Transcript

0:01

Good morning, everyone. It's so great to have you here on this live session for day 2, session 1. Of our Sports Emergency Care symposium 1.0. I'm Ray Castle. I'm moderating today's session.

0:16

And it's a pleasure to have those of you coming on board right now. We'll take a second or so as everyone's jumping on board. Welcome Barb. So you're North Dakota, Brian up in Portland, Maine. And, also, Chris from InterContinental College.

0:35

Welcome to many of y'all. I know a bunch of them jumping on board right now, and please let us know where you're going. There's hopper up in the Dallas area. Welcome aboard and also Steven from Quincy Mass, and it works a high school setting. So thanks again for joining.

0:50

As we get started, it's a pleasure to have Doctor. Marybeth Wardinski presenting the day on evidence based comparison, spine motion restriction, techniques in athletics. This is a great take off from yesterday where we discussed in the in the supposed and talking about emergency action plans and protocols and emergency care, and today's sessions are are going to continue to drive home that process where we really define your protocols, your your skills, your training specifically to the spine injured athlete. So as we get before we get started, I just wanna have a couple housekeeping notes. One is, as you're already doing right now, let us know where you're from.

1:31

There's a q and a area where excuse me. You can ask your questions at any time during the presentation. We will have time at the end of the presentation to address those questions. And if we do not get to all those questions, we're gonna wrap back around after this webinar, and we're gonna still give you those answers as well. A little bit different than other webinars is that we will try if you're interested, and I'll I'll when we get to the q and a's time, to simply just raise your hand if you'd like to ask the question versus than having us write it out.

2:10

A little bit different but I think it's important. And we think it's important even talking to Doctor Ordisky that we have a conversation. It's not one way that you can we can hear your voice and hear your questions loud and clear. And it's great to have also a c University of Nebraska, Omaha students welcome aboard as well. Think you're in for a great treat today.

2:29

So without further ado, welcome, Doctor. Horodyski. I'm gonna do a quick introduction So, obviously, her full accomplishments are on the webpage for the course, but Doctor Hardiskey is truly a an example of servant leadership in the profession of athletic training. She has served an NAT Board of Directors as vice president. She's been a district director for district 9.

2:54

Also, as serve as chair for the executive council for education as well, and also the research education foundation. Is part of her background. She has also had extensive experience in clinical practice as well as research She is she served 8 years as a assistant athletic trainer at the US Military Academy in Westpoint. She also has served since 1992 Ben University of West Florida, where she's had a number several roles being the program director for the graduate training program, also servicing a number of schools in the community, at community college, as well as 2 campuses. Currently, she's a director of research and the department of orthopedics And Rehabilitation University of Florida.

3:40

One of the things you'll you've seen about her is that she is actively involved in all aspects, especially for funding. And this is one of her areas of heavily funded researches and spun motion restriction and have she's had over 150 presentations and publications and is a frequent presenter. And I can go on and on. She's had so many awards as well, such as the NATA Fellow Award She's been in several hall of fame, including Natia Hall of Fame in 2017. And and most recently, if you're familiar with the Tim Karan award, the Natia gives is one of the most highest honors any of the profession can award in addition to Hall of Fame.

4:22

And without further ado, I'm gonna give it over to Doctor. Horwinski's pleasure to have you this morning. And I'm gonna give you the the the table, the and I'm gonna drink some coffee while while you're presenting, and listen in.

4:36

Well, thank you. And enjoy the coffee for me too, please.

4:39

Yes. I will.

4:40

So this is my title slide. And I was also asked to make sure that I provide any funding sources, and you can see that we our research team has received funding from numerous areas. And this talk is going to address a lot of things related to spine boarding, a tiny bit about equipment, but really you will go through a slide or another lecture that actually talks about the step by step procedures for spine boarding and equipment removal. This is one of my favorite slides. I also teach Gross anatomy here at University of Florida, and this is it.

5:16

This is the thing that we're trying to protect in all cases when we suspect a spine injury with our athletes. So the question is, what is the evidence? And every single year, I look at other journal articles, other research teams, and try and figure out what is it that we should be saying to our cells, and what should we be doing with our athletes if they have a potential spine injury? Well, the problem is, even today, it's generally recognize that there's no clear evidence for or against demobilization. And so I'm going to present some stuff where you will find that other people will say, no.

5:52

No. No. You should not be doing that at all. Important for us to keep in mind is that there's a ultimately 17,000 and actually that's probably a little higher right now. New cases of spinal cord injury each year in the United States with the 9% of those coming directly from sports.

6:10

The athletic population has some very unique characteristics sticks, and that allows us to maybe handle some of their injuries a little bit differently than what some people see in the literature or what others will tell you if they're addressing potential spine injuries, for example, in an automobile accident. The athletic population is most often younger, In some of the studies that I've reviewed recently, the main age in most of those studies was anywhere from 43 to 50, and our population that we deal with most of the time is younger. They have good bone health. Fortunately for us, fewer comorbidities. However, sometimes they may be wearing equipment.

6:51

The biggest thing that we're trying to preserve or prevent I should say is the potential for secondary spine injury to the cervical spine area. When we're handling these athletes with the potential spine injury. And Lenarson and all, their team had suggested that anywhere between 3 to 25 end of the injuries that actually happened to the spinal cord take place during the stages of management, be that in the prehospital setting in the emergency department or if the patient needs to go to the OR, how they are rolled or positioned for their surgical management in the OR. So some people say this is new vocabulary, and I really don't think it is. Do we compare the term spinal immobilization or spinal motion restriction, and you can go back over a decade now and find both of these words side by side, spinal mobilization definitely goes back many decades in the literature.

