# selective spinal



## zeektheman (Jan 17, 2014)

My region has had a selective spinal protocol in use since 2008.  I am a brand new medic and it is baffles me how many people are still placed in full spinal precautions even though this protocol exists.  Why is it that EMS providers are unable to adopt this new thinking.  Does anyone else have problems like this in there region?


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## Epi-do (Jan 17, 2014)

At least you have a protocol allowing you to do so.  At my full-time job, we are expected to c-spine everyone.  That being said, there are plenty of patients I have opted to no c-spine anyway, and have yet to be pulled in to the medical director's office.  I always document my findings to support not doing it, and so far, that has worked for me.  Rumor has it, we are going to be getting a protocol in the near future, but it has yet to appear.  

I think part of the problem is you have providers out there who have been doing this for a long time and hold on to "the way we used to do it" for all they are worth.  Let's not forget the CYA school of thought either.  You know the type.  We should do X, Y, or Z just incase there really is something wrong with the patient, that way we can't get sued.  Then there are all the newer providers that the previously mentioned two groups have mentored or trained.  

While EMS in my area seems to be slowly making the change to evidence based medicine, it is a slow and painful progression.  Medical directors that are progressive, coupled with well educated paramedics and EMTs who are willing to stand up to the critisism of "that's not how we always did it before" and want to continue furthering their education will go a long way towards changing EMS.  It's a slow, hard road, but, at least around here, things are changing, albeit at a snail's pace.


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## johnrsemt (Jan 17, 2014)

Same reason EMS providers have a problem doing anything new:   at my old area, when we went from Medics having to call for orders to give pain meds for trauma; to having written protocols "if they are in pain, fix it, don't call us  JUST DO IT"   the Narcotic usage across the county (from anywhere covered by that medical director) dropped by almost 30% the first year.     

   After a couple of years it went up to a lot higher than it was before.

  Same thing for chest pain;  when we were able to give pain meds for cardiac chest pain without calling first  the morphine usage went down instead of up.

 Old EMS providers are set in their ways and it is hard to get them to change.


Look at doctors themselves;    My aunt had cancer that caused a LOT of pain and the first time she had it the doctor she had perscribed Lortab;  she was miserable but got better.    after a few years of remission   it came back, her first doctor had retired and the new doctor gave her Fentanyl patches  and high doses of IV pain meds whenever she was in the hospital.   She was in very little pain,  was happy and got better faster due to her body not having to fight the pain and could help fight the cancer


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## mycrofft (Jan 17, 2014)

1. It is known spinal injuries can sometimes be hard to detect and can cause real disability or death.
2. Traditionally (circa 1970) field tech were always instructed to do spinal immob because traditionally it was assumed they were missing it…and they did before EMT was invented.
3. It is not generally accepted and not so easy to prove that spinal immobilization causes injury.

ERGO, spinal immobilization, while some leeway is being granted, will always be the personally safer course.


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## Bosco836 (Jan 17, 2014)

zeektheman said:


> My region has had a selective spinal protocol in use since 2008.  I am a brand new medic and it is baffles me how many people are still placed in full spinal precautions even though this protocol exists.  Why is it that EMS providers are unable to adopt this new thinking.  Does anyone else have problems like this in there region?



I know there are many medics around here who would LIKE to adopt it; however, we're still waiting for our Emergency Health Services Branch to give us the green light.  Until then, we're sort of stuck with our hands behind our back, despite the evidence that current practices may not be very beneficial at best and potentially harmful at worst.


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## Tigger (Jan 17, 2014)

mycrofft said:


> ERGO, spinal immobilization, while some leeway is being granted, will always be the personally safer course.



Even though there is no documented evidence that traditional spinal immobilization techniques immobilize the spine? And that there is evidence that it does harm? Along with evidence showing that doing nothing to help the patient actually manipulates the spine less than our own "protective" techniques?


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## LACoGurneyjockey (Jan 17, 2014)

Tigger said:


> Even though there is no documented evidence that traditional spinal immobilization techniques immobilize the spine? And that there is evidence that it does harm? Along with evidence showing that doing nothing to help the patient actually manipulates the spine less than our own "protective" techniques?



Coming from a system with a slowly progressing protocol for clearing spinal, can you attach links etc for any documentation showing traditional spinal immobilization does not immobilize the spine, and potentially further manipulates the spine?


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## frdude1000 (Jan 18, 2014)

Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. 
Acad Emerg Med, 1998; 5: 214–9.

Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976), 1999; 24: 1,839–44. 

McHugh TP, Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998;5(3): 278–280.


http://www.naemsp.org/Documents/Pos...autions and the Use of the Long Backboard.pdf


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## LACoGurneyjockey (Jan 18, 2014)

frdude1000 said:


> Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury.
> Acad Emerg Med, 1998; 5: 214–9.
> 
> Perry SD, McLellan B, McIlroy WE, Maki BE, Schwartz M, Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976), 1999; 24: 1,839–44.
> ...



Well thank you sir, that's just what I was looking for


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## Brandon O (Jan 21, 2014)

mycrofft said:


> 1. It is known spinal injuries can sometimes be hard to detect and can cause real disability or death.
> 2. Traditionally (circa 1970) field tech were always instructed to do spinal immob because traditionally it was assumed they were missing it…and they did before EMT was invented.
> 3. It is not generally accepted and not so easy to prove that spinal immobilization causes injury.
> 
> ERGO, spinal immobilization, while some leeway is being granted, will always be the personally safer course.



Just a couple supplementary points to flesh this out.

