The Importance of Being Spinally Immobilized

[Journey]

Originally Posted by Jon
Heres the thing - has there ever been a clinical trial showing that spine boards prevent any injury whatsoever?

Not to my knowledge, only showing harm.

But in fairness I think it would be impossible to create such a study.

Actually there is extensive research since the manufacturers also have to prove their device has some function. Cervical immobilizartion and LSBs are also researched by several different professionals in a variety of situations for patient care. Physiatrists, Sports Medicine Physicians, Physicial Therapists, Neurologists, NeuroSurgeons and various Neuro centers are constantly doing research. There are many, many groups with a vested interest in SCIs and how to build better equipment to prevent and stabilize these injuries. There are journals with this info and the studies in them. Sometimes EMS professionals may not see the depth or where all the data comes from. The problems also lie in lack of communication between EMS and the other disciplines or some realizing the learning curve associated with EMS to get everyone up to speed on the latest practices. Discussions with th e manufacturers of ambulances and the cots may also be needed to adapt better devices. Many of the concepts that are now just trickling in to EMS such as CPAP and hypothermia have been around for several decades but they are very new to EMS.

Occasionally in the hospital we seen an X-ray or CT Scan while the patient is immobilized that elicits an "oh crap" response from everyone in the room. We realize how lucky that patient and the staff were that there was some type of support when the patient was moved from gurney to sled. Of course we don't like the patient to stay on the board any longer than they have to and we will fill in the gaps for support until we know which direction we will move the patient. It doesn't take much to pull up cases where the X-rays and/or CT Scans were done with a C-collar or a LSB.

What also may skew some studies is the "manual traction" that some EMTs are taught in school. It does not take that much force and usually it is just to prevent movement rather than trying to put up the socks through the neck. So it may not entirely be the C-collar's fault but sometimes trying to make a neck fit into something it should can be a problem. Alternatives should be taught and discussed if you do not have the correct size and the proper amount of force applied to "align" and hold the neck in traction during extraction might be further examined.

In the hospital, we will only use something resembling LSBs to move patients from one bed to another. However, we have many other devices and special beds that restrict movement. We may also not allow the patient to bend at the waist and will do a reverse trendelenburg to achieve a 30+ degree angle for the head of the bed. Some patient may remain in a C-collar for 4 - 16 weeks even after their neck has had some repair. It will depend on the injury and the structures involved. Spinal injuries are not always that obvious and can be difficult to assess especially if there is an associated TBI. There have been several that have fooled even the ED physicians and have slipped through the assessments until the patient presents as a quad at home in his bed the next day.

 

[usalsfyre]

So I agree with some of this, but...

Actually there is extensive research since the manufacturers also have to prove their device has some function. Cervical immobilizartion and LSBs are also researched by several different professionals in a variety of situations for patient care. Physiatrists, Sports Medicine Physicians, Physicial Therapists, Neurologists, NeuroSurgeons and various Neuro centers are constantly doing research. There are many, many groups with a vested interest in SCIs and how to build better equipment to prevent and stabilize these injuries. There are journals with this info and the studies in them.

Laboratory research saying a device reduces the cervical motion of a cadaver by "x" amount is not the same as large scale clinical research. Show me large scale clinical trials involving immobilization vs no immobilization. They don't exist. The thought of such a study has IRBs quaking in their boots. I'm not convinced based on lab research of current methods they'd find much difference though, even if they could be done.

Sometimes EMS professionals may not see the depth or where all the data comes from. The problems also lie in lack of communication between EMS and the other disciplines or some realizing the learning curve associated with EMS to get everyone up to speed on the latest practices. Discussions with th e manufacturers of ambulances and the cots may also be needed to adapt better devices. Many of the concepts that are now just trickling in to EMS such as CPAP and hypothermia have been around for several decades but they are very new to EMS.

Agreed, EMS "immobilization" is pretty well ridiculous. Even when you try to bring people up to speed, there is pushback. Some of the reasons certain technology is just making it to EMS though has to do with cost and portability.

Occasionally in the hospital we seen an X-ray or CT Scan while the patient is immobilized that elicits an "oh crap" response from everyone in the room. We realize how lucky that patient and the staff were that there was some type of support when the patient was moved from gurney to sled. Of course we don't like the patient to stay on the board any longer than they have to and we will fill in the gaps for support until we know which direction we will move the patient. It doesn't take much to pull up cases where the X-rays and/or CT Scans were done with a C-collar or a LSB.

