As If New Orleans Hasn't Lost Enough...

The City of New Orleans has lost something today. With the resignation of Dr. Jullette Saussy, now former Director of the city’s Emergency Medical Services, our community has lost one of the few people in city administration who upholds the highest standards of integrity and ethics; a quality that few need to be reminded is often sorely lacking in our leadership.

Many, especially the Times-Picayune, are quick to attribute scandal where none exists. Several weeks ago, the T-P “broke” a story regarding Dr. Saussy. In it she was accused of holding a second job while working as Medical Director of EMS. The second job was with Vidacare, supplier of the EZ-IO device, now widely used in many ambulance services. She was also accused of taking donated sick leave from other employees while she was having cancer treatments. To top it all off, she was the highest-paid city employee at around $187,000 per year. All of these “accusations” are true.

So, why do I say that Dr. Saussy upholds the highest standards of integrity and ethics in view of these facts?  Because there was no scandal. Nothing Dr. Saussy did was in any way subterfuge or “under-the-table.” Her second job with Vidacare was cleared and blessed by none other than the city attorney and the Nagin administration. Anyone who wanted to could see that Dr. Saussy was holding another job. Nor is it anything unusual for physicians to hold second jobs. In fact, I cannot think of a single physician I know who does not have another job. Virtually every emergency room doctor I know has a second job; one owns a vineyard, one is a contractor and a lawyer, one has a holistic alternative medicine practice. Even the new acting Medical Director of New Orleans EMS, Dr. Jeff Elder, holds a job at University Hospital. 

Dr. Saussy’s second job did not take time away from her primary function as the city’s EMS Director. I know, because I was there. I witnessed firsthand that never did an issue come up that Dr. Saussy was not available to handle promptly. Therefore, despite the Times-Picayune’s insistence that Dr. Saussy’s second job was some sort of a scandal, it clearly was not.

Vidacare is the supplier of the EZ-IO device, a type of specialized needle that injects fluids and medications into bones rather than into veins. It is particularly useful in emergency situations where vascular access is difficult or impossible to obtain. New Orleans EMS uses the EZ-IO on all of its ambulances and sprint vehicles. Is it scandalous that Dr. Saussy worked for a company that supplies devices that her other job uses? As anyone who is familiar with the purchasing procedure regarding supplies among city services, which I will not describe in its arcane detail, it becomes quickly apparent that no matter whom the products’ representative is, they have no influence on whether the city purchases the product. As far as I know, there is not another device similar to the EZ-IO, and I have personally used it to save the lives of many of the citizens of New Orleans, perhaps even some of those who are so quick to declare “scandal.”

While receiving treatment for cancer, Dr. Saussy was donated hundreds of hours of sick leave by fellow employees. This was done under a policy approved by City Hall for city employees. If anyone has a problem with the donation of sick leave hours, I suggest they take it up with City Hall, the masterminds behind the policy. Many city employees are donated sick leave when they are out for an extended time. Does the Times-Picayune (or anyone else) have a problem with a firefighter being donated sick leave because of broken leg, or a paramedic who is out for an extended time because he contracted a disease from a patient? No? Then why is this practice a problem when Dr. Saussy utilized it? Never were any employees “coerced” or “forced” to donate sick leave, each one of us who donated did so voluntarily. Feel free to investigate the city’s email system (again) in a fruitless search for coercive correspondence. It isn’t there.

The Times-Picayune asserts that city employees complained that Dr. Saussy “quit showing up for work,” according to the Metropolitan Crime Commission. Have they taken into consideration that the offices at “work” consist of two trailers, the same two trailers that EMS has been relegated to since Katrina, one devoted to supplies and the other occupied by the shift supervisors? Where, exactly, was Dr. Saussy supposed to report to work, given the tiny trailers at 300 Calliope, and seeing that her office is actually within City Hall? Further, must we reiterate the fact Dr. Saussy was receiving treatment for cancer? If anyone is fighting for their life, isn’t it vaguely possible that answering phone calls and emails might temporarily take a backseat to survival? If any city employees did, in fact, complain, then shame on them. I hope others show as much mercy to them when they are fighting for their lives.