7:49

But the bottom line, regardless of what term you are using is that we're trying to restrict motion of the cervical spine area or sometimes other areas in the spine by using things like cervical collar patient driven, which is where spinal motion restriction has come in more frequently. Or if necessary, the spine board or other devices as they might be needed. The bottom line is spinal is geared towards preventing further harm to the spinal cord or spinal column. Here's some examples in our lab of some of the different things we've tested, the long spine board, the scoop stretcher, the American version of a vacuum mattress, which is the orange one, as well as the green, more European style vacuum mattress that's been used. So when we go to look further into spinal motion restriction or the mode when we might need to use a mobilization, oftentimes, people suggest that we look at the nexus criteria or the Canadian Sea Spine rules.

9:00

Well, those 2 different criteria were developed actually for in hospital use to decide whether or not a patient was going to have some form of imaging done. And the reason for developing these rules or these criteria was to prevent excess radiation to patients or radiating patients maybe when it wasn't even needed. But what are some of the key factors that we should look at, that these 2 criteria also represent. 1 is blood trauma or high energy mechanism of injury. Obviously, with Blunt trauma, we see that in several of our sports.

9:37

Altered level of consciousness, for any of the following drug or alcohol intoxication. Certainly, I hope that's not true with your athletes many, many years ago when I worked at West Point, the athletes When they played rugby, I can't guarantee that they were free from alcohol intoxication. Inability to communicate or some type of distracting injury. If they had midline spinal pain and or tenderness, that's another key factor to suggest spinal mode from restriction or those who wanna use immobilization would be indicated, or if they have focal neurological signs and or symptoms, such as numbness or motor weakness, or if you palpate and you feel anatomic deformity of the spine region. Now, I mentioned the Canadian SeaSpine rules, and a very recent article that just came out has is talking about looking at modified Canadian Sea Spine Rules for in the field use.

10:36

So in other words, they were looking at how paramedics would consider spine boarding or immobilizing patients. They looked at 4 1034 eligible patients, and then they were able to obtain imaging of 952. Of that group, 31 had abnormal imaging of the cervical spine region and they could then further classify them into 10 with an important abnormality suggesting that either improper handling could cause a secondary injury or they've already sustained an initial injury to the cervical spine. And then they also had one that had normal imaging but in fact had an abnormality that indicated injury had occurred to the cervical spine. So they class when they looked at this comparison, then they wanted to see how effective were the paramedics in the field in classifying the patients.

11:38

And they were able to develop it or demonstrate a sensitivity of 90% a specific specificity of 66.5%, and then an agreement between the actual research team and the paramedics of 94, a CAPA agreement. So really what it comes down to with all those numbers. Forget that point. The major point is the total of 2580 3 and mobilizations were avoided following this modified Canadian Sea Spinal Sea Spinal Criteria. So the use of the spine board is not without complications.

12:16

So any of us that say yes, you should use this spine board, we recognize that there are some things we need to be concerned about. The longer a person is left on a spine board, the more likely some of these negative side effects can occur. So sometimes when I'm lecturing to faculty, like for example, emergency department faculty or physicians, They get very upset with me when I say that they sometimes are the cause of further harm to the patient because they leave them laying on the long spine board if the person is coherent and able to respond versus taking care of the injury immediately. But things we need to be concerned about when we use a long spine board is the effect on pulmonary function, potentially impeding the airway ability or the airway management. So they're strapped to the spine board incorrectly, and then the paramedics on the way to the hospital and the ambulance need to apply airway management, then sometimes they can't do it as easily.

13:16

The cervical collar has been demonstrated to increase intracranial pressure in some patients. And then, of course, if left on the spine board for too long, pressure sores or ulcerations can begin. The key point though about why we don't throw the spine board out is the amount of motion enforces required to create that secondary injury are really not known and we do know that the spine board is effective in maintaining or decreasing the amount of motion that is occurring in the cervical spine. So what are the recommendations for treatment of a potential spine injury? Well, essentially, and of course, as we know, anyone with a possible spinal injury should have some form or level of spinal stabilization.

14:05

There is an exception to that rule. A penetrating wound to the spine should never be I I guess I shouldn't say never. Should not be stabilized on a spine board because the amount of time it takes to stabilize them on the spine board decrease, it increases the length of time to get them to the hospital. And in these cases, with penetrating wounds, the patient should be transported immediately. We also have to keep in mind that we have to prioritize airway maintenance and other lifesaving methods oversignal stabilization, whether you use the ABCs or some other versions, some folks use the ABC DE.

14:44

Technique, you need to keep in mind airway and circulation are most critical because if they don't have that, obviously, they're not going to survive even if you spine board them perfectly. The use of a hard ceased apart sea spine boards should only be used in shorter durations. Although, we do have evidence in the military where they've had soldiers on the long spine board for an extended period of time without any negative impact to their overall health. The use of vacuum stretchers are okay in most any other instance. Unfortunately, in the United states we don't use vacuum splints as well as we could or the the large vacuum splints, such as those used in Europe.

