Question: What do the above things all have in common?
Answer: All of them are things in which some people desperately wish to believe, despite the utter lack of credible evidence of their existence.
Now, before you roll your eyes and say, “There goes AD again, making unsupported blanket statements just to make his point,” I will cop to just a little hyperbole:
Bigfoot may actually exist.
I’ve seen plaster casts of his feet, after all, and that Patterson film looked pretty convincing to me.
But one thing that I’ve never seen, never treated, never even heard of in fifteen years of EMS, is a spinal injury not accompanied by readily detectable signs and symptoms.
That’s what occult means, after all. Hidden, as in “never had a clue until we looked at the x-rays.”
Yeah, I know every EMT has a colleague who dates an ER nurse in another city who works with the nurse who treated the guy that walked into the ER under his own power with an unstable hangman’s fracture who, had he even turned his head this much (fingers held about an inch apart for dramatic emphasis), would have been paralyzed for life!
Just like the guy who was painting his house in the nude, and somehow fell off the ladder and wound up lodging a paintbrush handle in his rectum, just about every EMT has heard some variation of the occult spinal injury story.
Hell, I’ve even told that story to my students, back when I actually believed there was some benefit to spinal immobilization.
Now, I’m not so sure.
Few EMTs understand the rationale behind spinal immobilization, or since immobilization is rarely possible, more accurately referred to as spinal motion restriction. When you’re trying to convince the belligerent drunk behemoth that he’s strapped to a rigid board for his own good, and he continues to demand that you “Get this Goddamn thing offa mah neck!” while writhing beneath your three straps and your flimsy cardboard or styrofoam head blocks, true immobilization is an academic exercise at best.
What we do instead is document our steps to restrict spinal motion, including everything we did to convince the belligerent drunk behemoth that strapping him to a board isn’t our idea of fun either, but still necessary.
First, spinal cord injury can basically be divided into two broad categories: primary and secondary.
Primary cord injury occurs at the time of the accident. It’s done. Nervous tissue is contused, destroyed, what have you, and it happens when the accident occurs. Immobilization is a moot point for such injuries. Keeping them still is not going to reverse or even limit that damage.
What spinal motion restriction proposes to limit is something we call secondary cord injury, which occurs after the fact. It may result from post-injury cord inflammation and ischemia, or bony fragments impinging on previously undamaged sections of cord, or worsening an existing primary cord lesion. Restricting movement in patients with spinal cord injury limits the potential for further damage.
At least, that’s the theory.
And that’s all it is really, a theory. Peruse all the medical literature out there, and you will find little, if any, evidence that restricting spinal motion actually accomplishes what it proposes. In fact, the best information you will find merely confirms that, at best, it does no harm.
Moreover, we have just about zero evidence that restricting movement for patients with spinal fractures and no cord injury – the patients who are neurologically intact – does any good at all. The vast majority of those patients have stable fractures, and thus gain no benefit from being strapped to a rigid board.
What you will find, however, is an increasing body of evidence that the practice is not a benign, precautionary procedure at all. It does indeed cause harm, and all for the theoretical benefit of reducing secondary cord injury.
Pain and anxiety.
Vomiting and aspiration.
15% reduction in respiratory capacity, and that’s in healthy, non-obese people.
Increases in intracranial pressure.
Pressure necrosis to occiput, sacrum and heels.
All of these things are possibilities when we strap someone to a spine board, and all for a clinical benefit more theoretical than proven.
Here at The Borg, we have a spinal clearance algorithm of sorts. Like all spinal clearance algorithms, it relies on the presence of a very reliable indicator of serious injury: pain. Sure, there are other indicators of neurological compromise that we assess, but the big one is pain.
If someone breaks their neck, pain will result. Not just the diffuse “Man, my neck kinda hurts,” pain that you commonly see in cases of acute insurance-itis, but specific, midline posterior cervical spine tenderness above the area in question.
Of course, there are other elements that point toward spinal cord injury that need be assessed as well – focal neurological deficits, for example. Just the other night I boarded a male motorcyclist who straightened out a curve, based on nothing more than his complaint of numbness and tingling in his hands. It could have been nothing more than cold weather and crappy riding gloves, but it could also have been the telltale signs of a cord lesion.
