8. Selective Spinal Immobilization Guidelines

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

8. Selective Spinal Immobilization Guidelines

I remember this scene from a hospital triage line vividly.  It is eight-thirty in the morning.  A woman in her middle thirties in a nice business suit is on a backboard with a tightly applied neck collar, two body straps, and her head is immobilized with thick duct tape going from the top ends of the board, down around her collar, cranking her neck back. Her problem, besides the poor job of spinal immobilization is she needs to pee.  She has been drinking coffee since she woke up and got her kids off to school, and was drinking it on the way into work when she was rear ended in traffic.  She has some minor back pain.  “Please,” she says for the third time to the crew and triage nurse, Let me off this board!  I need to use the bathroom.  Please, I can’t hold it any longer!”

The triage nurse snaps at her.  “Hold still, unless you want to be paralyzed.  You have to stay on that board until the doctor exams you!”

 I have seen similar scenes.  Triage nurses,EMS, even doctors shouting at people that they could be paralyzed unless they submit to being immobilized.

Come on, people!  What about the patient?  Does anyone really think that letting this lady get up to pee is going to paralyze her.  Does anyone think that her jerking around on the board is good for her supposedly injured spine?

 If we really cared about keeping patients still, everyone we immobilized, we would also sedate.  Got neck or back pain from a minor MVA?  You get spinally immobilized, and then given 5 of Versed and 100 of Fentanyl.  Hell, why not RSI them all?

 Actually, this is probably a bad idea because most alert people with spinal injuries have their muscles tense up, which helps them self-splint the injury to limit movement.

 I remember once I was called for a motor vehicle victim in a Chinese restaurant.  The patient had been in an MVA on the highway, fled the scene and finally called from the Chinese restaurant.  I tried to immobilize him.  He wanted no part of it.  I had two cops with me.  Somehow they ended up wrestling with him to try to get him to submit to being immobilized.  One cop had him in a head lock.  It occurred to me then that maybe it would be better for his spine if we didn’t try to force him into the collar.

We used to immobilize everyone.  Every motor vehicle, every fall over three feet, every shooting.  We immobilized to protect the spine based on mechanism of injury, not based on assessment.  There was no science behind it; just the conjecture that keeping people with possible spinal fractures still would prevent them from suddenly becoming paraplegics with the slightest movement.  In our state basics continue to c-spine everyone.  Paramedics are able to follow criteria to selectively omit spinal immobilization.  There is a plan that is slowly progressing through the channels to extend this to basics.

 The science of spinal immobilization is more extensive than I can cover.  While there is evidence that spinal immobilization causes back and neck pain, leads to decubitis in elderly and can hinder breathing, and delays transport of critical patients increasing their risk of death, to date, there is no evidence that it does what it claims to do – protect the spine.  It may, in fact, make it worse.

The study I like to cite the most is the one where they studied all spinal fractures in New Mexico brought in by EMS immobilized and all those from Malaysia who were thrown into the back of a donkey cart (I am joking here) without immobilization and taken to the hospital .  The patients in New Mexico did worse.  Did the study prove spinal immobilization was bad?  No, but it clearly did not provide any evidence that spinal immobilization was beneficial.  No study ever has.

Out-of-hospital spinal immobilization: its effect on neurologic injury.

 As a clinical coordinator, both at my hospital and in conversation with other coordinators, I do know of many cases where patients with cervical fractures were not immobilized (usually elderly victims of low falls), but I know of no cases where harm was done to the patient from not being immobilized.  I have had several patients with cervical fractures who I did immobilize.  Every one of them had significant neck pain.

Since we were able to omit spinal immobilization, countless people have been spared torture.  I am unawre of any patient who suffered neurological injury from not being immobilized in our system.  I would like to see the current guidelines extended to basics and I would like tto see the guidelines rewritten for paramedics to make spinal immobilization indicated only for suspicion based on assessment.  If in your clinical judgment, the patient may have a spinal injury, then immobilize, and immobilize fully and properly.  If you don’t believe they do, based on your assessment and judgment, don’t immobilize.