15:32

So if we look at those recommendations for spinal injury treatment, a couple of things do come out when we look some of the other research that's out there. 1, it's not necessary to use a cervical rigid collar on every single patient because if they are actually stabilized well on a long spine board, that cervical collar isn't assisting really very much if at all in maintaining the amount of motion or decreasing the amount of motion occurring at the cervical spine. The other thing is you're looking for treatment protocols, you always have to assess the situation first and make some good calls about the patient and the team available for taking care of the injured athlete. I just want to quickly mention a little bit because we've done a fair amount of research also in vehicular accident and self extrication. This self extrication is what they oftentimes call spinal motion restriction, where the patient they put a collar on the patient and then allow the patient to get out of the car on their own with the least amount of movement.

16:43

Now, of course, if there's other extenuating circumstances such as other injuries, inability, to follow directions or or talk, they would not use this technique. The lateral trauma, spine position, is another technique that actually doctor Hidermo was one of my former doctoral students. He's also an MD in Norway where he leads a a large trauma program in Norway. But the lateral trauma position requires at minimum two people. And what this is used for frequently in your in the settings there is it increases airway access in comparison to the long roll positioning.

17:29

It also allows a comfortable position for the patient, for traveling long distances, such as in a helicopter, and it has similar risks of other spine motions that occur, such as when you are putting someone on a long long spine board. What about equipment? Well, I'm really not going to get into this too much because that's in another lecture. But something just to keep in mind is we're talking of getting ready to talk about the different's mind boarding techniques is that the inter players' helmets and shoulder pads do cause problems for the medical team on the field. It it decreases the ability to properly assess the cervical spine region.

18:10

It also causes problems trying to stabilize the patient on the long spine board or in any other device. And also equipment may delay or decrease the ability to have access to the airway. Speaking of airway us, and I won't get into too much of this other than some of our research because there's another lecture associated to airway access. Airway access though does need to be completed prior to transportation. In this case, it might mean just removing a face mask or it might mean the helmet needs to be removed.

18:45

The bottom line is, though, if the patient has sustained blunt trauma such as a forced or a blow to the top of their head, The risk of cervical spine injury is tripled if the patient has a cranial facial injury, a glascocoma scale of less than 8, or a combination of both. We have to keep in mind that 10% of trauma patients with cervical spine injuries will need airway management. That's why they need to have access to the airway. So again, Doctor. Schwartz and his research team recommended it from their research, remove any and all existing barriers to expose the airway keep our our research team also assess this with methods to keep motion to a minimum.

19:33

And we've done a fair amount of research also on airway management, and one of the best techniques is the jaw thrust maneuver. And if you are not practicing it or not teaching it in your CPR classes or you're not getting it in your CPR classes as a student, please figure out a way to practice. The bottom line is you wanna maintain alignment of the cervical spine. So if we look at our research comparing the jaw thrust to the head tilt chin lift method. What essentially you see in a cervical spine that's unstable, and this was done in a cadaver model, is that the head tilt chin lift method had significantly more motion in just in in almost all, one was not, but in almost all of the 6 measurements that we measure.

20:22

So that tells us if we suspect a sea spine injury, but we need to manage the airway, please use consider using the jaw thrust technique. We've tested airway devices and more airway devices and more airway devices. So a little bit about airway management from our research team as well as others, The bag valve mask technique significantly gives higher ventilation volume compared to a pocket mask Using 2 responder ventilation methods increases the total number of ventilation as well as adequate the percentage of adequate ventilation And actually, removing the chin strap of the helmet significantly increases ventilation volume, and increases the amount of or adequate volume. And that's from Doctor. Michalik and his research team.

21:14

When we think about, okay, we gotta get access to the airway, there are lots of methods people suggest for removing the face mask if the athlete has a helmet on. The combined tool approach with the cordless screwdriver and a cutting tool resulted in a 100% success in COVID study. The on field conditions though throughout football season may modify the ability to remove the face mask and they did in fact have a longer removal time. However, they were very sick in almost all cases using the combined tool technique with through Gail's Eddall's research team. Continuing with face mask removal, we know that a lot of helmets now have the quick release.

22:01

The removal time for quick release face guard is definitely sometimes a little quicker and certainly has a satisfactory success rate. If we look at quick release versus traditional, which was done by, again, Doctor. Swartz and his research team, Whenever cutting was necessary to get the face mask off, it increased motion. It took longer to do and increased difficulty in successfully completing the trial or in other words, successfully getting the face mask off. If we look at face mask removal versus talent re removal.

22:40

Some folks will quickly say, well, of course, there's less motion just taking the face mask off in any of the planes measured It's, in some cases, significantly less time to complete. However, more recent research has is demonstrating that when people are trained in the two hands two people two hands technique, the helmet sometimes can come off faster than the face mask. Important things to keep in mind about the helmet. If they have air bladders, don't worry about deflating the air bladder before you try to remove it because it takes even more time. So looking at lacrosse face masks as comparison to the previous slides, which were all football helmet face masks.

23:26

There are significant differences in removal time between the different helmets. So that means as an athletic trainer or a care provider, For athletes, Animal Cross, you need to know what how much your athletes are, in fact, wearing. And, also, there were differences in the amount of motion that might occur with different face masks face mask removal techniques. So the key point is you need to practice or any type of face mask your athletes might be wearing. With respect to helmet face mask removal skill development, Right?

24:01

And all did some research in this area, and they did a 20 minute instruction module. And what that instruction module actually did was don't demonstrated a significant decrease in completion time. The cutting of the cheek loop strap took longer then the forehead strap, even though they were trained in this, significantly less motion with cutting the forehead strap occurred. And significantly easier to cut the forehead strap and easier with successive trials is what the subjects of the study reported. However, they gave their subjects who were the test people removing the face mask, a 3 minute limit for face masks face mask removal.

