Prehospital Clearance of Spinal Injury

[FL_Medic]

I wouldn't go that far, ERDoc!

I work in a system that sometimes allows me to use EBM to treat patients.

Tom

I haven't yet heard of a 100% EBM system. I think we should all strive for this, but some things never change no matter how little evidence there is to support it. While my system preaches evidence-based medicine, we are just now implementing an adequate QI/QA system. We have just removed Diprivan and finally rewritten our airway protocol, Amiodarone is suggested for WPW patients, we hold off on the Mag until our pregnant patients seize, and we still promote Trendelenburg position. Tom, all we can do is show them the research and hope for the best.

Where is the proof that spinal immobilization even works??

[Happiness]

Personally I really dont care what any study says because in reality it is one persons perception of any issue. They always change,remember when some said milk causes cancer (showing my age on this one), then years later it was proven that it dosn't. For every study that states one thing there is another that states the opposite.

When I have decided to do a spinal I will error on the side of caution and I do this because a very dear friend who isn't a medic anymore had a call of a lady who fell on a fish dock. Well this woman showed no signs of a spinal injury and had no pain. She for what ever reason she had a gut feeling and did the full spinal. Good thing the lady had a neck fracture.

If you always take a good look at the mechinism of injury, you will have some idea of whether a spinal is needed. Look at the age of the person a fall standing for an 90 yr old is very different than one from a 16 yr old. Do they have any numbness and tingling, well you can have that without pain and they will get a spinal. Spinals are need for many reasons not just car crashes and falls, dont forget the guy who has had the crap beat out of him, or the gun shot wound.

Some one said not to spinal because the board is to uncomfortable and the pt will move around anyways, we dont use the board if possible and will utilize the scoop or clam shell and alittle padding goes along way in pt comfort. The KED was also mentioned and as I have said before this is my favorite piece of equipment. I have spinaled a 6 week old baby that fell off a change table to a guy who landed on his feet from a roof. This guy crawled to his truck and drove 30 mins to the hospital just to find out he couldn't get out. The unfortunate thing with the KED is that the pt has to be stable and is usless on the calls that need the quick extration.

There are times when I have had men refuse the collar and I wisper in their ear that I dont have to put on the collar if they dont want it but to be aware that if you have a spinal injury and it is agrivated you are taking a chance of your penis not working. I have never written on my form collar refused.

I have had Drs without doing any assesment rip off the collar to my horror, then to find out they have a fracture. When this happened a Dr friend of mine was in town and explained that some drs are just like that and if I watch closer I will find other things they do wrong or not up to our standards.

It will only take one error for someones life to change so I dont understand why anyone would even take that risk just because some study says..................

Any who I will still spinal reguardless of what some study says because to tell you the truth I can always justify doing so but trying to justify not doing it is alittle harder.

[JPINFV]

Any who I will still spinal reguardless of what some study says because to tell you the truth I can always justify doing so but trying to justify not doing it is alittle harder.

So, basically, you don't want to practice evidence based medicine because it's 'too hard?'

[mobey]

Personally I really dont care what any study says because in reality it is one persons perception of any issue. They always change,remember when some said milk causes cancer (showing my age on this one), then years later it was proven that it dosn't. For every study that states one thing there is another that states the opposite.

Studies also say not to shake a baby..... At what point do you decide what study is credible and what is not?

When I have decided to do a spinal I will error on the side of caution and I do this because a very dear friend who isn't a medic anymore had a call of a lady who fell on a fish dock. Well this woman showed no signs of a spinal injury and had no pain. She for what ever reason she had a gut feeling and did the full spinal. Good thing the lady had a neck fracture.

I have never had such an experience... however.

There was an MVC lately and the driver refused ambulance. 2 days later he went to the hospital and had a Fx thoracic vertebra. Sooo using your formula, should I recommend ALL MVC victims to see the Doc at thier leisure within 2 days since they will be fine for that period of time?

If you always take a good look at the mechinism of injury, you will have some idea of whether a spinal is needed.

Somewhat agreed. I will let MOI influence my decision, but in the end assessment will dictate. If someone lives in a smoggy city and smokes a pack a day, I do not give them a salbutomol treatment without assessing for the need for one.

