It’s a familiar sight: emergency medical teams using a neck collar, head blocks, and tape to secure an injured person’s head to a backboard.
But the rule that required this common emergency medical procedure has been abolished in New York State, thanks to an advisory group led by an ECMC emergency room physician, whose report showed it can do more harm than good.
The report, which cited 21 studies, found that people immobilized on backboards – sometimes for hours as X-rays and other tests are completed – not only suffer pain, but are at risk for injury. The new policy was devised by a technical advisory group suggested, assembled and led by Dr. Joseph Bart, an emergency room physician at Erie County Medical Center.
“In many ways, this was a Western New York initiative,” said Dr. Brian Clemency, associate medical director for the local offices of Rural/Metro Medical Services, who led one of the studies cited in the report.
The new state requirements being taught give more options to EMTs and paramedics, who previously were required to suspect spinal injury after many impact injuries and use total spinal immobilization. The new rules mean that if the patient has certain symptoms, a collar will still be used to support the cervical vertebrae of the neck. The backboard will stay, but only as a means of transporting a patient to the padded ambulance stretcher.
The head blocks and tape will remain for the rare occasions when they are needed.
The change is significant, but rather than being skeptical, emergency medical professionals are embracing it, according to Bart.
“Once I explain this to EMTs and paramedics, they are smiling as they are walking away, so this is a win,” he said.
Bart worked as an ambulance paramedic before becoming operational medical director of the division of EMS at UBMD Emergency Medicine.
Spinal immobilization was first discussed in emergency medicine in the late 1960s, and by 1984, New York State protocol required the collar and backboard combination. An update in 2008 advised medics whose patients had suffered blunt-force trauma to “suspect that a spine injury is present,” to always use the collar, backboard, head blocks and tape as a set, and to never remove the immobilization devices outside the emergency department.
Now, “We have untied or divorced the concept that cervical collar always means backboard and head blocks,” said Bart. “What I’m telling EMTs and paramedics is, ‘You never again have to use a backboard if you have determined that it’s not going to be the best device or tool.’ ”
However, he said, “You need a rigid board to extricate people from some circumstances. The scenario of a prone, unconscious motorcyclist in the ditch – you’ll put him on a backboard 100 out of 100 times, because it’s the best tool for the job. The whole goal of it is to get them to the stretcher; the backboard is an extrication tool.”
Bart said an incident from a few years ago led to his push for statewide change. An elderly woman who had fallen in a back bedroom and injured her ankle was brought into a hospital by an ambulance crew. To get her out of the back room, the EMTs put her on a backboard. When they got outside, to complete the protocol, they added a neck collar and head blocks and taped her head to the backboard.
The elderly woman, whose back was slightly rounded, began to suffer back and hip pain from being on the hard, straight backboard. “This was not a benign thing,” said Bart, who had the woman removed from the immobilization devices.
But before that, resident physicians, who Bart said “are learning, as well,” took the collar and head blocks to mean that the woman had suffered a major traumatic injury. “She came in with an ankle injury and needed an X-ray, and she ended up getting a C-T scan of her head and cervical spine, a chest X-ray, a pelvis X-ray, and ankle X-ray – just because she came in on this backboard,” said Bart.
“I thought, ‘Enough is enough. We have gone so far in the opposite direction of the intentions here,’ ” he said.
Bart pushed for a study of the protocol and volunteered to be chairman of the Spinal Motion Restriction Technical Advisory Group, which issued its report last year. On Jan. 13, 2015, the New York State Emergency Medical Advisory Committee (SEMAC) unanimously approved the new protocols, according to the state health department.
Although similar changes had been made in other states, including Pennsylvania, Connecticut, Maine and New Mexico, “I was told time and time again, you have to move a mountain to change a protocol in New York State,” Bart said. However, “From the point where I first pitched this, it’s been about 14 months, which in New York State is rapid.”
The challenge in writing the report, Bart said, was to “convince other physicians, and people who have been doing it for 40 years, to change their practice. The answer is to do it with research, so we flooded it with research.”
Bart’s literature search uncovered about 110 studies from around the world evaluating the value of the backboard, collar and head blocks. In the end, the 21 studies cited in the report showed a wide range of negative factors caused by immobilization. One five-year study done at the University of New Mexico compared patients with blunt-force spinal injuries who were treated at a hospital in Kuala Lumpur, Malaysia, none of whom were immobilized on backboards, and at an Albuquerque hospital, all of whom were immobilized on backboards. The researchers found the Malaysian patients recovered more completely.
Clemency’s study looked at nearly 5,500 patients brought to ECMC by Rural/Metro on backboards over a period of years. Of those studied, fewer than half of 1 percent had the type of unstable fractures of the middle or lower spine that immobilization was designed to protect.
The new protocol will require that every EMT and paramedic in the state be retrained and retested by Oct. 31, which Bart calls “a pretty big lift.”
Until Oct. 31, Clemency said, “People in Western New York are going to see two different paradigms. I think that’s better than to hold everything back for a full two months until everybody is trained.”
“We get used to changes really quickly and I don’t think it’s going to be difficult for anyone to adapt to,” said Rob Orlowski, a paramedic and Continuing Quality Improvement coordinator for Rural/Metro. “Our paramedics and EMTs are clinicians, they go to continuing education classes all the time, so they are doing more, better evaluations of the patient and using more skills to bring the emergency department out to the field.”