Omission of spinal precautions

[Brandon O]

That fact is the whole reason the "board & collar everybody, even if they are perfectly fine" thing came to pass.

Where did that originally come from, anyway? Was it a reccomdation from ACOS or ACEP, or just something done textbook author postulated might be a good idea?

"Kossuth is recognized as the first physician to champion the need for accepted methods of extrication, which include protection of the cervical spine ( 19). Farrington is credited with thrusting the concept of prehospital immobilization into the arena of conventional medicine (20,21). According to **** and Land, the first widely distributed emergency medical service (EMS) textbook to address the specific techniques of immobilization was Grant and Murray’s Emergency Care in 1971 (22). In 1974, Hare invented an extrication-type collar that replaced the then-standard use of soft collars or a rolled-up blanket (22)."

19: http://www.ncbi.nlm.nih.gov/pubmed/5851121
20: http://medicteacher.com/EMTP2012/Death_in_a_Ditch_1967.pdf
21: http://journals.lww.com/jtrauma/Cit...ication_of_Victims_Surgical_Principles.2.aspx

Many injuries to the spinal cord are not immediately known. Instability presents in many ways as with swelling and movement. This should be clearer for those who have experienced an injury themselves moving a patient or in sports. It doesn't feel like much at first but later you are incapacitated. We see patients in the ER all the time who felt fine at the MVC and may even have been checked out by EMS for a spinal clearance. Some are just sore and some do have serious injuries which might require months of PT and maybe even surgery.

All very true. In fact, this is predominantly the true behavior of deteriorating spinal injuries, not the sudden early catastrophic worsening associated with movement. But there's very little reason to think that prehospital immobilization techniques can prevent this, and at least some reason to think it could make things worse.

The surgical intervention is usually not stabilizing but laminectomy to relieve compression.

 

[Clipper1]

All very true. In fact, this is predominantly the true behavior of deteriorating spinal injuries, not the sudden early catastrophic worsening associated with movement. But there's very little reason to think that prehospital immobilization techniques can prevent this, and at least some reason to think it could make things worse.

The surgical intervention is usually not stabilizing but laminectomy to relieve compression.

Why believe there is only one option with the long spine board? Why just throw care or caution to the wind and not limit movement even if a verbal instruction? Some can have a rolled towel to remind them to no move. Some could be in position of comfort with a leg or both legs raised to prevent them from moving out of pain. The problem is that other alternatives are not being discussed but rather just backboard or nothing. This mentality has lead to little acceptance for alternative immobilization devices which might be available commercially or for the development of new protocols.

You would be surprised at how many patients are transferred to neuro centers for surgical intervention. It may not be the TV style rush to the ER but rather an admission to the unit or floor for awhile to determine the extent of injury and to prep the patient for the OR. Some might be given choices and some might not.

 

[Brandon O]

Why believe there is only one option with the long spine board? Why just throw care or caution to the wind and not limit movement even if a verbal instruction? Some can have a rolled towel to remind them to no move. Some could be in position of comfort with a leg or both legs raised to prevent them from moving out of pain. The problem is that other alternatives are not being discussed but rather just backboard or nothing. This mentality has lead to little acceptance for alternative immobilization devices which might be available commercially or for the development of new protocols.

I generally agree. In most cases a low-impact compromise can keep movement reasonable without aggressive and harmful immobilizing measures. This approach is finally gaining traction prehospitally as well.

You would be surprised at how many patients are transferred to neuro centers for surgical intervention. It may not be the TV style rush to the ER but rather an admission to the unit or floor for awhile to determine the extent of injury and to prep the patient for the OR. Some might be given choices and some might not.

Yes, of course. But this should not imply that all of those people should have been wearing a collar. Apples and oranges.

 

[Brandon O]

Okay, you inspired me to get off my butt. I recorded a little tutorial to how I look at this stuff below (using head injury as an example, but it's essentially the same dynamic as spine injury).

[YOUTUBE]http://www.youtube.com/watch?v=B3qe2QrGYa4[/YOUTUBE]

 

[VFlutter]

Okay, you inspired me to get off my butt. I recorded a little tutorial to how I look at this stuff below (using head injury as an example, but it's essentially the same dynamic as spine injury).

Is there any difference between harming your patient with your actions as opposed to your inaction? Is being aggressive and causing harm worse then being prudent and allowing harm?

 

[Brandon O]

Is there any difference between harming your patient with your actions as opposed to your inaction? Is being aggressive and causing harm worse then being prudent and allowing harm?