24:47

And if it took them 3 minutes, then it was considered trial failure, and they had 12 trial failures. My concern about this is at no point in time should we be going out past even probably a minute in face mask removal attempts, and then we should switch to just getting the helmet off. Because if we're out there 3 minutes and then we start accessing the airway, that might be extremely detrimental to the recovery of the athlete. I mentioned previously the 2 by 2 technique, And we always like to remember that if you are going to remove equipment, the helmet comes off before the shoulder pads. I mentioned not worrying about deflating helmet bladders if there are because it takes much longer to deflate the bladder.

25:34

And it's also sometimes not always possible to deflate the bladder in an athlete who's laying sup supine. Some other things to keep in mind is if the helmet is going to be removed on-site prior to transport, the question I often get is, well, Do I remove the face mask first and then the helmet? The answer is actually probably you don't need to. If you take the helmet off without the face mask removal, yes, there was significantly greater motion. However, the time to take the face mask off and then the helmet was significantly greater than if they just left the face mask on and then removed the helmet.

26:24

So for some final things, and this is looking at 3 different research teams. The first one I have listed here is actually from our research team. But after the helmet is removed, if the shoulder pads are not removed, something to think about is if CPR were needed to be started, it could cause some additional problems in having successful CPR. But if you need to remove the helmet only, keep in mind you need to pad under the head to prevent hyper extension. A quick comment about pediatric high risk events because some of us now are branching into caring for pediatric patients.

27:03

Is that falls of greater than 3 or 5 stairs oftentimes result in spinal cord injuries or may results bicycle collisions, diving, and then an accident involving a motor vehicle. With respect to pediatric helmet protection, there's a debate that continues on whether helmets actually decrease cervical spine injuries, because the excess weight from the helmet is thought to cause more sheer stress in young children. Children are more likely to experience hyperflexion and extension injuries with the helmet on because of the weight of the helmet. And comparable associated cervical spine cord injury risks with non helmet and helmet use. So in other words, if they're comparable, the question is, you know, should the the young children be wearing a helmet.

27:56

Now if you'd wanna talk about concussions, that might be a different story because helmets are lightly to reduce extreme head injury, but potentially could increase spine injury. When we talk about shoulder pad removal, and again, I'm not going to get deeply into the how twos, we do need to know that there are various techniques such as the multi person lip, the by valve technique, elevated torso technique, and the flat torso technique. We've tested numerous techniques in our research for shoulder pad removal. But the main reason we did is if you see that 32 degrees versus 22 degrees, we're looking at the amount of flexion an extension that occurred during different techniques. So it's important to realize that just having the person sometimes laying flat on the ground and trying to shimmy those shoulder pads out from underneath may act increase the amount of flexion extension axial rotation and lateral bending, as well as translation for medial lateral motion or anterior posterior motion.

29:05

So it's important to think about what technique are you going to use to remove those shoulder pads and make sure that you keep the motion to a minimum with and that usually occurs with lots of practice. Another question our research team has addressed as have others is, which color type do you wanna use and why? The one piece collar or the two piece collar. I can tell you after the probably the 1st 5 or 6 years of us doing our research, I was always one of the ones at the head, either doing stabilization or putting the cervical collar on. And I could tell you that ICE could swear that the two piece color caused less motion at least.

29:42

That was my thought. However, when we actually did research looking at the application of 2 different color types. So two piece and a one piece. What we realized was there were really no significant differences between the 2 color types for angular or translational motion during the placement as well as if done correctly and carefully in the ED, the removal of the cervical collars. So that means practice makes perfect and the better you the more you practice regardless of the type of cervical collar, it's probably not gonna increase the amount of motion.

30:22

So a little bit more about cervical color, so that's very interesting. And this has been repeated in numerous studies is that Cervical collars do not effectively reduce motion in a truly unstable cervical spine. We've tested this in a cadaver model numerous times, 3 of the 4 references here are actually from our research team in in different studies. The thing to keep in mind with respect to whether you should or should not use a cervical collar is the time it's gonna take you to apply the cervical collar. If you've got critical life saving procedures that need to be done, airway circulation, then it might be better to have someone else stabilize the head and just begin the critical life saving techniques and not put that cervical collar on.

31:14

Banger and Blackam previously questioned the process of why we even put cervical collars on, particularly if they are conscious trauma patients. Even if we suspect a potential cervical spine injury, appropriate spine boarding management will probably take care of that without the risk of increasing intracranial pressure by putting a cervical collar on. What about hand placement? Well, we've looked at hand placement for the stabilization of the C Spine using the lift and slide technique as well as the long roll technique. Then we ask folks, you know, what hand placement are you going to use, whether the patient is supine or prone?

31:57

So in our lab, we've tested on our cadavers standard technique and then the modified or the trap squeeze technique. And what we typically saw in every case on a lift in slide, there was significantly less motion between the techniques, particularly for the modified lift slide. In other words, doing the lift slide technique to put the the cadaver in our case onto the spine board using the trap squeeze technique. What about now we're on the field and we haven't we've decided that we must put this athlete in some spinal motion restriction or immobilization technique. If they're supine, we have several options.

32:40

We can do the traditional long roll, the lift, and slide. And when I say that it could either be the straddle lift or the multi person lift, or a mechanical device such as the scoop stretcher or motorized spine board, which I don't believe anybody is anymore using the motorized spine board. But influencing factors on whether you will what technique you might choose has to do with the patient size and the personnel. In other words, how many people are available? What is the relative strength of everybody?

