# Omission of spinal precautions



## Melclin (May 2, 2013)

It has been my practice for a while now that I omit spinal immobilisation in a certain group of patients. Namely, the very old in high care nursing facilities, with significant comorbidities. These are patients that cannot be clinically cleared because of their age, comorbities or are poorly reliable to examine.  They do of course also have a mechanism of injury that for a person of their frailty could cause an unstable injury. 

I'm asking for your collective opinion on account of my practice stimulating discussion at work today regarding where I draw the line in terms of my not being absolutely sure who is a candidate and who isn't (a legitimate criticism). Additionally some argued it was an ethically dicey situation in which to put myself. It is also not strictly supported by my guidelines but, typical of our system, nobody seems to be too bothered by that part. Take today's pt for example:

95YOF, moderate to high care at nursing home, hx advanced dementia (nil ability to converse or interact meaningfully, apparently has little quality of life, occasionally able to answer questions like "where does it hurt" in a round about sort of way but rarely), depression, osteoporosis, osteo arthritis, visually impaired, traumatic intracranial haemorrhage from similar previous fall. Not for resus. Pushed to ground by another resident, nil LOC, head strike on ground, large haematoma on occiput.     

I do this because I see no point in submitting them to the discomfort and complications of immobilisation given that they will most probably, in my opinion, not be candidates for surgical decompression/stabilisation or other significant non-surgical management, or be highly unlikely to have a good outcome if they do. 

I also generally argue, especially for patients with dementia, that, should I be wrong about their candidacy for management, better motion restriction will be achieved by letting them lay still on the stretcher rather than attempt to fight off a collar etc the whole way to hospital. This, however, is not my primary argument. Its the first argument that is really in question. 



Lets try and ignore any question of whether or not immobilisation works. Lets accept for this thread that it is the current standard of care. This is an issue of the patients potential for good outcome, similar to the idea that we do not generally intubate a this type of patient. 

Opinions? Be brutally honest.


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## Achilles (May 2, 2013)

Melclin said:


> I do this because I see no point in submitting them to the discomfort and complications of immobilisation given that they will most probably, in my opinion, not be candidates for surgical decompression/stabilisation or other significant non-surgical management, or be highly unlikely to have a good outcome if they do.
> .


I concur. 
And I will give you an article that will explain why I agree. 
It's in essence an article on "how we can treat patients but why we shouldn't"
While it doesn't go into the discussion if back boarding, it's a good read.
http://amjmed.blogspot.com/2013/04/dismissing-immortality-myth.html?m=1


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## zmedic (May 2, 2013)

I guess my problem with this is that you are making decisions for the patient that you are going to treat them differently based on your perception of their quality of life. I'd be fine with you talking to the person who makes decisions for the patient and having them refuse backboarding. But I think it's a slippery slope to say "well, I'm not going to treat this person for condition x because I don't think the hospital is going to do anything for them anyway." 

I understand where you are coming from, but there is a reason why we have protocols. These elderly people are probably the only ones who should be getting boarded for these falls from standing height, since they have a real chance of spinal fracture ( as opposed to your 20 yo drunk who falls from standing height and has about 0% chance of a spinal fracture."

You can argue if spinal immoblization does anything. I'm with you. But as a medic/EMT you are putting yourself in risk by saying "yeah, the protocols say I should do this, but I'm just not going to." We do CPR on people who we know have terminal illnesses because they don't have a DNR. 

If you on on scene and really don't want to do something like backboarding the patient, I'd call medical control and get permission. (I'm writing this from the US, I see you are down in Oz, so you may have different rules and protocols.)


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## EpiEMS (May 2, 2013)

If they're going to fight it, then any sort of spinal motion restriction (short of sedation and boarding, I suppose) will probably be ineffective, so it doesn't really make sense. Not to mention that it'll cause them pain, which is what we're trying to minimize, anyway. And if SMR doesn't make a difference 99 of 100 times, the cost (discomfort) exceeds the possible benefit, when properly probability-weighted, I would think.

I always hate boarding people who have experienced similar things to your patient -- but my protocols require it, much as it probably doesn't help them.


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## SpecialK (May 3, 2013)

I am not sure which enrages me more, spinal immobilisation or inappropriate administration of oxygen. 

I also don't like the notion that you are treating these patients differently based upon their perceived quality of life or medical problems.  Obviously if we were talking about continuing life prolonging measures in somebody has significantly reduced health related quality of life from their 300 diseases then its a bit different.

For the patient you describe I would not immobilise them unless there was significant evidence of spinal fracture or history suggesting mechanism capable of producing one.

And lets face it; which is going to be better anyway; trying to get blind Nana with dementia to tolerate a cervical collar and being manipulated into an anatomically neutral position, or letting her adopt a position of comfort to minimise movement?


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## Handsome Robb (May 3, 2013)

SpecialK said:


> For the patient you describe I would not immobilise them unless there was significant evidence of spinal fracture or history suggesting mechanism capable of producing one.
> 
> And lets face it; which is going to be better anyway; trying to get blind Nana with dementia to tolerate a cervical collar and being manipulated into an anatomically neutral position, or letting her adopt a position of comfort to minimise movement?



I like option B.

My only issue is a fall from standing height in a patient like the one described is absolutely a mechanism capable of producing an unstable cervical fracture. Especially with the history of osteoporosis. 

Meclin while I agree with you about spinal immobilization I do agree with what others have said as far as making a decision that potentially is life changing for your patient who is someone you don't even know.

