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

- Rogue Medic

Why Do We Have So Little Respect For Our Patients?


Informed consent should require that we provide our patients with honest information about the treatment we are pushing.

Even implied consent assumes that an informed patient would make the decision to take the treatment if the patient had the capacity to make an informed decision and had honest information about the treatment.

What medical treatment do we use during cardiac arrest?

We use chest compressions and defibrillation.

Nothing else qualifies as medicine.


Ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, and procainamide, are witchcraft.

There is no evidence that ventilations, epinephrine, norepinephrine, vasopressin, amiodarone, lidocaine, or procainamide improve survival from cardiac arrest.


Why don’t we limit treatments to what actually works, rather than what makes us feel like we are helping?

We are only exposing our patients to adverse effects for no benefit to the patient.

Nature has demonstrated a strong bias in favor of reality.

Our bias in favor of superstition is unnatural and unhealthy.

All treatments should be limited to high-quality controlled trials until there is valid evidence of improved outcomes with the treatment.

Surrogate endpoints do not count.

If we wish to develop an understanding of what we are doing, we need to study what we use.

If a treatment does not work under controlled conditions, why believe that it works in uncontrolled conditions?

Research gives the best opportunity to see the difference in outcome that is due to the just the treatment being studied.

If we think the treatment works, we should be insisting on showing off.

We are all talk.

We run away when challenged.

If we accept excuses for not finding out what we are doing, we end up with epinephrine for cardiac arrest – 50+ years of use, but we still do not know if it is beneficial, if it is beneficial in some patient populations and harmful in other patient populations, or if the effect is neutral.

There is no outcomes research that has shown improved outcomes, but epinephrine is the standard of care and research has been discouraged because it would be unethical to deprive patients of this witchcraft.

Any treatment that is used outside of controlled trials, without evidence of improved outcomes, is witchcraft. Why can’t we be honest about that?

I was a baby, when we started using epinephrine for cardiac arrest. I am a cantankerous old coot, now. There has been only one placebo controlled trial of epinephrine for cardiac arrest,[1] but that was crippled by political pressure because it would be unethical to deprive patients of the eye of newt.

Someday, medicine will grow up and start treating patients with something that actually works.


[1] Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL.
Resuscitation. 2011 Sep;82(9):1138-43. Epub 2011 Jul 2.
PMID: 21745533 [PubMed – in process]

Free Full Text PDF Download from semanticscholar.org

This study was designed as a multicentre trial involving five ambulance services in Australia and New Zealand and was accordingly powered to detect clinically important treatment effects. Despite having obtained approvals for the study from Institutional Ethics Committees, Crown Law and Guardianship Boards, the concerns of being involved in a trial in which the unproven “standard of care” was being withheld prevented four of the five ambulance services from participating.

In addition adverse press reports questioning the ethics of conducting this trial, which subsequently led to the involvement of politicians, further heightened these concerns. Despite the clearly demonstrated existence of clinical equipoise for adrenaline in cardiac arrest it remained impossible to change the decision not to participate.

Edited 12-27-2018 to correct link to pdf of Jacobs study in footnote 1.


Mechanical CPR as an Excuse to Just Transport


Dr. Keith Wesley usually takes an approach that is focused on the patient.

Dr. Wesley is one of the doctors I use as an example of doctors who truly understand about the ways EMS can improve outcomes.

But . . .

Why is he suggesting that transporting during CPR is a good idea – except when it cannot be avoided?

Did the IAFF (International Association of Fire Fighters – EMS is about speed, not patient care) kidnap someone important to Dr. Wesley?

The researchers had a driver cover a predesignated course in the city with typical changes in direction, railway crossings and speeds up to 78 mph.[1]


Because it is about the speed of transport, not about the patient.

When the patient is dead, it is a good idea to slow down and transport safely, not try to make the rest of the occupants even more dead than the patient with the mechanical pulse.

Avoiding patient care, because we can drive fast!

How many of the Low Information Voters of EMS will look at this ridicule of IAFF policy and be proud that they value speed more than they value their patients’ lives?[2]


Keith Wesley’s Comments
Many may be asking why I reviewed a study with such obvious results.


Because the IAFF took your baby away?

Performing chest compressions is fatiguing and the back of an ambulance rolling lights and sirens through the night is downright dangerous. So dangerous, in fact, I consider it bordering on employer negligence if condoned or even sanctioned.[1]


This was a study comparing negligence with machine compressions to prove that it is less negligent to use a machine during transport.

