We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

A Change of the Dogma – If spinal immobilization helps only one . . .

How dangerous is spinal immobilization? We discuss that on First Few Moments. On this Spinal Immobilization podcast, Kyle David Bates, Russell Stine, Bob Lutz, Dr. Laurie Romig, Kelly Grayson and I discuss the lack of evidence of any benefit from spinal immobilization and the evidence of harm.

A Change of the Dogma: If it helps only one? Episode 36

What is it going to take to get the medical directors, PHTLS (PreHospital Life Support), BTLS (Basic Trauma Life Support), and ATLS (Advanced Trauma Life Support) to eliminate this dogma?

What is it going to take to get someone to do a large enough study of this dogma to find out just how good/bad spinal immobilization really is?

The Cochrane Reviews looked at spinal immobilization and were not impressed –

The review authors could not find any randomised controlled trials of spinal immobilisation strategies in trauma patients. It is feasible to have trials comparing the different spinal immobilisation strategies. From studies of healthy volunteers it has been suggested that patients who are conscious, might reposition themselves to relieve the discomfort caused by immobilisation, which could theoretically worsen any existing spinal injuries.

REVIEWER’S CONCLUSIONS:
We did not find any randomised controlled trials that met the inclusion criteria. The effect of spinal immobilisation on mortality, neurological injury, spinal stability and adverse effects in trauma patients remains uncertain. Because airway obstruction is a major cause of preventable death in trauma patients, and spinal immobilisation, particularly of the cervical spine, can contribute to airway compromise, the possibility that immobilisation may increase mortality and morbidity cannot be excluded.

Spinal immobilisation for trauma patients.
Kwan I, Bunn F, Roberts I.
Cochrane Database Syst Rev. 2001;(2):CD002803. Review.
PMID: 11406043 [PubMed - indexed for MEDLINE]

There is only one large scale study comparing spinal immobilization with no spinal immobilization –

RESULTS:
There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34).

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]

Kyle starts out with a great comment for all of those who say that we should not discuss, or criticize, our current protocols, for whatever reason they give.

**This podcast is not meant to change YOUR current practice, only your medical director can do that! …but nothing says you can’t try to convince them ;-) – KDB**

 


Picture credit.

 

Plus

 


Picture credit from Voodoo Medicine Man.

 

Equals

 


Picture credit.

 

Not a formula for success.

 

What do you think?

Go listen to the podcast.

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Comments

  1. There is so much we, as a society, “know” it be true.

    Wind mills and solar power can replace coal as a means of generating electricity.
    Low-fat diets prevent heart disease and diabetes.
    If we only taxed the rich more, all our fiscal problems would be solved.

    The list is endless. I’ve been convinced that backboarding should be included.

    • Jack Bode,

      There is so much we, as a society, “know” it be true.

      I keep working at pointing out the problems with dogmas as far as EMS is concerned. There is so much, that I would be overwhelmed trying to address the dogmas in other areas of life, not that I don’t do that occasionally.

      Wind mills and solar power can replace coal as a means of generating electricity.

      Not yet. Maybe not ever, but it is one way of trying to decrease the amount of pollution we produce. A great book on the oil business, and all aspects of energy production, is The Quest: Energy, Security, and the Remaking of the Modern World. It is reviewed favorably by both the NY Times and by Forbes, although each gives political spin to its interpretation of the book, much more politics than appears in the book. As reality is quite different from the political agendas of the left and the right, this book appears to be less interested in politics, than it is reality.

      Low-fat diets prevent heart disease and diabetes.

      We want simple solutions, especially if they come in a pill, or other packaging that does not require much self-control on our part.

      But, man, you’re never going to get any truth from us. We’ll tell you anything you want to hear; we lie like hell. We’ll tell you that, uh, Kojak always gets the killer, or that nobody ever gets cancer at Archie Bunker’s house, and no matter how much trouble the hero is in, don’t worry, just look at your watch; at the end of the hour he’s going to win. We’ll tell you any shit you want to hear. We deal in *illusions*, man! None of it is true! But you people sit there, day after day, night after night, all ages, colors, creeds… We’re all you know. You’re beginning to believe the illusions we’re spinning here. You’re beginning to think that the tube is reality, and that your own lives are unreal. You do whatever the tube tells you! You dress like the tube, you eat like the tube, you raise your children like the tube, you even *think* like the tube! This is mass madness, you maniacs! In God’s name, you people are the real thing! *WE* are the illusion! So turn off your television sets. Turn them off now. Turn them off right now. Turn them off and leave them off! Turn them off right in the middle of the sentence I’m speaking to you now! TURN THEM OFF..

      Network (1976)

      If we only taxed the rich more, all our fiscal problems would be solved.

      Too many people view taxation as a desirable thing for government to do, rather than as an undesirable, but necessary means to an end. The end is financing the necessary operations of government (federal, state, county, city, . . . ). Insufficient taxation results in the government not being able to function. Unreasonably high taxes will only encourage people to move to lower tax locations. We are fortunate that the top federal tax rate is as low as it is and the Social Security goes away before the top tax rate is applied. Our biggest problem has been a decade of tax and spend administrations and Congresses.

      The list is endless. I’ve been convinced that backboarding should be included.

      I agree.

      .

  2. I’ll be honest, I just got my EMT about 8 months ago.

    That said, I am not a fan of mechanism of injury to predict spinal injuries. Don’t let what a crushed car looks like to tell you what your patient is going to look like because cars today are MADE to crush.

    Having listened to this FFM podcast yesterday, and all the other EMS podcasts out there (Educast, EMS Research, EMS Newbie, the Garage, Pedi-U), here’s my view on Spinal Restriction: we (EMS as a whole) are assuming that patients have spinal injuries. What’s the explaination of ASSUME? It’s making an @$$ out of you (EMS as a whole) and me (as the provider).

    BTW, your backboarding formula is awesome.

  3. I completely agree with the issues about spinal immobilization. I cringed everytime i would show up on a call of an elderly fall patient, where the EMTs had them strapped to a hard, flat board. And while i was an ER paramedic, i realized just how long patients truly are on backboards – it can be hours if an injury is truly suspected, or if the ED is busy.

    Medical Directors do not want to risk a law suit by enabling an EMT with 6 weeks of training to not immobilize a patient with a possible spine injury, when it can easily be masked and lead to a horrible outcome. The prevention outways the risk.

    I invented the Back Raft, along with several other physicians, to address this issue. It enables full use of a back board, relieves pressure points and it’s economical. The company we sold the product to, Thomas EMS, will give you a sample by requesting one from their website.

    Backboards are a staple in EMS. Using a Back Raft addresses the damage and airway issues. I hope this was informative. Additional studies by Dr. Edlich are available onthe site, as well.

    • I think that you’re missing the point. While the Back Raft may be an excellent device for reducing patient discomfort, the fact is that far too many patients are being immobilized. The c-collar is perhaps the biggest our biggest enemy when dealing with neck/c-spine injuries, followed very closely by all of the additional moving and positioning (almost always in an unnatural and uncomfortable manner) that takes place in order to “properly immobilize” a patient.

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