Medicine by protocol sucks, no if ands or buts about it. Unfortunately it's something we have to do. I'm not totally sure how it works down in or neck of the woods but I would think you must have protocols or guidelines that dictate your treatments in different situations, right? Do I think this woman you described would benefit from spinal motion restriction? Absolutely not, but in this litigious society we live in to really cover your *** I think a call to an MD to cover iron it would be prudent if you weren't able to talk to a family member or POA for the patient and have them refuse SMR.

It might be worth attempting to get a *properly* sized collar on her but if she fights you at all just leave it alone. 

I've used the KED before with some success on elderly patients but n=1 and depending on your QA/I and relationship with ER docs it might not be an option.


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## TomB (May 3, 2013)

"I'd be fine with you talking to the person who makes decisions for the patient and having them refuse backboarding."

Five stars for this comment.

In the U.S. I've noticed that a lot of EMTs and paramedics have an attitude that an EMS call must be short and that we can't wait on scene for stakeholders in a patient's care.

I would challenge this convenient assumption, especially for a DNR patient who is suffering dementia and almost certainly not a surgical candidate. We can and should involve the person(s) who speak for the patient, explain the options, and consult online medical control if necessary (shouldn't be necessary for an appropriately trained paramedic but probably is necessary based on the DOT standards).

What's the rush? Do it right the first time. Be compassionate and competent and make the patient's well being first and foremost when you provide care. What's right for a 95 year old patient with dementia is not the same as what's right for a 35 year old patient who is fully functioning. But it's the durable power of health care attorney (or the spouse or son or daughter) who gets to make that call.

In a perfect world you would achieve consensus with the family, the staff at the nursing home, your partner, and OLMC. It can be done. It just takes time.


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## Rialaigh (May 3, 2013)

Unless you can make an argument that the patient is imminently in danger of harming his or herself or someone else I am not going to restrain the patient to backboard them, seems like something illegal honestly. 

I would much rather argue that the patient was in no imminent danger of harming himself then argue that there was imminent danger of life altering spinal injury given the statistics. 


Seems like a pretty basic CYA. Just because the patient is altered mentally doesn't mean you can restrain them for any reason, restraining to prevent imminent harm to yourself or the patient is the only legal reason I know of other then getting a doctors order or law enforcement involvement.


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## Melclin (May 5, 2013)

Achilles said:


> I concur.
> And I will give you an article that will explain why I agree.
> It's in essence an article on "how we can treat patients but why we shouldn't"
> While it doesn't go into the discussion if back boarding, it's a good read.
> http://amjmed.blogspot.com/2013/04/dismissing-immortality-myth.html?m=1



Interesting read.



zmedic said:


> I guess my problem with this is that you are making decisions for the patient that you are going to treat them differently based on your perception of their quality of life. I'd be fine with you talking to the person who makes decisions for the patient and having them refuse backboarding. But I think it's a slippery slope to say "well, I'm not going to treat this person for condition x because I don't think the hospital is going to do anything for them anyway."
> 
> I understand where you are coming from, but there is a reason why we have protocols. These elderly people are probably the only ones who should be getting boarded for these falls from standing height, since they have a real chance of spinal fracture ( as opposed to your 20 yo drunk who falls from standing height and has about 0% chance of a spinal fracture."
> 
> ...



*sigh* Now I'm just more confused. I can't tell how much of this involves systemic differences and how much involves my being wrong :unsure: 

I'll start by trying to clarify things. My questions is an ethical and medical one. Not a question of protocol. 

*Medical component:* I'm interested in opinions on whether or not these pts would be candidates for extra management. I would think not, but I'm no expert. Would they be candidates for any other kind of management before which immobilisation might prove useful? I'm not entirely sure. I would again think not. I've never once seen or heard of a patient like this ever being transferred out from the local hospital for specialist management. In fact I've seen pts younger and fitter not being sent. This is how my threshold for these types of things has developed. I omit immobilisation only in those who are much sicker and older than where I imagine the cut off to be, leaving wide a margin for error. But I'm still interested in something I might be missing or something about which I may be wrong.

*Ethical component:* I'd also like to clarify that its not purely based on a quality of life argument. Its more about the potential for meaningful management subsequent to our treatment, the likelihood of good outcomes that are meaningful to the patient. We don't RSI those that, for reasons of age or co morbidities (independent of age) are unlikely to have a good outcome. We don't fly them. We take them to different hospitals. These are all treatment decisions we make ourselves in the field, occasionally with the help of family, but not often. I don't know why spinal immobilisation should be any different in principle. The ethics, in my opinion are the same, but I'm open to arguments about why it isn't. Or why all of the above is wrong.

*Online medical control:*  I see an issue with calling a doctor making not immobilising the patient okay. Why does a phone call to medical control negate the argument about paternalistic decisions about quality of life etc being wrong? If a doctor makes that decision, is it more ethical than if I make it? We don't have medical control, so its academic (but interesting). We also have pretty liberal guidelines. Bending them is generally encouraged. A fair amount of room is made for differences of opinion and different interpretations of guidelines/literature etc. In short I'm not staring down the barrel of a hiding because I didn't precisely follow protocol X. If my senior clinical staff disagree with the idea, (I'll put the idea to them, because it almost certainly won't come up otherwise) it will most likely simply involve them telling me not to apply the idea in the future, or to adjust it a little. 





SpecialK said:


> I am not sure which enrages me more, spinal immobilisation or inappropriate administration of oxygen.
> 
> I also don't like the notion that you are treating these patients differently based upon their perceived quality of life or medical problems.  Obviously if we were talking about continuing life prolonging measures in somebody has significantly reduced health related quality of life from their 300 diseases then its a bit different.
> 
> ...



