Board to Death

“Better safe than sorry” is what we’ve all been taught about c-spine injuries. After all, few things scare healthcare providers more than the possibility of failing to properly identify and treat a condition that leads to the permanent disability or death of a patient. While relatively rare in terms of acute medical conditions, cervical spine injury does cause an estimated 6,000 deaths and 5,000 new cases of quadriplegia each year in the United States.¹

As a result, more than 1 million patients injured by blunt trauma along with an unknown number of victims of penetrating trauma will receive spinal immobilization this year. Virtually all of these patients will be subjected to a rigid spine board and cervical collar, most of them by EMS, many despite having no complaints of neck or back pain. ^2,3

Would prehospital care providers perform a clinical therapy thousands of time a day for more than 40 years without a validated, scientific reason?⁴ Would a clinical practice persist this long simply out of fear or habit?⁵ What scientific evidence is there to support any of the current practices associated with spinal immobilization by EMS? The answer—frighteningly little.^{6 7}

Some supporters of existing practices say, “Better to board too many, than miss one potential spine injury.” But is putting an injured patient on a rigid spine board with straps and cervical collar according to current methods going to make them better or even prevent further injury?

Costs & Risks

What are the consequences of immobilizing a victim of trauma using rigid spine boards and standard cervical collars? In addition to the tremendous costs of equipment, supplies and unnecessary ED evaluations, unnecessary immobilization may interfere with patient assessment and complicate and delay care.^8-12 Being immobilized with a cervical collar on a rigid spine board, especially for an extended period of time, can cause respiratory compromise,¹³ anxiety, back pain,^12,14-18 pressure sores,^15,19 respiratory compromise,^13,20,21 airway difficulties,^5,22 and neurological deterioration as a result of immobilization.²³ Cervical collars can cause separation of the cervical vertibrae²⁴ and increased intracranial pressure.^25-31 In addition, evaluation for removal of these devices will often require radiological studies (X-Ray, CT, MRI) resulting in unnecessary exposure to radiation.³²

Is the suggestion being made that spinal immobilization should no longer be performed by prehospital personnel? Not exactly. However, the time has come to take a look at the best ways to identify the selected trauma patients who will benefit from spinal stabilization as well as the best tools and techniques to treat them.

Penetrating Trauma

In September 2011 the paramedics, trauma surgeons and emergency physicians of the Executive Committee of Prehospital Trauma Life Support (PHTLS) produced the following recommendations, which will be included in all future PHTLS programs⁹:

• There are no data to support routine spinal immobilization in patients with penetrating trauma to the neck or torso.
• There are no data to support the routine spinal immobilization in patients with isolated penetrating trauma to the cranium.
• Spinal immobilization should never be done at the expense of physical examination or correction of life-threatening conditions in patients with penetrating trauma.
• Spinal immobilization may be performed when a focal neurological deficit is noted although there is little evidence of benefit even in these cases.

Despite what may seem to be a vast departure from current dogma, many see this stance as quite conservative in light of significant evidence that immobilizing victims of penetrating trauma may do more harm than good.^33-36

Blunt Trauma

So if immobilization doesn’t help victims of penetrating trauma, does it help victims of blunt trauma? In 1998 a landmark study began to change the way we thought about the need for routine c-spine immobilization. Lead by Dr. Mark Hauswald of the University of New Mexico, this study looked at blunt trauma patients with spinal cord injuries from two comparable hospitals—one in New Mexico where all patients received spinal immobilization and one in Malaysia where patients received no spinal immobilization. Surprising to many, there was no difference in outcomes between the patients who were all boarded and collared and the ones who were not, even after correction for mechanism of injury.³⁷ While there were certainly limitations with this study, it raised many questions about the mindset that “all blunt trauma patients absolutely have to get a board and collar.” This “sacred cow” of EMS would have to be re-thought.³⁸

So for nearly 15 years, Dr. Hauswald kept re-thinking it, eventually publishing what he calls “A Re-conceptualization of Acute Spinal Care.” In this “Re-conceptualization,” Dr. Hauswald describes his belief that the underlying theory that “spinal immobilization,” or working to restrict visible movement of the spine, is not helpful for victims of spinal injury, and likely does them harm.³⁹

Keep in mind that the goal of spinal stabilization is to identify and manage not “all potential cervical spine injury,” but rather injured areas of the spine that are unstable with the potential for further neurological injury. If we think of the normally functioning, uninjured spine as a set of interlocking and fortifying structures (vertibrae, disks, ligaments and muscles) that all work together to absorb the impact of walking, running, lifting and carrying, we can see that a great deal of force would be required to cause permanent damage to what is essentially the world’s best shock absorber. Somewhere in the area of 650–7,500 Newtons of force, in fact, which is why so few permanent spinal injuries occur in victims of blunt trauma.^40,41 The rate of cervical spine fractures of victims of severe traumatic injury admitted to hospitals is quite low (2%–5%) and the rate of unstable cervical fractures is even lower (1%–2%).⁴²

Thus, blunt trauma patients fall into one of three categories.