I would agree with the utilitarians and say ethically no. But medicolegally, you are probably more likely to get sued for missing something or failing to offer care than for the expected harms of over-treatment.

But if you can engage the patient in this decision via informed consent, this risk should be negligible either way. There's really very little reason that our belief system should be the one in control here; it's the patient's butt on the line, ask them.

 

[Melclin]

I don't think it is our place to make decisions based on how we perceive the patient's quality of life, or whether we think they are candidates for surgery, etc.

We already consider it to be our place in some circumstances. Certain patients are not candidates for RSI due to their comorbidities/quality of life issues. Cardiac arrest resuscitation decisions are made in regards to this idea. Transport decisions are often made based on this idea. A 93YO bed bound nursing home pt with 20 different medical problems, and is severely demented who has fallen with an obvious skull fracture probably isn't getting flown to a trauma centre.

So either you agree that none of these decisions are ours to make (are they anybody's?) or you say that they are an quibble about the threshold for making them.

I don't think you can omit questions like the effectiveness of the treatment. What you're trying to establish is the risk vs. benefit of the intervention, and that requires weighing both sides.

....

And I would have no problem documenting that, even in cases where a protocol does have things to say. I have brought in patients sans immobilization, with collar but no board, and many other variations because the harm clearly outweighed the risk. These are judgment calls (nurse: "yeah... I don't think she's going to let you put her in a collar..." you: "okay!"), so again, they require a pretty nuanced and intelligent understanding of the risk/benefit, but they're also fairly common sense.

Ethically, a shared decision with the relevant decision-makers (family, etc.) is certainly best. But when granny's lying on the tile and nobody's sure who to call it can be a little tricky to bake that cake in time.

I agree with all of the above with the exception of the issue of omitting discussion of efficacy.


Also, when it comes to a thread like this, you have to focus discussion a little. I didn't want another thread about the efficacy of spinal immobilisation. You know from our correspondence how I feel about spinal immobilisation and I think most of us are pretty down with it being a bit of a joke. None the less, it is the current standard of care. So if the person can't be cleared or there is a good reason not to immobilise in the normal fashion (ie curvature of the spine, CCF). I wanted the discussion to focus on whether or not the "too old and infirm for definitive treatment" argument was one of those good reasons, which it has.

The other issue is that with a case like this, none of the normal reason to modify immobilisation (curvature of the spine, CCF) were really apparent. With a soothing touch, a healthy dose of morphine and proper padding I think I probably could have cajoled her onto a stretcher or a vacuum mattress brought in by another crew. Or maybe I couldn't. Point is I didn't try because of the other reason. Hence the discussion.

 

[Brandon O]

Also, when it comes to a thread like this, you have to focus discussion a little. I didn't want another thread about the efficacy of spinal immobilisation. You know from our correspondence how I feel about spinal immobilisation and I think most of us are pretty down with it being a bit of a joke. None the less, it is the current standard of care. So if the person can't be cleared or there is a good reason not to immobilise in the normal fashion (ie curvature of the spine, CCF). I wanted the discussion to focus on whether or not the "too old and infirm for definitive treatment" argument was one of those good reasons, which it has.

The other issue is that with a case like this, none of the normal reason to modify immobilisation (curvature of the spine, CCF) were really apparent. With a soothing touch, a healthy dose of morphine and proper padding I think I probably could have cajoled her onto a stretcher or a vacuum mattress brought in by another crew. Or maybe I couldn't. Point is I didn't try because of the other reason. Hence the discussion.

Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) and benefit seems negligible, your threshold for surrender might be very low, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.

 

[Rialaigh]

Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) and benefit seems negligible, your threshold for surrender might be very low, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.

I think this is the key. Like I said earlier in the thread I'm not all about "forcing" treatments onto people that are confused as long as they are not an immediate harm to themselves or others. Confusion does not equal inability to refuse treatment unless there is a really strong belief that refusing treatment will cause immediate harm to themselves.

If I have a patient as described by the OP, and I start to feel around the neck and ask if they want to be place in a collar and the patient pushes my hand away, I am taking that as a refusal of that service.

 

[Bullets]

Fall from a standing height, with a contusion on the occiput, i may not even consider applying SMR to the patient anyway.

