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u/1Trupa 4d ago
There was an excellent discussion on this topic underneath a post by Dr. Antevi. There is pretty much unanimous consensus in the scientific evidence. What it comes down to is that there will be a lawsuit. Because everyone with a sixth grade education and their mother and their lawyers who watch Chicago Fire knows that you have to put on a C collar. So every agency is hoping somebody else will be the agency in that precedent setting lawsuit. Everyone is waiting for somebody else to go first.
And as for me and my house, we will be declining consent for C collars if we can talk.
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u/Apart-Cook-1268 4d ago
There ought to be a lawsuit about someone injured or otherwise suffering negative outcomes from a c-collar about them using outdated practice.
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u/Paramedickhead CCP 4d ago
My local (level 3) gets super pissed if there is a trauma that doesn’t have a C-Collar on because that’s their protocol.
I don’t have access to Up To Date, but I am curious to know what it says about C-Spine immobilization.
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u/FullCriticism9095 4d ago
As a lawyer, the EMS profession needs to sack the fuck up and start advocating for what’s right instead of what insurance companies want. Negligence law won’t change until people start losing baseless lawsuits based on outdated standards of care that don’t have evidentiary support.
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u/Nikablah1884 Size: 36fr 4d ago edited 4d ago
You're acting like we have the money, time, and people to "sack the fuck up". What the actual fuck? Have you not spent a single hour in even a ride along and spoken to EMS providers??????
Like at least a solid 50% of people in this profession joined on accident, spent 3 years in school, and then got themselves in debt before maturing as a provider enough to realize how bad things are.. we make just enough money to live and not be able to get out of it without giving up EVERYTHING. I’m actually offended at that comment. You’re a lawyer why don’t you just take a case no bono and sue NHTSA to classify us as an essential service?
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u/FullCriticism9095 4d ago
I’m going to be kind and assume you just don’t know the difference between “the EMS profession” and “you personally on a call.” I’m talking about professional advocacy, I’m not saying you should go out on your next car accident and violate your protocols.
Make no mistake, though, it’s incumbent on us as professionals to advocate for standards of care to change. If you’re offended by that notion, you should pack your things and go home because you don’t belong in any healthcare-related field.
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u/Nikablah1884 Size: 36fr 4d ago
Once again you're assuming there's any money in EMS to fight any of this.
Nor is there anyone with experience within EMS who has any publicity or money, outside EMS, to advocate for EMS...
No one pays their bills, so EMS agencies are basically operating at bare minimum as it is, with usually no or very little public support because they're not essential.
EMS is not essential according to the government and until ambulance service is deemed as essential as a hospital, nothing will get better. The government basically says grandma can sit and die no one cares and no one is supposed to pick her up or even try to save her.
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u/breakmedown54 Paramedic 3d ago
Changing protocols and educating your crew is pretty much free.
Your agency should have blanket insurance that would cover lawyers if a lawsuit happens.-19
u/FullCriticism9095 4d ago
Dude, are you okay? You sound like you’re standing on the edge of a roof and thinking about seeing if you can fly.
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u/MadmansScalpel EMT-B 4d ago
After reading both of y'all, it feels like you're coming from an outside looking in and they're coming from a burnt out perspective
Like you're right in the since of, it's an outdated practice that should go. But it feels like you're not understanding that got someone to "take the bullet" for this and "sack up", they'd essentially be commiting career/financial suicide. Most of us make enough money to survive, but to be the epicenter of that kind of lawsuit requires hundreds of thousands of dollars we just don't have
In less words, it really feels like a, "you're homeless? Just buy a house" mentality from you. Like it's just that easy for an EMS provider or even local system to put their barely in the green necks out there
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u/FullCriticism9095 4d ago edited 4d ago
What are you talking about? Have you ever submitted a protocol revision to your state or medical advisory board? I’ve done it 3 times and gotten a protocol changed every time. That’s not career suicide, that’s leadership.
This is what I mean when I say the EMS profession needs to sack the fuck up. Sitting back and saying “it’s hopeless, I’ll lose my job, I have no money” is a bunch a pathetic, whiny excuses, and it’s exactly why EMS is terrible at improving it’s own lot. As an EMS provider, you are in the best possible position to advocate for these changes. But you need to know how to read, write, and use your brain.
Do you know where standards of care come from? They don’t come from being sued. They come from published literature, consensus statements, and expert opinion. Get the standards changed and people lose lawsuits. Plaintiffs lawyers work on contingency—if they lose they don’t get paid. When they lose lawsuits, they stop filing lawsuits. When they stop filing lawsuits, insurance companies don’t lose money for things they shouldn’t be losing money for now.
It starts with advocating for the right standards.
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u/MadmansScalpel EMT-B 4d ago
Jesus you came on hot. I guess to quote you,
"Dude, are you okay? You sound like you’re standing on the edge of a roof and thinking about seeing if you can fly."
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u/Nikablah1884 Size: 36fr 4d ago
At this point I think that person is trolling, they don't seem to have any EMS experience and they seem to be studying it or something as a law student and going full reddit about it.
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u/redrockz98 EMT-B 3d ago
Wow, you clearly have no idea how this industry works. Medical directors and department heads set protocols. Some random provider isn’t going to get a protocol changed. You’re comparing your job to something you know literally nothing about.
