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Spinal Clearance. Do we even need to be backboarding people? I say NO.
From EMS1
http://www.ems1.com/ems-news/1338847-Confessions-of-a-recovering-ce...
By Dave Ross
My recollection of the beginning is murky. It all seemed so enticing — innocent, but insidious.
It must have been around 2005. At least, it seems that may have been when it dawned on me that our EMS system might implement a cervical spine clearance field protocol.
I did some quick research and became enraptured and engulfed in the possibilities. I presented a lecture on the topic at our local trauma conference. And even they seemed to buy the idea!
More consumed and enabled, I wrote a draft protocol and argued for its adoption to our region's EMS medical direction council. Somehow, I was able to overcome some of the skepticism of that group, and they agreed to include it in the subsequent protocol revision.
What a feeling. I was on top of the world. But like so many other cruel addictions, it proved to be a false high.
Slowly that world unraveled. Things didn't turn out as I had planned. We had some protocol misapplications that I thought would not occur. I started getting not-so-discreet phone calls at very inopportune times from receiving emergency doctors, advising me that I had a problem.
It got so bad that even members of my EMS "family" couldn't help but notice. Ultimately, with the fervor of a desperate spouse, the medical direction council suddenly awoke from its slumber of denial and dictated resumption of spinal immobilization for all patients with a mechanism of injury.
The wheels had come off. I came crashing down off that wild cervical spine field clearance ride. Fortunately, I went through a 12-step program before I wound up homeless, drinking bottles of Woolite on a street corner.
It was almost a tragedy worthy of Shakespeare. How could this happen? What went wrong? How am I managing in recovery? Will I relapse?
Pull up a chair, kids, and I'll tell you.
On the surface, it seems that field cervical spine clearance is simple. In fact, that's what so seducing about it. However, we learned quickly that it was a little more complicated than I thought. And, perhaps not surprisingly, some paramedics were more facile with it than others.
During this realization, I went back and spent a little more time with the literature to see if there had been clues all along that I might have missed.
And sure enough, there were. You see it turns out that only about 1 percent of all trauma patients have a spinal cord injury. This means that it takes thousands of patients to get a reasonable number of truly spine-injured patients. And what we really care about is how the cord-injured patients will do as a result of the treatment or protocol we are studying. So small studies don't help.
It also means that in our practice, we go a long time without encountering a spine-injured patient. This can give us the perception that we don't have to be careful.
First, let's examine why we even immobilize patients. A 1998 study by Hauswald and associates5looked at a relatively small group of non-immobilized Malaysians compared to a similar number of immobilized Americans. The study authors suggested there might be a trend for worse neurologic outcomes in the immobilized group.
During my "low point," these findings impressed me. However, a sober review of the paper raises concerns that the small number of patients really could not answer the question adequately.
For many ethical and medical legal reasons associated with the practice of immobilization in our country, it's likely there will never be a large-scale research study that will clarify the issue. So maybe we still need to be immobilizing patients at risk for cervical spine injury.
Then I began to wonder what problem(s) we were trying to solve by clearing spines in the field.
Since it appears we have to continue to immobilize, are we hurting patients with immobilization? Indeed, there are some papers describing healthy volunteers and suggesting that pressure as well as pain on areas of the back is increased when the subjects were placed on a spineboard — for more than an hour.1
But does that matter much if, at some brief point after hospital arrival, they are carefully removed from the board?
How about skin breakdown and ulceration? I could only find two studies addressing this. Both were from the late 1980s and primarily involved patients with penetrating trauma who had inordinate delays on spineboards in the emergency department and were not turned frequently in the ICU.5,6 Is this today's typical immobilized EMS patient?
What about the risk of respiratory compromise in the immobilized patient? Nothing.
What about the actual clearance protocols in the medical literature? After all, in my altered state, it seemed easy enough.
Two potential resources have been studied in emergency departments with emergency physicians. Related versions have been later evaluated with EMS personnel.
The most commonly quoted criteria were described in the National Emergency X-Radiography Utilization Study (NEXUS).4 This lists five patient characteristics to consider: Altered mental status, intoxication, distracting injury, spinal tenderness and neurologic injury in the extremities. A piece of cake.
But maybe not. When you think about it, there's a lot of subjectivity in those five criteria. We have to judge how altered the patient's "altered" is, how intoxicated the patient really might be, what really is a distracting injury, and whether my idea of spinal tenderness and a complete neurologic exam is the same as yours. Maybe not surprisingly, these things posed problems for us.
It turns out a good deal of research appears to show that EMS can successfully use variants of NEXUS well.2 During my clearance-addled phase, I lapped that up.
However, early in recovery, I reread them and realized that they all had some element of misapplication of the study protocol and/or a component of unrecognized potential for spinal injury in which patients were not immobilized when they should have been — just like we saw.
So now that I'm sober, it's clear that if a high-volume system is actively clearing spines in the field, the question is not whether there will be misses — it's when those misses will be.
Many of us have heard the phrase, "If you've seen one EMS system then... you've seen one EMS system." And I think that's true with respect to the spine clearance debate.
