MS 007 Why are we still using backboards?

“Long backboards are commonly used to attempt to provide rigid spinal immobilization among EMS trauma patients. However, the benefit of long back- boards is largely unproven.”

            When a young student enters a classroom to begin his or her studies as an EMS provider, they are taught two things: 1) Everybody gets oxygen and 2) All trauma patients must be placed on a backboard. Of course, as time goes by we have found that both of these are improper practice that may actually harm patients. So the question naturally becomes “Why do we still do it?” The answer tends to be that this is way we’ve always done it. This week, we’ll be addressing the routine use of Long Backboards (LBB) on patients that have experienced a traumatic injury.

First, a little history:

In 1966 Geisler et. al. published a retrospective study that analyzed delayed onset of paraplegia” in hospitalized patients with spinal injuries. The retrospective study discussed two patients, one of which has a depressed skull fracture. This patient initially had paraplegia with a sensory level at T10, which evolved to a paralysis below the level of T4. To be clear, this patient had a depressed skull fracture, and his paralysis evolved to the level of T4 AFTER surgery. The analysis went on to review another 29 patients that “Developed further paralysis after faulty handing” and determined that these injuries surely could have been avoided had further precautions been taken. After this study, it was suggested in 1971 that spinal immobilization using a cervical collar and backboard would be beneficial for patients that experienced blunt force traumatic injuries. The addition of cervical collars was secondary to a concern extrication could potentially worsen unstable spinal injuries. After this data was published, EMS providers began receiving education, and thus teaching others, that best practice was to immobilize a patient to a LBB and place a cervical collar in order to reduce the risk of exacerbating any occult spinal injuries. This was in 1979, when M*A*S*H* and Three’s Company were top TV shows in the country.

The use of backboards has long been established as a practice EMS has used “just in case”. Often it is heard in the classroom that “we don’t have X-Ray machines, so we don’t know what could be broken” which may be true, but we need not be blinded by anecdote, and we have reliable data that shows increased injury with the use of LBB and phenomenally low risk of spinal injury in patients experiencing blunt traumatic injury. Studies with healthy volunteers have shown that being placed on a backboard increases pain to areas not limited to areas of contact with the LBB, and persistent pain secondary to the placement of a cervical collar. This pain may cause unnecessary radiologic testing, as it may be impossible to determine whether pain is due to the injury or due to the backboard itself. Beyond that, further studies with healthy volunteers have shown that supine patients on a LBB have reduced forced vital capacity, forced expiratory flow, and forced mid-expiratory flow. This is all not to mention the increased risk of pressure sores, and thus the increased risk of infection.

It turns out that the use of LBB also increases mortality as well. Typically, placing a patient on a LBB may take as much as five minutes, which in the most critically injured of patients is five minutes that could be spent resuscitating the patient. In fact, in 2010 Haut et al. found that mortality was twice as high in patients that were immobilized when compared to patients that were not.

A study in Malaysia compared patients with spinal injuries to patients with similar injuries in New Mexico. The idea was to compare vastly different emergent settings, and to compare patient outcomes in immobilized and non-immobilized patients. This study was controversial, but in the end the results showed that the non-immobilized Malaysian group suffered less secondary injury and had better neurologic outcomes when compared to patients in New Mexico.

It is important to note that there have been no true RCTs comparing the use of LBB to a different treatment such as spinal motion restriction. However, the data show that the scarcity of spinal injury in the field hampers this research. In 2003 Domeier et al. found that the cervical spine injury rate in EMS patients experiencing trauma was approximately 1%, with only 0.3% experiencing a spinal cord injury.

The question then, is this. Why are we still using backboards? If there were another intervention that we knew increased injury and doubled mortality, would we keep using it? We are risking causing harm to patients under the guise of attempting to reduce the risk of harm. This is just shy of insanity. What is needed in EMS and Emergency care is a culture shift. We know that approximately one percent of patients may benefit from the practice of spinal immobilization, but there is no need to cause potential harm to the other 99%. This is a practice that has been taught and reinforced over decades of the “we’ve always done it this way” mindset and it is time for a change.

Additional Readings:

Chelsea C. White IV MD, EMT-P, Robert M. Domeier MD, Michael G. Millin MD, MPH & and the Standards and Clinical Practice Committee, National Association of EMS Physicians (2014) EMS Spinal Precautions and the Use of the Long Backboard –Resource Document to the Position Statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma, Prehospital Emergency Care, 18:2, 306-314, DOI: 10.3109/10903127.2014.884197