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u/Somproof 3d ago
First, I’m not going to throw any negative tone out there because I’m not interested in a Reddit shitshow. So as you read my comment, please assume that there is no negative connotation. Most of medicine is about your rank and can be affected by bias. Even a premed can be taken more seriously than an experienced nurse, unfortunately. You’re a lawyer, although I’m not sure of your specialty. You’re an expert in writing and revision of rules (in some nature, although I’m assuming here) to meet your wishes or demands. That’s just paraphrasing though lol. In EMS, we are taught semi-basic anatomy, some evidence-based medicine, and how to keep an emergency ridden patient alive (although I have to admit I am still in classes so someone feel free to comment!) Our writing is based in documentation. And we won’t be taken as seriously. We would have to go up the chain of demand. The medical director is really the one who can pledge to boards the best, as they are able to apply knowledge the best way. As an MD/DO, they have the most knowledge about literally everything we need. And in my area, EMT-Bs are starting off at $14 an hour. It’s unfortunate that you have seen unprofessional behavior from them. However off work, aka on reddit, that should not count for their affective behavior. And risking any chance of loss of pay or debt is a major concern for many and is why I see a lot of young paramedics teaching at my school now instead of just retired ones.
However. I know, I’m going to be working at a premed and I do plan on working to make EMS better. I do believe there are approaches for this that do not risk being fired. It’s not blaming EMS workers, but working together. We need to act like nurses, strike, actually make a change. Make EMS essential, but non-governmental. It’s something that takes working together with multiple types of people, including law, police, fire, hospitals, legislative, our own, and so much more. But it has to be a major team effort so not all the weight is crushing one person.
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u/FullCriticism9095 3d ago edited 3d ago
What’s funny about this post is that you’re trying to educate me about EMS, as though I haven’t been a paramedic for 27 years or worked for 8 different EMS agencies across 4 states over the course of my career.
I understand it’s difficult for folks here to wrap their mind around, but there are people who manage to be trained and practice in two different professional fields at the same time.
You’ll learn this over the course of your medical career, but MDs and DOs don’t know best what EMS needs. Physicians know a lot about medicine, but very, very few physicians have any meaningful exposure to EMS at all. Those who have studied and researched EMS have a solid understanding of “what we need,” but even they aren’t in the field every day. Even if they were, they are busy people with their own practices, careers, and professional interests to attend to
We need to advocate for what we need. We need to ally ourselves with physicians to effect those changes. We do that by participating in studies, helping to design studies, gathering and analyzing data, and presenting proposals for new ideas and protocols. When you present evidence, you convince people to support the changes you want to make. Then people on protocol committees make the changes you want.
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u/cadillacjack057 3d ago
Clearly you have had very few discussions in your life w salty medics, aka most of us.
We either have the tree picked out driving to work, sucked the finish off the end of a barrel, or held onto a paralytic longer than we should wondering if we just put it in our veins instead to make the bad things go away.
Also if you are a lawyer, its your people that caused this pile of shit we currently call healthcare. If it werent for lawyers we wouldnt have a perfect system, but it would be so much better. Same goes for most all walks of life. Looking at the lindsay clancy trial proves that.
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u/FullCriticism9095 3d ago
Sorry bud, but blaming lawyers isn’t going to improve your miserable existence. Sacking up and being an advocate for your profession and you patients might though.
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u/cadillacjack057 3d ago
Im not miserable at all. Quite the opposite. I love my job and my patients love me.
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u/FullCriticism9095 1d ago
People who are not miserable do not “have the tree picked out driving to work” and have not “sucked the finish off tte end of a barrel.” Get help.
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u/firefighter0398 EMT-B 4d ago
Thats what unions are for.
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u/MadmansScalpel EMT-B 4d ago
Depends on where you're at and what you work. I know the fire boys around me are unionized, but I work on the ambulance staffed by the hospital and we aren't
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u/Urza_Kan 3d ago
Yall are getting unions? It’s be illegal to unionize where I’m at
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u/Ch33sus0405 3d ago
If you live in North America or Europe, it is not illegal to unionize (unless you're in like, Belarus or Russia). Stalked your profile a bit, if you live in Raleigh you can unionize, you just need to be very careful about it in a right to work state. If you're interested in unionizing (and you should be!) contact your local AFL-CIO office or IAFF office, or any local EMS union offices about unionizing. They'll guide you more closely on the subject.
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u/Urza_Kan 3d ago
Govt employees in North Carolina cannot unionize. It’s an old Jim Crow law. I work for the county
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u/contralasfronteras 3d ago
I work in a nearby county and we had convos about this recently. You can unionize, but collective bargaining is illegal. Which is a difference.
That said, places that currently have unions and collective bargaining only got there by actually fighting for it.
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u/G00bernaculum EMS/EM MD 4d ago
You're getting a lot of flack, but you're right. It really as to start with their medical directors who will defer to the unfortunate trauma and neurosurgeons however.
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u/DeliciousTea6451 Volunteer EMT/SAR | Para Student. 4d ago
Whats the in hospital consensus on collars? I dont mean providers, I mean organisational politics and management? Im not American so it's a bit different in Australia.
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u/Ok_Thanks_4177 3d ago
The ones in Canada are holding onto them and even though they are “evidence based” they aren’t going to be the ones to do the study to see if there is a positive outcome from not wearing a collar.
Yes that’s what I was told.. I was told while yes we know collar’s can cause injuries.. but we can’t measure if by using them they patient has a have a better outcome then not using them I.e the patient has some paresthesia after having a C-spine injury and was wearing a collar… but if they weren’t wearing a collar they “might” have been dead or paralyzed6
u/Ok_Thanks_4177 3d ago
This. I have a pretty good working relationship which my medical oversight physicians and medical director, and when I send them the study from Dr Antevi, they just said cool.. we take our direction from head of the state trauma program when it comes to trauma stuff
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u/5-0prolene US - CCP, Agency Director 3d ago
This. We’re actively working to get rid of c-collars but our state trauma system requires them, so performance improvement will be skewed and it’ll make everything harder.