He swore his neck didn’t hurt, and I found no signs of injury at all – thank God for muddy, grassy fields! – but I boarded him anyway. Of course, after a two-hour wait on the board in a busy ED, it was determined that he didn’t have any spinal injury, and he was taken off the board.
The presence of pain is what makes an occult spinal injury not occult at all, and in all my years in EMS, I have never encountered a single reliable patient with an unstable spinal fracture that didn’t have it.
Now, not every patient is reliable, hence the other elements of the spinal clearance algorithms that assess mental status and potential distracting injuries. If the patient is deemed to be unreliable due to organic or chemical impairment, or the fact that he seems to be focusing all his attention on his broken leg rather than your fingers walking down the back of his neck, we restrict spinal motion anyway, just as a precaution. It’s the prudent thing to do.
Well, that is, if you believe that boarding and collaring someone is actually beneficial for a patient with spinal cord injury. There is at least one well-constructed study out there that shows otherwise, in which spinal injury patients who were immobilized had significantly worse neurological outcomes than those who were not. I wrote about it a couple of years ago. Go read that post, and then come back.
For patients with penetrating trauma like knife or gunshot wounds, there is no reason to immobilize if the patient is neurologically intact. Nonetheless, it’s common practice in many EMS systems to collar and board shooting victims, even if the time spent immobilizing in the field doubles the patient’s chances of dying.
By God, we’re gonna save you from being paralyzed, even if it kills you!
The National Emergency X-radiography Utilization Study was designed to develop a specific set of clinical assessment criteria that would help cut down on the number of unnecessary cervical spine x-rays in Emergency Departments around the country. It has been validated in many thousands of patients, and generally speaking, those clinical assessment criteria are more accurate than x-rays in ruling out cervical spine fractures.
Of course, NEXUS is rarely used as it was designed. It’s been my observation that the Emergency Department physicians use it to clear patients off our board, but the patient still gets the x-rays anyway. Now you may ask, why do they remove patients from our boards, when we obviously boarded them for a reason, using the same set of criteria?
The reason is that many EMS spinal clearance algorithms, including the one used by The Borg, do not use NEXUS, but instead are modeled after the Canadian C-Spine Rules, which note a higher incidence of spinal injury in patients over age 65, and patients who have sustained significant injury above the clavicles.
Of course, these two additional criteria don’t mean that the patient has a spinal injury, they just suggest that we look at these patients a little more carefully. EMS often adds an additional criterion, the nebulous and subjective “significant mechanism of injury.”
Rather than use MOI as it was intended – as a conceptual tool to tell us where to focus our assessments – EMS tends to use it as the assessment. We place all of our faith in the mechanism, and precious little in our actual assessment findings. We’ve built an entire belief system around it.
This misplaced faith in mechanism of injury is what transforms a useful clinical tool like a spinal clearance algorithm into just another poorly written protocol, where we shoehorn patients into a set of unnecessary treatment steps that offer no benefit.
The state of Maine, pioneers in the use of a statewide field spinal clearance algorithm, has been using NEXUS criteria for ten years now. Everyone from the newest EMT to the most seasoned medic can apply it. Several years ago, they dropped mechanism of injury from the list of assessment criteria because MOI was too unreliable an indicator of injury.
So far, no one has seen an inordinate percentage of quadriplegics tooling around Bangor or Portland in their motorized wheelchairs, and we’ve heard no reports of juries awarding record monetary damages for the patients who weren’t collared and boarded. It may just be that they’re on to something up there that other EMS systems around the country would do well to copy.
The Borg have a spinal clearance protocol, but its benefits are diluted because they insist on immobilizing anyone with a significant MOI, or patients over age 65, or patients with an injury above the clavicles. Not “exercise due caution” in these patients, mind you, just “immobilize.”
No ifs, ands or buts, no exercising clinical judgment, no consideration of what’s best for your patient, just immobilize. Strap ‘em all to a board, and let the radiologists sort ‘em out.
Now imagine yourself, say, at a bar. You’re flirting with the waitress, nursing a Coke because you’re drew the short straw for designated driver, when all of a sudden and for no reason, Sumdood clocks you right in the mouth. Splits your lower lip and knocks out a tooth, the bastard.