So you see, the media, specifically the Times-Picayune, has tried to create a scandal where none exists. Dr. Saussy’s salary is a matter of public record. Her outside employment got the thumbs-up from City Hall. It is impossible for her to have influenced anyone in city services to purchase the device she helped to market. And her sick leave donations were part of a policy that City Hall has had in place for years. So where is the scandal? Further, why has Mayor Landrieu and the rest of City Hall asked for her resignation for following the procedures that they, themselves, approve? 

It seems that some of the writers at the Times Picayune have a personal vendetta against Dr. Saussy. Why? We likely will never know. In addition, it is shameful that WDSU grouped Dr. Saussy in with their list of officials who have resigned since Mayor Landrieu took office, including Greg St. Etienne, Joia Perry, and the executives of the Public Belt Railway - all of whom are followed by legitimate, concrete evidence and accusations of wrongdoing.

As you’ve no doubt gathered, I know Dr. Saussy personally. I worked for the city’s EMS system for eighteen years, from 1991 until 2009. Dr. Saussy and I have not always seen eye-to-eye, but in our occasional differences, it was nearly always me that was in the wrong. Dr. Saussy’s mission has always been straightforward: deliver the best care possible to the people of New Orleans, and never do anything to tarnish EMS’ reputation. She not only preached this, she lived it every day. 

The paramedics and EMT’s of New Orleans EMS will continue to serve the public. Under Dr. Saussy’s leadership, and by that I mean genuine leadership, she has transformed our city’s EMS into a world-class example of prehospital care. I hope you remember that when the paramedics show up for you or your family’s crisis. We will care for you in the most professional, technologically advanced way this country has to offer. But for those who rejoice at Dr. Saussy’s departure, we will be ashamed of you.

-Sean H. Fitzmorris, EMT-Paramedic; RN

Councilman Stokes Is an Explosion In An Idiot Factory

Someone on Twitter, @RobRiscoe, asked my opinion on this fiasco:


The incident occurred in Jackson, Mississippi and there's been considerable hullabaloo in the EMS community regarding it. Normally I don't voice my opinion on things where the answer is as clear as this situation. But since I was asked...

As you can tell by the title of this article, Councilman Stokes has proved to the world that he knows absolutely nothing about the subject on which he has chosen to pontificate in hilarious ignorance.
"You got to take risks; you can't let citizens die!" In a backwards way, he is correct. The shooter and victim took their risks in whatever behavior preceded the shooting. The EMT's try not to let citizens die. But Councilman Stokes, I must ask you, had the EMT's arrived on an unsafe scene and gotten themselves shot and killed, then wouldn't there be two more citizens dead besides the first victim? We can continue this formula - then two more EMT's show up and get shot, and so on - until all the EMT's in the city are dead. You see, going into that scene and 'taking risks' might not be the best policy. As every EMT is aware, even scenes that are declared "safe" often remain very unstable and can go downhill to "extremely unsafe" in a heartbeat.

(Should we tell Councilman Stokes about what we do when that happens? Actually leave the scene?)

One of the solutions for this "problem" that Stokes has proposed is having the city go into the ambulance business themselves, rather than contracting with AMR. That's fine. No offense to AMR, but certainly few would have a problem with there actually being more ambulances in the city. Tell us, Mr. Stokes, where will you find the EMT's to staff your city ambulances? No doubt you wouldn't want those wimps from AMR to come over and work for you, with all their insistence on "scene safety" or whatever they call it.

Councilman, I have news for you. Your "problem" isn't with AMR. Every EMT in this country, to be certified as an EMT, has to go through an EMT course approved by the nation's Department of Transportation. And in every single one of those classes, the first lesson on day 1 is "Scene Safety." During that class, it is ingrained into the brains of every prospective EMT that you do NOT go into scenes that are not safe! If the scene becomes unsafe, leave! Every practical exercise that the EMT's will perform during class must include the question "Is my scene safe?" If they do not ask that question and determine scene safety, then no matter how magnificently they perform the practical exercise, they will fail. Every day from day one, scene safety will be burned into their brain.

That, Councilman Stokes, is the culture of the pool of EMT's from which you have to staff your nascent city ambulance service.

Perhaps Councilman Stokes would prefer if the class would go something like this: "Hello and welcome to EMT class. The first thing you should know is if you are called to a scene where gunshots are still going off or cars are still colliding with each other or gangs are stabbing each other all over the place, don't worry, just go right ahead in. Everything will be fine and unicorns and rainbows will sprout from your footsteps."

