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

- Rogue Medic

Spinal Immobilization Harm

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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Comments

  1. “But spinal immobilization protects the patient from injury!”‘

    Oh…my…god….this…statement. Every time I hear it I pretty much get hulk rage except I don’t turn green and don’t get any taller.

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