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Mon, 4 Feb 2002 19:27:22 BST

Pret,
I would consider splintage just as much of a medical treatment as PASG 
or a drug, and subject to the same level of scrutiny for benefit. In UK 
speak they would all be classified as "Health Technologies". I would 
not agree that splintage has "empirical value"- we have no idea if we 
are doing our patients good by putting on a C collar and using a 
backboard. How do you know how many have further injury 
prevented? How do you know how many have additional brain damage 
from the rise in ICP caused by the collar? How do you know how many 
have more difficult airways due to the splintage?

Performing a study in which one half of the patients do not have spinal 
immobilisation is exactly what is being suggested (realistic exclusions 
for the first stage might be neurological abnormality or 
unconsciousness). Without this study the argument will go round in 
circles for ever.

I am sure that ethical oversight would look at the study carefully, but 
as there truly is no evidence one way or the other I think that the study 
would be approved in the UK. (I would draw a parallel here with the 
CRASH trial which we have discussed in the past, and which has 
received ethical approval in more than 30 countries worldwide).

Unless we push for the funding to do the good science that is needed 
in pre-hospital care we will never get the answers.
Wax as uppity as you like.
Tim.

> Dr. Coats,
> 
> At the risk of waxing uppity (me?), I think the Cochrane Group's
> conclusions in this regard are whacked.  
> 
> Prefaced by a lack of evidence in any direction (the reader is left to
> regard this as unsettling), they nonetheless suggest that spinal
> immobilization may result in preventable morbidity and mortality via
> airway compromise.  They fail to admit that an absence of randomized
> controlled trials is likely a reflection of the empirical value of
> spinal immobilization.  A superior study would require half of
> spine-injured patients to randomly go un-immobilized.  Love to see
> that presented to the Human Subjects Committee.
> 
> "Because airway obstruction is a major cause of preventable death in
> trauma patients, and spinal immobilisation, particularly of the
> cervical spine, can [sic] contribute to airway compromise, the
> possibility that immobilisation may increase mortality and morbidity
> cannot be excluded."
> 
> Hmm.  I think I follow.  Let me try one:
> 
> "Because serial killers are typically white males, and white men
> comprise the majority of western neurosurgeons, there exists the
> possibility that your local brain guy may have a freezer full of
> dismembered prostitutes."
> 
> Wow.  That's easy!  Gotta get me a consulting job.
> 
> Now, before we go comparing long boards to PASG's, let's be sure we've
> zeroed the scales:
> 
> A long board is just a Big Frigging Splint (BFS).  Nobody ever
> promised much more or less. 
> 
> PASG's were long promoted by the military--followed promptly by
> manufacturers--under the unsubstantiated assumption that they
> accomplished some sort of curious autotransfusion, thereby
> ameliorating hypoperfusion with limited untoward effects. Each of
> these notions has been repeatedly and scientifically debunked, while
> the humble claims of BFS's remain unblemished (see paragraph #1).
> 
> I for one would resist packing away the long boards just yet.
> 
> Pret Bjorn, RN
> Troublemaker
> 
> 

Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.

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Spinal Immobilization question