Considering her history of osteo-degradation the possiblity exists for a fracture, but once we arrive, the fracture has occurred and there is little that is going to change that. I find the concept of an "unstable" cervical fracture to be a misnomer. A recent study evaluated the force needed to further exacerbate a fracture in pigs that had previously undergone surgical instability. Basically its physically impossible for the patient to apply the force needed to exacerbate the injury and the manipulation performed by EMS comes no where close. now i gotta find that link....

Also, what are we considering altered here? If the patient has dementia, and they dont know where they are, is that altered for them? or is it their normal mentation?

If i have to immobilize, i am preferring the scoop as the channel is more comfortable, but that is all going to change once we get the vacuum mattress!

 

[Melclin]

Sure, but you're already raising the question again. Should you beg, cajole, wheedle, invoke doctors, delegate family, threaten, reason, or otherwise lean on someone to undergo an intervention? We ALWAYS make that determination based on how essential it strikes us based on our clinical impression, regardless of whether checking off the box is strictly speaking the standard of care. You would move mountains to get the obvious STEMI to come to the PCI center. In this case, since the harms seem significant (even just the discomfort and inconvenience) and benefit seems negligible, your threshold for surrender might be very low, and I don't think that's wrong. I don't even think it's in opposition to the idea of spinal immobilization per se; it's merely placing it upon the spectrum of value rather than considering it sine qua non.

Threshold for surrender. Hahaha. I like that term and will shamelessly thieve it in the future.

You're quite right, of course, which is no surprise given how much you know about this topic (Feel like doing a guest lecture series convincing everyone around here of the idea? My understanding is that several of the boss cocky trauma docs here are ultra conservative about the issue and Australia in general I believe is a bit behind in this regard).

You can't completely remove efficacy from the discussion. Nor should you. I really just wanted a little focus on the aforementioned part of the problem rather than it being an entirely "boarding doesn't work anyway so don't worry about it" type of thread.

Fall from a standing height, with a contusion on the occiput, i may not even consider applying SMR to the patient anyway.

Really? I feel like a standing height fall in a pt of her age and comorbidities is plenty to produce a significant fracture

....

A recent study evaluated the force needed to further exacerbate a fracture in pigs that had previously undergone surgical instability. Basically its physically impossible for the patient to apply the force needed to exacerbate the injury and the manipulation performed by EMS comes no where close. now i gotta find that link....

I always suspected that the spinal cord would be pretty hard to damage from wee little movements of the neck etc, but I'd never seen it in the literature. I had a trip to one of the local butchers (who often helps us out in the err... anatomy department) planned to do some pseudo-science. Have you got a link to that or similar research?

Also, what are we considering altered here? If the patient has dementia, and they dont know where they are, is that altered for them? or is it their normal mentation?

Hang about...where is the altered bit coming into it?

If i have to immobilize, i am preferring the scoop as the channel is more comfortable, but that is all going to change once we get the vacuum mattress!

Yep. Vac mats are the bees knee's. They certainly don't fix all the issues though. They are still pretty uncomfortable.

 

[Arovetli]

I would opine from a legal standpoint, that it is good to note differences in legal systems among countries, and that, even though you might not realize this, legal philosophy underlies alot of what we do.

In the US, we have a much more fragmented legal system and a greater focus on common law, and this philosophy does effect the way we practice medicine...and as an extension, the way we work as paramedics.

SMR is so prevalent and persistant because it is what we have always done, so to speak. It is the common law of Prehospital trauma. And thus, it has a weight that is very difficult to overcome.

In countries such as Australia, the legal philosophy is different, and their laws are much less fragmented. This is why in other countires their EMS systems seem more progressive.

It is difficult to make changes in America, because you have to overcome the fact that SMR is how it was always done, and a peer comparison judgement system compares progressives against a large conservative mass.

American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care. Say the case of the canadian rules. I believe statistically in 4 out of a thousand instances it will not catch an injury, and to combat this liability the very few (.004) dictate the course of the many.

Our philosophies of law and economics can really screw up a feld like medicine which is progressive, research driven, evidence based, and should change quickly.

But, this is America, and it is how we have always done things.

 

[Brandon O]

American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care. Say the case of the canadian rules. I believe statistically in 4 out of a thousand instances it will not catch an injury, and to combat this liability the very few (.004) dictate the course of the many.

Although this is neither here nor there, in most studies the Canadian C-spine rule has been 100% sensitive for "clinically important" injury (defined a priori with a pretty conservative definition). For adult patients, anyway.

