Immobilization Errors in EMS

You and your partner have extricated to a long spineboard an obese 65-year-old unbelted driver of an old pickup that left a rural roadway, rolled down an embankment and landed on its top. The driver was partially ejected, and his legs were sticking out of the upside-down driver’s window. He was conscious, but confused and complaining of severe pain in the lumbar spine area.

You perform your initial survey, which reveals good pulses, movement and sensation in all extremities, place a cervical collar on him, secure him to the board with the three straps provided—one across the upper chest, one across the hips and one across the lower legs—and move him to a stretcher and then the ambulance.

During your trip to the trauma center, he complains loudly about pain in his back and says it’s so bad that it’s making him sick to his stomach. Without warning, he begins to vomit. Not having your suction set up, you quickly turn him and the board on its side and wipe vomit from his mouth. As you turn him, his trunk sags downward between the straps, and he screams. After that, he complains of numbness in his legs. You ask him to wiggle his toes, and he says that he is doing so, but there is no movement.

After dropping him off at the ED, you receive a call from your supervisor telling you to write a supplemental report; she has just been informed by the ED physician that your patient is paralyzed from L2 down. You are devastated.1

What went wrong? Your patient was in a collar and secured to the long spineboard. Why did he suffer an injury when you turned him on his side?

Every day in America, thousands of patients are transported in ambulances on long spineboards with cervical collars in place. They are usually described by medics as having been “spinally immobilized.” But are they truly immobilized? Does it even matter? When one group of researchers compared Malaysian patients who received no spinal immobilization efforts with a like group from New Mexico who were “immobilized,” they found there was less than 2% chance that immobilization had any beneficial effect.2

Still, in the U.S., most, if not all, EMS systems require that patients be placed in collars and on a spineboard in a variety of situations. Some use a selective spinal precautions algorithm, as is discussed elsewhere in this issue. Debate has risen in recent years on the subject, immobilize vs. do not immobilize, and many articles have been written.3

There is even controversy over what to call what we do. Many have discarded the term immobilization because it can readily be shown that complete immobilization rarely occurs; some use the term restrictions and some precautions. Semantics aside, what we’re talking about is the effort to minimize movement of a patient’s spine during transport.

Whether immobilization, or whatever we choose to call it, affords any benefit, if we are going to attempt it, we ought to do it as well as we can.

Following are some pitfalls that may occur with the procedure and practical ideas for improvement. None of these suggestions are in any way supported by research. Try them, subject them to the most stringent trials possible in the practice setting, and evaluate for yourselves whether or not they have merit. They are just ideas that I have picked up during two decades as a medic.

Most of them are obvious and simple, but often forgotten. Or, they aren’t done because providers think they take too long. We also tend to see through rose-colored glasses and assume that nothing bad will happen because of what we do.

Positioning Your Patient

We often log-roll a patient onto a board, only to find half of him hanging off the side. I have seen various parts of a patient’s body and clothing grabbed in an attempt to get him all the way onto the board. This usually results in patient movement that defeats the whole purpose of the immobilization maneuver.