We are excited to introduce a new featured columnist to brownEMS.org, Tim Satty. I have had the good fortune of knowing and working with Tim for nearly three years now, and can say that his experience in EMS and Fire is a huge asset to brown EMS. In addition to being an excellent provider, he is very passionate about the brown EMS corps. What follows is his first column on the topic of SPINEBOARDING.
In my mind one of the most idiotic things we do in EMS is backboard every trauma patient that presents to us with any sort of head or neck complaint. You cannot find me a single person that is comfortable on one of those babies. If you didn’t have back pain before being boarded, you do after.
Tim’s article in full after the jump:
In my mind one of the most idiotic things we do in EMS is backboard every trauma patient that presents to us with any sort of head or neck complaint. You cannot find me a single person that is comfortable on one of those babies. If you didn’t have back pain before being boarded, you do after.1 They are overused to an almost absurd amount. Anytime someone has the slightest ache they get the full immobilization procedure. Never mind that a trained monkey could follow the spinal clearance protocols used by ER doctors. This overuse simply leads to complacency. Patients are rarely immobilized well.2 When was the last time that you added pillows or towel rolls to every void the patient had between their body and the board? Furthermore, if as a system we still insist on immobilizing everyone we come across, there is a better tool out there.
Much of the small equipment we use daily in our ambulances has been improved overseas; it’s lighter in weight and much more efficiently designed…nobody sold or displayed any type of hard, spine-immobilizing backboards. The common method of spinal immobilization in Europe is the vacuum mattress. Maneuver the patient onto a soft mattress, suck out the air with a pump and you’ve filled every void under the patient while providing picture perfect spinal control. The mattresses come in all sizes and shapes from infant to adult. Extremity splints are also fashioned out of the same durable material.3
The author here was discussing a major EMS convention that he had attended in Germany. It seems that Europe figured it out a long time ago. Only backboard those people who may actually have a spinal injury, and then use a technology that is both easy and comfortable for the patient. A 2003 UK study even shows that a vacuum mattress system outperforms a rigid backboard both in effectiveness and in patient comfort.4
Spinal clearance protocols need to be put in place so that we can stop wasting time and energy immobilizing everyone who has been in a car accident. Additionally, the US needs to adopt vacuum mattresses to more efficiently and comfortably immobilize patients. Backboards still have their place in EMS, they are useful in CPR and complex extrication scenarios… but not for “routine immobilization.”
1 Cordell et al. “Pain and tissue-interface pressures during spine-board immobilization.” Annals of Emergency Medicine 26 July 1995
2 Wesley, Keith. “Proper Strap Tightness for Immobilization” JEMS 5 August 2007
3 Zygowicz, Wayne. “Imagination at Work” JEMS 12 June 2009
4 Luscombe MD, Williams JL. “Comparison of a long spinal board and vacuum mattress for spinal immobilisation.” Journal of Emergency Medicine September 2003
bravo!
I’d like to know what percentage of patients brought in on a board by EMS receive immediate spinal clearance by the EP.
As far as overuse is concerned, most hospitals do not even allow nurses to clear a patient off a board. (I don’t know why clearance isn’t included in the ER nurse’s scope of practice, since they are highly trained and see this sort of stuff ever day.) Anyway, given that, it seems unlikely that EMTs will be given the ability to clear anytime soon.
In the words of the great Andy Caruso, “You could train a chimpanzee to be an EMT.” I think spinal clearance is more appropriate for early hominids.
Several states do allow EMS to determine who gets immobilized and who doesn’t (”clearing C-spine” has legal implications). I believe Maine even has it as a BLS skill.
While I agree that EMS is far too quick to board too many people, we also have people in the field who are pronouncing live people dead (skim the news page of any major EMS magazine site, it won’t take long).
In my personal experience, even management-level doctors can get caught in complacency. I once transported a patient from (non-Providence ER to remain nameless) to RIH for urgent spinal surgery. It seems he’d been involved in an MVC, transported to said ER, and was cleared without X-rays by the ER’s Medical Director.
The next day he drives himself in to the same ER, complaining of severe neck pain. This time he does get X-rays, which find C4 and 5 broken right in half. He was told if he’d so much as sneezed the wrong way, he could’ve died.