Just because a collar or board was in place doesn't mean it provided any reasonable level of support. I'm not so much "anti-SMR" as I am anti-current EMS SMR methods. I just haven't seen anything that makes me think they work

What also may skew some studies is the "manual traction" that some EMTs are taught in school. It does not take that much force and usually it is just to prevent movement rather than trying to put up the socks through the neck. So it may not entirely be the C-collar's fault but sometimes trying to make a neck fit into something it should can be a problem. Alternatives should be taught and discussed if you do not have the correct size and the proper amount of force applied to "align" and hold the neck in traction during extraction might be further examined.

I don't ever being taught to apply traction. If the collar doesn't fit, I ditch it. To many providers don't though.

In the hospital, we will only use something resembling LSBs to move patients from one bed to another.

I'm not sure a beefed up smooth mover to th

However, we have many other devices and special beds that restrict movement. We may also not allow the patient to bend at the waist and will do a reverse trendelenburg to achieve a 30+ degree angle for the head of the bed. Some patient may remain in a C-collar for 4 - 16 weeks even after their neck has had some repair. It will depend on the injury and the structures involved. Spinal injuries are not always that obvious and can be difficult to assess especially if there is an associated TBI. There have been several that have fooled even the ED physicians and have slipped through the assessments until the patient presents as a quad at home in his bed the next day.[/QUOTE]

 

[usalsfyre]

Because I'm all thumbs and attempting to use tappatalk for the first time, here's the rest of my post

My grandmother is in a Miami J right now. She had a (GASP!) C1 and 2 fracture after a fall. You know, per EMS instructors she should have died if she wasn't rushed to the ED strapped to with in an inch of her life. Yet it was a couple of hours before she could be convinced to seek medical care, rode to the ED POV and walked into triage.

Spinal injuries are not always that obvious and can be difficult to assess especially if there is an associated TBI. There have been several that have fooled even the ED physicians and have slipped through the assessments until the patient presents as a quad at home in his bed the next day.

So I've yet to see a published case study where this happened, I'm not gonna say it hasn't. The problem is you can't write policies or protocol (at any level, from MD down) around andecotes like "that one guy". There has to be an established research base to back it up. If we save one patient but kill 100 others due to delays on scene, pressure sores, interference with respiratory effort or any of the other problems associated with SMR then where is the value in it? This is also where strong assessment and clinical judgement skills, as well as the ability to deviate from protocol come into play. If you see something that makes you think the patient doesn't fit, you deviate, explain and doccument.

 

[Journey]

My grandmother is in a Miami J right now.

Fxs can be stable. However, I bet your grandmother may not try removing the Miami J to see how far she can turn her neck.

Fxs can also be unstable and many of those high level C-spine injuries do not make it to the ED. Those that do also may be on a ventilator permanently.

It is unfortunate that those in EMS do not get an opportunity to see the many different ICUs in the hospitals especially the neuro unit. If you want cases, go to any of the grand rounds in a large neuro center. A large spinal rehab center will also have such cases in various degrees of healing.

If you want large scale studies, you might look at the Journal of Spinal Cord Medicine or American Journal of Physical Medicine and Rehab. You can also request the data manufacturers.

SCIs are not a new medical discovery and they have been in prehospital and the in hospital areas for a long time. We have evolved through many different immobilization and mobility devices.

I also stated that many studies are done by pulling up X-rays and CT Scans on the living and not the dead.

If you want case studies, you will probably find many more than just one on this site.
www.medscape.com

You may also have seen some if you have ever done routine transfers to LTC or spinal rehab facilities but you may not have read the chart closely to get the initial injury hx. It is really not hard to find SCI patients who were not aware they were badly injured at first or what can happen to the cord in terms of an infection from an injury that doesn't have to break any bones. Similar precautions may still have to be taken.

There has to be an established research base to back it up. If we save one patient but kill 100 others due to delays on scene, pressure sores, interference with respiratory effort or any of the other problems associated with SMR then where is the value in it? This is also where strong assessment and clinical judgement skills, as well as the ability to deviate from protocol come into play. If you see something that makes you think the patient doesn't fit, you deviate, explain and doccument.

