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

- Rogue Medic

Flipping the Patient the Bird

Mon, 04 Oct 2010 20:11:45 -0400 by
There is a nice sarcastic comment to The Bird is the Word – Coma Toast by Can’t say, clowns will eat me –

What? You mean oxygen doesn’t cure all ills?

It will be just our little secret, but oxygen is not a panacea . . . and . . . it . . . is . . . sometimes . . . bad.

The way it seems the vast majority of ALL EMS responders must think is that it’s better to give oxygen than to just transport. And god forbid you don’t have a pulse ox.

You have to consider the thought process involved.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

But want to call HEMS for the cool pins and a nice hat? You’re a hero.

Use the noisy flying gadget with a lot of flashing lights and the free lapel pins.

vs.

Use the gadget with the flashing light.

vs.

Use my brain.

Gadget with flashing light wins too often . . . and . . . it . . . is . . . sometimes . . . bad.

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So, go ahead and do us a favor and get some docs with you to replace the registry and possibly the joint while you’re at it.

I am just ranting away about these darned naked emperors prancing around with nothing.

These stark naked guys are the pall bearers for a lot of flight nurses, flight medics, EMS pilots, and patients.

These killer buffoons need to be stopped.

Some of the doctors are realizing this, but many emergency physicians are fanatical helicopterists. They will transfer patients from the suburbs by helicopter no matter how much the flight delays transport and even if those on the helicopter work on the ambulance when not scheduled on the helicopter.

This often has nothing to do with quality of care.

This often has nothing to do with speed of transport.

This is nothing new.

This is purely for the emotional satisfaction of the person calling for the helicopter – regardless of whether that person is a first responder with minimal medical training or a board certified emergency physician.

The only thing that changes, from Ricky Rescue to Dr. Rescue, is that Dr. Rescue uses fancier words when making his lame excuses.

This is irresponsible behavior.

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Filed Under: Critical Judgment, Ethics, Fraud, Helicopters, Heresy Tagged With: , , , , , ,

More on Lasix in EMS

Tue, 28 Sep 2010 06:24:51 -0400 by
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Some people may think that I am crazy for claiming that we should not use Lasix (furosemide). For a slightly different perspective, here is an emergency physician describing the appropriate treatment of unstable hypertensive acute pulmonary edema patients.

EMCrit is an excellent podcast blog with nice short podcasts. More important than being nice and short, the podcasts are science-based and address many of the issues that EMS treats. The first podcast from EMCrit is 10:33.

How important is furosemide?

Is the furosemide drug shortage important?

So, the first thing you do is get your Lasix . . .

Only

1:50

into

the

podcast.

–

OK,

maybe

I

was

thinking

of

a

different

podcast.

–

Maybe

I

was

wrong.

So, the first thing you do is get your Lasix and you throw it in the trash.

No.

I was right.

This is the podcast for me.

It’s not going to help you and it’s very potentially going to hurt you. No Lasix in these patients. Now, I’m sure your EMS providers have already given it. Well, that’s just fine, but you don’t have to exacerbate the problem. Most of these patients will end up volume depleted, not volume overloaded when you look at their intravascular space. You’re probably going to end up giving fluid to these patients, not trying to diurese them. The problem is not fluid overload.

Most of these patients will end up volume depleted,

Go listen.

10 minutes 33 seconds of somebody who understands CHF(Congestive Heart Failure)/ADHF (Acute Decompensated Heart Failure). And he isn’t subtle. 🙂

–

PS – Dr. Weingart, why not try to get those of us in EMS to improve our care of these patients, too?

High-dose NTG and CPAP are also treatments that can be given by EMS. In some places, these are given by EMS.

With sublingual NTG (NiTroGlycerin) we probably cannot give too much to these patients.

We should be using NTG by IV in EMS. In Pennsylvania, IV NTG is an optional drug for 911 services.

–

EMCrit’s page of references supporting this aggressive approach.

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Updated 02/08/11 to reflect the new blog address for EMCrit. http://emcrit.org/ The old links did not redirect appropriately.

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Filed Under: Critical Judgment, Drug Shortages, EMCrit, Heresy, Lasix, NTG Tagged With: , ,

First Few Moments – Mechanism Of Injury or Idiocy

Mon, 20 Sep 2010 19:26:35 -0400 by

On the First Few Moments podcast we had an interesting discussion about the usefulness of mechanism in making treatment and transport decisions.

