More Ambulance Driver Answers*

*Not to be construed as encouraging any EMT to deviate from their established protocols, no matter how regressive, restrictive or outdated, because medical directors, particularly the ones who write regressive, restrictive protocols, tend to get all pissy when some smartassed blogger exhorts their EMTs to do radical stuff like, oh, using critical thinking skills and clinical judgment.

Standard disclaimer aside, Anonymous asks in the comments from a previous post:

Hey, AD, I read in a previous post that you would like to answer questions to EMS related stuff — hope you are still interested . . . so my question is: there seems to be a wide disparity among EMS providers on what get spinal precautions and what doesn’t. What is your “rule book?”

Anonymous, most field cervical spine clearance protocols are based upon the NEXUS clinical exam criteria. NEXUS (National Emergency X-radiography Utilization Study) uses a set of clinical assessment standards designed to reduce the number of unnecessary cervical spine x-rays performed in emergency departments. You may have seen a physician perform just such an examination on boarded and collared patients you have brought in to the Emergency Department. The NEXUS exam has been validated in over 34,000 patients suspected of cervical spine injury, and boasts an accuracy rate of 98-99% at ruling out a cervical spine fracture. The accuracy of cervical spine radiographs is 96-97% at ruling out a cervical spine fracture.

In other words, the physical exam criteria is more accurate than the x-ray at ruling out a c-spine fracture.

A more important question to ask is not to whom should we apply spinal motion restriction (the term “spinal immobilization” is out of vogue because, well, they ain’t really immobilized no matter how hard we try), but should we perform spinal motion restriction at all?

There is strong evidence that it simply doesn’t work. One large study compared patients with spinal cord injury treated at the University of Malaya Hospital and the University of New Mexico Medical Center. All of the New Mexico patients arrived with professionally administered EMS spinal “immobilization,” while the Malaya patients arrived at the hospital via car, donkey cart or what-have-you, and none of them were immobilized in any way.

The Malaya patients had better neurological outcomes.

Most patients with spinal cord injury sustain their injury at the time of the accident, in what we refer to as primary cord injury. Patients with cervical pain and frank neurological deficits likely have primary cord injury. The damage is already done, and thus boarding provides no benefit. Most patients with cervical pain and no neurological deficits have, at most, a stable fracture and thus do not benefit from boarding, either.

The premise behind spinal motion restriction is to prevent potential secondary cord injury, resulting from manipulation of an unstable c-spine fracture. The Malayan study provides pretty strong evidence that the benefit of spinal motion restriction is only theoretical.

You also have to keep in mind the hazards of boarding, such as potential airway compromise from vomiting, 15-20% reduction in respiratory capacity, increased intracranial pressure, occipital, sacral and heel pressure ulcers, to name but a few. Boarding is not a benign intervention. It takes as little as 30 minutes on a board to cause a Stage I pressure sore. Ask anyone experienced in wound care which is easier – preventing decubitus ulcers, or stopping the progression once they’ve started?

In Maine, everyone from First Responder through Paramedic has been able to use their statewide spinal clearance algorithm for nearly ten years now. In over 16,000 patient encounters, the use of that algorithm resulted in only one missed unstable spinal fracture, and that patient had no long term neurological deficits. My sources also tell me that they no longer consider mechanism of injury as part of their criteria, since MOI is a notoriously poor predictor of injury compared to a thorough examination.

The NEXUS clinical exam criteria are as follows:

1. No posterior midline cervical spine tenderness

2. No evidence of intoxication

3. Normal level of alertness (for that patient. An Alzheimer’s patient isn’t necessarily excluded, for example, provided they are alert and lucid enough to be good historians)

4. No focal neurological deficits

5. No painful, distracting injuries. The devil is in the details on this one. Effectively, whatever the injury, if it distracts the patient from perceiving pain or participating with the exam, or distracts the EMT from conducting a thorough exam, that’s considered a distracting injury. Put another way, calm, alert 78-year old lady self-splinting her fractured arm and appropriately answering questions = not distracted. Hysterical teenager freaking out over his minor boo boo = seriously distracted.

Not to mention a 10.0 on the Wuss-O-Meter.

The Canadian C-Spine Rule ( an offshoot from the Ontario Prehospital Advanced Life Support Study, OPALS), also adds a couple more exclusion criteria:

6. Patient age over 65

7. Significant injury above the clavicles.

Generally speaking, if the above criteria are met (at the least, 1-5), you’re safe in not boarding the patient.

Now before I get a gazillion comments with the common refrain “Yeah but AD, even if it only saves ONE patient, it’s worth it…”


I say no. It is not worth it. We as a profession should be long since past the stage of doing interventions based on zero scientific evidence, in the hope that it benefits less than 1% of our patients. The same holds true for basing EMS system design on response time standards for cardiac arrest patients, which make up less than 1% of run volume in most systems.

If you’re routinely boarding people purely out of defensive medicine, protecting yourself from lawsuits, I feel your pain. Just keep in mind that standards of care change with advances in science, and we have plenty of evidence now to back us up in our decision to not board someone, and very little scientific evidence to support the practice.

I’ve also noticed that the EMS systems that expect their m
edics to board everyone also give you the crappiest tools to do it with; only three straps on the board and a flimsy cardboard head immobilizer.


If any readers are interested in some of the studies and articles I’ve collected, I’d be happy to e-mail ’em to you – but keep in mind it’s little more than what you could find for yourself in a Google or Medline search. There is no shortage of information. Just drop me an e-mail and I’ll send you what I’ve got. I also do a conference lecture on the subject, entitled Protocol Directed Torture: Unnecessary Spinal Immobilization.

The title kinda says it all, doesn’t it?