C-Collars On Their Way Out?

[firetender]

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.

 

[reaper]

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.

 

[Veneficus]

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.

 

[mycrofft]

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.

 

[Buzz]

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.

 

[Shishkabob]

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.

 

[Aidey]

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.

 

[Shishkabob]

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

 

[JPINFV]

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.

 

[Veneficus]

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)."

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?

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.

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.

 

[Shishkabob]

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:

 

[JPINFV]

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.

 

[Veneficus]

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.

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.

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.

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.

 

[Shishkabob]

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.

 

[Veneficus]

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

stop perpetuating fear and myth.

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)

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.

 

[Lifeguards For Life]

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?

 

[Two-Timer]

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.

 

[downunderwunda]

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.

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.

 

[Two-Timer]

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?

 

[MedicSparky]

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.