A Clear Mandate

      The call on this cold afternoon is for an auto accident in a congested area of the city. The Attack One crew is on scene quickly, and the drivers in the low-speed accident are sitting in their warm vehicles. The driver of the rear vehicle denies injury of any type. There is a young woman in the front vehicle with minor damage to the rear of the car.

   This patient states she is bleeding from her arm and has back pain. She denies neck pain, headache, loss of consciousness and any chest or abdominal pain. Her seat and shoulder belt are in place, as well as a protective pillow she's been sitting on. She says she sliced her arm on a piece of sharp plastic on the storage area between the front seats, and a gaping 6-cm laceration of the right mid-forearm is now just oozing some blood. Neurovascular status in the hand and wrist are completely intact.

   "My young children accidentally broke that storage area jumping between the seats," the woman explains, "and I should have covered it with some tape until I could get it replaced. What am I going to do about my children? I was going to pick them up from school when that lady ran into me. And my back hurts where I had my surgery."

   Crew members elicit the history of a surgery on the woman's sacral area for a cyst she'd had since birth. The surgery was seven days ago, and her surgeon told her it was successful. She had just returned to driving, but had to sit on a pad to avoid discomfort. The pain she's complaining of is the same pain she has any time she sits on the surgical site. She has no other medical problems, and is not taking any blood thinners.

   "Ma'am, that cut on your arm is still oozing blood and is going to need stitches," a crew member tells her. "If your back hurts, we are going to put you on a board and place your neck in a device that will hold it to protect it and your back from any injury. The doctors at the emergency department will check your spine, sew up your arm and make sure your surgical site is OK."

   The young lady immediately resists. "I cannot lie on any kind of board, and really can't lie on my back at all," she says. "I guess I have to get stitches and get my surgical site checked, but you cannot put me on a board. And my neck doesn't hurt at all--why would you put it in something? If I have to get on a board, I will refuse care."

   The Attack One members operate under a spine clearance protocol, and they initiate that process. They perform the necessary history and physical examination to complete the assessment for a possible spine injury, using these decision points:

1. The patient has a history of trauma, but not an obvious high-risk event.
2. The patient is not unconscious and has no altered mental status.
3. The patient has no history of LOC from the trauma event, and no impairment by drugs or alcohol.
4. The patient has no neck/spine pain related to the trauma.
5. The patient has no painful or distracting injuries that would prevent her feeling the pain of a spine injury.
6. The patient has no neck or spine tenderness upon evaluation.
7. There is no spine deformity to palpation.
8. There are no neurologic deficits (weakness, tingling, paralysis).
9. The patient has no pain on movement of the neck or back. As she was talking prior to the crew's arrival, she had been moving her head and neck in all directions, and is actually more comfortable when allowed to move her neck after examination. She then is able to move her neck and back painlessly through a full range of motion.

   Accordingly, the crew transports without spine immobilization and will document the process and findings.

   The crew places the woman in a position of comfort on the stretcher, maintains the bandage on her arm and allows her to use her pillow to make her sacral area more comfortable. She calls the school to arrange for care of her children.

   She is unchanged on the trip to the hospital, and arrives in the ED stable. The crew shares the history and examination with the emergency nurses and physician, and they place her in a care space. The emergency physician repeats the evaluation and confirms no spinal injuries. There is no obvious injury to her surgical site, and her wound is being sutured as Attack One goes back in service.

Case Discussion

   Traditional American EMS practice has been that all patients with a risk of spinal trauma require careful immobilization. Experts traditionally felt this was the most conservative and safest way to treat and transport patients while avoiding spinal cord injury. In practice, it has been troublesome that all patients cannot fit and remain comfortable on rigid spineboards and in cervical immobilization devices. Recent literature has demonstrated that some trauma patients, particularly those suffering penetrating trauma, have worse outcomes when spine immobilization is performed.

   It has now been more than 15 years since Maine published the first guidelines to permit EMTs to provide patient evaluation and treatment without the need for spine immobilization during transport to the hospital, or to clear and release a patient who does not want to be evaluated at a hospital. This process was established to recognize the need to provide appropriate patient care with correct use of immobilization tools and skills in managing injured patients. It is a conservative protocol, consistent with hospital practice and prehospital spine clearance protocols developed and studied in Maine. This method of care is supported by the NAEMSP.

