(Transcript is automatically generated).

Erik: [00:00:00] Looking for some sort of a, uh, a, uh, a benefit mm-hmm. For wearing C collars and none was to be found. 

Matt: If you had brought somebody in that had any sort of a mechanism of injury and you didn't have them fully spinal mobile restricted, I mean, the doctor was chewing your butt out.

Narrator: You are listening to. With your host, Erik Axene and Matt Ball. 

Erik: You look pretty uncomfortable there, Matt. [00:00:30]

Matt: I'll give you two guesses what we're talking about today. The first one doesn't count. 

Erik: Love it. I love it. Can we help you with that? 

Matt: Yeah, I got it. I got it. Uh, thankfully I don't have a spinal cord injury.

Erik: Yeah, it's the spinal cord injuries are pretty common. In fact, spine injuries are of the most common causes of traumatic injuries. Yes. Um, usually with blunt trauma, it makes sense that penetrating trauma. Yeah. Um, you know. I mean, penetrating trauma through the neck is different, but you know. Yeah.

Typically penetrating trauma doesn't injure your spine, uh, [00:01:00] unless it's direct. Right, right. But Right. But blunt trauma though, you get that whiplash. 

Matt: Yeah. MVAs, falls. Yep. Those kind of things. But before we start, make sure you like, follow our podcast. Mm-hmm. Follow our YouTube channel. Helps us out with, uh, getting this information out to more people.

So make sure you do that. And we're talking about C collars and spinal immobilization or spinal mobile restriction. 

Erik: Yep. 

Matt: Uh, because of a paper that came out last 

Erik: March and are That's right. Yeah. Challenges. The, [00:01:30] really, the standard of care has been in most municipalities, you get a trauma, put a C collar on. Oh yeah.

We've gone away from the backboards. 

Matt: Yep, yep. About 10 years ago. Yeah. Depending on where you're at. Yeah. Yep. 

Erik: Um, I mean, uh, and it does address it in the paper, backboards are useful for extrication lifting and there are certain lifting situations. Yeah. You know, you need 'em, but, but. They're not the standard of care anymore.

Matt: No, and I think this is good news. I think for, well, first off, it's good for the patients because [00:02:00] hopefully we're not gonna be unnecessarily making our patients uncomfortable or causing more harm, as this paper suggests. Mm-hmm. By putting them in these uncomfortable collars. Right. I think anybody that's been doing this for any amount of time, these collars hardly ever fit correctly. I mean, I wore that thing for about two minutes and I don't have an injury, and I'm sitting up, and I mean, it literally does, patients would always complain, I feel like I'm choking. It literally feels like it's choking you. 

Erik: I've seen these things placed backwards. Oh yeah. I've seen them sideways up over their [00:02:30] faces.

I mean, it's just, they just, 

Matt: yeah, they don't, they don't ever fit. They don't ever fit. Right. They make the patient super uncomfortable. Half the time they ask to take 'em off, and so I think it's a good thing. Yeah. That again, they're. This paper is saying there's the data shows there's no benefit. 

Erik: That's right.

Matt: And actually might be some negative outcomes. Correct. To putting patients in C collars. 

Erik: They looked at 4,000 pieces of literature. Yeah. And nowhere did they see a statistically significant benefit to wearing one of these [00:03:00] things. 

Matt: Right? 

Erik: Remember, it all started back in the forties. There was a hypothesis, right?

Well, that's not true. It really, it, it really started because we noticed anecdotally that people had these post incident sort of a neuro problem. Yeah. Neuro deficit like that, that other, I mean, get paralyzed after the incident. So what caused it? And the hypothesis, which is reasonable. It is, and it's logical.

That motion caused the The complication. [00:03:30] Secondary injury. The secondary injury. Right. And so. That was the, the hypothesis back, I think it was 1944 in the paper, if I remember correctly. 

Matt: Yeah, I think it was, we've got it right here. Howlet, I think it was the World War I or World War II, excuse me. World War II Yep.

Is when he created this hypothesis. That's correct. Battlefield and, 

Erik: and a lot of people and, and it makes sense to me too. We didn't have the imaging studies we do today. Sure. So back then it made sense logically and I think makes sense today logically. Mm-hmm. And it's not unreasonable to, to have that as a hypothesis to why these [00:04:00] secondary injuries occurred.

But it wasn't until, I think it was Gordon. I think Gordon was the next one, I think, if I remember correctly. 

Matt: Rogers. Oh, sorry, Rogers. Yeah, that's Rogers 1957. 

Erik: Yeah. Uh, he, he agreed with that hypothesis and, and he saw anecdotally a bunch of his patients with these secondary neuro deficits and he had developed some sort of a spinal motion restriction device.

Matt: Right. 

Erik: Which created some, some bias for him. 

Matt: Yeah, yeah. [00:04:30]

Erik: But the problem was, is the American College of Orthopedics and the American Medical Association back. Him and it became the standard of care. Yes. So for decades, I mean almost, almost a 

Matt: longer than you and I've been alive and we're two old dudes, we're 

Erik: getting close to a century here, you know, is the standard of care has been to throw a C collar.

But over the last few years. Uh, we've been challenging that since the spinal motion restriction with backboards, I think. Mm-hmm. We've been questioning these crazy things and Right. This [00:05:00] paper went out there. I'm just gonna read. Yeah. 

Matt: Yeah. This wasn't a paper where they had like a control group and all the, you know, I don't know all the technical terms you do, but this was a paper where several of the authors, or the authors of this paper looked back through 4,000 different articles.

Correct. Almost 4,000. Almost 4,000. 

Erik: 3,944 articles. 

Matt: Yeah. 

Erik: The manuscripts. 

Matt: Looking to see if there was any data. Yes. Correct me if I'm wrong, [00:05:30] any data that proved that there was a benefit. One, that there was a benefit to C collars, and two, that movement caused a secondary neurological injury. Correct. Does that pretty much sum it up?

What they were looking for? 

Erik: And this is powerful evidence here. This is called a meta-analysis. Yeah. And this is now none of the evidence that they looked at was. You know, like a, the best kind of evidence is randomized control trials. Right? Right. But a step above that would be this meta-analysis thing where you're looking at [00:06:00] thousands 

Matt: Yeah.

Erik: Of manuscripts and data looking for some sort of a, uh, a, uh, a benefit mm-hmm. For wearing and C collars and none was to be found. 

Matt: Zero, zero. Not just, there were a few, there was zero data or information found in their research that showed that there was a benefit, number one, that there was a benefit to C collars, a spinal mobile restriction.

And that secondary injury, actually they found that putting a C collar on can cause exactly damage. 

Erik: That's what I was gonna say is that not only did they [00:06:30] not find benefit, they did find, and I think, uh, it's 50. 50 something. Yeah. Incidents here of, of documented and statistically significant harm Yes. To patient and to, um, you know, by the use of, of these C collars.

Matt: Yeah. Respiratory depression, putting these patients in a c collar, laying 'em flat. Cause respiratory issues to cubitus ulcers. 

Erik: Even, even data to suggest that wearing a c collar actually is counterproductive to decreasing motion. Right. [00:07:00]

Matt: Yeah. 

