know that there are plenty of services and even entire states that utilize selective spinal immobilization? Additionally, you do know that spinal immobilization is not a completely benign intervention?



> I will do what Med Control tells me to do, and everything I feel will benefit my patient. It makes sense that when moving anyone with a possible head/neck/spine injury that you want to reduce the further movement of an injured area. Logically a spinal board is better than nothing. What we need now is -not- to keep arguing this on a forum full of people without command decisions. Leave the decision to the Medical Directors in your area. Make your own personal opinion; perhaps come up with ideas for replacing boards if you believe that boards are useful, but need to be changed.



Of course the last defense I'd want to use in court is the Nuremberg defense. In the end, we all have command decisions over our own actions because no one can force us to do, or not do, an intervention. 

Also, logically a lot of things don't work. Logically, it makes sense to put a lot of fluids into a trauma patient who is bleeding out, yet most systems now practice therapeutic hypotension. Logically, Trendelenburg works, yet there is no evidence that supports its use.


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## CAOX3 (Mar 15, 2010)

MedicSparky said:


> I will do what Med Control tells me to do



Agreed.  We can discuss this until we are blue in the face,  the fact still remains they make the decision.


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## JPINFV (Mar 15, 2010)

Also, even if the medical director makes the final decision, you can still open a dialogue to see why some procedures aren't available. Who knows, maybe the reason why there is no selective spinal immobilization protocol available is because no one has asked for it. NEXUS doesn't require anything more than the application of exam points you should already be looking for.


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## MS Medic (Mar 15, 2010)

Downunderwunda stole my thunda . I was about to post on the KED when I got an out of town IFT. When I came back, he beat me to it. I use the KED on a regular basis and proper aplication reduces many of the movement issues during extrication that were brought up. (Not to mention, that is the national standard of care for medical extrication.) 



Aidey said:


> No kidding. I really need to find a good diagram of the spine and why the pt putting their knees up is not going to compromise their spine, and is probably going to help. That way I can show it to the FFs on scene and they will stop arguing with the poor uncomfortable patients.
> 
> I'm a small person, and lying with my legs flat over arches _my_ lumbar spine, let alone someone who is carrying extra weight in their butt and hips.



I find the KED is also good for this problem. Since the spinal column ends at the sacrum, you can place the person in a KED and then sit them upright in the stretcher and still maintain proper spinal precautions.



MedicSparky said:


> Its anecdotal because there's no way to know if the pt was injured before their trauma, no way to know the extent of the injury after the incident/before the intervention, and there's no way to measure how stable the pt was during moving to the spine board.
> 
> To measure these things we would need to do a full battery of tests on a pt's head/neck/spine, subject them to injury, test them again without moving them, then test them during or after a move.



Anyone in the fields of sports medicine, trauma surgery, bio-mechanics will tell you that traumatic insult to the spinal column only occures when mechanism forces it beyond normal range of motion. If insults occures before treatment occures, there is nothing we can do in the field to make it any better. Likewise, there is not alot we can do that will make it worse IF we keep the pt from moving beyond normal range of motion. One of the safest extrication techniques I've seen involve completely removing a car roof and then creating a harness with a blanket and lifting the pt straight up, then secure them on a stretcher. I've also taken plenty of pts to the LVL 1 trauma center and the first thing they do is remove the peson from the board and perform NEXUS. Then the pt will sit in a bed with the large soft collar and wait sometimes quite a while before x-ray.

With that said, as long as you follow your local protocols and act in the best intrest of the pt, performing a through neuro exam and Hx of recent events, then using NEXUS is will protect you in court.


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## CAOX3 (Mar 15, 2010)

JPINFV said:


> Also, even if the medical director makes the final decision, you can still open a dialogue to see why some procedures aren't available. Who knows, maybe the reason why there is no selective spinal immobilization protocol available is because no one has asked for it. NEXUS doesn't require anything more than the application of exam points you should already be looking for.