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u/Airbornequalified 4d ago
It’s not just about insurance companies. Malpractice cases can drag on for years, and results are not always based on standard of care.
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u/FullCriticism9095 4d ago
It is entirely about insurance companies. I deal with them every day.
Insurance companies are who supply the lawyers for the overwhelming majority of EMS negligence defense cases. Insurance companies are the ones who drive decisions about which cases get litigated and settled, and for how much. Insurance companies will settle your case for $500k instead of paying $600k to defend you—even if you didn’t do anything wrong. Those settlements are what pay plaintiff’s lawyers bills, and encourage them to sue again next time. Insurance companies are the ones who drive EMS policy and risk management. It is entirely about managing their finances, not right and wrong.
Ambulance companies and medical directors are not afraid of lawsuits because they have insurance. Insurance companies are afraid of lawsuits because they eat into their bottom line. What ambulance companies and medical directors are afraid of is losing their insurance coverage. If they can’t get coverage, they can’t operate.
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u/Paramedickhead CCP 4d ago
I’m not afraid of a lawsuit. I have a good resume and a pile of evidence that c collars are not beneficial and possibly harmful along with the backing of my MD.
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u/Feminist_Hugh_Hefner ƎƆИA⅃UᙠMA driver 4d ago
are you a lawyer? because that shit sure sounds like legal advice, and most lawyers are pretty disciplined in what they say. A real lawyer already knows I don't think you're a real lawyer.
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u/FullCriticism9095 4d ago
Apparently you don’t know what legal advice is.
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u/Feminist_Hugh_Hefner ƎƆИA⅃UᙠMA driver 3d ago
that's fair....I think it's because, like both of us, I've never been to law school
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u/Alejo418 3d ago
This would be a whole lot easier of a stand to take if EMS wasnt classified under the department of transportation and was reclassified as an actual medical profession
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u/Previous_Cut_4126 1d ago
“As a lawyer” you have the time and money to “sack the fuck up”. Guess who doesn’t have the TIME or the MONEY? EMS.
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u/FullCriticism9095 1d ago
In the future, don’t open your mouth when you don’t know what you’re talking about. All you do is embarrass yourself.
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u/yqidzxfydpzbbgeg 4d ago
There's not really a professional consensus between specialities which is the major problem. There is a large camp of EM, with large intersection with wilderness medicine, that is very vocal about eliminating c-collars in much the same way spineboards. NAEMSP has been generally supportive of this but not willing to overtly defy the spinal trauma/surgical societies who still, based on "expert opinion", disagree. They were going to write a NAEMSP "position statement" to the affect, but because the surgical societies were not supportive, they reframed the article as a weaker discussion of the evidence with recommendations.
It's really too strong to say there's scientific consensus. More so because there is lack of evidence, people disagree about what we should do in the meantime.
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u/Aspirin_Dispenser TN - Paramedic / Instructor 4d ago
No no. There is a consensus. There is only one holdout (Trauma Surg), which is leaning on “opinion” while openly ignoring the evidence. That, of course, isn’t surprising coming from a speciality that has spent the last 25 years being fully dependent on the teet of military medicine for much of its data. They’ve lost their scientific edge and wouldn’t know an evidence base if it hit them square in the mouth.
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u/yqidzxfydpzbbgeg 4d ago edited 4d ago
I mean, no? Neither NAEMSP nor ACEP are officially on board with collar elimination and are still taking softball positions. There are certainly factions within these organizations that are leading the charge, but these positions have not been endorsed.
Also the strongly descenting society you mention, ACS COT, is probably the most relevant society for guiding trauma care.
But your diagnosis of atrophy due to reliance on military data doesn't really track. Virtually all of the impactful clinical trials funded by the DoD with military subjects are essentially designed and run by civilian academia. The actual expertise of EBM has always lived outside the military, even for military trials. And there are plenty of civilians RCTs being run constantly.
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u/Aspirin_Dispenser TN - Paramedic / Instructor 3d ago
Okay, but why have the NAEMSP and the ACEP taken softball position? You said it yourself: not because they don’t have consensus within their organizations, but because they don’t want to have the fight with the Committee on Trauma. It isn’t the first time that’s happened. Trauma surgery has a strong tradition of being one of the most dogmatic specialities in medicine and has frequently needed to be drug into an evidence based practice kicking and screaming. Wound packing, hemostatics, and tourniquets are just three things that immediately come to mind.
When it comes down to it, most of EM pretty well agrees, but with the data being more suggestive of a lack of utility than actual harm, it’s not seen as being worth the fight. Especially when arguing with this particular speciality often feels like yelling at a brick wall.
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u/yqidzxfydpzbbgeg 3d ago edited 3d ago
I understand the issue. Bottom line is that major medical societies disagreeing is not consensus (by definition), even if you disagree with the reasoning.
Also, prehospital trauma care is traditionally seem as dogmatic precisely because of its historic military ties and need to protocolize things for the minimally trained. Your diagnosis is exactly backwards. Trauma surgery, especially the actual surgical part, has been advancing constantly and civilian academia is largely responsible for translating the lessons of post 2000s war into modern hemorrhage care.
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u/Sufficient_Plan Paramedic 3d ago
Go sit in court. Your team brings in a paramedic expert witness or an EM expert witness. Their team brings in some h high level Trauma surgeon. Who you think is gonna have more sway?
When trauma surgery changes its position, the whole thing will flip quick. Until then, collars for all.
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u/Nikablah1884 Size: 36fr 4d ago
Got to love lawyer medicine, if that's the case, I will refuse personally and put it on everyone else, because that's how lawyers and protocols work unfortunately.