Do you not find that nursing home nanna with dementia and twenty other medical problems tends to get a lower standard of care in some regards than a sick twenty year old. I certainly find that is the case across the board and I think that is fine. The system simply can't afford to be pouring millions of dollars into tests/imagine/procedures for oldies in whom it probably won't make any difference and who are so close to death anyway as to make it all a bit pointless. Half of them want to die anyway and are trying really hard to do so. Why we can't just let nature take its course is beyond me.

Yep. I agree about the movement. But the question as I've said is not about the best way to immobilise someone but about the utility and ethics of doing it the first place.



Robb said:


> I like option B.
> 
> My only issue is a fall from standing height in a patient like the one described is absolutely a mechanism capable of producing an unstable cervical fracture. Especially with the history of osteoporosis.
> 
> ...



I completely agree that there is a decent chance of this mechanism producing an injury. If there wasn't, we wouldn't be having this conversation.

I disagree that medicine by protocol is something we _have_ to do and we aren't hyper litigious here..not yet anyway. So like I was saying, I'm comfortable with the protocol/legal aspect of this. Thats not what we're talking about. I'm interested in what you think about the medicine and ethics. Ignore your own protocols for a moment and don't worry about your laws. Thats a topic for another thread. 



TomB said:


> "I'd be fine with you talking to the person who makes decisions for the patient and having them refuse backboarding."
> 
> Five stars for this comment.
> 
> ...



There isn't a rush. I'm all for sitting around on the phone at scene. I once spent two hours on scene organising agency care for the frail spouse of the our patient after I'd organised for his cardiologist to take him as a direct admit to the ward, bypassing the busy emergency department that he really didn't need. 

I spent two and a half hours trying to talk a psych patient out of his bedroom, as well a phone calls to three different authorities looking for options before organising the geriatric psych team to attend him that morning and agreeing on a care plan with the family. 

Phone calls to relatives are not uncommon when we are unsure about a patients DNR status or about their wishes regarding invasive care. So I agree with you.

Informing the pt and asking them if they want to refuse spinal precautions is something I've done in the past, but I didn't consider calling the family in this case. I will in the future, although I'm really not sure how I could _properly_ inform them about the pro/cons of spinal immobilisation over the phone. I'd be happy to give it a crack though.


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## Handsome Robb (May 5, 2013)

Redacted. I read Rialaigh's post and hit reply before reading Melclins. Give me a minute and ill come up with something.


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## Handsome Robb (May 5, 2013)

Rialaigh said:


> Unless you can make an argument that the patient is imminently in danger of harming his or herself or someone else I am not going to restrain the patient to backboard them, seems like something illegal honestly.



If they're altered they cannot make decisions for themselves so the argument can be made that they are a danger to themselves. Just my opinion but restraining a patient that's altered, combative and you suspect a spinal injury requires chemical sedation as well to do it properly and safely for the patient.  With that said that's not the question in this thread. How and where do we draw the line for who we immobilize and who we don't? We've established the mechanism is appropriate so spinal motion restriction is indicated.

Like I said in my original post I agree with you overall, Melclin. I see patients all the time that fit the criteria you identified in this thread. 

If you can get family or the POA involved that's your best option but from here on we'll assume it's not an option. 

I think the presence of a DNR/Advanced Directive/Hospice/Living Will that specifies the patient does not want to be resuscitated is grounds enough to defer spinal motion restriction. At the same time though I've meant patients that are DNRs that have a great quality of life. If a patient is on "comfort care" it's not even a question in my mind.

If the patient is bed ridden I don't think it would be appropriate to board them. 

What I'm trying to get at is if the patient wasn't ambulatory before the fall it isn't appropriate to board them. However, if they're able to ambulance without assistance prior to the fall I don't want to be the guy that takes that away from them.

I'm beat from work so I'll revisit this tomorrow to come up with a better response.


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## the_negro_puppy (May 5, 2013)

You need to take a common sense approach to such things. There's no point wrestling a c-collar onto a distressed and combative dementia patient if its going to make things worse. I have done such in the past. Our service has progressed to using the Canadian C-spine rules as a guide for c-spine immobilisation, but obviously we are free to use our clinical judgement and common-sense should problems arise.


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## Melclin (May 5, 2013)

Robb said:


> If you can get family or the POA involved that's your best option but from here on we'll assume it's not an option.
> 
> I think the presence of a DNR/Advanced Directive/Hospice/Living Will that specifies the patient does not want to be resuscitated is grounds enough to defer spinal motion restriction. At the same time though I've meant patients that are DNRs that have a great quality of life. If a patient is on "comfort care" it's not even a question in my mind.
> 
> ...



After reflecting on the case I realised how much I went into it with blinkers on. I saw ninety something yrs old...head strike....advanced dementia and I said to my partner...we're not collaring this poor woman. *This is crappy practice.* She was less demented than I had expected but I think I was still in the frame of mind that she was demented beyond recognition. I also expected her to be non-ambulant. She was ambulant to a degree. Used a walker... and could move from A to B with assistance and direction from staff but wasn't independant.. Completely dependant ADLs. This case was interesting to me because I think my decision to not collar was more borderline than usual. I still stand by it for the reasons stated but I think that had a lot to do with the expectations of more severe disability going into the job and I don't know that I adequately readjusted my appraisal of the situation once I was actually on scene. So a good learning point here not to have the blinkers on.  



the_negro_puppy said:


> You need to take a common sense approach to such things. There's no point wrestling a c-collar onto a distressed and combative dementia patient if its going to make things worse. I have done such in the past. Our service has progressed to using the Canadian C-spine rules as a guide for c-spine immobilisation, but obviously we are free to use our clinical judgement and common-sense should problems arise.