   But 15 years later, many EMS agencies have not implemented spine clearance protocols, and patients have occasionally suffered unfortunate outcomes from immobilization. As demonstrated in this case, some patients are unwilling to go to hospitals because of immobilization mandates, forcing crews to complete difficult interactions for patient refusals of service.

   Implementing an EMS program for spinal clearance requires the writing of protocols that require providers to utilize the scene size-up, patient history and physical assessment to identify patients who need or do not need the process completed. If the patient has no high-risk mechanism of injury, no alteration of mental status and no distracting injuries, is not intoxicated, has no pain or tenderness along the spine and has no neurological deficits, the patient may be treated and transported without immobilization. This, like all protocols, must be approved for local use by medical direction and implemented using excellent training, followed with a quality assurance program. That QA program must utilize a reliable method of feedback for emergency physicians and nurses to provide immediate guidance if the protocol has been applied incorrectly, and for communication about patterns of misuse or bad patient outcomes.

   When immobilization is necessary, it must utilize flexible methods that allow patient comfort. This could entail a variety of boards and padding materials. For example, EMTs will want to use extra padding to prevent injury to the thin skin of older patients, and those with unusual spinal columns or recent surgery to the spinal area.

   For EMS systems that have implemented spinal clearance protocols, there is no doubt that many patients are more comfortable during transport and their initial time in the ED, and fewer patients are put at risk for skin breakdown, aspiration from vomiting, compromised airway or the discomfort of time on a long, rigid board. When the protocol is used correctly, some patients will later complain of pain along the spine, or have different findings on physical examination, or be found to have other factors that place them in a higher risk category. Those few patients may require immobilization after they arrive in the ED, or have x-ray studies done. But studies of the Maine protocol for spine clearance have found no significant unstable injuries or bad outcomes from its use.

Initial Assessment

   A 28-year-old female with a laceration to her forearm following a motor vehicle accident.

   Airway: Intact and uncompromised.

   Breathing: No distress, able to speak in full sentences.

   Circulation: Normal capillary refill, pink skin.

   Disability: No neurologic deficits.

   Exposure of Other Major Problems: A lacerated right forearm with no active bleeding and intact distal neurovascular function. Patient had recent surgery on her lower back and sacral area for a cyst and, due to this, refuses to have spinal immobilization performed.

Vital Signs

AMPLE Assessment

   Allergies: None.

   Medications: Hydrocodone for pain.

   Past Medical History: Surgery seven days ago for a cyst in the sacral area, which patient says went well.

   Last Intake: Lunch about 11:30.

   Event: Motor vehicle accident. Patient requests to go to the hospital, but insists she cannot be immobilized due to recent surgery.

Spine Immobilization/Clearance Process Decision Points

   With any of these factors present, immobilize.

1. A patient history of trauma or an obvious very high-risk event.
2. The patient is unconscious or has an altered mental state.
3. The patient had LOC from a trauma event or impairment by drugs/alcohol.
4. The patient has pain in the neck or spine related to the trauma.
5. The patient has painful or distracting injuries that may not allow him/her to feel the pain of a spinal injury.
6. The patient has neck or spine tenderness when evaluated for it.
7. There is spine deformity to palpation.
8. There are new neurologic deficits (weakness, tingling, paralysis).
9. The patient has pain on movement of the neck or back.

   If none of these factors are present, the patient can be cleared and the crew can transport without immobilization, caring for injuries as appropriate and providing trauma care per protocol. Document patient history, exam and application of treatment.

   Customer Service Opportunity: Patients often have great concerns about complications of recent surgical procedures, and may be adamant in wanting to avoid any process that might risk them. They often want to be evaluated where their surgeries took place and/or by the surgeons who performed them. These requests should be honored when possible, not only for the sake of good patient care and comfort, but also to allow surgeons to feel comfortable about their patients' welfare. In certain insurance circumstances, a patient's follow-up care will only be paid for if it is provided where the original surgery took place.

   Learning Point: Spinal clearance is an EMS process that provides excellent patient care and satisfaction. All EMS agencies should consider applying this process, using medical director input, provider education and EMS quality assurance to ensure an excellent implementation.

James J. Augustine, MD, FACEP, is an emergency physician. He is a medical advisor for Washington Township Fire Department in the Dayton, OH, area and director of clinical operations at EMP Management in Canton, OH. Contact him at Jaugustine@emp.com.