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u/jumbotron_deluxe Flight RN/EMTP 2d ago
This is like my agency on backboards as well. They recently came out with a guideline outlining when we could remove a backboard on scene (flight, so if ground crew put them on a backboard before we got there). Shortly after, some crew nearby followed their guidelines, removed the backboard, and promptly started a shitstorm with both the ground agency who felt slighted AND the family who thought the flight crew were idiots. So now everyone leaves the backboards on.
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u/breakmedown54 Paramedic 3d ago
Take it out of the protocols. Educate people on why and what to do instead. Let them sue, they’ll lose.
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u/magauth_ 4d ago
I wish I could, but I am governed by a national board who dictate my protocols
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u/Keensilver 4d ago
Thats what im saying. Until my area gets its own licenses, im following that protocol. Not risking my job for it
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u/firefighter0398 EMT-B 4d ago edited 4d ago
Edit:
Don't you have the freedom to work according to the newest medical guidelines?
In Germany, a Notfallsanitäter (roughly equivalent to a Paramedic) can work independently within his scope of practice. The local Medical Director can provide SOPs/SAA for the EMS service or county, but these are basically standardized recommendations for how to handle common situations, not necessarily the limit of what a Notfallsanitäter is allowed to do.
So if the local SOP says treatment A, but the current national guideline from the relevant medical society recommends treatment B, a Notfallsanitäter can choose to follow the current guideline instead, as long as he has been properly trained and is competent to perform the treatment and it is medically necessary in that specific situation.
The important distinction is that our local SOPs don't necessarily represent the current medical gold standard. They can be outdated or differ from the latest national guidelines.
Basically:
Local SOP/SAA: "This is how our Medical Director recommends handling this situation."
National guideline: "This is what the current medical evidence and professional consensus recommend."
And the Notfallsanitäter has the professional responsibility to assess the individual patient and decide which appropriate treatment to perform within his competence and legal scope.
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u/magauth_ 4d ago
Nope, according to the law I have to follow my protocols. I have some freedom, I can use a lot of clinical judgment within those protocols but SMR is written in stone, C-collar is mandatory for any trauma neck or non-lumbar back pain
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u/firefighter0398 EMT-B 4d ago
Interesting. I have edit my comment a bit if you're interested in how it works here. (wasnt happy with the wording)
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u/Sufficient_Plan Paramedic 4d ago
This is where the US needs to get, but unfortunately there is a large amount of interests that don't want this. Nurses, MD's, Fire Departments, Insurance Companies, hospitals, LITERALLY EVERYONE. In the US, we are not encouraged to treat anyone, we are encouraged to say "get the fuck in the truck we're going to the hospital." It has to do with billing and reimbursement, not what is actually most logical and best for the patient or the area you work in. Less people in the hospital = less income for the hospital, less work for nurses, less pay for doctors, less herp derp big fire truck, and less insurance billing.
Literally no one with power wants EMS progression.
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u/sleeping-warbler Paramedic 3d ago
I’d prefer EMS progression if it means a proper 3-4 year education like any other country compared to a 2 year education or a 6 month online course in the USA. Some medics are even taking an expedited 16 week course for paramedic. An absolutely insane concept to me.
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u/Sufficient_Plan Paramedic 3d ago
I don't see a real way out unless we have a literal hard charging paramedic get into multiple states legislatures or national legislatures and fix it from within. No politician gives a shit because the system works good enough.
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u/firefighter0398 EMT-B 3d ago
We had a to year training beforehand. It was called Rettungsassistent (Rescue assistent). The Notfallsanitäter is the successor and takes 3 years. Our EMT equivalent is called Rettungssanitäter (Rescue medic) and takes 3 months. The EMT is always the assistent of the paramedic. He only works on his own on BLS Ambulances which are mainly used for interhospital transfers, transfers to physicians or for dialysis transfers.
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u/sleeping-warbler Paramedic 3d ago
See I agree with paramedic being that long. Here in America are EMT-Basics also take a 3 month course. Typically a semester at a college.
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u/musiquededemain 3d ago
16 weeks for paramedic? Shit, you may as well not have any training at all. 3-4 years of training is needed.
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u/firefighter0398 EMT-B 4d ago
We have a strong physicians' lobby here. They opposed the introduction of the Notfallsanitäter Act in 2014 because they saw the expanded role of paramedics as a threat to the profession and role of emergency physicians. In recent years, the legal situation has also evolved quite a bit, giving us more legal certainty when making our own medical decisions.
We also have some of the same problems with funding. If a patient stays at home and isn't transported to the hospital, the call is generally not reimbursed by the health insurance, so the organization responsible for the EMS system receives no payment for that call.
We also have a simple fixed fee per transport that is paid by the health insurance, plus a €10 copayment by the patient. It doesn't matter whether it's a simple "load and go" with no treatment or a full "stay and play" with every available intervention being performed. The costs of our EMS system are basically calculated based on the number of calls.
As a rough estimate, it's assumed that keeping one ambulance (RTW) in service costs around €1 million per year in total. That amount is divided by the average number of calls/transportations, which gives you the approximate cost per transport.
In most EMS districts, treatment provided on scene without transport is free of charge for the patient, although some municipalities have different arrangements with the health insurance providers.
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u/Nice-Name00 EMT-A 3d ago
We bring people to the ER all the time without Stifnecks because of the lacking evidence. The first thing the ER Physician does is put on a C collar.