We already know that we should be resuscitating patients on scene.

Does this study provide any kind of evidence of improved outcomes from this rush to transport as compared with treating real patients on scene?


Does this even attempt to demonstrate benefit?


When you combine the poor outcome of these cardiac arrest victims receiving worthless CPR while exposing the responders to career- or life-ending injuries, I simply wonder who is reading the science at all. If this information was well-known and accepted, then every ambulance in America would be equipped with a mechanical CPR device. So why aren’t they?[1]


Why are apples not oranges?

Why are we putting apples on every ambulance?

Because of oranges!

This is EMS. We need to know if rapid transport with a machine to be resuscitated in the hospital improves survival when compared with resuscitating patients on scene.

Perhaps the idea of replacing a human being with a machine to save a life is unsettling.[1]


Allow me to rewrite that –

Perhaps the idea of replacing a human being with a machine to save a life transport a dead body is unsettling.

But the science doesn’t lie. If we’re going to save more victims of cardiac arrest, we have to overcome all obstacles and embrace the value—and effectiveness—of technology.[1]


Then show how this saves lives.

Where is the evidence of improved survival to discharge?

Surrogate endpoints lie.

This is just a surrogate endpoint paper.

This is just a lie with bad science.

What next? Scientists sat, this one trick will cure cancer.

Blood-letting is an excellent treatment – based on surrogate endpoints.

Should we go back to bleeding patients to death just because it makes the surrogate endpoints look good?


[1] Mechanical CPR Could Save More than the Patient’s Life
Karen Wesley, NREMT-P | Keith Wesley, MD, FACEP
December 2013 Issue | Tuesday, December 10, 2013

[2] EMS: The low information voters of healthcare – Making decisions purely on emotion and superficial knowledge
September 02, 2013
The Ambulance Driver’s Perspective
by Kelly Grayson


Selling scams to the most desperate patients

This is alternative medicine at its worst.

When it fails, blame the victim.

At prayer healing services in some Pentecostal churches, pastors invite people infected with HIV to come forward for a public healing, after which they burn the person’s anti-retroviral medications and declare the person cured.[1]


If only there were some documented cases of patients going from high levels of HIV to no HIV measurable with prayer as the only treatment.


The group was asked to undergo a test at a certain clinic in Nairobi, where they were all declared cured.

“We had joined him for crusades around Nairobi slums, telling the people how wonderful the pastor’s miracles were,” she added. “I was upbeat, but after two weeks I started falling sick. When I was tested, the virus was still in me and had multiplied since I was not taking the drugs.”[1]


Falsified AIDS tests convince people that they have been healed.

They then go tell others how wonderful it is.

Then they get sick again.

“I believe people can be healed of all kinds of sickness, including HIV, through prayers,” said Pastor Joseph Maina of Agmo Prayer Mountain, a Pentecostal church on the outskirts of Nairobi.[1]


He is using that belief to kill people.

Maybe you do not believe that convincing people to stop taking the medications that are keeping them alive is killing them.

But the controversial ceremonies are raising red flags as believers’ conditions worsen, and a debate has opened over whether science or religion should take the lead in the fight against the AIDS epidemic.[1]


I propose a simple, clear solution.

Compare the outcomes of AIDS patients who are treated with the magic ceremony against the AIDS patients treated with conventional medicine. Have periodic blood tests to make sure the magic ceremony patients really are not taking medication.

Then compare the numbers at various times.

How many died with each treatment at 3 months, 6 months, 9 months, 1 year, 15 months, . . . .

If prayer works, then the prayer and placebo patients will do as well as, or better than, the prayer and real AIDS medicine patients.

The benefit of the real AIDS medicines would be nonexistent after the benefit of an immediate prayer cure. The side effects of the real AIDS medicines would still be there.

Have half of the patients take a placebo and the other half take real AIDS medicine.

The study would not be overly expensive, unless you count the lives of those going for treatment, since they were going for the prayer treatment anyway.

Even better.

Make it a randomized placebo controlled study among people already going for the prayer treatment.

If the pastor has faith, he has nothing to lose.

Except the pastor appears to be intentionally scamming people for money.

“We don’t ask for money, but we ask them to leave some seed money that they please.”[1]


As if seed money is not real money.

Because separating the request for money from the magic healing ceremony would probably result in much smaller donations.

Pentecostal church pastors often tell people that a lack of faith is the reason the prayer healing isn’t working.[1]


Blame the victim.