Mechanism of Injury or Idiocy?

Dr. Jeff Myers, Kyle David Bates, Rick Russotti, and Scott Kier.

Should anyone view mechanism as anything more than an indication of where to pay closer attention during assessment of trauma patients? In this case, a trauma patient does not mean a patient going to a trauma center, but a patient who has had any kind of injury.

–

One of the points mentioned is that the main controversies that have been discussed recently by several of us on other podcasts (such as Dr. Bill Toon mentioned on Doctor Doctor Doctor: EMS Garage Episode 101) is that too often we use treatments in the absence of a specific indication.

Oxygen – not to treat any signs of hypoxia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

Spinal immobilization – not to treat any signs of spinal cord injury, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently transport the patient.

Naloxone – not to treat any signs of opioid overdose, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient and manage the airway.

50% Dextrose – not to treat any signs of hypoglycemia, but because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS appropriately assess and treat decreased levels of consciousness with the appropriate treatment – for symptomatic hypoglycemia, titrate 10% dextrose to an appropriate response.

Epinephrine – not to improve survival from cardiac arrest, but because of the short term buzz of getting a pulse back and we figure it can’t hurt and What if . . . ?

The alternative is to limit EMS to effective treatments.

Mechanism Of Injury (MOI) – to replace assessment – not to improve assessment, and because we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess the patient.

It is important to train/educate EMS well enough to be able to provide this competent assessment.

It is idiocy to have EMS use an irrelevant damage report on the motor vehicle, which we will not be treating.

Endotracheal intubation – not because it provides a better airway, but because somebody called it a Gold Standard and we figure it can’t hurt and What if . . . ?

The alternative is to have EMS competently assess and manage the patient’s airway.

Helicopters – not to improve treatment or make a significant difference in transport time, but because we figure it can’t hurt and What if . . . ?

The alternative is to have competent EMS.

–

The answer seems to be that we need to improve EMS and EMS education – a lot.

Maybe we need to create a No Fly Zone around each trauma center. For example, if the patient is closer than an hour drive time from the trauma center any flight should be treated as a sentinel event and investigated thoroughly.

Maybe we need to have the fire companies and ambulance companies pay for any flights that are determined to have been unnecessary. If we really want to limit unnecessary flights, what will work better than forcing those of us who call for the helicopter to have to have the ability to justify the flight medically.

If a helicopter is called, just because it is easier to send a patient by helicopter than by ambulance, a $10,000 to $20,000 convenience charge may be a great way to fund helicopters and to discourage abuse of helicopters.

If we do not understand what is going on medically with the patient, we should not be making patient care decisions.

Calling for a helicopter because I am too stupid to assess my patient is bad medicine.

If we are calling for helicopters, we are making medical decisions, so we need to be able to justify those medical decisions.

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Filed Under: Critical Judgment, EMS Garage, Ethics, First Few Moments, Fraud, Helicopters, Heresy Tagged With: , , , , ,

Do Drug Shortages Really Impact EMS? – Answer 1

Wed, 08 Sep 2010 18:39:51 -0400 by
–

–

Here is part 1 of the details from the points I raised in commenting on the discussion of the drug shortages and the way these affect EMS. I already gave the short answers in Do Drug Shortages Really Impact EMS? – EMS Office Hours. These will be a bit longer, so I broke it up by answer. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

–

1. Do the drugs help patients?

I have recently written about why these drugs are inappropriate here, here, here, and here.

These drugs are based on either, or both, of 2 bad ideas.

First – Expired expert opinion. Opinion that is not supported by good research. When the research has been done, the research has not supported these treatments.

By expired, I do not mean that the expert has expired, but that the opinion has been kept in use long past any possible justification. If this were canned food in your cupboard, the can would be bulging at both ends from the disgusting growth on this very dead opinion.

Second – Not just expired expert opinion, but opinion that is not based on any research. There is the possibility that research will someday demonstrate that these treatments are effective, if anyone ever appropriately studies these ideas. It is also possible that the parts of the moon that have not been examined actually are made out of cheese. This is the morass of Class IIb level of evidence.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIa. Weight of evidence/opinion is in favor of usefulness/efficacy

IIb. Usefulness/efficacy is less well established by evidence/opinion.[1]

There is no requirement for any evidence.

The highlighting is mine, but the wording is 100% ACC/AHA (American College of Cardiology/American Heart Association). The people who thought antiarrhythmics were the answer to everything, until research showed an antiarrhythmic fatality rate several times higher than placebo.[2]

Oopsy.