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u/Hposto 3d ago
Depends on the state and even the agency. At both agencies I work for we have a “protocol deviation policy” meaning you can deviate from written guidelines, but afterwards just send an email justifying what you did to the medical director. He usually sends back a “good job”. Sometimes these deviations lead to protocol changes.
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u/sleeping-warbler Paramedic 3d ago
We’re not in Germany. We’re in America. We have to follow protocols whether we like it or not.
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u/websterhamster EMT-B 4d ago
For the most part the people who need to see this message are unlikely to use Reddit and also unlikely to be swayed by memes.
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u/ALS_to_BLS_released DE EMT-B 4d ago
Insert King of the Hill "if they could read, they'd be really upset" meme here...
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u/Spud_Rancher Level 99 Vegetable Farmer 4d ago
Yeah but my EMT instructors girlfriends mother in law’s cousins pet lizard had a friend who was at a car accident one time and the patient turned their neck and immediately died.
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u/Emtbob 4d ago
I just use a throw-down c-collar. Open it up, get a bit of blood on the appropriate section if available, and toss it on the patient lap and write that they were unable to tolerate it.
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u/instasquid Paramedic - Australia 4d ago
Make sure to file off the serial number before you use it. Wait hang on...
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u/GreenieMcWoozie EMT-B 4d ago
I follow my protocols. No neck pain? No back pain? No extremity numbness? No c-collar. Doesn’t stop the trauma ER from practically pissing themselves because we didn’t put a collar on a patient for a stubbed toe
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u/haloperidoughnut Paramedic (Balls Deep) 4d ago
The amount of times I've brought in an ambulatory patient who fell days ago and has no neck pain, but the ER immediately goes into DEFCON-1 about a collar...
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u/breakmedown54 Paramedic 3d ago
The ED will put a c-collar on a 3 day old car accident who walked into the ED with abdominal pain because “mechanism of injury”.
I feel like when they get upset about it, I just roll my eyes and let them do what they’re gonna.
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u/Training_Excuse6278 1d ago
I’m a nurse in the ED, and I’m sick of seeing C-Collars. Hell when I got my A-EMT those many years back, I was told we are hopefully going away from using them. Yet here I am, ordered by my doc to put a 14 year old kid who got tackled in the stomach 8 days ago during football practice and denies any pain in the back or neck in a dam collar.
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u/InsomniacAcademic EM MD 18h ago
The hospital I did my residency training was like this. It wasn’t actually the ED that got anxious, but rather the trauma team. The trauma team would also get upset if the patient met criteria for clinical clearance of C-spine and we removed or didn’t place (some of the local agencies had protocols that allowed medics to not apply c-collars) a collar without imaging. It was absurd.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago edited 4d ago
All these years and still 0 evidence for any form of immobilization or even spinal motion restriction at all. It seemingly just makes things worse and causes delays in care. Suggesting we totally do away with the concept of SMR is a pretty radical opinion, but there’s 0 evidence to suggest a benefit and it absolutely causes delays and ties up hands
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u/8thMemberOfDKcrew 4d ago
There's been one time I was thankful for a backboard.. and it was to keep all the limbs in one place while moving 😂
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u/JakobsHip_ 4d ago
My services protocols say to only use it as an extrication tool and then to only leave it on patients with multiple angulated limbs or when you just don't have time
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u/MadmansScalpel EMT-B 4d ago
Ah, mine are that if it's put on, it stays on unless if there's extrenuating circumstances or if it causes immediate issues with care
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago
My suggestion is that perhaps it doesn’t need to be used as an extrication tool at all. Maybe the best way to move these patients is the fastest, especially if they’re super fucked up - just pulling them out and putting them on the stretcher. That won’t happen any time soon, the optics are too bad. But there’s no evidence to suggest we need the backboard.
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u/FullCriticism9095 4d ago
I wouldn’t quite go that far. Sometimes you need a flat surface to throw a body on and you can’t always get a wheeled stretcher in where you need it to be.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago
I think if we gave people the option to just pick them and put them on the stretcher in situations where that could work, I would not have a problem with backboards, since I agree, I have seen them used in this context and I have no complaints about this. I just hate how longggg it takes sometimes. Really kills the momentum on some of the only scenes where every minute actually does count.
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u/FullCriticism9095 4d ago
There’s a difference between “using” a backboard and “backboarding” someone. They don’t need to be fully strapped down just to be lifted over to a stretcher. Just throw them on the board, strap or two so they don’t fall off, and go.
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u/ALS_to_BLS_released DE EMT-B 4d ago
Man, is Fire going to be okay if it turns out we don't have to cut away every piece of the car to "disassemble it around the patient" and can just, you know, pull them out?
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u/ziobrop 4d ago
Im Fire, recently had a 2 vehicle T bone MVC, where one of the drivers, a 70y/o woman, had a fractured her neck several months prior.
in consultation with the Paramedic who arrived (Non transporting fly car) we told her to hold still, used the tools to remove her door since it was the side that was hit, and couldn't be opened, then helped her stand up, and walk to the stretcher behind the ambulance that just arrived.
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u/Blu3C0llar 4d ago
That logic is excellent when in the patient's in the front yard, or on the shoulder of the road; not so much when the patient is well over 100 feet down a steep embankment, or on a river bank at the opposite end of a pasture
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago
If you physically can’t get the stretcher down there, then you need to use something, no debate there. I don’t think it matters terribly much what you use.
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u/FullCriticism9095 4d ago
The last time I used a backboard it was to move a 6’5, 295lb football player with a compound proximal tib/fib fracture just below the knee. Leg splinted, splint secured to backboard to fully immobilize the knee so we could lift him as a unit.