“When you are told there is an easier option, you want them (drugs) out of your life,” said Nyawera.[1]


This is the same tactic used by the rest of alternative medicine.

There is another important reason to invest in this kind of study.

The prayer healings are especially worrisome because people who quit treatment may become resistant to the drugs.[1]


Killing people by coercing them to stop taking their medications is bad, but generating more drug-resistant strains of AIDS harms even those who never fell for the scam.


[1] Pentecostal pastors in Africa push prayer, not drugs, for people with HIV
Washington Post
By Fredrick Nzwili
Religion News Service
Published: December 4


JAMA Opinion Article in Support of Anecdote-Based Medicine

There is a horrible defense of ABM (Anecdote-Based Medicine) in the current issue of JAMA (Journal of the American Medical Association).

Apparently, because there is no evidence to support some things the author believes in, the problem is with the evidence.

For example –

There is no evidence to suggest that hospitalizing compared with not hospitalizing patients with acute shortness of breath reduces mortality.[1]


While R. Scott Braithwaite, MD, MS does appear to realize that it is therefore reasonable to conclude that we do not know if this improves outcomes, he advocates that ignorance intuition is bliss.

We had thousands of years of blood-letting that was based on Dr. Braithwaite’s flawed reasoning.[2]

We had thousands of patients killed by assuming, based on Dr. Braithwaite’s flawed reasoning that getting rid of ectopic heart beats would improve survival of patients who had already had a heart attack.[3]

Almost every proposed medical treatment does not make it through the FDA’s (Food and Drug Administration) evaluation of safety and efficacy.


When we require evidence, we find that most treatments fall into three categories.

1. Not effective.

2. Not safe.

3. Not safe and not effective.

What evidence satisfies Dr. Braithwaite’s flawed reasoning?

In each case, these hypotheses have been untested and therefore there is no evidence to suggest otherwise, presuming a definition of “evidence” that requires formal hypothesis testing in an adequately powered study.1 [1]


What is reference #1?

The satirical piece about parachutes that was published a decade ago.[4]

Does EBM (Evidence-Based Medicine) really work the way presented in a satire piece?

Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.[5]


Is it intellectually honest to base criticism of anyone, or anything, on an exaggeration?

If we accept Dr. Braithwaite’s flawed reasoning, yes.

But Dr. Braithwaite’s flawed reasoning is dangerous.

However, deciding to intervene when “there is no evidence to suggest” also may make sense, particularly if the intervention does not involve harm or large resource commitments, and especially if benefit is suggested by subjective experience (eg, the qualitative analogue of the Bayesian prior probability).6 [1]


Dr. Braithwaite’s wishful thinking is encouraging him to experiment on people with no ethical approval and no acceptable documentation for research purposes.

You are Dr. Braithwaite’s guinea pig and he says that it is unethical to withhold a treatment that is based on logical fallacies, such as cherry picking[6] and basing decisions on sample sizes too small to produce any valid information.[7]

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


Beyond its ambiguity, “there is no evidence to suggest” creates an artificial frame for the subsequent decision. It may signal to patients, physicians, and other stakeholders that they need to ignore intuition in favor of expertise, and to suppress their cumulative body of conscious experience and unconscious heuristics in favor of objective certainty.[1]


Ignore intuition, rather than choose a treatment based on intuition?

Dr. Braithwaite does not go that far, but he does claim that a lack of evidence of harm justifies abuse treatment by intuition.


[1] A piece of my mind. EBM’s six dangerous words.
Braithwaite RS.
JAMA. 2013 Nov 27;310(20):2149-50. doi: 10.1001/jama.2013.281996. No abstract available.
PMID: 24281458 [PubMed – in process]

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

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

[4] Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
Smith GC, Pell JP.
BMJ. 2003 Dec 20;327(7429):1459-61. Review.
PMID: 14684649 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] Evidence based medicine: what it is and what it isn’t.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.
BMJ. 1996 Jan 13;312(7023):71-2.
PMID: 8555924 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[6] Cherry picking (fallacy)

Cherry picking, suppressing evidence, or the fallacy of incomplete evidence is the act of pointing to individual cases or data that seem to confirm a particular position, while ignoring a significant portion of related cases or data that may contradict that position. It is a kind of fallacy of selective attention, the most common example of which is the confirmation bias. [1] Cherry picking may be committed intentionally or unintentionally.


[7] Hasty generalization
From Wikipedia

A person travels through a town for the first time. He sees 10 people, all of them children. The person then concludes that there are no adult residents in the town.