Yeah I saw that you guys are using canadian c spine now. I feel like that would be hard to use in an unmodified form in the prehospital environment...it being a tool of spinal clearance and what we do is selective immobilisation. The various clauses seem to complex to use at that moment you have a bucket of things to do as well as clear their c-spine early. 

I find elements of CCR to be confusing too. Like rollover being high risk...I've seen heaps of people walk just fine out of rollovers. Or bicycle collision...when do you say its a high risk mechanism and when is it a scraped knee after coming off your bike.


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## Rialaigh (May 5, 2013)

Robb said:


> If they're altered they cannot make decisions for themselves so the argument can be made that they are a danger to themselves. Just my opinion but restraining a patient that's altered, combative and you suspect a spinal injury requires chemical sedation as well to do it properly and safely for the patient.  With that said that's not the question in this thread. How and where do we draw the line for who we immobilize and who we don't? We've established the mechanism is appropriate so spinal motion restriction is indicated.
> 
> Like I said in my original post I agree with you overall, Melclin. I see patients all the time that fit the criteria you identified in this thread.
> 
> ...




My point was if the patient is altered mentally, but is not threatening you or anyone else or themselves in any way, they are just non compliant with what you are trying to ask them to do. I see backboarding or chemically restraining this patient as very iffy...AMS does not mean we can restrain, only if they are a immediate danger to themselves or others. I think AMS patients get restrained quite often for the simple fact that they don't follow directions very well and I think its probably poor practice.

Back on topic though, I like what you said about using the patients ambulatory ability pre fall to determine course of treatment for spinal precautions. I think that is a very sensible approach and when combined with patients who are elderly (70+) I think its very good practice.


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## Brandon O (May 9, 2013)

Melclin said:


> Lets try and ignore any question of whether or not immobilisation works. Lets accept for this thread that it is the current standard of care. This is an issue of the patients potential for good outcome, similar to the idea that we do not generally intubate a this type of patient.



I don't think you can omit questions like the effectiveness of the treatment. What you're trying to establish is the risk vs. benefit of the intervention, and that requires weighing both sides.

Obviously local protocols may have something to say, but if you have leeway to act in the patient's best interest, I think it's completely appropriate to consider these issues. The caveat is how confident you really are in your evaluation. For instance, if you say, "There's almost no chance this bird's getting aggressive stabilization measures no matter what a CT shows, so why bother," and later a doctor wants to put her in a collar for a month or a halo or operate on her neck, do you stand by that decision? In other words, is it based on probability and a sensible estimate of treatment threshold (in which case guessing wrong is not wrong), or was it based on absolute certainty in your diagnosis (in which case being wrong means you did the wrong thing)?

Old, fragile patients may be higher risk for spinal injury, but they're also higher risk for the adverse effects of immobilization, including pain and most especially pressure ulcer development. They may also present challenges due to kyphosis or combativeness. With all these considerations, there are certainly patients who you could look at and say, "I think there's a big chance this will cause problems and a small chance it will accomplish anything, so let's pass or take an alternative pathway."

And I would have no problem documenting that, even in cases where a protocol does have things to say. I have brought in patients sans immobilization, with collar but no board, and many other variations because the harm clearly outweighed the risk. These are judgment calls (nurse: "yeah... I don't think she's going to let you put her in a collar..." you: "okay!"), so again, they require a pretty nuanced and intelligent understanding of the risk/benefit, but they're also fairly common sense.

Ethically, a shared decision with the relevant decision-makers (family, etc.) is certainly best. But when granny's lying on the tile and nobody's sure who to call it can be a little tricky to bake that cake in time.


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## Carlos Danger (May 9, 2013)

I don't think it is our place to make decisions based on how we perceive the patient's quality of life, or whether we think they are candidates for surgery, etc.



Brandon Oto said:


> Old, fragile patients may be higher risk for spinal injury, but they're also higher risk for the adverse effects of immobilization, including pain and most especially pressure ulcer development. They may also present challenges due to kyphosis or combativeness.



This is the real issue here.

If ever there was a time when it was appropriate to exercise the "protocols are just guidelines that don't apply to everyone" mantra, it is here. These patients just don't immobilize well, and are far more prone to complications from it. 

There is no evidence that I'm aware of that any patient has ever been found with a suspected cervical fracture but neurologically intact, and then suffered a SCI during ambulance transport because of lack of cervical collar. In someone who the collar fits well and who won't fight you and is unlikely to be harmed by it, then why not? It is a very low-cost, low risk intervention that just may help. But in someone who is likely to fight you, and/or who the collar won't fit well, and who may develop some significant complications from it, then the benefit needs to be a lot more apparent than I think it actually is with immobilization. 

Even though a cervical fracture is certainly a possibility, in the patient described I'd be much more concerned with the possibility of a SDH.


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## Dwindlin (May 9, 2013)

Halothane said:


> I don't think it is our place to make decisions based on how we perceive the patient's quality of life, or whether we think they are candidates for surgery, etc.
> 
> 
> 
> ...



You can frequently have no deficits with a cervical fracture. Now, someone show me a shred of evidence that pre-hospital immobilization has any positives what so ever?  Because I can't find it.

Only thing the spine boards on our trucks are for is moving completely unconscious people to the cot, it's actually very handy for that purpose.


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## Aidey (May 9, 2013)

There are also a number of cervical (and other spinal) fractures that are considered subclinical. It's surprising the number of people who assume all spinal fractures are unstable. It never occurs to people you can have a hairline fracture of a posterior spiny process and the only treatment is pain meds.


