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Spinal Immobilization: You Make The Call

With apologies to Happy Medic for borrowing one of his regular themes, allow me to present an exercise in distinguishing Doing What Is Right from Doing What Is In The Protocol:

It's a balmy late summer night, and you respond to lovely, pastoral Decubitus Manor Convalescent Home for a patient injured in a fall. Upon your arrival, you find a charming and alert elderly male complaining of neck pain. He fell 24 hours before, went to the local ED that night and had staples put in his scalp. Skull and C-spine x-rays revealed no obvious fractures, and patient was discharged back to the nursing home.

He complained of neck pain throughout the day today, and finally the doctor ordered him sent back to the ED for a CT scan of the cervical spine. The gentleman had been back at the nursing home today until 9:00 pm, when the radiologist finally interpreted the CT scan. The unofficial, verbal interpretation relayed to the rad tech was "odontoid fracture, and comminuted fracture of C-1."

Our charming little old man is neurologically intact, and has been doddering around the nursing home for 24 hours with no ill effects. The nursing home doc wants him to go somewhere with an on-staff neurosurgeon, which the local ED says is a facility 70 miles away. They call an ambulance to make the transport.

Enter your intrepid hero, Ambulance Driver.

Now here's the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.

My protocols are pretty clear on this issue: Gramps gets the full spinal package. Not only is he over 65 with an "injury above the clavicles" (two of our sillier criteria, based on the Canadian C-spine rules), but he has the cervical spine tenderness, not to mention the friggin' CT scan that reveals a potentially unstable high C-spine fracture.

Now, an 80+ minute trip strapped to a spine board isn't the cruelest thing I can think of doing to this man, but the other two possibilities involve nipple clamps and a live ferret. He weighs less than his age, and his chart already includes orders for a Fentanyl patch PRN and gel seat pads for his wheelchair. I don't like the idea of boarding him if I can help it.

But we're not talking about what I would do. What would you do?

Do you shrug your shoulders and say, "Protocols are protocols," and tell him to suck it up for the 80+ minute trip to the hospital with neurosurgery, or do you explore other options? If so, what are those options? You tell me what you'd do in my place, and I'll post what I actually did in a few days.

You make the call.

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Comments - Add Yours

  • http://www.facebook.com/profile.php?id=583471044 Wes Ogilvie

    Creative spinal motion restriction comes to mind.  I’m imagining a lot of padding with blankets and such and maybe a towel instead of a c-collar.  Follow that up with liberal dosing of pain meds and benzodiazepines to relieve both pain and anxiety.

  • http://petercoti.com Peter Coti

    I would MacGyver a Turley Backboard Pad, which just adds a layer of foam between the patient and the backboard. To do this I would just grab some of the gel seat pads or quilts (typically are made softer) and belt them down to the backboard. Hopefully that will make his voyage much more enjoyable. 

  • Scribbles412

    Ok we consulted medical control on one of these. Of course the commute was only 45 mins not 80. We got the doc to tell us to put them on CPR Board strapped down and pillows for the decubes c collar and MANUAL cspine. Yea I was in a lot Of pain, but my comfort doesn’t come before my patients care. Is the first rule do no harm?

  • http://www.facebook.com/TamaraCougarButler Tamara Butler

    as a student EMT, i only have one question….would you or could you in that situation place him in a KED?…i would think that you would do as best you could to see to his comfort  but also make sure that C-Spine was in place.

    • CajunMedic

      You know, that’s actually a pretty good idea. would hold the head still, but with a KED you have to be EXTREMELY careful when immoblilizing the head, and use plenty of padding between it and the head, if not you may hyperextend the c-spine

      • BH

        I guess somebody should tell our state, where every EMT is trained that not having the back of the head in contact with the inside of the KED is grounds for failure….?

        • Anonymous

          I’m sure you already realize this, but that’s just idiotic.

          Ambulance Driver

          ________________________________

          • BH

            Couldn’t be.  It came from the state.  The same people who require EOAs but not SPO2s.  *snort*

    • Anonymous

      Supposing you used the KED… what position would you transport in?

      Ambulance Driver

      ________________________________

      • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

        Which positions does the patient find acceptable for comfort? Ideally supine, but discomfort breeds movement.

      • Fern the Fire-Rescue newbie

        KED, sitting upright in the captain’s chair, and seatbelted in.

      • JDVista163

        KED in whatever position he found most comfortable would be my first choice given my agencies supplies. I liked the idea of a vacuum mattress at first but it lacks the ability to adjust positioning once initially set, and seems more restricting.

