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These Are Your Protocols? How… Quaint.

In the recent mass stabbing at Lone Star College in Harris County, TX, fourteen people were transported to local hospitals by EMS. A blog reader pointed me to the CNN.com story on the event, and the associated photo gallery. There are a couple of video clips, as well. You EMS folks, go look at the photos and video, and come back and tell me what's wrong with those pictures.

I'll wait.

 

Okay, we all back?

If you answered, "Why are those penetrating trauma victims spinally immobilized?" you win the cement bicycle and a two-night's stay at Buford's Bed and Breakfast, Tire Repair and Oil Change in that lush vacation destination of LaDonia, TX.

Now, with the caveat that every medic is an expert about some other medic's call, I wonder if the ambulance crews who responded are aware of the research that discourages prehospital immobilization of penetrating trauma victims:

We performed a retrospective analysis of penetrating trauma patients in the National Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital spine immobilization, using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to treat and number needed to harm for spine immobilization.

In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spine-immobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized patients was 2.06 (95% CI: 1.35-3.13) compared with non-immobilized patients. Subset analysis showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord injury and underwent operative spine fixation. The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.

(emphasis mine)

It would seem that, given two groups of penetrating trauma patients, well-matched for mechanism, injury severity scores and blood pressure, the act of strapping a patient to a rigid board makes them twice as likely to die as simply placing them on the stretcher.

By performing prehospital spinal immobilization, you will harm or kill 16 penetrating trauma patients for every 1 it will potentially benefit.

I say "potentially" because there is still zero evidence that spinal immobilization to a rigid board does any good at all, even for people with broken necks.

Either there's a whole bunch of people upstairs wearing halo devices, or we're boarding way too many people.

 

Cy Fair Volunteer Fire Department, the primary response agency at the incident, is a combination paid/volunteer department that serves the Cypress and Fairbanks communities of unincorporated Harris County, TX. With over 500 members (200 paid) and 12 stations, they bill themselves as the United States' largest volunteer fire department.

In other words, this ain't some rooty-poot, half-assed, mom-and-pop ambulance service firmly stuck in the 1980's.

No, this is a major metropolitan EMS system firmly stuck in the 1980's.

Now, I'm going to give the Cy Fair medics the benefit of the doubt. Plenty of good medics are stuck in systems with ancient, outdated protocols that force them to do ineffective and potentially harmful stuff to patients every day. It is what it is.

Some might even say that it's easy to have liberal, progressive protocols at a smaller department. When you only have a couple of hospitals to convince, and a medical director who knows all his crews personally., training and education are a fairly simple matter. I knew that to be the case at The Little Ambulance Service That Could, when I wrote what were, at the time, the most progressive and advanced prehospital treatment protocols anywhere in our state. We could do anything short of opening the cranial cavity without direct medical orders, and we were good at what we did.

In 1997, after the Airway Call From Hell, I did a weekend's worth of research and developed an RSI protocol and airway management training program for that service. We implemented it a week later, and were using it for nearly a year before the state got wind of it, and shat their bureaucratic pants. Ultimately, after a couple of years percolating through the bureaucracy and my current employer throwing their not-insignificant support behind my proposal, RSI was added to the state EMS scope of practice.

But when you have 2000 medics to train, educate and monitor instead of 20, change comes slower. It wasn't too many years ago that my fellow Borg drones had to call for permission to start an IV, or do BLS CPR while the medic got on the phone to a hospital and begged for permission to implement ACLS protocols.

Thankfully, that is no longer the case, and The Borg has an extensive system in place to train, QA and educate their crews, and protocol revisions are an ongoing thing. We get minor changes frequently, and a major revision every few years. Things like equipment upgrades and protocol revisions to keep pace with current medication shortages are an almost monthly thing.

All this is to say that, if you've got good crews and a medical director who trusts them, change can come pretty easily, even in a big EMS system.

But what if your medical director is the EMS equivalent of Bigfoot or the female clitoris; lots of men have heard of it, but very few have every actually found one? What if your medical director has never even met the vast majority of the crews whose medical practice he is responsible for delegating, much less been actively involved in their training, QA and supervision?

I'm guessing that's how you get restrictive protocols, and wind up still doing things that were proven not to be beneficial ten or twenty years ago.

With a little digging through online public records by a couple of friends, I found Cy Fair's medical director.

Since 2008, he has been listed as medical director for 137 EMS agencies or entities in south Texas.

