Regarding 'clearance' of C-spines in the field.
Tim Peterson, MD, FACEP
Bureau of EMS Medical Director
Iowa Department of Public Health

Response: This issue was addressed by QASP a couple of years ago, and the existing literature at that time was reviewed including the following.

1. Muhr et al. "Paramedic Use of a Spinal Injury Clearance Algorithm Reduces Spinal Immobilization in the Out-of-Hospital Setting" Prehospital Emergency Care 1999; 3:1-6.
2. Cone et al. "Current Practice in Clinical Cervical Spinal Clearance: Implication for EMS" Prehospital Care 1999; 3:42-46.
3. Scheck. "When Clearing Cervical Pine Injuries, EMTs and EPs Rarely Agree" Emergency Medicine News August 1999, Volume XXI, Number 8.

The general conclusions were that the 1998 NHTSA EMT-Paramedic curriculum (for the Iowa PS) provides the basis for doing a more comprehensive field assessment for possible injury. This provides the framework for medical directors to write a protocol to allow for appropriate field treatment, including what patients must be immobilized based upon the field assessment. Based upon training and certification 'assessment based spinal immobilization' would be limited to the Iowa certified PS. QASP elected to monitor this issue and revisit it from time to time. I am currently unaware on any such protocol authorized by a physician medical director in the Iowa EMS system.

The recent article from the Annals of Emergency Medicine by Stroh and Braude (June 2001) cited in your EMS list serve discussion provides more support for development of an appropriate protocol for cervical spine immobilization in the field. Of the 504 patient brought to the hospital by EMS there were only three injuries missed by the protocol criteria and two missed because of protocol violations, and of these five patients there was only one adverse outcome.

I take issue with use of the term 'clearance' in this and pervious articles. The only way to effectively assure 'clearance' of a cervical spine is a combination of clinical assessment (history and physical exam) and radiological studies when indicated. Technically speaking, we are talking about a 'spinal immobilization protocol' versus a 'spinal clearance protocol'. Think any protocol drafted would be titled something like 'assessment based spinal immobilization.'

The issue of developing a 'spinal immobilization protocol' is ripe for further discussion in Iowa. The appropriate forum is for an interested end-user to introduce this through QASP for broad stakeholder discussion and subsequent public policy development through standardized statewide EMS protocols. We must remember that the stakes are high for the patient and EMS system for the one missed injury cited in the study. Consequences are severe and involve morbidity, mortality, and costs related to litigation. The benefits to the EMS system are potentially providing more efficient care. The bottom line is that we must assure that we do the right thing (effectiveness), and error on the side of patient care whenever possible.

Tim Peterson, MD, FACEP
Bureau of EMS Medical
Director Iowa Department of Public Health
401 SW 7th Street, Suite D
Des Moines, IA 50309
515-725-0323

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