Back to us for the wrapup- if we want to practice EMS like our European cousins, I think we might want to get the same education they have before hitting the streets. But that’s a conversation even larger than spinal immobilization.
New Hampshire, where I took my basic course, is one of the states that allows prehospital advanced spinal clearance at all provider levels (EMT-B,I,P) as standing orders. It is considered a mandatory supplement/addon to the national standard. The whole addon is summarized in this document for instructors:
http://www.nh.gov/safety/divisions/fstems/ems/training/documents/AdvancedSpinalAssessmentInstructorLessonPlan2005.pdf
Basically (see the doc for checklist), if you have a CAOx4 pt with no neck pain, non-tender spinal column, positive distal nvs and range of motion in all extremities (there are specific finger/feet tests to determine the integrity of certain nerve roots), can differentiate between soft and sharp touches on all extremities, AND “can flex, extend and rotate their neck without pain, then spinal immobilization is not necessary.”
The overall exam is pretty straightforward and can be taught to anyone. Getting providers to do it completely and consistently is the key, then.
What’s the opportunity cost of spine-boarding every patient who has head or neck complaints? In Brown EMS’ case, almost nothing. That’s why we should keep on doing it.
Are we wasting time? The potential cost of not spine boarding (as superfluous as immobilization may seem in many instances) is more than worth the time that it takes to spineboard the patient. This is certainly true of Brown, which has a low call volume. The instances in which the extra 10 min. (w/ two EMTs, RI protocol) have overlapped with another call, preventing us from providing effective care to other patients, are rare to non-existent. Even if we were unavailable, Providence is a phone call away.
In short, we have enough time resources at Brown EMS to be somewhat wasteful with it, providing extra care to patients who might not receive that treatment elsewhere. This may not be true at other services, where the marginal benefit of spine boarding every patient who complains of head or neck pain may be outweighed by the cost of patients who did not receive prompt treatment from EMS b/c all of the trucks were tied up.
Wasting energy? Again, speaking in the context of Brown EMS, I have to assume that ‘wasting energy’ is only a rhetorical point. Maybe the next time a Brown EMT passes out from exhaustion we should reconsider this point.
W/ regards to the point that EMTs will become lax about spineboarding because they do it so often… I don’t think that medical protocols should be designed with mediocrity or complacency as a factor. Job descriptions would look a lot different if they were all designed to reflect probable degrees of indolence and incompetence in the candidates.
If people are becoming complacent about the quality of their immobilization, the answer is higher levels of accountability, training, or quality assurance, not lowering expectations to the level of the indolent.
The vacuum mattress sounds a lot better than the long spineboard, b/c it seems designed to minimize provider errors, time spent on scene, and patient discomfort.
The NH Protocol (above) specifically states three reasons for mandating prehospital spinal assessment and management:
“A. Effort to align prehospital care with ED care.
B. Studies (i.e. NEXUS 2000) and recommendations (i.e. 2000 Update - EAST Cervical Spine Clearance Document) showing that a stepped clinical decision rule for suspected SCI is effective in the prehospital setting.
C. Potential complications of full immobilization:
1. Increased pain and discomfort
2. Psychological affects
3. Nausea/vomiting
4. Complicate treatment of patient when not necessary”
Of the three, the potential complications of full immobilization alone are enough to consider spinal clearance as a beneficial intervention, provided that it is done correctly.
Additionally, the number of calls at Brown EMS that end up “turfed” to Providence Fire mutual aid because the rescue is out of service or onscene is not trivial, in fact that was the main argument for keeping the second rescue back in 2006.
While Brown does not charge for its ambulance services provided to the student body, Providence does. The cost of spineboarding every potential spinal cord injury may not be seen for Brown EMS personnel, but the patient not only receives the hassle and potential adverse effects of an unnecessary treatment, but possibly the bill as well.
As someone who appreciates Rhode Island’s generous scope of practice, it seems silly to deny providers a set of basic assessment skills to reduce unnecessary interventions. It’s not lowering expectations, rather, it’s giving prehospital care providers the ability to make additional critical decisions in the field and *raising* expectations that they will make the correct ones. It was like this with transcutaneous pacing and they haven’t taken that away. I’m confident we will see spinal clearance (and hopefully EZ-IO for cardiacs!) added to the protocols in the future.
