NREMT Releases Spinal Immobilization Guidance

2018 UPDATE: See the latest recommendations on spinal motion restriction, complete with teaching points and a flow chart for better understanding of when and how to use SMR. Go to Spinal Motion Restriction Flow Chart

Whenever there are changes in practice, students and educators alike wonder (or more like agonize about) how and when the changes will be implemented on the NREMT exam.

Fortunately, the NREMT is pretty straightforward with information in this regard. They have posted dates for American Heart Association changes and changes to bleeding control when tourniquets became mainstream (again).

You can now find the resource document for spinal motion restriction on the NREMT web site.

The document provides 7 indications for spinal motion restriction based on clinical research and physician group’s position papers. Yet there will still be questions by some students and educators—especially about the statement that follows:

In these individuals, a cervical collar should be applied. Long board use should be considered weighing the possible complications against the patient’s clinical situation.

Why? It doesn’t pull the trigger and say definitively whether a spine board should be used or not. Some in EMS have trouble dealing with embracing clinical decision making vs teaching facts for an exam.

Quite frankly, the NREMT’s statement was right on the money. The NREMT isn’t in the business of regulating practice. They test application of knowledge at an entry level based on current practice and science.

So how would an educator teach spinal motion restriction (SMR) so a student would be able to practice with varied protocols and also pass the test?  A majority of patients who are ambulatory but require SMR are going get a collar and are instructed to carefully sit down on the stretcher. Patients on whom we do a rapid extrication will be gently slid off the backboard onto the stretcher in a majority of cases.

What about the patients who the NREMT says might stay on the backboard? They are likely the major trauma patients in whom you use the backboard as a giant splint or those who complain of too much pain when you try to transfer them from the backboard to the stretcher.

When teaching spinal motion restriction:

• Don’t express your anxieties to your students. Confidently teach SMR concepts and let students know that SMR requires judgment and decision making much like oxygenation and dozens of other EMT skills.
• Provide practice decision-making in SMR. Make sure your students know the NEXUS criteria and how to use it to make decisions. In practice—not just lecture. Have your students create three patients as part of a dynamic learning exercise: one who was in a crash but would receive no SMR, one who would get a collar and be placed on the stretcher and another who might stay on the board during transport. Have then justify each patient and decision. Compare the patients from different students or groups.
• Acknowledge that the spinal skills of immobilization are (for now) still part of the NREMT psychomotor exam even though they are likely to be used with much less frequency.
• Create high quality decision making questions for your cognitive exams so your students will have practice before they get to the NREMT exam.

Do you have ways you teach the new SMR material to your students? Do you have a story about how your protocols don’t match current spinal theory? We’d love to hear from you!