first spine boards now the c-collar?

[Veneficus]

Does anything in EMS actually work?

"Study prompts worries that cervical devices may harm some patients"

http://www.emsresponder.com/publication/article.jsp?pubId=1&id=13772

 

[MrBrown]

Does anything in EMS actually work?

Not on our budget

This doesn't strike me as being much different than other things ambos did which turned out to maybe not be the best; D50 vs D10, secondary brain injury caused by intubation and hyperventilation, spine boards, MAST pants ...

 

[SeeNoMore]

It is so depressing I want to jump out of the back of a moving vanbulance.

But all in all I guess it's good that we know. What terrifies me is how many EMS people I know that don't even have the barest hint of interest in studies like these.

EMS needs national oversight, and we need a new way of doing things. There are so many systems that use outdated ways of thinking and methods, and seem in no danger of getting better.

Make me hate this field.

 

[reaper]

Not something to really worry about. Very small number of pt's.

 

[adamjh3]

This quote was particularly interesting to me, I'll do a little more research and come back with an opinion on it

Additional research published by the Journal of Trauma also found higher mortality in victims of penetrating trauma who were spine-immobilized.

 

[Stephanie.]

There is now a company making the 'X COLLAR' which allows you to stabilize the head and spine in any position found. They say that it should be less compromise when holding c-spine.

http://www.xcollar.com

 

[adamjh3]

There is now a company making the 'X COLLAR' which allows you to stabilize the head and spine in any position found. They say that it should be less compromise when holding c-spine.

http://www.xcollar.com

As I understand it, the C-collar was designed to limit flexion of the neck and to keep the weight of the head from compressing the cervical spine. So "immobilizing" (it's really restriction, there is no way to obtain full immobilization in the prehospital setting) the neck in the postion it was found seems hardly beneficial. Someone correct me if I'm wrong?

 

[terrible one]

Have you ever had to be "immobilized" with a c-collar and LSB?
Not surprised they can do more harm than good at all. In fact I'd like to see a study where it shows just how effective they really are.

 

[FLEMTP]

This quote was particularly interesting to me, I'll do a little more research and come back with an opinion on it

Additional research published by the Journal of Trauma also found higher mortality in victims of penetrating trauma who were spine-immobilized.

The reason is because these patients need an OR for repair of their injuries... putting someone in spinal motion restriction takes time...and time is the one thing that these patients do not have when dealing with penetrating trauma

 

[rhan101277]

Here, if no nuerologic deficits or complaints are found for a penetrating injury then spinal immobilization is not indicated.

 

[firetender]

One of the most amazing aspects of publishing my book 25 years after leaving EMS was that MOST if not all of the drugs and procedures I was dependent on to save lives back then have been debunked if not banned!

But I saved lives. Sure, not as many as they told us we'd be able to save using these new-fangled procedures, but taking action in the ways we did sometimes worked. This, then, becomes an exploration into the Great Mystery.

Because throughout history, EVERY quack cure has cured SOMEONE, maybe many ones until they were de-bunked, or in so many cases trampled by competing economic interests.

Think I'm kidding? The AMA took precedence in our health care system because it literally "beat out" the lobbying and advertising efforts of Homeopathy and Chiropractic, two different schools of thought.

Drugs and surgery became the treatments of choice not because of their proven value but because of the economic support of those corporations who provided the practitioners with the tools. The sad part of the gig, though, was most often the tools don't work. But because other corporations are set up to develop other tools that just "might", they keep up a supply of things to try. Just look at medications in EMS. Perhaps the minimization of the other philosophies was based on their lack of "toys" to create. Essentially our medical system, headed by Physicians, became a true "Delivery" system.

These corporations are still guiding us, especially in EMS. Death is still winning; no matter what we throw at it. Trust me, most of what YOU are using will have been found marginally effective, if not banned, 25 years from now.

Think I'm kidding? How about this; the ONLY thing I offered back then that has been proven to REALLY makes a difference is rapid intervention with defibrillation!

 

[Aidey]

The longer I do this, the more I have come to dislike c-collars (and backboarding in general). We take these hard, unforgiving things and try and make our patients conform to them...it just doesn't make any sense to me. I would love to see some sort of malleable foam pieces that could be cut or molded to fit each patient exactly. Or even a mold with a foam spray if you want to get really crazy. It wouldn't work to well for patients lying down, but for those sitting up with 360 access it could have potential.