    • Anonymous

      Supposing you used the KED… what position would you transport in?

      Ambulance Driver

      ________________________________

  • CajunMedic

    I’d have to take the hit from the QA/QI department and plead for mercy due to not following the almost religious adherence to protocol. It’s confirmed only involving C-1, so the board isn’t really necessary. C-collar only, but I like Wes’ comment below about using a towel, since we still carry the big orange Ferno head blocks, might rig something up to the cot to keep his head inline if he could tolerate it for the ride. Liberal pain mangement and sedation, vitals, O2, and ETCO2 since all the meds plus his own Fentanyl are going to affect his respiratory status, hang a Fuelman drip (SMOOTHLY as possible) and head for the hospital. 

  • http://twitter.com/emtgirl Renee Roberts

    I would choose a prudent, but kinder, gentler route for this gentleman…

    My suggestion that I would provide to medical control in this situation (And pray that they would agree with me):

    C-Collar – yes
    Board – no

    Assuming permission is given: Position him on the gurney where he is comfortable. Start a line, and provide some light sedation and pain medication). I had thought about possibly taping his head to the gurney, also. But CajunMedic mentioning the blocks made me think that may work as well, if not better. And a nice and EASY trip to the hospital.

  • Brandibaker13

    Protocol!!

    • Anonymous

      Even if the protocol is likely to cause increased pain and anxiety at the very least, decubitus ulcers, respiratory difficulty and increased ICP, and despite the fact that there is no scientific evidence whatsoever that demonstrates a benefit to spine boarding, even for patients with C-spine fractures?

      Ambulance Driver

      ________________________________

      • 9-ECHO-1

        Well…you know that there are those systems and medical directors out there that have no trust or faith in their EMS folks, don’t allow (under threat of losing a job) any deviation on the part of lowly EMS folks…but then again, there are those EMS folks out there that don’t have any sort of  imagination to find a ‘different’ way to accomplish a goal. I fault the vast majority of EMS indoctrination, er, training programs, for that shortcoming.

    • Anonymous

      Even if the protocol is likely to cause increased pain and anxiety at the very least, decubitus ulcers, respiratory difficulty and increased ICP, and despite the fact that there is no scientific evidence whatsoever that demonstrates a benefit to spine boarding, even for patients with C-spine fractures?

      Ambulance Driver

      ________________________________

  • Sinspired

    Considering the arthritis and ANXIETY, I’d say patient comfort should be a significant consideration. As a new EMT, I’d probably run it past the on-duty supervisor, but it seems as if the KED board is the right option here. You can pad it to keep the patient comfortable, and it splints the patient above and below the injury for safety. Of course, my company is so awesome that I suspect the dispatcher and supervisor would have already sent me with an idea of the correct option. ;)

  • Sinspired

    Considering the arthritis and ANXIETY, I’d say patient comfort should be a significant consideration. As a new EMT, I’d probably run it past the on-duty supervisor, but it seems as if the KED board is the right option here. You can pad it to keep the patient comfortable, and it splints the patient above and below the injury for safety. Of course, my company is so awesome that I suspect the dispatcher and supervisor would have already sent me with an idea of the correct option. ;)

  • Greg helmuth

    C collar only if allowed, otherwise lbb and collar with LOTS AND LOTS of padding. Unfortunately pain control does not prevent ulcers. Would NEVER secure a patients head alone to cot.

  • usalsfyre

    While I’m not a huge “call the doc” fan there’s probably not a good way around it here. Consult med control
    for a collar only. Fit the collar well, pad as needed. Transport, probably in Semi-Fowlers with padding to keep the head neutral. Perhaps dab of pain control PRN, what we don’t want is his muscles relaxing.

    As noted he’s been tooling around the NH for 24+ hours without compromising his spinal cord, I’d wager a guess it’s unlikely he’s going to now. Just place him in a collar to support the musculature.

    If WE start jerking on him though, all bets are off, so no taping his head to the bed and he gets to dictate how we move him.

    • Anonymous

      Get. Out. Of. My. Head.

      Ambulance Driver

      ________________________________

  • http://williamthecoroner.wordpress.com/ WilliamtheCoroner

    This is silly.  Put a soft collar on him.  He’s been mobile for 24 hours why torture him?  Let the patient determine a comfortable position, he’s OLD, not stupid.

    • Anonymous

      Wise words, and a common sense answer.

      Unfortunately, many medical directors are not wise, nor do they trust their medics to use common sense.

