Patient Care, Training, Trauma

How to Teach Flexible Immobilization

Issue 7 and Volume 35.

Spinal immobilization is one of the most fundamental psychomotor skills taught to all levels of EMS providers. Many times, teachers focus exclusively on the use of commercial devices. Our students become experts on applying these devices in the correct manner on manikins or classmates positioned either supine or sitting in the classroom. They’re evaluated using checklists to ensure that all critical actions and assessments performed by the provider are successful.

Although this is a measurable system to assess competency with the immobilization tools, and the step-by-step procedures of their use, instructors often forget the importance of teaching the “art” of immobilization. Assessing the patient, their injury, physical size, position and circumstances, and developing the best immobilization system for the individual patient, has become a lost skill. As educators, we must teach the psychomotor skills. But, we must also develop situations and scenarios that challenge our students to master not just immobilization, but also the proper packaging of the patient.

The Theory
From our earliest days of instructional theory in EMS education, one of our favorite psychomotor skills has been spinal immobilization. We start by demonstrating the entire skill with brief descriptions as we proceed.

Then, we break down each part of the skill to its basic parts, explaining each in detail. Finally, we demonstrate the entire skill without commentary or interruption, as if we’re taking a practical skill exam ourselves.

One common mistake instructors make is showing a new provider how “not to do it.” It’s been shown that a student in the early stages of learning a skill will remember the wrong way and may eventually repeat the error. Therefore, during the early stage of psychomotor learning, it’s imperative the educator demonstrates only the skill in the correct order and manner.

Immobilization education must begin before we introduce such psychomotor skills as establishing C-spine support and applying adjuncts, including short, long and specialty immobilization devices.

When we discuss anatomy and physiology of the central nervous and musculoskeletal systems, we need to build the foundation of proper immobilization. Addressing structures of the spine, skull and jaw present exceptional opportunities to discuss how injury can affect immobilization. Using a skeleton, we can show how flexion and extension will cause further injury, and we can demonstrate how improper C-spine support or an improperly sized, rigid collar could harm the patient.

Understanding the Patient
If all our patients were 70 kg, didn’t have underlying conditions and were lying supine on a floor or outside a mangled vehicle, immobilization would be an easy skill. However, today’s providers are dealing with more obese patients who have more underlying medical conditions than ever before.

We also know that these patients are often found in unique positions and places as a result of their injuries. When teaching immobilization, we need to simulate these patient conditions and inspire empathy in our providers for what their patient will feel and experience during immobilization.

An obese patient can become severely orthopneic and deteriorate rapidly when immobilized in the supine position. So, when you lecture about obesity and other comorbid factors (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disorder and osteoporosis), emphasize how patient position adversely affects their health and comfort.

We can also develop the best packaging system for patients by instructing providers to listen carefully to the patient’s history. Patient empathy is a powerful learning tool, and using students as patients may create that empathy. Placing students in a standard immobilization package for 15–20 minutes, and leaving them supine to demonstrate how uncomfortable immobilization can be for even the healthiest patients will leave a lasting impression.

Students also gain a better understanding when you ask them what’s causing the discomfort and how that discomfort can be addressed. Also, using appropriate padding to fill multiple void spaces, or changing from use of a rigid spineboard to a vacuum mattress, will add to the reality and experience you’re creating in the classroom.

The Practice
For years, instructors have debated using properly protected students as patients in vehicle rescue drills. Weighing the risk of the tactic against the benefit to the student is something many instructors can’t agree on. Because many of our spinal-injured patients are found in motor vehicles, it’s imperative we get our students the proper experience in this environment.

The Pennsylvania College of Technology paramedic program in Williamsport, Pa., came up with a unique solution. Partnering with the college’s auto body education department, instructors modified a junk car’s passenger compartment, making it safe from all hazards, and placed it in their practical lab. They then placed the car on a hydraulic lift system, which allows the prop to be rotated on its side or roof. Now, EMS students can practice immobilization skills in the safety and comfort of the lab setting.

You can make less elaborate props to enhance the simulation experience. For example, a bucket seat removed from a scrapped car and mounted on a large, wooden base is inexpensive and effective. It’s more realistic than a classroom chair and can be used effectively to teach seated spinal immobilization. It’s also portable enough to move around the room to create different scenarios.

Using other household items as props to create limited space can also add to a scenario and enhance students’ problem-solving skills. I’ve seen institutions use old bathtubs and toilets to recreate the limited space and other challenges presented when a patient falls in a bathroom.

Look around your training and station facilities for unique areas where you can stage scenarios. Small rooms, cluttered offices, basements, stairwells, bathrooms, kitchens, bunkrooms and garages work well. And, if your area has some locations where immobilization may present unique challenges, explore opportunities to practice skills there. These areas all present realistic access and space limitations. In any situation where using a student as a patient may place the student at risk, use a manikin instead.

Utilizing Commercial Devices
Almost every immobilization could be accomplished with a particular commercial device. As educators, we must become intimately familiar with the features and limitations of the devices our students will be using. Among these limitations, don’t forget to discuss size restrictions. Immobilization devices that don’t properly fit the patient may cause further pain, injury or discomfort. And although more bariatric and pediatric devices continue to appear, we don’t have a “one size fits all” device for our many patient populations.

Correct sizing of cervical collars is especially important to provide proper immobilization and eliminate further harm to the patient. Not every student in your class has the same neck size, so take advantage of this teaching opportunity. Randomly select students and demonstrate proper sizing and application techniques. Then, have your students do the same to perfect this skill.

When a student finds that a commercial collar won’t fit, use the standard supplies carried on a typical EMS unit, and ask the class to improvise in order to immobilize this patient. This allows you to show the flexibility of such tools as towels, blankets, cravats, gauze bandages and vacuum splints.

Encourage your students to try different techniques and explain the pros and cons. Emphasize how the proper immobilization of the neck, without movement, flexion or extension, can be accomplished using alternative techniques.

When demonstrating how to utilize devices, we often forget to stress how setup and preparation can affect immobilization. Illustrate how properly packaged straps, collars, cervical immobilization devices and boards can result in smoother and more efficient deployment of each device.

At the end of an application, show your students how to properly store equipment and prepare it for its next use. Emphasize how proper cleaning of Velcro®, storing of straps and other components can make for a less stressful application the next time the equipment is needed. It’s a good opportunity to point out that it’s easier to apply straps that aren’t stored in a fully extended position.

Another good drill for students is to have them don extrication gloves and immobilize a patient. If straps aren’t left with large enough tabs, gloved hands may not be able to grab the strap to tighten it. Learning this in the safety of the classroom is far less harmful than at a noisy junkyard practice session.

In order to master spinal immobilization, students must also learn the skill of patient packaging. Teaching this skill involves introducing basic anatomy and physiology, building psychomotor skills, using advanced props and simulations and creating an environment in which your students think about what’s best for the patient.

EMS has a saying for extrication: “Do not be a one-tool rescuer.” We need to instill the same philosophy in our EMS students. Commercial devices work well for many patients, and we need to make sure our students master their use. However, we must teach our students to read and assess our patients’ injuries, develop the best method to immobilize them, prevent further harm and provide as much comfort as possible. To be able to consistently achieve these objectives, we must ensure that our students master the “art” of immobilization.


  • National Guidelines for Educating EMS Instructors.
  • Heightman AJ. ‘Distracting’ injuries. JEMS. 35:14–16. 2010.

This article originally appeared in July 2010 JEMS as “Flexible Immobilization: Improvisational tools for teaching this skill.”