Erik: So there's a lot of evidence. Uh, out there and there was no evidence of benefit, but there was evidence of harm.

Right? So in the conclusion here to the article, now most people, when they read papers because of time, they just look at the abstract. 

Matt: Mm-hmm. 

Erik: Um, there's a lot to be seen in this paper, and you and I. Dissected perused it. Yes. We, we really took a strong look at it. And there's a lot of other data out there too that we looked at, but I thought it was interesting.

And this is, this [00:07:30] is, I think, uh, in the conclusion here, given the lack of data supporting clinical benefit and the extent of data demonstrating the evidence of harm, spinal immobilization and SMR should not continue to be upheld to standard of care. So that, uh, is specifically related to C collars. 

Matt: Mm-hmm. 

Erik: Uh, this is a pretty profound statement.

Mm-hmm. And I think, uh, certainly appropriate to talk about today. And we kind of mentioned it earlier, the hypothesis was mm-hmm. Motion Yes. [00:08:00] Caused harm. 

Matt: Well, and if you think about it traditionally, like what do we do with any, uh, suspected bone fracture? We, we splint it. Yeah, yeah, absolutely. You know, legs, arms, whatever.

We splint it up. Heck, we used to do, uh, the sandbags or saline bags. If you, they had a flailed segment, you know, you would, the whole mindset was splinted. And now, because, and again, you gotta think EMS is relatively a new area of medicine. Mm-hmm. Right in, in the grand scheme of things. [00:08:30] And so they're looking at a lot of the things that we're doing and they're getting more and more data in.

And so that's why so much of this is changing is because they're seeing the data going, oh, this has this benefit or it doesn't have benefit. Yeah. And so this is one of the things that has been a staple in EMS and emergency medicine for, like you said, decades. 

Erik: And they're expensive. Yes. Not only are they hurting patient, they're expensive we're spending a lot of money on them, and, uh, you know, the.

I just read this recently, $443 billion [00:09:00] we spend in the US annually on, um, on traumatic injuries, 

Matt: right? 

Erik: And one of the more common traumatic injuries is spine injuries. And it was interesting. I read that. Um, 

Matt: now, is that the most common actual injury? No. Or the most suspected injury?

Erik: I think the most common injury, well.

That's a good question. The mechanism was falls, right. Is the most common. Right. And when you fall, obviously traumatic brain injuries were high. 

Matt: Sure, yeah. 

Erik: Which were often associated with [00:09:30] potential spine injuries, but the actual spine injuries were. Not the most common thing, but relatively common. Mm-hmm.

And when you're talking about, um, you know, the, the number of people that are involved in traumatic injuries, I think the number was 1.7 million. And, and I think, I think it worked out, gosh, I, I don't quote me on this, but it was, I think 800,000 people. 

Matt: Mm-hmm. 

Erik: But all that to say, um. A lot of people get C collars placed.

Yeah. But what was [00:10:00] interesting was, and this was one of the harms brought up in the paper, was that when, when a patient comes to the emergency department with a C collar on between 88 and 94% based on different studies mm-hmm. But the vast majority of them get a ct. 

Matt: Sure. 

Erik: They get irradiated, they get a CT scan.

Um, even though the, like the likelihood of injury may be low, they still got that. That, uh, CT scan, which is harm to a patient when they didn't need it. And the data suggests that [00:10:30] 88% of patients who are wearing a C collar don't have an injury and 12% do potentially. Right. You know, but. Those that do have an injury shouldn't necessarily be wearing the C collar anyway.

This is not because it's just causing harm. 

Matt: And that's, yeah. So they, the theory again was the, the, the movement is what was causing the injury and 

Erik: Yeah, that was the hypothesis. That's the theory. Exactly. That's right. And 

Matt: now they actually are saying, no, it's hypoperfusion that's causing the injury or causing the secondary [00:11:00] neurological testing, 

Erik: just to be clear and to, to, to, just to be fair.

Right. Um, there really isn't a lot of data out there. Right. Backing up this hypothesis, but it does seem to hold true. We know about spinal shock. We know that, uh, injuries to the spine, uh, when they don't, we don't get blood flow. Mm-hmm. Can, can cause subsequent damage and secondary injury. Mm-hmm. Um, and that to me, I agree with you.

I think that's, it doesn't, we don't, we can't say that it is what it is. Right. But we [00:11:30] know it does not appear to be based on this data. 

Matt: Mm-hmm. 

Erik: Motion. Right. And I agree with you. I think it is hypoperfusion that causes those injuries. You get a patient with a spine injury. 

Matt: Yeah. 

Erik: And then lack of blood flow to that injury is what's causing those subsequent, um, uh, deficits that we've seen anecdotally.

Matt: Yeah. Yeah, I think it's good to talk about the evolution of this whole spinal, IM, you know, immobilization mm-hmm. In, in this paper they kind of talk about it, but like when I started an EMS 20 years ago, [00:12:00] you know, it was anybody, I mean, this was something e everybody that's taken National Registry Skills exam in the last 20 years, EMT or paramedic like, yep.

You go into your trauma thing and it's like, if you don't immediately get C-spine, you fail. You're done. That's right. It's a huge, huge leaf. Uh, pushed mindset within EMS is that if you have any trauma patient, you have got to get C spine. Yeah. You gotta get the collar on you and back again. When I was doing, when I was going through school, it [00:12:30] was c collar, it was a rigid backboard.

You get the head bed out, I mean, you strapped these patients to a hardboard, you get 'em on your cot and they're bouncing down the road like a corpse on this cold hardboard. Yeah. Especially little grandma, right? Yeah. And then. We did that for about the first 10 years of my career with everybody. Yeah.

Right. And if you had brought somebody in that had any sort of a mechanism of injury and you didn't have them fully spinal mobile restricted, I mean, the doctor was [00:13:00] chewing your butt out, you know? Yeah. For not doing it. 

Erik: That's happening today. 

Matt: Yeah, that's what I'm saying is that there's probably still areas mm-hmm right now that this is still part of your protocols.

And if it is, if you're still using rigid spine boards and you know, strapping people into these long boards with C collars on 

Erik: hopefully, hopefully not the rigid spine boards, even the vacuum splints. 

Matt: Yeah, even, yeah, I mean that's what my department currently, currently carries is the vacuum splints. But yeah, if you, are you still using rigid spine boards for more than just lifting [00:13:30] purposes?

And that's in your protocols. You need to talk to your medical director. Yeah, like you've got to talk to your medical director. There's science that backs up that is very harmful, much more harmful for your patient to transport them on a, on a board as opposed to not, they didn't fit right. They, you know, they didn't fit around the, um, the, the holes and the barriers in the body.

Um, so we got rid of those like 10 years ago. You know, in, in my department they said, these don't work. Mm-hmm. And now, then we went to, okay, we're only going to do, and [00:14:00] again, this is just my specific protocols, we're if they had like pain, like if you're doing a head to toe exam or they're complaining of pain in their neck, or if you're doing an exam and you're palpating and they're like, oh, my neck hurts, then we would spinal mobile, we put them in a C collar, have them on the cot. We'd usually have them sitting up at about 30 degrees. And that's how it's been for about the last 10 years. Yeah. Where we would only use, now we have the vacuum mattresses. Yeah. But those can be moldable, which is better than the hard spine boards.

