We Asked, You Answered
We expected the cover article for our March issue, “Spinal Immobilization: Time for a change,” by Jim Morrissey, MA, EMT-P, to raise some eyebrows. The cover blurb posed the question, “Are we going over-board?” Even though it is phrased as a yes or no question, the issue is remarkably complex, and most readers had additional thoughts when answering this question in the emails and comments posted on our website and Facebook page.
The article on why spinal immobilization protocols need to be updated was long overdue. Those of us who teach wilderness emergency care (which I have been doing for nearly 30 years), however, always train students to clear the spine if possible, because in a wilderness emergency you almost never have the equipment to backboard a patient. If there really are indications of a spinal injury in the wilderness, usually the only way to ensure spinal immobilization is to bivouac and send people out for help and equipment, which would mean ending the trip (at a minimum) or in some situations, putting the whole group at risk. So wilderness responders need to know how to clear the spine.
They also need to know how to do it right, if there is a possible spinal injury and they have the equipment. I have seen far too many examples of ineffective spinal management in the classroom and in the field. Moreover, many EMTs never learn how to align a patient with possible spinal injuries who is found in a bent or twisted position—perhaps because the illustrations in EMT textbooks always seem to show the patient lying perfectly straight and supine?
And perhaps familiarity breeds contempt for technique in responders who backboard every trauma patient? If that is the case, one hopes that teaching EMTs to assess for signs and symptoms of spinal injury, and only backboard patients who may need it, will encourage responders to do the procedure more effectively.
Author Jim Morrissey, MA, EMT-P, responds: Thank you for the letter and your observations, Steve. Certainly those who work in prolonged, wilderness, tactical and other high-stress, high-risk environments have many priorities and issues to contend with in addition to patient needs. If at all possible, following objective criteria, clearing an individual from needing spinal motion restriction is critical in these environments. Simply stated, in the wilderness environment, it’s important to know what is wrong with the patient, and is also important to know what is not wrong with the patient. You aren’t clearing a trauma patient because you don’t have a backboard. You’re clearing them because evidence shows that one can use objective criteria to assess the patient and accurately determine if a spine injury is present. Thankfully, increasingly more EMS agencies around the country are adopting this approach and omitting spinal motion restriction if the criteria are met.
The other issue revolves around what to do with a spine-injured person in a backcountry situation. One option is to set up shelter and wait for help, which could be hours or days. In some cases, this is the best option. The position of the patient requiring spinal motion restriction doesn’t mean they need to be flat on their back. Instead, spinal motion restriction should focus on protecting the patient from from further injury caused by gross movement. This may include allowing patients to be comfortably positioned and able to eat, urinate and generally doing the things they need to do to stay safe.
Evidence cited in the article suggests that “full immobilization” as we know it isn’t needed for most stable injuries. One could easily make a case for walking someone out with a stable spinal column injury if the risk of spending the night out on an exposed mountaintop outweighs the benefit of immobilization. If a decision is made to walk out a patient with a possible spinal column injury, be sure to avoid falling or any mechanism that might replicate the original mechanism of injury.
From Our Facebook Audience
Our Facebook fans responded to the question: “Do you think every trauma patient with a significant mechanism of injury should be immobilized?”
Shaun W: Only if patient presents with neurological compromise or altered mental state, whether from closed head injury or chemical substance (EtOH, pharmacological or illicit).
Mark K: I had a two-car head-on collision a couple weeks ago. No one was injured. Why would I board and collar them? Because their cars are smushed?
Justin S: Should anyone be spinally immobilized?
Taylor G: No! We’re trusted to administer electricity and medications, but not allowed to use common sense when it comes to spinal immobilization? As long as we also educate the ER physicians as well (who doesn't enjoy getting an earful from the ER doc because a patient isn't immobilized?), let’s make this happen.
Linda K: I was starting to think it was a little ridiculous until I saw a patient come in to the ER with full spinal motion restriction which I thought was overkill. Patient had full function and feeling but the X-ray showed a near complete separation of C5 and C6. Had he not been immobilized he would probably have permanent deficits.
Jason W: If there is trauma, they get boarded. I don’t care if it takes time. If the patient is fine with it then there’s no reason not to. It’s better to have done C-spine and nothing was wrong then to have not, and then later on you find out there was a spinal fracture.
Christopher W: I had the pleasure of hearing the author, Jim Morrissey, speak at a trauma conference in our area. He offered this question to those who would immobilize based on mechanism alone: “Do you put a traction splint on everybody who had the mechanism for a femur fracture?”
Weston D: It’s awesome to see so many people embracing progressive medicine instead of using outdated draconian procedures in the name of “just in case.”
Patrick L: The problem is we've been taught that we have to “rule out” spinal precautions. This is faulty reasoning. They are a treatment, same as a medication. SMR has indications, contraindications and side effects. Putting a patient on a backboard and hiding behind “better safe than sorry” is a weak excuse for practicing medicine.