To Collar...Or Not to Collar, that is the question!

[ALSfirefighter]

I'm looking for input, on any regions/states that are now employing newer protocols in regard to the use of collars and backboards. I have read studies where they are re-evaluating the use of backboards, due to cases where they have caused injuries. Recently our medical director gave us leadway (following a few hours of updated training) to not place patients on backboards, if they followed the new curriculum (no loss of MNF, ambulatory, etc.) he gave us. Any input on your areas policies or rumors/talks of would be greatly appreciated it.

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The above is for my use only, it doesn't reflect any opinion/thought of any dept./agency I work for, deal with, or am a member of. http://www.firehouse.com/forums/biggrin.gif

[Resq14]

So are you kinda asking if any system allows providers to "clear the spine" in the field?

If that's what you're asking, I can fill you in on Maine's Spine Injury Protocol.

[mike m]

not applying spinal immobilization to a victim of any type of trauma of any sort of mechanism of injury no matter the degree of severity would in my opinion constitute either malfeasance or mis feasance or in theworst case scenario negligence.i have seen trauma victims ambulatory at MVA's where at a later time on back boards in the ER with R/O spinal injuries.for a medical direcror to ok scene triage for spinal injuries,i think he is openning a can of worms.he is definetly putting the crew at risk for possible litigation.my opinion lets board all potential c spine injuries and let the doctors in the ER make the final determination on R/O c spine injuries.
,thats why the get the big bucks.remember when in doubt board,and later it wont come back to bite you thanks mike m

[ALSfirefighter]

Resq14,

I would like that very much. I've heard in some conferences that Maine had a protocol for this but no one ever went into detail about it. Could you post it here, or if there is a website where I could read it, post the link, or if its okay with you, post your email and I will send you my address. Do to certain conflicts and privacy issues I refrain from posting my address on here openly, so I understand if you don't want to also.

Mike,

Thank you for your opinion and I respect it. But I disagree. I wasn't looking for opinion, I'm looking for input on what other states/regions have/or are trying to implement clearing the spine. We put hours into training every year to update us on assessing and clearing the spine. Also, our medical director knows the people who are under him. If he wasn't comfortable doing this he wouldn't. In fact one of the things many Med. Directors are looking at are injuries that persons are suing for, that were caused by being on a backboard. Also, not placing someone on a backboard doesn't fit the negligence criteria for litigation. Only if there was an injury present, and it was made worse by not putting the person on a backboard. Which by the way, does fit if you cause an injury with use of a backboard, and the lawyer can prove it came from that. (as I've said there have been cases already) I'm not saying don't collar. The neck is the easiest part of the spine to injure. A lot of research is going into the benefits of just a collar with no backboard. Every area of the country is different with training and protocols. We are still begging to carry thrombolytics in the field, while some scream that we shouldn't. Then there are counties in GA that are already using them. But like I said thank you for the input.

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Again, the above is my thoughts/opinions only and doesn't reflect that of any dept./agency I work for, deal with, or am a member of. http://www.firehouse.com/forums/biggrin.gif

[Resq14]

I understand why many people don't favor "clearing the spine" prehospitally. After all, none of us have X-Ray vision, right? Since that is the definitive assessment tool for evaluating spine injuries (and since we're not MD's), I can see why nontraditional treatment and assessment modalities for patients can stir strong emotions.

What's important to understand about Maine's protocol is that it is not intended to relieve EMS personnel from "precautionary immobilization," or to decrease the number of times we implement immobilization procedures. The point is to provide the correct level of care for the patient. Actually, we may end up immobilizing MORE patients because of this protocol. Also, it's not something you just decide by quickly looking at your patient. After reading all this, you'll probably end up thinking it'd just be easier to immobilize the patient than to perform this assessment. But in reality, it can be done very efficiently.

It's also important to view the spine as just another "long bone" rather than separating it into neck and back. This reinforces why we don't simply collar without boarding, or vice versa.'Spine' injury is a better way to view these than 'neck' or 'back' injury.

1. Mechanism of Injury (MOI)
First, the provider determines the likelihood of a spine injury based on the MOI. Progressing through the protocol means someone has an Uncertain MOI (see below).
Negative MOI : twisted ankle, finger laceration, chest pain, shortness of breath. As you'd probably suspect, immobilization is unnecessary in these cases.
Positive MOI : high velocity vehicle crash, fall from 20 foot roof, high velocity GSW near spine. Based on your training, and as you'd most likely suspect these patients are immobilized.
Uncertain MOI : trip over lamp cord, low speed fender-bender, fall from 3-4 feet. These are traditionally the "gray areas" and can sometimes be very hard to categorize. If the patient has an UNCERTAIN MOI, we then proceed with the rest of the protocol.

2. Spine Pain/Tenderness
The patient is asked if he reports any spine pain (superficial injuries excluded). Next, the spine is firmly palpated for pain, tenderness, or deformity. Any ABNORMAL finding requires spinal immobilization.

3. Neurologic/Motor Function Exam
Motor function is tested in all extremities.

Upper extremities: finger abduction/adduction, and finger/hand extension.

Lower Extremities: foot flexion, foot/toe dorsiflexion

***Any unilateral differences, or the inability to conduct the test (post-CVA, for example) buys the patient immobilization***

4. Neurologic/Sensory Exam
Abnormal sensations: any type of weakness, numbness, tingling, or pain of unknown etiology is an abnormal finding.