1. Patients who are in some way hurt, but have stable c-spines and virtually no potential for spinal injury.
2. Patients who have spinal injury, but whose spines are mechanically stable, at least for the amount of time during which they will be in the field.
3. Patients who have unstable spine injuries which typically occur during the accident itself, and not during patient assessment and treatment.

Another way to say this is that because the spine is very strong where it needs to be strong, and very flexible where it needs to be flexible that the vast majority of our patients spines will be:

1. Uninjured.
2. Injured, but at initially stable.
3. Injured and mechanically unstable but with further Injury unlikely to occur after the initial catastrophic impact.

Remember that the criteria for spinal immobilization is not “Do they have a potential C-spine injury?” but rather it is “Do they have an unstable C-spine injury that will get even worse if it doesn’t receive EMS C-spine stabilization.” Guidance for treatment of these patients should consider the following:

• The patients in category 1 have no injury and will receive no benefit from spinal stabilization, should therefore not have to take the risk or pay the cost of being immobilized.
• The patients in category 2 should be considered for spinal stabilization, but are unlikely to have their injury worsen with normal patient care and handling because they are generally stable.
• The patients in category 3 should be considered for spinal stabilization, but are unlikely to receive worsen with normal patient care and handling because the catastrophic damage has already occurred.

While it may seem a “no-brainer” that spinal stabilization should be a priority for patients categories 2 and 3, we must keep in mind that further physical damage is not the only way that the spine can be further injured. Spinal stabilization may be considered for these patients, but it may not be more important than airway management, bleeding control or other critical care priorities. Spinal cord injury from local hypoxia (from blood vessel damage, contusion or edema around the injury site) or from global hypoxia (because the patient, as a whole, is becoming hypoxic) is a significant risk. Thus, we have to keep in mind that we may be doing the patient more harm than good by limiting or delaying our ability to assess and treat the patient as a whole due to an unwarranted focus on immobilizing a patient to a rigid spine board.³⁹

Our goal should be to avoid unnecessary treatment of patients in category 1 and minimize additional energy absorbed by the injured areas of the spine for patients in categories 2 and 3.

Spinal Injury Assessment

When the American Academy of Orthopedic Surgeons (AAOS) published the first textbook for EMS in 1971, the recommendation was for prehospital personnel to primarily use symptoms and physical findings to identify potential spinal injury in need of immobilization.⁴³ Over the past 40 years this EMS text (now in its 10th edition) and other books like it have greatly expanded their recommendations for “immobilization,” initially by adding “Mechanism Of Injury” to the criteria and then promoting MOI to the primary assessment tool for spinal injury.

And yet during the same time period, in-hospital treatment moved in a significantly different direction.^44-46 Numerous studies have established the ability of emergency department physicians to successfully use clinical criteria, rather than mechanism of injury, to determine the potential for significant spinal injury.¹⁰ This is why fans of auto racing may sometimes see a crash in which a driver with what EMS would consider significant mechanism of injury get up and walk away. Consider that for any major auto race there is a medical command physician on-scene to evaluate and care for drivers. Drivers may sometimes be allowed to walk away from the wreck and wave to the crowd both because:

1. There are many safety features in place in their cars.
2. Highly experienced trauma physicians evaluate based on clinical presentation, not mechanism.

Thankfully many of the same safety innovations that protect racecar drivers can be found on virtually all late model automobiles on the road today, a fact that must further alter our perception of mechanism of injury. This is even reflected in the reference document for many of the trauma alert criteria for EMS systems across the United States: The CDC Guidelines for Field Triage of Injured Patients 2011.⁴⁷

In the late 90s, in pursuit of efficient and effective care for victims of suspected spinal injury, the National Emergency X-ray Utilization Study (NEXUS) found five simple clinical criteria could help physicians screen blunt trauma patients to identify those who did not need radiographic studies or further cervical spine stabilization.^48,49

These criteria are summarized in the simple mnemonic, NSAID:

• Neuro Deficit
• Spinal Tenderness
• Altered Mental Status
• Intoxication
• Distracting Injury