Um, but that's pretty much been the [00:14:30] standard of care for a long time. Oh yeah. And it's kind of scary. 

Erik: Well, it still is. Uh, it seems to be it's still lingering this, yeah. Oh yeah. This, this, uh, whole C collar thing. Uh, I will confess to you that it's, uh, it used to be a critical action on my, my checkoff that I do.

Mm-hmm. When I had a trauma patient, one of the checkoffs was the C collar. Yep. It, I'm, I'm thinking of a specific case right now. The motorcycle accident. 

Matt: Mm-hmm. 

Erik: That's one of the things they had to do. Sure. It's no [00:15:00] longer there. 

Matt: Yeah. 

Erik: Uh, it's no longer there. Uh, the um. In the NFL. 

Matt: Mm-hmm. 

Erik: Um, we go through training, mandated training, all about spinal immobilization.

Matt: Really? 

Erik: It is. Yeah. And it's happening today. 

Matt: Yeah. 

Erik: And, uh, so, uh, it's, it's, there's a lot, there's a lot of, um, value in, in, uh, challenging the null hypothesis. Yeah. Is that, and you know, for decades we have not challenged it. Yeah. It's [00:15:30] so logical and it becomes such a, a checklist on what we do for trauma patients that we don't even question it anymore.

In fact, in the hospital not putting a C collar on a trauma activation, oh man, almost seems like I haven't done my job. 

Matt: Yeah. 

Erik: But we need to really rethink these things. 

Matt: It's kind of, it reminds me of when we first started talking about not doing chest compressions immediately on trauma patients. Right. I remember being at a fire department, pulseless trauma patients.

Yeah, yeah, yeah, yeah. I'm sorry. Thank you. Pulseless. [00:16:00] Yeah. A, a traumatic arrest patient. Just be clear. Good clarification. Yes. Yeah. Yeah. A traumatic arrest patient. Yeah, sure. You know when, when you know. I don't know how long ago. It was five years. Four or five years ago. And we were teaching this mindset of, 'cause for so long, you know, it was, they're in cardiac arrest, you've gotta get on the chest, right?

So we pounded that into our folks' head and then we're coming back and going, well wait a minute. Hang on.

Erik: So you're telling me, oh, not to do chest compressions on a pulseless patient. 

Matt: Exactly. That was [00:16:30] exactly the statement. I've not been there. Yeah, it's hard. I teach in the class and this came out and I was like.

You know, I'm not, we're not saying don't do it. We're saying it shouldn't be the first thing that you do right away on a trauma patient. Yeah. And that was exactly the response of one of the guys that was in one of my classes one time was like, what are you telling me? I'm not supposed to do CPR on somebody without a pulse?

And I'm like, think about what you're doing. Like think about what has happened to the patient. Right. Yeah. And this is another thing, like I can just imagine going into a fire department or a private MS agency doing [00:17:00] a class and saying, Hey, you can take these and throw 'em in the trash. And we're not saying.

You know, do that yet, but it's probably coming. 

Erik: Well, we're gonna get to that. Yeah. I look forward to talking about what I have planned, uh, you know, in our department as we phase these things out and the way we're gonna handle it. 

Matt: Yeah.

Erik: Uh, it's probably gonna be a bit of a hybrid initially, but 

Matt: Yeah. 

Erik: Um, we're gonna, it's gonna be gone.

Matt: Yeah. No, that's good. We, I know I've already talked to my medical director and I would encourage everybody, I will put a link to this paper. Um, I'll put [00:17:30] it on, it'll be in our link tree. I'll put it on the YouTube video if you're watching this on, or listening to this on YouTube. So it, like I said, just came out last month.

So. Uh, if you're a pre-hospital provider, EMT, paramedic, if you're a registered nurse, listen to this. If you're a physician listening to this, you know, forward this onto your medical directors, because like I did when I, when we first got this paper, I sent it to him and, and he read it and he's like, this is interesting.

Yeah. And, but then, you know, he, he, he was talking about, which was interesting coming from a, uh, medical [00:18:00] director's perspective was that, you know, if, when you're the first one to do stuff. That can be difficult and sometimes people without much buy-in, you can get nailed to the cross sometimes on what are you doing?

You know? 

Erik: Well, you know, you, when you and I were working on the OMI stuff, oh, those 12 EKG patterns that we haven't historically really looked for and we haven't recognized as STEMI equivalents. Yeah. Um, we're not asking people. To, to throw STEMIs out the window. Right. We're just asking people to [00:18:30] open up their eyes a little bit and consider the fact that there are other patterns we should be looking for to be emergently revascularized.

Right? That's right. That's really what we were doing is like we're expanding the definition of what a heart attack is. 

Matt: Yeah. 

Erik: That was difficult. To just expand our view. Yeah. What we're doing here. This different, 

Matt: oh yeah. This is, this is You're taking them away. Yeah. Essentially we are no longer, uh, again, something that has been a staple in EMS Yeah.

For decades is we're not. [00:19:00] Maintaining C-spine anymore. Now that's not saying that you're letting the patient, which that's what's always been funny to me is when I put one of these on a patient Yeah. They're sitting there pulling at that collar and they're moving their, we're causing them to move more.

Yes. By putting this uncomfortable collar on than it would be if we just. Put 'em on the cot and said, you know, hey, try to keep your head still and stuff. But they're comfortable. I think we were causing more movement with this. It was counterproductive to what it was trying to do. 

Erik: Now you can, no, don't, I'm gonna say something here and I, and I, I think it's [00:19:30] important.

I, I got to hear our former surgeon General, US Surgeon General, talk about spinal injuries and he actually took a preserved C Everett Coop was his name. Mm-hmm. He's no longer. 

Matt: Mm-hmm. 

Erik: Our surgeon general. Yeah. And I don't even think he's alive anymore, but he took a spine, a preserved spine with attached levers to it to try to dislodge it and separate it. And he couldn't do it, 

Matt: really 

Erik: could not do it. The spine is a pretty durable, durable, tough deal. Now you can injure it, obviously you can fracture, you [00:20:00] can do things. But it's um, when you, when we get injured, we have a spine injury, we actually have a natural sort of a protection device.

Mm-hmm. Uh, all the muscles around the spine constrict 

Matt: mm-hmm. 

Erik: To almost protect the spine. Yeah. And, um. Uh, that I think can contribute to part of the problem with hypoperfusion. Mm-hmm. With the evidence we need to fi we need to study these things. Mm-hmm. But, um, the fact that we think that this is gonna stop an injury from occurring, uh, if [00:20:30] you st if you just step back Yeah.

Think about it logically, think about it, um, some of the complications of wearing this device or hurting patients, and it really doesn't make a whole lot of sense. 

Matt: Mm-hmm. 

Erik: With this, uh, you know. There are some unstable spine injuries out there in certain situations where these may be warranted, but mm-hmm.

To think that this is gonna prevent injuries from happening. I, I think that's pretty archaic and, and clearly based on the evidence, I think it is, uh, a harm causer and not a, uh, it does [00:21:00] not produce any sort of a benefit. Right, right. So pretty straightforward. 

