Even before EMS was established, rescue personnel have used their best efforts to save patients by means of current techniques and equipment available. Since its infancy, emergency medicine has evolved thanks to continued improvements in the methods and tools necessary to meet the needs of critical patients in challenging conditions.
One such evolution is Cervical Movement Restriction (CMR). A series of steps and multiple personnel are required to perform c-spine immobilization procedures on a single trauma patient with potential cervical spinal injury. This important procedure must wait to be performed until EMS providers and rescue crews have addressed other priorities like scene safety, patient assessment, triage (if multiple patients), ABCs, treatment of the most critical patients, extrication (if limited or no access) and many other issues.
Searching for the Best Care
The need to improve the way c-spine management has been performed became evident to me after applying hundreds, if not thousands, of conventional c-collars on patients. As an EMS provider performing this BLS procedure, I always reassured and instructed patients to be still while informing them that the collar would work as a reminder not to move, all the while knowing the devices we were using worked marginally at best. My frustration grew as I began to question the efficiency of the devices and procedures used, and if we were actually providing the best care possible for our critical patients. I was compelled to do something that would enhance the way we approached c-spine management, expedite treatment and improve the outcomes of trauma patients.
There were several problems that needed to be addressed in order to substantially improve the practice of this procedure. The first problem we faced with conventional c-collars was that they work by wedging hard plastic between both of the trapezius muscles and around the base of the cranium to restrict motion of the patient's head. This action, upon the presence of a fracture or ligamentous injury, inevitably has the tendency to separate the head from the body, therefore extending the neck and potentially creating distraction of the cervical spine. As a result, EMS providers could involuntarily worsen existing injuries, causing irreversible neurological damage, internal decapitation and even death. (See clinical study by: Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury, Journal of Trauma-Injury, Infection, and Critical Care 60:2 447-450, August 2010).
Secondly, the techniques currently used need improvement since they were developed within the inadequate limitations of conventional c-collars and other equipment used. Most c-spine management protocols mandate that providers place trauma patients with suspected cervical spinal injuries into the in-line neutral position unless they complain of pain or discomfort. This contradicts the principles of avoiding movement to prevent further injury. We should not need to wait until our patients complain of pain upon movement to stop our efforts of re-aligning their heads.
Why is the Neck Different?
Basic first aid and common sense teaches us to splint broken bones and injured joints in the position found or "position of comfort" to avoid further injury. Why don't we treat the neck the same way? Why do we move our patients' heads before stabilization and transport? Why do we place our ambulatory patients on full spinal boards in cases where we only have the suspicion of a cervical spinal injury? When asking these and many other questions to every EMS provider and doctor I know, I was unable to obtain a satisfactory or compelling answer.