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September 06, 2012

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Out of the Box
by Dave Ross

Confessions of a recovering cervical spine field clearance addict

When I realized this method was more complicated than I thought, I scoured the literature to see if I'd missed any clues

By Dave Ross

My recollection of the beginning is murky. It all seemed so enticing — innocent, but insidious.

It must have been around 2005. At least, it seems that may have been when it dawned on me that our EMS system might implement a cervical spine clearance field protocol.

I did some quick research and became enraptured and engulfed in the possibilities. I presented a lecture on the topic at our local trauma conference. And even they seemed to buy the idea!

More consumed and enabled, I wrote a draft protocol and argued for its adoption to our region's EMS medical direction council. Somehow, I was able to overcome some of the skepticism of that group, and they agreed to include it in the subsequent protocol revision.

What a feeling. I was on top of the world. But like so many other cruel addictions, it proved to be a false high.

Slowly that world unraveled. Things didn't turn out as I had planned. We had some protocol misapplications that I thought would not occur. I started getting not-so-discreet phone calls at very inopportune times from receiving emergency doctors, advising me that I had a problem.

It got so bad that even members of my EMS "family" couldn't help but notice. Ultimately, with the fervor of a desperate spouse, the medical direction council suddenly awoke from its slumber of denial and dictated resumption of spinal immobilization for all patients with a mechanism of injury.

The wheels had come off. I came crashing down off that wild cervical spine field clearance ride. Fortunately, I went through a 12-step program before I wound up homeless, drinking bottles of Woolite on a street corner.

It was almost a tragedy worthy of Shakespeare. How could this happen? What went wrong? How am I managing in recovery? Will I relapse?

Pull up a chair, kids, and I'll tell you.

On the surface, it seems that field cervical spine clearance is simple. In fact, that's what so seducing about it. However, we learned quickly that it was a little more complicated than I thought. And, perhaps not surprisingly, some paramedics were more facile with it than others.

During this realization, I went back and spent a little more time with the literature to see if there had been clues all along that I might have missed.

And sure enough, there were. You see it turns out that only about 1 percent of all trauma patients have a spinal cord injury. This means that it takes thousands of patients to get a reasonable number of truly spine-injured patients. And what we really care about is how the cord-injured patients will do as a result of the treatment or protocol we are studying. So small studies don't help.

It also means that in our practice, we go a long time without encountering a spine-injured patient. This can give us the perception that we don't have to be careful.

First, let's examine why we even immobilize patients. A 1998 study by Hauswald and associates5 looked at a relatively small group of non-immobilized Malaysians compared to a similar number of immobilized Americans. The study authors suggested there might be a trend for worse neurologic outcomes in the immobilized group.

During my "low point," these findings impressed me. However, a sober review of the paper raises concerns that the small number of patients really could not answer the question adequately.

For many ethical and medical legal reasons associated with the practice of immobilization in our country, it's likely there will never be a large-scale research study that will clarify the issue. So maybe we still need to be immobilizing patients at risk for cervical spine injury.

Then I began to wonder what problem(s) we were trying to solve by clearing spines in the field.

Since it appears we have to continue to immobilize, are we hurting patients with immobilization? Indeed, there are some papers describing healthy volunteers and suggesting that pressure as well as pain on areas of the back is increased when the subjects were placed on a spineboard — for more than an hour.1

But does that matter much if, at some brief point after hospital arrival, they are carefully removed from the board?

How about skin breakdown and ulceration? I could only find two studies addressing this. Both were from the late 1980s and primarily involved patients with penetrating trauma who had inordinate delays on spineboards in the emergency department and were not turned frequently in the ICU.5,6 Is this today's typical immobilized EMS patient?

What about the risk of respiratory compromise in the immobilized patient? Nothing.

What about the actual clearance protocols in the medical literature? After all, in my altered state, it seemed easy enough.

Two potential resources have been studied in emergency departments with emergency physicians. Related versions have been later evaluated with EMS personnel.

The most commonly quoted criteria were described in the National Emergency X-Radiography Utilization Study (NEXUS).4 This lists five patient characteristics to consider: Altered mental status, intoxication, distracting injury, spinal tenderness and neurologic injury in the extremities. A piece of cake.

But maybe not. When you think about it, there's a lot of subjectivity in those five criteria. We have to judge how altered the patient's "altered" is, how intoxicated the patient really might be, what really is a distracting injury, and whether my idea of spinal tenderness and a complete neurologic exam is the same as yours. Maybe not surprisingly, these things posed problems for us.

It turns out a good deal of research appears to show that EMS can successfully use variants of NEXUS well.2 During my clearance-addled phase, I lapped that up.

However, early in recovery, I reread them and realized that they all had some element of misapplication of the study protocol and/or a component of unrecognized potential for spinal injury in which patients were not immobilized when they should have been — just like we saw.

So now that I'm sober, it's clear that if a high-volume system is actively clearing spines in the field, the question is not whether there will be misses — it's when those misses will be.

Many of us have heard the phrase, "If you've seen one EMS system then... you've seen one EMS system." And I think that's true with respect to the spine clearance debate.

If your system is clearing spines, OK. But accept that there have been, and will be, misses. Hopefully, your leadership understands that and has acknowledged these occasional circumstances.

For us, and specifically me in recovery, we've decided to minimize the risk of misses by continuing with our recent return to spinalling primarily based on mechanism.

Now I think I've explained how this dark period of my life happened and what went wrong. You're probably just dying to know the answers to the other two questions: How am I managing in recovery, and will I relapse?

To quote big-time athletes, I'm taking things one day at a time. It's not been easy. I still get the shakes now and then. But I'm happy to report that my wife and kids decided to not leave me.

I don't think I'll relapse. But you never know. I have episodes of weakness, and I get scared I might succumb. Especially since I have some smaller EMS systems that I still allow to clinically clear.

Thanks for your attention. It helped me a lot.

References

1. Cordell, et al. Pain and tissue-interface pressures during spine-board immobilization. Ann. Emerg. Med. July 1995 26:31-36.

2. Domeier, et al. Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann. Emerg. Med. 2005;46:123-131.

3. Hauswald, et al. Out of hospital spinal immobilization: Its effect on neurologic injury. Acad. Emerg. Med. 1998; 5:214-219.

4. Hoffman, et.al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM. 2000;343:94-99.

5. Linares, et al. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987 April;10(4):571-573.

6. Mawson, et al.  Risk factors for early occurring pressure ulcers following spinal cord injury. Am. J. Phys. Med. Rehab. 1988 June;67(3):123-127.

About the author

David Ross, DO FACEP is an EMS medical director in Colorado Springs, CO. He works with numerous agencies in the area including AMR which holds an exclusive, governmental contract for 911 services in the city and surrounding county. He is also an emergency physician at Penrose Hospital and a partner in Front Range Emergency Specialists, PC in Colorado Springs. Ross can be contacted via e-mail at dave.ross@ems1.com.

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Comments
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Bill Aughton Bill Aughton Wednesday, February 05, 2014 10:26:04 AM I think Dr. Ross is missing the boat. With good training clearing the spine, where possible,usually, irrespective of the MOI, produces a better patient

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