Matt: Yeah. I, I think so. Well, let's take a break and then we'll come back and talk a little bit more about this new data.

Erik: Sounds good. All right, Matt, so we, we covered over a little bit about the paper mm-hmm. And the hypothesis of, of, um, you know, injuries being caused by movement. Yes. Which is a decent. A reasonable hypothesis. Yep. But based on decades of data that's probably not benefiting patients by, 

Matt: [00:21:30] well, they couldn't find any.

They found zero data zero that showed that there was benefit to that or that spinal mobile restriction decreased the possibility of a secondary neurological deficit. Yeah. And well said. They talked about the hypoperfusion. More than possibly being the cause. Correct. Not that's, you know, like you said in the first part, there needs to be more research done on that theory, Uhhuh.

Right. And we're not suggesting that we're saying that's what they talked about in the paper, but it makes a little bit more sense. 

Erik: It does. And, and you know, I think I [00:22:00] agree with that hypothesis. I think that's probably the biggest thing because I, I think some of the cornerstones of management of, of spine patients, spine injuries, and.

Trauma patients is avoiding hypotension. 

Matt: Mm-hmm. 

Erik: There is some permissive hypotension with some of those hemorrhagic sort of injuries and things like that, but avoiding hypotension is important. And then, um, and then like keeping the patient comfortable. We're not telling you that it's not important to avoid movement.

No, it is. Right. Just but maintaining comfort [00:22:30] and avoiding those situations where we could interfere with blood flow. 

Matt: Yeah. 

Erik: Or cause and a lot of talk too about those, the decubitus ulcers. 

Matt: Yeah. 

Erik: Causing that subcutaneous ischemia mm-hmm. Can cause, um, the potential for an infection. Right. Uh, there's a lot of damage that these things cause, and then we also talked a little bit about it, but I think it's worth mentioning here too, is that.

Just the over testing of injuries that don't exist. Right. By wearing one of these things into the [00:23:00] hospital, it's like your ticket to ride the CT horse and it's like, I don't wanna ride it. Yeah. But I get forced to. Yeah. And a lot of, well-meaning physicians wanting to rule it out, but we'll talk a lot about what we can do clinically, uh, to rule out spine injuries.

In a bit, but, but I think, I think it's worth talking about some of the management principles. 

Matt: Mm-hmm. 

Erik: I know we, we talked a little bit about some of the stories we'd heard. 

Matt: Yeah. Well one of the authors of this paper was on the [00:23:30] EMS Avengers Podcast. Right. A friend of ours, Jimmy. Mm-hmm. And I, listen, we listened to that podcast and he is, uh, the doctor, um, I, forgive me if I'm saying his name wrong, Dr. Abbal, I believe is how you say it. Mm-hmm. Um, medical director out in Florida. Mm-hmm. Um, and he was he has basically taken them out. If I understood his practice, he's pretty much gone completely away from them. Mm-hmm. Uh, at his fire departments. And he had talked about like maybe just putting a, if you suspected a spinal cord injury, maybe putting a towel around their [00:24:00] neck.

Comfort. He talked a lot about patient keeping the patient comfortable. He talked about one call that he was out when he was riding out as the medical director. I don't remember if it was an MVA, but it was pretty significant mechanism of injury. Uh, he went on the call, rode with the medics to the hospital, did not put on a C collar.

Mm-hmm. Um, and got to the hospital and the ER folks are freaking out, like, why didn't you put this patient in a C collar? And he's like, 'cause there's no data. But he, I just, you know, researched all these documents and he's like, 'cause [00:24:30] there's no data to back up that it helps. And they, according to his story, they went over and immediately put a C collar on this patient aggressively.

Erik: But apparently he describes it as, yeah. Like a pretty abrupt Yeah. We gotta do this. 

Matt: Yeah. We're trying to restrict movement, so let's go crazy 

Erik: and, and in and in a bow about, yeah. Anyway, in his defense too, he talked about how the patient had had this waxing and waning of consciousness. Yeah. And it was, there was something going on and he saw that and he [00:25:00] said, woo, I'm not gonna put this patient in it.

C collar. Right. And I'm gonna do this because I, I think it's the best thing for the patient. 

Matt: Yeah. 

Erik: Which should always be our goal. Exactly. And then in the hospital. And he and I agree with him. I mean a lot of times we put on seat collars 'cause that's the checklist protocolized thing to do with the trauma activation.

And that's what the nurses are trained to do. That's what the teeth trauma team's, it's been pounded into our heads. And so they aggressively almost like, hurry, put it in. Yeah, protect the neck. [00:25:30] And what happened. 

Matt: According, according to him, he said she threw a clot and had a, had a stroke, big stroke, and, yep.

Yeah. So yeah, go listen to his podcast. Go listen to the Em s Avengers podcast. You can listen to that. Great podcast, great information. Um, it

Erik: is worth mentioning too, that the C collar is a unique, uh, part of the spine where the vertebral arteries run through the bones of the, uh, of the cervical vertebrae, right.

Matt: Very common injury too. We, we, you know, people that crack their necks. Yeah. I've run on these people. We think we [00:26:00] had a, a guy I worked with Yeah. Used to do that all the time, sit there and crack his neck and one day and all of a sudden they thought he was having a stroke at the fire station. Yeah. Oh yeah.

They called a co activated coach to him about this. Yeah. Yeah. And transported him. And he had like deficit, you know, all this stuff. And it was because he kept cracking his neck. And I, if I remember right, he was creating, causing a weakness in those vertebral arteries. Yeah. Yeah. It's, uh. Not good. That's interesting.

So what are we doing with these things, you know? 

Erik: Right, right. Well, you know, so, um, if we do [00:26:30] have a, a. A traumatic, now we talked a little bit about this earlier. You get a blunt trauma, patients maybe got a neuro deficit or, or tingling in the hands, right. You know, from some sort of a cervical spine injury.

Um, and you're concerned about a possible fracture. 

Matt: Mm-hmm. 

Erik: This doesn't appear to be the answer, so I like what you said is, uh, could something comfortable. Yep. Right? Yep. Uh, a comfortable way to immobilize a patient, you know, to protect the spine. Mm-hmm. Um. Uh, but, uh, again, [00:27:00] immobilization doesn't appear to be the thing that's gonna help 'em.

Matt: Yeah. 

Erik: Avoiding hypoperfusion, maintaining our blood pressure, 

Matt: which is what we're focused on with trauma patients anyway. Right, right. That's right. Keep that map up. Keep your blood pressure, you know, it doesn't, you don't have to have a blood pressure of 120. Yeah. Right. But if your blood pressure's 80, yeah.

You know, you probably need to be addressing that with fluids, blood pressures, something like that. 

Erik: And it's worth mentioning too, the spinal shock is a real. Thing. Mm-hmm. And, uh, this is obviously not necessarily the cervical, I think it's [00:27:30] more thoracic, but, um, is when you've got a tremendous blunt trauma.

Uh, with a spinal injury you can have that spinal shock. Mm-hmm. Pattern to the battles. Sure. The hypotension and bradycardia. 

Matt: Right. 