I agree,  I like the idea of selective immobilization and I believe we are headed in that direction in my area.  Sooner then later hopefully.


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## Aidey (Mar 15, 2010)

MS Medic said:


> I find the KED is also good for this problem. Since the spinal column ends at the sacrum, you can place the person in a KED and then sit them upright in the stretcher and still maintain proper spinal precautions.



I love KEDs, unfortunately I'm private EMS and we don't extricate. We will sometimes assist with packaging once the pt has been moved away from the car. Other than that the only time do the back boarding is when it is a fall or the pt isn't in a vehicle. 

The only time I can see using a KED myself is if we had a fall patient that has to be extricated from a house using a stair chair because a back board won't fit around a corner or something.



I think what we really fail at to is assessing the difference between back pain and spinal pain. A good example is the person who asks a fall patient "Do you have any back pain?" and the pt answers yes, and they leave it at that and don't assess any further. Then, before I know it the patient is on a board. After we get them in the ambulance I find out it is really posterior shoulder pain, not spinal pain at all. 

What drives me nuts too is when we put a c-collar on the people who fall and we suspect a hip fx so we put them on a back board to move them and to stabilize the injury. Just because the patient is on a back board doesn't mean they automatically get a collar. People seem to forget that the long spine board is technically a splint, and not just for suspected spinal injuries.


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## MS Medic (Mar 16, 2010)

Aidey said:


> I love KEDs, unfortunately I'm private EMS and we don't extricate. We will sometimes assist with packaging once the pt has been moved away from the car. Other than that the only time do the back boarding is when it is a fall or the pt isn't in a vehicle.


I work for a private service too. Don't you do medical extrications or does fire do everything involving removing a pt from a vehicle?




Aidey said:


> I think what we really fail at to is assessing the difference between back pain and spinal pain. A good example is the person who asks a fall patient "Do you have any back pain?" and the pt answers yes, and they leave it at that and don't assess any further. Then, before I know it the patient is on a board. After we get them in the ambulance I find out it is really posterior shoulder pain, not spinal pain at all.


Amen. A couple of follow up questions could solve that.


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## Aidey (Mar 16, 2010)

Fire does everything involving vehicles because we don't have the PPE to be in the "hot zone". We will help once the pt is away from the car in extrication cases. 

In cases where the pt self-extricated, was ejected, or was never in a vehicle we will help too.


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## Two-Timer (Mar 17, 2010)

Loving this thread. While much research does exist, in court we (as EMS providers) are likely to be held to the standards of our service. The real argument will occur when the Medical Director defends his choice of standards. There must exist a case where this debate occurred and perhaps we should look at the legal literature as well as the medical references.

Padded boards have existed for ages- I was using one twenty-five years ago and EMS migrated away from them. It seems that the market is presently shifting back to their use. Of course we are all taught padding is essential to the good practice of boarding. The problems that arise from boarding seem proportional to the time patient's spend on those boards. It was a combination of long restraint times, coupled with reactive boarding, that led to the adoption of clearance protocols in my area. It is crucial to note that those protocols mainly eliminate the knee-jerk boarding of patients. To simplify the protocol; if you were exposed to a major MOI, have an altered mental status, have drugs on board or point tenderness- you still bought a backboard. We also seldom use KED's. The thinking being that if a patient needs immobilization then they need a backboard and they migrate directly to it. We do nearly all of the extrication and all of technical rescue in our area. If you use KED's a lot in your area do you transfer them to boards as well? I couldn't tell from the discussion.