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## Carlos Danger (May 9, 2013)

Dwindlin said:


> You can frequently have no deficits with a cervical fracture.



That fact is the whole reason the "board & collar everybody, even if they are perfectly fine" thing came to pass.

Where did that originally come from, anyway? Was it a reccomdation from ACOS or ACEP, or just something done textbook author postulated might be a good idea?


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## Clipper1 (May 9, 2013)

It seems the back board and c-collar are the only means of immobilizing in EMS.  In the hospital we try to restrict movement as much as possible with the position of comfort. Spinal precautions should include limiting movement rather than just a strict back board and collar.  It shouldn't be all or nothing. Not all injuries are that black and white.


Unfortunately a CT Scan or MRI table are not comfortable and neither is moving the person to them. But, it is necessary for the test.  Some one who is combative will get sedated so some tests can be done to ensure there are no injuries to the head or spine since both are difficult when a person is altered for a variety of reasons. It is also for the safety of the staff.  If you are not comfortable with what medications you have to quiet a combative patient then there is no choice to transport as is. 

Many injuries to the spinal cord are not immediately known. Instability presents in many ways as with swelling and movement. This should be clearer for those who have experienced an injury themselves moving a patient or in sports.  It doesn't feel like much at first but later you are incapacitated.   We see patients in the ER all the time who felt fine at the MVC and may even have been checked out by EMS for a spinal clearance. Some are just sore and some do have serious injuries which might require months of PT and maybe even surgery.


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## Brandon O (May 9, 2013)

Halothane said:


> That fact is the whole reason the "board & collar everybody, even if they are perfectly fine" thing came to pass.
> 
> Where did that originally come from, anyway? Was it a reccomdation from ACOS or ACEP, or just something done textbook author postulated might be a good idea?



"Kossuth is recognized as the first physician to champion the need for accepted methods of extrication, which include protection of the cervical spine ( 19). Farrington is credited with thrusting the concept of prehospital immobilization into the arena of conventional medicine (20,21). According to **** and Land, the first widely distributed emergency medical service (EMS) textbook to address the specific techniques of immobilization was Grant and Murray’s Emergency Care in 1971 (22). In 1974, Hare invented an extrication-type collar that replaced the then-standard use of soft collars or a rolled-up blanket (22)."

19: http://www.ncbi.nlm.nih.gov/pubmed/5851121
20: http://medicteacher.com/EMTP2012/Death_in_a_Ditch_1967.pdf
21: http://journals.lww.com/jtrauma/Cit...ication_of_Victims_Surgical_Principles.2.aspx



Clipper1 said:


> Many injuries to the spinal cord are not immediately known. Instability presents in many ways as with swelling and movement. This should be clearer for those who have experienced an injury themselves moving a patient or in sports.  It doesn't feel like much at first but later you are incapacitated.   We see patients in the ER all the time who felt fine at the MVC and may even have been checked out by EMS for a spinal clearance. Some are just sore and some do have serious injuries which might require months of PT and maybe even surgery.



All very true. In fact, this is predominantly the true behavior of deteriorating spinal injuries, not the sudden early catastrophic worsening associated with movement. But there's very little reason to think that prehospital immobilization techniques can prevent this, and at least some reason to think it could make things worse.

The surgical intervention is usually not stabilizing but laminectomy to relieve compression.


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## Clipper1 (May 9, 2013)

Brandon Oto said:


> All very true. In fact, this is predominantly the true behavior of deteriorating spinal injuries, not the sudden early catastrophic worsening associated with movement. But there's very little reason to think that prehospital immobilization techniques can prevent this, and at least some reason to think it could make things worse.
> 
> The surgical intervention is usually not stabilizing but laminectomy to relieve compression.



Why believe there is only one option with the long spine board?  Why just throw care or caution to the wind and not limit movement even if a verbal instruction? Some can have a rolled towel to remind them to no move. Some could be in position of comfort with a leg or both legs raised to prevent them from moving out of pain.  The problem is that other alternatives are not being discussed but rather just backboard or nothing.  This mentality has lead to little acceptance for alternative immobilization devices which might be available commercially or for the development of new protocols.

You would be surprised at how many patients are transferred to neuro centers for surgical intervention. It may not be the TV style rush to the ER but rather an admission to the unit or floor for awhile to determine the extent of injury and to prep the patient for the OR. Some might be given choices and some might not.


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## Brandon O (May 9, 2013)

Clipper1 said:


> Why believe there is only one option with the long spine board?  Why just throw care or caution to the wind and not limit movement even if a verbal instruction? Some can have a rolled towel to remind them to no move. Some could be in position of comfort with a leg or both legs raised to prevent them from moving out of pain.  The problem is that other alternatives are not being discussed but rather just backboard or nothing.  This mentality has lead to little acceptance for alternative immobilization devices which might be available commercially or for the development of new protocols.



I generally agree. In most cases a low-impact compromise can keep movement reasonable without aggressive and harmful immobilizing measures. This approach is finally gaining traction prehospitally as well.



> You would be surprised at how many patients are transferred to neuro centers for surgical intervention. It may not be the TV style rush to the ER but rather an admission to the unit or floor for awhile to determine the extent of injury and to prep the patient for the OR. Some might be given choices and some might not.



Yes, of course. But this should not imply that all of those people should have been wearing a collar. Apples and oranges.


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## Brandon O (May 9, 2013)

Okay, you inspired me to get off my butt. I recorded a little tutorial to how I look at this stuff below (using head injury as an example, but it's essentially the same dynamic as spine injury).