Erik: Uh, you see that, you know, obviously you could see the same thing with like a beta blocker overdose, and there are some situations, but in the context of trauma. 

Matt: Yeah, 

Erik: it's really important to get those fluids up.

You may even, you, you need some pressors. 

Matt: I was gonna say. Yeah. Pressors are gonna certainly help you get that [00:28:00] vasoconstriction. 'cause with those, uh, spinal shock patients, you're gonna get a lot of vasodilation. That's right. Right. So the pressors are gonna help you Levophed. Correct. You're gonna get, that's those va vasoconstriction along with the fluids.

Erik: It's unopposed parasympathetic. Yeah, the autonomic nervous system gets all wackadoo. 

Matt: Yeah. It's not sending the signal to, Hey, we gotta increase the heart rate here 'cause our blood pressure's dropping. Nope, we're gonna keep it at 50. 

Erik: The brains of the autonomic nervous system are in the thoracic spine.

Right. And that, and that's the key there. Um, but, but management of [00:28:30] these patients is not to include the C collar anymore. It's not the standard of care. And so maintaining patient comfort. Maintaining blood pressure Yes. Should be a management priority for us. 

Matt: I have a question for you from a medical director.

Yeah. And, and I didn't even ask you this beforehand, so this is an unfair on the spot question. 

Erik: I love it. 

Matt: But as a medical director, 

Erik: I've always promised I'd never do that to you. 

Matt: I know you have and I hate it when you do it. 

Erik: Have I done that to you? 

Matt: Oh, no, I'm, oh, I don't know. Oh, I'm sorry if I do. Oh, no, it's fine.

Erik: Nobody likes to get a question they're unprepared [00:29:00] for. 

Matt: Well, and a total idiot. Well, I think that this, this is not something that you should know. 

Yeah. 

Because this is a new thing. So I'm not asking you something that, oh, if you don't know this, you're in trouble. My question is, as a medical, I'll say something real quick.

Yeah, go ahead. 

Erik: Is it something that's, we don't talk about this enough because oftentimes when we're teaching and when I'm teaching a group of firefighters, nobody wants to look like an idiot. Of course. Of course. But I think it's really good. I, I found as a physician, for me, some of the most powerful moments I've had is when I've not known something and I've learned something and I've admitted a hundred [00:29:30] percent I was wrong a

Matt: hundred percent.

And that needs to be, that's, you know, when, when I'm teaching, not to get, we're squirreling here, but yeah. Um, when I'm teaching, I want to create an environment of, there's no stupid question now, but that takes time and trust. Okay. You can't do that the first day you go to department safety, you know?

Mm-hmm. And if somebody says something that's kind of, you know, most people would be like, well, that was a stupid, like, no man. It wasn't a stupid question. Like, that's what you thought. Mm-hmm. Maybe you were taught incorrectly. Who [00:30:00] knows? Right? Yeah. You had the guts to ask the question. I'm not going to embarrass you over that question.

Let's discuss it. Right. 

Erik: Anxiety in the learning environment is, 

Matt: should not be that is, we say it on the fire ground all the time, is that, hey, this is, this is where you make the mistake. Yeah. Right. You make the mistake on the fire ground, so you don't make it on the or in at training, so you don't make it on the fire ground.

Right? Right. Same thing with CEs. Right? Ask the dumb question in CEs. That way you're not making a bad clinical decision on your patient. 

Erik: Totally agree. Sorry, go ask question. 

Matt: No, no, no, you're fine. So, but again, it's important. [00:30:30] This isn't something that you should know. This is what is your opinion on something.

Okay. So as a medical director, I go on an MVA as one of your firefighters, and my patient is unresponsive in a car, Uhhuh, we're extricating the patient out. Okay. Typically, we would, you know, put a c collar on. We would slide them over, slide them onto a backboard, maybe get a KED out, strap them into a KED.

Yep. And then lift them out. What do we do now if, if this trend is moving this direction of, mm-hmm. We're not really worried about C collars and stuff, what would be [00:31:00] the process there, in your opinion? Right now, 

Erik: spinal immobilization or spinal motion restriction using backboards would be appropriate with extrication.

Okay. I don't know that a c collar would necessarily be needed. Um, if you've got them on that backboard and you've, for patient safety, you've mm-hmm. You've, you've, you've secured them to that backboard mm-hmm. Just for extrication. Mm-hmm. You get them to the g 

Matt: Well, but you usually are using the backboard.

We're sliding it under their, their butt. Yeah. And then if they're still sitting [00:31:30] in the seat, you know, upright, somebody's holding it from the back, and then we're rotating them. Laying them on the backboard simply to get them from the car over to the cot. Yeah. Yep. Yeah. 

Erik: Yep. I hear you say. Yeah. And I think there's a certain amount of motion we can't avoid.

Uh, 

Matt: exactly. 

Erik: Yeah. And, and I, I, if I was on that ride out with you in this patient's situation, um, I think, uh, I would, I would limit the motion as much as I could. Mm-hmm. Yeah. Okay. And get them into an environment where we get them onto that gurney. Mm-hmm. Safely 

Matt: Okay. 

Erik: [00:32:00] Away from the accident. Yep. In a comfortable, you know, sit in a comfortable position as much as we can.

Yeah. Um, and uh, uh, I would not place a C collar on that patient. Mm-hmm. Unless I had a really good reason to. There are some, I would consider it in maybe that really old osteoporotic patient. Mm-hmm. You know, maybe there might be some evidence there that might. You know, we, there could be a study that comes out in five years, right?

Right. Showing that, uh, [00:32:30] in women from nursing homes that have terrible osteoporosis, men can have a too, but it's typically women terrible osteoporosis. Maybe those, those fractures can be more unstable potentially. Sure. I know in down syndrome patients, there's a lot of cervical spine abnormalities that are congenital associated with that, um, genetic condition down syndrome.

Mm-hmm. That creates some serious cervical issues. There may be evidence that in those patients, a cervical collar may be more beneficial. Maybe there could be data that would come out.

Matt: Yeah. [00:33:00]

Erik: To, to bend those things. But for now, based on what we're seeing, I, I would do a towel, uh, that vacuum, you know, sort of inflatable device, you know, I could, I could try to, uh, and.

Maintaining patient comfort mm-hmm. Is to keep them still. And, um, uh, you know, if, if motion isn't causing any harm, uh, you know, restricting their motion, actually that may not be the answer. 

Matt: Mm-hmm. 

Erik: I would be focusing again on patient comfort, treating their pain, and maintaining blood pressure. 

Matt: [00:33:30] So in the car.

Am I still holding C-spine? Am I still holding their neck as we're removing them from the vehicle to try to keep it in line at least? Yeah. Okay. So you're still doing that part, but not taking the C collar out it Yeah. But just keeping, keeping some spinal, 

Erik: absolutely. Yeah. Maintain. Maintain that position of comfort.

Try to restrict motion. Gotcha. As much as you can, you, you know, I'm not saying be afraid of touching the head. Right. You know, like, 'cause you wouldn't want the head fall. 

Matt: Right. Hobbling. Right, 

Erik: right, right. You know. I think, and, and I know you know that, [00:34:00] and I, I think that that would be, I would try to limit motion.