You had me at ‘Controversial post for the week’ – Part II

In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]


Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]


We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.

Image credit.

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]


PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. 😳

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.


We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]


The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.


[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser


Why Did We Remove Atropine From ACLS? Part I


As of 2010, atropine is gone from the ACLS (Advanced Cardiac Life Support) treatment guidelines and nobody seems to be upset. We never had good evidence to support treatment of dead people with atropine, but we practiced this witchcraft because we chose optimism over evidence.

Some people claim that the constant changes to ACLS are evidence that evidence does not work.

That is not true. We ignored the lack of valid evidence. We chose to be ignorant.

We keep changing guidelines as we keep learning more. We should require valid evidence before adding treatments to guidelines, but too many of us are overly optimistic about treatments that are not supported by valid evidence. We believe that this time will be different. After we study treatments, we generally find out that we have been harming more patients than we have been helping.

Atropine is one example.

Look at all of this evidence of benefit.

Click on images to make them larger.[1]

What do the LOE (Level Of Evidence) and Good, Fair, and Poor categories mean?

The LOEs were subdivided into three major categories, depending on the type of question being asked: intervention, diagnosis, or prognosis. The quality of evidence categories were reduced from five categories in 2005 to three (good, fair, poor) in 2010.[2]


There is no further explanation of how Good, Fair, and Poor were to be decided, but there is an explanation of what the LOEs mean.

Level A is the evidence least likely to be misleading –


Level B is evidence that is much less likely to provide an accurate representation of the true effect of the intervention, because there are many more variables that are not controlled for –


Level C is the lowest evidence possible and even includes a category that is not really evidence – Expert Opinion


Expert Opinion is lower than the lowest of the low evidence.

In the chart Evidence Supporting Clinical Question, there is no column for expert opinion, because there is no good reason to include expert opinion in the analysis of evidence.

But what about the evidence that is there supporting the use of atropine?

Why is everything poor evidence?

Why isn’t there anything better than LOE 3: Studies using retrospective controls?

If the most positive study was back in 1984, and it was only LOE 3, why did we only remove atropine from the cardiac arrest guidelines in 2010?

The supporting evidence is not the only evidence, but that is not a good answer to my question.

The weak evidence in support of atropine in cardiac arrest is more than matched by stronger evidence that atropine does nothing useful –


There is also weak evidence that atropine is harmful –



How did atropine ever make it into the ACLS guidelines based on such poor evidence?

To be continued in Part II and Part III.


[1] Atropine for cardiac arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Appendix: Evidence-Based Worksheets
Part 8 ALS
Swee Han Lim
Evidence-Based Worksheet Download in PDF format.

That link is no longer available, but the overall page of evidence-based worksheets is available in PDF format here.

[2] Classification of Evidence
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 2: Evidence Evaluation and Management of Potential or Perceived Conflicts of Interest
Evidence Evaluation Process
Free Full Text from Circulation.


Does Science Work? Is Science the Enemy? What About Spinal Immobilization?


Most of us are afraid of what we do not understand. Few understand science. Science gets blamed for everything or people make up nonsense about science and expect that they can get away with it. Some people accept medical advice from Jenny McCarthy.

Although immunization is known to provide effective life-saving benefits for children, it has sometimes been blamed for an array of diseases that have unknown causes (eg, autistic spectrum disorder [ASD], multiple sclerosis and sudden infant death syndrome). This is not surprising, given that immunizations are common and that humans are primed to attribute causality to events that precede an incident. We all use the ‘after it, because of it’ logic. This is how we learned not to touch a hot stove as young children. Unfortunately, this logic can be faulty.[1]


Say it ain’t so, Jenny!

This article reviews recent controversies surrounding immunizations and ASD, and concludes that there are no data to support any association between immunization and ASD. It replaces the Canadian Paediatric Society’s 2001 position statement on this topic (3).[1]


What About Spinal Immobilization?

We put the patient on the board.

The patient arrived at the hospital without making their spinal injury worse.

Therefore, the spinal immobilization must have been the reason the patient was not paralyzed by EMS!

This could never go wrong.

Image credit.

Four of the five patients in the early group (mean age 56 years) developed neurologic worsening during application of cervical immobilization less than 24 hours after injury.[2]


Maybe the unstable spinal injury patients who make it to the hospital without paralysis are much more stable than we realize.

If they were truly unstable, would they survive the manipulation of EMS spinal immobilization?

