C-Collars On Their Way Out?

[JPINFV]

While we probably cannot forgo stabilization for legal issues,

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

 

[MedicSparky]

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

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

 

[JPINFV]

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

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

 

[MedicSparky]

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

Good point ^^

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

 

[JPINFV]

The evidence for selective stabilization is mostly anecdotal.

Err... which journals are you looking at?

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

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

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


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


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

 

[MedicSparky]

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

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

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

 

[JPINFV]

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

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

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

 

[MedicSparky]

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

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

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

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

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

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

 

[JPINFV]

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

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

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

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

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

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

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

 

[CAOX3]

I will do what Med Control tells me to do

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

 

[JPINFV]

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

 

[MS Medic]

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

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

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

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

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

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

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

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

 

[CAOX3]

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

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

 

[Aidey]

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

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

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



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

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

 

[MS Medic]

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

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

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

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

 

[Aidey]

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

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

 

[Two-Timer]

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

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

 

[Veneficus]

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

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

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

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

 

[Scout]

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

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

 

[medic4ever]

The hospital freaked out!

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