Protocols in the field
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
October 5th, 2006 at 12:33 pm
I also struggle with this same issue. Full spinal immobilization due to the mechanism of injury needs a closer look. I am an EMS Lieutenant with 20 years in the service and have boarded many patients I felt didn’t need it, many of them against the patients better judgment by using our skills of persuasion.
Are we doing “no further harm”, I’m not sure. I think the full spinal precautions are a throwback from a time that EMS responders didn’t have the evaluation skills they have today, we don’t place a line in every patient just because we are transporting.
EMS responders I feel are quite capable of clearing C-Spine in the field, we are trained to paralyze patients and intubate why not clear C-Spine?
What about the transport of “victims” involved in MVA’s that refuse treatment but have no transportation. We work in a rural environment and often find ourselves responding to a scene with one patient and two people who were in the vehicle that refused treatment but have no transportation from the scene. We end up arriving at the hospital with one patient back boarded and two people out of the same incident, same mechanism of injury with not treatment or at best only a color. Patient refusals being what they are we are uncomfortable with this practice but certainly can’t leave them beside the road to freeze!
Jerry L. Kiffer
EMT III
Ketchikan, Alaska
October 10th, 2006 at 1:43 am
I have been working with the c-spine protocol for about 5 years. It is a good tool, however it does not make up for a qualified assessment. Our protocol states that if anyone on the team has a concern as to whether the patient needs to be immobilized, it happens. There are other criteria to go with this. An important one is the “unreliable pt exam”; if you can’t get a good account of the event that occurred, the pt gets the board. I’m curious what other criteria is out there. I work in a very busy metropalitan area, and also in a rural enviroment 50 miles away from the other.
Tim Vasquez EMT-P
Johnson City Texas
October 18th, 2006 at 3:47 pm
Our ems protocol changed to selective c-spine immobolization and have had great turnouts ad results,I beleive this procedure this procedure has had a big impact on our scene time plus patient comfort as long as thy meet the five requirement. bruce suttton emt-p paxton twp. ems. ross co. ohio
December 3rd, 2006 at 3:35 pm
Its good to see the discussion of selective spine stabilization becoming more common in the EMS world. This has long been an issue in wilderness and technical rescue where spine stabilization can often increase the risk of further injury to both the patient and rescuers. Even in an ambulance, it inhibits the management of critical system injury and renders the patient completely helpless. Pre-hospital personnel can and should be allowed to exercie judgment in the application of stabilization. It is not a risk-free procedure. Jeff Isaac, NREMT, PA-C.
April 9th, 2007 at 9:52 am
As professional rescuers, lifeguards make spine stabilization decisions with many rescues, both on land and in the water. In the debate over protocol, questioning the ability of “basic” rescuers to appropriately make that decision consider that lifeguards as young as 15 or 16 years old, like all professional rescuers, must rely on the consistant and appropriate training provided to them to make decisions that can and do effect victims lives. I am a first aid/CPR/AED and lifeguarding instructor. Spinal injury scenarios are often the make or break factor in whether I certify a student or require additional training before I sign my name to someone’s certificate. It is the clear definition of signs and symptoms and the application of protocol and a consistant standard of care that makes this type of first aid valuable to the well-being of the general public should they require our care.
June 12th, 2007 at 12:34 pm
For the past approx. 5 years, Maine has had a spinal assessment protocol which allows EMS providers to complete a detailed physical and neuro assessment to identify those patients who may be transported safely without immobilization. Although mechanism of injury is a factor, it is no longer the ONLY factor when deciding whether to immobilize or not. The Maine Spinal Assessment Protocol requries that the patient be reliable ( i.e. no altered mental status, intoxication or acute stress reaction); no distracting injuries; no spine pain or tenderness and no abnormalities in the sensory/motor part of the exam. It is a wonderful tool to use, but it is just that: a tool. The intent of the protocol, which was written by Peter Goth, MD, was that every EMS provider would perform the sensory/motor exam the same way. Like in any other profession, some of us are very true to this process, other are lazy and do not do a thorough exam. The other point I’d like to make is that even when properly performed, some patients slip through the cracks. Recently, I had an MVC patient whose small car collided with a dump truck. There was significant intrusion into the smaller vehicle. The unbelted driver self extricated and pased the spinal assesment with flying colors. Because I am old, and also old school, I elected to immobilize him anyway, due to the mechanism that we’ve becomed accustomed to downplaying. The short version is that this patient ended up with a C5 fracture, but did not complain of neck pain until after an hour in the ER. So yes, the ability to make a field decision about boarding vs. not boarding is an great tool; but I firmly believe that mechanisn still needs to play a role…it is defining that role of mechanism that continues to elude us.
My second comment is related to effective immobilization of patients with kyphosis. We have had success using the vacuum mattresses. They do not alow the patient to move, but do so without the need to force these patient flat onto a backboard. Supine, neutral position is “abnormal” for patients with kyphosis. The other advantage of the vacuum matress is that it reduces the risk of tissue ischemia that accompanies being on a back board for any significant length of time.