Of those, he is listed as the current medical director for 71 ambulance services or entities that provide EMS or EMS training. He let 48 licenses expire in those five years, and another 18 services he directed voluntarily surrendered their business licenses, either by going out of business or to avoid disciplinary action.

Busy man, that doctor.

Then again, not as busy as he used to be. Maybe he decided that a full-time medical practice and serving as medical director for 137 ambulance services was stretching himself a little too thin, and he cut it back to a more manageable 71.

Call me a wild-eyed conspiracy theorist, but I think I see a big part of the problem.

Comments - Add Yours

  • Vince D

    Well stated! The same thing goes through my mind every time I see clips from one of these major incidents.

    I love how many of the patients have their arms up, holding onto the semi-rigid collars – clearly because they’re so comfortable that they don’t want to risk them falling off during the transport. Lifesaving stuff right there…

  • Texmed

    If only we were as smart as you!

    • Ambulance_Driver

      I make no claim to be especially smart, Tex, just passionate about my profession.
      My point was, if medics in a system are using outdated treatments, the fact that their medical director supervises 71 ambulance services might be a big reason why.

      • BH

        “supervises”

        • Ambulance_Driver

          You know what I mean.

          I’m not talking about direct supervision, but it is the job of the medical director to provide medical guidance and supervision, and to actively participate in the training and QA process.

          There’s absolutely no way you can do that for 71 ambulance services. You’re getting a signature on the paperwork that requires “MD” after it, and that’s all.

          • BH

            I was being sarcastic. Tried verbalize the Dr. Evil meme.

            (Hell, our MD is the MD for just us, and all we get is his sig. But then, in our state he can’t limit our practice individually or as a service, or allow us to do anything more than what the state protocols allow, so….)

          • Ambulance_Driver

            LOL.

            Disqus needs a sarcasm font.

    • totwtytr

      If you were only half as smart as AD, you’d be twice as smart as you are.

  • lone medic

    Texmed, most of us know medics are constrained by protocols. I am fighting this fight as well, but defending people that are doing something that is statistically harmful through ad hominum snark is in no way helpful. A lot of medics out in the blogosphere want the right things done amd AD is one of the best voices.

  • http://www.facebook.com/profile.php?id=778451257 Ernest Sharp

    I spoke with several medical directors, including the state EMS director, at the state EMS conference here in Florida back in 2011 on this very subject. They said that the problem is one of liability. No one wants to be the medical director that is going against common practice and opening themselves to legal liability.

    The studies are meaningless because they are retrospective studies and not blind studies, which carry much more weight.
    So that is where we are here.

    • Ambulance_Driver

      The problem is that you will never get a prospective trial that compares withholding treatment to providing a long-standing standard of care past an IRB, no matter how ineffective the accepted standard currently is.
      Still, I’m not sure I buy their argument. We cleared those hurdles in resuscitation science, and I don’t see why it can’t be done for spinal immobilization.
      Plus, if there never were any blinded, randomized trials to SUPPORT the practice in the first place, it seems pretty silly to dismiss a retrospective study that may demonstrate lack of benefit, and that’s where we are with spinal immobilization: studies that prove its benefit? None. Studies that demonstrate that, AT BEST, no harm? Every single study out there.
      Kelly Grayson

      • http://www.facebook.com/profile.php?id=778451257 Ernest Sharp

        The consensus of the medical directors was that no prospective trial would be done without a sponsor willing to pay for it. No sponsor would pay for a study to prove that a product is not needed, as there is no profit motive for doing so. No study, no changes. This is a basic flaw with capitalism: if there is no money to be made, there is no reason to do it.

        The law here is set up around accepted practice. We do it because we have always done it, and to deviate is to leave yourself open to lawsuits.

    • Tom

      They could always compare with best practice in other first world countries – like the UK where immobilisation isn’t practiced nearly so much as it is the US & where it is the pt is immobilised on a scoop/vacuum mattress.

    • totwtytr

      Funny, Maine instituted a field evaluation protocols for all levels down to first responder in 1995. Last I heard the streets of Bangor were not flowing with hoards of quads in their powered wheel chairs. If they can teach guys who spend most of their time hauling lobster traps or chopping down trees to do this, then surely we can teach highly trained full time paramedics and EMTs to do it.

      The science that exists indicates that there is very little benefit and potentially much harm to mindless immobilization.

      What it will take is for hospitals to be on the hook for the medical costs of the injuries to these patients and EMS systems to be sued for their indiscriminate use of what can only be termed an iatrogenic procedure.

