This video of spinal immobilization for leg pain was sent to me by Dan Crawford.
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[youtube]JpXerAwOapM[/youtube]
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This apparently begins 2 minutes after the motorcycle crash. Nice response time, but from there things only get worse. This guy looks as if he would rather go by taxi than by ambulance.
He has leg pain, so that does qualify as distracting pain for those who believe that spinal clearance criteria matter. So immobilizing him is following protocol.
That does not mean that there is any benefit to the patient.
Is there even any potential benefit to the patient?
That only depends on how imaginative you are in your What if the sky really is falling? scenarios. In the real world, there is no reason to believe that there is any benefit to this patient from being strapped to a board.
There is obvious harm.
Spinal clearance criteria assume that there is some benefit to immobilizing patients who actually have spinal injuries.
There is no good evidence to support this belief.
There is good evidence that the opposite is true.
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The OR for disability was higher for patients in the United States (all with spinal immobilization) after adjustment for the effect of all other independent variables (2.03; 95% CI 1.03-3.99; p = 0.04).[1]
RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04).[1]
For a person with a spinal injury, being immobilized doubles the likelihood of being disabled.
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Back to the video. The injured guy is complaining of leg pain. We should address any life threatening injury first, but there do not appear to be any life threatening injuries to address.
What about the possibility of disability if he moves his neck?
I’ve seen bobble-head dolls that move their necks less than this immobilized collared patient.
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The cervical collar does nothing to decrease movement of his neck. If anything, the irritation from the collar probably causes the patient to move his neck more than he would otherwise. Cervical collar = more neck movement. EMS in action.
When strapping the patient to the board, what benefit is there from putting a strap over the injured leg? This only causes more pain and therefore more movement.
At 4:12 of the video is this exchange –
Patient – It hurts!
EMT – I know it hurts. It’s going to hurt more if you keep moving.
Ouch!
What he means is –
Stop complaining about me hurting you. I am only hurting you out of a misguided attempt to protect myself from you and the theoretical lawyers who will sue me for NOT harming you.
Our only defense is ignorance.
Maybe it should be IMS in action. Ignorant Medical Services.
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When medicine is a bureaucracy, we are better off on our own.
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Footnotes:
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[1] Out-of-hospital spinal immobilization: its effect on neurologic injury.
Hauswald M, Ong G, Tandberg D, Omar Z.
Acad Emerg Med. 1998 Mar;5(3):214-9.
PMID: 9523928 [PubMed – indexed for MEDLINE]
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Are they for real? Someone remind me that if I get to NYC at any time NOT to get injured with those clowns about. Spinal immobilisation is one of those issues where people can hide behind a protocol, and the cowards and imcompetent among us do. But when immobilisation IS appropriate it would be nice if it was performed correctly. They just left that guy swinging in the wind, they basically did nothing for him. Awful.
Andrew Eneas,
When is the procedure we do under the name “spinal immobilization” (or “spinal motion restriction” for the more PC and up to date) ever appropriate?
There is no evidence that well done spinal immobilization is beneficial.
There is no evidence that well done spinal immobilization is not harmful.
Our trauma patients would probably be much better off if we did not put rigid collars on them.
Our trauma patients would probably be much better off if we did not strap them to backboards, even if we pad all of the gaps.
We have a procedure that is based on a theory. The theory has been tested and failed, but we continue with the abuse.
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RogueMedic , I agree with a lot of what you’re saying but most of the harm that is done to patients by immobilisation is to the INappropriately immobilised ones, and I’m pretty sure that in the UK we send as many people to hospital immobilised un-necessarily as EMT’s do in the US. Same as Ken says above we’ve at last moved away from the LSB and towards the scoop, but I know that if I was ejected from a vehicle or fell from a roof causing serious injury I’d want to be immobilised in the least restrictive manner. Until of course it is proven and generally accepted that this would not be the way to treat the patient. What I DON’T like is the ambulance crews who – like I said above – hide behind protocol and immobilise old Ethel because she fell over while out shopping and could possibly have rubbish bones.
Is there no duty to act? Is the videographer an EMT/Medic? He states the EMS crew response time indicating that he was there, aware of the incident but favoured taking the video over providing patient care. If the videographer is an EMT/Medic, abandonment comes to mind. Just a thought….
In what state is there a duty to act for bystanders, regardless of their training and education? Why would a bystander face legal liability over abandoning a patient where there was never a patient-provider relationship?
So all morals go out the window? Hope you don’t need CPR and a trained civilian has the same ideals. Perhaps the videographer will film “from here to eternity” starring yours truly. A sad day for sure. Don’t take this personnaly but when the world sinks to that level off concern for their fellow man, it’ time to get off. Glad you can live with your thoughts!
Morals, ethics, and legal requirements are not the same thing. You asked a question regarding a legal requirement (abandonment), thus I gave an answer framed in the law.
You don’t say. Enough said!
