Are We Taking Care of Cervical Injuries Properly?

Replies to This Discussion

Permalink Reply by Todd Webb on June 8, 2009 at 3:22pm

I do agree with some of your comments about how field EMS works. Now about the xcollar, first to ask have you seen the xcollar? The study was to show how much improvement there is with this new technology verses market collars which do not support the cervical spine but is only a reminder to not to move. With the xcollar, you are secured and not able to move like the market collars. Second, witht he market collars, you have to measure the patient (2 or 3 fingers) than measure market collars to find one that fits, with the xcollar, there is no measuring, the xcollar is adjusted while you apply the xcollar to the patient. How do you apply a collar on a patient when the head is not in neutral position? With the Xcollar, you can apply the xcollar to the patient when the head is not into neutral position and secure the cervical spine. What an improvement in patient over marketed collars where your not able to do. You really need to actually have one in hand and try it to really see how much it really improves patient care with cervical injuries and than ask the question, is it impressive? Your answer will be yes. What type of level do you work in EMS? If you work for a service, ask them to try one and realy see how it works is the best way. If you would like to do that, contact me and I can seel your service one to try out.

Lee said:

"How do you feel about how we treat cevical spine injuries today"?

I believe we overdo it. I've been in countless arguments discussions about various settings and scenerios. I've personally had a victim of a collision deny any pain or discomfort. She refused all treatment, ambulatory without any deficit, turn her head to answer a question and drop dead on the spot. We all know about the "Prudentialitis" victims when the MOI (mechanism of injury) didn't knock the dirt off the bumper complain of "severe" neck pain. The 80 year old who slid out of their wheelchair to the floor who denies injury, but the nursing home wants them transported.

In the majority of cases, we immobilize not to protect the c-spine, but rather to protect our own ass. We try to justify it by citing the MOI. MOI IS an important consideration we should use to formulate the type of treatment, but it should not dictate. Trauma guidelines state one should transport all patients in the same vehicle, to a trauma center if there was a fatality in that vehicle. The problem with that rational is the one who died, failed to wear their seat belt and "french kissed" the windshield, while the other passengers were properly restrained and suffered minor injuries.

I skimmed through your attachment, and a few things jumped out at me.

Our study employed healthy volunteers in a controlled setting.... Mean age was 23.2 What about the elderly patient with osteoporosis, who is already shaped like a question mark? What about facial trauma especially to the maxilla, zygoma, and orbits? Anyone who has been in this profession more than a couple of weeks, has had these types of patients, and knows the device mentioned in this study is not going to be any better than the others, in these type of situations,

The subject was coached to maintain an upright back position to prevent rounding and anterior flexion of the shoulders. Can we affect the results of any study any more than by coaching the subject?

Now, being open minded and in all fairness, the xcollar by design probably does a little better job on normal non-deformity patients than those compared, but I would stop short of calling it impressive. Different, yes. Would I use them? Probably.

I do not now nor will I advocate using a c collar by itself without manual stabilization even in an MCI setting. One does not put a collar on a patient and leave them. What if we were allowed to think instead of saying "the manual says this"? What if we were taught to clear the c spine of "walking wounded" or where the MOI does not equate to actual injuries or symptoms? But as I stated earlier, we must watch our 6 because, the one time we don't will be the exception to the rule, and will come back on us.

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Permalink Reply by Kevin Collopy on June 10, 2009 at 8:46pm

This is a great topic for discussion. A few thoughts to get this cooking. Cervical collars were never intended to be immoblization devices. Their original intent was to limit cervical spine flexion and extension during the extrication process. At some point in their history the collar suddenly was thought of as an immobilizer. The collar is an aid in immobilization and c-spine control but is not a stand alone system.