      When doctors have to pay for this stuff out of their own pockets, then they’ll suddenly be less likely to inflict this so called treatment on patients.

      I’m not holding my breath though.

  • Jen

    So non-EMS person here. I live in Houston, and until a year ago lived ten minutes from that campus and within CFVFD’s service area. According to local news, at least two of those patients had severe slash/stab wounds to the neck and cheek. Would restraining their heads in that manner not make it easier to control the bleeding and such? Meaning maybe they were secured for the (literally) less than five minute ride across to the other side of the highway to Memorial Herman Hospital to keep them from moving rather than to protect their spine? Don’t flame me – it’s really just an “inquiring minds” kind of question. To a layperson, that makes sense – don’t move so you won’t bleed as much, especially with conscious, panicked, dramatic, excitable young women.

    The bigger issue to me was why they called LifeFlight to get one patient down to Ben Taub and the trauma center. Houston notwithstanding, traffic is just not that bad at that time of day – we’re talking 30 min MAX via ambulance. LifeFlight is freaking expensive and can be dangerous – I’ve read your posts about unnecessary helo transports. Plus there are two major hospitals – St. Luke’s and Mem Herman, within five to fifteen minutes ride via ambulance from that campus. NO ONE at either of those ED/ER could handle that crisis?

    • SS

      You obviously don’t know about traffic and time. That campus is 25 miles to the closest trauma center. Last I checked it takes much longer than 5 minutes to go 25 miles. With traffic even with lights and sirens thats 40 minutes at best.

      • Jen

        The five minutes referred to Memorial Herman WIllowbrook which is right across the street from the LSCC Cy-Fair Campus. Literally on the other side of the Hwy 249. St Luke’s is about a 15 minute lights and sirens ride down the service road. I said about 30 minutes at that time of day in an ambulance to the trauma center – which, according to local news reports was Ben Taub, but I stand corrected by the poster above.

        • TJ

          You need help. Cy-Fair campus is no where near Willowbrook. Look it up.

    • Ambulance_Driver

      No worries, I won’t flame you.

      If they were attempting to limit movement, the cervical collar alone should be enough. There is no indication to board a patient with penetrating trauma who is neurologically intact.
      Or for that matter, no indication for a patient who is neurologically compromised, either. The damage is already done.
      Moreover, supine positioning on a board could compromise the airway of the woman with the cut cheek. Sitting up, she can spit out the blood that collects in her mouth. Flat on her back and immobilized, she can choke on it. Placing the cervical collar on the patient with a neck wound can impede access to the wound, limiting your ability to monitor it or apply pressure.
      I didn’t address the helicopter issue because I’ve experienced Houston traffic and it is horrendous. Two of the patients are still in critical condition. For a critical patient, that 30 minutes max could be too much.

      • Jen

        Thank you, Kelly. That answers my question. There was one woman I saw who was sitting up with a huge pressure bandage on her face, but they weren’t hurrying along with her. But like you, I did see several on a board. So your point is that the restraints do more harm than good in damn near every situation.

      • Jen

        Another thought – with Mem Herman just five minutes from there, it probably took longer to do all the boarding and restraining than it did to ride them across the highway, where they were then probably unstrapped from all the gear pretty quickly. That protocol seems like it would have just added to the delay in getting folks transported.

    • Dogg Tired

      No flames.. just straight rebuttal.

      1) Ben Taub does not have a helipad. They do not get trauma flights. Their patients come by ground.

      2) there are two level 1 trauma centers in Houston and they are next door to each other. Penetrating trauma to the torso or neck is criteria for evaluation at a level 1 or 2 trauma center. While practically every other hospital in the region is credentialed as a level 3 trauma center (or level 4 or not credentialed at all) that does not mean they are really geared up for penetrating trauma or hardcore trauma patients. I am speaking from the point of working both in a trauma center and a community hospital. St Lukes is NOT in the trauma business. Trust me on that. The difference between community hospital and the med center? Trauma surgeon in house. Vascular surgeon in house. OR crew in house 24/7. A high volume intervential radiology department for things they cant reach surgically. A trauma ICU that is accustomed to taking care of trauma patients – critical in the first few hours to days of care. None of these exist in the community.

      3) This was a mass casualty event for the first few EMS units, and a multiple casualty event for the receiving hospital. The difference – Mass casualty exceeds the capabilities available (at first, or for the duration of the event).

