Spinal Immoblilzation a risk factor for death?

Hmmmm:

Emergency spine immobilization may do more harm than good, study says
January 11, 2010 | 3:57 pm
When emergency responders reach a gunshot or stabbing victim, they try to immobilize the spine to reduce the danger of paralysis upon movement of the victim. That effort, however, can have a fatal toll.

A study published in the Journal of Trauma has found that, among these types of trauma victims, those whose spines are held still are twice as likely to die as those whose spines aren’t immobilized.

Read the news article, but they’re talking only (apparently, I don’t get this journal) about penetrating trauma. Those discussing the article wonder if the reason for the increased mortality is “Stay and Play” vs “Load and Go”, the two basic precepts of transporting the ill and injured in prehospital medicine.

While I would agree a collar and backboard on a neurologically intact GSW patient is probably overkill, I suspect it’s a surrogate in this study for injury severity.

Anyone read JOT and want to help us out? I wonder if Injury Severity Scores were compared, in addition to transportation times.

And, my unrelated but sort-of related rant: we’re now getting, as policy, patients packaged for transportation like we’re going to sling them from helos and airdrop them into Afghanistan. Straps, zippers, tape, collars, etc. Very often applied to patients who were walking when EMS arrived on the scene. (I have given up asking EMS why, they just rote-repeat “Policy”), and have so far restrained from asking patients ‘why did you let someone strap you down like Hannibal Lecter’?)

Worrisome spinal tenderness, AMS, or an abnormal neuro exam? By all means. But a lot of it seems to be because they have a hammer, so every trauma patient is a nail…


Comments

  1. I have to wonder what the DOD is doing about battlefield spinal immobilization these days. Turns out that under the correct circumstances they found that tourniquets are saving lives over there. Anybody know?

  2. EMS services as a whole are the biggest money pit in this country They only gotta know to treat
    Cardioresp arrest
    Seizure
    Hypoglycemia
    Catch a rapidly delivering baby
    Know how to BVM ventilate well
    Everybody else can wait 15 min for transport to the nearest urban hospital

    Non urban and long transport folks need to know more. We could save a ton of money in training/treatments/protocol revisions etc etc

    Try telling that to an EMS guru…..

  3. It isn’t just policy, it is how medics are trained. (I was an EMT-B in NY in 2003-2004). Threat of litigation is also a factor. However, look at this section from the EMT-Basic guidelines:
    “For every patient who is involved in any type of traumatic incident in which the
    mechanism of injury and/or signs and symptoms indicate a possible spinal injury,
    complete spinal immobilization must be conducted. Critically injured or ill patients may
    be rapidly moved only with spinal immobilization techniques utilized. A short
    backboard or spinal immobilization device will be used on non-critically injured patients
    at the scene prior to movement of the patient. However, when patients present with life
    threats, or the scene is unsafe for the EMT-Basic, the patient is moved by a rapid
    extrication technique. Failure to immobilize the spine or treat the head injured patient
    will lead to increased patient morbidity and mortality.”

    “Penetrating trauma” is specifically listed as an area to “use a high level of suspicion” aka: most of the time, board and collar them.

    The curriculum board and the medical directors behind the national EMT curriculum are a mixed bunch. Mostly Paramedics but there are two Emergency Medicine MDs listed as co-directors. If you want to see a change, I’d recommend starting with them. The full EMT-B pdf is here: http://www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pdf

    That said, I do think the article (and yourself) have a point. Penetrating traumas probably don’t need to be boarded and collared. Every patient shouldn’t be receiving the Hannibal Lecter treatment. Sadly, most of the medics really don’t have a say in the procedures they follow. And for NG, the services may be a money pit, but the pay is not great, even for an EMT-P. It remains a blue-collar profession.

  4. Goatwhacker says:

    Agree with Mel above that threat of litigation plays a role. Like C-sections, angiograms and many other tests/procedures you will hardly ever be faulted for putting somebody on a board, only for not putting somebody on one. Therefore everybody gets boards whether they need it or not.

  5. Except now that this study has been published, litigants can argue that it is now known that the risk of death increases when patients with penetrating trauma are immobilized. Still, it will likely take a successful, expensive wrongful death suit before policies and training standards are changed.

  6. It’s not so much ‘policy’ as ‘protocol’. Our protocols are written by our medical directors and they are very clear about the whole backboard thing. We often don’t like to do it, but we’ll get hung out to dry if we don’t.

    Pretty much anybody with trauma above the shoulders gets a backboard, and there is no exemption just because they are walking around before when we get there. Quite the contrary, we are taught a specific technique to backboard a standing patient (called a ‘standing takedown’). I got yelled at about this just the other day, by an ER nurse no less, who was indignant that I did not backboard a very frail elderly man who had fallen at home and fractured his hip. I made an independent judgement that the backboard would cause him more harm than good, being as how he had no neck pain or stiffness, no sign of head trauma, and that he denied hitting his head when he fell. Probably good call on my part, but if there was a spinal fracture there (even if it was unrelated to the fall) I’d be in serious doo-doo now. If you get in the habit of ignoring your spinal protocol, it’s only a matter of time before you’ll be asked to turn in your card.