Here is our current spinal immobilization guideline:

OMITTING SPINAL IMMOBILIZATION

Paramedics shall make spinal immobilization decisions based on mechanism of injury and clinical
criteria. The decision to not immobilize a patient is the responsibility of the paramedic.
Indications for Spinal Immobilization:

1. Any patient who has sustained a significant mechanism of injury (includes windshield spider,
dash deformity, ejection, rollover, fall from > 10 feet, and vehicle space invasion > 1 foot).
2. Any patient with positive or questionable mechanism of injury and who has one of the following
clinical findings:
a. Altered mental status
b. Hemodynamic instability
c. Evidence of intoxication or unreliability
d. A significantly distracting painful injury
e. Neurological Deficit
f. Spinal Pain or tenderness

Procedure:
1. Determine Mechanism of Injury
Significant mechanism (including windshield spider, dash deformity, ejection, rollover, fall from >
10 feet, and vehicle space invasion > 1 foot) immobilize patient.
Positive Mechanism or questionable mechanism (including patients with trauma above the clavicle,
falls, MVAs, trauma to the spine head or neck, abrupt accelerating, decelerating or rotational forces)
maintain stabilization and proceed with spinal assessment.
2. Assess Patients
Assess mental status. If patient is not alert and oriented, immobilize.
Assess hemodynamic stability. If patient is hemodynamically unstable, immobilize.
Assess for intoxication and reliability. If patient has evidence of intoxication, mental impairment, or
gives unreliable answers, immobilize.

Assess for distracting injury. If patient has an injury, which may distract from patient’s awareness to
pain, immobilize.
Assess neurological function. If patient has neurological deficit, immobilize.
Assess spine. If patient has pain on palpation of spinous process of cervical, thoracic or lumbosacral
spine, immobilize.
If the above are negative then:
Assess range of motion. Direct patient to touch their chin to their chest, look up extending their neck,
and then turn head from side to side. If patient has any neck pain during their normal active range of
motion, immobilize.

Decision:

Patients, who pass the above assessment, may have immobilization omitted at the discretion of the
paramedic.
Extra caution must be used in pediatric and geriatric patients. When in doubt, immobilize.
All pertinent exam and history findings must be included in run form.
In cases where the paramedic does not accompany the patient to the hospital, the paramedic needs to
provide their name to the transporting BLS provider for documentation purposes.

Remember: The decision to not immobilize a patient is the responsibility of the paramedic.
 

***
16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

 

 

5 Comments

  • Gousios Spiros says:

    Dear Sir,
    congratulations on your article!
    I am a medical student from Greece and 2 years ago I took the PHTLS course. I was wondering, what is the background (why do we do it) of immobilizing a patient with positive mechanism of injury accompanied by hemodynamical unstability?? What is the connection between the possible bleeding (hemodynamical unstability source) and the damaged spine? I think I am missing s’thing!

    Thank you in advance,
    Gousios Spiros

  • Kyle says:

    The thing about not immobilizing patients is that what medic is going to be willing to risk possible lawsuits over not collaring someone? There is no way of knowing for sure in the field and like your directive says “Remember: The decision to not immobilize a patient is the responsibility of the paramedic.” so unless they are refusing, why not throw them on the board and CYA (cover your ass). Unless it ever becomes acceptable to not immobilize patients entirely, I can’t imagine anyone would be willing to take that chance so the patient can be a little more comfortable.

    • medicscribe says:

      Hi Kyle-

      I inderstand your concern. I know many share that fear of being sued, although I believe that fear has been exaggerated by generations of EMS instructors who have drilled immobilization into us from day one of EMT school.

      Fear of being sued is not a justification for not doing what is right for the patient. Failure to do what is right for the patient is more likely to lead to a lawsuit. If I follow my guidelines appropriately, I will not be successfully sued. We don’t put traction splints on people unless we suspect they have a femur fracture, we shouldn’t be immobilize people unless we suspect they have spinal fractures. If we following the spinal guidelines appropriately, and we have no other reason to suspect they have a spinal fracture, then we should not be immobilizing them. If we immobilize just to immobilize, we are exposing ourselves to being sued for failure to act in the patient’s best interest. I hope what I just wrote makes sense.

  • BH says:

    so unless they are refusing, why not throw them on the board and CYA (cover your ass).

    Because a monkey could do that. Professionals know that CYA is a cop-out for people who shouldn’t be allowed to touch patients.

  • mpatk says:

    Spiros,

    IIRC, the thought behind immobilizing someone with hemodynamic instability (let’s just call it what it is, hypotensive shock) is that the source is due to disruption of the nerves to the veins and arteries. It’s “spinal shock”, a form of distributive shock, where some or all of the blood vessels below a spinal injury fully dilate and cause hypotension.

    It might be better for the protocol to require “UNEXPLAINED hemodynamic instability” to prevent protocol monkeys from immobilizing someone with uncontrolled bleeding by mistake.

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