      The first couple units arriving were dealing with patient identification, rapid triage, rapid initial treatment and summoning of resources. The first in truck would have been remiss in simply grabbing the two sickest, throwing them in the back of the truck and making a beeline for the trauma center. In this situation, the helo’s were appropriate and 4 folks were airlifted in two separate birds to the med center. Others followed on via ground, and the less urgent patients were seen locally at the 3 or 4 closest hospitals..

      • Jen

        I got the Ben Taub info off the local news report. Guess they got bad info too.

    • totwtytr

      If that’s why they applied the cervical collars, it’s a reasonable thing to do. Although manual pressure is better to control bleeding. However, that doesn’t involve taping the head down or lying the patient flat.

      I’m going to go with what AD suggested, outdated protocols and a rubber stamp medical director.

  • http://burnedoutmedic.com Burned-Out Medic

    i threw a stabbing on the gurney and drove him to the trauma center. the trauma team high-fived me because he wasn’t in c-spine. apparently loads of them get brought in on a longboard.

    • Vince D

      i like this.

  • NC Medic

    That is a horrible study to use as the basis of your claim. It is like comparing apples and oranges – the study does not separate out any of the physical assessment findings and it is so random an approach to research that if anyone is basing their treatments on that, they would only learn to regret it with the NEXT study. Seriously? All penetrating trauma is the same? Don’t get me wrong, I think spinal immobilization is over used as well, and yes, I believe that we have needed selective spinal immobilization protocols for years. In NC we have such a protocol and it reduces the number of patients that are being immobilized unnecessarily. It needs to go further. But, it is based on assessment – not a generalized shotgun approach that states that NO XYZ EVENT should receive ABC TREATMENT.

    • http://www.facebook.com/brandon.oto Brandon Oto

      Well, if you followed a rational approach like that — at least attempting to note whether the missile path involved the spine — you’d be doing better than some. (The EAST committee recommends this.) However, even then, what the available studies have found is that almost nobody benefits. Even when the bullet involves the spine, generally either: 1) the cord is obliterated on the initial impact (no benefit from immobilization); 2) the cord is not involved and not threatened, with no later stabilization judged necessary (no benefit from immobilization); or 3) the patient dies. In very rare cases there is potential for instability and neurological deterioration — I say potential because even then, said deterioration has never been shown to actually happen prehospitally, nor we do have reason to think that our collars and boards would prevent it if so — but in much-less-than-rare cases we know that our fiddling kills people. Presumably it’s from the scene delay, airway compromise, hiding important exam findings, and so forth. PHTLS, the NAEMSP, the ACS, and so forth mostly all recommend against the practice.

      If you go to http://emsbasics.com/digital-research-library/spinal-immobilization/ and type in “penetrating” you’ll pull up most of the worthwhile research on the subject.

      • Ambulance_Driver

        Brandon beat me to it.

        You don’t like the methodology of a retrospective study that points to doubling of mortality in penetrating trauma patients associated with spinal immobilization.
        That’s a fair objection.

        Of course, your default – immobilizing the patient – has never been based on any studies, methodologically sound or otherwise.
        So let’s approach this from another perspective; cite me a study that demonstrates a benefit from spinal immobilization, for any type of patient, any type of injury.
        Keep in mind, now, that lack of evidence of harm does not equate to evidence of benefit.
        I’ll wait for your reply.

        But all this debate misses the point of my post, which I see now that I didn’t make clear: how can a system employ current, medically sound treatments and protocols, provide QA and continuing education for its medics, when that service’s medical director is dividing his time between SEVENTY-ONE ambulance services and presumably a full-time medical practice?
        Simple answer: it can’t. He’s a rubber stamp, absentee medical director.

        • Ted

          There are plenty of case reports of missiles being found in unlikely locations after intrasomatic ricochet. You don’t have radiology, you don’t know where the bullet went. That said, AD is right that penetrating trauma is over-immobilized (and this coming from a guy who thinks AD is overexcited about the whole spinal immobilization issue).

          But all this debate misses another point: Calling out an apparently well-connected physician in a state where your (medical industry) employer operates right after publishing an article about career suicide.

          AD, you sure you thought this all the way through?

          BTW, glad to see you posting more EMS stuff lately.

