Defensive Medicine (C-Spine Immobilisation)

There were some interesting responses to my last post about the treatment of a minor collision victim by firefighters. The general thought was that they immobilised the patient to prevent being sued by overzealous lawyers. In addition I was told that only doctors were able to remove the immobilisation collars, that the ambulance staff wouldn't touch the collars.

This makes me incredibly angry.

At what point did we stop performing good medical treatment and instead treat everyone as if they are angling to make money off of us.

The placing of a C-Spine collar is something that should only be done where there is a clinical need for it. We are trained to decide if there is a risk of a C-spine injury. We shouldn't be putting collars on just because we might get sued. Once we start doing that there is an argument that we should just follow written protocols. If we are doing that then we are be going to lose our skills and this will impact the care of our patients.

If I place a C-spine collar on someone it is because I have a reasonable suspicion that they have a neck injury – if I have this suspicion then the patient will be cut out of their car and placed on a hard backboard.

If I have someone cut out of their car and put onto a hard backboard (which can cause injuries itself) for no good reason then there could be the case for me to be sued for unnecessary treatment. And for ordering the destruction of the patient's car.

One more case of damned if you do and damned if you don't.

But unlike some of the dilemmas we have in this job (and there are plenty of them) we have the training to rule out serious neck injury. We shouldn't be doing this treatment unless it is needed.

Whenever I treat, or don't treat a patient I am thinking constantly of what benefit this has for the patient. I am always able to justify my treatment of a patient, whether to the patient, to the hospital staff or to a judge, magistrate or coroner. This isn't 'defensive medicine' this is 'good medicine'.

I try to keep up to date on the current research, and for those of us who don't, we also have medical bulletins from our management explaining the correct way to do things.

This isn't even counting the research that is initiated by the LAS.

We aren't stupid and we shouldn't be doing treatments 'just because', we should be confident in our use of evidence based medicine. We should also be confident enough to correctly document our treatment so that we can justify our decisions to anyone.

To do anything else turns us into taxi drivers.

24 thoughts on “Defensive Medicine (C-Spine Immobilisation)”

  1. This proves one thing only: America is loopy.Five years ago I was in West Virginia when I passed out inexplicably and bumped my head on a rock. My friends thought it sensible to have me checked out at a local hospital. So they took me there and it was quickly determined that my loss of consciousness was due to dehydration and that the bump on the head wasn't serious. I was in the hospital less than three hours. When I got back to the UK, I received a bill for over $2,500 for this service (luckily I had good travel insurance that covered it without any quibbling).

    Its things like that that make you really appreciate what we have “for free” in the UK.

  2. Tom, you are in the state that invented the frivilous lawsuit. As long as medicine continues to be big industry here in the US it will continue to be this way. It may sound like I've thrown my hands in the hair as if I have given up, but alot of the things we may want to do for our patients can't be done because of the threat of a lawsuit.

  3. Without defending the protocols don't forget that older US cars are heavily engineered (or built like tanks) and transfer more energy to the occupant and that seatbelt wearing is probably less than 50% so the chance of a c-spine injury is greater.

  4. I'm on holiday at the moment, looking after my daughter for a couple of weeks while she's on her school summer holidays. This means I've been watching more TV than I usually do. I don't think a day has gone past that I've not seen half a dozen adverts for injury compensation legal services – had an accident? Sue!I completely agree with you that treatment administered should be based on medical necessity, but as a society we do seem to be following down the US's path of becoming rather litigation-happy…

  5. Tom, I agree with you wholeheartedly- but as it stands, if we find a drunk a in a dark alleyway- we must collar according to protocols (and don't you dare not answer this question correctly on your national certification test!)This 'defensive medicine' is not only practiced by the EMT's in the field (I'm one of them), but also by nurses, doctors, and medical centers as a way to prevent ANY kind of medical liability, which is the biggest cash crop for lawyers ever!

    So, untill the whole of Amrican society changes from sue-happy to having-a-clue, it's only going to get worse!

    Eug

  6. It's a vicious, snowballing circle and nobody can escape.The lawyers tell you they can get you $$$ from the “incompetent” medical personnel – just sue.

    The Doctors' malpractice insurance premiums soar… the doctors start to charge exhorbitant rates for their services.

    The lawyers tell you that they can get you $$$ from the “incompetent” medical personnel to offset that huge medical bill…. just sue.

    I know there are problems with the medical system in the UK, but compared to what we have here in the USofA, you guys are doing miraculously well. That $2500 for 3 hours story is not a joke. My 3 days in hospital for angina, after all tests and “specialist” fees was over $75,000.

  7. Right on, Tom. Medical decisions should be made on medical grounds. It can't be said often enough or loud enough. The US system is so sick it should be on life support. I don't see an IV, though. Fear of a Really Big lawsuit? Fear of socialism? Fear of really big socialist lawsuits?

  8. The business of performing ridiculous overkill began when the American courts in New York and Califorina decided that anyone who suffered any kind of an injury was entitled to cash compensation.This applies to anyone anywhere with the sole exception of Acts of God. This exemption ends if the lawyers are ever able to prove a link between God and the Catholic Church.