      Ambulance Driver

      ________________________________

      • http://www.facebook.com/profile.php?id=100000426321035 Christopher Rozman

        Dislike irksome med commands.  Can’t blame them based on some of the things I see our fellow paramedics doing sometimes…

    • http://roguemedic.com/ Rogue Medic

      A great idea, but most systems do not seem to carry soft collars. When I worked in a trauma center, one of the first things we would do after the initial assessment was to replace the EMS collar with a much more comfortable Philadelphia collar. For an example of the collars EMS uses, see the image from this paper - 

      Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
      Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA.
      J Trauma. 2010 Aug;69(2):447-50.
      PMID: 20093981 [PubMed - indexed for MEDLINE]

      http://www.ncbi.nlm.nih.gov/pubmed/20093981

  • http://thehappymedic.com the Happy Medic

    Had to review my protocols.  C-spine precautions are indicated based on the midline tenderness and reported positive radiological reading, but are fuzzy when it comes to WHEN to apply them.
    Option 1: Contact requesting physician to request position of comfort.
    Option 2: If requesting unavailable, contact receiving MD for same request.
    Option 3: Apply C-spine precautions, per protocol, prior to arrival at receiving facility.

    Easy answer: Let him self splint like he’s been doing and meet the protocols on the way.

  • http://twitter.com/NealParkes Neal Parkes

    How about a full body vacuum mattress? You could immobilise him in a semi sitting position.

  • BH

    Doesn’t matter if I’m going 70 miles (impossible in my system) or 70 yards.   Maaaaybe a scoop.  Maybe.  More likely, collar and position of comfort.  I could get behind a KED, depending on the situation. 

    And nobody will QA me for it because there is no QA, and the ER won’t make a stink about it (even if they knew what our protocols were).  EMS 2.0 by virtue of overall system failure, I suppose. 

    • BH

      Ugh.  HTML fail. 

  • Flobach

    I’d be going AGAINST our rules if I transported him on a longboard – we should only do that if they are time critical.
    Y’all applying for my service now? ;-)

  • Rapdes

    My basic partner states she would put a c-collar on him and use a KED instead of a LBB, this was he can sit up more comfortably and still have his c-spine protected

  • Bobball

    Up and about 24 hours after injury? If the patient isn’t a quad now, he probably won’t be. So, I’d be inclined to follow my agency’s protocols…c-collar to remind him not to move around much, and gentle placement (in position of comfort) on the cot. Analgesia and perhaps a little sedation if it’s really bugging him.

    Destination? I might be inclined to speak to the patient’s primary doc, or our doc on that one. In all likelihood the original ED recommended the far-away hospital because they have some sort of referral agreement with them. So, I’d be more inclined to see if the patient’s doctor had a better (read, closer) suggestion (presented by me).

    Either destination- he’ll be far less uncomfortable than he would be on Satan’s Hammock…I mean Long Spine Board.

    • Too Old To Work

      “Satan’s Hammock”. I’m going to steal a page from AD’s book and steal that from you.

    • 9-ECHO-1

      I, like TOTWTYTR, am going to ‘borrow’ the “Satan’s Hammock” reference. That is good.

      • Fern the Fire-Rescue newbie

        Ditto.

  • http://www.facebook.com/profile.php?id=100000426321035 Christopher Rozman

    My protocol allows for patients to refuse any treatment or
    intervention.  As a paramedic I’ve learned how easy it is to sway
    someone’s decision.  “Sir, my protocol says to transport someone with
    a C1 fracture I should put you on this uncomfortable, stiff, and painful
    backboard.  You have the right to refuse any treatment you feel isn’t
    right for you.  My concern is getting you from point A to point B in a
    manner that is most comfortable for you.  What can I do to make you
    comfortable?”   He’s made it
    this far without a backboard, why should I put him on one now?

    I really like full body vacuum splints.  I think that is a good
    “protocol” or by someone’s book answer that supersedes a backboard
    (no matter how much padding one uses).  If your protocol doesn’t allow the
    Pt. the option of no backboard, I would choose this.

    C-collar only… not a fan.  With this method I would worry about hyper-extending
    the neck and increasing displacement of the fractured area.  I’ve also seen pressure sores on the elderly
    from a c-collar.  2-3 hours stuck in one of those causing wounds around
    the neck that last for months… not cool.  Sad.

    Padding around the head and neck for comfort is my solution.  Nothing keeping them secure except the straps holding them on the cot.

    When securing someone on the cot and throwing them in the back of a modified
    pick-up truck, the ride is far from pleasant for the majority of the
    elderly.  Their only friend from the nursing home didn’t come back after
    the ambulance took them.  They were left at the nursing home by a surly
    crew of EMTs who burned rubber with their ambulance as they left.  They
    already went to the ER/ED yesterday and left thinking they were healed. 
    This is a frustrating situation for the PT. and frustrating for the
    providers.  Keep them comfortable.  
    Treat them like a Pt.  Human care, BLS care, & then ALS care if needed. 