Right! There is no manipulation when we do it.

And there is never any significant interruption of chest compressions for intubation when we do it.

4 out of 5 patients with early deterioration got worse during the manipulation of spinal immobilization after being transported.

These patients were OK during transport, but not during immobilization.

In this series, paramedic endotracheal intubation efforts were associated with more than 1.5 minutes of CPR interruptions. Select endotracheal intubation efforts resulted in more than 6 minutes of CPR interruptions.[3]


Since we should not trust the reports of experts without evidence, how should we determine what works?

Science-based medicine is more than a set of methods or certain philosophy of medicine – it is an entire approach to what should be the core questions for any interventionalist profession: is it real and does it work?[4]


We know that vaccines work, that vaccines are safe, and that Jenny McCarthy does not understand science.

What about spinal immobilization?

Does strapping a patient to a back board protect the unstable spine?

Does strapping a patient to a back board injure the unstable spine?

How do we know?

How do we find out?

The primary lesson of the history of medicine is that new ideas need to go through a rigorous process of evaluation before they should be generally accepted and implemented. We are constantly examining and refining those rigorous methods. They include careful evaluation of possible mechanisms and overall scientific plausibility, coupled with clinical evidence designed to eliminate all forms of bias and illusion.

The alternative is to be overwhelmed by bias and illusion, which tends to lead us to false positives – confirmation of our cherished guesses, and even to entire systems of medicine based on fairy tales and imagination.[4]


Since spinal immobilization is not a new idea, but has not been adequately tested, we need to find out if it works, or if we are just fooling ourselves and our patients.

This should be perfectly reasonable, but this is the response from the most influential person in spinal immobilization.

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.


Original cartoon

If we don’t know if it works, how can this be a known treatment?

We should assume that every treatment is bad, until we have good evidence to the contrary.

We cannot just assume that any treatment works – that is dangerous and irresponsible.

Why are we afraid to find out if back boards work?

If science proves some belief of Buddhism wrong, then Buddhism will have to change. In my view, science and Buddhism share a search for the truth and for understanding reality. By learning from science about aspects of reality where its understanding may be more advanced, I believe that Buddhism enriches its own worldview.[5]


We need to find out if EMS use of back boards for spinal immobilization protects against injury.

We need to find out if EMS use of back boards for spinal immobilization causes injury.

What are we afraid of?

Are we afraid because we already know that back boards cause harm?

We can continue to practice witchcraft, we can abandon back boards, or we can find out what works.


[1] Autistic spectrum disorder: No causal relationship with vaccines.
[No authors listed]
Paediatr Child Health. 2007 May;12(5):393-8. English, French. No abstract available.
PMID: 19030398 [PubMed]

Free Full Text from PubMed Central.

An important factor to consider is what has happened to autism rates since the removal of thimerosal from vaccines. In studies from Canada (25), Denmark (20) and the United States (26) the rates of autism have continued to increase despite removal of thimerosal from vaccines.


[2] The cause of neurologic deterioration after acute cervical spinal cord injury.
Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ.
Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6.
PMID: 11224879 [PubMed – indexed for MEDLINE]

This paper was cited by the ACS (American College of Surgeons) as a justification for the use of spinal immobilization for blunt trauma patients.

[3] Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation.
Wang HE, Simeone SJ, Weaver MD, Callaway CW.
Ann Emerg Med. 2009 Nov;54(5):645-652.e1. doi: 10.1016/j.annemergmed.2009.05.024. Epub 2009 Jul 2.
PMID: 19573949 [PubMed – indexed for MEDLINE]

Free Full Text as PDF Download from emed.wustl.edu.

[4] Irlen Syndrome
by Steven Novella
August 7, 2013
Science-Based Medicine

[5] Our Faith in Science
The New York Times
12 November 2005
Tenzin Gyatso, 14th Dalai Lama.


Where is the Evidence FOR Spinal Immobilization?

Some things are bad ideas, even if they once appeared to be good ideas.

MAST/PASG (Medical Anti-Shock Trousers/Pneumatic Anti-Shock Garment), an amp of Bicarb (NaHCO3) for cardiac arrest or even for acidosis, withholding morphine for severe pain, because slowing the patients respirations from 60+ to 20 would indicate dangerous respiratory depression, Lights and Sirens for everything, because you can’t be too safe.

What about spinal immobilization?

It once seemed like a good idea.

Then dangerous people started claiming that You can’t be too safe! (Of course you can. Reasonable people can give plenty of examples, but that is not the point here.)

