Wednesday, 13 April 2016

Curse of the Collar

Ski Patrol EMT's lead the way
For many years fitting a neck collar as part of the complete package of trauma management has been the gold standard. This came about mainly because US dept of transport (DOT) figures from the 1980's showed a very high incidence of post MVA patient extraction spinal injury morbidity. Mainly but not exclusively cervical spine. To reduce this morbidity much emphasis was put on vehicle extrication care, often initially removing the patient from the vehicle (now they remove the vehicle from the patient) with what became known as a "KED" and applying the rigid cervical collar which was a pre hospital single use collar based on the "Philladelphia" collar. If it was a rearward extraction out the back window or from the side, or a whole spine immobilisation the "back board" was used to slide the patient out onto, and then rigidly immobilize them. Laerdal USA sniffing a commercial interest produced the "Stifneck Extrication" collar (keyword extrication as that was what it was initially for), followed later by Ambu and others which were mostly inferior. This whole body immobilisation was based on the collar being a flag to alert responders down the line that the spine in its entirety was at risk, as well as providing support. Laerdal produced a training course and slide and video set to show best practice that could be used by instructors on the US DOT "EMT" courses. I had a set which is somewhere in BASP
The old collars were crap. Pete with me inside the Lost Valley gorge for a woman with a flail chest, tpnx and hypothermia

As the US DOT EMT programme was developing for out of hospital care, the Advanced Trauma Life Support programme was coming in for emergency room providers. Before ATLS most trauma victims were most often not assessed in any semblance of life threat priority. The first ATLS courses brought ER junior and senior staff onto the same song sheet, and the same basic priorities of AcBCD. Airway with C spine control and part of that was fitting the collar as soon as possible, often while the patient was on a spine board (if not already) and with sandbags and with tape over the forehead. The scoop stretcher could also be used to get the patient onto the board. The first UK ATLS course was at the Royal London in 1990 and the second in Glasgow in 1991 which I was invited to be a candidate on as one of the UK's only Paramedics.
Sticking chest drains into pigs flanks in the Vicky's old Victorian mortuary was thought provoking

The best of their day as faculty including Tom Patey's daughter Rona

At that time there were only about 60 Paramedics in the UK and Ireland and none in the NHS. To become a Paramedic you had to either go to Dublin who ran the US DOT EMT programme, or go through a modular system often taking 3/4 years taking the US DOT approved courses and getting clinical skills signed off by mentors. Lucky for me I was also studying human physiology and later pharmacology which was to prove invaluable or I would have sunk. On that first Scottish ATLS course the first two folk to become Scottish Ambulance Service Paramedics as part of a trial scheme also attended. I later did some shifts on the early first response Land Rover Discoveries, long before a Paramedic on every ambulance as is the norm these days, and also some training in military medical stuff with folk from sneaky beaky land.

My main interest was trauma in the mountains and perhaps the doyen of that at the time was Jack Velloton in Chamonix. It was interesting to take back some of different experience and training and apply it to Scottish MR/Ski Patrol which was and maybe still is a dinosaur in a wee Glen. At the time this was going on, Ski Patrol at Cairngorm already had a vac matt. In 1989 along with many of the founders of BASP I attended several "ski patrol" training weekends which BASP was founded on. I think it’s only Stephen Myers, Tony Cardwell, Gerry and I that are still involved from that initial founder group. Through RGIT Aberdeen and "doctor bob" we all became first aid instructors and went through the RGIT first aid training scheme which went from basic to advanced. Cairngorm had a vac matt first in the UK.

Ski patrol at Glenshee were next to get a vac matt then Nevis Range, Glencoe and Glencoe MRT which was the first MR team. These were either Hartwell matts imported from the USA or red/grey ones which were heavier duty from a euro company. Ferno also started to make vac matts but they were crap.  The point is that ski patrol were early adopters of the ATLS guidelines including collars and way ahead with vac matts. 

It was always immediately apparent that fitting a collar pre hospital in a cold mountain environment was a far cry from a nice warm ambo or well-lit ER. Mountain rescue victims most often also had head injuries and had enough airway compromise already that fitting a venous tourniquet for long periods was observably detrimental to patient care.  As ATLS took hold a trauma nurse version was also on the go. Most of the flak about collars came from the ER nurses who would phone up and ask why a collar wasn't fitted or had been slackened off.  We felt that as long as the vac matt was doing its job then keeping the ICP down was also a priority.  Some staff nurses were a pain in the arse, but a couple came on the EMT course and one joined the faculty and they were much more aware of pre hospital problems and took that back to the advanced Trauma nurse team.
A well fitted collar tolerated well by a seriously injured trauma victim who could speak and who at least you new had an airway. Spinal #  so no fucking about putting her on her side as the airway was patent.
The first ski patrol EMT courses ran from 1992 at Glencoe Outdoor Centre and sometimes two a year with up to 16 on each. We had a great faculty (Tony and I) and HEMS docs, ATLS instructors, Ambo trainers and some folk from the sneaky beakies on course or helping out.

A few years later we ran them at Glenmore Lodge. We always tried to keep to ATLS guidelines we had adapted, we also kept common sense and looking at the patients’ needs including when to release the collar justifiably.  We must have got something right as both Tony and I managed to get the EMT course ratified by the RCs Edinburgh faculty of pre hospital care as an accepted pre hospital care course.  Both Tony and I were founders of the faculty, and accorded full membership which felt like quite an honour. I later did some courses through them such as BASICS and PHECS

One of the first Lodge courses.  Some rope tricks to make folk think about isolating a rope system as well as dealing with a casualty. Rescue and medicine working hand in hand.
So BASP and ski patrol was ahead of many ambulance services in equipment, application and common sense.  It's nice that ILCOR are catching up!

Tables are turned. Venous tourniquet applied (yes my neck was fucked) and out for the count. Waking up strapped to that fucking board was he most painful thing. Getting morphine for pressure sores. Bring on the vac matt's. Waking up strapped to one of these with rotors turning and loosing feeling in your arms is a head fuck. Thankfully just pressure from a very small bleed, but a bullet dodged. The skull bit probably knocked some sense into me. Glad they took really good good care of my neck.  Just because you cant or don't fit a collar does not mean you don't take care of the spine.