Clinical solution: A freeway crash
By Patrick Lickiss
Editor's Note: No readers weighed in with a correct answer to columnist Patrick Lickiss' scenario, which addresses spinal immobilization. While standard practice has been to place patients on a long spine board, studies suggest this may complicate or worsen spinal cord damage. Because he is experiencing difficulty breathing associated with his chest injury, laying him flat could make his condition worse.
Many of you did, however, bring up ethical concerns about stopping at the scene of an accident while already transporting a patient, which Lickiss addresses at the end of the article
Motor vehicle collisions like the one described last week are common. If a patient does not have significant injuries, often he or she will have left the vehicle and moved to a different location. Standard practice for these patients has been to place them on a long spine board and transport them in a supine position for evaluation at the emergency department. Some EMS systems allow these patients to walk to the gurney where a spine board has been position and perform the immobilization there.
Recently, however, this trend has been called into question. Several studies have been published suggesting that standard spinal immobilization may delay and complicate treatment  or even worsen spinal cord damage . Recently, the National Association of EMS Physicians (NAEMSP) released a position statement on the use of spinal immobilization . This position statement recognizes the risks of widespread use of spinal immobilization via long spine board. While the paper recognizes the need to protect the cervical spine of a patient with a potential injury it rejects the assumption that spinal immobilization is an “all or nothing” procedure.
Instead, the NAEMSP paper lists several patient conditions which should be placed on a long spine board, specifically:
- Blunt trauma with altered level of consciousness
- Spine pain or tenderness
- Neurologic deficits
- Anatomic deformity of the spine
- High energy mechanism of injury AND one of the following:
- Drug or alcohol intoxication
- Inability to communicate
- Distracting injury
The paper goes on to discuss which patients are not suited for spinal precautions at all including those with none of the above indications and for penetrating trauma with no sign of spinal injury. Finally, the paper suggests that adequate spinal stabilization is provided by the placement of a cervical collar and then securing the patient to the stretcher.
What the NAEMSP has done is to treat spinal immobilization as a treatment, rather than a procedure. Procedures (like venous access or a 12 lead ECG) are performed essentially the same way every time. Treatments on the other hand have indications (deformity to the spine), contraindications (penetrating trauma), side effects (pressure sores) and doses (collar only, collar and long board, or nothing at all). Reviewing spinal immobilization as a treatment gives the EMS provider latitude to make decisions in the patient’s best interest following a thorough evaluation.
Based on the patient’s lack of neurologic deficits found during your assessment and the fact that he self-extricated from the vehicle, you determine that he will not need full spinal immobilization. This decision is confirmed by the fact that he is experiencing difficulty breathing associated with his chest injury. Laying him flat would probably make his condition worse. Since he is experiencing neck pain, you place a rigid collar on him and wait for your transporting unit to arrive. Once the unit arrives on scene, you and the other crew lift the patient to stretcher and secure him to it.
After completing your transfer, you meet up with the other crew at your deployment center. They tell you that during their trip to the hospital, the patient’s shortness of breath increased and he lost lung sounds on the left side. The patient required a needle decompression and was transported to the regional trauma center. His condition improved after the decompression and he was expected to make a full recovery after his hospital stay.
NOTE: While treatment in the above scenario is based on the NAEMSP-identified best practices, it is not a substitute for your local protocols. Please consult medical direction before deviating from local policy and procedure.
Epilouge: The ethics of stopping
While reading the comments on the original scenario I noticed that most focused on whether or not it was appropriate or even ethical to stop at the scene of an accident if a crew was already transporting a patient. The term “abandonment” was used with regard to the driver of the ambulance stopping at the scene of a new accident. It is important to realize that the legal definition of abandonment requires both that the patient not be given notice and that the caregiver inappropriately terminate their relationship with the patient without ample provision for continued care. I would argue that the treating crew member remaining in the back of the ambulance with a stable transfer patient provides for continued care. Additionally, the provision of “duty to act” applies to the crew in the scenario because there are no medical providers on the scene of the accident they will drive past anyway. One could argue that refusing to stop would be ethically incorrect.
As with all advice, be sure to consult with your employer and/or medical director before changing your practice.
1. Brown, JB; et. al. “Prehospital spinal immobilization does not appear to be beneficial and may complicate care following gunshot injury to the torso”. J Trauma 2009 Oct;67(4);774-8.
2. Ben-Galim, P; et. al. “Extrication Collars Can Result in Abnormal Separation Between Vertebrae in the Presence of a Dissociative Injury”. J Trauma 2010 Aug;69(2);447-50.
3. National Association of EMS Physicians and American College of Surgeons Committee on Trauma. “EMS Spinal Precautions And The Use Of The Long Spine Board”. Prehosp Emerg Care 2013 Jul/Sep;Early Online (3);1-2.