    They survived 24 hours without immobilization.  Can they survive 80 miles on a backboard?

  • medic155

    C-collar or towel roll only. That high of a fracture won’t benefit from a LSB. Then use either the head block method mentioned below or blanket rolls taped along with the head to the stretcher. If you really wanted to secure entire spine, KED or a CPR board. Of course, I would probably contact med control also.

  • 9-ECHO-1

    Seated on the stretcher in position of comfort to allow full use of restraints (we require shoulder straps on all of our stretcher patients. If the patient can lay back to the mattress, with a pillow, then I would place small blanket rolls on each side of his head. Then fashion a ‘horse collar’ from another blanket to wrap around his neck. Not that it is too necessary due to he has been up and mobile for so long. However, it would be comfortable, and would satisfy most (or some) medical directors. I have actually done this a couple of times before on similar situations and it has worked really well.

    • 9-ECHO-1

      But, I am also fortunate to be working in a system that allows for autonomy and original thought on the part of our medics and EMTs.

  • http://profiles.google.com/erniemedic Ernie Sharp

     One thing that many medics overlook is the liability aspect of things. I feel like this is one of those situations where what is best for the patient is not what is the legally accepted standard, and like it or not, our profession is regulated more by JDs than it is by MDs.

    We had a lengthy discussion on this very topic at Clincon a few months ago, and I was soundly beat up by several physicians on it. Many of these physicians were well known, and more than one of them has authored a study that directly concerns EMS. I was talking about the studies that show that spinal immobilization is actually increasing patient mortality. Here is a summary of the responses that I got:

    1 Those studies are all retrospective. There are no prospective studies on this topic, because those studies require funding, and there is no money to be made in NOT placing people on a backboard. After all, the studies that support spinal immobilization are all financed by the manufacturers of c-collars, backboards, CIDs, etc.
    2 The accepted practice in EMS is spinal immobilization. There are years and years of court cases where this practice has been proven in court to be the best course of action. In order to change this, one would have to convince a judge and jury that years of court cases all got it wrong. The legal profession is even more resistant to change than is the medical profession.
    3 For the above reasons, no doctor wants to be the first one to place his neck on the chopping block. Even though it is NOT in the best interests of the patient, a doctor that wants to keep his license, his money, and practice is wise to keep his mouth shut and keep ordering those backboards.

    It sucks, but that is the consensus I got from them.

    • Anonymous

      And yet, increasing numbers of physicians are becoming brave enough ti challenge the status quo. Indeed, entire STATES have done it.
      As a lawyer/medic friend puts it, these cases are always decided by who has the more believable expert witness. When  one has reams of studies demonstrating harm or no no benefit, and the other expert only has  “Well, that’s the way we’ve always done it,” which one is more believable?
      If lawyers held absolute sway over standard of care and not science, we’d still be using rotating tourniquets and giving lidocaine prophylactically to MI patients.

      Ambulance Driver

      ________________________________

      • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

        Which is also the catch 22. If the standard of care is what the average provider does, then in order to use cutting edge evidence based medicine, one must choose not to provide the standard of care.

        • Anonymous

          But when is selective immobilization/field C-spine clearance no longer cutting edge? Maine has been doing it statewide for 15 years now. It ain’t exactly new.

          Ambulance Driver

          ________________________________

          • http://emtmedicalstudent.wordpress.com/ Joe Paczkowski

            Well, on one hand when I wrote my “4 Phrases” article, I had a physician email me criticizing every point (professionally, though), including how NEXUS is entirely inappropriate for selective spinal immobilization. He never responded to my reply though (So, again, these patients don’t need an x-ray, but need a board?).

            Additionally, given the state of evidence supporting spinal immobilization, isn’t selective spinal immobilization simply selective patient torture? What would it take to, at a minimum, at least produce a decent study on a board vs cot mattress? 

          • http://roguemedic.com/ Rogue Medic

            Selective spinal immobilization presumes that there is some kind of benefit to the patient from being strapped to a board. There is no good evidence to support that, but there is plenty of evidence to the contrary.

            All of the research on selective immobilization is about being able to identify spinal injuries. The huge bias in these studies is that they act as if there is some reason to believe that spinal immobilization provides a benefit. 

            If we selectively use rotating tourniquets and correctly identify all of the patients with CHF, does that mean that any of the patients benefit from the rotating tourniquets?