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## Veneficus (Mar 17, 2010)

Two-Timer said:


> Loving this thread. While much research does exist, in court we (as EMS providers) are likely to be held to the standards of our service. The real argument will occur when the Medical Director defends his choice of standards. There must exist a case where this debate occurred and perhaps we should look at the legal literature as well as the medical references.
> 
> Padded boards have existed for ages- I was using one twenty-five years ago and EMS migrated away from them. It seems that the market is presently shifting back to their use. Of course we are all taught padding is essential to the good practice of boarding. The problems that arise from boarding seem proportional to the time patient's spend on those boards. It was a combination of long restraint times, coupled with reactive boarding, that led to the adoption of clearance protocols in my area. It is crucial to note that those protocols mainly eliminate the knee-jerk boarding of patients. To simplify the protocol; if you were exposed to a major MOI, have an altered mental status, have drugs on board or point tenderness- you still bought a backboard. We also seldom use KED's. The thinking being that if a patient needs immobilization then they need a backboard and they migrate directly to it. We do nearly all of the extrication and all of technical rescue in our area. If you use KED's a lot in your area do you transfer them to boards as well? I couldn't tell from the discussion.



part of the problem is mechanism has been showm not to be a good indicator. Especially for MVAs. When many of the mechanisms were established cars were steel and didn't have near the safety equipment or features today. Seatbelts were the exception not the rule also. Even the hight and age of falling patients is up for debate. 

I agree it will be a medical director that has to make the change, but few seem so inclined.


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## Scout (Mar 17, 2010)

Two-Timer said:


> If you use KED's a lot in your area do you transfer them to boards as well? I couldn't tell from the discussion.



Pt > KED > Board.
When we use the KED as an extrication tool you always get a board or Vacuum Mattress


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## medic4ever (Apr 23, 2010)

*The hospital freaked out!*

How does everyone feel about forgoing the use of a semi-rigid collar after multiple attempts at placement but unsuccessfull due to the patient's anatomy. In this case the patient was 'immobilized' on a backboard with 4 straps and towel rolls secured with tape. CMS intact before and after with no visual or palpable abnormalities noted with the spine. So what if they found a C-1 fracture.  Do you feel that this is sufficient?


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## Mountain Res-Q (Apr 23, 2010)

So, last night we had a CEU Class that I arranged for my Team on Spinal Care and Head Injuries in the Wilderness Environment.  Our Speaker is an MD/FACEP at a local Level One Trauma Center and was a Paramedic on Ambo and for SAR back in the 70's/80's.  A few interesting facts that he brought out:

Although the stats are a bit old:  Out of the 2.5 million "spinal immobilizations" we perform every year, only 11,000 of those patients have actual cord injuries.  Of those 11,000 injuries, 5,000 resulted in some sort of paralysis.  However, out of those 5,000, some 2/3 are lower back injuries, and not cervical, as many are led to believe...  

There are only a handful of documented cases where a pre-hospital provider made a spinal injury significantly worse due to their care.  The fact is that any injury to the spine that the patient has was done before you arrived on scene.  Injuries damage the spine... Medics and EMTs do not.

Spinal immobilization is a STUPID TERM... you CAN NOT completely immobilize the patient without a halo.  All we are trying to do is assist the patient in maintaining a semi-inline posture that will assist them in preventing movement that could (in a long shot) cause further injury.

A pre-hospital evaluation of the neck can never be accurate and reliably dictate the use of a collar and board.  Does your neck hurt?  Sure.  I wake up in the morning and my neck hurts... Do I need a collar?  If we are gonna collar and board every person that has neck pain then I will be spending the next 40 years in a collar, because my entire spine has pain.  How true is that for every one of you?  How much more pain and injury are we causing my placing a person with generalized back and neck pain (99.9% not spinal) in an confined position where muscles can tighten and spasm?  Last year we ran a call where a 17 year sustained a ground level fall on a hike was experiencing mild lower back pain.  Two CNAs on the trip immediately placed the kid supine and placed packs and bedding around him to keep him in your standard “spinal board” position”… for over 15 hours until one of them could hike out and call for us.  My medic evaluated and sat the patient up.  “Oh thank God, that feels so good.”  His neck was not sore, but his entire lower back was now killing him.  No crap.  You hike for 8 hours with 40-50 lbs on your back and then after that torture you are held down on your back for 15 hours you are gonna be in pain.  The point is that neck/back pain is not a true indicator for a spinal injury anymore than a headache is proof that you must have a brain bleed.  And our “just in case” treatment usually causes more pain than it might prevent… just ask any EMT student that has been the patient during skills testing… LOL

C-Collars were originally designed to be extrication tools not a "long term" immobilization device.