The validated NEXUS criteria was followed by another somewhat more complicated, but slightly more accurate validated spinal injury clearance criteria called the Canadian C-Spine Rule.^2,44,50

Might it be possible for EMTs and paramedics to use these same clinical criteria in the field to identify blunt trauma patients who don’t need c-spine stabilization? With a very high (Class II) level of medical evidence numerous studies say “Yes!”^51-54

In fact, these ideas aren’t just in the lab. Every day they’re put into practice in the field. EMS practitioners of combat, tactical, wilderness and austere emergency medicine have long practiced “selective c-spine” stabilization. In the early 1990s, selective c-spine immobilization went “main-stream.” In 1994 Dr. Peter Goth published spine injury assessment guidelines for EMS providers in Maine, and in Fresno, CA, in 1991 EMS Policy Number 530 called for spinal immobilization using the same five criteria as NSAID, plus two more—multisystem trauma and severe head/face trauma. Variations of such protocols are still widely used across the U.S. today by systems like Augusta, ME, Ann Arbor, MI, Alameda, CA, among others.^51,55

Providing Spinal Stabilization

With validated selective c-spine criteria to identify the patients in category 1 above (trauma patients without c-spine instability) from the patients in categories 2 and 3 (trauma patients spinal injury) we must now look at how best to provide c-spine stabilization for patients in need of it.

While a wide range of options are currently available for EMS providers in the United States to use to move and stabilize trauma patients, the commonly used for spinal immobilization, the long spine board, is probably also the worst. Even when all proper procedures are followed and all patient voids have been padded, long spine boards have been shown to cause pressure sores, pain and allow patient movement, all while doing a poor job at actually keeping the patient in the anatomical position.^17,18,39

Improved options include padded mattress devices, flexible stretchers, “scoop” and “break-away” stretchers, vacuum mattresses, and other similar devices. These devices are not only more comfortable and ergonomic than the standard long spine board, they have been in use as primary spinal stabilization devices in EMS systems across Europe for many years.^15,56,57

The other major component of traditional immobilization is the cervical collars that may cause discomfort, anxiety, increased intracranial pressure, and separation of cervical vertibrae.^{24,25,27-29,58} While few innovative options exist for prehospital care providers at this time, new devices like the X-Collar claim to provide superior cervical stabilization without the negative consequences of traditional cervical collar design.⁵⁹ While these devices do not provide the definitive solution, they demonstrate the innovative thinking that will be required for EMS to improve outcomes for patients with unstable cervical injury.

Of course, even prehospital care providers with the best available equipment must still somehow move the patient onto/into that equipment. Here again new studies show the problems with traditional methods. Dr. Hauswald suggests that providers keep in mind that the goal for care of the unstable cervical injury is not necessarily to avoid visible motion of the injured area of the spine, but rather to avoid the application of force to that area.³⁹ This idea is easy to understand when we consider that an EMS provider who is restraining a hostile or seizing patient to provide spinal immobilization “for their own good” may be minimizing motion, but the force applied to the spine can cause damage, even in the absence of visible movement. Thus, forcible application of spinal immobilization is perhaps the best example of dogmatic application of treatment “rules” that cause increased harm, rather than benefit to the patient.

While motion of the spine is not necessarily the cause of increased spinal injury, we find that the “Log Roll” technique, the most commonly taught method in spinal immobilization, causes significant unwanted motion in all directions during transfer to and from a spine board.⁶⁰ With this in mind, “split” and “scoop” style stretchers designed to avoid the “Log Roll” and similar techniques begin to gain appeal.

Even so, in many cases the best approach may be one of “hands-off.” Several recent studies suggest that for patients capable of doing so, self-extrication to spinal stabilization devices with some form of cervical collar in-place may cause the least amount of movement/force to injured areas of the spine.^61-63 While this may at first seem counterintuitive, on further inspection we will find that it is only counter to common practice. Any emergency care provider considering this must ask him or herself, “How many times have I seen a patient moved to accommodate applying a device, rather than a device used to stabilize a patient with no movement or application of force to the patient’s spine?”

Advanced Level Therapies

Many advanced level therapies are being evaluated for their ability to improve patient outcome from spinal cord injury. These include prehospital administration of neuroprotectives, steroids (methylprednisolone) and therapeutic hypothermia, but none have yet been clinically proved to improve patient outcome.⁶⁴

Scope of Practice, Common Practice and Standard of Care

While many EMS providers may wish to provide care as described by the recommendations above, they might be hesitant, believing that doing so will place them outside their scope of practice and/or the standard of care. While both scope of practice and standard of care for healthcare providers differ from state to state, it is helpful to consider the meaning of both of these terms.