Perhaps I am putting too positive a spin on the Class II levels of evidence. Some of what is classified as IIa is not much different from IIb, because there is still the allowance for expert opinion. Any reading of this research should be preceded by the words, Wouldn’t it be nice if . . .

However, that is not the way to decide what chemicals to test on a patient.

Let’s be honest. That is all we are doing. We are testing chemicals and/or procedures on patients. We are not treating patients, because treatment implies some sort of concern for the patient. This is just a bunch of large scale never-to-be-published, uncontrolled, unregistered, unreasonable experiments on patients who are not informed of their guinea pig status.

I want to know the real risks and benefits of this treatment.

Wouldn’t it be nice if . . .

How far do we need to go to demonstrate that bad ideas really are bad ideas?

We need to demand that medical directors base their EMS protocols on research.

Why are medical directors ignoring what is best for their patients?

Why are medical directors ignoring what is best for our patients?

Why should we tolerate this ignorance?

I’m a doctor.

Wouldn’t it be nice if . . .

–

Continued in –
Do Drug Shortages Really Impact EMS? – Answer 2
Do Drug Shortages Really Impact EMS? – Answer 3
Do Drug Shortages Really Impact EMS? – Answer 4

–

Footnotes –

[1] Manual for ACC/AHA Guideline Writing Committees
Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines
Section II: Tools and Methods for Creating Guidelines
Step Six: Assign Classification of Recommendations and Level of Evidence
Free Full Text Article

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[2] C A S T and Narrative Fallacy
Rogue Medic
Article

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Filed Under: Critical Judgment, Drug Shortages, EMS Office Hours, Heresy, Physician Oversight, Research Tagged With: , , ,

Do Drug Shortages Really Impact EMS? – EMS Office Hours

Tue, 07 Sep 2010 14:18:49 -0400 by
–

–

There is a discussion of the drug shortages and the way these affect EMS. There are many points covered for a podcast that lasts less than 40 minutes. Do Drug Shortages Really Impact EMS?

–

1. Do the drugs help patients?

Short answer – No.

–

2. If the protocols insist that we give these drugs, how do we convince doctors that doctors should act as if they learned something in medical school?

Short answer – Ridicule.

–

3. Should we switch from Lasix (furosemide) to Bumex (bumetanide)?

Short answer – No.

–

4. Should CPAP (Continuous Positive Airway Pressure) be ALS only (Advanced Life Support only)?

Short answer – No.

–

Continued in –
Do Drug Shortages Really Impact EMS? – Answer 1
Do Drug Shortages Really Impact EMS? – Answer 2
Do Drug Shortages Really Impact EMS? – Answer 3
Do Drug Shortages Really Impact EMS? – Answer 4

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Filed Under: Critical Judgment, Drug Shortages, EMS Office Hours, Heresy, Physician Oversight, Research Tagged With: , ,

Helicopter Crash vs. Ambulance Crash

Tue, 31 Aug 2010 15:14:15 -0400 by
In the past week there have been a couple of EMS crashes that have made the news.

The first crash is from Maryland on Friday, August 27.

Captain Oscar Garcia, spokesperson for Montgomery County Fire and Rescue, says the ambulance had just refueled after dropping off a patient at Shady Grove Hospital and was heading back to Station 3 when for some reason, the ambulance went off the road and down a hill into a ravine on Falls Road near Liberty Lane.[1]

Elsewhere it was reported that the crash was a rollover –

MOI OMG Panic! Double Panic!

Get Me A Helicopter, Yesterday!!!11!!!!

A Rollover!

The four firefighters had minor injuries and were taken to the hospital to be checked out, but they are expected to be ok. The car failed to stop and left the scene.[2]

It seems that somebody on scene decided to actually assess the patients, rather than triage them according to Mechanism Of Idiocy.

The second crash, this morning, did not have such a positive an outcome.

The Air Evac Lifeteam helicopter was flying to pick up a traffic accident victim when it went down near the Scotland community in Van Buren County at about 4:30 a.m., Federal Aviation Administration spokesman Lynn Lunsford said.[3]

Air Evac has experienced several fatal crashes in recent years.

In 2008, an Air Evac helicopter crashed in an Indiana cornfield killing three people. In 2007, another three-member crew was killed when an Air Evac helicopter crashed in Colbert County, Ala.