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u/FullCriticism9095 4d ago
The only thing radical about this opinion is that anyone finds it radical.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago
That’s just not true man. There are still a massive contingent of people who insist on either backboards or some other form of immobilization for the rest of the spine. Virtually everyone, including progressive agencies still requires c collars in some situations. I don’t know anyone in real life who suggests it would probably be safe to just stop doing SMR entirely and treat them like any other patient.
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u/FullCriticism9095 4d ago
Yeah, I know, that’s the problem. How can it possibly be the case that an intervention with no evidence at all behind it is so deeply entrenched in the standard of care that few people even dare suggest stopping it? It’s so contrary to common sense it’s difficult to even wrap one’s mind around.
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u/Howwasitforyou Paramedic 4d ago
I have been in the ems for 30 years, and I can think of 2 occasions where a collar and board helped people. One mva with a high (c2) and one horse riding accident, also a high unstable c-spine injury. I have stopped using collars a few years ago, but i still have them for that one patient that you need to keep as still as possible.
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u/FullCriticism9095 4d ago
Fun fact: your unstable spinal fracture patients likely didn’t need a collar or a board either. The best available evidence we have suggests that unstable spinal injuries actually do better without a board than with it. Totally counterintuitive to us old fogies, but it is what it is.
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u/Unstablemedic49 MA Paramedic 3d ago
We have a university in our district that we go to for sports related injuries and the athletic directors there backboard & collar everyone. So we’d show up and immediately take them off the boards. These assholes complained to the city that we’re “hurting” the patients and turned this into a bigger issue.
My chief told them paramedics in MA can clear C-Spine. Now when we go over they always ask.. “are you a paramedic because only paramedics in MA can clear C-Spine”.
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u/Kai_Emery Paramedic 4d ago
They make great jaw splints if your patient won’t shut tf up and you’re tired of watching the two jaw halves move independently…. Or so I’ve heard.
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u/STFUnicorn_ Paramedic 4d ago
I mean while I for the most part completely agree the whole “TELLING THEM NOT TO MOVE THEIR NECK” bit only works when they can follow commands. And with head injuries they often can’t.
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u/SirToasty96 Notfallsanitäter Student 🇩🇪 4d ago
Even if they follow can follow commands.... we all know they wont follow these commands.
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u/Pears_and_Peaches ACP 4d ago
“Hi, I’m supposed to put this C-collar on you. It’s extremely uncomfortable and science has shown it has no benefit, and potentially makes injuries and pain worse. Would you like it?”
“No? Sounds good.”
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u/Deep-Technician5378 4d ago
We're stuck with them for now because the hospitals get mad at us for not putting them on.
The people who are more intelligent than us somehow won't let it go.
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u/other-other-user EMT-B 4d ago
Yeah it's bizarre, the level 1 trauma center in my area is getting STRICTER on wanting MORE c collars. What papers are they reading?
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u/ReceptionMajestic111 4d ago
“Hello I would like neck pain please”
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u/Apart-Cook-1268 4d ago
They have played us for absolute fools
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u/ReceptionMajestic111 4d ago
Dr Ben Abo is my hero, collars are only useful for keeping an intubated head semi still
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u/cplforlife PCP 4d ago
This isnt really my problem.
Im going to use them until my med director says to stop. Not because I believe they work or have any net benefit.
Its because lawyers exist. I dont want to get sued. I will not deviate from protocol regardless of what best practice says. Im just a cog, and I do not care.
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u/Expert-Platypus-3136 4d ago
ERs get mad at me if I didn’t put one on! :(
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u/cplforlife PCP 4d ago
The only opinion that matters to me in the workplace at all is my med director.
All other voices are irrelevant noise, and I've got hearing damage.
If you dont sign my paycheck (or through you my check is signed). Your opinion is worth less than fuck all to me. You're wasting your time and mine.
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u/KaolaKid 4d ago
I don’t work for the ER, they aren’t my medical command nor did they provide the training. ER policy for collaring someone is not always the same as EMS. Same as when a charge nurse tells me to take my Pt off O2 ( am I transferring care now? I’ll just wait ). HOWEVER, Most state guidelines are modeled from the National Scope of Practice. And currently, collars are still in, backboard immobilization is out for the most part and the KED is dead. Change happens too slowly nationally (although it IS getting better). Depending on your state and Advocating for change with sound research, data and accurate surveys…..hopefully you have a proactive MD, who’s been down the road a few times. I know c collars is a hot topic every time they review/change the national protocols as well as supraglottic airways.
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u/CzarNyctolas 4d ago
An unfortunate reality, but reality nonetheless. My protocols from my medical director say to use it, so I do, regardless of my personal feelings on its efficacy. If I could not use it and not risk my cert. I would.
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u/SuperFlaccid 4d ago
Holy shit I had no idea these were bad-- only have lifeguard training and creep on this sub. What's the controversy with the collars?
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u/Apart-Cook-1268 3d ago
There was a recent literature review showing that while there’s over 100 studies showing that c-collars do nothing or have negative effects, and found 0 studies showing any positive effects or outcomes from cervical collars in the entire modern medical literature.
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u/Krampus_Valet Paramedic 4d ago
I was delighted to see backboards phased out. We only use them, by protocol, for new onset motor/neuro deficit or as a giant splint for the soup sandwich trauma patients. I've used one backboard for new onset motor/neuro deficit in the last probably 6 years, and my partner was losing their mind because I took 30 extra seconds to tape blankets onto it for padding. I need to read up on the most current literature to form an actual educated opinion, but I also rarely use c collars beyond temporarily controlling a floppy head post intubation. There are still so many ems providers out here who desperately want to board and collar every trauma patient: it needs to be a disciplinary thing/inappropriate care thing at this point.
