Passing the Boards

It’s late afternoon on a quiet day when the dispatcher requests that Attack One respond to an automobile accident. Light traffic allows a rapid journey to a residential area. The Attack One driver parks in a protective position, and the crew finds two patients sitting on a curb. The young woman was driving a vehicle that collided with a parked truck, sustaining moderate damage to the front. A young child is in the arms of some bystanders.

The crew begins to assess the victims, with the woman complaining of chest and neck pain. The young one is her 2-year-old, who was restrained in a child seat in the back of the car. The impact of the collision deployed the air bags and jammed the sedan’s front passenger door into the back one. The detonation of the air bags filled the car with powder and smoke, and the mother and bystanders feared there was a fire. A bystander tried to open the rear passenger door, but it wouldn’t move, so he smashed out the side window and pulled the child out of his car seat. In the course of this, the child got some broken glass on him and suffered a laceration to his arm. There is no fire, and the vehicles are both stable.

The young woman stands up when the Attack One crew members approach and insists on standing as they evaluate her child. The child is a smiling and happy 2-year-old boy. He had been restrained in a properly fitted car seat at the time of impact, and his injury appears to be limited to a single superficial 3-cm laceration of the right upper arm. It is not actively bleeding, and distal pulses, movement and sensation are intact.

The mother is assessed and found to have some superficial bruising on her chest wall from the air bag and a strap mark on the left side of her neck from the shoulder belt. She is moving around and talking to her child and the bystanders, in no distress. She wants to go to the hospital for assessment and knows her child will need to have the laceration checked.

The Attack One members operate under a selective spinal motion restriction protocol, and they initiate that process for the mother. They perform the necessary history and physical examination to complete the assessment for a possible spine injury, in this order:

Step #1—The young lady had a history of trauma but not an event of very high obvious risk.

Step #2—The young lady was not unconscious and had no altered mental status.

Step #3—The young lady has no impairment by drugs or alcohol.

Step #4—The young lady has no pain in the posterior neck or spine related to the trauma. Her only neck and spine pain is where the strap of her shoulder belt abraded the side of her neck.

Step #5—The young lady has no painful or distracting injuries that would interfere with her feeling the pain of a spine injury.

Step #6—The young lady has no tenderness along the bony parts of the skull or spine when the paramedic evaluates for it.

Step #7—There is no spine deformity to palpation.

Step #8—There are no neurologic deficits (weakness, tingling, paralysis).

Step #9—The young lady has no pain on movement of the neck or back. As she talked prior to arrival of the Attack One crew, she was moving her head and neck in all directions, and was actually more comfortable when she was allowed to move her neck after examination. She then was able to move her neck and back painlessly through a full range of motion.

Her exam is positive for superficial bruising and mild tenderness over the anterior portion of the mid-chest, where it is likely the plastic cover of the steering wheel air bag struck her as it deployed. There is no bony tenderness or respiratory compromise, and breath sounds are clear and equal. The young lady has no other complaints of pain and no other findings of injury.

With this complete evaluation, the paramedic decides they will transport the young woman without spine immobilization, being sure to document the process and findings. They place her on the ambulance stretcher, and she requests that her young son be placed in her arms for transport to the hospital.

One of the Attack One crew members is able to retrieve and inspect the child safety seat from the car. The broken glass is removed from it, and it has sustained no damage to any part. The paramedic advises the mother that they will use the intact and undamaged car seat to transport the child to the hospital; it will be belted into the chair in the passenger compartment. The child is likely to be more comfortable in his usual seat than in any other seat in the vehicle, and department policy will not allow a child to be transported in a parent’s arms except in very unusual medical circumstances. The mother protests for a moment, but the paramedic insists that transport of the child can only occur in the child seat.

The young lady is secured on the stretcher and able to talk with the paramedic and her child in the ambulance compartment. The child is comfortable as he is placed in his car seat and it’s belted securely.

That safe packaging is still in place when the ambulance is about halfway to the hospital, traveling down a busy street. A car attempting to cross traffic abruptly turns directly into the ambulance’s path, forcing the ambulance to a sudden stop. The squealing tires are the first noise, and then everything loose in the back of the ambulance goes flying and sliding toward the front. Fortunately no one in the rear compartment is struck, and all passengers were restrained in their appropriate seats.

The mother is the first to note her child is OK. “Thanks so much for putting him in his seat!” she exclaims to the paramedic. “He would have flown out of my arms if I’d been holding him!”

The operator is so close to the other vehicle that he jumps out to see if an impact has occurred. It hasn’t, but the other driver appears to be under the influence of alcohol, so the ambulance lights are activated and the crew remains in place until a police officer arrives. They were inches from a head-on impact, so the vehicle operator will have to complete a report after the patients are transported to the hospital.

The patients are unchanged by this mid-trip experience and arrive in the emergency department stable. The crew shares the history and examination with the emergency nurses and physician, and they place both family members in a care space. The physician repeats the evaluation and confirms no spinal injuries. The injury to the child’s arm will not benefit from sutures, so it is cleaned and dressed, and the mother instructed regarding wound care. The mother’s injuries are minor as well, and she is released from the ED.

Case Discussion

This is the 20th anniversary of EMS providers in Maine publishing the first guidelines to permit EMTs to evaluate and treat patients without the need for spinal motion restriction during transport to the hospital or on release of a patient who doesn’t want to be evaluated at a hospital. This process was established initially for adult patients. The reduced use of spinal motion restriction was affirmed by the National Association of EMS Physicians and the American College of Surgeons’ Committee on Trauma in a published statement in 2013.¹

Recent efforts are dedicated to providing appropriate pediatric patient care, with correct use of immobilization tools and skills in managing injured children. In all circumstances where immobilization of a child is indicated due to a high-risk mechanism of injury, complaints of pain or an evaluation that reveals potential spinal injury, EMTs will need to utilize flexible methods of spinal motion restriction. The risk of vomiting and aspiration is high with injured children, so the immobilization technique must allow the patient to be rolled to the side quickly. Children can have spinal motion restriction performed and yet be comfortable using a variety of boards and padding materials. Extra padding will prevent injury to the thin skin of young patients and those with unusual spinal column anatomy.

To implement an EMS program to reduce spinal motion restriction for children, protocols will need to be written and implemented that allow providers to utilize the scene size-up, patient history and physical evaluation to identify those who do not need the process performed. If the patient has no high-risk mechanism of injury, no alteration of mental status, no distracting injuries, no pain or tenderness along the spine and no neurological deficits, they may be treated and transported without packaging the spine. The program must be coordinated with the regional pediatric trauma service, then approved by medical direction and implemented with excellent training, followed up with a quality assurance program.

For EMS agencies that have implemented adult protocols that reduce rigid spine immobilization, the development of pediatric protocols will usually be well received. There is no doubt that both children and adults are more comfortable during transport and their initial time in the emergency department, and with children there will be much less struggling to keep them in the packaging. The reduced use of rigid immobilization puts fewer patients at risk for skin breakdown, aspiration from vomiting, compromised airways and pain.

Selective use of spinal motion restriction may need to be an element of a regional public education program. The public should be taught that appropriate use of long backboards will be reserved for high-risk mechanisms of injury and signs and symptoms of spinal injury. Recognizing patient comfort as an element of customer satisfaction is another way EMS systems can provide excellent patient care.

Reference

1. National Association of EMS Physicians and American College of Surgeons Committee on Trauma. Position Statement: EMS Spinal Precautions and the Use of the Long Backboard. Prehosp Emerg Care, 2013 Mar; 17: 392–3.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.