“In god we trust, all others must bring data.”
The quote comes from a man named W. Edwards Deeming, a noted management expert circa 1950s. It sums the bane of my existence as an undergrad psychology student. If it cannot be studied, proven beyond a 5% reasonable doubt and peer reviewed then it ceases to exist. There is good reason for this strict empirical approach to research. Bad things can happen when we believe good public speakers with little evidence. Consider spinal immobilization.
Boarded until proven otherwise. Such is the attitude for most spinal immobilization training in the pre-hospital environment. If the mechanism of injury suggests potential spinal involvement we break out the velcro. If the Px thinks about the words pain and neck in the same sentence we lunge to take C-spine. Our otherwise stable Px with no neurological deficits is then tightly strapped onto a rigid backboard, hands and feet bound.
There is growing evidence which suggests this all-encompassing practice has evolved not from empirical research but from dogma and fear of litigation. Dr. John Burton, of the Albany Medical Centre, discussed the over utilization of spinal immobilization in a 2008 Podcast. Among his points was a candid look at the anatomy of a spinal injury.
What we dread in our Px is an unstable spinal column fracture that we, and they, are unaware of. As we shuffle and bump them out of their environment and into ours, an unstable spinal injury might permit secondary damage to the spinal cord itself. Dr. Burton describes three problems with this picture:
- Damaging the spinal cord requires specific, high-energy, mechanisms of injury (MOI)
- Even with a severe MOI, the Px spinal column actually has to be damaged. You cannot bleed to death without bleeding
- Even with a spinal injury, as mentioned above, it has to be unstable
A 2001 Canadian study looked at 8,924 Px you and I would probably immobilize. The study’s goal was to reduce unnecessary head/neck x-rays by developing more accurate selection criteria. If the Px was older than 65, complained of acute paralysis or suffered a dangerous MOI (crash over 100 km/h, diving accident, etc.) they were considered at risk for C-spine trauma. Of interest were all the other Px. The girl who was rear-ended in traffic or the teen who’s neck began to hurt half an hour after an MVA (ref: Stiell, 2001). After analyzing clinical findings based on who actually had an unstable spinal injury the group produced the 3-step Canadian C-Spine Rule (CCR).
The CCR algorithm was put to the test with a new set of 8,283 Px (everything really is bigger in Canada). Of this group, 217 had a spinal injury. Of these 217 only 169 had a dangerous (unstable) spinal injury (ref: Stiell, 2003).
Two percent of a very nasty segment of Px (MOIs included MVAs, motorcycle crashes, diving accidents, falls from height, etc). And how predictive was the new CCR algorithm? 99.4%. A whopping 394 different physicians used the CCR after just one hour of training and missed one Px out of 8,283.
Yes but surely boarding someone does no harm – better safe than sorry right? Actually no. A 1998 study compared 5-years of Px charts from a New Mexico, USA trauma hospital and a Kuala Lumpur, Malaysia Hospital. All of the American Px were boarded, none of the Malaysian Px were. 21% of the immobilized Px suffered permanent neurologic deficits, 11% of the non-immobilized Px did. The study mentions that it takes 2,000-6,000 Newtons to damage the cervical spinal column. Dropping your Px head off the end of a stretcher applies about 40 Newtons of force – even in an elderly Px (ref: Hauswald, 1998).
Having led first with empirical evidence consider now the anecdotal. Have you ever been boarded? I have, both in practice and after a personal MVA. It is awful. Picture yourself as a Px requiring technical rescue. A group of innominate strangers descend onto probably the worst 20 minutes of your life. Your vision and hearing are almost immediately obscured by tight velcro straps and sand bags. You can see the litter basket being tied-in yet have no idea what to expect as you are raised or lowered into the abyss. As your vital signs are stable and you are fully alert you can expect to wait a few hours in the ER before radiology will free you from this velcro prison. If you have to pee there are three options: hold it, pee your pants or accept a catheter.
Can I sign a DNR card for immobilizing?