The "benefits" of a collar should outweigh any negatives, which means that you have to be 100% sure that the collar is needed to prevent further injury and is 100% effective...  If you can not collar and board them in a manner that achieves the goal then DON’T!

So, should c-collars be taken out of protocols… perhaps there is sufficient evidence to support that the entire concept of spinal immobilization is overrated and should be done away with.  At the very least we really need to get away from treating the MOI and not the patient’s actual injuries.  You fell off the roof… does your neck hurt?  No?  Well if the patient is evaluated properly and all reasons of immobilization are eliminated, why do we still say, “but they fell from that height… they might have a spinal injury.”  If you fall on your outstretched hands you might have a broken wrist.  So why don’t we put every fall victim in bilateral arm splints as well as a board?  Personally, I beleive based on the research I have seen and my personal experience that our "great" spinal immobilization skill is medically overused (for sure) and (probably) unnecessary.

However, there are two reasons why c-collars are unlikely to leave the greater EMS System:  1. MONEY…  2.5 million immobilizations.  How many boards, collars, head beds, and straps are sold every year?  2.  Until we get away from the cook book medicine that is being taught to EMTs because we are afraid to increase educational requirements and actually teach our “medical providers” how to make good educated decisions without opening up a protocol handbook written by someone that is not on scene… we CAN NOT eliminate the cookbook medicine that dominates most systems.

IMHO…  Just something to think about the next time you "bolt" the collar onto grandma and then "force" her onto the board just because local protocol tells you to treat the mechanism and not the patient.


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## FLEMTP (Apr 23, 2010)

CAOX3 said:


> It isn't about what I believe, its about what my medical director assumes responsibility for.
> 
> Its his job to stay current on evidence based medicine and publish his treatment guidelines to echo those findings.  We operate under his lic.  he makes the rules, he wants me to immobilize every patient I come in contact with thats his decision regardless of my beliefs and opinions.
> 
> I agree with you completely, however you doc better be on board with your decision especially in such an extreme example you presented, because if he isnt you will be the one blowing in the wind to catch the poop storm thats a coming.



If you believe that it is your medical directors job to stay current on evidence based medicine.. and his alone..then you have failed as an EMS provider... 

In many areas and systems.. the medical director has other commitments and responsibilities outside of EMS... typically a practicing emergency physician, or a family practitioner...

YOU are the one that is using the tools and skills of EMS on a daily basis. It is ALSO your job to stay on top of the most current evidence based medicine, and be a good advocate for your patients and your fellow EMS coworkers, and bring new ideas and suggestions to your medical directors attention!

If you dont like something that happens in your protocols then find evidence to support the change and make it happen. By sitting back and doing nothing because "its not my job" is NOT an excuse...and you can argue until you're blue in the face, but this level of complacency in EMS makes me sick sometimes because people always want to complain something isnt working, but then no one is willing to put the time and effort into making an effective change that benefits the field, and ultimately, your patient.


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## FLEMTP (Apr 23, 2010)

Buzz said:


> I was chewed out by an ER doc relatively recently for boarding and collaring a patient that he felt didn't really need the backboard. Unwitnessed fall, dementiated patient didn't remember falling, and she was complaining of pain in her arm (there was swelling, but we couldn't determine if there was deformity). Based on protocol, we boarded her. We taped a folded blanket down to the board to try and make it a bit more comfortable. After I finished writing my report, the nurse let me know the doctor wanted to talk to us. He wanted to rant at (to?) us about torturing old ladies and unnecessarily back boarding people. We ended up giving the only explanation we had; it's our protocol--it doesn't matter what we think about it. He did bring up some pretty good points, though I wish he'd had a more personable way of conveying it.



