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

- Rogue Medic

Confessions of a recovering cervical spine field clearance addict – Part I

Here is an introduction to the problems with the anti-spinal clearance article by Dr. Dave Ross.

What is spinal clearance?

Spinal clearance is the use of a guideline to decrease the treatment of patients with a harmful bit of EMS voodoo.
 

Spinal immobilization has never been demonstrated to improve outcomes for EMS patients.

Clearly, we need to know what the effect is on patients.

It is unethical to use potentially harmful treatments without evidence of greater benefit than harm.

For many ethical and medical legal reasons associated with the practice of immobilization in our country, it’s likely there will never be a large-scale research study that will clarify the issue. So maybe we still need to be immobilizing patients at risk for cervical spine injury.[1]

 

Tony Soprano tells me that medical ethics is too corrupt for the Mafia. The Mafia prefers to be more honest about the ways they will inflict harm on people.

On the other hand, Mafia lawyers are finding the legal ethics of medicine to be very tempting, but they are concerned about the effect that lowering their ethical standards will have on their reputation.
 

Medical ethics?
 


Image credit 1. Image credit 2. Click on image to make it larger.
 

This is medicine, we are just protecting ourselves from our patients by using a legal fraud that seems to work on juries because of the jurors’ lack of knowledge of medicine.

If hokus pokus convinces juries (chosen for their ignorance of medicine), how can a doctor oppose that?

The defense of the doctors is –

We don’t know.

We don’t want to know.

We let the lawyers tell us what is good medicine.

We just need something to believe in – no matter how corrupt.

We don’t want to cause you disability, but we are too stupid afraid lazy impotent to do what is best for our patients.

Iatrogenic disability is not important enough for us to do anything to help our patients.

If we were to honestly provide patients with information to make an informed decision to consent to treatment, it would be something like this –

We don’t know if spinal immobilization does anything good.

We have no intention of finding out if spinal immobilization does any good.

We use the oxymoron of medical ethics to justify harming patients with mythological standards of care.

Agree to this painful, and probably harmful, medical mythology – or else!

We don’t know how much disability spinal immobilization causes, but the only study of spinal immobilization did show that patients were twice as likely to end up disabled from an unstable spinal injury with spinal immobilization than without spinal immobilization.[2]

That study was not perfect, but a truly ethical response would be to find out the actual benefits/harms of spinal immobilization.

Where are the ethical doctors?

Why do we allow anyone to claim that protecting a dangerous standard of care is more ethical than protecting patients?

There is no evidence of benefit of spinal immobilization.[3]

We are worried about the colors of the paint on the witch doctors’ faces.

Why aren’t we worried about how many patients we are permanently disabling with our dangerous treatment of spinal immobilization?

To be continued in Part II, and Part III, and probably Part IV, and maybe Part V, et cetera.

Footnotes:

[1] Confessions of a recovering cervical spine field clearance addict
September 06, 2012
EMS1.com
Dr. Dave Ross
Article

[2] 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).

[3] Nothing.

Look as much as you want, but there is no evidence that EMS spinal immobilization ever protected any real patient.

.

Comments

  1. I had quite the debate with Dr. Ross on this subject a while back.

    He seems willing to ignore or minimize the data that shows that it may be harmful, or ignore the studies where immobilization resulted in improper positioning or excessive manipulation.

    Ye he is perfectly willing to believe in something for which he has zero evidence – that it works.

    Odd, that.

    • Unfortunately, it’s not that odd. Rogue’s reference to Max Planck’s theory on new scientific truth (about 1 screen down from the top) is more true than any of us like to admit.

      Also, look at it from the point of view of someone who has been immobilizing people for a long career. That person has been trying to help people for years; and now you tell them that all those actions s/he thought were helping were actually harmful? It’s understandable that some people have trouble coming to terms with that. Granted, it’s still wrong and unacceptable; but it’s human nature.

  2. outstanding! looking for the follow ups

  3. How about the age old doctor response of “you are alone in the back if they vomit, you can’t roll them on their side and maintain spinal alignment. I in the ER have unlimited hands and can roll them while they vomit and maintain spinal alignment. That’s why you have to immobilize them”.

    So many holes in that logic I don’t know where to begin, but with various changes for dialects and regional inflections I’ve heard that from countless doctors. Isn’t part of medical school supposed to be about research, objective evidence, and maybe “first do no harm”? Or did I miss the point while going to clown college?

  4. General question to all: How would you design a study to determine if there are benefits (or risks) from spinal immobilization? I’m not talking about the legal and publicity problems with such a study; but how would the study work in practice?

    Obviously, double-blind studies are not feasible since there’s no way to blind anyone (researchers or subjects) to whether a subject got the treatment or the placebo. I suppose randomization of subjects could be handled simply by alternating between immobilization and no-immobilization. Consent might be an issue because those who are getting the placebo will know they’re getting the placebo. I’m playing Devil’s Advocate here; but I do believe that the study needs to be done and I’m curious if others think these might be issues or (even better) have answers to eliminate the problems I’m perceiving.

    IMHO, a big part of the problem with spinal immobilization (aside from poor technique) is the equipment used: namely a hard rigid board. Perhaps the inflatable devices submitted for patents could prevent movement without the risks of pressure ulcers and other effects of placing a curved body on a flat rigid board. Someone correct me if I’m wrong; but all the problems I’ve heard with spinal immobilization stem from the method and equipment of immobilization, not the fact that the patient is prevented from moving.

    As for the Hauswald article, I’ve expressed my opinion about it before. Suffice it to say that I disagree with Rogue about the study’s conclusions that spinal immobilization is harmful; but strongly agree with Rogue that well-designed studies of the effect of immobilization on trauma patients needs to be done.

    • Just a quick reply and I might not be firing 100% now, but here’s a thought. Take one of the many large cities that have multiple transporting ALS providers. Each day at the service level(or even the individual transporting crew level if you want) randomly assign a backboard/no backboard status. I know it’s nowhere near double blind, but you at least get randomized.

    • A thought from someone who isn’t a medic and has never been immobilized. Is it even possible to immobilize a living patient? I don’t see any practical way to keep a person from moving in practice. And the more I am restricted from moving, the more I tend to fight (or want to) against the restrictions. So perhaps you need to remove the concept of “immobilization” from your vocabulary.

      So you really need studies to answer how much movement is too much in what situations.

      • MV,

        A thought from someone who isn’t a medic and has never been immobilized. Is it even possible to immobilize a living patient? I don’t see any practical way to keep a person from moving in practice. And the more I am restricted from moving, the more I tend to fight (or want to) against the restrictions. So perhaps you need to remove the concept of “immobilization” from your vocabulary.

        In EMS, we rarely let reality get in the way of something we think is important.

        So you really need studies to answer how much movement is too much in what situations.

        We like having absolute answers from authority figures. We don’t like thinking.

        We definitely do not like research, because research almost never leads to absolute answers.

        We don’t know a lot about what we need to do to protect patients, and we don’t seem to want to know.

        Better to deny there is a problem and act as if everything is perfect.

        fortunately, this appears to be changing, even if the change is often slow.

        .

      • MV,

        “Immobilization” is short for “spinal immobilization”, which is a poorly descriptive phrase for “prevent the spine from twisting, bending, or otherwise moving out of a normal anatomical alignment.” You’re right in that the use of “shorthand” phrases and jargon tends to cause problems. People tend to lose track of the intent of the procedure, and instead consider the “shorthand” to be the true description; thus you get patients lashed down to the board, rather than positioned with padding and straps to prevent torsion and bending of the neck and back.

        So you really need studies to answer how much movement is too much in what situations.

        Exactly.

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