  9. It really depends on who someone is employed by as to how aggressive they are about C-Spine protocols. I happen to work a lot of “event medicine” (Baseball games, triathlons, wrestling matches, volleyball games, etc). If I C-Spine'd everyone who had a minor hit to the neck or head, we'd be too busy using boards to provide care to others. Each company or agency sets up their own protocols, which have to be observed by those working for them, or they risk losing their jobs. Litigation does drive a lot of this, unfortunately.Now, that said, there may be changes occurring in the industry. I actually see less C-Spine at accidents nowadays than, say, 5 years ago. Considering there has been no appreciable difference in outcomes from patients placed in C-Spine vs not (I come from when we didn't routinely do this… back in the late 70's and early 80's), it seems this may switch back to major injuries only. Which is better for us, and more importantly, better for our patients. If you have ever been strapped to a board for more than an hour (I have), you know how bad your back feels just from the board. I can't remember where I heard about it, but there is a study from (I think) Australia that shows outcomes were no different.

  10. Because each state has its own protocols, indeed, its own levels of EMS training (ie NY has EMT Basic, EMT Intermediate, and Paramedic while PA does not have the middle option) you won't find this c-collar rule to be the same everywhere. We are taught to carefully consider the mechanism of injury and and patient complaints before applying a collar. I recently assisted at a scene with a vehicle rollover, and when we arrived all four occupants of the rolled over van were standing there consoling each other. To look at the vehicle and the M of I you'd think it would be an immobilisation situation for sure, but based on what the patients were telling us they were not only not collared but they all boarded the ambulances under their own power and were just fine. Immobilising two of them would have been silly, and the other two just would have been upset by it; they were fourteen years old and already upset by having been in an accident. EMS actions in the US aren't only driven by fear of lawsuit; some of us do employ good training and common sense.

  11. Sounds like you are observing, in one protocol, the ethos of a nation.Can we make the Atlantic a bit wider? I would much prefer that the fat lawyer syndrome stay in quarantine.

    Apart from a board being very uncomfortable, what are the other risks? pressure sores?

  12. Here in Ohio though, chances are that we would have asked them (nicely of course!) to lay down on that very comfortable looking backboard… (at least in my experience).But yeah, a case like that where the patients are seemingly not injured should be cleared without the use of a C-Spine, but the recommendation (in my protocols) is that just because they are walking doesn't mean that they are injured, and if we DON'T immobilize them and something happens- then you can kiss your license and probably the whole EMT dept. goodbye (to a tune of multi-million $$ lawsuit!).

    And short of revamping the whole system here in the states, I don't see a solution…

    Eug

  13. When I was in a car accident a few years back, I got out of the car by myself, and didn't feel any pain til after my adrenaline rush subsided. Once I calmed down, I started noticing bruises, scrapes, that kind of thing, as well as the fact that my back sort of hurt, but in a tight muscle sort of way. The moment the ambulance got there, they asked “does your back hurt?” I said a little, but only achy. they collared and strapped me to a backboard anyway, despite the fact that I'd been walking around, and as a result all my injured muscles got stiff, causing me more pain. It sucked, and I felt like it was pretty unnecessary.

  14. Tom, you are so right. Medical treatment should (must) be based on what is best for the patient, not what would look best in court.My training tells me that if I suspect a spinal injury. the patient should be immobilised with a collar and long board. A collar alone does not provide sufficent immobilisation. I can foresee an interesting legal case: “well, you must have suspected a spinal injury because you collard me. But you didn't immobilise the rest of my spine. Therefore you are negligent and I will have thousands of dollars compensation, please”

    If a patient presents at A&E wearing a c-collar, is there a danger that a spinal injury is automatically assumed, and the patient treated accordingly – possibly to the detriment of other injuries? Conversely, if in the US this is normal practice, could we have a “cry wolf” situation here where a genuine spinal injury is overlooked?

    Finally – I know someone who is allergic to c-collars. Seriously allergic (like needing hospital within 10 minutes of wearing one). Now THAT could make an interesting court case if one were put on unnecessarily.

  15. First of all, no EMT worth a damn would ever collar someone without also boarding them. Secondly, making the determination in the field about what is best for the patient is not always an easy or readily apparent choice. That is why we have protocols that provide a measure of 'if x then y' to treatment. In the case of a motor vehicle accident, the mechanism of injury dictates what our protocols are. I'll give you an example – our service responded to a man with 'tingling in his extremities'. On arrival he was going downhill fast and by the time he got to the ED he was fully unresponsive and in a bad way. The day BEFORE he was the driver in a car accident where it was hit side on by another car on the passenger side. The passenger's head hit him in the neck. He signed off and refused transport at the scene as he had 'no injuries'. Clearly he did. Last I heard he was in ICU. I have no idea of the outcome.The point is that you don't have X-Ray vision or the clear ability to determine the extent of a patient's injuries in every case. While it may be overkill to board and collar every patient with a certain Mechanism of Injury, it prevents overzealous providers from making judgements without all of the facts. It's not just a fear of litigation that drives this – who among us wants to exacerbate our patients condition if they should have a spinal injury ? Better to be safe than sorry for everyone concerned.