Some one said not to spinal because the board is to uncomfortable and the pt will move around anyways, we dont use the board if possible and will utilize the scoop or clam shell and alittle padding goes along way in pt comfort.

Solid advice.

Hint: for long transfers, put the BP buff under the lumbar area and inflate/deflate to pt's comfort.

There are times when I have had men refuse the collar and I wisper in their ear that I dont have to put on the collar if they dont want it but to be aware that if you have a spinal injury and it is agrivated you are taking a chance of your penis not working. I have never written on my form collar refused.

I have been known to remove the collar once they are boarded.

Any who I will still spinal reguardless of what some study says because to tell you the truth I can always justify doing so but trying to justify not doing it is alittle harder.

Don't be afraid of a little hard work to progress the profession

[chbare]

Personally I really dont care what any study says because in reality it is one persons perception of any issue. They always change,remember when some said milk causes cancer (showing my age on this one), then years later it was proven that it dosn't. For every study that states one thing there is another that states the opposite.

When I have decided to do a spinal I will error on the side of caution and I do this because a very dear friend who isn't a medic anymore had a call of a lady who fell on a fish dock. Well this woman showed no signs of a spinal injury and had no pain. She for what ever reason she had a gut feeling and did the full spinal. Good thing the lady had a neck fracture.

If you always take a good look at the mechinism of injury, you will have some idea of whether a spinal is needed. Look at the age of the person a fall standing for an 90 yr old is very different than one from a 16 yr old. Do they have any numbness and tingling, well you can have that without pain and they will get a spinal. Spinals are need for many reasons not just car crashes and falls, dont forget the guy who has had the crap beat out of him, or the gun shot wound.

Some one said not to spinal because the board is to uncomfortable and the pt will move around anyways, we dont use the board if possible and will utilize the scoop or clam shell and alittle padding goes along way in pt comfort. The KED was also mentioned and as I have said before this is my favorite piece of equipment. I have spinaled a 6 week old baby that fell off a change table to a guy who landed on his feet from a roof. This guy crawled to his truck and drove 30 mins to the hospital just to find out he couldn't get out. The unfortunate thing with the KED is that the pt has to be stable and is usless on the calls that need the quick extration.

There are times when I have had men refuse the collar and I wisper in their ear that I dont have to put on the collar if they dont want it but to be aware that if you have a spinal injury and it is agrivated you are taking a chance of your penis not working. I have never written on my form collar refused.

I have had Drs without doing any assesment rip off the collar to my horror, then to find out they have a fracture. When this happened a Dr friend of mine was in town and explained that some drs are just like that and if I watch closer I will find other things they do wrong or not up to our standards.

It will only take one error for someones life to change so I dont understand why anyone would even take that risk just because some study says..................

Any who I will still spinal reguardless of what some study says because to tell you the truth I can always justify doing so but trying to justify not doing it is alittle harder.

What about all the people who develop iatrogenic injuries from being placed and left on a LSB? While I appreciate your anxiety, a practical evidence based approach that emphasizes education and experience of EMS providers regarding practices and techniques is critical.

Unfortunately, doing something the same old way based on anecdotal evidence is just as silly as basing our practice on "feelings." However, you are not totally accurate when you say EBM is based on "feelings." EBM looks at the past and present evidence and makes theories and assumptions based on the said evidence. While far from perfect, it is a better method than simply saying I do not do something based on anecdotal evidence.

In fact, the goal of good EBM is to take the "feelings" out of the practice and use the best and most accurate evidence possible. You are correct that some studies are suspect; however, the goal of good EBM is to look at the evidence and how it was collected. Remember, we need to use good evidence. Unfortunately, many of us are not all that good at recognizing good evidence from suspect evidence, or even identifying limitations of the evidence.

Without EBM, we would still be back in the good old days cramming EOA's and placing MAST pants on every patient.

Take care,

chbare.

[Dustdevil]

What about all the people who develop iatrogenic injuries from being placed and left on a LSB?

While I am completely on board with the concept of SSI, I still have to call BS on this oft given justification. I have yet to see any credible literature that showed a serious risk of iatrogenic injury from short term spinal immobilisation. The best I have seen is unsubstantiated claims of patients with a red spot or soreness. That's hardly "injury". Hell, my feet are red and swollen after a few hours of standing on them, but they haven't ulcerated or fallen off yet.