But you’re pretty badassed yourself, and you didn’t even leave your feet. You’re more pissed than anything, really, and would like nothing more than to exact a little revenge, but Sumdood, as he always does, has vanished like a wisp of smoke. Your buddies cluck sympathetically at your mangled lip and missing tooth.
“Dude,” they say, “you oughta get that checked out. Call an ambulance or something. You’re gonna need stitches and everything.”
So then the ambulance arrives, crewed by Rookie Partner and a burly but nonetheless rakishly handsome and devilishly charming paramedic, namely… me, Ambulance Driver.
“Yep, that’ll need stitches,” I agree as I examine your face. Other than the split lip and missing tooth (carefully stashed by your buddy in his go cup filled with a White Russian because it has milk in it, and everyone knows you’re supposed to put dislodged teeth in milk), there isn’t a mark on you. Your pupils are fine, you didn’t lose consciousness, your neck doesn’t hurt when I palpate it, and you’re moving all your limbs appropriately. I even have you close your mouth and smile, checking for malocclusion of your teeth that may tell me you’ve suffered a fractured jaw.
You’re moderately impressed by my thoroughness, and thankful that The Borg employs such dedicated and skilled medics. They’re a pretty damned impressive outfit, you’re thinking. They’ve got their shit together. I’m in good hands, you’re thinking.
And then I say it.
“Um,” I say apologetically, “to take you to the hospital, we’re gonna have to put a collar around your neck and strap you to a board.”
“But I didn’t hurt my neck!” you protest. “Why is that necessary?”
“We have to,” I repeat, mentally biting my tongue to keep from agreeing with you wholeheartedly. “It’s, um… well, it’s the protocol. It’s for the best, really.”
“So you’re saying that strapping a guy with nothing but a split lip to a board is actually in his best interests?” you ask dubiously. “Dude, what have you been smoking?”
But hey, the guy has an injury above the clavicles, and the protocol clearly states that I’m required to immobilize that guy.
That’s a scene I am forced to repeat, day in and day out, several times a shift. And I am faced with the choice of explaining to my patient that my medical director is not a monosynaptic, booger-eating dullard, just that he writes protocols designed to be used by medics that are, or I can follow the protocol as written and have the patient think I’m the monosynaptic, booger-eating dullard.
Either way, it doesn’t reflect well on The Borg, or EMS in general.
Ironically, the same medics who immobilize everyone in the belief that if it keeps even one patient from being paralyzed… are the same medics who are card-carrying members of the No Neck Fits Everyone Society, and believe that three straps are all that’s necessary to properly secure a patient to the board.
Now, being an ornery type who refuses complete assimilation into the Hive Mind, I rebel at doing unnecessary and potentially harmful things to my patients, and carefully explain to them that they have the right to refuse any medical treatment that we offer *wink wink, nudge nudge*. Sometimes I just refuse to follow the protocol, and I get my pee pee whacked for it fairly regularly.
But a great many of my colleagues don’t even go that far, and simply follow the protocol blindly, never questioning the wisdom (or lack thereof) behind it. Some of them even tell the patient things like, “If you want to go to the hospital on my rig, you have to go on the board.”
That’s a practice that doesn’t just flirt with the legal definition of coercion, it gives it a naked lap dance and slips its cell number and hotel key into Coercion’s pocket. It’s wrong, and we shouldn’t make our patients submit to painful and unnecessary treatments just to get the help they seek.
Every time the FTO Drone whacks me on the pee pee for not immobilizing someone needlessly, he’s almost apologetic about it. “It’s not you, AD,” he’ll say as I’m taking the online spinal immobilization tutorial for the umpteenth time, “it’s all these other yahoos who aren’t using their heads at all. If we’re going to discipline them for it, we can’t let you get away with doing the same thing.”
And he’s right. Discipline needs to be applied uniformly, even if it occasionally requires that a good medic who exercises his brain receive the same punishment as the bad medics who didn’t.
Of course, they could also re-write the protocol to allow more freedom to exercise clinical judgment, and hire medics worthy of that level of trust.
Like, you know, ones that don’t believe in Bigfoot, aliens and occult spinal injury.