Maine, holler
The arguments that I was making were not only Brown EMS specific. You have to look beyond Brown here. Spineboarding one patient who was found in his dorm room is not a big deal. But, municipal EMS services may have 2-3 MVA calls per shift, each requiring 1-2 backboarded patients. (I have done it, it sucks) That is a waste of energy and time. It is quite a hassle to backboard a patient from a car just because they have a headache without any neck or back pain. Especially in the rain, on a major highway.
That being said I have had calls at Brown where we had to backboard patients and carry them down several flights of stairs because they fell and now have a headache. It was both non-trivial and time consuming.
In the end though it really comes down to doing our patients a disservice. Long boards are uncomfortable, and they are just going to be yanked off of them quickly in the ER. Yes, everyone can make mistakes with anything (spinal assessment is no different), but that is why we need more training and good QI.
great article, great discussion. most successful post yet! two thumbs up for satty says.
W/r/t NH protocols…
1) Increased pain and discomfort, so long as they are not life-threatening or permanent, aren’t really factors that should prevent a treatment that may preserve overall health. If this wasn’t the case, we wouldn’t administer vaccines due to the ‘increased pain and discomfort’ of the shot. Ditto for 2) psychological “affects” (it’s comforting that the author of these protocols can’t spell) and 3) nausea/vomiting (btw, what’s the explanation for that?). As for 4… strikes me as a bit of a cop out. Might as well have put “et cetera”.
Time spent spineboarding = 10 minutes.
Based on Maine protocols… Time spent having EMT-Basics determine the nature and severity of the MOI, determine pt is cao w/ no loc, determine if pt has distracting injuries, acute stress reaction, etoh, altered loc, determine if pt has discomfort/pain in spine, palpate for tenderness, then run several neuromotor tests per extremity, then several neurosensory tests per extremity… = probably around ten minutes.
The required time, if the proper procedure is taken to clear c-spine, is comparable. This is especially true when you consider that patients may not be aware of neck/back pain soon after the incident, or will not develop it til 10-15 minutes later, yet still have fractured vertebrae. Pt. cleared at one point may not be cleared 10 minutes later.
Why bother exposing EMS practitioners to liability and patients to potentially life-threatening injuries for the sake of a few minutes per call? I won’t resort to personal anecdotes about faulty clearances even higher up the chain, because anecdotes are inherently non-representative and frankly I don’t have many, but until we get field x-rays I think it’s a bad decision to make field calls about the c-spines of any pts who complain of neck or back pain.
And if you’re worried about complacency affecting quality of work, then you should worry more about EMTs clearing c-spine in the field rather than sloppy spineboarding. Even the sloppiest spineboard immobilizes more than a erroneously cleared patient.
I don’t have the numbers to run nor the initiative to dig them up, but my guess is that the number of faulty c-spine clears and the resultant damage would far outweigh the damage saved by getting to the next patient 2 minutes earlier.
A search of Pubmed brings up few hits (at least using the search strings I tried). Many of the papers say there is a need for further investigation, and do not draw definite conclusions. One paper, about Canadian paramedics (I think they use this term to refer to both techs and medics) is in favor of clearing in the field.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4W4S2Y5-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=456af9a7bd0cf4faf1d042979c86c97d
“Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule. CONCLUSION: This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.”
The air mattress sounds like a good piece of equipment that would be nice to implement here. Anecdotal, I remember one call involving an elderly woman with dementia who fell. She was backboarded and spent the entire ride screaming in pain and confusion. It would be worth it to provide her with more comfort. As EMTs, it is strange to be put in the position of making a patient’s condition worse, almost to the point of torture, all for the sake of a protocol. Patient care is supposed to by our primary concern, but the current protocol is written in such a way that this is not always the case. Brown EMS transports are usually <5 minutes because of proximity to the hospital. In more rural services, transports can take much longer periods of time. Stressing patients with pain, discomfort, and anxiety at being immobilized does not improve their health.
*note: It may be the case the the woman I refer to above would not be cleared in the field because of her mental status, etc, etc. I’m just using her as an example of how backboarding can result in extreme discomfort for a patient.