If your system is clearing spines, OK. But accept that there have been, and will be, misses. Hopefully, your leadership understands that and has acknowledged these occasional circumstances.
For us, and specifically me in recovery, we've decided to minimize the risk of misses by continuing with our recent return to spinalling primarily based on mechanism.
Now I think I've explained how this dark period of my life happened and what went wrong. You're probably just dying to know the answers to the other two questions: How am I managing in recovery, and will I relapse?
To quote big-time athletes, I'm taking things one day at a time. It's not been easy. I still get the shakes now and then. But I'm happy to report that my wife and kids decided to not leave me.
I don't think I'll relapse. But you never know. I have episodes of weakness, and I get scared I might succumb. Especially since I have some smaller EMS systems that I still allow to clinically clear.
Thanks for your attention. It helped me a lot.
References
- Cordell, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann. Emerg. Med. July 1995 26:31-36.
- Domeier, et al. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann. Emerg. Med. 2005;46:123-131.
- Hauswald, et al. Out of hospital spinal immobilization: Its effect on neurologic injury. Acad. Emerg. Med. 1998; 5:214-219.
- Hoffman, et.al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM. 2000;343:94-99.
- Linares, et al. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987 April;10(4):571-573.
- Mawson, et al. Risk factors for early occurring pressure ulcers following spinal cord injury. Am. J. Phys. Med. Rehab. 1988 June;67(3):123-127.
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Replies to This Discussion
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Permalink Reply by dr-exmedic on -
I just ran across a town in SW Ohio that has actually gone the other way: no backboarding of alert pts, though you can collar them if they fail NEXUS criteria. Non-alert pts are still to be boarded.
I think this makes sense, because people with true cord injuries will fail NEXUS by having neuro deficits, and people with intact protective reflexes and spine (but not cord) injuries will tend to self-splint. There's actually a motion-capture study out there that never made it to print, but did become a poster at a national meeting, which compared C-spine motion using rapid extrication, KED, or patient standing & moving to the stretcher with a collar and specific instructions to keep their neck still. The last group had the least movement....
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Permalink Reply by Scott Lancaster on -
There is...
Edward Greenwald said:. I am not opposed to c-spine clearance in the field if good research leads us to it.
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Permalink Reply by David Ross on -
Thanks for all of the comments, including those emailed to me personally. Spinal immobilization and field clearance is clearly a controversial issue.
I agree with Skip that we should be thinking of comfort measures when awake patients are immobilized. There are a number of products out there. But just a foam lining on the board would be nice.
I agree with Duncan that we all tend to read abstracts or very limited sections of articles. This is true of everyone in healthcare and it leads to conclusions based on substantial limitations. We should also recognize that the authors of any study have biases that they work from. It's human nature.
With regard to Duncan's questions about misapplications and why we still have some field clearance going on in two of my smaller systems, here is what I can offer.
While there are problems with the subjectivity in any of the NEXUS criteria when applied, what we have found more consistently is failure to do a thorough extremity neuro exam. So, in any system, I would emphasize this aspect of training. You may have noted that "mechanism" and age of the patient does not appear as a NEXUS factor at all. They do in the Canadian C spine rules, but, generally, I think the Canadian C spine rules are a little more cumbersome to use.
In my smaller systems, we have a limited group of very experienced medics with very little turnover. This is not the case in some of my larger systems. So, I can go over the criteria with these crews once a year with them in the same room. Then, because they have a small volume of calls, it is very easy to quickly QI any call.
By the way, I still get occasional complaints from EDs about failure to spinal despite the changes described in the article. Some of these complaints I think are legit, and some are not.
I hope this helps clarify some of the issues that have come up. Thanks for reading.dave
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Permalink Reply by Nathan on -
Thanks for replying.
I know there are many people who want to know if the "misses" you described result in a poor outcome. If they did was it caused by the initial injury or was it directly related to the patient not being immobilized? I want to emphasize that I acknowledge there will be misses but are those misses actually a problem in these cases? I dont want to completely dismiss the ER complaints but again, if there was no harm done than the misses are nearly irrelevant. Wouldnt you agree?
This from the Malaysa study:
"Neurologic injuries were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as explanatory variables."
"There was less neurologic disability in the unimmobilized Malaysian patients..."
Can you explain how that study does not disprove some things (backboarding)? Im not trying to be sarcastic here I want to know if there is some science you know that we dont know that would explain your stance on the issue.
Second point: If we place something padded on the board couldnt we just place them on a thin mattress? Maybe a stretcher mattress? I've used the backraft devices (inflatable air mattress that straps to board) and while they are good at giving the patent comfort they defeat the dogma that patients must be immobilized on a hard board for their own safety...
David Ross said:
Thanks for all of the comments, including those emailed to me personally. Spinal immobilization and field clearance is clearly a controversial issue.
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Permalink Reply by Duncan Hitchcock on -
Thank you, Dr. Ross for replying to the questions stimulated by your article.
As I suspected, and as has been my experience, continuing education and remediation to insure skills and knowledge retention can be an issue in larger, high volume systems. I’m sure that several of the frequent contributors to these forums can quickly reference many studies that demonstrate the evidence to support this observation.