Surely if you’re going to commit to immoblising the patient you would at least do it properly. In London standard practice now is to only use the rescue board to extricate from cars, everything else is done using the scoop.
Not to mention the fact that they didn’t once hold his head, they applied a collar and left him sat on his own, the then had him lie down with no support, they literally shoved him onto his side with no head support to get him onto the board and most importantly, didn’t even check his c spine, let alone attempt to clear it.
If that’s how you guys in the US put people onto boards routinely, I’m not surprised that you have a high rate of disability post restraint. That is truly shocking treatment.
Also, he was already mobilising at scene, clearly moving his head without any pain. Unless he had crashed at high speed which looks unlikely given the heavy volume of traffic and obvious urban setting, I’d have left well enough alone.
Part of it’s standard, part of it isn’t. I’ve seen fire medics have people crawl out of the hole they cut in a car on its side (teenage student driver hit the center Jersey barrier. Driver and passenger (mother) were both seat belted and denied any issues while we were waiting for fire to come and cut a hole in the windshield) and walk over to the gurney and lay down on a board. The mother was smart enough to just climb into the ambulance sans backboard.
Besides that and the lack of padding (because nothing says “properly splinted” more than trying to push a set of bones that are normally curved into a straight line), it’s not standard. I guess it’s too much to ask that if you’re going to shake the magic beads to shake them properly.
and most importantly, didn’t even check his c spine, let alone attempt to clear it.
First, we didn’t see everything. It’s pretty clear that when the video starts, their treatment plan has been decided- which may have included assessments that we didn’t see.
Secondly, they aren’t allowed to “clear it.”
I hate the phrase “clear c-spine.” Can you “clear” an intervention when the intervention isn’t indicated? Do you walk into a scene with the intent to defibrillate a patient until you “clear” the rhythm? Do you start patient care with the intent to transport with lights and sirens until it is “cleared” with an intervention?
What other interventions are considered to be automatic -unless- specific criteria are met? Shouldn’t all interventions be consider to not be needed until the proper indications are met?
While I agree with you that we didn’t see everything, to me they appear to be robots, just going through the motions. Is 2 minutes even enough time to properly assess and determine the need for immobilization and then get all the supplies to perform it? I doubt they assessed, kind of hard to visualize his back through his shirt.
Also, NYC does have a protocol for skipping spinal immobilization. Unfortunately, what tends to happen in NYC is that the supression heroes get their first and put c-collars on everyone since they are only required to be trained to a CFR level (a major problem since they are the supposed lifesavers and go on serious medical calls). In NYC, once a collar is applied, it cannot be removed. Since the medical control doctors have no problem restricting crews for the most minor of issues, basically stripping them of their livelihood, quality patient care has to be deferred in those cases in exchange for blindly following the protocol. While that is not the case in this situation, it happens way too often in NYC.
That really surprises me that CFR level firecrews can instigate an intervention and that a subsequently arriving paramedic cannot decide that it is un-necessary. If the supression heroes (water fairies or Trumpton over here (long story) ) are making unreversable decisions then is there much point in adding a higher qualified person to the mix? Fire crews do co-respond in the UK but most definitelly do not make decisions that the qualified crews have to defer to. It sounds like – as RogueMedic suggested – in the original article that the fear of litigation basically takes common sense out of any decision making. Still got to say though that the crew in the video were absolutely piss poor, and need a kick up the arse (ass).
Same is true with CPR. Once they start CPR, no matter how dead the patient is, we need a doctor’s permission to stop, which usuall requires a definitive airway (luckily the docs in the box accept rescue airways in this category), IV or IO access, and 2 rounds of meds. And since there are more heroes than EMS providers, they tend to get to many calls first. NYC, the self proclaimed best fire and EMS in the world with nothing to back that statement.
It is very unfortunate you work under those restrictions. I’m not aware of any study showing that the lack of an advanced airway in a cardiac arrest patient prohibits recognition of obvious death…
We can pronounce obvious death without any interventions. An advanced airway is required if we wish to pronounce after any measure have been taken to resuscitate a cardiac arrest patient. Since FDNY is only required to be trained to a CFR level and they don’t want to do EMS, assessment is not their top priority, which leads them to start CPR on obvious DOAs from time to time. Not every FF does this, some were even medics once, but it happens more often than it should.
We do get some over zealous CFRs starting CPR on obvious deaths, and to be honest it’s understandable as they’re not allowed to call a death, but a resuscitation, as we all know, is a horrible, brutal and undignified procedure, and at that point my thoughts go to the family as they often know that their loved one is dead, and may be pleading for this ‘assault’ to stop. For the senior person at scene to not be allowed to cease CPR on somebody with pooling, rigor etc,. just seems to take away any compassion that we give to the family. Death is an inevitability, we need to care for the people left behind and let them start grieving properly. This isn’t a criticism of individuals, just a system that seems too rigid.