 

[sdadam]

I've been preaching this for years! And been yelled at and called stupid for doing so a lot of the time.

Here is a thread from a while back where a lot of good info was posted about both backboards and c-collars:

http://www.emtlife.com/showthread.php?t=15864

 

[Melclin]

Not suprised.

I hate spinal immobilization. Have done ever since I got fully immobilized in class and realized how little it prevents movement and how much extra pressure and strain its causes. I was not surprised when I discovered this was supported in the literature.

I don't think that spinal immobilisation should be too formula based. I think things like collars and and KEDS and boards should be used to augment the whole process of minimizing movement. But they do not in themselves offer a perfect answer. Regarding the issue of multi-trauma, if providers were educated enough to properly understand the physiological state that a patient is in, and the real medical priorities for that patient, then I don't think you would find any increased mortality in trauma pts simply because a collar was used. Instead however, you have idiot 1 fumbling with the O2 regulator trying figure out why his NRBM will not inflate, while idiot 2,3 and 4 take 10 minutes to immobilize the patient based on MOI exactly as the "EMT for idiots" text says, ignoring the fact that they are actually moving the pts neck more because of it. Once the pt is out, idiot 2 takes 10 minutes to start an IV, and run fluids wide open into a patient with penetrating chest trauma.

 

[Ravemtech]

Hi Melclin,

When you were immobilised in class, did the person immobilising you correctly follow Ambulance Victoria's (AV) WI 5.1.11 (ie padding under the torso, head and lumbar). Most people fail to pad and this leads to pain and pressure sore development. Strapping is also often done incorrectly thus allowing too much movement.

The attached document below (which also includes WI 5.1.11) is with Ambulance Victoria at the moment and reviews multiple studies on padding Boards, and the significant difference it makes.

Anything is dangerous when done incorrectly, or to a poor standard, or inappropriately. Research clearly supports Boards are comfortable when used correctly. There are no studies that demonstrate Boards are dangerous when used correctly, but many studies do show complications with Boards when used incorrectly.

But as you said, there is no perfect answer, but since AV introduced the Board in the mid 1990's, we are significantly better off than without. It is just too many have forgotten what it was like before we had Boards and too many fail to use the Board correctly leading to problems.

 

[Melclin]

I don't think that spinal immobilisation should be too formula based. I think things like collars and and KEDS and boards should be used to augment the whole process of minimizing movement. But they do not in themselves offer a perfect answer.

Bolded for emphasis.

The formulas I was getting at were things like, "All trauma pts are boarded, collared and strapped. FULL STOP". "All falls are immobilized" etc. Being as it is that MOI is a poor indicator of occult injury.

When you were immobilised in class, did the person immobilising you correctly follow Ambulance Victoria's (AV) WI 5.1.11 (ie padding under the torso, head and lumbar). Most people fail to pad and this leads to pain and pressure sore development. Strapping is also often done incorrectly thus allowing too much movement.

The attached document below (which also includes WI 5.1.11) is with Ambulance Victoria at the moment and reviews multiple studies on padding Boards, and the significant difference it makes.

Anything is dangerous when done incorrectly, or to a poor standard, or inappropriately. Research clearly supports Boards are comfortable when used correctly. There are no studies that demonstrate Boards are dangerous when used correctly, but many studies do show complications with Boards when used incorrectly.

But as you said, there is no perfect answer, but since AV introduced the Board in the mid 1990's, we are significantly better off than without. It is just too many have forgotten what it was like before we had Boards and too many fail to use the Board correctly leading to problems.

Yeah it was done to the letter of the law on account of the fact that it was the first time we'd had the procedure demonstrated. Took forever. Never seen it done that way on the road though, which, I suppose echos your point.

Don't get me wrong. I think spinal immobilisation has a role. The derisive tone in my post above was not directed at Australian practices, but rather at the American obsession with boarding everyone.

My objection to certain uses of the long board is not based on my experience of it being uncomfortable. It was just an anecdotal introduction to my point.

