Sunday, August 8, 2010

Putting a sacred cow to pasture - cervical and spinal immobilization

The American Emergency Physicians News recently published a piece on the use of spinal immobilization and cervical collars. Despite evidence against the use and very little evidence that using immobilization techniques and equipment protects the patient from further injury this practice continues to put patients at risk for injury. There is increasingly more literature that discusses the harms associated with inappropriate cervical and spinal immobilization, which is defined as either incorrectly applied devices or inappropriately placed on patients without signs/symptoms of injury. This practice has been under scrutiny since the 1980s yet both pre-hospital and emergency departments use this practice routinely despite valid and recent evidence recommending otherwise. Disclaimer: this is not to say that there are not situations that spinal and/or cervical immobilization is not appropriate or necessary; and there is literature that supports this practice.

Further contributing to increased morbidity is prolonged immobilization once in the emergency department. Delays in being evaluated by an emergency department physician or nurse practitioner leave the patient lying immobilized for a prolonged period of time increasing the risk for extension injuries, skin complications, airway complications, elimination issues and emotional distress. Many nurses are not trained or competencied to adequately care for a patient with cervical collars and/or spinal immobilization let alone application and removal; this is often the case in non-trauma centers or in an academic institution with medical residents. Nurses often lose track of how long their patients are immobilized and a substantial delay occurs before being evaluated and removed from such devices. Once in the emergency department, nurses must advocate for their patients and treat immobilization as a priority of care.

Both paramedics and nurses must be familiar with evidence-based practices and know both the risks and benefits of the care they provide. Performing a skill on the basis of “that’s how we’ve always done it” is dangerous business for the patients we care for and it is incumbent upon us to ensure the care we provide is rooted in evidence and not just another scared cow.


  1. Amen.

    I've been preaching the same thing for years.

  2. Awesome post! One of my favorites. I re-tweeted on Twitter and posted to Paramedicine 101 FB fan page. One of my biggest complaints about the dogmatic EMS education (and I use the term lightly) is that we substitute broad non-EBM treatments in place of requiring thinking clinicians.

    If everyone gets a backboard and 100% oxygen no one has to think.


  3. Absolutely! Unfortunately with limited resources and stretching personnel too thin, we actually create situations that put patients at risk; it's easier and cheaper to do things the same way regardless of evidence. I see this frequently - staff concentrate on completing tasks instead of performing assessments, interpreting patient data and critical thinking. This [immobilization issue] is just another example of a procedure that results in poor patient outcomes.

    Thanks for the comments!

  4. Amen,with our medical director he still insists that even with minor injuries the pt must be placed on a backboard. Too bad he has never spent two hours on one, might be a different tune then.

  5. Great thought...I am sure if we experienced half the things our patients' did we would think twice before doing any unnecessary procedures - backboards and collars included! Thanks!

  6. i will dance on a pile of longboards when we finally get rid of the "standard of care" that is CYA spinal immobilization.