I have only been a medic for three years so maybe that is the cause for my trepidation. I don't understand any reason to put a c-spine clearing criteria into protocols. I backboard and c-collar anybody with mechanism regardless of pain. Now for your pt I would have used a scoop to avoid rolling and towel rolls, a pillow or even a cut up blanket. I have even transported kyphotic pt's with there head taped to my stretcher with towel rolls. The hospitals have better collars that can fit pt's with no necks. My question that no one seemed to address is what if the rib pain which is extremely painful was hiding any neck or back pain? Until medics can carry malpractice insurance I wouldn't risk it. As a lifeguard I saw a kid break his neck diving into the water from a 1.5 meter board. He didn't have any pain just heard a pop. My point is he hit the water awkwardly and broke his neck. He had no further injury because my guards boarded him but I wouldn't want to be the medic on the one call that was the exception to the rule. Plus you would get destroyed in court. Which is better, an $800 bill that can be written off or even reduced, or being paralyzed for the rest of your life?
1,2 are just two papers discussing the fact that mechanism has almost not worth in predicting occult injury in general.
From (3):
The current practice of immobilising trauma patients before hospitalisation to prevent more damage may not always be necessary, as the likelihood of further damage is small. Means of immobilisation include holding the head in the midline, log rolling the person, the use of backboards and special mattresses, cervical collars, sandbags and straps. These can cause tissue pressure and discomfort, difficulty in swallowing and serious breathing problems.
The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.
(4) Is one example of the mistake free application of C-spine clearance.
From (5):
Comparison of spine injury patients from 2 study populations, one with out-of-hospital spinal immobilization and the other without, showed a higher rate of neurologic injury in the immobilized group. Acute spinal immobilization may not have significant benefit for the prevention of neurologic deterioration from unstable spinal fractures.
So:
-We have decent tools (NEXUS and CCR) to inform the hx taking and physical exam.
-The evidence clearly exists that they as well as other clinical indicators are quite safe to use.
-There is no evidence to support the use of spinal immobilisation.
-There is some evidence that it may in fact cause more harm than good, especially when misused as it often is.
-Spinally immobilising if nothing else causes pain, anxiety and discomfort as well as costing the system quite a bit extra.
So tell me again why you're immobilising everyone who crosses your path based on mechanism?
A few other points:
-You cannot possibly know that the kids immobilisation is what prevented further injury. To suggest it as fact is absurd.
-Aren't you covered by your covered by your agency/medical director in terms of insurance?
-The fear of being sued, often evident on this board, seems dramatically disproportionate with the actual likelihood of being sued. On top of that them winning is a whole other board game, so I'd like to think that providers wouldn't practice in some archaic and probably harmful way based on some silly fear of lawyers.
(1)Boyle MJ, Smith EC, Archer F. Is mechanism of injury alone a useful predictor of major trauma? Injury. 2008;39(9):986-92.
(2)Domeier RM, Evans RW, Swor RA, Hancock JB, Fales W, Krohmer J, Frederiksen SM Shork MA. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehospital Emergency Care. 1999;3(4): 332-337.
(3)Kwan I, Bunn F, Roberts IG. Spinal immobilisation for trauma patients. Cochrane Database of Systematic Reviews 2001, Issue
2. Art. No.: CD002803. DOI: 10.1002/14651858.CD002803.
(4)Armstrong BP, Simpson HK, Crouch R, Deakin CD. Prehospital clearance of the cervical spine: does it need to be a pain in the neck? Emergency Medicine Journal. 2007;24(7):501-3.
(5)Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Academic Emergency Medicine. 1998 ;5(3):214-9.