I am a big believer in not backboarding elderly people. after as little as 10 minutes on a firm surface such as a back board, skin breakdown and pressure sores can develop... and especially in people with other chronic medical conditions, such as diabetes, that  reduce the ability to heal normally, a skin ulcer can ultimately lead to a person's death due to infection, or other co-morbidity factors. 

If a person has a ground level fall, and has no neck or back pain that is new since the fall, (and not from laying on the floor for 12 hours) and no neurological changes, then I do not back board them. I clear the spine in the field (yes our guidelines say this is an accepted practice in our agency) and place them on the stretcher in a position of comfort.

In fact, I rarely backboard anyone... unless there is a very good indicator of spinal injury, or a high likely hood of such...things like MVA with a significant mechanism of injury, or falls from distances of greater than 4 feet. I do not bother back boarding or immobilizing shootings, or stabbings unless there is a confirmed case of loss of sensation or movement post event due to spinal process damage.

I am a huge fan of the full body vacuum splint. I would love to see these become the mainstream in US EMS systems, as it does a better job and is MUCH more comfortable for the patient and will conform to the curvature of the spine more effectively.


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## Mountain Res-Q (Apr 23, 2010)

FLEMTP said:


> If you believe that it is your medical directors job to stay current on evidence based medicine.. and his alone..then you have failed as an EMS provider...
> 
> In many areas and systems.. the medical director has other commitments and responsibilities outside of EMS... typically a practicing emergency physician, or a family practitioner...
> 
> ...



+1.  Are you providing the best care for your patient as dictated by the current scientific research?  If you are then, then you are medical provider.  If not, then what is the point?  Protocols should be guidlines based on current research into the subject... not absolutes based on tradition and obsolete thinking.  Things do not change unless there is someone screaming so loud that the powers that be must take note.  Change is not easy... but it must come...


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## karaya (Apr 23, 2010)

Mountain Res-Q said:


> However, there are two reasons why c-collars are unlikely to leave the greater EMS System: 1. MONEY… 2.5 million immobilizations. How many boards, collars, head beds, and straps are sold every year? 2. Until we get away from the cook book medicine that is being taught to EMTs because we are afraid to increase educational requirements and actually teach our “medical providers” how to make good educated decisions without opening up a protocol handbook written by someone that is not on scene… we CAN NOT eliminate the cookbook medicine that dominates most systems.


 

I thought maybe you could elaborate on a few points from your above post. Your point, MONEY. Are you suggesting that EMS product developers, suppliers, etc. have an influence or input as to what is published in our EMS textbooks? Or somehow have directed EMS educational standards to such an extent that it assures use of a product even if it contrasts evidence not to use such type of products in prehospital care?

Who or what is afraid to increase educational requirements? What do you consider "cook book medicine"?

These are some pretty outstanding claims and I thought you could provide some detail or better yet, citations.


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## mycrofft (Apr 23, 2010)

*This raises the sidebar:*

Do we need more training and clinical and refreshers and less-restrictive (lowest common denominator of knowledge) protocols (and fewer EMT's to work in more areas); or, do we need more EMT's , but the present or a lesser level of training etc. and the present or more-restrictive protocols because Marty or Mary Medic needs their hand held?
And, in the end, how loosely will corporate and civis lawyers allow the EMS system to hold their hands?

Remember, without a change of name and administration, regulations are always tightened and complicted, not loosened and simplified, as a matter of demonstrating reactive "due diligence".

This is all aside from the fact that many people we would board without chemical restrain would fight immobilization, rendering cervical spinal immobilization moot and imposing risks arising from their struggles.


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## medic4ever (Apr 23, 2010)

*well said*



Mountain Res-Q said:


> The "benefits" of a collar should outweigh any negatives, which means that you have to be 100% sure that the collar is needed to prevent further injury and is 100% effective...  If you can not collar and board them in a manner that achieves the goal then DON’T!