Scope of practice is typically defined as the actions and procedures that a licensed or certified healthcare provider is allowed by the agency issuing their license or certification. For EMS providers, practices are often spelled out by state agencies making them clearly defined, but often difficult to update to keep pace with current medical science. As a result, such scope of practice documents are often written in such a way as to leave them open to the continual advancement of healthcare knowledge and practices.

Looking to the National EMS Scope of Practice Model upon which many states base their own scopes of practice, the only mention of cervical immobilization is that all levels of EMS providers will have “manual stabilization of suspected cervical spine injuries” as a minimum skill.⁶⁵

The most common misconception of standard of care is that it is the same thing as common practice. That is, “If everyone else uses a standard board and collar to immobilize patients, it must be the standard of care and any deviation from that standard will risk punishment.” In actuality, standard of care is based on practice guidelines, current research and expert testimony. While common practice may be taken into consideration, courts typically do not base standard of care decisions on it. Speaking on the subject in 1903, U.S. Supreme Court Justice Oliver Wendell Holmes stated, “What usually is done may be evidence of what ought to be done, but what ought to be done is fixed by a standard of reasonable prudence, whether it usually is complied with or not.” That is to say, it may be common or customary for EMS providers to use a long spine board or collar, decisions of standard of care and negligence are based on what is the best, reasonable care, not on what is usually done.⁶⁶

Thus while many EMS providers may believe that their scope of practice and standard of care mandates a specific cervical immobilization device or practice, they may find that this is not the case.

Education

While we are in great need of more quality research and prehospital treatment options for c-spine injuries, many providers may find themselves asking, “How can we make my system better now?” While many prominent emergency healthcare organizations have called for various steps in the overhaul of current practice in c-spine stabilization (including the PHTLS Executive Committee, the National Association of EMS Physicians, the American College of Surgeons Committee on Trauma and the U.S. Metropolitan Municipalities EMS Medical Directors Consortium—The “Eagles” Coalition) the answer lies chiefly education. Education on the state of science and current best practices must include all key players in emergency systems of care.

The key players must include:

• Medical directors;
• ED staff;
• First responders;
• EMTs; and
• Paramedics.

The education must include:

• The history and background of spinal immobilization.
• Current science & best practices.
• Availability of new equipment.
• Simple and effective field protocols.
• A quality improvement feedback loop.

Supporting documentation may include:

• This article.
• The NAEMSP Position Paper on Indications for Prehospital Spinal Immobilization.
• Avoiding Common Prehospital Errors by Lawner, Slovis, Fowler, Pepe and Mattu.
• A Reconceptualization Of Acute Spinal Care by Mark Hauswald.
• PHTLS Provider Textbook 8^th edition (not yet available).

Final Recommendations

The consequences of traumatic spinal injury can be both catastrophic and wide-ranging. However, the old adage, “Better to board them all, than miss one,” is both outdated and incorrect as it presumes no consequences and risks in providing spinal immobilization as treatment.

To make an informed risk/benefit assessment, we must understand that the risks of spinal immobilization include pain, respiratory compromise, spinal movement, unnecessary radiation exposure, and interference with life-saving patient assessment and treatment priorities.

In looking at the patients who may benefit, we find that virtually all victims of penetrating trauma do not, nor do victims of blunt trauma who do not have an unstable spinal injury.

Thus the rational goal must be to identify the few patients who may benefit and exclude patients who have nothing to gain from spinal stabilization. To accomplish this EMS providers can rely on simple, validated and accurate field-tested clinical criteria that have already been in use in the United States for more than 20 years.

Once identified, we must find the best currently available options for spinal stabilization. These include the use of vacuum mattresses, padded devices and scoop/split style stretchers as opposed to the venerable and anatomically incorrect long spine board. While no perfect cervical stabilization device yet exists, current generations of cervical collar provide the best available option to support and stabilize unstable cervical injuries. Finally, while we know that the techniques used to move injured patients to these devices leave much to be desired, we may still follow best practices by moving the patient in a unified and coordinated manner, not forcibly restraining patients with potential unstable spinal injuries, and allowing selected patients to self-extricate rather than to be manipulated by EMS providers.

While we may still have a long way to go in our search for the best possible prehospital care for patients with unstable spinal injuries, there are many tools available to EMS providers right now that we can make use of to reduce both the risks and costs of providing trauma care while improving patient outcomes.

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