            We are more selective in our use of lidocaine and amiodarone than we used to be, if we identify the patients with ventricular tachycardia and ventricular fibrillation, does that mean that any of these patients benefit from these drugs?

            If we selectively use blood letting and correctly identify all of the patients who are sick, does that mean that any of the patients benefit from the blood letting?

      • http://profiles.google.com/erniemedic Ernie Sharp

        Additionally, there is a law in Florida that states that a physician who loses three malpractice suits loses his license to practice medicine. This means that medical directors are not willing to do anything that will attract the wrath of the plethora of “no recovery, no fee” malpractice attorneys.

        • http://roguemedic.com/ Rogue Medic

          Then these reckless spinal immobilization physicians should consider avoiding causing harm to their patients. Why shouldn’t we expect a smart plaintiff’s attorney to start bringing malpractice cases against these physicians? 

          There is plenty of evidence that spinal immobilization is harmful and no evidence that it protects patients’ spines. What more does a jury need?Have a lawyer show a jury that the physician doesn’t care about harming the patient and don’t be surprised if that jury ignores the spinal immobilization party line and awards some money to the plaintiff. If, as you state, Florida does have a 3 strikes law, a $1 verdict is as bad as a $1 million verdict. Maybe the doctors should start doing what is best for their patients, not what some amateur attorneys think is best for the courtroom. 

  • Mmorsepfd

    I’d have to call for a private ambulance.

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  • Elli

    I think there have been at least three times I’ve collared and not boarded a patient – one very very kyphotic LOL, one drunk self-extricated from roll-over and antsing around on the ice, easier to guide to the rig than to wrestle for a standing take-down, one anxious autistic patient transported in the captain’s chair, didn’t want him to panic and fight, he did tolerate the collar.

    And all three times I’ve been reamed out by nurses or doctors who have removed the collar at once saying, this is useless on without a back board.  Well, I don’t argue and say it’s better than nothing, or it reminds her not to turn her head, or best I could do under the circumstances.

    I’d be inclined to collar this pt, maybe KED, lots of padding to the sides. Maybe use the large vacuum splint under his head and upper torso if he’s small.   And expect a major major reaming out – C1! You transported a C1 without a board!   Not being that experienced yet, I’d convey my inclinations to medical control, and follow orders.

  • http://cursesfoiledagain2.wordpress.com/ Jake

    C-collar, and probably a KED, after talking to the sending doc (or med control if the sender isn’t available). Given that he’s gone 24 hours with a C1 fracture, I wouldn’t be too worried about actual instability under normal circumstances, but a long ride in the back of a truck isn’t what I would consider “normal”, either. I would also worry about the change in internal stresses caused by the resistance of the collar if he tries to move his head normally. But, given the confirmed injury, I would certainly CMA six ways to Sunday on *any* relevant protocol deviation.

    I have actually been in a similar situation at an earlier point in the process. Charming and alert elderly female at a nursing home fell 24
    hours before, went to the local ED that day for evaluation, and (we were told) skull and C-spine x-rays revealed no obvious fractures, and
    patient was discharged back to the nursing home. She kept complaining of neck pain, so we were called to take her back for more x-rays. While we were waiting for her films to be checked, the radiologist came out (the *actual* radiologist, not a tech) to get us to board her and transfer her to the ER for an _unstable_ C2 fracture. Then we found out the NH staff had lied and/or been mistaken – when she had been at the ER before, they did NOT do any spinal clearance (for whatever reason).

    Talk about pucker factor. See, when we moved her from her bed to our stretcher, a) the nursing home nurse yanked the pillow out from under her head, letting her head just fall to the bed, and b) based on being told her spine had been cleared previously, we just used her sheet to transfer her to our stretcher, without any spinal precautions at all beyond being gentle and making sure her head was supported.

    Needless to say, my narrative for the transport to the hospital (which was finished by the time the radiologist came out) was trashed, and a new, *much* more detailed one was written.

  • http://www.facebook.com/profile.php?id=100000136827582 Kenneth Reed

    Here is my 2 cents worth. I’d  KED him with padding the voids then let him sit in a position of comfort on the cot. Pain meds as needed. But what do I know, I’m just a EMT-B with 0 years of field experience. It just makes more sense to treat it like any other fracture, immobilize above and below the injury and make him as comfortable as possible for the long ride.

  • Ramffpara

    How about the c-collar, light sedation, and maybe a full body vacuum splint with some imaginative shaping. Could be more comfortable than a KED and would still provide some support and immobilzation.

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