Spinal Immobilization Procedures by Lifeguard Personnel

by Gerald M. Dworkin
January 9, 1997

The American Red Cross Lifeguard Training curriculum is currently advocating a sub-standard procedure for the immobilization of suspected spinal injured patients in shallow or deep water. This issue is being presented to solicit the opinions of other Lifeguard and EMS personnel, instructors, and administrators.

In order to properly recognize and manage suspected spinal injuries caused from head-first entries into the water, Lifeguard, Water Rescue, Public Safety, and other Rescue personnel must be trained to evaluate the mechanism of injury as well as the signs and symptoms associated with spinal trauma. The rescuer must assume that a spinal injury exists if the forces causing or resulting from the trauma are sufficient to damage the spine.

The Principles of Spinal Motion Restriction should include:
(a) manual motion restriction of the head and neck while assessing the ABC’s;
(b) placement of the head and neck in neutral position when possible and not contraindicated;
(c) immobilization on a rigid spine board, with the use of an appropriately sized cervical extrication collar, a cervical immobilization device (C.I.D.) to anchor the head to the board, and an appropriate strapping system to secure the body to the board.

These principles have been advocated for the past 20 years within EMT, Paramedic, First Responder, and even First Aid and Lifeguard Training courses. Yet, with the release of the 1995 American Red Cross Lifeguard Training Programs, the Red Cross has abandoned these principles and is now advocating that spinal immobilization in the water be accomplished by as few as two lifeguards using a rigid board with a commercial head immobilizer, a sub-standard strapping system, and without the use of a cervical extrication collar.

It is our belief at Lifesaving Resources that the procedures advocated by the American Red Cross do not meet the Standard of Care dictated by the EMS community, and that these procedures are dangerous which can increase the severity of the injury. It is our belief that the procedures advocated by the Red Cross should be the exception, not the standard. Therefore, we encourage the Red Cross to reconsider their position and to modify their procedures to include the following:

(A) Proper rescue procedures require the use of at least 3 rescue personnel to effectively maintain in-line stabilization of the head and neck, to immobilize the patient to a rigid backboard, and to remove the victim from the water. In situations where appropriately trained personnel are not available, we encourage the Red Cross to advocate that the patient should be supported in the water until appropriate EMS personnel can be obtained unless contraindicated.

(B) Adequate in-line stabilization and support requires a rigid backboard, a cervical immobilization device (i.e. commercial head immobilizer), and an appropriately sized cervical extrication collar. The use of a Cervical Immobilization Device (C.I.D.) should be used in conjunction with an appropriately sized cervical extrication collar. The C.I.D. does not replace the need for the cervical collar, nor does the use of the cervical collar replace the need for the C.I.D.

(C) Appropriate immobilization requires the use of an effective strapping system which would prohibit movement laterally (side-to-side), anteriorly (up from the board), or head-to-foot (towards the head or towards the foot of the board). The strapping system advocated by the Red Cross which uses 3 straps placed laterally across the patient does not accomplish these goals. We recommend two straps placed diagonally across the patient’s chest with one anchor point being directly over each shoulder and the other anchor point being just below each armpit. In addition, at least 3 straps should be placed laterally across the patient at the torso, hips, and lower extremities.

A 1988 study identifies secondary cord injuries as a significant source of major neurological deficit. Improper handling and transportation techniques by pre-hospital personnel may be responsible for up to 10% of these secondary injuries. We believe that the procedures advocated by the Red Cross will be responsible for causing an increase in secondary injuries during the rescue phase by improperly trained lifeguards.

The rationale used by the Red Cross to explain the change in their procedures to exclude the instruction in the use of cervical collars is as follows:

• any facilities do not have different sizes of collars for proper application.
• Lack of facility in-service training results in degradation of skills.
• Many times there is a lack of staff to perform the procedure which results in backboarding being a two-person task.

It is our belief at Lifesaving Resources that this rationale should warrant an increase in the education and training of lifeguard personnel through formal lifeguard training programs and in-service lifeguard training. It should not be an excuse to eliminate the instruction and use of cervical extrication collars.

The advances in pre-hospital equipment, education and training have reduced the number of spinal cord injured patients and the severity of injury. Only through the availability of appropriate spinal immobilization equipment and the effective training of lifeguard and other rescue personnel can we expect to reduce the number and severity of spinal cord injured patients in the water.