All Are Born Mad

If you've read this blog for any length of time, you know I believe we c-spine waaaaaaaaay too many people.
The procedure is one of our Sacred Cows in EMS, and we do it with abandon.
5 mph fender-bender with no visible damage to either car? Board 'em!
Drunk college student trips and lands hard on their bum? Board 'em!
Nana Noodles farts? Board 'em!
Why do we do it so often?
Sometimes I think it's from an over-abundance of caution.
Rarely because it seems like it's in the patient's best interest.
But most often I think it's another example of the CYA-based medicine we are forced to practice in this state, because we all know how reluctant the Powers That Be would be to make any medic or EMT's life miserable if, from Boston and after the fact, it were deemed a mistake to not c-spine a particular patient.
(Note: and if you're wondering, the answer is "not at all reluctant." Plenty of good medics and EMTs have felt the wrath of the almighty bureaucracy here)
I wrote a post a few months ago that talked about a study that showed that placing c-collars on the few patients for whom they are actually made could contribute to their deaths.
You can read that post here.
In another study that highlights why working in EMS in Massachusetts is like being trapped in a perpetual production of "Waiting for Godot," ("All are born Mad, some remain so"), earlier this year The Journal of Trauma reported on some interesting -- and disturbing -- findings regarding penetrating trauma and c-spine immobilization.
Before we review the results of the study, let us think for the moment what hell would befall any medic or EMT in this state who showed up in the trauma bay with a patient with a gunshot wound to the chest without c-spine immobilization.
The folks in Boston would undoubtedly unleash an investigation for the ages, and certainly a suspension and lots of "re-training" would follow.
But what the Journal study points out is that those medics and EMTs probably deserve a medal for doing -- or not doing, actually -- what the evidence, rather than a protocol book, says is in the patient's best interests.
What the study found was pretty dramatic.
There are two main take-home points:
1 -- in patients with penetrating trauma, those who are c-spine immobilized die twice as often as those who aren't, and
2 -- it takes 1,032 c-spine applications in penetrating trauma to benefit 1 patient (defined in the study as patients with incomplete spinal injury who ended up needing spinal surgery for vertebral spine repair, spine fusion, laminectomy and/or halo placement). It takes just 66 c-spine immobilizations to contribute to a single patient death.
The study authors performed a restrospective analysis of 45,284 victims of penetrating trauma listed in the National Trauma Data Bank, and concludes simply: "Prehospital spine immobilization is associated with higher mortality in penetrating trauma and should not be routinely used in every patient with penetrating trauma."