33:09

Although that's less of a concern if you have sufficient number of people. And what is the preparedness of the people there? How what techniques have they practiced and what are they familiar with? But let's look at the spine boarding transfer techniques, and this was a study done by our research team, where we looked at model versus lift slide versus multi person lift. The lift slide being a straddle lift slide technique.

33:34

In the multi person technique, some of you maybe know it as the 6 plus, but the reason we now call it multi person is simply because you just add more people if the person's bigger. And what you see the red arrows pointing to on each of these graphs is simply that with global instability, the log roll technique had significantly more motion in the cervical spine, which is exactly what we don't want to have happen. So we wanted consider in most cases with the supine patient, Lyft slide or the multi person Lyft is what we want to be using. Here's another study from our research team also looking at the different techniques. But in this case, We were looking at thoracolumbar spine instability.

34:21

You often times may see this type of injury in motocross type injuries. And once again, if you look at the destabilized versus a normal spine that was before we cut the ligaments in the cervical spine region, what we still see is that the lift and slide technique had significantly less motion than the law rule. Well, what about that supine patient? And you might have some other tech equipment available to you such as a scoop stretcher as you see in this picture. Well, years past, the scoop stretcher got a bad wrap because it was made out of aluminum and it would bend and break if you put a heavy athlete on it.

35:07

Nowadays though, the newer scoop stretchers are very good to use. And in this study, they assessed 31 healthy subjects used electromagnetic sensors But what they realized when they compared the log roll to using the scoop stretcher is there were 6 to 8 degrees greater motion in all three planes during the long roll compared to the scoop stretcher. Our research team also did a similar study, and we found very similar results to the previous study. Now what about the vacuum mattress that I mentioned that's used more frequently in Europe than in the United States? Our research team assess the vacuum mattress on numerous different studies.

35:50

And what you're looking at is the amount of motion that occurred by the vacuum mattress. The the 4 red boxes tell you the ones that were had significantly less motion. But really, what you're looking at is we had less motion in all six measurements motion measurements that we were looking at with 4 of them being significantly less motion with the vacuum mattress versus the spine board. So you can really package your patient in a vacuum mattress. Well, why might we see greater motion with the log rule?

36:23

If you look at this positioning, when you roll someone to their side, the shoulders are definitely in most cases for the adult patient wider than the hips. And this difference is even greater if the athlete has shoulder pads on. So what happens is you end up seeing that oftentimes with the low goal, the ability to maintain inline stabilization is more difficult than a lift slide. We were once asked by a very well known internationally well known neurosurgeon, if we could write a manuscript about eliminating the long roll altogether. Well, I'm going to tell you you can't eliminate that, and you'll see why in the next few slides.

37:07

But we did do the research, and we published 2 different papers on 2 different times where we took the patient or in our case, the cadaver, from the field all the way on to a table that's called that we would use to position the patient in the OR for their spine surgery. And so we put all of that together, and if you look at the bottom bullet, that here's the key point. Overall cumulative motion to the unstable spine can be reduced by about 50% if we avoided the log roll and did lift slide motion throughout the different transfer technique procedures that we had to do. So what about that patient that has equipment on. Some things to keep in mind.

37:58

The impact of the equipment when your log rolling is much greater than the impact of the equipment when you lift slide or you do the multi person lift. Rolling over the equipment almost always will create greater motion. The equipment fit in youth athletes is even a a bigger problem because oftentimes the helmets don't fit, you know, mom and dad, they buy the bigger helmet so that the their sun can grow into it, so to speak. But that's not the best answer. So in many cases, you need to look at the fit of the helmet and consider removing the helmet before transferring because the head is not stabilized in a very loose helmet.

38:41

So in summary, the multi person lift generates less motion than the law rule. The scoop's stretured likewise, generated less motion than the law rule. So consider when possible with the supine patient that you either do the multi person lift or scoop stretcher as an alternate to the law rule. And also remember, if you have access to a vacuum mattress, after practicing, it provides a good level of stable stabilization to the cervical spine. Well, we also have a problem the beginning of the season, when I work with my athletes, I always tell them if they're gonna have a concussion or they're gonna have a cervical spine injury, please lay in face up.

39:21

But in this case, they didn't listen. If you look at all these pictures, they're face down. So they're our prone patient. What are our options? Our options are the log roll pull pull versus the log roll push.

39:32

A log roll one time, so going from prone all the way over to the spine board or a long roll where you roll halfway and then position the spine board and then the other half. Some things again influencing factors on what technique you'll use is history. Sometimes convention is good. And the training of the personnel how much they practice the different techniques and the availability of if there's a spine board available in that situation. In these two pictures, what you're looking at was one of our research studies where we did the push versus pull in the thoracolumbar spine, as well as we also then did it in the cervical spine.

40:15

On the in the first picture, on the left, you're looking at them doing a long roll push where one person's handling the spine board, the others are pushing the patient onto the spine board. The second or the picture on the slot on the right is looking at the patient being pulled onto the long spine board. So our research team, you guessed it, we decided to compare Should we be doing the push technique or the poll technique? And although these graphs are a little bit call to follow, what you can actually see is that reflection extension, axial translation, and anterior post year translation, we did in fact have a significant difference in the amount of motion with the push technique having a lot less motion. So we find that we light the push technique much better than the pull technique.