Further, no study has ever proven that full immobilization of trauma patients is BENEFICIAL. One study showed that there was a lighly negative outcome from immbilization but it was not statistically significant. Multiple studies have shown patients are more likely to have back pain after being immobilized

Devices that focus on c-spine control alone do not take the more wholistic approach to immoblization; full spine immoblization requires limiting the movement of the hips, shoulders, and the head...the three heavy weight centers that affect spine movement.

That said, I feel there are two schools of spine care provided...we ALL know what proper and thorough immobilization is. One school practice good immobilization, with lots of straps Xing the weight centers, padding, and careful movement. I have also seen another school that uses minimal strapping, doesn't secure patients to backboards tightly, etc. I have watched this latter crowd put a c-collar on a patient who is in a MVC and the patient get out of the car on their own, stand up, walk to the stretcher, and then lay down on the board!! I was shocked! I have seen paramedic crews in the ED tell me "we know he feel but dont know how far, how hard, or if he lost consciousness, he has a large hematoma on the head, so we threw on a c-collar" but they didnt immobilize the patient...

We need to reeducate our peers to proper immobilization; these issues come mostly from laziness and nothing else. I think we will do a better job immobilizing people when more providers (1) care about their job, and (2) know they are only immobilizing patients who need it. there are two ways to get to this latter point. Criteria for immobilization is at best subjective and not research based...so lets develop some researched criteria.

Another way to get to more efficinent immobilization is introducing well-followed spine assessments. I do NOT mean selective immobilization where a mechanism is ruled out, or half-assed assessments. I mean researched, studied, assessments; typically those that are based off of the NEXUS study. A thorough spine assessment will be the best and most immediate benefit to improving the INTENT providers put into immobilization. Do this, and the devices can then be adjusted to meet these new patients.

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Permalink Reply by Kevin Collopy on June 10, 2009 at 8:49pm

There are a few other ways we can improve immobiliation. We do not need to be immoblizing all patients flat supine. Many patient groups would benefit from being immoblized on their side (not flat with the board tilted). Try placing someone on their side some time on a board, and then add extra padding (pillows and blankets) along the extra voids and spaces. Pregnant women, those with osteoporosis, and those with impaled objects, are all much more comfortable on their side than being layed flat or on a tilted board.

Also place PADDING on the longboard beneath the patient. A few blankets on the rigid board can make any transport more enjoyable.

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Permalink Reply by Todd Webb on June 11, 2009 at 6:20am

Kevin,

I understand where your going but have to relize that there has been studies done and the need for better equipment in cervical spine immobilization. The cervical spine has not been addressed in patient care for over 35 years as we have always done the same thing with same equipment in which doesn't support cervical spine. When the patient is truly immobilized properly, the patient will be placed in the Neutral Spinal Positioning when ever possible but in some cases, the patient can not be placed in the neutral position which in turn doesn't allow us to place a cervical collar on patient which in turn makes us improvise to secure the cervical spine. I have seen numerus services immobilize a patient incorrectly on a long board with the market collers used today. To be in the Neutral Spinal Postion, the adult patient is to have the nose, vael, and toes in align and the head must be off long board approximate 1 to 2 inches to have the patient in the neutral spinal postion but with the market collars today, EMT's place the collar on the patient and then place the patient onto the long board with the head flat against the board, not putting patient into the properly neutral spinal postion and actually hyperextending the neck backwards. So are we actually casuing more injuries to cervical spine patients when we immobilize the patient? The DOT states that 25% of injuries seen at the ED's are from moving the patient when not having the cervical spine properly secured. So when did the actual injury occur, when we moved the patient to neutral position, when we improvised with head turned, when we applied the collar, when we moved the patient to long board, when we moved the patient to cot, or when we transported the patient to ED? We can now eliminated most of these by using the Xcollar Cervical Splint which took methology of splinting and placed it to the cervical spine which splints above C1 and below C7, securing the cervical spine properly. The padding you we talking about has other devices in use that can be applied to the board which is air supported or non-air supported to help take up the void and make it more comfortable for the patient. But to transport trauma patients on there side must only be used in special cases and not to be used as normal immobilization of the patient which does not put the spine in proper alignment which does not support the spine. The question to you is have you ever seen the Xcollar cerivcal splint and if not, should look at one, try it, and then answer the question, do this splint improve patient care with cervical injuries and why did it take so long to develop this new tool?