I mean, that's okay. I think that with any traumatic injury, um, we don't, we don't want to exacerbate things. Sure. And I think in an abundance of caution is to try to decrease the, the patient's movement. Mm-hmm. You know, just like you wouldn't want a patient to just get up and walk. Right to the ambulance.

Right. You're gonna carry them over because they've significant mechanism. 

Matt: Right. Right. 

Erik: I think the same thing is true for any sort of potential spine injury. 

Matt: Yeah. [00:34:30]

Erik: Um, it, it's, it makes sense logically to, so we're, we're not doing 

Matt: the C collar as they're standing up and then the backboard behind the back reaching through and dropping 'em on the ground like we used to do.

Oh no. Yeah. We're not doing that anymore, which is good. Yeah. Which is good. Okay, good. I was curious about that. Like the KEDs, you know, again, that, that MVA patient, you know, maybe unresponsive in the car, you know, how do we handle that now? You know, and again, we're not, you have to go with your local medical director.

Mm-hmm. Uh, this is gonna be protocol change and all [00:35:00] kinds of stuff, but it's an interesting, 

Erik: it is interesting. It's turning it all upside down. With what? The way we've done, 

Matt: not the patients, the information, the mindset. Yeah. Not the patients. Yeah. Don't turn your patients upside down. That would be bad. But no, I think it's great.

'cause like I said, I have hated and I think most people, um, you know, they hate putting these c collars on because, you know, you got little old grandma, you know, my protocols 65 years in age and older with any sort of mechanism of injury. And so, you know, you get 80-year-old [00:35:30] grandma fell outta bed at the nursing home and we're taking her in 'cause the nursing home staff wants her transported.

And so, and I've gotta put this collar on her and it doesn't fit right, and it's up over her ears, or it's popped up over her chin into her mouth and she's uncomfortable. I'm like, this is stupid. Yeah, this is dumb. Is this, or like, I'm like, I'm not doing it. Then I get to the hospital and the doctor's yelling at me because, well, why didn't you put her. Doc, she slid outta bed. Onto her butt. I don't think she needs a C collar, you know? I mean, but it's just, like you [00:36:00] said, it's this, uh, it's this stigma that you have got to do this in these patients. And thankfully we're actually using our brains to say, wait a minute, there's no data to back up that this helps, or that movement is causing problems.

That's true. So what are we doing it for? Yeah, I like that. 

Erik: Totally agree. 

Matt: Yeah. I think a lot of times when we have these protocol changes, I get. You know, questioned all the time, like, well, what are we doing this for? What I think a lot of people will like this change that we're actually taking something out as opposed to adding something to your protocols.

Erik: That's right. That's interesting. 

Matt: But, uh, this is, this [00:36:30] is why, because the data says it's better. 

Erik: I think unfortunately though, um, it's going to require a better exam. Okay. And we'll talk about that in our last segment here. But, uh, what do we do now moving forward? 

Matt: Okay. 

Erik: How do we handle these patients? And, and, and as a medical director, I, uh, I look forward to sharing my plans with, uh, what we're going to do.

And it may change. Mm-hmm. I may have to adjust and pivot based on what my colleagues do in the area and, uh, what the data shows out. Right. Exactly. But, um, based on this data, I'm making some changes and, [00:37:00] uh, moving forward, we're gonna, we're going to, we. Handle things differently. Mm-hmm. In our, my fire departments.

Matt: Alright, well let's get to it. 

Erik: So where do we go from here, Matt? What do, what am I gonna do? 

Matt: Yeah, yeah. You're the guy in charge. You're the guy dictating what uh, I get to do pre- hospitally. 

Erik: Well, I think, you know, in your position as an EMS Captain 

Matt: mm-hmm. 

Erik: You're interfacing with your medical director at your municipality Yep.

And your fire department very closely to try. You know, what do we need to implement to be, [00:37:30] to improve the safety of our community? Right. If it's true. Yep. Just throwing a c collar on every trauma patient we see isn't helping anybody. Nope. It's hurting them. 

Matt: Yep. 

Erik: So, um, in, uh, we're one of the places where I'm a, uh, the medical director, we, we are going to no longer use C collars.

Matt: Mm-hmm. 

Erik: Period. Well, like totally. Or yeah. We're not going to use the C collars anymore. We'll have them if we need them. 

Matt: Okay. 

Erik: So clinically, if there's a situation where my paramedics feel like they need to have a c collar for [00:38:00] some reason they can use it. 

Matt: Mm-hmm. 

Erik: I do, I do have some pearls in our protocols, like, uh, the down syndrome patients or someone with severe osteoporosis where Right.

You know, I and I, and honestly, I don't think there's any evidence to support doing that. Mm-hmm. But clinically, these are, these are things that can increase the risk for cervical Sure. Fractures, right, sure. Neuro deficits and things like that. But based on this evidence, I don't think that the C collars are gonna help anybody, even with a, even with that fracture right [00:38:30] now, uh, I, I don't say we let them move around willy-nilly.

Right. We're just going to, um, protect their spine. Mm-hmm. Just like we would protect any patient, but maintaining comfort. 

Matt: Mm-hmm. 

Erik: The C collar isn't the answer for that. Yep. But the one thing that I, I, I am also doing is that we're the Nexus criteria. These were developed in Canada. I think they were developed in Canada.

Matt: We pulled it up right here. Yeah. It's the, uh, uh, nexus, [00:39:00] N-E-X-U-S, national emergency X-ray radiographic utilization study. 

Erik: Correct. And so this is, uh, a standard of care for clearing somebody's c-spine in the emergency department. But I, I think it's good information here. Um, if we're not gonna use C collars, we better document things really well.

Yeah. 

Matt: Our assessments really well, right? 

Erik: Yeah. Your neuro exam has gotta be on point. 

Matt: Don't just click all no abnormalities in your flow chart in ESO, please stop doing that.

Erik: Cause if you don't have a good neuro exam Yeah. And you [00:39:30] don't put on a collar mm-hmm. And then somebody Yes. Has has a neuro deficit documented later.

Matt: Yeah. 

Erik: You look pretty bad. Yes. But if you've documented your neuro exam and this patient has no neuro deficits, no strength, weakness, nothing, no sensory deficits. Right. And you documented all of that. Um, a certain percentage, a significant percentage of spine injuries do happen over time after the initial insult.

Mm-hmm. So it's reality and that's why they hypothesize that motion caused those things. 

Matt: Right, right. 

Erik: These [00:40:00] things happen. Yeah. But it's. It's, it's based on what we're seeing here. It's not motion. Right. Hypoperfusion, we talk about this. Right. And so when we're dealing with a spine a, a trauma patient, blunt trauma, um, likely, um, we are going to want to document the, the, our physical exam.

Part of that is going to be the first component of Nexus is the midline tenderness. 

Matt: Yeah. 

Erik: You know, are they 

Matt: palpating the neck? Yeah. Do you feel any pain here? 

Erik: Whoa, it really hurts. Yeah. Oh, 

Matt: don't touch that. Oh, that [00:40:30] hurts. Yeah, exactly. 