Really, Councilman Stokes? Would you actually want EMT's who were schooled to take such risks? If they are willing to "take risks" with their own personal safety, then what kind of risks will they take with the care they deliver to their patients? When you're in the back of that ambulance one day, maybe when the medic pulls out some big scary tube or needle to put into your body, will you want the EMT's to say "I've never done this procedure before, but I'm willing to take the risk!" Or maybe "You don't have to sterilize the site where you're going to stick in that needle/tube/scary device. It's a risk that he may die from a horrible infection, but we're willing to take it!"

As a casual aside, according to the news video, which I trust more than the "facts" of either Councilman Stokes' or the outraged mother-in-law of the victim, I notice that AMR is accused of taking 21 minutes to arrive at the patient. But then later in the video, the dispatch, en route, arrival and at-patient times add up to only 7 minutes and 25 seconds. This is well under the national average of 9 minutes. Did Stokes even bother to actually investigate the details of the call? Or is he just taking the word of some emotional, angry woman off the street?
Councilman Stokes, you are a fucking idiot.

"Found Wanting" now available for everyone!

Just wanted to announce the release of my book, "Found Wanting." If you've seen my Facebook profile, you know I've been yammering about various problems with its release. Well, finally, it's out now! It hasn't yet hit retailers like Amazon and the iPad app store, but it's available already! You can get it from the wholesale publishers (for a LOT cheaper than my original publisher!).

If you'd like the print version, a real, actual book, then click this link: http://www.lulu.com/product/paperback/found-wanting/12812792
Just click Add to Cart and checkout like any purchase!

If you'd like to download "Found Wanting" to your mobile device like iPhone, iPad, Kindle, Nook, Kobo, Stanza or other device, then click this link from your mobile device: http://www.smashwords.com/books/view/25111
You have to register (it's free) and select which format you want. Don't panic!  Pretty much any device will read the .Epub format. If you have a Kindle, you can download the .Mobi file. You can also read a free preview of the book! Just remember to go back and purchase the full copy!

"Found Wanting" will be available via retail outlets like Amazon and the iPhone app store in 4 - 8 weeks, so get your copy now! Why wait?

Thanks to everyone, and enjoy "Found Wanting"! All the best!
-Sean

Scary

I don't know what's more frightening - that "frank petta ems" was used as a search term or that "frank petta ems" was a search term for TWO different people?!

From the traffic report on this webpage via Google Analytics:

Five years later...

This article was written two years ago: http://blog.nola.com/editorials/2008/10/a_911_for_ems.html. In it, EMS' plight in securing a new home following Hurricane Katrina was addressed. Back then, EMS was responding to "700 calls" a week. That number has increased greatly, yet New Orleans EMS is still operating from two trailers in a parking lot under a bridge. Employees are still dodging trash thrown from the bridge, there's nowhere near enough space for parking, supply storage or even washing the ambulances.

Now, call volume has required the purchase of additional ambulances and sprint vehicles, taking up more already scarce space, yet EMS is still relegated to their position of "trolls hiding under the bridge." There is talk of new headquarters on City Park Avenue, but little or no progress has been made toward moving there. How long will one of the city's most vital components be ignored and have to "make do," especially in view of the scads of unoccupied territory everywhere in the city? Everyone understands that New Orleans' city budget is tight, yet every firehouse and police station has been rebuilt, renovated or relocated, but the red-headed stepchild of emergency services remains barely an afterthought in the grand scheme of things.

Repost this, tweet it on Twitter, write an email or letter to your city councilperson, spread it on Facebook... whatever. Help to spread the word and get those that will help you and your loved ones in a crisis a decent headquarters.

It's a damn shame.

EMS Gets a Little Recognition - Especially "portly, balding Chris Martinez"

This makes me proud to have spent the last twenty years working with Martinez, Schlumbrecht, Frezel, Petta and ALL the medics of New Orleans EMS! It's not for just anybody...

Original Article: http://www.nola.com/crime/index.ssf/2010/07/citys_ems_teams_handle_life_an.html

City's EMS teams handle life and death on the streets of New Orleans

Published: Monday, July 05, 2010, 5:59 AM     Updated: Monday, July 05, 2010, 9:19 AM

 Ramon Antonio Vargas, The Times-Picayune 
Follow

Share this story

Story tools

The paramedics heard the call from two different points in the city.