[YOUTUBE]http://www.youtube.com/watch?v=B3qe2QrGYa4[/YOUTUBE]


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## VFlutter (May 9, 2013)

Brandon Oto said:


> Okay, you inspired me to get off my butt. I recorded a little tutorial to how I look at this stuff below (using head injury as an example, but it's essentially the same dynamic as spine injury).



Is there any difference between harming your patient with your actions as opposed to your inaction? Is being aggressive and causing harm worse then being prudent and allowing harm?


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## Brandon O (May 9, 2013)

Chase said:


> Is there any difference between harming your patient with your actions as opposed to your inaction? Is being aggressive and causing harm worse then being prudent and allowing harm?



I would agree with the utilitarians and say ethically no. But medicolegally, you are probably more likely to get sued for missing something or failing to offer care than for the expected harms of over-treatment.

But if you can engage the patient in this decision via informed consent, this risk should be negligible either way. There's really very little reason that our belief system should be the one in control here; it's the patient's butt on the line, ask them.


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## Melclin (May 17, 2013)

Halothane said:


> I don't think it is our place to make decisions based on how we perceive the patient's quality of life, or whether we think they are candidates for surgery, etc.



We already consider it to be our place in some circumstances. Certain patients are not candidates for RSI due to their comorbidities/quality of life issues. Cardiac arrest resuscitation decisions are made in regards to this idea. Transport decisions are often made based on this idea. A 93YO bed bound nursing home pt with 20 different medical problems, and is severely demented who has fallen with an obvious skull fracture probably isn't getting flown to a trauma centre. 

So either you agree that none of these decisions are ours to make (are they anybody's?) or you say that they are an quibble about the threshold for making them. 




Brandon Oto said:


> I don't think you can omit questions like the effectiveness of the treatment. What you're trying to establish is the risk vs. benefit of the intervention, and that requires weighing both sides.
> 
> ....
> 
> ...



I agree with all of the above with the exception of the issue of omitting discussion of efficacy.


Also, when it comes to a thread like this, you have to focus discussion a little. I didn't want another thread about the efficacy of spinal immobilisation. You know from our correspondence how I feel about spinal immobilisation and I think most of us are pretty down with it being a bit of a joke. None the less, it is the current standard of care. So if the person can't be cleared or there is a good reason not to immobilise in the normal fashion (ie curvature of the spine, CCF). I wanted the discussion to focus on whether or not the "too old and infirm for definitive treatment" argument was one of those good reasons, which it has. 

The other issue is that with a case like this, none of the normal reason to modify immobilisation (curvature of the spine, CCF) were really apparent. With a soothing touch, a healthy dose of morphine and proper padding I think I probably could have cajoled her onto a stretcher or a vacuum mattress brought in by another crew. Or maybe I couldn't. Point is I didn't try because of the other reason. Hence the discussion.


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## Brandon O (May 17, 2013)

Melclin said:


> Also, when it comes to a thread like this, you have to focus discussion a little. I didn't want another thread about the efficacy of spinal immobilisation. You know from our correspondence how I feel about spinal immobilisation and I think most of us are pretty down with it being a bit of a joke. None the less, it is the current standard of care. So if the person can't be cleared or there is a good reason not to immobilise in the normal fashion (ie curvature of the spine, CCF). I wanted the discussion to focus on whether or not the "too old and infirm for definitive treatment" argument was one of those good reasons, which it has.
> 
> The other issue is that with a case like this, none of the normal reason to modify immobilisation (curvature of the spine, CCF) were really apparent. With a soothing touch, a healthy dose of morphine and proper padding I think I probably could have cajoled her onto a stretcher or a vacuum mattress brought in by another crew. Or maybe I couldn't. Point is I didn't try because of the other reason. Hence the discussion.



Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) _and benefit seems negligible_, your threshold for surrender might be very low, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.


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## Rialaigh (May 17, 2013)

Brandon Oto said:


> Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) _and benefit seems negligible_, *your threshold for surrender might be very low*, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.




I think this is the key. Like I said earlier in the thread I'm not all about "forcing" treatments onto people that are confused as long as they are not an *immediate harm to themselves or others*. Confusion does not equal inability to refuse treatment unless there is a really strong belief that refusing treatment will cause immediate harm to themselves.

 If I have a patient as described by the OP, and I start to feel around the neck and ask if they want to be place in a collar and the patient pushes my hand away, I am taking that as a refusal of that service.


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## Bullets (May 17, 2013)

Fall from a standing height, with a contusion on the occiput, i may not even consider applying SMR to the patient anyway. 

Considering her history of osteo-degradation the possiblity exists for a fracture, but once we arrive, the fracture has occurred and there is little that is going to change that. I find the concept of an "unstable" cervical fracture to be a misnomer. A recent study evaluated the force needed to further exacerbate a fracture in pigs that had previously undergone surgical instability. Basically its physically impossible for the patient to apply the force needed to exacerbate the injury and the manipulation performed by EMS comes no where close. now i gotta find that link....

Also, what are we considering altered here? If the patient has dementia, and they dont know where they are, is that altered for them? or is it their normal mentation? 

If i have to immobilize, i am preferring the scoop as the channel is more comfortable,  but that is all going to change once we get the vacuum mattress!


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## Melclin (May 18, 2013)

Brandon Oto said:


> Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) _and benefit seems negligible_, your threshold for surrender might be very low, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.



Threshold for surrender. Hahaha. I like that term and will shamelessly thieve it in the future. 