In 2006, an Air Evac helicopter crashed in Gentry in northwest Arkansas, killing the three-member crew.

Last month, an Air Evac helicopter made a forced landing near Tulsa, Okla., after the aircraft’s hydraulics failed. No one was hurt.

(This version corrects to delete information on a crash in western Tennessee; that helicopter did not belong to Air Evac.)[3]

At least the patient was not yet on board.

There is no information provided about what kind of injuries the patient was being flown for – that is assuming the patient actually was injured and not being flown for MOI (Mechanism Of Idiocy) by a protocol monkey.

Maybe the patient did have serious injuries, but considering that most patients sent to the trauma center by helicopter do not have serious injuries, betting on serious injuries would be a bad bet.

Our study demonstrated that the majority of trauma patients transported by medical helicopter from the scene had nonlife-threatening injuries.[4]

Our findings are similar to other studies that have documented that a significant number of trauma patients transported from the scene to a hospital by medical helicopter do not receive any added benefit from helicopter transport.[4]




Even though these patients receive no benefit from being transported by helicopter, these patients are exposed to significant risk and exaggerated costs.

This is the difference in outcome between a rollover crash of an ambulance and a crash of a helicopter.

Rollover crash –

Minor injuries. None of the patients transported by helicopter.

Helicopter crash –

Dead Pilot.

Dead Flight Medic.

Dead Flight Nurse.

The patient being transported by someone else.

Air Evac has identified the crew members who died in the crash as pilot Ken Robertson, flight paramedic Gayla Gregory, and flight nurse Kenneth Meyer, Jr.[5]

Helicopter services do not even seem to care how many of their employees and patients they kill.[6]

–

Footnotes:

–

[1] Four Hurt In Maryland Ambulance Accident – All onboard suffered non life-threatening injuries.
JEMS.com
Article

–

[2] Ambulance Rollover Injures 4
Firegeezer
Article

–

[3] Three Dead In Arkansas Medical Chopper Crash – Medevac was enroute to pick up a patient.
Chuck Bartels
Associated Press
Tuesday, August 31, 2010
Article at JEMS.com

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[4] Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.
Bledsoe BE, Wesley AK, Eckstein M, Dunn TM, O’Keefe MF.
J Trauma. 2006 Jun;60(6):1257-65; discussion 1265-6. Review.
PMID: 16766969 [PubMed – indexed for MEDLINE]

Full Text PDF

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[5] Medical helicopter went down near Scotland in Van Buren Co.
todaysthv.com
Pictures are also from here.
Article

–

[6] Not Clear On The Concept
Too Old To Work, Too Young To Retire
Article

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Filed Under: Critical Judgment, Heresy Tagged With: , , ,

That’s not Klingon It’s One Word Dyspnea: EMS Garage Episode 98

Tue, 10 Aug 2010 06:54:36 -0400 by
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We were supposed to be talking about the potential harm from the way we use oxygen in EMS, but we ended up with That’s not Klingon It’s One Word Dyspnea.

First, I mentioned that I am blogging at a new location – here. Also at EMS Blogs will be Black Hearts Incorporated, EMS Bloggers, EMS Office Hours, Medical Author Chat, Ready Fodder, The Social Medic, and Too Old To Work, Too Young To Retire. So far, EMS Office Hours, Too Old To Work, Too Young To Retire, and I are posting while things are being worked out. The blog transfer has not been fun, but it has been educational. I expect to learn a lot more. And I have to thank David Konig, who has been putting his blog, The Social Medic, on hold and guiding us through this. He has also come up with a nice simple design for my blog that I like a lot.

Then the topic turned to the recent medical helicopter crashes and Ambulance Driver’s post Is that helicopter really necessary? in response to the M.D.O.D. post Do You REALLY Need the Helicopter? Before the podcast, I wrote a post mostly about the comments on Ambulance Driver’s post. Fly Everyone, Let the NTSB Accident Investigators Sort ‘Em Out.

It should come as no surprise to people who are familiar with any of the participants, that we were very critical of the abuse of helicopter EMS by medical directors, by ED physicians, and by ground EMS personnel.

Why should we try to justify abuse?

The comments in support of helicopter abuse (on Ambulance Driver’s post) are depressing for those of us trying to improve the quality of EMS. These comments do point out the problems I wrote about in Confirmation Bias and EMS. Many of us do not appear to make any attempt to be objective in evaluating what we do in EMS. We only seem to look at things through the filter of our biases. The people writing these comments seem to have decided that helicopters always save lives and they deny that helicopter crashes are a problem.