    Oh, and one last thing. Any patient can refuse ANY treatment. Collar, board, IV, blood pressure cuff. They have the right to say 'no'. It is our duty to inform them of the relevant risks and benefits of treatment.

  16. Wait until you get really sick in the UK. My father has some gastro intestinal issues (amongst other things) and needs to have a gastroscopy. He has been waiting 3 weeks for an 'emergency' appointment.My mother who has knee problems that are making it hard for her to walk takes care of my Dad. Her GP thinks she need arthroscopic surgery and wants to take an X-Ray to confirm this. Her appointment for this is 3-4 MONTHS from now. That's just the X-Ray, not the surgery. The ONLY good thing about the NHS is that it is universal, but increasing numbers of Brits are using their hard earned money to go private for some procedures because the waits are so long.

  17. I agree that legal fears should not always determine medical practice, but this situation to me seems to be about a cost benefit ratio. That is, we know the risks can be serious about not putting a C-Collar on an injured patient. Are those risks greater than putting a C-collar on a non-injured patient? I'm not an EMT, so I'll let others sort that one out.Dominic A. Carone, Ph.D.

    Founder and Webmaster of MedFriendly.com and The MedFriendly blog.

  18. I work as EMT-D in Milano, Italy.70% car accidents patients I get called to usually suffer of that terrible illness named “insurance trauma”.

    Most of them think that getting out the Hospital with a report diagnosing a Whiplash makes them earn a lot of money from insurances…

  19. As an ex-pat now residing in sunny Florida (Land of attorneys), I can tell you sometime youre damned if you and damned if you dont which certainly makes life interesting!Case in point, several months ago, we may or may not have respond to a Motor vehicle Collision (Accident is not used as it implies someone was at fault) 2 vehicles, one rear ended another at an ATS. The driver in the stationary car ok, but complaining of a sore neck, but after talking with the Paramedic who deemed him to be competent, took a signed refusal.

    The idiot, (sorry driver) of the second car that caused the accident (sorry, I meant collision, and he is officially a victim until the courts determine he was at fault, as he is fighting the moving violation ticket the deputy gave him, so he may not have caused it after all?!?!) There were no skid marks either to show that he had even attempted to stop, let alone slow down.

    Is screaming like a baby, as he may or may not have been wearing his seatbelt and may or may not have been talking on his cell phone at the time of the alleged collision. His older model car didnt have airbags and a nice head shape can be seen indented in the windshield along with the cell phone that is embedded in the glass. His seatbelt hanging nicely as they do when not fastened correctly.

    All attempts to enquire as to his injuries where met with my neck, my neck, which we countered by a c-collar and an extraction by removing the roof of the vehicle. (I like to do this to give the medic some thinking time to accurately asses his true injuries).

    We get him out, put him on a back board as we are about to load him into the nice shiny ambulance, starts to demand we let him go as he wants to refuse treatment (now that the deputy has given him his ticket and left to direct traffic) So we call through on the radio to the county medical director as we class him as a high risk refusal, meaning his should go against his wishes. The Doctor agrees and we now call the deputy over again to assist us. Eventually he agrees to go but not before promising to get even with us.

    Fast forward several months, we all got subpoenaed as a local well know law firm that is suing is for unlawful detainment, coercion of a patient against his wishes, and the full cost of replacing his beat up old car as we had to remove the roof. Not to mention a whole bunch of other legal B/S. This is from one of the law firms that tells TV viewers that they are working on the weekends to make sure the client gets every penny of insurance money his is entitled. Of Course the law firm will get 33% of the total awarded.

    Now if Someone was paying attention to the road conditions, not talking on his cell phone, and had actually seen the big red traffic signal, the stationary car ahead of him with their brake lights lit up like Christmas (Holiday) time, and had been wearing his seatbelts, we would still be sitting in big comfy chairs at the firehouse.

  20. Ah, to collar or not to collar!I hate the bloody things, and as far as I'm aware research has shown that they are of very little benefit except in a few very specific circumstances (e.g. unconscious with high index of suspicion for a spinal injury).

    As Tom says, applying them can cause more injuries than it helps to treat. The boards inparticular carry a high risk of pressure damage, back pain etc., and often make it more difficult to extricate/treat the patient (thus leading to treatment delays for other injuries, and therefore potential harm).

    Most people who are involved even in high risk incidents don't infact have a spinal injury (for example, I read some research recently that showed that only ~8% of people thrown at speed from a motorbike have any spinal compromise). There is little evidence to suggest that in those who do have a spinal injury, immobilisation actually prevents deterioration.

    Almost everything we do in this area of care is based on ritual, shaky opinion and defensive medicine. We'd be best to do away with spinal immobilisation altogether.

  21. And of course the medical side of things doesn't even begin to take into acount the traumatic experience of the patients – these people are involved in a traumatic incident which may have left them already in pain, they're then physically restrained and taken to hospital where they're stripped naked, still tied down to the board, and poked and prodded by a whole load of strangers.

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