Pain Sensation: tests are performed on each extremity that evaluate the patients ability to differentiate between a "sharp sensation" (a la broken Q-Tip) or a "dull sensation" (a la soft part of Q-Tip). Sharp/dull is compared in each extremity, and then bilaterally. Any inability to correctly identify the sensations, or any unilateral differences (ask patient, "does this -test left hand- feel the same as this -test right hand-?)

Any abnormal test results, again, gets the patient a ride on a board. And as above, the inability to conduct these tests results in immobilization.

5. Reliable Patient Exam
If we've made it this far with no abnormal findings, we need to make sure the patient is calm, cooperative, sober and alert. Things that would make the patient fail this exam include: Acute Stress Reaction, brain injury, intoxication/AOB, altered mental status, distracting injuries, and communication difficulties (perhaps very old, or very young and unable to communicate, language barriers, distracted patient). If the patient meets any of the "failing" criteria, then the patient is immobilized.


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And there you have it. In my opinion, it's a great example of basing treatment modalities on scientific studies and outcomes. We're justifying why we're doing things. Not every patient who goes to the hospital has a CAT scan. Likewise, not everyone we encounter needs to be collared, KED'd, and strapped on a board.

The assessment has many safety considerations built in, and in my opinion, is a very valuable tool in our state. The one complaint I have is that we all interpret "uncertain MOI's" in different ways. Vehicles that simply slipped off an icy road and tipped-over are considered by many to be Positive MOI's, whereas others consider them to be Uncertain at best. But to my knowledge, no patient that has been assessed using this protocol has been incorrectly cleared prehospitally with respect to the patient's actual injuries.

Finally, this protocol makes us assess both Positive and Uncertain MOI's in a thorough manner, regardless of our intent to provide/hold-off on immobilization. I will say that all of the findings in these exams should be *fully* documented on the PCR, especially if a patient with an Uncertain MOI is 'cleared' (for obvious reasons).

Hope that helps.
-Tony

The course is taught using...
"Spine Injury: Clinical Criteria for Assessment and Management" by Peter Goth, MD - 1995)

[This message has been edited by Resq14 (edited 04-23-2001).]

[mike m]

Dear ALS FF, I realized that i did state an opinion rather than responding to your post.i have never heard of a lawyer challenging a treatment modality such as backboarding a victim of a trauma.yes,i do agree that applying a collar with a backboard is time consuming and not every payient will benefit from this type of pre hospital treatment.but as was mentioned in the previous post we dont have x-ray vision and to clear a patient for c-spine injuries in the field does have its merits i still would think twice about following a protocol that would allow me to impliment this protocol.i have taken patients on boards to trauma centers were the attending physician did clear the patient for c-spine and the time spent on the board was minimal. thanks mike martin

[ALSfirefighter]

Resq,

Thanks for posting it. Now I know where our medical director got his info from, we pretty much utilize your protocol exactly as you posted it. I appreciate it very much.

Mike,

I completely understand, and like I said I appreciate your post and your input. The case I was referring to never made it to the court room. They basically laughed it off. But with the right lawyer we never know anymore. With trauma centers, yes there are times where the patient isn't on a backboard for an extended period of time. But get 2 or 3 trauma's at once like happens here and a minor MVA victim can be on there for as long as an hour. In my career I have never had, nor has any of my colleagues I associate with ever had a fracture to the thoracic or Lumbar spine where there hasn't been pain on palapation to each spinal process. Yes the patient was ambulatory, and had no obvious pain to the back, but once pushed on, scream city. The neck we don't play with, unless they are moving it like being at a tennis match. But I completely understand your concern, and its nice to know there are a lot of people out there who still take serious what we do. Thanks again for you input. And I do apologize if I made you feel slighted, I didn't intend to do that.

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The above is my thought/opinion only and doesn't reflect that of any dept./agency I work for, deal with, or am a member of. http://www.firehouse.com/forums/biggrin.gif

[Althea Forhan]

There was a time this winter when I was playing the victim at a first responder class when I was very improperly backboarded. It started out ok, everyone asking the right questions, proper techniqes, etc. But when it came time to put me on the millerboard, the students rolled me correctly, but the guy who was supposed to position the board didn't do it very well, and I ended up with the edge of the board jammed into my spinal colum. In that situation, I would have preferred to have my mythical injury cleared in the field.



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Althea Forhan
"Don't blame me
I voted for Gore"

[jedge168]

ok, I'm goning to have to go the way of, yes it's being done here, some as a matter of protocol, some as a matter of protocol deviation (requiring med con's approval). But I don't necessarily agree with it myself. As was stated earlier, I don't have X-ray vision.

[Trauma_Dog]

I have read many good points for and aganst spinal clearence in the field, actually the service I work for has done it for the last 2 years. There are some points of interest I think some of you should be aware of

1) Doctors in the ER don't order x-rays to clear c-spine on a vast majority of the pt who come in for mva ect. This may be a reginal thing.....You may want to pull charts from all you c-spine pt and see just how many receive x-rays.

2) Which bring me to may next point. How do they do that? Your protocol should reflect a similarity of the one most or you pts going to.

3) Paramdics here have to call on-line med controll for clearence and a follow up is done on each pt. The some of the things they a looking for is passive ROM w/o pain, no loc ect.

4) If the paramedic is uncomfortable, his options are just place the pt in spinal restriction, it that simple. No stress or fuss, no one should ever ask..."So, exacty why did you c-spine that pt?"

Old habits are hard to break in this business. All I ask from people is to try and get honest information, give it an honest go at it. If you still don't like it thats ok, but at the least you can say you tried.