In Praise of CEMSMAC

Last Thursday I was extremely proud of the actions of the Connecticut Emergency Medical Services Medical Advisory Committee (CEMSMAC) who voted unanimously (5-0) to back the draft document on spinal boards proposed in October by the National Association of EMS Physicians (NAEMSP), and to use that document as a guideline to developing statewide guidelines limiting the use of long boards for spinal immobilization.

National Association of EMS Physicians Position Statement Backboards

The National Association of EMS Physicians Believes That:

• There is no evidence that the use of a backboards reduces spinal injury or effectively
provides anatomically appropriate spinal immobilization or protection.

• There is evidence that backboards result in harm by causing pain, changing the normal anatomic lordosis of the spine, inducing patient agitation, causing pressure ulcers, and compromising respiratory function.

• The only practical value of backboards is for extrication to a transport vehicle. Once
extricated, patients should be taken off the backboard.

• Backboards should not be used for spinal immobilization. Placing ambulatory patients
on backboards is unacceptable.

• In general, patients should not be transported or otherwise kept on backboards for any
length of time.

Draft – board approval pending
10-26-12

CEMSMAC is composed of the chairman of Connecticut’s five regional medical advisory committees. They meet once a month to address issues and guide policy for Connecticut’s EMS system, and advise the Commissioner of Public Health. While Connecticut does not have statewide treatment guidelines, the actions of CEMSMAC are useful in aiding the local regional committees and their policies can, when endorsed by the Commissioner of Public Health, have the force of statewide policy.

Several months ago, the Yale-New Haven Sponsor Hospital program, which provides medical control for the New Haven area and many surrounding towns, issued the following memo:

Effective immediately, long backboards will no longer be utilized for spinal immobilization of ambulatory patients. Patients who are ambulatory at the scene, but who require cervical spinal immobilization based on our selective spinal immobilization protocol, will be placed in an appropriately sized collar, seated on the ambulance stretcher, and secured in the position of comfort, limiting movement of the neck during the process. This change in procedure is the first step toward eventually using long boards only when needed to facilitate extrication, and not during transport.

As stated, it was their intention that the document be a first step toward eliminating the use of spinal boards for everything except extrication and movement. They were evidently waiting ratification of the NAEMSP’s draft position paper. Unfortunately, however, the NAEMSP’s Board of Directors chose instead to co-endorse the following statement jointly with the American College of Surgeons Committee on Trauma.

EMS Spinal Precautions and the Use of the Long Backboard

Position Statement of the National Association of EMS Physicians and the American
College of Surgeons Committee on Trauma

The National Association of EMS Physicians and the American College of Surgeons Committee
on Trauma believe that:

• Long backboards are commonly used to attempt to provide rigid spinal immobilization
among EMS trauma patients. However, the benefit of long backboards is largely
unproven.

• The long backboard can induce pain, patient agitation, and respiratory compromise.
Further, the backboard can decrease tissue perfusion at pressure points, leading to the
development of pressure ulcers.

• Utilization of backboards for spinal immobilization during transport should be judicious,
so that potential benefits outweigh risks.

• Appropriate patients to be immobilized with a backboard may include those with:

o Blunt trauma and altered level of consciousness;
o Spinal pain or tenderness;
o Neurologic complaint (e.g., numbness or motor weakness)
o Anatomic deformity of the spine;
o High energy mechanism of injury and:
* Drug or alcohol intoxication;
* Inability to communicate; and/or
* Distracting injury.

• Patients for whom immobilization on a backboard is not necessary include those with all
of the following:

o Normal level of consciousness (GCS 15);
o No spine tenderness or anatomic abnormality;
o No neurologic findings or complaints;
o No distracting injury;
o No intoxication.

• Patients with penetrating trauma to the head, neck or torso and no evidence of spinal
injury should not be immobilized on a backboard.

• Spinal precautions can be maintained by application of a rigid cervical collar and
securing the patient firmly to the EMS stretcher, and may be most appropriate for:
o Patients who are found to be ambulatory at the scene;
o Patients who must be transported for a protracted time, particularly prior to
interfacility transfer; or
o Patients for whom a backboard is not otherwise indicated.

• Whether or not a backboard is used, attention to spinal precautions among at-risk patients
is paramount. These include application of a cervical collar, adequate security to a
stretcher, minimal movement/transfers, and maintenance of in-line stabilization during
any necessary movement/transfers.

• Education of field emergency medical services personnel should include evaluation of
risk of spinal injury in the context of options to provide spinal precautions.

• Protocols or plans to promote judicious use of long backboards during prehospital care
should engage as many stakeholders in the trauma/EMS system as possible.

• Patients should be removed from backboards as soon as practical in an emergency
department.

NAEMSP Board of Directors Approved: December 17, 2012
ACS-Committee on Trauma Approved: October 30, 2012

(A typical compromise document that can’t come out and say what it wants to say. This is my favorite line: “… the benefit of long backboards is largely unproven.”)

The issue before CEMSMAC that Thursday was: Based on these three documents, what should Connecticut do, if anything, in addressing the issue of long boards? Adopt any of the three positions detailed above? Or take no position and let the defacto standard – that long boards are essential to complete spinal immobilization continue?

They considered training issues (how do you eliminate something that is part of the National Registry Test?) and the possibility of potential liability from not following what some regard as the national standard. They also considered the evidence for and against using the backboard.

Here is what they chose:

The health of patients over fear of lawyers.

Evidence of harm over no evidence of benefit.

To lead rather than to follow.

Bravo!

There is an old saying that no one wants to be the first to adopt a change and no one wants to be the last. CEMSMAC was not the first EMS group to adopt this – some major metropolitan EMS systems have done it — but as state groups go they are certainly in the vanguard on this one. May their example encourage others to follow.

Shout outs also to the drafters of the NAEMSP’s document, the Yale-New Haven program and their physicians for leading the way in Connecticut, all the researchers such as Mark Hauswald who shined a bright light on this issue, and those who have written so passionately about the issue such as Bryan Bledsoe, Rogue Medic, and many others.

The actual writing and implementation of the guidelines may take a little while, but they are coming. I’ll post on their development and implementation.

6 Comments

  • Rick Goulet says:

    It is time for Paramedic/EMS services got in touch with the 21st century with reagrds to immobilization of concious mobile patients. Good on the above service. There are many studies that support the above. CanadianC-Spine Clearance Rules have been supported for use in pre hospital environment.

  • Carin M. Van Gelder says:

    Thanks, Streetmedic. This is why EMS is officially a medical subspecialty – we (EMS docs) proved it by pushing for true evidence-based guidelines.

    https://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__4128/DesktopDefault.aspx

    • medicscribe says:

      Thanks, Karen. You and your Emergency Medicine collegues are reshaping EMS for all of us, and we thank you for it. Keep up the fight!

  • Christopher says:

    Brilliant work by Xenia Township, Yale (thank you Dr. Van Gelder), Alameda County, and now CEMSMAC! I’m working on getting this in my service area.

  • Becky Heath says:

    Have known several patients that have benefited from not using a LBB. It’s just not always in the best interests of.the patients . Common.sense.folks-the.ability.to.know when it’s needed and when it’s not. So glad it’s finally being reconsidered

  • Joe W. says:

    Dr. Van Gelder is a former medical director of mine and I have to say Carin; Al, Sandy, Dr. Cohn and Kevin Burns have been continuing the great medical direction you had put forth when you were down here. The omission of long boards is working quite well and has been definitely an improvement.

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