Immobilization Errors in EMS

You and your partner have extricated to a long spineboard an obese 65-year-old unbelted driver of an old pickup that left a rural roadway, rolled down an embankment and landed on its top. The driver was partially ejected, and his legs were sticking out of the upside-down driver’s window. He was conscious, but confused and complaining of severe pain in the lumbar spine area.

You perform your initial survey, which reveals good pulses, movement and sensation in all extremities, place a cervical collar on him, secure him to the board with the three straps provided—one across the upper chest, one across the hips and one across the lower legs—and move him to a stretcher and then the ambulance.

During your trip to the trauma center, he complains loudly about pain in his back and says it’s so bad that it’s making him sick to his stomach. Without warning, he begins to vomit. Not having your suction set up, you quickly turn him and the board on its side and wipe vomit from his mouth. As you turn him, his trunk sags downward between the straps, and he screams. After that, he complains of numbness in his legs. You ask him to wiggle his toes, and he says that he is doing so, but there is no movement.

After dropping him off at the ED, you receive a call from your supervisor telling you to write a supplemental report; she has just been informed by the ED physician that your patient is paralyzed from L2 down. You are devastated.1

What went wrong? Your patient was in a collar and secured to the long spineboard. Why did he suffer an injury when you turned him on his side?

Every day in America, thousands of patients are transported in ambulances on long spineboards with cervical collars in place. They are usually described by medics as having been “spinally immobilized.” But are they truly immobilized? Does it even matter? When one group of researchers compared Malaysian patients who received no spinal immobilization efforts with a like group from New Mexico who were “immobilized,” they found there was less than 2% chance that immobilization had any beneficial effect.2

Still, in the U.S., most, if not all, EMS systems require that patients be placed in collars and on a spineboard in a variety of situations. Some use a selective spinal precautions algorithm, as is discussed elsewhere in this issue. Debate has risen in recent years on the subject, immobilize vs. do not immobilize, and many articles have been written.3

There is even controversy over what to call what we do. Many have discarded the term immobilization because it can readily be shown that complete immobilization rarely occurs; some use the term restrictions and some precautions. Semantics aside, what we’re talking about is the effort to minimize movement of a patient’s spine during transport.

Whether immobilization, or whatever we choose to call it, affords any benefit, if we are going to attempt it, we ought to do it as well as we can.

Following are some pitfalls that may occur with the procedure and practical ideas for improvement. None of these suggestions are in any way supported by research. Try them, subject them to the most stringent trials possible in the practice setting, and evaluate for yourselves whether or not they have merit. They are just ideas that I have picked up during two decades as a medic.

Most of them are obvious and simple, but often forgotten. Or, they aren’t done because providers think they take too long. We also tend to see through rose-colored glasses and assume that nothing bad will happen because of what we do.

Positioning Your Patient

We often log-roll a patient onto a board, only to find half of him hanging off the side. I have seen various parts of a patient’s body and clothing grabbed in an attempt to get him all the way onto the board. This usually results in patient movement that defeats the whole purpose of the immobilization maneuver.

A simple procedure for avoiding this is outlined in the PHTLS Manual. Position the board beside the patient with the foot end somewhere between the patient’s knees and hips. When your patient is rolled onto the board, but doesn’t quite make it to the center, you only need to move him upward in a straight line to place him correctly on the board. This minimizes lateral movement.

Minimize Lateral Movement

Use a minimum of four straps (ideally more, or a vacuum device4), filling in the spaces between the patient and hand-holds where the straps are anchored with blankets.

No matter how many straps you use, unless the patient’s body rests against the straps on each side, there will be lateral movement if the board is tilted. Roll some blankets and pad either side so there’s no room for movement—simple and easy.

There are commercially available devices that use multiple straps, usually four or five with a shoulder harness, which provide support at multiple points along the body, plus over the shoulders. With four straps, you can use one set at the ankles, another just above the knees, one at the hips and one on the upper chest, running across the axillae just under the clavicles.

Avoid crisscrossing straps from the upper chest to pelvic area. This “x” configuration does not secure the patient properly and is not recommended.

Getting the straps in the right place depends on the patient’s height. Fill in with duct tape, unless the patient is stripped bare. In that case, consider using the thickest type of plastic wrap, which does nicely when wrapped completely around the board and patient. You can see through it, it’s not a barrier to x-ray or other radiological studies, and it’s easy to cut off.

I don’t recommend using rolled bandages or cravats, because cloth stretches, and your restraints will become loose. Again, padding must take up all space between the patient and the edges of straps or the board.

An ankle hitch is useful to keep the patient from moving up the board if you have to tilt it head-down for any reason. A micro-fiber stretcher sheet folded lengthwise, about 2.5" wide, works well. Lay the middle of it over the patient’s ankles, then tuck each end under one ankle and back toward the middle, making a loop. Then, bring the ends together between the ankles and down, with one “tail” going through each of the end hand-holds and tied together in the center. You can do this in 30 seconds if you’ve practiced it once or twice, and one person can do it while the other straps are being secured.

