Dr. Bledsoe article on Spinal Immobilitzation

[VentMedic]

I believe this article is more about the need for quality monitoring rather than should or should not a Paramedic be allowed access to this protocol. Just like intubation, some in EMS have not had the proper oversight or monitoring measures in place to see where the need for improvement exists.

Danger at the Door

http://www.ems1.com/columnists/bryan-bledsoe/articles/426350-Danger-at-the-Door

by Bryan E. Bledsoe

I am a proponent of EMS personnel having a more independent practice. The days of calling “Rampart Hospital” for an order of “D5W TKO” is a thing of the past. I truly feel that most of our educational programs are strong enough to support independent decision-making by EMTs and paramedics. But it is important to remember that independent decision-making also requires one to take responsibility for their decision and actions. This is somewhat of a new concept for EMS personnel.

One area where independent decision-making has been delegated to EMS personnel is selective spinal motion restriction (spinal immobilization). There is an excellent body of research that shows that the application of an established protocol allows EMS personnel to accurately and safely determine which patients should be immobilized and which should not. We have added it to our textbooks and many EMS systems have adopted it.

Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.

Now, let’s look at this a little more closely. In the system where 13.5 percent of patients with spinal injury were not immobilized, a policy was in place to allow EMS personnel to determine who should be immobilized and who should not. The premise is that all patients should be immobilized unless they meet the criteria to bypass immobilization. The protocol requires that EMS personnel complete a structured, standardized exam (e.g. altered LOC, spinal pain or tenderness, neuro deficit, distracting injury). If the patient meets any of the established criteria, they must be immobilized.

So in 13.5 percent of the cases, EMS personnel performed an exam and came to the conclusion that immobilization was not necessary. Thus, from a negligence standpoint, this was an act of commission and not an act of omission. A jury would probably look more unfavorably on an act of commission. In reality, what this tells me is that some EMS personnel are NOT properly applying the protocol or applying it selectively. The protocol only works if applied in a standardized fashion—the same, each time and objectively—to ALL trauma patients.

http://www.ems1.com/columnists/bryan-bledsoe/articles/426350-Danger-at-the-Door

Quality monitoring in EMS should detect issues such as this — this is how the trauma system detailed above discovered the 13.5 percent miss rate — but quality monitoring must be applied uniformly and EMS personnel must be given the results on a regular and constructive basis. Personnel who are taking short cuts and making clinical assumptions should be counseled. This spinal immobilization trend may well turn out to be like the trend we saw in the late 1990s with unrecognized esophageal intubations. It cannot be tolerated.

http://www.ems1.com/columnists/bryan-bledsoe/articles/426350-Danger-at-the-Door

 

[karaya]

Excellent post, Vent! This does not surprise me. For example, as you know the use of KED is not indicated with a rapid extrication patient. About 15 years ago or so one of my my host providers developed a protocol for determining MVC patients that would be rapid extrication candidates whereby a KED would not be used. Since implementing the protocol the use of KED's overall declined, including MVC patients requiring such immobilization. I think is was best said in another thread here as "laziness" and I agree.

When I started to photograph for this provider, I worked nearly two dozen MVCs and never once photographed a KED being used. I can tell you that nearly all of these were not rapid extrication patients.

Now the host is developing a protocol for clearing spinal immobilization and I fear what Bledsoe discusses in his article will trickle in there as well.

 

[firetender]

I'm just curious.

Does that indicate, since, of all the Basic, basic things to do that is the most time consuming (not to mention frustrating!) , the un-directed medic will opt out of the work involved 13.5% of the time?

In the case of physician-directed immobilization then, that means, in the absence of actually seeing what's up they would have a natural tendency to direct immobilization as a logical, natural err on the side of caution
action.

 

[MSDeltaFlt]

Vent, those numbers are surprising. I thought they'd be higher. Those who tend to get lazy and miss a poss Fx are the ones who do not touch their pts. Where I work part time on the ground, we have a selective spinal protocol.

Yes, if the pt does not have ALOC, pain, or any neuro deficits, they must also not have any MOI for them to not be packaged. One more thing. If there is even any high index of suspicion, then you package.

I wonder how many of those who were missed were ever even touched by the medic?

 

[VentMedic]

It is my understanding that this was an isolated study where the results were expected to be good.

I see alot of spinal fxs not immobilized in the elderly from falls.

 

[mycrofft]

I wish I had the URL's at hand...

1. Study was done where field techs had choice about spinal immobilization. In a very significant percent of times, receiving hospital personnel disputed the decision. The study did not cite a corresponding prevalence of undxed spinal fx and associated morbidity. (Ergo, hospital people want their feeder techs to pkg their patients no matter what).

2. Spinal immob once pt was in hosp (i.e., keep pt on board even afer MD in ER has cleared pt to go to radiology), versus just wheeling them cautiously around, in most cases yielded no significant benefit. (Ergo, people in hospitals need to remember that a long board is not a Stryker frame, and that spineboards, stiff C collars etc were intended for extrication and transport).

Locally the County EMS office, weak as it sometimes is, made this pronunciamento: "Everyone shall have the same boards, and when you drop off a pt you just take a board set that's is already there and leave yours". Effect was intended to make the process faster and hence encourage spinal immob, but the actual effect has been that people buy cheaper straps and headblocks, then cherry-pick the boards left at the ER.