Michael DeMocker / The Times-PicayuneParamedics prepare to transport Chester Reeder after he was shot in the head in Algiers on May 24, 2009.

Chris Martinez and Scott Schlumbrecht were cruising the streets in an ambulance near the Crescent City Connection.

7

0

6Share

Dave Frezell and Frank Petta were standing on the porch at EMS headquarters -- two trailers in a parking lot under the bridge -- when the radio emergency line crackled to life.

"Male down, 34S." It was a shooting near the corner of Ptolemy Street and L.B. Landry Avenue in Algiers. Next came "Code 3," a life-threatening emergency. Then, the orders: Wait for police to secure the scene, but get in position.

"Crap," Petta said. "We gotta go."

Petta and Frezell hopped into separate sport utility vehicles, blared their sirens, turned right on Calliope Street and barreled toward the bridge's on-ramp. Petta quickly hit 70 mph. Some cars deftly shifted out of his path. Others were perilously slow to do so.

Schlumbrecht and Martinez, slightly ahead, drove the ambulance.

Six minutes later, the rescuers approached the intersection, not knowing exactly what they might see.

Working as an emergency medical responder in New Orleans, the country's most murderous city, is not for the faint of heart. The city's paramedics are like MASH doctors in wartime. Sometimes their patients suffer a heart attack or a stroke. But far too often, paramedics are rolling out on a shooting or stabbing, where the victim's chances of making it depend on how well the EMS team does its job. It's a hugely stressful line of work, and one that brings with it constant reminders of man's capacity for cruelty.

'Save him, y'all'

The four medics sailed through a mob of people drawn from a nearby second-line parade to the crime scene by the gunshots, flashing lights, and yellow crime scene tape put up by police officers.

Frezell and Petta put on latex gloves and fetched equipment from their trunks. Martinez and Schlumbrecht grabbed a stretcher and spine board from the ambulance.

The victim, in a white T-shirt and blue jeans, lay unconscious, face-up atop a rusty storm drain. He had been shot once in the head. Blood covered his face. It mixed and clumped in with dry grass in his dreadlocks.

The paramedics rushed out with the spine board, the stretcher and an electric heart monitor. A crowd of spectators in quiet conversation watched them. Police officers implored them to back up. One woman, her voice shaky, called out, "Save him, y'all."

Martinez jogged to the man's feet. He pulled a pair of scissors from a belt holster and snipped off the victim's jeans and T-shirt. Martinez spared the man's boxers because hundreds of strangers surrounded him. He ran his eyes down the man's legs, torso and arms but saw no wounds apart from the gunshot wound to his head.

The man's toned stomach rose and fell slowly. Frezell pressed his fingertips on the man's wrists. "He has a pulse," he said.

The man was alive, but he had lost a lot of blood. His breathing was slowing. They had to hurry. If he was to live through the next hour or two, the four paramedics needed to carry out a frantic but crucial process in less than 10 minutes to stabilize him. Then, they had to whisk him to an emergency room six miles away.

"Let's load him and go," Martinez said.

Petta ran to the ambulance to prepare a thin breathing tube. Frezell strapped on a dark blue brace that immobilized the man's spine. Schlumbrecht grabbed the man's side and gingerly rolled him to the left. Frezell and Martinez checked his back for bullet holes but found none.

All three slid the spine board under the man and gently rested him on it. They snapped the yellow board onto the stretcher and wheeled it under the tape, past the growing crowd.

A bright red bubble suddenly emerged from the man's mouth and popped. Blood sprayed onto his closed eyelids.

A woman watching gasped. She said, "Oh Lord, he's dead."

The man's arms dangled. His head lolled to the left. Blood pooled in his right ear.

A trembling voice called out to the rescuers once more: "Save him, y'all."

Frantic, yet controlled, activity

Martinez -- portly, his dark head of hair balding -- placed a plastic shield over his own face when he boarded the ambulance bay, occupied already by his three colleagues and the stretcher.

Paramedics work on Chester Reeder, who was shot in the head after a second line in Algiers on May 24, 2009. They stabilized Reeder and rushed him to a hospital, but he died two days later.

Related stories

• Work of EMS team gives one family time to say goodbye

He shut the door behind him. The murmur of the crowd disappeared. It was replaced with the ripping of plastic and paper equipment wrappers.

The smells outside -- barbecue, beer and grass -- gave way to the smells of sweat, rubbing alcohol and latex.