It seems you are set to have only one fixed protocol. But, from your statements it doesn't seem like EMS will evolve to a point where a broader decision making protocol can be used. At no time did I say we only used one devices just like the Miami J is not the only C-collar. We have several different C-collars and methods to immobilize. I also stated that a LSB is utilized for some and not for all. However, you may still have to consider how to get a patient from point A to point B without gross movement that could exacerbate a situation. You also should anticipate problems such as losing an airway. This should be part of your training.

 

[usalsfyre]

Fxs can be stable. However, I bet your grandmother may not try removing the Miami J to see how far she can turn her neck.

Fxs can also be unstable and many of those high level C-spine injuries do not make it to the ED. Those that do also may be on a ventilator permanently.

It is unfortunate that those in EMS do not get an opportunity to see the many different ICUs in the hospitals especially the neuro unit. If you want cases, go to any of the grand rounds in a large neuro center. A large spinal rehab center will also have such cases in various degrees of healing.

If you want large scale studies, you might look at the Journal of Spinal Cord Medicine or American Journal of Physical Medicine and Rehab. You can also request the data manufacturers.

SCIs are not a new medical discovery and they have been in prehospital and the in hospital areas for a long time. We have evolved through many different immobilization and mobility devices.

I also stated that many studies are done by pulling up X-rays and CT Scans on the living and not the dead.

If you want case studies, you will probably find many more than just one on this site.
www.medscape.com

You may also have seen some if you have ever done routine transfers to LTC or spinal rehab facilities but you may not have read the chart closely to get the initial injury hx. It is really not hard to find SCI patients who were not aware they were badly injured at first or what can happen to the cord in terms of an infection from an injury that doesn't have to break any bones. Similar precautions may still have to be taken.



It seems you are set to have only one fixed protocol. But, from your statements it doesn't seem like EMS will evolve to a point where a broader decision making protocol can be used. At no time did I say we only used one devices just like the Miami J is not the only C-collar. We have several different C-collars and methods to immobilize. I also stated that a LSB is utilized for some and not for all. However, you may still have to consider how to get a patient from point A to point B without gross movement that could exacerbate a situation. You also should anticipate problems such as losing an airway. This should be part of your training.

I'm really not seeing the point your making. Yes I'm aware of stable vs unstable fractures and the fact that most unstable fractures present dead. I'm still not sure how the cheap collars common in EMS help.

Living or cadaver, preventing "x" number of mms movement does not equal clinical results. Renal dose dopamine worked in the lab too.

I've been in ICUs, I've hauled pts in HALOs and other devices around, and I've even taken care of a couple of acute spinal injuries. Everyone that was not impaired complained of neck pain. Most of the impaired ones did too. The unconscious ones couldn't participate in an exam, so injury was presumed. None of that changes the fact that the devices EMS applied did VERY little to meaningfully restrict spinal motion, and nothing proves that it's helpful in the first place.

As for the last part, what makes you think I'm interested in one protocol? What I want is protocol and devices that are based around something that has a deeper basis than the medical equivalent of voodoo rituals. How you infer my, or all of EMS's, decision making ability from that I don't know. Like I said before, I'm not anti-SMR (in the right setting with better equipment I'm sure it has value), I'm anti-doing something that some "expert" thought was a good idea 30 years ago. I've yet to see meaningful literature that SMR does ANYTHING helpful clinically. I've seen a growing pile of evidence it's harmful in many settings. What needs to happen is an honest look at when and why it's applied.

 

[JJR512]

That is why I wish there was an up-to-date national EMS board that issued treatment and protocol recommendations.

I argued for something like that right around the time you were joining this forum: http://www.emtlife.com/showthread.php?t=10881

Except my suggestion wasn't just a board, it was an actual federal agency with the power to actually do something and not just recommend it.

 

[sdadam]

On topic see this lecture abut spinal immobilization, it's lecture #19 in the list;

http://itunes.apple.com/us/podcast/emergency-medicine-lecture/id268702506

Really great information that I wish more people knew.

 

[MedicOut]

Harm or Good?

Someone would have a pretty darn tough time convincing me that strapping a patient with a possible spinal fracture to a LSB and then proceeding to bounce them down the road in our bambalance is good prevention of further injury.

But, we do it because it's our a$$ if we don't.

How many of us have done this exact thing to a patient only to have the ED take the pt off the board before we leave the room?

Heck, at least I got my board back.