Kevin Collopy said:

There are a few other ways we can improve immobiliation. We do not need to be immoblizing all patients flat supine. Many patient groups would benefit from being immoblized on their side (not flat with the board tilted). Try placing someone on their side some time on a board, and then add extra padding (pillows and blankets) along the extra voids and spaces. Pregnant women, those with osteoporosis, and those with impaled objects, are all much more comfortable on their side than being layed flat or on a tilted board.

Also place PADDING on the longboard beneath the patient. A few blankets on the rigid board can make any transport more enjoyable.

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Permalink Reply by Kevin Collopy on June 11, 2009 at 11:31am

Todd, you raise some valid points and ask some good questions. I agree 100% that we have performed cervical spine immobilization the same way without asking outselves why or how we can improve it. I agree with your description of the neutral position, however I disagree it must be performed in the supine position. The same can be accomplished with the patient on their side. This however is a moot point at the moment and a great discussion for later on.

Your original question was do we properly care for cervical spine injuries. I think our agreement here is no we currently do not routinely provide the best care we are capable of providing. This is yes, a function of cervical collars being treated as immobilization tools rather than the movement-reduction tools they were intended to be.

I question the DOT's statement that 25% of spine injuries are EMS induced. I have never seen one scientific study to support this, and if this were the case then patients would not be removed from longboards immediately upon ED arrival.

I agree with you that we need to be doing a better job with this skill. I am open to any equipment that truly improves immobilization as long as it is used as a whole with other immobilization tools (longboard). My initial fear is that some providers will use this product as an excuse to not place patients on a backboard and only apply the cervical splint. This would be a huge detriment to patients.

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Permalink Reply by Todd Webb on June 12, 2009 at 7:39am

If I remember right, we are also taught to place pregnent patients on there side is the only time to place a patient on long board. The 25% from dot is fact published by DOT and is on a trauma fact sheet from one of the Wisconsin State Trauma Committee's website also. I do not feel that they will not continue to long board patients but will be able to do it more secure than they we able to do it for 35 years as with the xcollar having the cervical spine so secured, you will only need to tape down the nead with xcollar cervical splint to long board and eliminate using head blocks along with xcollar cervical splint. Also, with using the xcollar cervical splint, using a KED is easier to use as with the KED, the head is the hardest area to keep secured in a KED but with the xcollar cervical splint already securing the cervical spine, the use of the KED is made alot easier to secure patient in. By using the xcollar cervical splint makes other procedures easier to be done, faster, and more secured. Wow, just what we want in the field for us EMT's to be able to do things quicker with improving patient care. So we are actually improving other procedures while improving cervical spine care makes it very impressive new tool and technology which makes it worth while to look at, buy and use in the field. I feel that EMT's out there in the field already just place a collar on patient without long boarding the patient which is putting there careers in EMS in jeapory and possibly being sued for causing life threatening injuries above the injuries already with patient.

Kevin Collopy said:

Todd, you raise some valid points and ask some good questions. I agree 100% that we have performed cervical spine immobilization the same way without asking outselves why or how we can improve it. I agree with your description of the neutral position, however I disagree it must be performed in the supine position. The same can be accomplished with the patient on their side. This however is a moot point at the moment and a great discussion for later on.

Your original question was do we properly care for cervical spine injuries. I think our agreement here is no we currently do not routinely provide the best care we are capable of providing. This is yes, a function of cervical collars being treated as immobilization tools rather than the movement-reduction tools they were intended to be.

I question the DOT's statement that 25% of spine injuries are EMS induced. I have never seen one scientific study to support this, and if this were the case then patients would not be removed from longboards immediately upon ED arrival.