Martinez kneeled at the wounded man's head and prepared to slide the breathing tube into his trachea. But blood in the man's mouth choked him and blocked Martinez's view.

Martinez reached for a catheter and suctioned out some blood. He tried sliding the breathing tube in again but the man gagged, nearly vomiting into Martinez's mask.

"He's still choking on his blood," Schlumbrecht offered.

Martinez pressed a stethoscope against the man's chest. "I know. It's all up in there," he said. He reached for the catheter and suctioned out more blood.

Schlumbrecht placed the heart monitor's leads on the victim's left bicep and right pectoral muscle. They registered a beat. As the monitor emitted an unnerving beep every three seconds, the man's stomach rose and fell, rose and fell.

Frezell sat on a bench seat to the right of the stretcher. Martinez's suction hose, wine red, wrapped around his right arm and across his chest like a bandolier.

Not bothered, Frezell wound a band tightly around the man's right upper bicep. A vein bulged. He slid a needle and catheter in and removed the needle. He then started an intravenous saline drip -- to compensate for the blood the victim had spilled on the street -- and secured it with adhesive tape.

Petta mirrored Frezell's actions across the stretcher. When they were done, they peeled off their bloodstained gloves and ducked under the bevy of tubes to the side door and out of the cramped quarters.

Back in the bay, Martinez slid the breathing tube in. The patient's stomach jutted out abruptly, and he gagged. But Martinez didn't remove the tube. He slowly slid it further down. The patient didn't resist, and Martinez announced, "Good. We're good."

Schlumbrecht jumped out of the back doors and hopped into the driver's seat. Martinez attached the breathing tube's tip to a bag connected to a pump. He handed it to a New Orleans firefighter who had climbed aboard to provide help.

"Hold on to this. Just squeeze the pump for me every few seconds," Martinez instructed. He flipped a wall switch. Air whooshed through the tube.

"Scotty, we can go! Let's go!" Martinez shouted.

Schlumbrecht backed out. Martinez radioed doctors at Interim LSU Public Hospital to brief them about the new patient.

Seven minutes after the ambulance arrived at the scene, it was headed to the emergency room.

'Damn. That's the guy I worked on'

Five days later, Martinez, 44, threw a copy of the newspaper onto his kitchen table. After pouring himself his morning cup of coffee, he sat down and perused the headlines.

"Man dies two days after being shot" grabbed his attention. A paragraph detailing the location of the shooting then jumped out: the corner of L.B. Landry and Ptolemy, near a second-line parade on May 24, 2009.

"Damn," Martinez muttered. "That's the guy I worked on."

Unless paramedics specifically ask emergency room staff about patients they care for, they rarely learn their fate. They often don't even catch the name of the victim or his exact age during the frantic race to the emergency room, unless they handle the paperwork.

Martinez and Petta had worked to save three shooting victims, two of them 15 and one 18, the night before they worked on the 25-year-old on Ptolemy Street. Martinez didn't know any of their names.

The weekend before that, Martinez tried to help two shooting victims: Devin Goines, 23, at the corner of North Broad and Duels streets, and Qian R. Sabatier, 26, at a bar in the 8500 block of Hickory Street. Both died.

Typically, if patients' names and ages don't make the news, it means they survived. The New Orleans Police Department doesn't release the names of shooting survivors, and the coroner's office can identify only homicide victims.

Martinez read on. The young man he tried to save was Chester Reeder III, who made a living in Houston but was in town briefly to visit his mom and kid sister for the Memorial Day holiday. He died at 6:29 p.m. two days after the shooting.

"Two days," Martinez thought. "At least his friends and family had two days."

He folded the newspaper and set it aside. He wished he hadn't read it.

A nightmarish scene

Longtime paramedics say those who can shake the images of shattered skulls and bloody bodies -- and suppress their revulsion at the culture of violence that feeds the carnage -- have the best chance at a career in New Orleans EMS.

Those who are haunted by what they see, or who turn to alcohol or drugs to dull the pain, don't last.

Martinez doesn't talk much about his job. At family gatherings, his relatives can't stomach the few stories he does share.

"I don't want to hear no more," they often say, almost immediately after he begins one.

Generally, he just tries not to think about work during his free time. If he did, he'd go crazy.