The key to great immobilization is practice and rehearsal. The acid test during practice is to tilt your patient 90º to the side and see if he moves. A great way to measure movement is with a laser level device used to draw straight lines on walls. Project the line on the supine “patient’s” midline (watch to avoid their eyes) and trace it with chalk. Then, after tilting to the side, project the laser line again to see if there’s any deviation. The larger your patient, the more straps and supports will be required.

Minimizing Pressure Pain

Spineboards come in one general size and shape; patients come in all sizes and shapes. Prolonged restraint on a hard board can become excruciatingly painful, notwithstanding any other painful injuries the patient may have. Consider judicious use of analgesia, but also remember that analgesia will do nothing to minimize the development of tissue necrosis from pressure.

New to the market are some promising devices that supply a degree of padding: inflatable mattresses and detachable padding; however, many services cannot afford these items. And, those you buy have a tendency to disappear from the ED when you leave them with your patients. I suggest you have GPS chips embedded in your equipment for easy track-down. If it works for your dog and your Cadillac, it ought to work for your full-body vacuum splint.

You can also consider placing a folded blanket on the spine board before placing the patient on it. Tape it with three or four pieces of 2"–3" tape and you’ll have a little bit of padding that will add to your patient’s comfort. Ensure the blanket is wrinkle-free, as wrinkles promote increased pressure and tissue ulceration. It only takes 30 minutes on a spineboard to begin promotion of tissue breakdown.

Don’t forget to place extra padding in the spaces between the patient’s back and the board. Older patients, who often have kyphosis, will absolutely require it.

Back to the Scenario

As you might imagine, a lawsuit was filed against the EMS agency, its medical director and the two medics.

In documentation written by the medics and their deposition testimony under oath, they both admitted that the spineboards on their rigs were supplied with three straps, that they had more straps available but did not use them, and they had never practiced spinal immobilization in the CE setting to see whether or not their patients could be adequately secured with three straps. The plaintiff’s paramedic expert testified that, in her opinion, the service and its medics were guilty of gross negligence in patient care, which was the proximate cause of the patient’s paraplegia. She also testified that their failure to have suction immediately available was a contributing cause to exacerbation of the patient’s injury.

The plaintiff’s physician expert testified that had the patient been properly immobilized, he could have been turned on his side without increasing his spinal injury.

The defense presented testimony from an ED physician, an orthopedic specialist and a neurologist saying the patient’s injuries were the result of the accident, not the actions of the medics, and that he was adequately immobilized. They also presented testimony from a nationally known EMS physician, who used charts and graphs to explain several research studies that showed further injuries from failure to properly immobilize were statistically unlikely.

In rebuttal, the plaintiff’s attorneys presented a medical incident reconstruction expert, who used a computer-based reenactment of the patient’s movement on the spineboard to show there was significant lateral movement of the lumbar spine when the patient was tilted. Both an orthopedic specialist and a neurologist testified that the reenactment accurately depicted the forces and movement experienced by the patient and swore that the patient’s injuries were caused by the failure to adequately immobilize him.

The jury returned a verdict of $3.8 million against the service and the medics, which was appealed. On appeal, the court found there was sufficient evidence for the jury to find either that the injuries were not caused by the failure to properly immobilize, or, in the alternative, that they were and the factual findings of the jury should not be overturned. However, the appeals court remanded the case to the trial court to reassess the damage award, declaring it excessive.

Before the case went before the trial court again, the insurance company settled with the plaintiff for $1.5 million. State EMS board action against the two medics resulted in reprimands and six-month suspensions. The company was assessed a $1,000 fine for failure to provide adequate equipment, but the company contested the action and won, since it was able to prove there were no statewide requirements for the number of straps that must be on a spineboard.

References

1. This scenario is entirely fictional and may or may not be medically accurate. For example, some papers have discounted the possibility of injury exacerbation from handling by prehospital personnel. Although early emergency medical literature identified mishandling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and are probably anecdotal rather than scientific. Mechanistically, it seems unlikely that, after a significant trauma, the proportionately small additional energy imparted to the spine by EMS would cause a patient with a spine fracture to develop a cord injury not caused by the initial trauma.
2. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: Its effect on neurologic injury. Acad Emerg Med 5(3):203–214, Mar 1998.
3. Chapleau W. To board or not to board. Emerg Med Serv 31(5):64–65, 2002.
4. Johnson DR, Hauswald M, Stockhoff C. Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. J Emerg Med 14(4):369–372, Jul 1996.

Additional Reading

• Domeier RM. Indications for Prehospital Spinal Immobilization. Position Paper, National Association of EMS Physicians. Prehosp Emerg Care 3(3): 251–253, Sep 1999.

The author’s suggestions are his own and are not research-based. Neither the author nor EMS Magazine assume any responsibility or liability for any injury or damage arising from the use of any of the suggestions presented herein.