I agree with you that we need to be doing a better job with this skill. I am open to any equipment that truly improves immobilization as long as it is used as a whole with other immobilization tools (longboard). My initial fear is that some providers will use this product as an excuse to not place patients on a backboard and only apply the cervical splint. This would be a huge detriment to patients.

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Permalink Reply by Kevin Collopy on June 16, 2009 at 1:46pm

Todd,
I have taken some time to decide how to continue this discussion. I guess my first point is that you asked the question "do we immobilize the cervical spine well?" We have agreed the answer is no, not really. You keep though, pushing one product the XCollar is the only alternative and the best. I am trying to discuss alternative ways to immobilize in general and other ideas to get people to think. It is disrespectful to people to try and force one product as the only solution.

Secondly, I challenge your assertion that 25% of spine injuries are induced by the immobilization process. I understand that it is on websites and fact sheets. But I challenge where that information comes from. That means that one out of 4 people with spinal column injuries have them as a result of EMS actions. If that were the case we would see frequent lawsuits, fractures occuring in hospitals, nursing homes, from standing falls, etc much more frequenty. Hospitals would also not immediatly remove patients from longboards so quickly.

I think it would be more accurate to state that 25% of patients who are immobilized who do not have neck/back pain at the time develop neck/back pain by the time they arrive in an emergency department. This is because longboards are uncomfortable, not because of the immobilization process. Further then would be the movement of the patient, not the c-collar application itself that does this and your product would not reduce this "number." Again, I have not seen a single research paper that demonstrates your position, please find a research paper that backs up this claim.

I am not trying to suggest the Xcollar is not beneficial, I have been given several to review and test. I will be doing so this week. My only real request is that you don't admonish other ideas to push your own agenda. I am well aware of what studies have and have not been performed. I regularly read all the EMS related published research. What I didn't see was a 50% reduction in the spine neck movement you state occurs. I read the paper published in Prehospital Emergency Care this spring and depending on the type of movement, there is a great amout of reduced movement (especially flexion) but other movements are not as well restricted.

Like i said, the product seems to have a lot of potential, but it shouldn't be pushed as the only option to "how can we immobilize better?"

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Permalink Reply by Michael Fraley on June 20, 2009 at 10:41pm

I would even be interested in the links to the web sites you mention. As a sales rep for XCollar you must have this information readily available. And please don't take our skepticism the wrong way. It is just that EMS has a long history of accepting new ideas and flashy products and putting them into practice without questioning the science.I am glad to see the tide changing.

Thanks

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Permalink Reply by Todd Webb on June 21, 2009 at 11:26am

What links are you looking for?

Michael Fraley said:

I would even be interested in the links to the web sites you mention. As a sales rep for XCollar you must have this information readily available. And please don't take our skepticism the wrong way. It is just that EMS has a long history of accepting new ideas and flashy products and putting them into practice without questioning the science.I am glad to see the tide changing.

Thanks

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Permalink Reply by Michael Fraley on June 27, 2009 at 10:17pm

The Wisconsin Trauma Committee and the DOT sites you mentioned on june 12.

Todd Webb said:

What links are you looking for?

Michael Fraley said:

I would even be interested in the links to the web sites you mention. As a sales rep for XCollar you must have this information readily available. And please don't take our skepticism the wrong way. It is just that EMS has a long history of accepting new ideas and flashy products and putting them into practice without questioning the science.I am glad to see the tide changing.

Thanks

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Permalink Reply by Todd Webb on June 28, 2009 at 6:59am

I will have to get the DOT link from my Company but I have included the Dane Cty Letter which has there link on it.

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Permalink Reply by Michael Fraley on August 4, 2009 at 11:57pm

Todd, I would still like to see these documents. I have looked back through this thread and do not see them. If you are going to drop names you really should be prepared to provide the proof. Please either post a specific website URL or full citation of the study. Thanks.

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