He was called out in March, for instance, to one of the most gruesome crime scenes in memory -- an Upper 9th Ward home where a 25-year-old mother and her 7-year-old daughter, 4-year-old son and 17-year-old sister had been fatally shot, allegedly by a relative.

There was little for Martinez to do but connect the leads of a heart monitor to their corpses and watch as a doctor pronounced them dead.

As he drove away from the nightmarish scene, he was troubled. "Even animals don't do s--t like this," he thought.

But he said he was able to "let it go" by the end of his shift.

"Seeing those kids shot was horrendous," said Martinez, a paramedic for 18 years. "But I can't spend time trying to make sense of it. ... I couldn't do this job otherwise. No one could."

In a career where he routinely works on the victims of suicide, shootings and car accidents, he has never seen a trauma counselor.

"It must be something that's built into you," Martinez shrugs. He knows some may be confounded by his seeming ability to erase human tragedies from his thoughts. It puzzles even him.

When his grandparents died in 2008 and 2009, Martinez could not cry. He was sad, even depressed. But he simply could not cry.

Several weeks later, Martinez's husky, Sheba, died from a seizure.

The hardened paramedic sobbed for days. He couldn't explain it, even to himself.

"I guess animals, especially dogs, have unconditional love," Martinez said. "That's hard to find in human beings."

Ramon Antonio Vargas can be reached at rvargas@timespicayune.com or 504.826.3371.

Muddying The Waters of C-Spine Stabilization Even More

From EMS1:

Link to the original article.

Prove It: Extrication Collars Cause Internal Decapitation

By Kenny Navarro

Highlights:
 The Scenario
 The Review
 What It Means for You

The Scenario
Medic 3 responds with the fire department to a reported motor-vehicle collision at a busy intersection. Two patients are present on the scene; both were front seat passengers in a car versus telephone pole collision. The seat-belted driver is walking around, has no complaints, and no evidence of traumatic injury. The second patient was not wearing his seat belt at the time of the impact and is sitting in the vehicle.

Inspection of the vehicle reveals a broken area in the windshield that approximates the shape and size of the patient’s head. The patient is a male, age 42, who is conscious and alert with multiple lacerations on the forehead. Bleeding appears controlled. The patient denies loss of consciousness, complains of mild neck pain, but is able to move all extremities. The remainder of the physical exam is unremarkable.

One of the firefighters enters the back seat of the vehicle and maintains the patient’s head in a neutral position with manual in-line stabilization. The paramedic measures and selects an appropriately sized extrication collar and applies it to the patient’s neck. The rescue team successfully removes the patient from the vehicle, secures him to a long backboard, and places him in the ambulance.

The patient remains conscious and alert with a Glasgow Coma Score of 15. The patient’s blood pressure is 130/86 mmHg, the pulse is 90 bpm, and the respiratory rate is 14 bpm. The head-to-toe exam is unremarkable for trauma except for the lacerations to the forehead. En route to the hospital, the patient begins complaining of a tingling sensation in the arms and legs and increased discomfort in the neck.

Emergency department X-rays do not discover evidence of cervical fractures, although the patient continues to have worsening paresthesia. Magnetic resonance imaging (MRI) reveals significant disruption of the upper cervical ligaments and an atlanto-occipital distraction.

Back at the station, the medics wonder if application of the extrication collar may have made the situation worse, since the tingling only began after spinal motion restrictions occurred. The shift duty officer assures them that they performed exactly as protocol dictated and that without the collar, the injury could have been much worse.

The Review
Article: Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of Trauma Injury, Infection, and Critical Care, [Epub ahead of print].

Using fresh whole human cadavers, investigators from the Spine Research Laboratory at the Baylor College of Medicine in Houston examined the effects that spinal motion restriction devices have on a destabilized cervical spine (Ben-Galim, Dreiangel, Mattox, Reitman, Kalantar, & Hipp, 2010).

None of the cadavers had previous cervical spine injuries or abnormalities. The research team placed the cadavers in a refrigerated state until the effects of rigor mortis subsided and then warmed the specimens to room temperature. Previous investigations demonstrated a high correlation in vertebral movement between room temperature whole cadavers and asymptomatic live humans (Brown, Reitman, Nguyen, & Hipp, 2005; Subramanian, Reitman, Nguyen, & Hipp, 2007).

In this study, researchers focused on the first and second cervical vertebrae. The first cervical vertebra (C1, otherwise known as the atlas) forms a ring of bone upon which the skull (more specifically, the occiput) rests (Marieb, 1989).