The purpose of the helicopter is to make a significant difference in transport time for the patient who really is unstable. These patients are not as common as many suggest. They seem to be most commonly encountered by the least experienced people. In other words, as people become more skilled, they panic less and fly fewer patients. The people denying the problems with helicopters seem to be trying to demonstrate that they cannot assess patients well enough to recognize which patients are unstable, which are stable, and which were never even injured.

The people denying the problems with helicopters also seem to demonstrate that they do not understand that they are not saving significant amounts of time. They often are delaying a patient’s arrival at a trauma center just so they can put the patient in a helicopter.

Finally, we did briefly mention harm from oxygen, but that should be covered in an upcoming podcast. Preferably a show with at least one physician on it. There is a lot to discuss, when considering the over-use of oxygen, and it does appear that we use too much oxygen. We have too many patients receiving oxygen without any evidence of hypoxia.

In the absence of hypoxia, there is not evidence of benefit from oxygen, but there is evidence of harm. This goes back to at least 1950, so the idea that oxygen is harmful is not at all new. This is another example of what I write about in Confirmation Bias and EMS.

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Filed Under: EMS Garage, Ethics, Fraud, Helicopters, Heresy Tagged With: , , , , ,

Spinal Immobilization Harm

Sat, 28 Nov 2009 03:23:24 -0500 by
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What do we do to protect our patients from injury when we immobilize them?

But spinal immobilization protects the patient from injury!

Maybe, but if spinal immobilization does offer any protection from any injury, it may only offer that protection when spinal immobilization is performed perfectly. We do not know what perfect spinal immobilization is, but it probably is not the method we currently use – strapping people to pieces of wood, or pieces of plastic.

Here is one example of spinal immobilization creating more of a risk of paralysis.

Imagine that we are dispatched to a motor vehicle collision. There is significant damage to the vehicles. Our patient is up and staggering around. We attempt to assess our patient and find that he is not cooperative. Mr. Charming is behaving in a way similar to other patients – patients who have stated that they might have consumed some alcohol, but only 2 drinks. However, Mr. Charming is not as charming as these previous patients. He does not even answer most of our questions, never mind demonstrating that his math skills become undefined beyond the number two.

Protocol states that Mr. Charming should be immobilized to protect his neck from possible movement during transport. We attempt to put a collar on Mr. Charming, but find that we have to wrestle with him to keep the collar on his neck. In a moment of inspiration, we call medical command for possible orders to either sedate Mr. Charming or to not immobilize Mr. Charming. Tonight, medical command is Dr. Charming (no relation). The doctor is about as charming as Mr. Charming, but no more reasonable.

Dr. Charming is worried about the possible harm that might come from not immobilizing Mr. Charming. It seems that this harm is legal harm that would affect Dr. Charming. The possibility that Mr. Charming’s combativeness might convert a stable fracture to an unstable fracture, or an unstable fracture of the spine to a permanent injury of the spinal cord – these risks are insignificant compared to creating a legal alibi. Mr. Charming is applying significant forces to his cervical spine, by wrestling with us, by fighting with the collar, and once he is strapped to the board, those forces applied to the cervical spine are increased exponentially.

This understanding of mechanism, or kinesiology, is ignored by Dr. Charming. Mr. Charming will be laying on his back, his head taped to the board, wearing a cervical collar. He will be continually raising his head against the restraining tape. He will be applying the kind of forces to his neck that essentially clear his spine as far as unstable fractures are concerned, because if this does not result in paralysis, nothing will. Dr. Charming does not understand, but he has seen people play lawyers on TV and he is more worried about his theoretical legal problems.

Dr. Charming’s concern about sedation is that sedation may mask the ability to thoroughly assess the patient. No, we’re not considering sedating the doctor – that would affect the assessment. OK, we’re not completely ruling out sedating the doctor, but don’t tell anybody. Shhh. That will be our secret. Even though that ability to thoroughly assess Mr. Charming is little more than a hallucination, Dr. Charming believes it is significant. Dr. Charming believes that, if we do not sedate Mr. Charming, he will be the ideal patient. Dr. Charming is worried that a sedative may convert Mr. Charming from a combative and uncooperative patient, to a sedated and uncooperative patient. Dr. Charming does not realize that this is one of the benefits of sedating Mr. Charming.