Erik: And, and I'm telling my guys, don't put a c collar on. Yeah. But maybe a towel or, uh, the vacuum splint just to get, just to keep the patient comfortable and to limit the motion.

But the c collar to limit the motion I'm not doing anymore. 

Matt: Even if they have point tenderness, 

Erik: uh, you didn't have point tenderness. Okay. Um, now I'm in discussion with some other medical directors and, and one thing that is true when you're changing things [00:41:00] drastically mm-hmm. Uh, you don't wanna be the only one doing it.

Matt: I was gonna say, yeah, that's 

Erik: so 

Matt: same thing my medical director said. 

Erik: Yeah. So I think, uh, there's gonna be some collaboration here. Sure. And, uh, and things may change, uh, when we actually implement these on actually just in a couple weeks, right. Uh, we're gonna implement these and add these directives to the protocols, but, um, that, that.

The midline tenderness is important to document and paraspinal tenderness is tenderness just to the side of the spine. Right. Which is common. Mm-hmm. Those muscles, like we talked about. Sure. Get tight, 

Matt: whiplash type. Yeah, yeah, yeah. 

Erik: Yeah. [00:41:30] The, there's supposed to be a curvature to the spine. It's called, it's like called lordosis.

Matt: Mm-hmm. 

Erik: And as sometimes when. You've seen those older folks mm-hmm. Where the, the curvature goes the other way. Kyphosis. It's kyphosis. Correct. Yeah. But that lordosis is the way we're designed and, and when we get that whiplash injury, it can straighten that cervical spine. Mm-hmm. And it's because of those muscles.

Yeah. So anyway, the point is on your physical exam with these patients, document where they're tender. Yeah. And, and if they are tender in the cervical spine, [00:42:00] I'm gonna, I'm gonna have them pay special attention to that and make sure they've documented their physical exam and make sure they protect the spine as much as they can and keeping the patient comfortable.

Got it. We don't want to cause the hypoperfusion, that seems to me to be a more realistic and more reasonable hypothesis to what's causing some of these post-incident neuro deficits. 

Matt: Right, right. Maintaining blood pressures, maintaining maps. It talks about in here that, so that's the one, there's five criteria with this Nexus criteria.

Mm-hmm. No posterior midline [00:42:30] cervical tenderness. Yeah. Read them all. Yeah. Two, uh, no intoxication. Mm-hmm. So obviously if your patient is under the influence of alcohol or other substances Right. That could numb their senses and they could not be feeling any pain. Right. Yeah. And obviously this is in the context of a patient that's been in, has a mechanism of injury, right?

Yeah. So DUI, you go on, which super common call that we all go on, we go on a wreck. Yeah. And somebody's intoxicated, which is the cause of the wreck and there's a lot of damage. Yeah. Those patients you need to use extra caution on. Yeah. [00:43:00] Because they might not be feeling the any pain in their neck. Right.

Or any other pain. Right? Yep. And so, again, not. Necessarily putting them in a C collar, but cautiously moving them to the cot, putting them in a position of comfort, maintaining their vital signs, and documenting a good head to assessment. 

Erik: And it's tough with these intoxicated patients. Yeah. They're oftentimes combative.

Yeah. And, uh, you know, a combative patient. Um, 

Matt: that's why I love ketamine. 

Erik: Yeah. Well, I mean, that's, that's a key, right? Yeah. I [00:43:30] mean, uh, uh, we got, we gotta, we, there needs to be more literature studies mm-hmm. Some of these patient populations, but yeah. Um, putting someone in a c collar is causing harm. Yeah.

And I'm not sure it benefits these patients. Yeah. Um, so lots of why are we doing it? Discussions. Yeah. And I've had patients too that, that are altered or they're angry when they put the collar on and actually move more. Fighting it. 

Matt: Oh, yeah. That's what we talked about in the last part. Oh, a hundred percent.

Grabbing at it, pulling, we just had a patient the other day that was, he [00:44:00] got hit by a car. He was riding his bike, got bumped, got bumped by a truck, but he had a pretty good hematoma on his head, bleeding, you know? Mm-hmm. He was a little altered, and we put the C collar on him and he, he wanted that thing off.

Take this thing off of me. He kept pulling at it, yanking at it. The medics, you know, we're, yeah. 'cause that's what's ingrained, you know, you gotta keep that collar on. So hopefully we can go away from that. And which brings us to our next point, normal level of alertness. Yeah. Like this guy didn't have a normal level of alertness.

Yeah. He was like A and O times one, maybe two. Yeah. Like [00:44:30] he was a little bit confused on some things. So that would be a patient again, that we would cautiously move. Yeah. Per your recommendation. Yeah. To the cot. Mm-hmm. Put a towel around their neck, something like that. And again, monitor vitals, resuscitate if needed, 

Erik: and get 'em to the place where they can get the imaging done.

Right. And then, and really ascertain what, what, what's going on. 

Matt: Right. 

Erik: And a lot of these things can't even really be seen on an X-ray or a CT. It's gonna need an MRI. Right. So, you know, um, and, and we'll let those [00:45:00] neurosurgeons and those trauma surgeons 

Matt: let those really smart people figure it out. That's right.

That's, 

Erik: uh. You know, we're, we're, we're there in the pre-hospital environment. Um, and, and then the ER is kind of where I am. I'm kind of the interface between the two. Mm-hmm. You know, you guys are that crucial seven to 10 minute time, 

Matt: we like to call ourselves the tip of the spear. 

Erik: You are, you are. And then I interface the patient you give me.

Yeah. With the experts that can fix it. Yeah. But I think with an altered patient, you gotta be careful. 

Matt: Yeah. Oh, for sure. 

Erik: Document the heck out of it. [00:45:30]

Matt: Yeah, definitely a patient that you wanna, because we don't know what's going on, why are they altered? Right? Yep. You know, again, we talked about intoxication, but is this, do they have a concussion?

Do they have a brain bleed? Do they have, you know? 

Erik: Yeah. Things 

Matt: like that. So be looking out for that. 

Erik: Distracting injuries, that's the fourth one. 

Matt: Yep. Which is. That was in our protocols. Right. Uhhuh, if they had a distracting injury. C collar. Yeah. Gotta get a C collar. Yep. Right. 'cause that, you know, you got a broken femur, you're sitting there, they're hurting that femur, they're gonna be moving around.

They're not, they're not paying attention to [00:46:00] that. Yeah. Spinal pain. 

Erik: So I think it's a good clinically to be aware of that. That's a, that's a normal physiologic response. When you got tons of pain, your, you know, your arm's been cut off. You may not feel that hangnail anymore. 

Matt: Yeah. 

Erik: Right. I mean, this makes sense, but, um, so if you do have that distracting injury, does that, that physical exam's gonna just have to be.

All the more careful. 

Matt: Yeah. 

Erik: Yeah. Yeah. And I think the last one is when you do that neuro exam, which is important for anybody with a potential spine injury 

Matt: mm-hmm. 

Erik: Document the strength. Yep. Right. [00:46:30] Equal grip strength. 

Matt: Yep. 

Erik: Uh, you know, moving their feet. Exactly. Yeah. Put all that document that, you know, when you have somebody, uh, that the grip strength and the, and pushing the feet down, you're, those are some of the longest nerves in the body mm-hmm.