The atlas rests on the axis, which is the second cervical vertebra (C2). A small bony protuberance called the odontoid extends from the body of the axis into the opening of the atlas alongside the spinal cord. Under normal conditions, connecting ligaments and other tissues limit movement of these vertebrae.

However, damage to those ligaments, as might occur during traumatic injury, permits abnormal movement or allows the skull to separate from the spinal column, a condition known as internal decapitation (Brown, Reitman, Nguyen, & Hipp, 2005). Most patients who suffer this type of dissociative injury die almost instantaneously (Bucholz & Burkhead, 1979), although the literature describes dozens of survivors (Anderson, Towns, & Chiverton, 2006).

Two previous investigations of fatal atlanto-occipital injuries describe complete disruptions of the supporting ligaments, with and without associated fractures (Bucholz & Burkhead, 1979) (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

For this investigation, the researchers replicated this type of upper cervical spine injury by leaving the muscles intact but surgically transecting the supporting ligaments. In addition, the team fractured the odontoid at its base.

Using a standard EMS spinal immobilization protocol that included manual stabilization, the team applied a commercially available and properly sized extrication collar. Researchers obtained before-collar and after-collar fluoroscopic images in the first four cadavers. The five remaining cadavers received before and after computed tomography (CT) scans. Researchers then measured the degree of distraction or separation between C1 and C2.

In every cadaver, proper application of an extrication collar resulted in abnormal separation between these two vertebrae. The mean of the average distance was 7.3 mm with a standard deviation of 4.0 mm. In effect, application of an extrication collar in these cadavers resulted in separation of the head from the spinal column.

What It Means for You
There are approximately 12,000 new cases of spinal cord injury in the United States every year (National Spinal Cord Injury Statistical Center, 2010). The most common cause is motor-vehicle collisions, which account for almost half of the injuries. Patients who survive often face devastating physical immobility and a lifetime of related health issues.

Since the birth of the modern emergency medical service system, training programs stressed the need for proper application of cervical collars to safeguard against the possibility of further damage during movement to the hospital.

This direction is in spite of the absence of proven benefit from spinal immobilization (Domeier, Frederiksen, & Welch, K. 2005). Quite to the contrary, researchers have demonstrated that rigid spinal immobilization procedures can result in tissue necrosis (Cordel, Hollinsworth, Olinger, Stroman, & Nelson, 1995), increased intracranial pressure (Dunham, Brocker, Collier, & Gemme, 2008), reduced pulmonary function (Bauer & Kowalski, 1988), and even death (Papadopoulos, Chakraborty, Waldron, & Bell, 1999).

Although the results of this study add to the collective knowledge about the harm that cervical collars can create, one must be careful about making false assumptions about the results.

Extrapolating the results from an investigation involving specific research conditions to a much larger population involves a concept known as generalizability. Some conclusions are easily generalizable across a broad spectrum of conditions while others are not.

For example, suppose an observer (or researcher) watched cars travelling on a road for a period of a month. At the end of the study period, the observer saw 5000 people driving on the right-hand side of the road. The observer might conclude drivers operate their vehicles in that right hand lane.

However, those results are not generalizable to all drivers everywhere. We are all aware that drivers in some other countries operate their vehicles on the left side of the roadway.

The cervical collar study examined only one specific type of injury, namely atlanto-occipital dissociative injuries. In the general population, these injuries are rare and almost uniformly fatal at the moment of impact (Cooper, Gross, Lacey, Traven, Mirza, & Arbabi, 2010).

Motor vehicle collisions and falls can produce many other types of cervical injuries. No convincing data demonstrates similar degrees of distraction in other cervical injuries as the result of rigid extrication collar application.

Therefore, one cannot reliably conclude that application of cervical collars will produce dangerous spinal cord stretching in ALL patients with cervical injuries.

Another limitation that also addresses the issue of generalizability is in this study’s use of cadavers. Cadavers lack muscle tone. Normal muscle tone provides a considerable degree of stabilization in upper cervical spine injuries (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

It is possible that this inherent stabilization limits the separation between C1 and C2 in conscious patients with this type of dissociation injury including those with extrication collars applied. However, it is reasonable to assume that the lack of muscle tone in cadavers mimics the reduced tone found in patients rendered unconscious from the trauma or from subsequent rapid sequence induction procedures.

