Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Spinal Immobilization – You Make the Call

Kelly Grayson of A Day in the Life of an Ambulance Driver asks what we would do with an unimpaired ambulatory nursing home patient with a day old cervical spine fracture that has been confirmed by CT (Computed Tomography) scan. Well, what would you do?

Now here’s the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.[1]

Here is a very important part of this presentation.

alert and able to follow commands appropriately

Not necessarily alert and oriented to person, place, time, events, and the completely irrelevant question about who is President.

Alert (not sedated).

Able to follow commands.

Is a disoriented person able to localize pain? If we are to believe the Glasgow Coma Scale (GCS), then following commands indicates higher function than just localizing pain.

We should expect the ability to localize pain to be what best protects the patient from further injury.

Best Motor response
1 – None
2 – Inappropriate extension to pain
3 – Inappropriate flexion to pain
4 – Withdraws from pain
5 – Localizes pain
6 – Obeys commands

We should also expect that the GCS will be replaced by something simpler, but more accurate, such as just the Motor response. There have been several papers written on this. I will address them in other posts.

Suppose this is a patient with dementia – can’t remember the day of the week, the month, the year, the President, or any other information we seem to believe is essential for being able to identify/clear a spinal injury. We already know he has a spinal fracture. What we care about is whether the patient can protect himself from injury.

Can I tell you that I have an injury?

Will I permit movement that will make my injury worse?

These are completely different questions.

There is no reason to apply spinal clearance criteria to this patient. We already know that the patient has a spinal injury.

Spinal clearance criteria are only to identify potential spinal injuries. This spinal injury was identified before we were even dispatched. The known spinal injury is the reason for the dispatch.

Do spinal clearance criteria have anything to do with the ability of the patient to protect his injured spine during transport?

Absolutely not.

All that matters with these criteria is whether they identify a spinal injury, not whether that spinal injury would be made worse by transport without spinal immobilization or made worse by transport with spinal immobilization. It is assumed that transport of a patient with a spinal injury with spinal immobilization will protect the spine from further injury. There is no good evidence to support this. To make such a huge assumption in research is a fatal flaw, but we ignore that, because we don’t want to admit that we are practicing voodoo.

Have spinal immobilization methods demonstrated any ability to prevent worsening of an injured spine during transport?

Absolutely not.

What about nice slow transport with a cervical collar and no backboard?


Picture credit.[2] Click on the image to make it larger.

During transport, is a cervical collar, especially a hard plastic cervical collar, going to help?

During transport, is a cervical collar going to hurt?

Can you prove it?

I have been fortunate in receiving orders to not wrestle patients, with potential spinal injuries, into restraints. Why force an injury to get worse?

I had one fall patient with compression fractures and kyphosis that caused her back to take almost a 90° turn. When I contacted medical command, his immediate response to this information was, Please tell me that you do not have this patient on a backboard.

Some medical command doctors are smart enough to realize that the best protection against malpractice is to not injure the patient.

Here is an imaginary scene from a court room. While this is imaginary, it is definitely not impossible and not even improbable.

Doctor – I know that my orders/protocol caused permanent injury to this patient, but I have to follow the standard of care or else I will be sued for malpractice.

Lawyer – Since your orders/protocol resulted in the injury to this patient, do you regret your actions that harmed this patient?

Doctor – Yes, but please understand that I have to injure my patients to protect myself from my patients.

First read the You Make the Call post, then read the Conclusion.[3]

What kind of harm will we cause our patients just to avoid having to call medical command, or to avoid having to explain our actions to QA/QI/CYA, or to avoid the possibility of being written up/suspended/fired?

If I have to injure one patient a year, is my job worth it?

If I have to injure one patient a month, is my job worth it?

If I have to injure one patient a week, is my job worth it?

If I have to injure one patient a shift, is my job worth it?

“The maxim is ‘Qui tacet consentire’: the maxim of the law is ‘Silence gives consent’. If therefore you wish to construe what my silence betokened, you must construe that I consented.”
—Thomas More in A Man For All Seasons – play and screenplay by Robert Bolt

Does harming patients protect us from liability?

Does a failure to contact command for at least an attempt to protect the patient in any way protect us from liability?

Footnotes:

[1] Spinal Immobilization: You Make the Call
A Day in the Life of an Ambulance Driver
Article

[2] Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA.
J Trauma. 2010 Aug;69(2):447-50.
PMID: 20093981 [PubMed – indexed for MEDLINE]

[3] Spinal Immobilization: The Conclusion
A Day in the Life of an Ambulance Driver
Article

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Comments

  1. You are the only one who can deliver a point and message from asking a series of questions. Do you ever hope to have someone try to address each one?

    -She can walk to hospital- might be safer and cause the least amount of forces to FX? Mostly kidding.

  2. Great discussion! There is NO evidence that spinal immobilization helps anyone with spinal injuries. There IS evidence that it hurts patients: decubitus ulcers, anxiety, increased pain, and as referred to in this article, further distraction of high cervical column injuries. I believe that part of the reason the spinal injured patients did better in Malaysia than in New Mexico is partly due to the extended on-scene time it requires to put someone into immobilization. Extended on-scene may have delayed time to definitive care that may have reduced secondary spinal cord injury.

    Backboards help the provider. They were originally used for extrication and evolved to be considered “treatment” (probably guided by litigation). There is a problem when the primary reason we follow a “standard of care” primarily to protect our license or certification and NOT to care for the patient.

    Thanks for the article citations, too.