41:06

However, I will tell you you need to practice both because if the person is laying against the wall, the only option you might have is the pool technique. Remember, you can't use the lift and slide on a prone patient because then you have them on your spine board face down. But the question we might say is, how many times should you move the patient? Decide in advance in the situation and how to handle it? But keep in mind, with every transfer, there's the potential or opportunity for motion to occur and potentially cause secondary injury to the spinal cord.

41:42

So that's why we suggest trying to do any of your movements with that patient in 1 slow and controlled motion. Some other things that we have is with the long roll for that prone patient, sometimes they don't end up in the middle of the spine board. So what do you do once you've placed them on the spine board, but they're not in the middle. How do you get them to the middle? Well, I was taught never slide the patient horizontally.

42:11

So we learn different things like the VSlide or the JSlider or various different techniques. However, our research team decided to look at this, and what we found out was that there was significantly less lateral bending, medial lateral translation and flexion extension when we centered the patient simply by sliding them carefully to the horizontally, to the middle of the spine board. And that might be simply because we were going through less motion just going straight across versus going down and up as if you were doing a j or a v maneuver. What about strapping techniques. When you put your patient on the spine, where where you have the 3 strap technique, which is pretty much not a good technique and shouldn't be used.

42:57

A 7 strap technique, which many of you have learned, as well as the spider straps, which when they were introduced to me years ago, I didn't like them at all. But once I learned how to put them away correctly and get them back out correctly, it was I find that I very much like the spider straps. Well, what did we learn from our research? And this is when we put the athlete or the in our case, the cadaver on the spine board strap them in carefully. We measured the pressure for the strapping so that we could keep everything the same, and then we tilted the spine board.

43:29

And what we found out is that the 3 strap technique had significantly more motion in the cervical spine area than the spider strap The spider strap technique was not significantly different from the 7 strap and pretty much they were very comparable. One question we get asked frequently is should the advanced trauma life support protocol be modified for removal from the spine board? Because you know, when they get to the hospital, what they typically do is law roll them off the spine board and palpate the spine. Well, in most cases, at that point in time, why would you long roll them off the spine board and palpate the spine? Because if they don't have a penetrating injury, The next step is most likely gonna be some sort of imaging.

44:15

So therefore, the lift slide technique had significantly less motion than the long rule. In every one except for one of the axial translation, you can see, in every one of the motions that we measured. So, yes, our research team would suggest that to get take them off the spine board once you arrive to the ED, they should use the lift slide technique. And finally, I guess the question might be, what is best care? You know, many times we're not sure what best care is.

44:50

And I started my lecture by saying, you know, there's generally disagreement. Either for or against using a long spine board or other immobilization techniques. So best care actually likely encompasses a variety of treatment strategies. Maybe it's acceptable success rates in the strategies that your team of athletic trainers and your your medical team altogether work as you work together and the techniques you find, the most successful or the easiest to do for those that you're working with. But the bottom line is we have to keep in mind that with any technique we choose, there is a little bit of reasonable inherent risk no matter what we're doing.

45:37

But what I want to show you is this EMS it's IMMO for immobilization protocol. This is a newer and modified protocol where they're using the ABC DE method for assessing their patient But this allows them to decide whether they'll use either minimal immobilization and early transport should not be delayed such as blood trauma or a penetrating wound, or if they're going to decide that manual inline stabilization needs to be continued until further assessment, and then they do a complete immobilization. This article, by the way, is from 26 pain, but it still is a lot of excellent information, and I encourage you to try and obtain this article and read through it. Because it pretty much goes over a lot of the things that I've addressed today. So moving forward, what are we looking at?

46:35

Well, our research team in August just this past August did a lot of research, and I was trying to calculate how many times I did some sort of lift slide or long roll or lateral trauma position or vacuum mattress, all different types of techniques. And it probably comes out to during that 1 week time for each kid ever, we probably did at least 200 to at 250 motions on one could ever times 10 could ever. So, yeah, we were tired at the end of the week. But that being said, We're working on calculating the space available for the spinal cord. A couple years ago, one of my former doctoral students used this method where we used a so so to speak a robot that could take the cervical spine and move it through a a very controlled motion each time, and then we would decrease the stability of the cervical spine each time we ran it to the test.

47:38

By cutting some of the ligamentous structures that were holding the the vertebrae in place. And what we saw was a decrease in the space available for the spinal cord. So this year, what we were capable of doing is CT, all of our cadavers, and then rebuild the C5C6 level, and then using several different computer programs. Begin to assess the space available for the spinal cord as we're going through these various motions. And in some cases, we're finding interesting that we're seeing a lot less motion when we think we would not.

48:17

So more to come on that because we've now been able to shift our you know, model in the lab to a model actually in the cadaver setting. So what is the evidence? I've kind of started with this. Generally, it's recognized that there's no clear evidence for or against immobilization, particularly if the immobilization technique is done correctly, and if the patient is not left on the long spine board for extended amount of time. Some final thoughts.

48:52

I can't emphasize anymore, the planning and practice that needs to go into spine boarding. And again, yes, if you're saying, well, what would you do? If they're supine, I'm going to try and do the the lift and slide technique. If I need to take the helmet off, I will. I will feel comfortable doing it, but all of that comes with planning and practice with your medical team.

49:18

Thank you. Okay, Ray. You have to stop drinking your coffee.

49:26

Yes. I'm done coffee. I didn't have very much. So that was fantastic. It just you know, I know, hopefully, I think most of you on the on the call, have a lot of questions, had 1 or 2 coming in already.