I just think it cheapens the case of SSI to throw down the iatrogenic injury card when there is no real evidence of it. After all, this is supposed to be EVIDENCE based medicine, not "well, it could theoretically happen" based medicine.

Edited June 3, 2009 by Dustdevil

[chbare]

While I am completely on board with the concept of SSI, I still have to call BS on this oft given justification. I have yet to see any credible literature that showed a serious risk of iatrogenic injury from short term spinal immobilisation. The best I have seen is unsubstantiated claims of patients with a red spot or soreness. That's hardly "injury". Hell, my feet are red and swollen after a few hours of standing on them, but they haven't ulcerated or fallen off yet.

I just think it cheapens the case of SSI to throw down the iatrogenic injury card when there is no real evidence of it. After all, this is supposed to be EVIDENCE based medicine, not "well, it could theoretically happen" based medicine.

However, I did qualify my claim by stating "being placed and left." Unfortunately, many people are placed and left on the board for extended periods of time. While this may be more of a facility problem, EMS should take a proactive role in emphasizing the sequale of leaving patients on a LSB.

This is especially true in my neck of the woods where people are taken to small facilities and left on the board until after they are eventually transferred to a trauma centre. The risk of iatrogenic injury is still a consideration.

Take care,

chbare.

Edited June 3, 2009 by chbare

[Lone Star]

Since "iatrogenic injury" has been thrown into the mix, one must ask, "How long must the patient be left on the LSB before this becomes a serious risk issue?".

It sounds alot like the whole "Don't put high flow oxygen on a COPD patient during a 10 minute transport, because you'll knock out his/her hypoxic drive."

Another point was mentioned as well, and that being 'distracting injuries'. Since the body can only recognize one 'distracting injury' at a time, wouldn't that affect the patients ability to recognize even moderate to severe back pain in the first place?

With all things being equal, we're brought back to a point I made earlier. If the patient doesn't recognize the back pain as 'significant, how can we 'clear the spine' based on the symptoms of the patient?

Since we're not the ones feeling the pain of the injuries, logic would dictate that with the MOI considered, we already know what injuries are possible, and therefore should take the appropriate precautions to prevent further injury to the patient.

We've all heard stories about patients involved in motor vehicle crashes getting out of the vehicle by themselves, walking around as we arrive on scene. The patient looks around and drops over dead because they moved their heads ....not knowing that they've fractured one or more cervical vertebrae.

We know that blunt force will follow a certain pathway, and can affect parts of the skeleton not directly involved in the injury. For example, a patient with a colles fracture can also experience surgical neck fx.

[chbare]

I have seen sources quote 1-3 hours. However, there is more to consider than just skin breakdown. Concepts such as airway clearance issues, discomfort, and compliance issues could be problematic.

In addition, since we are discussing EBM, is there any good peer reviewed evidence that says spinal immobilization with a LSB is even effective?

Take care,

chbare.

[FL_Medic]

Experience is a priceless quality, but not accepting evidence-based medicine because of anecdotal evidence is pure lunacy. I cringe when I hear someone say they don't care what some study says. Fortunately this is a case where they decide to err on the side of caution. That isn't always the case though, and if we refuse to practice EBM our field will refuse to progress. The EMTs and the paramedics are the ones that have to move this field forward, in my opinion, not the docs that aren't on the ambulances. The more we know, the more we prove our competence, the further we will come.

Personally I really dont care what any study says because in reality it is one persons perception of any issue.

'et al' means and others or along with others.

While there is plenty of contradicting evidence, there is plenty of hard evidence out there as well.

ps. nearly every treatment modality you have was once supported by a study. You probably wouldn't be doing much more than first aid if it weren't for these studies. So without the studies you would never have had your own anecdotal evidence. Thank you for your opinion, but I will have to strongly disagree with your main argument.

It sounds alot like the whole "Don't put high flow oxygen on a COPD patient during a 10 minute transport, because you'll knock out his/her hypoxic drive."

Before ventmedic gets in here and does this:

CLICK HERE