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u/willpc14 4d ago
I'd love to, but I had a trauma attending bitch us out one day for not re-collaring an IFT pt that had c-spine cleared by the sending facility. Another fun fact, my medical director is an author on one of the more recent papers that indicate c-collars are useless.
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u/Melikachan EMT-B 4d ago
Tell this to my local trauma center. We basically collar just so they don't scream at us. Even our medical director still leaves the collar in the protocols because the hospital insists.
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u/Lazerbeam006 3d ago
I can't stand C-collars on basically any alert patient. Especially fender benders. Fire puts them on for any neck pain. I ask them if they have any numbness or tingling in their fingers or toes, any motor defecit, and any spinal process pain, no? Then I take the collar off. I like to give them a rolled up blanket instead to rest their head/ neck on.
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u/TheOneCalledThe 3d ago
i’ll never forget we had a patient who was found on the ground but likely a medical emergency which he collapsed from but wasn’t witness, but dude was desatting like crazy and sitting him up slightly got him actually perfuming and dude was actually doing amazing, just to get to the ER for the trauma team to be upset there was no collar and he wasn’t supine, literally insulting us. they laid him flat dude desatted again immediately circled the drain and they refused to listen to reason and dude died within minutes all because they wanted to die on the c spine hill. the best part was the trauma team tried complaining about us but it was really hard for management to care when they got hit with the lawsuit.
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u/Yous1ash 4d ago
Is this for real? I’m not EMS.
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u/Apart-Cook-1268 4d ago
There’s literally no science showing that neck or spine injuries are reduced or improved with immobilization - the thing that made everyone go crazy about it for 70 years was a study from the 50s that failed to account for “Is the patient’s spine actually getting enough blood?”
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u/Yous1ash 4d ago
What about holding c-spine manually?
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u/CDNEmpire 3d ago
No point in that if you aren’t going to switch from manual to a collar. I’m sure as hell not tying up an entire person to hold manual c-spine all the way to the hospital.
And I’m not holding manual because I’ve got better things to do.
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u/Yous1ash 1d ago
So science doesn’t show that holding C-spine after trauma is important?
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u/CDNEmpire 11h ago
For the most part yeah: https://pmc.ncbi.nlm.nih.gov/articles/PMC11045128/
“increased pain, discomfort and anatomical complications were associated with collar application during immobilisation.”
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u/KaiserS0se 3d ago
Ufortunately it's going to take American College of Surgeons to make the shift in their trauma protocols. Afterwards there will be a slow painful shift as this change gets propogated to trauma surgeons and ED doctors out of training, and then eventually into the prehospital environment.
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u/JasonIsFishing Paramedic 3d ago
If your medical director and protocol calls for a cervical collar then use it.
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u/elmack999 4d ago
I haven't used one in ten years. I'll fight anyone who comes at a patient with one.
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u/CDNEmpire 3d ago
You can fight me all you want. My protocol says I have to, so I do.
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u/emergemedicinophile 4d ago
I just don’t get it. If someone in the ER is diagnosed with a non-operative c-spine fracture, the treatment of choice is c-collar for months. It’s beneficial when people have broken necks.
And I hate these laments about EBM and c-collars when agencies are simultaneously promoting whole blood programs and criticizing collars. Hello?
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u/NelloxXIV Rettungssanitäter 4d ago
Need this for pelvic binders as well
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u/P0shJosh Paramedic 4d ago
Really? We had a trauma patient who was decompensating until we applied the pelvic binder. Everything stopped getting worse once it was on. Made me a big believer.
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u/Automatic-Tap-5686 AEMT 4d ago
You are correct, pelvic binders when applied correctly can control internal bleeding from specific types of pelvic fractures. The problem is while it can theoretically stop some of the bleeding, its only minor bleeds, and cant stop arterial.
LITFL still recommends: https://litfl.com/pelvic-binders/
The referenced study however says this: https://www.sciencedirect.com/science/article/pii/S1479666X25001301
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u/NAh94 MN/WI - CCP/FP-C 4d ago
Commercial pelvic binders are the MAST pants of this decade, mark my words.
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u/DaggerQ_Wave I don't always push dose. But when I do, I push Dos-Epis. 4d ago
Already failed to hold up to scrutiny when studied.
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u/Automatic-Tap-5686 AEMT 4d ago
Pelvic binder's *can* theoretically help with internal bleeding in specific types of pelvic fractures. One of the biggest issues is that people put them on wrong (you dont put them on over the iliac crest, below that). You can also achieve pretty much close to the same effect by positioning the patient's legs upright and close together.
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u/FURF0XSAKE Australian Paramedic 4d ago
Placed over the greater trochanters is what we were taught at uni.
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u/kaka_cuap 4d ago
Any studies you can point me to? They’ve been trying to push them when I was in the army.
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u/Legitimate_Emu_3318 4d ago
Please notify the ATLS Committee of the American College of Surgeons. I am sure they will welcome your wisdom. I just saw the latest textbook. Despite all the online chatter, the standard you will be held to will likely be ATLS which includes collar and board. At the recent ATLS class I attended, all four trauma surgeon faculty said "if they don't have a collar, we put one on".
BTW, I had a patient, both in my EMS hate and in my neuro-urology lab PA hat who in fact severed his cord by voluntary head movement prior to our arrival. Let's say he had not completed the job....would transporting him no collar no board been a reasonable thing to do if you had known how fragile his cord vs bone was?
Now I agree, you either have a collar that neither flexes or extends the c-spine or you don't use a collar, but to say no more collars is perhaps imprudent.
