Safe Spinal Clearance Equals Better Care For Spinal Injuries: Part 1


Dave Ross is at it again on EMS 1 about spinal immobilization.  In his previous column, Confessions of Recovering Field Spine Clearance Addict, he describes problems with implementing a C-spine clearance protocol at his service.  To summarize:

For us, and specifically me in recovery, we’ve decided to minimize the risk of misses by continuing with our recent return to spinalling primarily based on mechanism.

To me that means giving up and accepting that we will continue to perform this barbaric ritual of backboarding patients.  Of course there were a flurry of comments in response, and I am pleased with his response in a follow up piece.  Here he writes:

I don’t believe that anyone has been able to elucidate how much secondary injury is a factor in patient outcome, and we don’t know what role non-immobilization plays in worsening secondary injury.

For the foreseeable future, we are going to have to immobilize patients with spinal injuries.  The question is whether or not we can figure out which patients don’t have injuries, and how to better immobilize the ones who do. Part 1 covers clearing low risk patients, Part 2 will cover immobilizing injured patients.

We can all tell when a patient is quadriplegic or paraplegic. And we will promptly immobilize them (I think). The challenge is to identify the partially-injured spinal cord patient with less obvious findings on exam. I simply do not know how well a careful extremity neurologic assessment is emphasized either during initial EMS training or in refreshers across the country.

I suspect that there is inconsistency, to put it politely. But I do know that it is very important to stress in systems that are clearing potential spine-injured patients. This assessment needs to be done carefully.

I was not taught how to do this in EMT or paramedic school.  We are taught to assume that everyone with whiplash or a bump on their head has a spinal injury, and that they will be paralyzed if we allow them to turn their head.  Then we expect a two-person ambulance crew to hold C-spine, apply a collar, log roll the patient, and slide a board behind them, strap them down, and apply head blocks, all while keeping their spine in line.   A dirty little secret is that we often clear patients’ spines before we immobilize them, or for that matter even touch them.  We rapidly extricate stable patients from vehicles because the KED takes too damn long to put on.  We have patients get out of their vehicles and walk to the board.   Standing take downs?  Forget it.  As long as they show up at the hospital on a board and are not paralyzed, no questions are asked about how they got there.

If patients with spinal injuries are missed when a clearance protocol is applied, it is naive to think that patients’ spines are actually “immobilized” while being placed on the backboard.

After arriving at the hospital with a patient on a backboard who is not a trauma alert, the triage nurse is likely so ask the nearest doctor or PA the following question:

Can you clear her off the board?

Notice the word choice.  She did not ask them to assess for a spinal injury.  There is an expectation that the patient does not have one.  If they did, they should have gone to a trauma center.   Missed partial cord injuries are also missed trauma activations. Patients with spinal injuries need a trauma center, probably more than they need to be immobilized.  Even if we don’t clear patients, a broader knowledge base will allow us to better care for ones who are injured.

Notice who clears patients off boards in the hospital.  Often it is a PA who is assigned to fast track.  So if PA’s can assess patients thoroughly enough to safely clear patients off the board, why don’t we demand that EMS providers who put patients on the board have that same knowledge base about spinal injuries as they do?  We have the first contact with patients after they are injured.  If harm really can be caused from movement after spinal injuries, we are the ones who can make it better or worse.

Last year I wrote about my experience getting cleared off of a backboard by a PA with no X-ray, and asked why we can’t do that.  One solution is to do a study of low risk patients.  Start by learning how how PA’s and physicians clear spines.  Perform that exam on patients before we immobilize them, document whether or not this person’s spine could have been cleared, and compare our exam findings to the hospital’s.

We need to learn more about spinal injuries, and learn how to perform a more thorough assessment.  Assuming that everyone has a spinal injury, or attempting to clear patient without a broader knowledge base, is not working.

In Part 2, I’ll discuss Dr. Ross’s desire to study getting rid of backboards, and better ways to immobilize people with injuries.

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