Danger at the Door
I am a proponent of EMS personnel having a more independent practice. The days of calling “Rampart Hospital” for an order of “D5W TKO” is a thing of the past. I truly feel that most of our educational programs are strong enough to support independent decision-making by EMTs and paramedics. But it is important to remember that independent decision-making also requires one to take responsibility for their decision and actions. This is somewhat of a new concept for EMS personnel.
One area where independent decision-making has been delegated to EMS personnel is selective spinal motion restriction (spinal immobilization). There is an excellent body of research that shows that the application of an established protocol allows EMS personnel to accurately and safely determine which patients should be immobilized and which should not. We have added it to our textbooks and many EMS systems have adopted it.
Spinal immobilization is uncomfortable and can cause complications in certain patients. Thus, like any other skill or procedure, it should be used when the patient stands to benefit from it. That is, when the patient has the possibility of a spinal injury. Certainly, with spinal injuries, we want to be extremely cautious and should have a high index of suspicion. Likewise, we don’t want to subject a patient to unnecessary discomfort and pain.
Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.
Now, let’s look at this a little more closely. In the system where 13.5 percent of patients with spinal injury were not immobilized, a policy was in place to allow EMS personnel to determine who should be immobilized and who should not. The premise is that all patients should be immobilized unless they meet the criteria to bypass immobilization. The protocol requires that EMS personnel complete a structured, standardized exam (e.g. altered LOC, spinal pain or tenderness, neuro deficit, distracting injury). If the patient meets any of the established criteria, they must be immobilized.
So in 13.5 percent of the cases, EMS personnel performed an exam and came to the conclusion that immobilization was not necessary. Thus, from a negligence standpoint, this was an act of commission and not an act of omission. A jury would probably look more unfavorably on an act of commission. In reality, what this tells me is that some EMS personnel are NOT properly applying the protocol or applying it selectively. The protocol only works if applied in a standardized fashion—the same, each time and objectively—to ALL trauma patients.
EMS personnel want more autonomy, but autonomy requires integrity. Integrity is what you do when nobody is looking. Medicine requires an extremely high degree of integrity; shortcuts in medicine can harm people. In emergency medicine, we assume a patient has a severe injury until proven otherwise. It is the only safe way to approach things in a short period of time. This same adage holds true in EMS.
Quality monitoring in EMS should detect issues such as this — this is how the trauma system detailed above discovered the 13.5 percent miss rate — but quality monitoring must be applied uniformly and EMS personnel must be given the results on a regular and constructive basis. Personnel who are taking short cuts and making clinical assumptions should be counseled. This spinal immobilization trend may well turn out to be like the trend we saw in the late 1990s with unrecognized esophageal intubations. It cannot be tolerated.
There are many of us working to improve EMS. More pay and more independence are needed, but these come with the associated responsibilities. It is frustrating in that every time we make some progress, EMS finds a way to shoot itself in the foot and set things back. Let me close with this: Every time you are using a selective immobilization protocol, assume that the patient is a member of your immediate family. Apply the protocol systematically and uniformly. If in doubt, immobilize. Please, let’s not take another step backwards.
Related Resource: Spinal Assessment Protocol — Maine EMS