Dr. Charming is also concerned about Mr. Charming’s blood pressure, which appears to be elevated, but it is difficult to obtain, due to the way his combativeness does not exactly assist with our assessment. Mr. Charming says he will allow a blood pressure, but only if we agree remove the collar and remove him from the long board. Dr. Charming considers the inability to be able to obtain a clear blood pressure as a sign that it must be on the low side, perhaps dangerously low, even though all indications are to the contrary. Dr. Charming is worried that giving a depressant, and sedatives are almost all depressants, will lower Mr. Charming’s blood pressure to even more dangerous levels, although there really is no indication that there is a problem with the blood pressure.

Number three on Dr. Charming’s hit parade is the possibility that the sedative may induce nausea and vomiting. These are significant risks in the immobilized patient. We can deal with vomiting in a couple of ways. We can give anti-emetic medication, but Dr. Charming is afraid that the sedating effect of the anti-emetic may similarly compromise assessment. Not to worry – we can still turn the long spine board on its side, while we shovel the vomit out of Mr. Charming’s airway. Remember, this is EMS. Immobilization is much more important than airway. In EMS, we consider it more important to keep the immobilization just so, than to make airway management the priority.

Let’s see, the research on breathing vomit does not exactly include randomized placebo controlled trials, but the purely observational nature of the research does seem to have produced a consensus. Breathing vomit does not lead to a long life. Even I do not criticize this conclusion.

On the other hand, the evidence that the immobilization device actually protects the patient from further injury, even without the complication of a vomiting patient – that evidence does not exist. That evidence is really just expert opinion, just like the Golden Hour, prophylactic lidocaine, giving medication down the endotracheal tube, System Status Management, high flow oxygen is harmless and good for everything, MAST (Medical Anti-Shock Trousers) creates an auto-transfusion of blood from the legs to the upper body, if it wheezes it is asthma, if it crackles it is CHF and will have pink frothy sputum, and so on. All of those expert opinions have been shown to be wrong, so how much should we endanger our patients in defense of this not yet discarded expert opinion?

Is the concern about sedation leading to vomiting a legitimate concern?

Yes. And. No.

Huh?

Yes. One of the side effects of medication is vomiting. Even anti-nausea/anti-vomiting medication can cause vomiting. Combining the sedative with a condition that may lead to vomiting on its own (intoxication), may increase the chances of vomiting.

No. Mr. Charming probably has eaten chili, hot wings, pizza, and washed it down with some cheap imported beer (such as Budweiser), followed by some jet fuel/miracle semi-digested food propellant even cheaper home grown tequila. Therefore, Mr. Charming already has a total stomach evacuation scheduled. Maybe he will wait until he is safely being ignored in a hallway bed. Maybe he will not vomit at all, but not being prepared for vomiting is stupid, especially with such a charming patient.

While the one large study to compare a system with spinal immobilization and a system without spinal immobilization was not large enough to clearly demonstrate that spinal immobilization is harmful, that is the way the numbers were trending.[1]

I am sure that none of us will ever deal with an intoxicated person, who has a mechanism where the protocol indicates full spinal immobilization be applied, it is good to think about what might happen in the rare event that we come across one of these trauma zebras.

First do no harm is a pithy phrase that is more of a medical punchline than a medical reality, but we should wonder if this spinal immobilization treatment is even as safe as any alternative. If we wish to claim that spinal immobilization is safe and/or effective, we need to provide some research to support it.

Without research, spinal immobilization is just another experimental treatment.

Should we be experimenting on our patients?

We do not have IRB (Institutional Review Board) approval

We do not have researchers.

We do not have control groups.

This is just a huge uncontrolled unauthorized experiment on the unsuspecting.

Can spinal immobilization be said to have satisfied any requirements to be treated as not experimental?

No.

But – It would be unethical to study this, because that would deprive some patients of this obviously beneficial treatment!

That is what doctors say about treatments based on expert opinion. They keep saying that – right up until the evidence of harm is unavoidable – or the doctors come up with a new and improved expert opinion treatment perhaps as a way of deflecting the claims about the discarded treatment.

Is there any evidence that those with spinal fractures are not harmed by immobilization?

Is there any evidence that those with spinal fractures receive any benefit from spinal immobilization?

As far as I know, the answer to both questions is No.

Footnotes:

[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]

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). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.

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Filed Under: Critical Judgment, Heresy, Research, Spinal Immobilization Tagged With: , ,
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