Long Board Immobilization - Bob Heflin, APP Board Member
When in Doubt Immobilize? Maybe not!
Dogma; Merriam Webster defines dogma as “A point of view or tenet put forth as authoritative without adequate grounds”
Why do we immobilize potential thoracolumbar spinal injuries on a long spine board(LSB)? Mostly we do it because we were taught to in some EMT class years ago. Whole sections of state licensure tests were designed to test our ability to completely immobilize a patient on a hard board with straps and duct tape and head restraints. Cervical spine injuries got all of the above with the addition of a c-collar and more tape. But why? Where was the evidence that showed this to be a good thing for the patient? Aggressive immobilization of trauma victims with suspected spinal injuries became common during the Vietnam War when it was assumed that doing so was protective of further injury to the affected area. Immobilization above and below the injury required placement on a long board. Admonitions to pad the voids created by having a non flat spine placed on a flat surface were common as well as trying to pad the board itself, suggest that the idea that pressure points could lead to decubitus ulcers was being considered. In fact, in a five year retrospective study done as far back as 1998 and published by Hauswald, Ong, Tandberg, and Omar.. compared outcomes in similar hospitals receiving trauma patient in both Albuquerque, New Mexico and Kuala Lumpur, Malaysia, showed that in the US where all suspected spinal injuries are placed on an LSB the outcomes were worse than in the Malay study where most trauma cases arrived POV or were brought in by police or bystanders with no LSM use Both Hospitals in the study were University teaching hospitals and the physician's level of training and radiological services were similar.
There is also evidence that LSB immobilized patents are subjected to radiological examination at at statistically significant higher rate than trauma patients not immobilized. In addition addition of cervical immobilizing devices often causes pain and and can lead to restricted breathing or airway compromise.
Recently the American College of Emergency Physicians released a policy statement regarding
Spinal Injury Management. ACEP concludes that ”Backboards should not be used as a therapeutic intervention or as a precautionary measure either in or outside of the hospital, or for inter-facility transfers. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal trauma.”
Additionally the US Consortium of Metropolitan Medical Directors in their “Position Statement on Spinal Immobilization” have this to say;
“Current best practices reflect that there are randomized controlled trial to evaluate the benefits of Spinal Immobilization in out of hospital patients. As result, current EMS protocols are based principally on historical precedent, dogma, and medico-legal concerns, and not on scientific evidence. This situation is further complicated by the reality that such studies will not likely be performed in the future, primarily as a result of perceived legal and ethical concerns. There is however, a growing body of literature that points to the deleterious effects of spinal immobilization, whether or not this modality is applied in an appropriate fashion.”
These policy statements should the basis for a serious re thinking of how we approach the care and management of these patients in the Ski Patrol setting. NEXUS and the Canadian C-Spine rules give us well researched and clear guidance on how to treat suspected C- Spine injuries.
Personal experience has made it it clear that clothing worn by skiers and the environments they are found in makes correct selection and application of cervical collars difficult at best and potentially dangerous at worst. The use of vacuum mattresses has revolutionized the management of traumatic injuries and though expensive, when used correctly, they are the most appropriate and humane choice for stabilization of traumatic injury.