    There is a good point to be made here though – EMTs and ED staff should work closely together, and understand each others needs and expectations, but too often it doesn’t happen. How often do we become annoyed by one another, even when everybody is doing exactly what they are supposed to be doing? It’s a shame we don’t train together and follow the same policies, at least in those areas where we overlap. Life would be a lot easier for all of us if we did.

  7. Renoun-DOD has been pretty solid for a number of years that C-SPINE precautions are not indicated on the battle field. This is backed up by data (Vietnam era, so 40+ years) from an author whose name escapes me at the moment. Permissive hypotension is now the standard for trauma until the patient reaches surgical care.
    _______________________________________________________________
    C-spine precautions IMO are for rapid deceleration trauma, not battlefield type injuries (GSW, penetrating trauma) as a general rule of thumb. I would bet there is a statisticaly significant number of EMT’s/prehospital folks who forget to treat life threatening injuries as they find them. It’s been a few years but I recall they teaching you to stop during your initial assessment/rapid trauma exam and intervene when faced with a life threatening injury. Only after completing your inital assessment did you worry about C-spine. Maybe patients are being allowed to lose airway or blood while efforts are focused on other “protocols”.

  8. N.G.-While EMS services are a “money pit” most of that comes from other issues, not from the personnel. Having to pick up every single person who calls an ambulance for a ride to the hospital. Folks giving out fake names so they don’t have to foot the bill for services rendered or folks flat out not being able to pay. Patients using emergency services for non emergent issues are probably the biggest fiscal drain.

    The problem you have is the vast majority of programs that train prehospital personel have/are required to adhear to national standards. Those standards have to apply across the nation. So the training becomes a one size fits all kind of approach. Your ideas are where the local medical director comes in.

    And you forgot things like bleeding out, establishing airways etc.. A serious bleed or airway compromise cannot wait 15 mins.

  9. Having been on both sides of the coin (EMT-B and now an ER intern) I agree with a lot of the comments above. The prehospital curriculums are definitely taught to the lowest common denominator and leave little room for clinical judgment- especially at the EMT-B level.

    The problem is that putting someone on a backboard is not a benign procedure- even before this study came out. Patients get pressure sores from being on backboards and they are very uncomfortable. However, in EMT classes it is taught as an automatic part of trauma care. In the case of penetrating trauma below the clavicles- maybe it shouldn’t be. I remember a study a long time back that essentially busted the myth of c-spine injury in patients with GSWs below the clavicles.

    So now there’s a study saying that these patients have double the mortality. Granted, it’s nothing more than a data dredge from a trauma registry which has major limitations, but these kinds of studies are very good for identifying trends which can be better in the future in a prospective manner (looking forward instead of backwards).

    In penetrating trauma- minutes really do count and that 5 minutes you spent properly packaging a patient may be better spent on the OR table. Don’t get me wrong- if the patient is yelling that they can’t move their arms or legs then use your clinical judgment and put them on the backboard, if not then you should scoop them off the ground and go.

    Another study showed that trauma patients brought in via police or POV had lower mortality- probably because they got to the trauma center faster. Trauma is treated by diesel (or jet fuel) first.

    My 0.02

  10. Aside from any policies, procedures, fear of litigation, these things need to be constantly revisited.

    Some of the problem may come from excessive reliance on passive measures like restraints to stabilize which do not allow for EMT intervention or modifications for comfort. We still end up with a human deciding when the conditions are such that restraint is a good idea. Perhaps the value of this study lies in the demonstration that restraint is not the default safest approach, so that people think about what they’re seeing at the scene.

    We’ve gone through this in hospitals too, where the dangers of 4-point restraints have to be considered whenever this is being applied.

  11. Spinal immoblization by rote is a result of a few things: outdated protocols, EMS medical directors who are just going through the motions, and EMS services that do the same.

    We’ve had a C-spine clearance protocol in place where I work for over 10 years and we accomplished it by being proactive. We did research on statistical incidences of real spinal injuries from minor traumatic injuries, such as ground level falls and fender benders that don’t even leave a mark on the vehicles involved. We researched C-spine clearance protocols of other EMS services nationwide. When we had a protocol in place that we found to be reasonable, we approached our medical director for his approval. He approved it, and here we are. Grandma doesn’t get full spinal immobilization every time she slips out of her wheelchair (unless she has midline spinal pain that is new onset since the fall), our patients are more comfortable, and the equipment gets used when it’s really needed – like the 70mph rollover on the highway with the unconscious driver.

  12. I think the study result is simply a result of selection bias.

  13. While 32% of the penetrating trauma patients had a neck or torso injury, only 4.3% of the patients in the study had spinal immobilization. This is important, since PHTLS has not recommended the use of spinal immobilization for patients with penetrating trauma for years. If the trauma doctors are opposed to it, why does it continue?

    The study was done at Johns Hopkins. It appears to have been motivated by someone wondering why Maryland did things differently from most of the rest of the country. Let’s hope that Maryland stops demanding that this lethal practice be followed. Doubling, or even tripling, the fatality rate by immobilizing penetrating trauma needs to be stopped.

    I wrote about this in much more detail at Spine Immobilization in Penetrating Trauma: More Harm Than Good?