You're quite right, of course, which is no surprise given how much you know about this topic (Feel like doing a guest lecture series convincing everyone around here of the idea?  My understanding is that several of the boss cocky trauma docs here are ultra conservative about the issue and Australia in general I believe is a bit behind in this regard). 

You can't completely remove efficacy from the discussion. Nor should you. I really just wanted a little focus on the aforementioned part of the problem rather than it being an entirely "boarding doesn't work anyway so don't worry about it" type of thread. 



Bullets said:


> Fall from a standing height, with a contusion on the occiput, i may not even consider applying SMR to the patient anyway.
> 
> *Really? I feel like a standing height fall in a pt of her age and comorbidities is plenty to produce a significant fracture*
> 
> ...


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## Arovetli (May 18, 2013)

I would opine from a legal standpoint, that it is good to note differences in legal systems among countries, and that, even though you might not realize this, legal philosophy underlies alot of what we do.

In the US, we have a much more fragmented legal system and a greater focus on common law, and this philosophy does effect the way we practice medicine...and as an extension, the way we work as paramedics.

SMR is so prevalent and persistant because it is what we have always done, so to speak. It is the common law of Prehospital trauma. And thus, it has a weight that is very difficult to overcome.

In countries such as Australia, the legal philosophy is different, and their laws are much less fragmented. This is why in other countires their EMS systems seem more progressive.

It is difficult to make changes in America, because you have to overcome the fact that SMR is how it was always done, and a peer comparison judgement system compares progressives against a large conservative mass.

American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care. Say the case of the canadian rules. I believe statistically in 4 out of a thousand instances it will not catch an injury, and to combat this liability the very few (.004) dictate the course of the many.

Our philosophies of law and economics can really screw up a feld like medicine which is progressive, research driven, evidence based, and should change quickly.

But, this is America, and it is how we have always done things.


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## Brandon O (May 18, 2013)

Arovetli said:


> American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care. Say the case of the canadian rules. I believe statistically in 4 out of a thousand instances it will not catch an injury, and to combat this liability the very few (.004) dictate the course of the many.



Although this is neither here nor there, in most studies the Canadian C-spine rule has been 100% sensitive for "clinically important" injury (defined a priori with a pretty conservative definition). For adult patients, anyway.

The lowest sensitivity when applied by doctors or paramedics has been 99.4%, which for the prevalence of 2% would mean .00012% missed injuries, or .12 in 1000 -- call it 1 in 10,000. Of which even fewer than that will have any neurological sequelae and something close to zero (perhaps zero) could have been prevented. I'm a conservative guy, but at some point you have to be willing to let the scale tip.

I haven't seen the 4 in 1000 number. If there's a study floating around that I've missed, let me know.


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## Arovetli (May 18, 2013)

no, you are correct. that is what i get for trying to rely on remembering an old number and my memory.

regardless i was trying to point out how minimal the error is in the rules, yet how difficult it is to implement them, and have them accepted. The overwhelming propensity is to push against change. Conservatism dominates our thought, and this is reflected in medicine as well.

however you make my point, because it matters not what paper you pull off pubmed, or what actual number gets quoted, outside of medicine, nobody really cares. clinicians would do well to learn this. we like to argue our knowledge of statistics and numbers and who is right and who is wrong but...

 while it really does matter inside the medical bubble....outside of it, to administrators, politicians, businessmen, lawyers, and anyone else holding the reins, it doesn't matter, but one day it will, perhaps. 

philosophy of thought and money dictate care far more than any study.

and our philosophy of thought is anything but grounded in science.

because for so long, there was no science, and other methods of reasoning were developed. Hence why Stephen Hawking denounced philosophy for science as a thought methodology, as he believes we are to a stage where the scientific method should guide our thinking. But we are still largely dominated by philosophers of old.

when your thinking has been developed over thousands of years, and it has developed to favor slow change, it is unlikely to change quickly.


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## Arovetli (May 18, 2013)

Brandon Oto said:


> I'm a conservative guy, but at some point you have to be willing to let the scale tip.



But, would you consider adherence to past methods and a sluggish change process a safeguard?

Is it better for one good change to be implemented incrementally in order that 9 bad changes are not implemented quickly?


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## Brandon O (May 18, 2013)

Yes. But obviously I'd rather not be either kind of idiot.

I think you're correct in all respects. However, I also think that change can happen surprisingly easily when someone's simply willing to take the first step. That's what most of this comes down to; whether or not there's any real liability to implementing a new approach, it's more that nobody wants to be first out the door. Often the decision-making locus is literally one person (head of a department, medical director of a state's EMS office, or similar). When they're reluctant, that ripples down to create a gigantic boulder of inertia, but similarly, if they're willing to step out from the bulwark, the whole boulder moves with them. We're just starting to see this happening with prehospital spinal immobilization.

It's not like this is the worst example of physiologically-based care turning into dogma without any evidence on outcomes. But for EMS it's probably the most implemented, and in terms of sheer volume, it's therefore impacting the most people.

And it's the most irritating to me.


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## Arovetli (May 18, 2013)

Arovetli said:


> American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care.



let me restate another way,

Our legal process is slanted against the scientific method. To introduce a study into evidence, it must adhere to a body of odd rules of admissibility. Rules which were crafted well before the scientific method existed. 

A much different vetting process.

While it would matter not in reality, if the expert witness took the stand with mustard on his tie, a jury may disregard his opinion and the weight of evidence and science solely because he is a sloppy eater.

Tie mustard ought not outweigh science, but it certainly can.