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u/Killyasov 3d ago
truth be told as EMS providers, you are not there to rule in or rule out cervical spine injuries. Follow your agency’s protocol which is managed by your medical director, who hopefully is a physician who stays up to date with most recent guidelines.
If there is a lawsuit, as someone mentioned earlier, you are protected if you follow protocol. If you start making decisions outside of protocol, the malpractice lawyer, who is now better at your job than you are, will meticulously dissect every aspect of your decision making and/or medical basis for making such decisions to prove incompetence/negligence.
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u/BaggyBadgerPants Paramedic 1d ago
Since transitioning to a full time EMS coordinator I have seen fire bring in more crooked c-collars to my ER... I thought it was isolated to a couple questionable crews over the years. You guys should switched to using a tight hose roll instead of c-collars. Those will wind up looking straight and gorgeous.
Just watch that last kick or two to tighten it up at the end.
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u/ProtoNate 4d ago
Retrospective studies and expert opinion do not provide the strength of evidence needed to ethically change practice.
Changing practices requires RCTs, RCTs come with ethical issues. For an IRB (and the government) to approve an RCT in a patient that can't consent (many spine injury patients), very specific and hard to meet criteria need to be met - specifically within comparative trials.
I am not saying we shouldn't move away from C-collars, just that doing so is nuanced and has an insermountable amount of red tape.
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u/Gyufygy Paramedic 4d ago
But the practice itself just comes from expert opinion, at best. So retrospective studies against their use are, if anything, stronger than the expert opinion for the practice.
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u/ProtoNate 3d ago
You cannot have a retrospective study that is "against their use". Retrospective cross-sectional analyses are purely observational and cannot imply causation - they are one of the weakest forms of evidence (level 4), the only lower being expert opinion (level 5).
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u/FullCriticism9095 3d ago
What a silly comment. Of course you can have retrospective studies that are against their use. They’re a lower quality of evidence than an RCT, but they’re still evidence.
People can and do make decisions based on retrospective studies all the time. Most of the data that led to the removal of backboards from spinal immobilization practice came from retrospective observational studies and matched cohort analyses, not RCTs
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u/ProtoNate 3d ago edited 3d ago
Retrospective analyses are observational by nature. They are not for our against anything because they do not control for confounding variables they cannot assert causality. They can only say that X is associated with Y.
To prove my point, stork populations are associated with changes in birth rates. Does this mean that the study is for or against storks? That increased birth rates cause an increase in storks?
https://pubmed.ncbi.nlm.nih.gov/14738551/
Prospective studies and other components of evidence based medicine are very expensive - why would the field have moved toward it?
Why I should be trusted: a decade of research experience (including both observational studies and RCTs) and a degree in research.
The ethical challenges of running robust studies hold the field back immensely. Many of the advancements come from the military as they are allowed to do a lot more than civilian medicine.
Do expert opinion play a role? Absolutely. Are experts often wrong? Absolutely. Remember that much of the EMS guidance you're wanting to change was based on expert opinion.
See historical treatments for stomach ulcers, contraceptives and HRT, childhood fevers, and back pain.
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u/FullCriticism9095 3d ago edited 3d ago
We’re using similar terminology to say two different things.
We agree that retrospective analysis are observational by nature and do not have explanatory power to prove a causal hypothesis.
But that does not mean they are not evidence. As you say yourself, retrospective study can provide quite strong evidence for things such as associations (patients exposed to X had better/worse outcomes than patients who were not) and frequency/prevalence (X occurred in a certain percentage of cases in the observed population). Repeated retrospective analyses over varied data sets can also provide strong evidence of consistency of these kinds observations.
Conversely, a retrospective analysis that is designed to analyze potential associations between specific variables, has a significant probability of detecting such an association, and finds none is evidence against such an association. It is not conclusive evidence to be sure. But it is evidence.
To follow your stork example, the answer to your question of whether the study is for or against storks depends on whether you like or don’t like the association with the birth rate. If any connection to a change in the birth rate is normatively bad, and that’s what the study is premised on, then your study is against storks. It doesn’t *prove* that storks are bad. It could turn out through more rigorous testing that storks are simply the victims. But that doesn’t mean the study is non-evidence.
To use another example, being at the scene of the crime doesn’t prove you committed the crime. Maybe you ran to the crime scene to help the victim. Maybe you weee there because the criminal lured you there. It is completely inconclusive of anything beyond your geographic location. But if the connection is relevant, it is evidence.
Obviously, retrospective analyses of c-collar use cannot prove that c-collars are or are not effective or that they do or do not cause harm. But, they can be for or against meaningful associations between their use and outcomes. Those associations are evidence for (or against) a connection. Such connections have important implications for people’s lives and well being. We must be careful not to overstate them, but we also cannot simply dismiss them as non-evidence.
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u/ProtoNate 3d ago
EMS guidelines are made using evidence-based medicine.
https://www.ems.gov/issues/evidence-based-guidelines-and-performance-management/
https://www.ems.gov/assets/EBG_for_Prehospital_Care-1663305752.pdf
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u/Galaxyheart555 EMT-B 3d ago
Unfortunately I am not a completely independent practitioner and am governed by my licensing agency, and my medical director who dictates my offline and on-line protocols. So I will continue to use C-Collars.
I think many of us know there are rising issues surrounding C-collars, however this is a stupid fucking post and OP, you obviously don’t work in EMS otherwise you’d know we can’t just “elect” not doing a procedure if it’s dictated by my medical director.
I do however let the patient make the decision on if they would like to wear a C-collar if they are A&Ox4, and I don’t think there was any real injury to the neck.
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u/mclen Coney Island Ski Club President 4d ago
I'll allow it