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August, 2005
MOUNTAIN MEDIC
BACKWOODS SPINAL INJURY
By Jon Tierney
When a member of your party is injured in the backcountry, one seeks a balance between the dangers of providing too little care and the risks of providing too much. When dealing with a potentially injured spine the party must make decisions that may have immediate and/or long term ramifications. A working knowledge of the mechanisms, assessment and treatment expectations surrounding spine injuries is paramount to a successful outcome. The following information is based on material taught in Wilderness Medical Associates training programs and my own experiences as a backcountry mountaineering ranger and paramedic.
Spinal Anatomy
The vertebral column consists of 33 vertebrae. These irregularly shaped bones have many wings or processes that extend to the side and to the back providing attachments for muscular structures. Within these protective vertebrae is the spinal cord - the human equivalent of the information superhighway. Injury to the cord usually occurs either by direct cutting or swelling and pressure caused by trauma or illness.
Spinal Assessment
Assessing a traumatic injury begins by assuming that all problems exist until proven otherwise. Start by checking the ABC’s (airway, breathing, circulation [i.e. pulse]) while maintaining hand stabilization of the head. If these are okay then do a thorough physical exam as you collect further history from the patient, and collect vital signs. Pain or tenderness along the spinal column, obvious deformity, or any abnormal sensory or motor responses found during the exam suggest possible spine injury. Often in urbanized care the decision to fully immobilize a non symptomatic person is based purely on the existence of whether there was mechanism for spinal injury (fall, impact, etc.). In the wilderness setting, the complexity and consequences of full spinal immobilization dictates that a more detailed spinal assessment be made. Indeed, treating all victims as if they have a spine injury may significantly delay care for other injuries and predispose the patient and rescuers to unnecessary environmental and technical risks.
The decision to not immobilize must be carefully considered and must be made only by people who have received specialized wilderness medical training. A caring, calm and honest discussion with the patient about the situation is crucial.
Spinal Treatment
If the possibility for a spine injury exists then appropriate precautions must be taken to protect the spine both before and during evacuation since as little as a 1/2” of movement can further injure a compromised cord. But immobilization does not mean leaving them how they were found. While working as a climbing ranger in the Rockies I came across a woman who had been left twisted on the boulders, in the pouring rain and snow, where she had fallen. Bystanders, though concerned for her welfare, were afraid to move her and she nearly died from cold related injury. Also, to get from the backcountry to the hospital, the patient will need to be aligned and moved. The only valid reasons for not aligning a person are 1. You don’t know how, 2. You encounter resistance when you try or 3. There is a significant increase in pain. Commonly used moving and immobilization methods average 2 - 3 inches of vertebral movement, so it is clear that better methods must be utilized. First the patient should be gently straightened out. This puts the body and spine in normal alignment and relieves undue stress on the spinal cord. An aligned patient is usually more comfortable as well. Let’s say the head is to the side and the hips / legs are out of alignment with the spine. Grasp the patient’s head and gently pull it away from the top of the shoulders, bringing it back into alignment with the shoulders while someone else stabilizes the shoulders and hips. Once the head is aligned have someone continue holding the head in position. Now straighten the legs and hips by pulling the legs toward the feet and bringing the legs in line with the direction of the torso while others hold the hips, shoulders and head.
I f you are alone and you need to leave the patient alone or are faced with difficult airway maintenance you will want to position the person on their side. I remember struggling to reach a fallen mountaineer who had a good chance of survival only to find that he had been left in a sitting position by his friend and had drowned in his own blood. The usual log roll to the side position can be modified to achieve both airway maintenance and minimize spinal impact. If you are kneeling at the patient’s side, this technique starts by placing the arm farthest from you above their head and crossing the leg closest to you over the other leg. Grasp their chin with your hand that is closest to their feet and drop your elbow onto their chest. Take hold of the back of their head, just above the neck with your other hand with the goal being to work this arm under the shoulder as you start to roll. Pin their chest and back with your forearms as you roll them away from you creating sort of a spine sandwich between your arms. The head is placed on the outstretched arm and the patient cribbed in position. If you are in a group, this log roll can be simplified by placing people along the body and at the head and turning the person as a unit.
