Protocols in the field
Posted by Julie Brady on September 27th, 2006. Published in EMS. 6 Comments »
I often think back to a motor vehicle crash that I responded to about 15 years ago. It was a low impact crash with minimal vehicle damage. I was directed to one of the drivers who was standing on the sidewalk. She really wasn’t injured but wanted to be checked at the hospital.
I was dutifully following protocols and attempting to provide standard spinal stabilization. The patient had severe kyphosis and was adamant that she did not want to be placed on the long board. She insisted that her doctor had told her not to ever be placed on a board and that we would do more damage by stabilizing her on a long board. After much talking and padding, we were able to provide spinal stabilization on the long board to this patient. My duty was done but she was not happy.
As time passed I often would think about why I insisted on spinal stabilization for that patient. I truly didn’t think she needed it. The easy answers are that was what the DOT curriculum taught and that was our department protocol. Therefore, it was the right thing to do. It was what was expected – by my department, my co-workers, my medical director, the ED staff and the State. It was our standard of care.
But was it the right thing? Does every patient involved in a motor vehicle crash need spinal stabilization? It is well documented that spinal stabilization has multiple adverse effects which include: restricted ventilation, increased skin pressure and pain. Adding the patient’s kyphosis into the mix, I’m sure it was even worse for her. So what could be done? Working with our medical director, our department changed our protocols to allow for selective spinal stabilization. It is not always easy to change how it “has always been done” (at least for the 20 years I’ve been in EMS). There has to be some foundations for change. Selective spinal stabilization has been controversial for at least 10 years. There have been studies showing that with training, assessment and following well-defined protocols, selective stabilization can be performed with accuracy in the prehospital setting. In the State of Maine, EMS has been doing selective stabilization for many years. Despite the studies that have been done and the success of selective stabilization in multiple states, the standard of immobilizing every patient after a motor vehicle crash persists. Why?First of all we do not clear C-spine in the field. We evaluate the patient and determine if they are truly at risk for spinal injury (cervical, thoracic or lumbar) and really need spinal stabilization. With selective stabilization protocols then number of patients requiring spinal stabilization is cut by about 40%.Initially, only paramedics were allowed to perform selective spinal stabilization. In time the ED staff became receptive to selective stabilization. Yes, the same staff who would take off our stabilization devices as soon as a patient was turned over, did not like that we no longer brought every patient in on a long board.
Then after a couple years protocols were expanded to allow Basic EMTs to perform selective stabilization. Another uproar! How could a Basic be allowed to do that? With the same well-written protocol and good assessment skills, a Basic should also be able to determine the appropriateness of stabilization in a given situation. After all they are following protocols to perform spinal stabilization.
All the protocols that I have seen follow the ED algorithm for choosing the need for spinal stabilization. First, the mechanism of injury must be considered. This is the vaguest part of protocols. What makes it significant MOI? Does that vary by age and general health of the patient? The patient must be alert and oriented without intoxication or distracting injuries. Then the patient exam needs to be done. Does the patient have any complaints of neck or back pain? Are there any deformities found on palpation. Is there any numbness, tingling or funny feeling in their extremities? Aren’t Basic EMTs able to ask these questions and perform these evaluations?
However, the controversy still rages. Should the standard of care be changed to allow for selective stabilization in the field? Who should be allowed to perform the skill? Do we need more research to change the standard of care?
Julie Brady, RN, NREMT-P, is an EMS instructor/coordinator at Waukesha County Technical College (WCTC) which is located in southeastern Wisconsin