Random Thoughts About Someone Elses Post

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Brooks Walsh, over at Mill Hill Ave Command has a good post about the value of various types of C Spine immobilization. In order to protect the c-spine, should we stop helping? It’s a well thought out post without hyperbole or hyperventilation, other bloggers could learn from it.

I originally was going to post a comment there, but as I typed I realized that it was getting long enough to be a blog post of my own. Not a long post, but long enough to allow me to expand my thoughts a bit. It’s poor form when your comments on another bloggers post are longer than the original post.

Read his post first and my comments will then be in the proper context.

A couple of thoughts, in no order of priority.

The KED was designed to do one thing, but is now routinely used for another. To properly used the KED the way that it was designed, the roof has to be completely removed from the vehicle. Even then I wonder if it really does what it’s supposed to.

Just because a device works better than the KED, doesn’t mean it’s necessary or beneficial to the patient. Devising better ways to perform an at best unnecessary task seems futile to me.

Method #3, while frowned on officially is what most EMTs that I’ve ever worked with or observed actually use. As dangerous as the doctors and lawyers tell us it is, it still seems to be less dangerous to the patient than a KED. The KED is what most people consider the “Gold” standard, although it seems like Fools Gold to me.

Doctors and lawyers like the KED and full immobilization for patients, even patients with no obvious injury or complaint of injury because they believe that it reduces the liability of the doctors and EMS systems. When patients start to sue because of the injuries inflicted upon them in the name of “protecting” their C Spine, that will change. Not that I’m a big fan of civil litigation, but that does seem to be a behavior modification technique of some efficacy.

Additionally the doctors and lawyers know that it is highly unlikely that they will have this treatment inflicted on them.

Much of what we “know” about C Spine immobilization was learned in the 1960 and 1970s. In case the doctors who write the text books haven’t noticed better car design, air bags (sort of), better seat belt design, and more seat belt wearing have decreased the likelihood of C Spine injury.

“Occult” cervical injuries are pretty much unknown. Almost always a cord injury manifests itself immediately. Fortunately they are rare, but the few I’ve seen from any cause have been obvious to us and the patient immediately.

Any amount of pain is very likely to limit movement of the neck or head, which means that the patient will “self immobilize”.

Alcohol is probably the most confounding factor to all of the above. As well as drugs.

Placing the KED and moving the patient to the backboard always seemed to go smoothly if the patient was slender, short, and driving a large car.

Actually I’ve found that it goes most smoothly if the “patient” is on a hard backed plastic chair that has no arms and that said chair is in the middle of the room with nothing around it. That holds true also for the device that predated the KED, the short back board. And if you were around during the “Build A Board” days, that still applies.

What hard science exists on the topic seems to indicate that there is more harm than good in all C Spine immobilization techniques, that it’s over used, and that patients often sustain serious injury when immobilized for too long.

But I’m not going to hold my breath waiting for that to change.

3 COMMENTS

  1. TOTWTYTR, I wish I could write as fast as you! I swear I just hit “publish.”

    You make some good points. I agree that intoxicated patients are the fly in the ointment – the clinical exam may still work after 2 beers, but not after “just 2 beers.”

    One observation – I’m not sure that most ER doctors have much of an opinion about the KED. If anything it probably just confuses those without significant EMS experience! As for immobilization in general, however, you’re right. We’re an inherently conservative bunch, slow to adopt change, and skeptical of methods that weren’t “how we did it where I trained.”

    A brief personal experience with the long spine board would probably be instructive for all emergency health-care workers, doctors included. I still have a touch of PTSD from almost being dropped while strapped in during my EMT-B class. Jeezum, that was scary.

    • Luck of the draw, doctor. I just happened to be going through my list o’ links and found that post. Yeah, my comments were about immobilization in general, although I had one medical director who was totally in love with the KED. As you might expect he was always worried about getting sued. When I went to EMT school back during the Middle Ages were all got a turn being the patient. It was painful then, it would be excruciating now.

      Those guys at SOLO should have spent more time monitoring their students and less pretending to be Keebler Elves! 😉

  2. “slow to adopt change”

    No kidding! My squad has been pushing for an OMD approved c-spine clearing protocol for about the last ten years. We’re finally getting one… because it’s part of the new regional protocols that are going into effect over the next month or so.

    Honestly, I’m not really surprised at the results of that study, and any EMS provider with experience who’s been paying attention shouldn’t be, either. There’s a ridiculous amount of patient manipulation involved, requiring coordination between 3 or more providers, to get someone out of a vehicle. Applying a KED increases the amount of manipulation and coordination needed, at least doubling it, and complicates it due to the usually cramped space and improperly shaped seats (don’t forget, in addition to being intended for use with the roof removed, the KED was designed to be used in race cars, not modern subcompacts, and it was designed around a standardized seat that is nothing like the seats used in consumer vehicles). Compare all that manipulation and coordination to simply putting a collar on a patient and telling them “get out and sit on this cot, and don’t move your neck”. It’s a simple set of a few motions for the patient, compared to a complicated series of evolutions requiring constant coordination between multiple people who may not even be able to see each other.

    Which one of those scenarios is more likely to result in unnecessary c-spine movement?

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