Severe pain + 2mg of Morphine = severe pain.

- Rogue Medic

Would I Want ‘Spinal Immobilization’ For Myself If I Were Injured?

 

In the comments to What is the Future for EMS? is the following comment from Can’t say, clowns will eat me
 

So. Here’s the question that has come to my mind now. Say you’re in an MVC off duty. You now have neck pain and would like to be transported. You have no deficits. Would you allow yourself to be “immobilized”? I have a feeling I know the basic answer but I look forward to your detailed answer as to why/why not.

 

Based on the history of medicine and the continuing failure of weak hypotheses to work out in favor of patients, there is no real decision to make.

My answer is No “Spinal Immobilization.”

Maybe I need my own variation on a DNR (Do Not Resuscitate) order – A DNUQ (Do Not Use Quackery) order.

If I am not alert enough to mock a proposed treatment that lacks appropriate evidence, then someone is to do the mocking for me – until the people who want to abuse me give up. :-)
 


Original cartoon
 

“Spinal immobilization” is supposed to get rid of bad movement of the spine.
 

We used to use blood-letting to remove the bad humors.[1]

Doctors agreed that this was the right thing to do for centuries.

How many tens of thousands of patients did we kill?

There was much more evidence of the benefit of bleeding to remove bad humors than there is for “spinal immobilization.”

The hypothetical explanation for the way bleeding was supposed to work (getting rid of the bad humors) was just as valid as the hypothetical explanation for the way “spinal immobilization” is supposed to work.

The Universal Quack Defense of It is wrong to criticize something with no evidence of harm was regularly used.
 

We used to give antiarrhythmics to get rid of PVCs (Premature Ventricular Contractions) in patients who had PVCs after having an MI (Myocardial Infarction or heart attack).[2]

Doctors agreed that this was the right thing to do for about a decade.

How many tens of thousands of patients did we kill?

There was much more evidence of the benefit of antiarrhythmics for post-MI PVCs than there is for “spinal immobilization.”

The hypothetical explanation for the way antiarrhythmics were supposed to work (getting rid of the bad heart beats) was just as valid as the hypothetical explanation for the way “spinal immobilization” is supposed to work.

The Universal Quack Defense of It is wrong to criticize something with no evidence of harm was regularly used.
 

We used to use rotating tourniquets to keep the blood in the extremities and out of the lungs of CHF (Congestive Heart Failure) patients.[3]

Doctors agreed that this was the right thing to do for decades.

Did we kill anyone?

We do not know, but we have no reason to believe we helped anyone and we have good reasons to believe that we did cause harm.

There was as much evidence of the benefit of rotating tourniquets for CHF as there is for “spinal immobilization.”

The hypothetical explanation for the way rotating tourniquets were supposed to work (keeping fluid away from the lungs) was just as valid as the hypothetical explanation for the way “spinal immobilization” is supposed to work.

The Universal Quack Defense of It is wrong to criticize something with no evidence of harm was regularly used.
 

We used to use Trendelenburg position to move the blood from the extremities and to the vital organs of hypotensive patients.[4]

Doctors agreed that this was the right thing to do for decades.

Did we kill anyone?

We do not know, but we have no reason to believe we helped anyone and we have good reasons to believe that we did cause harm.

There was as much evidence of the benefit of Trendelenburg position for hypotensive patients as there is for “spinal immobilization.”

The hypothetical explanation for the way Trendelenburg position was supposed to work (auto-transfusing fluid from the extremities to the vital organs) was just as valid as the hypothetical explanation for the way “spinal immobilization” is supposed to work.

The Universal Quack Defense of It is wrong to criticize something with no evidence of harm was regularly used.
 

More recently, we gave rofecoxib (Vioxx) for arthritis and other painful conditions.[5]

60,000 dead.

There was much better evidence of efficacy and safety than for “spinal immobilization.”

The Universal Quack Defense of It is wrong to criticize something with no evidence of harm was regularly used.
 

I could keep going on for a long time, but you either get the idea or you don’t.

Without evidence, there is no reason to assume a treatment is safe.

Without evidence, there is no reason to assume a treatment works.
 

The Universal Quack Defense has regularly been used by doctors to defend treatments that only cause illness/injury, when we are lucky, but kill a lot of us when we are less lucky.

If a doctor claims that we need evidence of harm to stop using an treatment that has no evidence of improved outcomes, then that doctor is dangerous.