49:41

I'll go ahead and ask one If you would, make sure to go ahead and put your questions into q and a. That way, everybody can see one. So here's first one for you is from Lisa. And question is how long is considered a long time to be on a spot long spine board?

50:02

That's an excellent question. I made reference to a how long the military were on the long sweat, spine board. And actually, some of them, and if you know anything about evacuation of injured military or soldiers, There's oftentimes it's a two tiered tech method where there's a close, like, in the war zone area. Medic area, and then they get evacuated further out to hospital more like a level 1 trauma center. And, actually, some of them were on the long spine board for 17 hours.

50:39

That was the maximum. So but in all honesty, anything greater than an hour, you need to start questioning what's going on, particularly knowing that in most cases, except for if you're in our very rural communities, In most cases, the athlete can be in the hospital in less than 30 minutes. So if they're continuing to be kept on that long spine board for another 30 minutes. Someone needs to start questioning what's happening in the ED.

51:11

Excellent. Thank you. Thank you, Lisa, for private questions. So if any other questions, please feel free to sent cement those in if you would. So while we're waiting on a question, Doctor.

51:23

Wardeski, one of the questions I had was really about the I guess, in your experience, what is the biggest barrier or the or the issue that you've seen, athletic trends, other providers in making the in making a shift to the one lump to, you know, the type being most effective in their in their spine boarding to or their I'm sorry, their mobilization to spine motion restriction techniques. What's the what's the hardest skill component of all the different types that are that are that you've seen that is a barrier?

51:57

I think if I understand your question, the barrier to shifting. And if I were hoping that people are shifting, particularly for the supine patient, the shift is to you know, doing a lift slide technique of some form. I think the biggest barrier is just people not a, believing the research, even though our team is no longer the only research team that is demonstrating this. And b, just failing to take the time to practice and practice. So then when they get out in the field and they say, someone says, okay, we're gonna do the lift slide, they all panic for a moment because they don't feel comfortable.

52:39

Practice makes you comfortable. However, I can give you a quick funny was that the an unfortunate situation I came across was a I saw an accident where a young man hit a a bicyclist on a street. So, of course, I was the next car back, so I stopped to help. Unfortunately, I knew the woman, but I immediately did in line stabilization had the young man call for an ambulance. And when the ambulance crew got there, the paramedics knew me.

53:09

And they go, oh, hey. And, yes, I had taught them the Lyft slide technique. So, of course, what did they think we were going to do? They said, well, we'll do the left side. I said, no, we won't.

53:19

And they looked at me and sheer shock. There were only four of us there. And if I'm maintaining in line stabilization, that meant there were 3 left. 2 to help lift the person and one to put the spine board in. Is that not doable?

53:35

So we in fact did the law rule. Now had the imbalance come with a a fire truck that would have brought us quite a few more hands and few more paramedics, and we would have yes done on the left side.

53:48

But that that would be probably more in a rapid trauma situation where they're trying to move, get the patient. Again, it goes back to what you said early on is airway rapid trauma assessment. They're just simply going to they're going to load and go, especially with multi trauma or polytrauma. A patient. They don't have time to wait around.

54:07

They're getting get

54:08

a And we were not with this patient, we were not gonna wait around for another group of people that were well trained in what to do, we needed to get her in the ambulance in on her way.

54:19

Great. Thank you for that. That's just what I was asking. Exactly. David asked what is the best practice for rehearsal of this technique with the staff?

54:30

The best practice for rehearsal. Here's several things. And and I like to say that everybody gets involved, and everybody practices each position because you never know if somebody's gonna be missing on a day when you need to do the list slide. So I think the best method is to obviously have someone who's going to be your patient but everybody practices every single position. What I have found in the past is working on a sports medicine team that oftentimes people think immediately the person with that highest ranking, so that would oftentimes be your MD, should be at the head.

55:12

That's not necessarily true. The person with the most experience and the person that knows you know, has done it the most or practiced the most, should probably be the person at the head because they are also calling all the commands. Notice I said when the ambulance got to the seen in the accident that I was at at because they all knew me, they didn't ask me to give up head the head position and move because they knew that I would know the commands and I would know what to do. So it's important that everybody learns the commands. It's important that everybody practices every single position that they, you know, that they could be in, be it on the side lifting on the end, putting the spine board in, or the head position calling all the commands.

55:58

Hopefully, I answered that question. I think that's what you were asking me.

56:01

That that was a great question. That was presented to you. I think that's the looking at the being controlled, the situation is paramount, and it doesn't necessarily mean being putting your being the person put your hand on head. So just because once you do that, you can't do anything else, especially if you're the most trained to delegate and manage people. Great.

56:20

So next question is from Mandy. And this is a situational question. It is it is if it was an axial load injury, and tendered to palpate under I'm sorry, palpate the upper sea spine, would you spine board? And the quest, I guess, responses. I had a situation where we had EMS come, and they put a seat collar on and made them get upright and guide to get to the stretcher.

56:47

Okay. So even though you're talking about spinal motion restriction and self extrication, that's what they call it. Even though that occurred, I'm not going to get in the middle with your paramedics or whomever, But in most every place you read, palpation of the cervical spine resulting in increased or significant pain is an indication for spinal immobilization. And so that person should not have gotten up and walked. As a matter of fact, I can tell you of 2 different spine surgeons where patients were allowed to get up and walk and knee from the the injury scene to the ambulance.