There is a pathetic, power hungry, self-proclaimed trauma center that made an ambulance pull over while transporting a stab wound to the abdomen and c-spine the patient.  Now they are trying to crucify a good medic who brought a large trauma patient, who he tried 4 times to put a c-collar on but did not fit on patient, and the patient became combative and refused the collar when they tried.  He did backboard him and immobilized his head using towel rolls.  The patient had no deficits pre or post to the hospital but was found to have a C1 fx, along with severe chest and abdominal trauma.  The self proclaimed trauma center says that if no c-collar is used, the pt is not 'c-spine' immobilised.  I wounder how they will feel when I bring them a GSW to the chest with no c-spine in place, as my MC is not living in the 80's.


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## MrBrown (Apr 23, 2010)

We threw out long boards years ago and infact the two I have seen on the Ambulance (at one time or another) are "mostly for show".  I will say they are handy to throw somebody on and quickly extricate them out of somewhere they have SNAFU'd themselves but other than that serve little purpose.

You strap somebody down to a hard board (be it wood or any other material) and it's gonna be as uncomfortable as a biatch.  Do you honestly think that is going to result in less movement or more as the patient fidgets and packs a fit because they are uncomfortable.  What about if your transport time is half an hour? 



> *1.3 CERVICAL SPINE IMMOBILISATION*
> Consider the possibility of cervical spine injury in all patients suffering from trauma. High risk patients are those with injury secondary to road crash or significant fall (especially head first), and patients with pre-existing cervical spine abnormalities (e.g. ankylosing spondylitis or rheumatoid arthritis). Life threatening abnormalities within the primary survey always take priority over the cervical spine.
> 
> Patients should have cervical spine immobilisation unless all of the following criteria are met:
> ...


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## mycrofft (Apr 24, 2010)

*This sounds like it needs a poll and a lock.*

..................


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## eynonqrs (Apr 26, 2010)

Very intersting. One question: Scoop stretchers, I know alot of services don't carry them anymore. I know they are good for hip fx, beacause you don't need to move them from the floor. What about a pt that fell and is lying on the ground ? I think that we would be more comfortable. Also the nice thing about them is that give more support and comfort. Just a thought. There is minimal movement with a scoop, and you don't have to worry about moving the pt 20 times. Also you can still collar and head block on them. Anyone here still use scoop stretchers ?


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## FLEMTP (Apr 26, 2010)

eynonqrs said:


> Very intersting. One question: Scoop stretchers, I know alot of services don't carry them anymore. I know they are good for hip fx, beacause you don't need to move them from the floor. What about a pt that fell and is lying on the ground ? I think that we would be more comfortable. Also the nice thing about them is that give more support and comfort. Just a thought. There is minimal movement with a scoop, and you don't have to worry about moving the pt 20 times. Also you can still collar and head block on them. Anyone here still use scoop stretchers ?



We use them quite often here.. however a ground level fall with no acute onset of neck or back pain and no neuro deficits does not get spinal immobilization. I will clear c-spine with exam, and then move them onto a scoop if appropriate


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## Mountain Res-Q (Apr 26, 2010)

karaya said:


> I thought maybe you could elaborate on a few points from your above post. Your point, MONEY. Are you suggesting that EMS product developers, suppliers, etc. have an influence or input as to what is published in our EMS textbooks? Or somehow have directed EMS educational standards to such an extent that it assures use of a product even if it contrasts evidence not to use such type of products in prehospital care?
> 
> Who or what is afraid to increase educational requirements? What do you consider "cook book medicine"?
> 
> These are some pretty outstanding claims and I thought you could provide some detail or better yet, citations.



Sorry it took so long to reply.  I was Recerting my Swiftwater this weekend and just didn't have the energy to even turn the computer on.  But here is my clarification.