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## Arovetli (May 19, 2013)

Brandon Oto said:


> Yes. But obviously I'd rather not be either kind of idiot.
> 
> I think you're correct in all respects. However, I also think that change can happen surprisingly easily when someone's simply willing to take the first step. That's what most of this comes down to; whether or not there's any real liability to implementing a new approach.




indeed there is colossal "liability" in being the first guy out the gate. If you are doing something different than everyone else, you stand out from the crowd.

In a legal system that favors the crowd, you are the odd man out.

When 99 of your peers perform a different way, you have a hurdle to surmount in getting your behavior accepted. 

There is some work on establishing so-called safe harbor legislation, creating immunity for actions performed based on a scientific expert consensus, to encourage faster change in medical practices.

To change things, It is just as important to write laws as it is to publish studies, a fact often overlooked.


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## Aidey (May 19, 2013)

Arovetli said:


> There is some work on establishing so-called safe harbor legislation, creating immunity for actions performed based on a scientific expert consensus, to encourage faster change in medical practices.



On the state level or federal level? If it is the federal level, who do we talk to to get involved with that?


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## Brandon O (May 19, 2013)

Bullets said:


> A recent study evaluated the force needed to further exacerbate a fracture in pigs that had previously undergone surgical instability. Basically its physically impossible for the patient to apply the force needed to exacerbate the injury and the manipulation performed by EMS comes no where close. now i gotta find that link...



Pass it along if you do, please.


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## Aidey (May 19, 2013)

I have that one, or a similar one around somewhere.


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## Arovetli (May 19, 2013)

Aidey said:


> On the state level or federal level? If it is the federal level, who do we talk to to get involved with that?



Mainly at the state level but is gaining ground nationally through the American Medical Association backing. However it is all bungled up with Obamacare.

here is an article, though it focuses more on the obamacare involvement...but part of the underlying push is to create protections for implementing changes based on research and a consensus of an established scientific advisory board.

http://www.amednews.com/article/20130415/government/130419963/1/


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## Aidey (May 19, 2013)

Brandon Oto said:


> Pass it along if you do, please.



Hauswald - A re-conceptualization of acute spinal care. I have the full text if you can't get it, but I'll need you e-mail address.

Also, Hauswald (Mark, MD, University of New Mexico) has a lot of published studies on the uselessness of "spinal immobilization". Look up his other stuff on the topic.


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## Brandon O (May 19, 2013)

Aidey said:


> Hauswald - A re-conceptualization of acute spinal care. I have the full text if you can't get it, but I'll need you e-mail address.
> 
> Also, Hauswald (Mark, MD, University of New Mexico) has a lot of published studies on the uselessness of "spinal immobilization". Look up his other stuff on the topic.



I have that Hauswald paper, but it's just a review; there's no porcine experimentation either performed or cited, although he obviously would agree with the claim. Great review though.

He's done lots of good stuff on the topic. His Malaysia study is really the closest thing anyone's attempted that gets at the heart of the issue.

I have a vague memory of a pig study along these lines, but I can neither locate it now nor remember where I encountered it.


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## Brandon O (May 19, 2013)

Arovetli said:


> Mainly at the state level but is gaining ground nationally through the American Medical Association backing. However it is all bungled up with Obamacare.
> 
> here is an article, though it focuses more on the obamacare involvement...but part of the underlying push is to create protections for implementing changes based on research and a consensus of an established scientific advisory board.
> 
> http://www.amednews.com/article/20130415/government/130419963/1/



Maybe I'm misreading, but the way they're describing it seems to be different -- almost opposite -- from your description. They're depicting a law that would protect doctors adhering to the EXISTING standard of care, in the event that plaintiffs allege they've violated NEW "standards" created by the Obamacare metrics -- in other words, emphasizing that you won't be liable for practicing the same old medicine even with new, possibly distinct goals and guidelines out there designed to improve efficiency.

In fact, it seems to explicitly omit the sort of counter-protection you mentioned:

"The only way we were willing to allow the bill to go forward was to have it go both ways," Clark said. "If a physician can't be held accountable for malpractice for failing to adhere to a payment guideline, then they also shouldn't be able to use their compliance with a standard as evidence that they complied with the standard of care. If it can't be used against you as a sword, you also can't use it for a shield."

Although in any case this seems mostly about the Obamacare guidelines and not evidence-based medicine per se.


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## Arovetli (May 19, 2013)

Brandon Oto said:


> Maybe I'm misreading, but the way they're describing it seems to be different -- almost opposite -- from your description. They're depicting a law that would protect doctors adhering to the EXISTING standard of care, in the event that plaintiffs allege they've violated NEW "standards" created by the Obamacare metrics -- in other words, emphasizing that you won't be liable for practicing the same old medicine even with new, possibly distinct goals and guidelines out there designed to improve efficiency.
> 
> In fact, it seems to explicitly omit the sort of counter-protection you mentioned:
> 
> ...



Do not take political propaganda at face value. its not that you are misreading it, it is just a confusing tangle.

as i already pointed out, it has become bungled with obamacare, and the article is written with a different slant, but it is the slant that is working to achieve national momentum.

Any bill contains subterfuge, compromises, competing interests, pork, and a plethora of words which have no meaning.

Dislike of obamacare may provide enough momentum to overcome the trial lawyer lobby.

the article is merely a starting point and provides national attention relevant to a broad audience, and names a few key players. 

A google search of safe harbor legislation, malpractice reform, or other keywords may point you towards information more focused on your locality. I can PM you many details of what is going on in Georgia if you are interested in the origin of this particular push.

Malpractice laws are very fragmented and each state is different and faces different challenges. A federal issue has its own challenges, and obfuscating safe harbor inside of an obamacare response may be effective and seems to be gathering some steam.


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