The lowest sensitivity when applied by doctors or paramedics has been 99.4%, which for the prevalence of 2% would mean .00012% missed injuries, or .12 in 1000 -- call it 1 in 10,000. Of which even fewer than that will have any neurological sequelae and something close to zero (perhaps zero) could have been prevented. I'm a conservative guy, but at some point you have to be willing to let the scale tip.

I haven't seen the 4 in 1000 number. If there's a study floating around that I've missed, let me know.

 

[Arovetli]

no, you are correct. that is what i get for trying to rely on remembering an old number and my memory.

regardless i was trying to point out how minimal the error is in the rules, yet how difficult it is to implement them, and have them accepted. The overwhelming propensity is to push against change. Conservatism dominates our thought, and this is reflected in medicine as well.

however you make my point, because it matters not what paper you pull off pubmed, or what actual number gets quoted, outside of medicine, nobody really cares. clinicians would do well to learn this. we like to argue our knowledge of statistics and numbers and who is right and who is wrong but...

while it really does matter inside the medical bubble....outside of it, to administrators, politicians, businessmen, lawyers, and anyone else holding the reins, it doesn't matter, but one day it will, perhaps.

philosophy of thought and money dictate care far more than any study.

and our philosophy of thought is anything but grounded in science.

because for so long, there was no science, and other methods of reasoning were developed. Hence why Stephen Hawking denounced philosophy for science as a thought methodology, as he believes we are to a stage where the scientific method should guide our thinking. But we are still largely dominated by philosophers of old.

when your thinking has been developed over thousands of years, and it has developed to favor slow change, it is unlikely to change quickly.

 

[Arovetli]

I'm a conservative guy, but at some point you have to be willing to let the scale tip.

But, would you consider adherence to past methods and a sluggish change process a safeguard?

Is it better for one good change to be implemented incrementally in order that 9 bad changes are not implemented quickly?

 

[Brandon O]

Yes. But obviously I'd rather not be either kind of idiot.

I think you're correct in all respects. However, I also think that change can happen surprisingly easily when someone's simply willing to take the first step. That's what most of this comes down to; whether or not there's any real liability to implementing a new approach, it's more that nobody wants to be first out the door. Often the decision-making locus is literally one person (head of a department, medical director of a state's EMS office, or similar). When they're reluctant, that ripples down to create a gigantic boulder of inertia, but similarly, if they're willing to step out from the bulwark, the whole boulder moves with them. We're just starting to see this happening with prehospital spinal immobilization.

It's not like this is the worst example of physiologically-based care turning into dogma without any evidence on outcomes. But for EMS it's probably the most implemented, and in terms of sheer volume, it's therefore impacting the most people.

And it's the most irritating to me.

 

[Arovetli]

American malpractice philosophy affects so much of what we do, so while it is nonsense, it can largely dictate care.

let me restate another way,

Our legal process is slanted against the scientific method. To introduce a study into evidence, it must adhere to a body of odd rules of admissibility. Rules which were crafted well before the scientific method existed.

A much different vetting process.

While it would matter not in reality, if the expert witness took the stand with mustard on his tie, a jury may disregard his opinion and the weight of evidence and science solely because he is a sloppy eater.

Tie mustard ought not outweigh science, but it certainly can.

 

[Arovetli]

Yes. But obviously I'd rather not be either kind of idiot.

I think you're correct in all respects. However, I also think that change can happen surprisingly easily when someone's simply willing to take the first step. That's what most of this comes down to; whether or not there's any real liability to implementing a new approach.

indeed there is colossal "liability" in being the first guy out the gate. If you are doing something different than everyone else, you stand out from the crowd.

In a legal system that favors the crowd, you are the odd man out.

When 99 of your peers perform a different way, you have a hurdle to surmount in getting your behavior accepted.

There is some work on establishing so-called safe harbor legislation, creating immunity for actions performed based on a scientific expert consensus, to encourage faster change in medical practices.

To change things, It is just as important to write laws as it is to publish studies, a fact often overlooked.

 

[Aidey]

There is some work on establishing so-called safe harbor legislation, creating immunity for actions performed based on a scientific expert consensus, to encourage faster change in medical practices.

On the state level or federal level? If it is the federal level, who do we talk to to get involved with that?

 

[Brandon O]

A recent study evaluated the force needed to further exacerbate a fracture in pigs that had previously undergone surgical instability. Basically its physically impossible for the patient to apply the force needed to exacerbate the injury and the manipulation performed by EMS comes no where close. now i gotta find that link...

Pass it along if you do, please.