When some doctor comes up with an explanation for why something works, but no evidence of improved outcomes, we need to wait for the evidence.

The evidence will almost always show that the explanation is fatally flawed.

Why don’t we care if we do more harm than good?

Should we trust a doctor who is so careless that he does not want to know if a treatment is safe?

Should we trust a doctor who is so careless that he does not want to know if a treatment works?

If a treatment is not safe, why take it?

If a treatment cannot be shown to work, why take it?

-

Footnotes:

-

[1] Answer to What is this Dangerous Treatment and How Long Did it Take to Stop Using it
Wed, 01 Feb 2012
Rogue Medic
Article

Blood-letting does work for hemochromatosis and a few other illnesses, but that does not mean that there was anything appropriate about killing patients based on a weak hypothesis.

-

[2] C A S T and Narrative Fallacy
Mon, 20 Jul 2009
Rogue Medic
Article

Some antiarrhythmics do work, but that does not mean that there was anything appropriate about killing patients based on a weak hypothesis.

-

[3] What do I expect to see less of in EMS in 2013?
Tue, 01 Jan 2013
Rogue Medic
Article

Tourniquets do work for otherwise uncontrolled bleeding, but that does not mean that there was anything appropriate about harming patients based on a weak hypothesis.

-

[4] Springtime for Witchcraft in Wake County
Tue, 28 Apr 2009
Rogue Medic
Article

Trendelenburg position can help increase the dimensions of veins, such as for starting an EJ (External Jugular) line, but that does not mean that there was anything appropriate about harming patients based on a weak hypothesis.

-

[5] Rofecoxib
Wikipedia
Article

Rofecoxib may be appropriate for patients who are not able to use anything else, if the patients are aware of the risks and are at low risk of the harmful/fatal side effects of rofecoxib.

.

Comments

  1. I was already in this quandary many years ago. I was hit head-on by another car. I was in a small Mazda truck and I was hit by a late 60s Buick.

    I had a small laceration to my forehead (the rear view mirror came off and hit me in the face), a pretty good laceration on my right knee where the parking brake handle dug into me, and my neck was a little stiff. By the time EMS got to the scene I was already out of my truck and was limping around. I had no loss of consciousness, I was fully oriented, and was not nauseous, until I saw what was left of my beloved Sundowner…..

    Between my forehead and my knee, I was going to need stitches (wound up with three on my forehead and eight on my knee). I wanted to go to the ED.

    I wound up having to refuse and got a ride with a friend home, then got the other car and drove myself to the ED.

    Why?

    Well, because of mechanism, I was classified as a trauma patient.

    That meant a cervical collar, a long backboard, high flow oxygen, and two large bore IVs.

    EMS did take my vitals- BP 124/72, HR 72, RR 16, SPO2 99%. The bleeding was controlled with simple pressure, and I had full movement in my neck, no other discomfort other than a little stiffness, and I had full sensation in all of my extremities.

    But…if I went to the hospital via ambulance, per their protocols, I had to go with ‘the whole package’.

    No thanks.

    • That “full package” idea is just nonsense: patients have the right to refuse any and all interventions they want while still requesting transport via EMS.

      My personal policy on immobilization is that if I’m physically capable of fighting off someone coming at me with a collar then I don’t want it, but if I’m too sick and altered to put resist, then go right ahead.

  2. I have two experiences with spinal immobilization. When I was 16 and hit by a car, while on my bike, I was fully immobilized. At the time to me it meant that I was in good hands and that help was there I knew that the standard was to do full spinal immobilization. Looking back at it I flew a good 10 feet high and was unconscious for a good minute, however after the one block drive to the hospital I was taken off the spine board but the c-collar stayed and I still fell over when they tried to get me to stand up after 2 hours prone on the bed.

    Over winter I crashed hard while snowboarding off rocks. There was no way I was going to let ski patrol board me and sled me down the hill. This is probably because I now work in EMS and know what spinal immobilization can cause more issues.

    Though I am finding it hard to educate other providers that there is little evidence, if any, of benefit of spinal immobilization. Most people have been scared into always immobilizing. I got told off for letting a Sprint Car driver get out of his car after it rolled. He was in a full roll cage and 5 point harness with a helmet and neck brace. He had no pain and moved very well, running, from the leaking car.

Trackbacks

Speak Your Mind