57:35

And then when they saw the patient in the ED in one case, And actually, in the office, a week later, in another case, they had significant movement of the C Four vertebrae. It was sliding forward. And I got to see the x rays, and it was pretty scary. So the bottom line is, in most cases, anytime you have something that really clearly says to you, This is a c Spine injury or potential c Spine injury. They should be handled with more than just a cervical collar, especially since we know cervical collars do not necessarily maintain, you know, a stable spine.

58:19

This is a great question. You have it happen more frequently in younger patients, the pediatric patient where they want them to get up and get moving. You have it frequently more often when the patient is coherent and able to respond, and the paramedics wanna do the self extrication. Just to give some of you may or may not know, I actually started with one of my doctoral students down this path of research and I really wanted to keep it going because my own daughter sustained a c Spine injury where the physician in the ED felt she was hyperventilating, not that her arms and legs were numb and tingling. And then later when assessed by a spine surgeon, she, in fact, had an ability.

59:05

Not a major one. It didn't prevent her from going on to be a collegiate gymnast in a happy life, but the bottom line is if there's some signs or symptom there, they should be handled appropriately. So the other thing you might think about is meet with the paramedics and make sure they understand your protocol on the field. And we do that actually in Gainesville, not only just for the collegiate athletics, but also with we meet with the paramedics for all of the high schools. We have a group meeting and we discuss some of our very specific protocols, for example, for heat illness, for spine boarding, if we're concussion, that type of thing.

59:48

Great question. Thank you, Doctor. Werteski. I think one thing to add to that is just to and we talked about some in the in the previous yesterday sessions is that came up in in same here is understand that unless there's a state jurisdictional issue where you have to relinquish care to EMS, Remember that you are the provide the provider is there, you have control. And if it's something that you deem as being unsafe based on practice and what protocol is for that, then you need to step in.

1:00:18

I think that sometimes we get into that point of just handing it over to EMS without making sure that's what's going to be done the next step. And I know that's that's a hard disc discussion to have in the field, but at the same time, you have we're we're they're protecting the directing the patient, and that may be they may not be doing something correctly as well. So we assume that just to think in mind. And we've got time for about one more question we're getting right by the minute or so after is from Jay. Is what about scoop stretchers to lift the person onto a stretcher?

1:00:54

How about working on ice at a hockey rink?

1:00:59

That's a excellent question. And, yes, when I worked at West Point, we did have ice hockey, and, yes, There is ice hockey in Florida too. So a couple things about the lift slide in using a scoop stretcher. 1, if your hockey players are fairly large, the scoop stretchers most scoop stretchers that are available aren't going to work with the hockey player because when you try to scoop them, they're bigger than or wider with their all their equipment on. Then the actual scoop stretcher won't be stabilized.

1:01:34

However, if you are able to use the scoop stretcher on the on Actually, on the ice, that's a good option. You have to keep in mind though that how tall the athlete is also because the scoop stretcher can be expanded for taller, but there's a limit in in the length that it can be expanded. And if the hockey players Really heavy skates are hanging off the end. That's gonna also impact the amount of motion on the scoop stretcher. You can very safely and carefully use straps and use the 7 strap technique to stabilize someone onto the the scoop stretcher before you move them off off the ice.

1:02:19

Okay. Great. Do you have time for one more question or we need to jump off, Doctor Hardisky? One quick question. If you

1:02:24

can ask me one more, if you'd like. Okay.

1:02:25

One more quick. Okay. Good. Okay. This from in in your opinion, has there been an increase in emergency department staff removing athletic equipment with spinal injury in the ED when injured athlete arrives with equipment at all?

1:02:40

Okay. So, actually, unfortunately, the experience is still in most cases If the athlete arrives in the ED, in some cases, if there's been correspondence beforehand, The ED physician will ask particularly if there's an athletic trainer that came in with the athlete to assist and lead the group in getting the equipment off. Unfortunately though, what you're then doing is, like, for example, if it were me going to the ED with my athlete, I'm now trying to get untrained nurses or MAs or other types of medical staff to help remove equipment, and they've never practiced it or trained on but trained in doing it versus if I were in the field and it's not one of those life threatening, you know, scoop and go type things, if I'm in the field and I've got my athletic training staff and our physicians and so we've got a full medical team trained in the technique that we use and we've practiced at once, it might be better to take the equipment off in the field versus in the ED. Unfortunately, sometimes though as an athletic trainer, you get to the ED, they won't even recognize you as being able to provide care for the athlete anymore now that they're in, quote, their house, their you're in their ED.

1:04:03

So now they will try to remove the equipment by themselves. And they don't always have the technique down very well. One thing I will tell you, if you have the option between a level 1 trauma hospital versus maybe a hospital that's just a tiny bit closer, it is better to actually pass that tiny bit that the little hospital that's a little bit closer, pass it and go to the level 1 trauma hospital, because your your athlete will be handled with better care. Unfortunately, what happens sometimes you go to the closest hospital they see the patient, they don't have the ability to care for it. So now they have to package them back up and ship them over to the level 1 trauma hospital.

1:04:47

Well, fantastic. Doctor Hardiskey, I think just this is a fantastic topic area that you had and more critical topic area, not just on knowledge of the techniques we're doing, but also emphasizing skill and confidence, which will that comp confidence, which will and also further your confidence level as well. It's been a pleasure having you on the presentation and the symposium today. And for the audience, make sure you if you would, fill out the evaluation form. We're gonna be signing off now we'll be getting other reminder emails on the next session coming up shortly.

1:05:26

Again, thank you. This is Ray Castle, Doctor Hardesky. Thank you again so much.

1:05:30

Thank you.

1:05:31

Have a great day, everyone.