Although the International Trauma Life Support guidelines warn against the prehospital application of in-line traction during stabilization procedures (Augustine, 2008), field application of cervical collars appears to produce distraction or stretching of the spinal column in some patients.

While this study does not mean that EMS should abandon the use of cervical collars, it does suggest the need for a reevaluation of the risks and benefits of the currently accepted practices for cervical spinal immobilization.

Medical directors must ensure that field providers utilize proper restraining techniques, including choosing appropriately sized collars. In addition to the dangerous distraction for some patients with normal use, cervical collars that are too large for the patient or those strapped too tightly around the neck may worsen distraction by pushing the head even farther away from the trunk (Ben-Galim, Sibai, Hipp, Heggeness, & Reitman, 2008).

Perhaps future research will lead to an evidence-based redesign of cervical collars or the realization that collars are no more effective than rolled-up blankets used decades ago.

References
Anderson, A. J., Towns, G. M., & Chiverton, N. (2006). Traumatic occipitocervical disruption: a new technique for stabilisation. Case report and literature review. Journal of Bone and Joint Surgery British Volume, 88, 1464-1468.

Augustine, J. J. (2008). Spinal trauma. In J. E. Campbell (Ed.), International trauma life support for prehospital care providers (6th ed., pp. 161-182). Upper Saddle River, NJ: Pearson Education.

Bauer, D. & Kowalski, R. (1988). Effect of spine immobilization devices on pulmonary function in the healthy nonsmoking man. Annals of Emergency Medicine, 17, 915-918.

Ben-Galim, P., Dreiangel, N., Mattox, K. L., Reitman, C. A., Kalantar, S. B., & Hipp, J. A. (2010). Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. The Journal of Trauma Injury, Infection, and Critical Care, [Epub ahead of print].
Ben-Galim, P. J., Sibai, T. A., Hipp, J. A., Heggeness, M. H., & Reitman, C. A. (2008). Internal decapitation: survival after head to neck dissociation injuries. Spine, 33, 1744-1749.

Brown, T., Reitman, C. A., Nguyen, L., & Hipp, J. A. (2005). Intervertebral motion after incremental damage to the posterior structures of the cervical spine. Spine, 30, E503–E508.

Bucholz, R. W. & Burkhead, W. Z. (1979). The pathological anatomy of fatal atlantooccipital dislocations. Journal of Bone and Joint Surgery, 61, 248-250.

Cooper, Z., Gross, J. A., Lacey, M., Traven, N., Mirza, S. K., & Arbabi, S. (2010). Identifying survivors with traumatic craniocervical dissociation: A retrospective study. Journal of Surgical Research, 160, 3-8.

Cordel, W. H., Hollinsworth, J. C., Olinger, M. L., Stroman, S. J., & Nelson, D. R. (1995). Pain and tissue-interface pressures during spine-board immobilization. Annals of Emergency Medicine, 26, 31-36.

Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46, 123-131.

Dunham, C. M., Brocker, B. P., Collier, B. D., & Gemme, D. J. (2008). Risks associated with magnetic resonance imaging and cervical collar in comatose, blunt trauma patients with negative comprehensive cervical spine computed tomography and no apparent spinal deficit, Critical Care, 12. Retrieved May 17, 2010, from, http://ccforum.com/content/12/4/R89

Marieb, E. N. (1989). Human Anatomy and Physiology. Redwood City, CA: Benjamin/Cummings.

National Spinal Cord Injury Statistical Center. (2010). Spinal cord injury facts and figures at a glance. Retrieved May 16, 2010, from www.nscisc.uab.edu/public_content/pdf/Facts%20and%20Figures%20at%20a%20Glance%202010.pdf.

Papadopoulos, M. C., Chakraborty, A., Waldron, G., & Bell, B. A. (1999). Exacerbating cervical spine injury by applying a hard collar. British Medical Journal, 319, 171-172.

Subramanian, N., Reitman, C. A., Nguyen, L., & Hipp, J. A. (2007). Radiographic assessment and quantitative motion analysis of the cervical spine after serial sectioning of the anterior ligamentous structures. Spine, 32, 518-526.

The author has no financial interest, arrangement, or direct affiliation with any corporation that has a direct interest in the subject matter of this presentation, including manufacturer(s) of any products or provider(s) of services mentioned.

Link to the original post.