At some point immobilization to a long board, litter or improvised spine splint will be necessary for transport. If you are paddling commercial rivers, long boards or litters are often cached along the sides for emergency use. A cervical collar alone does not constitute neck immobilization. In most cases, it will be better to seek help that can return with appropriate tools unless you are very confident of your ability secure the patient or to build an improvised model. Keep in mind that a spine injured patient is at greater risk of hypothermia due to an inability to use muscles to produce heat and that heat loss may be greater due to vasodilatation. Warm water bottles, insulation and something warm to drink will be welcomed.
When I shattered my own lower spine in the Chugach Range of Alaska I was packaged in a ski sled / splint and lowered for several hours. I was given my friends’ down jackets and extra clothing, put in a bivouac sac with warm bottles and given lots of energy gel and food. Yet, I began shivering uncontrollably in a short time. This, along with the unbearable pain of being immobilized, led me to decide to walk (creep would be a better word) short distances. A real choice but clearly not ideal. Despite all this effort to stay warm, my temperature was still 93 when I got to the ER many hours later.
A rigid litter is the tool of choice for most backcountry work as it serves as both a splint and carrying device. Litters can be padded with foam pads, sleeping bags or blankets or clothing (if you won’t need it later). When moving a patient into a litter, a multi-person straight lift is used. This requires about six or seven rescuers - one at the head, and one at the shoulder, hips / legs on each side and one to move the litter into position. The patient is lifted up 10 - 12” and the litter slid into place allowing the patient to be lowered into it. You can also use this technique to move patients to shelter if needed by shuffling them in small increments along the ground. Moving patients is justifiable if there are significant environmental factors such as rain or cold or dangers in the present location. As a general principle try to align the body anatomically (as if one were laying flat) and move in directions toward the feet or head rather than pushing them sideways. A cervical collar can be applied if it is not already in place. A SAM splint wrapped around the neck then taped to itself and crimped under the ears makes a good improvised collar as do some pack waistbands and PFDs. When securing the patient for evacuation, consider all dimensions and directions of movement. Straps should be snug to the body and applied in a circumferential manner. The space between the strap and the patient must be filled in by using long “tootsie rolls” made from rolling up foam pads or clothing. Empty spaces can be minimized by finding the lowest attachment points on the litter. Using individual straps rather than one long one allows you to micro manage future patient needs and insures that if one part of the strapping fails the whole system doesn’t.
Begin by strapping across the shoulder and chest in an “X” fashion or fashioning a chest harness that surrounds both shoulders and can be anchored to the side. This limits movement toward the head of the litter and minimizes cervical compression if the litter should stop suddenly while moving head first. Next secure the pelvis against movement toward the foot of the litter by creating horseshoes around each leg and tying them toward the head. A strap over the lower abdomen is also in order as well as one over the mid chest and upper arms. Concern about making it difficult to breath is unfounded in most cases. The patient’s head is then secured preferably using smaller “tootsie rolls” on either side of the head for stability and tape or straps to secure to the litter. The legs and feet should then be secured with any remaining straps that you have. Bringing the feet together and flexing the knees limits lower spine torque and increases patient comfort. When you are finished, recheck your straps one more time, and get ready for the long carry to the road. Check in on the patient often – they will appreciate that.
It is highly recommended that all outdoor enthusiasts enroll in at least a two day Wilderness First Aid course, and ideally a 72 hour Wilderness First Responder course.
About the author: Jon Tierney has been guiding and working emergency care since the early 80s. He is an AMGA certified rock and alpine guide as well as a paramedic who specializes in wilderness care. Jon is the owner of Acadia Mountain Guides Climbing School and he also instructs courses for Wilderness Medical Associates.
References: Haines J: “Positioning an Unconscious Patient with Suspected Neck Injury.” Journal of Emergency Medical Services. 21(2): 85, 1996.
Manix T: How Effective are Body to Board Strapping Techniques?” Journal of Emergency Medical Services. 20(6): 44-50, 1995.
Goth P: Spine Injury - Clinical Criteria for Assessment and Management. Medical Care Development / Maine EMS, Augusta, Maine. 1994.
McGuire RA et al: “Spinal instability and the log-rolling maneuver.” Journal of Trauma. 27(5):525-531, 1987.
Chandramohan K: “The Emergency Care of Spinal Trauma.” Emergency Medicine. 24(15): 203-214, 1992.
Email nick [at] noumbrella [dot] com with your questions, comments and concerns.
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