C-Collars On Their Way Out?

[Mountain Res-Q]

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

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

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

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

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

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

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

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

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

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

 

[FLEMTP]

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

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

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

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

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

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

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

 

[FLEMTP]

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

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

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

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

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

 

[Mountain Res-Q]

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

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

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

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

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

 

[karaya]

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

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

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

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

 

[mycrofft]

This raises the sidebar:

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

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

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

 

[medic4ever]

well said

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

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

 

[MrBrown]

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

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

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

Patients should have cervical spine immobilisation unless all of the following criteria are met:
• GCS 15, alert, cooperative and
• No neck or upper back tenderness on palpation or active movement and
• Normal peripheral sensation and movement and
• No painful or emotional distractions.

These criteria may be used for children provided they are old enough to understand and cooperate with examination.

Immobilising the cervical spine
• Immobilisation must not impair maintaining adequate airway, breathing and circulation.
• Place the patient supine in a well-fitted hard collar with the head in a neutral position (3-4 cm of flat pillow or folded towel behind the head). If the patient is placed on their side keep their spine in alignment.
• Head blocks (or lateral padding) are not required as a routine.
• The head and shoulders must not be independently immobilised unless the entire body is also immobilised. Entire body immobilisation is not required as a routine but should be considered if significant movement (e.g. over rough terrain) is anticipated.
• Spine boards and other rigid flat boards are to be used as sliding or extrication devices only. Patients must not be transported on such boards.
• Devices such as the KED should not be used as a spinal immobilisation device in their own right. Their primary function is to keep alignment of the spine during extrication. KED should only be used in patients with a normal primary survey.
• Clinical judgement must be used for uncooperative patients. If attempts to immobilise the cervical spine result in the patient ‘fighting’ then it is appropriate not to formally provide immobilisation if this approach minimises cervical spine movement.
• If significant respiratory distress is present gently sit the patient to 45 degrees, with a cervical collar in place and the spine in alignment.

 

[mycrofft]

This sounds like it needs a poll and a lock.

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

 

[eynonqrs]

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

 

[FLEMTP]

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

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

 

[Mountain Res-Q]

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

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

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

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

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

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

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

Just MHO...

 

[mycrofft]

You mean...critical thinking on the scene?

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

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

Quit first.