First, I am not saying the money is the number one deciding factor in the continued use of c-collars and boarding.  However, anyone that says that money doesn't have some bearing on almost anything in the healthcare field needs to spend some more time watching FOX and CNN.  In my experience, business and politics tend to come before providing sound medical care... at least in the greater health care arena.  Look at the "evolution" of products that are used in the skill of back boarding.  Old school methods included the use of homemade heavy wood boards, blankets for collars and head beds, and cravats for straps.  Was this method ineffective in boarding a potential spinal patient?  No, if done right it accomplished all the goals in this skill.  And yet, look at the amount of commercial products available out there for back boarding; the number of manufacturers designing and selling every style of board, strap, collar, and head bed.  Each of these products finds a nitch in some department and in some cases the new product has a value; whether it be easier to use or lighter or cheaper.  But out of the handful of agencies I have worked for and with, I can say that no two agencies use the same equipment.  Is that to say that one agency is doing this right and the rest are wrong?  No... as long as the goals of back boarding are achieved safely.  But many are led to believe that spiders are better than D-rings... that disposable head beds are better than towel rolls... that the new Laterdal collars are better than the same version of 5 years ago...  So, yes I believe that there is always a financial element; although it may not be the primary factor and I AM NOT saying that the various companies influence the education requirements directly... although I am sure that they influence the entire EMS Community by lending to the belief that if someone is creating a newer “better” product, this must be the answer to “correctly” performing a “vital skill”.

Which brings me to number 2:  When I refer to cook book medicine, I am speaking of those systems (which seem to be the majority) that lay out protocols that state:  “If patient X presents with MOI Y than you will perform skill Z.”  Back boarding is the perfect example.  In your local protocols you will likely find a list of indications for back boarding such as “If patient falls from a height of more than X feet” or “if patient is in a MVA with speeds greater than X mph.”  The problem with making such statements in local protocols is that often they are not presented as guidelines, but as absolutes, thereby removing any judgment on the part of the Medic or EMT (and yes, I include ALS with BLS in this because the ability to make judgment calls is often taken away from medics too).  Now, unfortunately, this has turned out in many cases to be a good thing, since many EMTs and Medics providing care do indeed lack the judgment to make decisions based upon the evidence at hand due to the fact that education is not the focus in teaching and training many pre-hospital care providers; pushing them through and just teaching them skills tends to be.  Seriously, we all know of those providers locally that we DO NOT want to work with or would ever have them lay a hand on us; their judgment and ability SCARE us.  So they provide a level care that consists of recognizing the MOI and basing their treatment off of that.  Not sound logic in my mind; TREAT THE PATIENT NOT THE MOI!  If your protocols states that you will back board all patients that sustain a fall of greater than 5 feet, what should you do?  Take out a tape measure and if the fall was 4’11” you don’t board?  What if it is 5’1”… do you then board the patient?  I know of people that have fallen a hundred feet while rock climbing and sustain no spinal damage.  I know of people that have rolled off a couch and sustain spinal damage.  Why don’t we evaluate the patient and then make an educated judgment call on how we treat the patient rather than let some textbook or protocol try to pigeon hole the patient into a category of treatment?  Could it be that we are scared that some in the pre-hospital world will screw up and so they have to be told what to do?  In a lot of areas, the protocols reveal a lack of faith in pre-hospital staff… and maybe it is deserved… but as Rid says maybe the fix is EDUCATION.

As for me, when it comes to this issue and some others, I will violate protocol every day of the week if it is in the best interest of the patient.  Thankfully I work in an EMSA that is trying to progress and tends to carry the motto of “You can never get in trouble for providing the best care possible for your patients”… if only that were 100% true. 

Just MHO...


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## mycrofft (Apr 26, 2010)

*You mean...critical thinking on the scene?*

Or working with signs and symptoms, and not just with patient complaints and protocols?

If you know what you are doing, doing right will help the patient and can save you in court or protect your license, but your employer can still fire you.

Quit first.


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