1.5 Primary injury at the time of the initial trauma is not modifiable by EMS intervention

1.6 Secondary trauma occurring after the injury, presumably due to an unstable spine, is theoretically modifiable by EMS intervention

1.7 Such secondary injury has been reported:
 -- 1.7.1 In the days after injury: occasionally
 -- 1.7.2 In the ED: on exceptionally rare occasions (a few times in the reported literature)
 -- 1.7.3 During EMS care: possibly never, or close to never

1.8 It is not known how many of these secondary injuries are preventable at all, and how many are the inevitable progression of the initial damage

1.9 If some are preventable, it is not known whether our methods actually do prevent them.


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## Tigger (Jan 21, 2014)

LACoGurneyjockey said:


> Coming from a system with a slowly progressing protocol for clearing spinal, can you attach links etc for any documentation showing traditional spinal immobilization does not immobilize the spine, and potentially further manipulates the spine?



A brief primer that I have not updated in a bit but should suffice for now:

This one talks about cervical spine movement during vehicle extrication with various adjuncts:
http://www.jem-journal.com/article/S0736-4679(12)01075-X/fulltext

Here is an earlier study on the same topic:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691505/

This blog post from a Connecticut paramedic includes the highlights from the upcoming position statement regarding spinal immobilization from the Association of EMS Physicians. The whole article is excellent and includes some progressive protocols being used by a few Connecticut EMS agencies. The position statement is farther down the page. It should be in print soon.
http://medicscribe.com/2013/02/in-praise-of-cemsmac/

This is the EMS Physicians' position statement from 1999, it has a nice outline of the risks associated with long backboards.
http://www.naemsp.org/Documents/POSITION IndicationsforSpinalImmobilization.pdf

In reference to the scoop stretcher, this one looks at comparing a scoop and backboard. It was sponsored by Ferno so some question its validity but I figure Ferno sells both scoops and backboards so it's not that big of a deal.
http://www.ncbi.nlm.nih.gov/pubmed/16418091

FInally there is this article from the Journal of Emergency Medical Services that does a great job summing up the current research and has a lot of studies listed at the end.
http://www.jems.com/article/patient-care/research-suggests-time-change-prehospita


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## mycrofft (Jan 22, 2014)

Tigger said:


> Even though there is no documented evidence that traditional spinal immobilization techniques immobilize the spine? And that there is evidence that it does harm? Along with evidence showing that doing nothing to help the patient actually manipulates the spine less than our own "protective" techniques?



I'm hearing you here in the choir loft.:lol: :lol: :lol:  :lol:

 It may not be the right thing to do, it may actually be clinically contraindicated, but the people who write and enforce protocols will tend to order an immob because they still see it as "mother's milk" and do not want to be seen as not performing to "the community standard" at a lawsuit.

And, as I always reiterate, I think SOME cases _do_ require spinal immobilization IF the necessary patient movement (say, auto extrication of an unconscious patient) will pose a real danger. Just don't haul that thing out for every single case. 

 I know that a patient, even in a KED and LSB and Stokes litter and cervical collar; ands even if he/she has not actually experienced a spinal insult;  needs to be handled very carefully, and some people think they're done being so careful once the pt is "packaged".


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## Tigger (Jan 23, 2014)

mycrofft said:


> I'm hearing you here in the choir loft.:lol: :lol: :lol:  :lol:
> 
> It may not be the right thing to do, it may actually be clinically contraindicated, but the people who write and enforce protocols will tend to order an immob because they still see it as "mother's milk" and do not want to be seen as not performing to "the community standard" at a lawsuit.
> 
> ...



Actually all currently accepted vehicle extrication and immobilization techniques increase cervical spine manipulation when compared to just having the patient get out of the car slowly on their own. 

http://www.jem-journal.com/article/S0736-4679(12)01075-X/fulltext


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## HunterAsesino (Feb 16, 2014)

If only we had something like this in NJ...Instead we're forced to strap the little old lady with "question mark back" to the board because she has been lying on the floor for 45 minutes and has lower back pain (surprise!).


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## mycrofft (Feb 16, 2014)

Tigger said:


> Actually all currently accepted vehicle extrication and immobilization techniques increase cervical spine manipulation when compared to just having the patient get out of the car slowly on their own.
> 
> http://www.jem-journal.com/article/S0736-4679(12)01075-X/fulltext









The joker in ANY/all articles about this stuff, other than scientific studies, is that they have to generalize to make a tasty headline (sell the article), or the authors have to be ignorant.

Yeah, real "frame-bender" accidents like this are not common, but accidents where the pt cannot get out normally due to deformation of the car (or collapsed building, etc) call for some sort of immobilization because playing Twister is the alternative. The spine board of old, however, needs an update; plywood was fine when you are trying to get them out to the country, but we are forty years out now and other devices are available or need to be invented and marketed and mandated. No more unpadded straight splints to the spine.

Falling from your feet, etc…silly to do it if there is any other way, and there usually is.


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## mycrofft (Feb 16, 2014)

HunterAsesino said:


> If only we had something like this in NJ...Instead we're forced to strap the little old lady with "question mark back" to the board because she has been lying on the floor for 45 minutes and has lower back pain (surprise!).



You know, there's nothing _physicall_y keeping you from putting someone on a board_ on their side_, so long as they are immobilized (And, I presume, the board is padded like a featherbed).

In fact, and as I've griped about before and before, putting a patient supine on a board then immobilizing them is a damned fine way to kill someone (airway issues, unnecessarily moving fractures, sheer PAIN adding to shock).


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