          • Ambulance_Driver

            Doesn’t matter where the bullet went. If your patient is neurologically intact, it hasn’t hit the spine, and is vanishingly unlikely to do so through simple movement.
            The purpose of spinal immobilization is to prevent secondary cord injury from bony fragments impinging on the spinal cord during patient movement.
            The patients we see with those conditions – unstable C spine fractures who are still neurologically intact – are only 0.5-1.0% of severe trauma patients, almost all of which are blunt trauma patients.
            In identifying those 0.5-1.0%, physical exam criteria are more accurate than X rays, thus negating the whole “Let’s immobilize your neck just to be safe until we can get you X-rayed” approach.
            Immobilization does nothing to aid the patient suffering from primary cord injury, ie the patients who are not neurologically intact. The damage is already done, and immobilization does not make it better.
            Secondary cord injury following primary cord injury occurs from edema, and not manipulation. Moreover, manipulation within the normal range of movement is highly unlikely to cause that secondary injury, even in a patient with an unstable fracture.
            And all of this presupposes that immobilization ACTUALLY DOES keep the cervical spine immobilized in a neutral position, which we have no studies that demonstrate that it does, and a number of studies that demonstrate that it does not.
            So, no, I don’t think I’m overexcited. I think we’re on the cusp of seeing prehospital spinal immobilization as we know it being abandoned as ineffective and harmful.
            And good riddance.

          • Ted

            “If your patient is neurologically intact”…aye, there’s the rub. I don’t know a lot of medics who know how to check (for example) median, radial, and ulnar nerve function. There are some of you out there, but you’re certainly not the standard of care.

          • Ambulance_Driver

            And again I’ll state that, even if neurological function were compromised, immobilization is of little benefit to primary cord injury, and secondary cord injury is more likely to occur from edema than a bullet migrating into the spinal canal because you laid a patient on a cot mattress instead of a board.

            And I’m sure you’ll agree that a guy ambulating around a scene with a bloody shirt pressed against a knife wound probably has intact neurological function.

          • Ted

            Probably, but not necessarily. Some of those nerve root injuries can be pretty subtle. The other issue is risk tolerance. Most patients and providers would much rather take a chance on some increased back pain rather than (less likely but more devastating) worsened neurological injury. The ill effects of immobilization that you cite seem to be more due to prolonged time on a board, rather than initial use of the board; I prefer to address this by rapidly assessing and treating the patient in the ED rather than not immobilizing during a bumpy ambulance ride.

            Don’t get me wrong: I’m in favor of NOT immobilizing most penetrating trauma patients. If you put an isolated lateral abdomen stab wound on an LSB I promise I will wonder why. My main concern is that the default setting in trauma should be “when in doubt, immobilize” rather than the opposite.

          • totwtytr

            Old school mythology. As far back as Vietnam the military studied this and found that with rifle caliber gun shots to the head, there was a well below 1% incidence of occult C Spine injury.

            The study was done by performing autopsies on soldiers killed with gun shot wounds to the head. The “You don’t know where the bullet went” myth goes along with the “Tourniquets are bad” myth, and the every popular, “All patients need O2 by non rebreather” myth.

  • Peter

    Wilderness folks rarely use spinal immobilization, and it hasn’t been a problem. Our spinal assessment protocols(NH statewide) were based on the common wilderness criteria.
    When we do decide to immobilize, I much prefer the vacuum mattress, especially for our older patients. Arthritis, no body fat, tissue-paper skin? There is a better option than strapping her to a rigid board.

    When I did some research on boards vs. vac mats, I especially liked the study in which 100% of young,healthy test subjects who were boarded reported head or neck pain AFTER being on the board for a while…….

  • Chris

    Just wondering if you have seen their protocols? IF not, it’s a big assumption you are making. My service’s protocols don’t call for c-collar, but I bet that 90% of the old-heads 1) haven’t read them and 2) would c-collar. To observe a field providers actions and make judgements about their protocols/doc is a big stretch.

    • Ambulance_Driver

      That’s a fair criticism.

      In essence, I was trying to give the medics the benefit of the doubt, and hypothesizing that it was due to outdated protocols instead of outdated medics.
      I see now that, in trying to make my point, I got everyone focused on the tangential issue.
      My main point was, how can a doctor serve as medical director for 71 different ambulance services, and actually DO what a medical director is supposed to do?

      • Chris

        If that’s the main point, a valid concern. My guess would be that is all that agency wants or is willing to pay for though…

        • Ambulance_Driver

          Rumor has it, he charges $1200/month to be a medical director. For 71 services, that’s over a cool million a year.
          Of course, with 71 services, what are you getting for your money other than a signature on documents?

          • jp2134

            Most of those services are going to be BLS dialysis transfers. all they want is a signature on documents.