Thank you for that document. Very interesting indeed. I have to admit I was not familiar with the extent of research into improving comfort. I've been a massive fan of vacuum mattresses for a while too. None the less, what the research says to me is that boards are less uncomfortable, not comfortable per se. That means that if a person is pointlessly immobilized, then they may still have iatrogenic back pain, albeit less according to a VAS. The fact remains that when an otherwise perfectly healthy person roles into ED after being on a board for 45 mins, and are asked if they have back pain, they will still say yes, regardless of reductions in VAS, which will then lead to the various pointless investigations. My point is that spinal immobilization is not benign and it should only be applied when indicated, as I'm sure you agree with, and not used in "all trauma" or "all falls" as is still the case in some parts of the US.

The other thing I was getting at when I said 'augment' is that in a non compliant pt who is intoxicated etc, the lesser of two evils may be just to put them on the stretcher and coach them to lay still (+/- a collar, +/- strapping etc,) rather than wrestling them all the way to the ED while they do themselves a great deal more damage despite being 'immobilized'. That approach seems common here, but I couldn't count the amount of times I've heard stories on this forum about pts being sat on while they swing punches.

Additionally, I have a big problem with seriously ill trauma pts and sometimes medical pts (paging Vene to beat me over the head for making that distinction ) being immobilized without indication at the expense of timely transport. Pt experiences syncope of apparently cardiac origin, no indications for spinal immob, clear inferior STEMI, cardiogenic shock, 15 minute scene time blow out because of a "fall" from standing hight. But its okay because they're being "treated for shock" by the firefighter who is holding their legs in the air. That's what I have a problem with.

 

[Akulahawk]

Cervical collars are basically a reminder tool. They generally remind the patient to NOT move their neck. Nothing you can do prehospitally is going to completely immobilize the neck. In fact, the patient him or herself is far more capable of minimizing spinal movement as long as they have motor control over that area than any external device we have available in the field.

Placing someone in full spinal precautions is not a benign event. Unless they're well padded and supported or you can get the patient off the board fairly quickly, you just bought them a stage 1 decub or a few within a relatively short time (like less than an hour). Fortunately, those heal rather quickly. I'm a huge fan of vacuum splints simply because they do fill voids well and allow good weight distribution and support. They can delay onset of decub ulcers for a long time.

Really, it's little wonder why the ED takes the patient off the board as soon as they can. Done right, those boards do help with patient transfer, remind the patient not to move, contain gross movement... but get them off as soon as possible.

Something to remember: No injury can happen without a mechanism. Not all mechanisms will lead to injury. If you know the mechanism and body/injury kinematics, you can get a pretty good idea where you'll find an injury and where you're not likely to find an injury.

In other words, with traumas, the MOI will tell me where to look and what to be suspicious for. I won't triage to a trauma center based on MOI alone.

 

[Melclin]

Something to remember: No injury can happen without a mechanism. Not all mechanisms will lead to injury. If you know the mechanism and body/injury kinematics, you can get a pretty good idea where you'll find an injury and where you're not likely to find an injury.

In other words, with traumas, the MOI will tell me where to look and what to be suspicious for. I won't triage to a trauma center based on MOI alone.

Definitely. If you smack your arm against against a sign post, I'll look at your arm. This often comes up a lot and I'm sure I'm not telling you anything akulahawk, but just to clarify my position and for those playing at home:

There is a difference between targeting your assessment based on mechanism to look for certain types of injuries, and assuming that because of the mechanism, there must be injuries. In the absence of injuries on examination that are indicated by mechanism, 'extremity' of MOI alone is a poor indicator of occult injuries as far as I know.

 

[emt_irl]

The longer I do this, the more I have come to dislike c-collars (and backboarding in general). We take these hard, unforgiving things and try and make our patients conform to them...it just doesn't make any sense to me. I would love to see some sort of malleable foam pieces that could be cut or molded to fit each patient exactly. Or even a mold with a foam spray if you want to get really crazy. It wouldn't work to well for patients lying down, but for those sitting up with 360 access it could have potential.

there is such thing. A vaccum mattress, there only new enough in our system but in our spinal cpg it says lsb or vaccum matters. it moulds around them and fully immboalises/splints their entire body

 

[zmedic]

Speaking on MOI, I understand the spinal cord is one long piece, but it still doesn't make sense to me that someone who is shot in the chest needs a c-collar. I haven't been convinced that moving the head really moves the spinal cord in the chest/lumbar region much. The converse also goes for whiplash injuries. Those patients leave the hospital in a c-collar, walking. So I don't understand why someone who gets rear ended at 20 MPH, has neck pain but no back pain needs a board. Just collar them. I know that hasn't been proven with research but someone should get on it.