Since strapping curved spines to flat boards was such a good idea, we began to inflict it on everyone who might have hit something at some time, or might know someone who once witnessed something hitting something else. You can’t be too safe!


The NAEMSP position paper on spinal immobilization makes it clear that the largest group of EMS medical directors do not support using back boards on most of the patients we put on back boards.

This seems to be just as much a standard of care as any other.

Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher, and may be most appropriate for:

  • Patients who are found to be ambulatory at the scene
  • Patients who must be transported for a protracted time, particularly prior to interfacility transfer
  • Patients for whom a backboard is not otherwise indicated[1]


A collar and no back board!


What does the NAEMSP base this radical change on?

Dr. Bryan Bledsoe describes the research.

However, medicine in the 21st century calls for evidence-based practice. We must provide care that has been demonstrated in unbiased ways to improve patient outcomes. Such is the case with prehospital spinal immobilization.[2]


For example, here are two bits of evidence for spinal immobilization.

A Canadian study found spinal immobilization techniques during simulated vehicle motion to be generally ineffective.4 A 1998 Tennessee-based study examined the commonly used Aspen cervical collar and concluded “full cervical immobilization is a myth.”5 [2]


If that is the evidence for spinal immobilization, I don’t want to see the evidence against spinal immobilization.

Here is just one example.

Spinal immobilization also restricts respirations. In one study of 39 healthy volunteers, it restricted respirations by an average of 15%, and this was more pronounced at the extremes of age.12 [2]


Is there something else we should consider about strapping people to boards?

Kelly Grayson and Gene Gandy describe an example of a rollover patient, who was up and walking around, but was strapped to a board by EMS, transported to the hospital, and later found to have an unstable cervical fracture.

“Thank God we immobilized her,” the medic breathes in relief. “She’d have been a quad for sure,” her partner agrees.

The truth is, the crew of Medic 4 has no way of knowing that their attempt to immobilize their patient’s spine contributed in any way to her favorable outcome.[3]


Why do we assume that we know we improved the outcome for patients?

Because we do not understand what we are doing.

At best, the studies show no evidence of further harm from spinal immobilization. That’s far from a ringing endorsement for the efficacy of one of our most long-held practices.[3]


In other words, the EMS immobilization could have made things worse, but there is no reason to believe that the back board provided any benefit.

Given the devastating long-term effects of spinal cord injury, it may be tempting to say, “If it only helps one patient, it’s worth it.” That presumes we are doing no harm to the many thousands of patients who do not benefit from immobilization. But are we?[3]


That also presumes that we doing no harm to the patients with unstable spinal fractures.

There is no evidence to show that we are helping patients with unstable spinal fractures.

When it comes to prehospital c-spine clearance, agencies that refuse to adopt the practice are now one generation behind the treatment curve. The debate now is not whether EMTs can effectively determine which patients do not require immobilization in the field, it is whether we should immobilize at all.[3]


There are other articles to read questioning whether back boards help any patients.[4],[5],[6]

A podcast may be more to your liking.

At First Few Moments, Kyle David Bates, Russell Stine, Bob Lutz, Dr. Laurie Romig, Kelly Grayson and I discuss the lack of evidence of any benefit from spinal immobilization and the evidence of harm in A Change of the Dogma: If it helps only one? Episode 36.


[1] EMS spinal precautions and the use of the long backboard.
[No authors listed]
Prehosp Emerg Care. 2013 Jul-Sep;17(3):392-3. doi: 10.3109/10903127.2013.773115. Epub 2013 Mar 4.
PMID: 23458580 [PubMed – in process]

Free Full Text in PDF Download format from NAEMSP.

[2] The Evidence Against Backboards – What does the spinal science say?
Bryan E. Bledsoe, DO, FACEP, FAAEM
August 1, 2013
EMS World

[3] Does Spinal Immobilization Help Patients? – Who needs c-spine clearance?
Steven “Kelly” Grayson, NREMT-P, CCEMT-P AND William E. “Gene” Gandy, JD, LP
August 1, 2013
EMS World

[4] In order to protect the c-spine, should we stop helping?
Mill Hill Ave Command
Saturday, December 15, 2012

[5] Why We Need to Rethink C-Spine Immobilization
By Karl A. Sporer, MD, FACEP, FACP
Created: November 1, 2012
EMS World

[6] Another Nail in the Board
StreetWatch: Notes of a Paramedic
January 17, 2013
Peter Canning