A point that I found very interesting was your statement about one of the causes of failure of pre-hospital providers in clinically clearing the spine was “failure to do a thorough extremity neuro exam”. And as you pointed out, this is clearly a training, QA/QI and re-training issue.
It has long been my opinion that when adequately trained, the paramedic can successfully and consistently clinical evaluated the patient’s need for immobilization. I am of the opinion that the current practice of placing patients on a long, straight, hard board full of voids and gaps and lacking of adequate support and protection of the natural curvature of the body is grossly inadequate and poor medicine.
So, when will a medical specialty group or a professional organization with the supporting evidence of research and the drive to affect a positive change in the way we treat these patients step forward? Our dedication to “Do no harm” needs to move this treatment modality from the realm of arcane to one of appropriateness. We owe it to our patients.
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Permalink Reply by The Cannulator on -
Ahh, but in assessing a mechanism of injury, you would, in the case of an MVA take into account mitigating factors, such as direction of force, dissipated forces , vehicle type and so on. Mechanism is more than how smashed up a car is. Deceleration is deceleration despite crumple zones and air-bags at 100km/h for example.
No different to falling drunk as opposed to sober.
If we went on patient presentation, we would ignore the walking Hangman's fracture
The downside to vacuum splints and mattresses in particular is the cost per unit and space that they may take, Having enough changeovers in a system as big as ours would send us broke.
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Permalink Reply by dr-exmedic on
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Nathan said:
Thanks for replying.
I know there are many people who want to know if the "misses" you described result in a poor outcome.
In most of the studies I've read, the missed injuries were primarily stable fractures to begin with; missed injuries with unstable injuries were even less common and bad outcomes due to the misses were extraordinarily rare. It's also important to note that "stability" of an injury, like "invasiveness" of a procedure, is not an either/or but a continuum.Edit: here, a quote: "Of two recent studies, only 48 of 13,652 patients with spinal injuries were missed by application of this pre-hospital criteria. No patient suffered an adverse outcome." Refs: 1, 2 Further edit: just by reading the abstracts, this quote is demonstrably incorrect; there were only 422 actual spinal injuries in 13k pts, 33 of them not immobilized, zero of those with cord injuries. Haven't hit the actual studies yet.
Can you explain how that [Hauswald et al Malaysian] study does not disprove some things (backboarding)? Im not trying to be sarcastic here I want to know if there is some science you know that we dont know that would explain your stance on the issue.
I was about to take a good shot at this, but the SAEM website (it publishes the journal that study was in) is acting up this morning. The American Assn of Neurological Surgeons reviewed this study in its policy paper on spinal injuries, and sums up the flaws: pts who died were excluded from analysis, the injury patterns were different between the Malay and NM populations, and the Malay populations were apparently immobilized manually during transport but did not use devices. I've often used this to theorize that being aware of the spine's movement may be more important than how you actually accomplish minimal movement, and that gentle handling may be of more importance than what (if any) devices you use.The AANS paper is available here, and it's quite a good read. (It's a nearly 600-page document, but only 34 of the pages are on prehospital spinal immobilization--less than 30, once you discount the bibliography.)
Second point: If we place something padded on the board couldnt we just place them on a thin mattress? Maybe a stretcher mattress? I've used the backraft devices (inflatable air mattress that straps to board) and while they are good at giving the patent comfort they defeat the dogma that patients must be immobilized on a hard board for their own safety...
The only reason to use a backboard is during pt movement. Once they're not being carried any more, any stable device will do, including a standard mattress--if you'll notice, your local trauma center removes the backboard within minutes of them ending up on the ED cot (or they should, if they're not), and pts with confirmed spine injuries will spend their hospital stay on a regular mattress (or a special anti-bedsore type), not a spine board. So while the Backraft may make a LSB more comfortable, you really couldn't carry someone around using just the Backraft (if you make the assumption that the LSB is needed at all).
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Permalink Reply by dr-exmedic on
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Incidentally, the motion capture study I mentioned previously did actually get published, though not in one of the big journals. Full text available here.
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Permalink Reply by Trevor on -
The issue of backboarding patients or not is WAY bigger than actually backboardign patients (was that philosophical enough???)...
The real problem is that EMS (as a whole) continues to have a dogmatic approach to EVERYTHING we do! Why do we backboard people??? Provide me ONE SINGLE STUDY that shows that backboarding people provides ANY benefit. I challenge you... I have never seen one, or heard of one... Is it a good tool for moving people? Yes. Does it protect their spines? I would say no... What i can show you though, is mutiple studies that show that it hurts people, injuries people, delays scene times, AND THAT WE DONT EVEN SPINALLY IMMOBIOLIZE PEOPLE EFFECTIVELY ANYWAY!
What we need to do is step back, and think about what evidence we have FOR backboading patients... ANd the answer is... NONE. Its just simply something we've always done, so we continue it... Dogmatic huh?
Before you apply any treatment to patients, you should have medical rationale (read *proof) that this is good for them...
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