That are starting up at the brain all the way down to the hands and feet. 

Matt: Yep. 

Erik: You, your, you're your, um. In sensory too. You want to sensory and if you wanna do a full neuro exam, go for it. You know, just 

Matt: go ahead and do the babinsky, whatever you've been told. If you want a babinsky, go, go for it, bro. That's funny.

Erik: No, I, I, but I, I look [00:47:00] for those neuro deficits. It's in document that there are none. Yeah, it's. You gotta do that. 

Matt: Yeah. Again, documentation's super important. Um, you know, especially as we're transitioning away possibly from C collar and which it looks like that's story, the direction EMS is going. Yeah. Is that we're probably gonna be moving away from this.

So, you know, make sure in the interim that we're documenting well, yeah. Because even the general public, I would think, knows about C collars, right? Mm-hmm. I mean, it's not like some hidden secret. Everybody's seen this, you know, in the TV shows and things like that. And so [00:47:30] yeah, documentation is gonna be super important.

Erik: It's kinda like a pupil exam. 

Matt: Yeah. 

Erik: You, you know, I know that a pupil exam is something parents expect, so I'll do it 

Matt: looking in the eyes For trauma patients, you mean like if they come in like trauma, a kid comes in. Okay. Yeah. 

Erik: And I, and I'm, if I don't look at the eyes, I know there are, there's a significant number of mommies and daddies who are gonna say, 

Matt: is that not a good exam?

Erik: No. Oh, I didn't know that. I mean, do it, but it doesn't, I mean, I know that a herniation is a late finding. Oh, that's true. Yeah. [00:48:00] If I'm seeing herniation 

Matt: and you're gonna see dis Yeah. 

Erik: If I, if I'm seeing herniation 

Matt: Yeah. 

Erik: On my pupil exam, I probably intubated the patient already. Yeah, right. So 

Matt: they're gonna have other signs like Cushings or something like that.

Yeah. 

Erik: You know, you could have what's called like an abnormal pupil or something from like a traumatic iritis or you know, from head trauma, like a bar fight or whatever. Right. But that doesn't mean you're herniating. Yeah. And a herniation is a, a late finding. Yeah. And so 

Matt: it's kinda like tracheal deviation with a pneumo, right.

Yeah. I've heard that. Like almost nobody's [00:48:30] ever seen that. I've never seen it. Yeah. 

Erik: I've never seen it. But the, the, the, the, the whole pathogenesis of, of increasing ICPs, we're not talking about that today here. Right, right. But. It's kind of like C collars, right? Yeah. I mean it's like this, this C collar is just kind of something we just do, but we don't think about it.

Matt: It makes us feel better. It does make us feel better when we put the C collar in. It's almost, and 

Erik: I've been there. Yeah. In the ER when I have that trauma patient that walked in in an A TV accident. 

Matt: Yeah. 

Erik: Get 'em in a C collar. Right? Yeah. Right. And I feel like, and I think we can all identify [00:49:00] with this did the right thing for my patient, the checkbox.

Yep. It's like, okay, I can take that off my list. Yeah. It's kinda like the trauma progression. You go, yes. Okay. Patient's talking to me, airways good, breathing's good. C ABCs. Right. I move on to the, you know, so this helps me to move on in my progression of assessing a trauma patient. Okay. Check that box. Got the cervical spine taken care of.

Yep. Actually, I've just increased the risk of injury. Yep, exactly. And that's the way we gotta look at it. And it's, it's gonna take some time 

Matt: and we're, we're lowering on the priority [00:49:30] scale, what is actually could be causing the secondary injury, right? Yeah. We're not looking at, well, what's the blood pressure, what's their map look like?

Right. 

Erik: Let's prioritize that. Let's prioritize those blood. The blood pressure, our physical exam, patient comfort, 

Matt: and a lot of times we don't do these good assessments because we put them in a C collar. That's right. We're like, well, I, I'm, I mobilize their spine so I don't need to check, you know, if they've got movement in their feet.

'cause I've already done everything, 

Erik: you know, I've had, I've had patients ticked off because of the cervical collar and I'm like, I walk in and I say, sir, are you doing okay? You feeling any better? [00:50:00]

Matt: Dang thing off.

Erik: Yeah, everything's fine. Except for this thing you put on my neck.

Matt: Yes. I feel like I'm choking.

Yeah. 

Erik: Now I'll say this though too, as we've kind of finished this out here, is that, um, nothing is simple in medicine. Nope. And we're not looking for that thing where we just always don't use it. Right. That's not, nothing's a hundred percent is what usually say. We don't wanna overreact and we gotta be careful.

Um, but this is a pretty reliable piece of information here we see, and I don't think it would be prudent, and it's not wise and it's not good for our patients to [00:50:30] not change what we're doing if we're putting C collars on everybody. 

Matt: Yeah. Like I said, I will put a link to this. It'll be in our link tree.

You can find that on all of our social media and everything. I'll put it in our YouTube video for this podcast. You can click to that link and get to this article. Read the article. I think sometimes too, a lot of EMS providers, we're not like you guys. Yeah. You guys read a lot of research as physicians and we don't do that that much.

It's not really ingrained in us to to read research. Yeah. But this is a really good one that's gonna have a lot of [00:51:00] impact on what we do every single day as EMS providers. So read it. Um, and then take it to your medical director. Make sure that they are aware of it. 

Erik: Do we have time for one minute advice?

One minute of advice. 

Matt: Go. Ready. Go. 

Erik: Have 30 seconds. Yeah. You're wasting time. 'cause you and I talked about this. I think it's important to un, like when you read a paper, figure out what the purpose of the paper is first. Oh yeah. And then understand what is your purpose? How does this affect you and your job.

And then after that first P, you go [00:51:30] to the second P, which is to peruse. Look at the like, go look through it and and see if you can find problems. Mm-hmm. See if you read it and something doesn't make sense. Yeah. Trying to deconstruct it. Read how many people were in this study, what kind of study is it?

Right. Um, and then 

Matt: were they trying to sell something related to this study, right? Yeah. Was their, 

Erik: and then, and then ask yourself the last P, which is practice. How does this change my practice? Right. Just do that and then ask your medical director, Hey, I was looking at this study based on what I read.

This is what I think. What do you think? Can you read this? Mm-hmm. I would love it if one of [00:52:00] my paramedics or EMTs or firefighters did that for me. 

Matt: Yeah. Yeah. It's a different way to learn, right? Mm-hmm. And it's, uh, this is then you'll start to understand why protocols change is because of research and data.

Exactly. Right. And that's what you guys, you know, like I say, you guys are ingrained in that. Mm-hmm. It's not really ingrained in the EMS. 

Erik: It sounds complicated, but it's really not that hard. The three P's really. Yeah. Just to, well, like anything rep purpose. Peruse the paper, ask questions, look for problems.

And the last P of course is, uh, the practice. How does it change your practice? 

Matt: Yeah, well, it's a good podcast. Maybe we'll [00:52:30] go away from C collars for the majority of our patients now.

Erik: Safe out there.

Matt: See you on the next one.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.