Primum Non Nocere, Mostly....

It would be ironic if it weren't tragic.

Imagine a procedure we perform tens of thousands of times per year, knowing that 990 of every 1,000 occurrences are a complete waste of time.

But we rationalize it, deciding that the procedure is harmless for the 990 patients for whom it is unnecessary, and for the remaining 10 -- well, it can be positively life-saving.

Or so we think.

All such rationalization is moot anyway -- the bureaucrats who plague our profession have proven more than willing to suspend any medic or EMT who fails to do this procedure despite the indications, or lack thereof, and lots of tort lawyers (those are the guys with the bad hair, billboard ads and late night TV commercials) have paid for their summer houses on the Cape under the auspices of that old rule that says certain kinds of back pain are hard to disprove.

Now imagine that that procedure turns out to be not only useless for most patients, but potentially fatal to the 10 critical patients for whom such exacting adherence to the rules exists in the first place.

That's exactly the situation we face today, with our blind application of cervical collars and longboards to everyone who in any way suffers the effects of misguided kinetic energy, no matter how trivial or brief.

So it was with a mix of fascination (because it was fascinating) and frustration (because I doubt things will change) that I read an article this week challenging one of the most basic precepts of EMS.

The latest issue of the Journal of Special Operations Medicine includes an article by Dr. Peter Ben-Galim, of the Spine Research Laboratory at Baylor College of Medicine, where he is also an assistant professor of medicine.

In it, Dr. Ben-Galim comes to two interesting conclusions:

1 -- there is no evidence that a c-collar "can truly prevent abnormal motion of a severely injured spine in a trauma patient," and,

2 -- after experiments with fresh cadavers and examining other physical evidence, Dr. Ben-Galim found that for patients with unstable spine injuries, "the collars may be doing more harm than good," including all sorts of devastating sequelae, including death

In other words, there's no proof that what is perhaps the single-most common procedure in EMS (ie, aggressive c-spine immobilization as currently practiced) does even an iota of good, while there are some pretty significant indicators that it could be fatal to the statistically tiny fraction of patients for whom the whole megilla was concocted in the first place.

Like I said, it would be ironic if it weren't tragic.

Dr. Ben-Galim's conclusions were based on research he and his colleagues in Houston conducted on fresh human cadavers, on whom various c-spine immobilization devices were applied after a process in which the cadavers were frozen, then re-warmed to room temperature (there being a strong correlation between spinal movement in uninjured, asymptomatic living humans and room-temperature cadavers).

The research team surgically severed the ligaments holding high cervical vertebrae in place (C1 and C2), and fractured the odontoid, a small bone that extends from the beginning of the axis to the opening of the atlas, alongside the spinal cord.

Typically, these conditions result in instantaneous death, though Dr. Ben-Galim notes that there are almost two dozen instances in the literature of patients surviving this condition (aka internal decapitation).

The researchers then applied a properly-sized cervical collar and compared the resulting anatomical changes using flouroscopy and CT scans.

In EVERY SINGLE case, the "proper" application of cervical collars resulted in gross and potentially fatal separation between C1 and C2.

"The current presentation of our data supports several previous studies in suggesting that extrication collar designs can effectively push the head away from the shoulders, resulting in grossly abnormal displacements between the occiput and the spine," Dr. Ben-Galim writes. "Although these collars are applied to millions of trauma victims each year with the intent of protecting against secondary injuries in the RARE CASE of a serious cervical spine injury, IT IS IN THESE VERY UNSTABLE SPINE INJURIES THAT THE COLLARS MAY DO MORE HARM THAN GOOD." (Emphasis mine)

Dr. Ben-Galim applauds the move away from in-line "traction" to "stabilization" in EMS over the recent years, and encourages research into new ways of c-spine immobilization.

"These observations," he concludes with great understatement, "raise the question for a need of an entirely new concept of EMS and pre-operative cervical spine and head stabilization."

Of course, in EMS you can raise the question, it all just depends on who's going to provide the answer.