Chris Montera, Scott Keir, Dr. Dave Ross, Sam Bradley, Patrick Lickiss, and I discuss the lack of evidence of any benefit from spinal immobilization.
Immobilization or not that is the question: EMS Garage Episode 156
Any standard of care that does not have evidence of benefit needs to have an expiration date.
What do we do that causes the most stress on an unstable spinal fracture?
Placing a cervical collar on the neck and strapping the patient to a board increases the stress on any unstable spinal injury.
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Why do we let a superstition become the Standard Of Care?
Because we can’t tell the difference between superstition and medicine.
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There is no evidence that spinal immobilization ever provided any benefit to anyone.
There is evidence that spinal immobilization doubles the rate of disability among people with spinal injuries – exactly the people it is supposed to protect.[1]
Spinal clearance protocols do cut down on the pain and suffering of those without spinal injuries.
Spinal clearance protocols make it more likely that the people with spinal injuries will be endangered by manipulating their spines into rigid EMS collars and onto rigid boards.
Making the patient fit the board, rather than making the board fit the patient, is not good medicine. It does not even make sense.
Without evidence of safety, spinal immobilization should be stopped.
Without evidence of benefit, spinal immobilization should be stopped.
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Also listen to – A Change of the Dogma – If spinal immobilization helps only one . . .
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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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I’ll listen to the podcast later today; but the study you cite is poor science that should not be used to support or disprove anything.
** Most prominent of its flaws is that it ONLY looks at discharge condition. There is ZERO mention of on-scene condition; so any conclusions about pre-hospital immobilization are pure guesswork.
** The mechanism of injuries between the two hospitals don’t match up at all, either. The Malaysia hospital had the same raw number of fall patients as the U.S. hospital, but only 20% of the number of MVA patients. Given the relative forces involved in those mechanisms, it’s just as reasonable to conclude that the U.S. hospital should have MORE THAN twice the incidence of spinal-cord injury because it had 5x the number of high-energy incidents.
** The comment about the force needed to damage a spine (beginning of the Discussion section) is IMHO deliberately misleading. Yes, it takes a lot of force to damage an intact spine; but that’s not what EMS is dealing with. We’re dealing with potentially compromised spinal columns (i.e. damage already done), so a small force can cause disproportionate damage as a result.
“Making the patient fit the board, rather than making the board fit the patient, is not good medicine. It does not even make sense.”
It’s also not the proper method of immobilization. In EMT school, the instruction is that you should expect voids between the patient and the board, the result of putting a curved spine on a flat board. The idea is to use additional padding to make the board fit the patient, not the other way around. Forcing the patient to match the board is incompetence, not the fault of the procedure.
Immobilizing everyone with a “severe MOI” is voodoo medicine. PROPERLY immobilizing higher-risk patients based on the findings of a scene size-up and physical exam is prudent medicine.
mpatk,
I agree that the study has flaws.
This is the only study that has been done on spinal immobilization.
This study shows harm. Until there is evidence that spinal immobilization is not harmful, we should prohibit spinal immobilization.
The study is 14 years old. If there were any confidence in the safety, or the efficacy, of spinal immobilization, somebody should have studied this.
Where is ANY research to contradict this study?
Where is there any research to demonstrate any benefit from spinal immobilization?
There is no research to contradict the findings of this study. This study does have limitations, but that does not mean that the results, or the conclusions are wrong.
The authors of this study point that out and ask for better studies. Those defending spinal immobilization make excuses for not doing research.
Why do we assume that it is wrong to find out how dangerous spinal immobilization is?
This study is much better than all of the studies that do not exist.
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Rogue,
“Where is ANY research to contradict this study?”
There is nothing to contradict. This study says NOTHING about the effect of pre-hospital immobilization. Absent the comparison of pt condition on-scene vs. hospital arrival vs. discharge, all it tells us is that people in Malaysia were 1/2 as likely to have spinal damage from traumatic accidents.
“This study is much better than all of the studies that do not exist.”
Something is not always better than nothing. Your quote by Niels Bohr about understanding true and false things applies here. This study is IMHO misleading and not merely flawed.
As for the lack of studies and who is responsible? IMHO that’s politics, public opinion, and liability resulting in bad science. If removing a “standard of care” for an experiment resulted in statistically significant increase in permanent neuro deficits, the result would be the injured parties crying havok and letting slip the ambulance chasers of liability; God forbid there was any question of informed consent with any of the bad outcome patients. The attitude of the Powers That Be will always be a twist on the title of the older podcast (which I’m still trying to find on iTunes): “If even one person is harmed by not immobilizing the spine…” :-/
I’d love to get definitive evidence one way or another; I doubt most medics are sadistic enough to want to immobilize patients on a hard board unless necessary. I think unfortunately that we’d need to have a first study to show that the immobilization is done correctly (i.e. proper padding of voids, proper movement onto the board, etc…) before you can convince anyone to study whether the technique itself is valid.
I just want to put out this idea: the idea that the spinal immobilization being practiced every day across America is the same spinal immobilization from our textbooks is farcical. The average “extrication” consists of asking the walking, cartwheeling patient to sit upon a board, after which they are “immobilized” about as seriously (from an intervertebral point of view) as legs in pants. Although I recognize that the plural of “anecdote” is not “evidence,” at some point it may be meaningful for us to recognize that there is no epidemic out there of secondary spinal cord injuries being sustained after the initial trauma, despite the fact that our real efforts to prevent them are often token.
mpatk,
My response is Comment on Immobilization or not that is the question – EMS Garage Episode 156.
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Oh, how do you get quote boxes and boldface/italics/underlining here? Is it HTML-type tags?
mpatk,
Yes. HTML works.
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Rogue, good points, good effort, as always.
Two things I believe, as a reader, would improve quality of content, or perhaps answer my questions as a reader.
What is the solution you propose? In Malaysia, the patients received ZERO spinal immobilization, but not providing a faux “treatment” as we are now would be met with extreme resistance. Heck, my agency changed bags and it caused a big stink. For Christ’s sake, its a bag, its sole purpose is to hold things.
Second, more research has to be done! There are less than 10 quality studies done on spinal immobilization that I have found on a research paper/proposal I have created, submitted to my medical director (and swiftly, yet rudely given a swift NEGATIVE on). This is not your fault, nor anyone’s. The lack of research may be attributed to lack of the community viewing this as a prudent issue, unfortunately.
The solution is perhaps easier for us in Canada – we don’t have malpractice lawyers dictating our standard of care. And, yes, you’re right : it’s not their fault – we actively participated in allowing this to become the “standard of care”. I exchanged messages with Rogue earlier tonight. The message IS spreading, and yes, there are multiple ERs in rural Canada that ARE practicing in direct contravention of the “standard of care”. Which I will defend in a court of law or before a College hearing any day of the week. I predict altered practice is going to spread from rural to metropolitan – it’s easier, changing ivory towers is always going to be harder.
Do explain why ER’s put patient’s in collars while awaiting a scan to? How is that patient who’s walking about the ER having his spine protected…
Because silly medic, collars are for docs. The medic puts it on the board, or it gets the hose again. How many times must we douse you before you get it?