Spinal Immobilization: The Conclusion

In my post on spinal immobilization, I asked if any of you would collar and board an elderly patient (24 hours post-injury) with clear radiographic evidence of a comminuted C1 fracture and cervical spine tenderness, but no neurological deficits.

And to my overwhelming delight, few of you said yes. I think there is a clear difference here between doing what is in the protocol, and doing what is best for the patient, and most of you recognized that. Some of you work in systems that allow such judgment calls, and a healthy number of you mentioned contacting medical control for permission to deviate from protocol in this instance.

I tried that myself.

Problem was, I was unlucky enough to get the one arrogant horse's ass doctor on the phone who doesn't like giving orders to paramedics. His words to me were, as close as I can remember them, "You do what you feel you must do, but understand that I haven't examined this patient. I only know what you're telling me."

In other words, if something bad happens, he's going to do his best to duck any responsibility for it, placing all blame on my shoulders.

Rather than give him a primer on the "hold harmless" clause written into most state EMS legislation that makes online medical control possible, I politely thanked him for his time and hung up the phone. Why argue with someone who is unclear on this whole "physician extender" concept? I mean, we're taught from Day One that we are the eyes and ears of the Emergency Department physician in the field, and if he doesn't trust any assessment not done with his own eyes and hands, it's pretty much useless to ask such a man for orders beyond "monitor and transport."

So, I went hospital shopping.

After politely inquiring of the charge nurse why Hospital X was chosen as the receiving facility, she replied, "Because Podunk General said that's the closest hospital with neurosurgery capability."

Now, I know for a fact that this isn't true. There is a hospital in my response area, only 20 minutes away, with neurosurgery. They know me there. I asked the LPN at Decubitus Manor if they were wedded to the idea of transporting to Hospital X, and she imperiously waggled a finger at me and informed me, "Hold on a second, I've got our doctor on the phone now."

Meaning, of course, the gerontologist who sees most of the patients at that facility.

She went on to inform the doctor, "That ambulance driver doesn't want to take the patient to Hospital X… no, he's right here… would you like to talk to him?" She then handed me the phone and smugly folded her arms, no doubt waiting to hear the epic ass-chewing tthat awaited me.

So I favored her with the winning smile I bestow upon uppity nursing home LPNs and brain injury patients with severe cognitive impairment – but then, I repeat myself – and said hello to the Doc. I went on to explain my reasoning at not boarding the man, and informed her that there was a comparable receiving hospital only twenty minutes away.

Much to the LPN's chagrin, the gerontologist agreed with my plan, and gave me her official blessing to transport to Hospital Y.

So I transported the man with cervical collar – an undersized one –  in place, seated in semi-Fowler's position on the stretcher, with the admonition not to move his head. He cooperated like a champ, and arrived at the ED just like I found him – comfortable, and with zero neurological deficits. I was prepared to administer pain relief and sedation, but in the end it wasn't necessary. The ED doc, agreed that – protocols be damned – collaring and boarding would have been counterproductive in this case.

Here's the thing: we have zero evidence that the practice of collaring and boarding is beneficial, even for the patients with spinal fractures. On the other hand, we have a growing mound of reliable evidence that it does harm. Vacuum mattresses and such may have indeed been a reasonable compromise, but they are not available in my system. In the case of high C-spine fractures and internal decapitation, there is at least one study out there that indicates that even a properly-sized cervical collar can result in cervical distraction of 2 centimeters or more. An undersized cervical collar results in far less distraction, but allows 30% greater lateral movement. The authors of that study go on to say that, in the unimpaired patient – neurologically or cognitively – there is already a mechanism in place that limits movement: pain.

Simply put, if you're awake and alert, and it hurts like hell to move a certain way… you're not gonna move that way. That degree of self-splinting is likely as good or better than anything we'd accomplish with a rigid cervical collar. Now, had he had neurological deficits or cognitive impairment of any sort, I may have chosen a more elaborate splinting method – perhaps even a spine board.

Blanket rolls and horse collar arrangements, like many of you suggested, are probably also good ideas, but they all relate to the point that most of us got – boards are imperfect solutions to imagined problems, and we always need to balance patient comfort with the proposed benefits of any treatment. As the admonition goes, "First, do no harm," and in this case a board would likely have done more harm than good.

So if you would have transported our patient in a position of comfort, and tried the most reasonable and non-tortuous means of limiting his spinal movement, you made the right call.