Every four years in June, a peculiar epidemic bursts into the world's view. Healthy young men, most with an elite level of physical fitness, are suddenly stricken down. The victims drop to the ground at the slightest hint of physical contact and proceed to roll around, hands grasping their faces as if mourning the death of a loved one. Bucket stretchers are raced onto the scene, and the once-spry young men are hauled off like corpses to the morgue.
Thankfully, this horrible condition is fleeting. The ill are miraculously cured on reaching the perimeter of the milieu. They pop off their stretchers and sprint back to their comrades, right as rain. Does this floppy disease and its treatment seem odd to you? If the answer is “yes,” you may be surprised by the parallel that exists between World Cup soccer and traditional Emergency Medical Services practice.
The training and culture of our prehospital providers has resulted in millions of people being unnecessarily strapped to hard plastic boards for nearly 50 years. This practice of spinal motion restriction (SMR) remains standard in many places. Such restriction might prevent injury progression in severe spinal trauma, but the use of backboards can be painful and even harmful in other situations.
Imagine a run-of-the-mill highway crash. The police and paramedics have been called, and the driver has escaped his battered vehicle. He admits, when asked by paramedics, that his neck is a tad sore from whiplash.
Next thing this guy knows, he is pinned to a hard board with a stiff collar around his neck. His head is taped down, and straps impinge his chest. He has received the full-on SMR treatment, and he will not be free of it until he arrives at the ED.
The paramedics have done exactly what they were trained to do, but have they done this patient any good? Almost certainly not, and it's time we all recognize that SMR has virtually no basis in evidence.
Full-on SMR began in the late 1960s as the field of EMS was just emerging. A handful of case reports recommended its use, and it quickly became standard treatment and tradition. Today, some five million patients are bound to backboards in the United States each year. Only about one percent of these will actually have any sort of serious spinal injury, and only a miniscule percentage might actually benefit from being on a backboard. The estimate of an unstable but incomplete injury is on the order of one in 10,000 injured patients, according to a 2010 study by Haut et al. analyzing data from the National Trauma Data Bank. (World J Surg 2014;38:1882.) Let me repeat that: one in 10,000 patients with a traumatic event might have an incomplete unstable spinal injury in the field. The full-on SMR at its best may treat about 10,000 patients. That assumes that it can help prevent progression of injury, an assumption yet to be proven.
Evidence, on the other hand, is accumulating against backboards. We've always known that backboards cause pain and anxiety. A significant proportion of healthy patients put on a backboard for an hour will complain of pain when on the board, and some of them will still have pain after 24 hours. Supine positioning with a backboard can make airway assessment and management difficult, can mask neck and upper chest injuries, diminish respiratory function, and decrease cerebral perfusion pressure in head-injury patients. Patients may aspirate or, in a struggle to escape, cause harm to themselves or others. The full-on SMR treatment causes pain for ED throughput, too — clogging the works with EMS wall time, staff time, disruption (from clearing patients and disposing of boards), unnecessary x-rays, and increased length of stay. Rather than help, the full-on SMR causes pain to all.
Does this sound as silly as a stretcher for an uninjured soccer flopper? I think so, especially considering the damage that a backboard can cause: Picture your elderly mother tightly strapped to a hard surface for 30 minutes.
This is why many EMS jurisdictions are changing the way they use backboards for injured patients. These revised protocols narrow the criteria for using full-on SMR to situations where they truly may benefit the patient, such as when evidence shows a neurologic deficit. Everyone else who fails the Maine EMS protocol (the equivalent of the NEXUS criteria) can receive a modified approach, like a hard or soft cervical collar. Implementing this type of protocol in Alameda County, CA, in 2012 resulted in a one-year reduction of backboard use of 58 percent without any reported adverse effects. (Prehosp Emerg Care 2014;18:429.) Other EMS jurisdictions, including mine in Marin County, CA, are following suit. My ED is already seeing far more patients arriving with increasingly reasonable (and comfortable) “modified” approaches to SMR.
Now that the EMS community is on its way to absolving an unnecessary treatment for trauma, can soccer do the same? Several possible solutions have been proposed (including retrospective replay review and yellow cards), but I wonder if a soon-to-be archaic form of EMS torture might do the trick. A soccer flopper who can't get up on his own should get a full-on ride on a backboard complete with straps and a collar that takes him right out of the stadium.