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Care of Soldiers on the Battlefield with Possible Spinal Cord Injuries

Posted on: 11/30/1999
Soldiers in Iraq are not just coming home with missing fingers, toes, or limbs. Many active-duty service members involved in Operation Iraqi Freedom end up paralyzed for life because of spinal cord injuries. Emergency care given on the battlefield through transport back to the United States is the topic of this article.

Because high-energy blast trauma injures more than just the spinal cord, these patients can't be treated the same way civilian spinal cord injuries are handled. Military emergency personnel learn how to manage the soldier who has what is referred to as polytrauma -- a spinal cord injury plus traumatic brain, chest, back, bone, organ, and/or other injuries.

Getting the injured soldier on the first aeromedical transport isn't the only goal. Assessment and protection to survive the flight home with no further harm is the central focus of battlefield emergency medical personnel. In these wartime situations, the phrase Do no harm becomes Do no further harm.

How do they accomplish this? When a soldier is down on the battlefield, the nearest service member or combat medic attempts to get him or her as far from the front line action as possible. If under enemy attack or fire, it may not be possible to protect the spinal cord from further injury. The hard cold fact is that the risk of death outweighs the risk of spinal cord injury. And keep in mind, not only are these folks often still under attack, there is often more than one comrade down and in need of care.

Emergency personnel are advised what to do as well as what not to do. Sandbags to hold the head in the middle are not a good idea. Experience has shown they can become more of a liability than an advantage -- especially if they slip and push the patient's head to one side. Rolling the patient like a log has been replaced by a different technique called the HAINES maneuver. HAINES stands for "high arm in endangered spine."

Resources are limited on the battlefield. There may not be enough backboards and protective neck guards to go around. Medics learn how to evaluate each injured soldier for risk of spinal cord injury. Red flags suggesting a need for immobilization include altered consciousness (e.g., amnesia), unconscious state, or paralysis (even if only temporary). Type of injury can also raise a warning flag. Soldiers involved in explosion or blast, fall from height, ejection from vehicle, or vehicle rollover must be assessed carefully.

The current protocol for managing potential spinal cord injuries is to immobilize immediately to protect the spinal cord. But the authors point out that there isn't enough evidence to really support this approach. In fact, there's even some proof that patients have worse outcomes when they are placed in restrictive splints, neck braces, or strapped to a rigid backboard.

Not only that, but there are cases where spinal immobilization actually increases the risk of other problems like pain, decreased ability to breathe, failure to recognize other injuries, edema (swelling), and skin ulceration from pressure.

There are some changes in the way seriously injured soldiers are treated in today's war time. Surgical teams are posted much closer to the front lines than ever before. That means patients get help much faster -- sometimes going from battlefield to field hospital in under an hour. Once they are stabilized, they can be transported to Germany within 12 hours and stateside by day 5. That sure beats the 15 hour delay soldiers experienced just getting off the battlefield in World War II.

Once the injured solder has been removed to an area where helicopter transport can pick him or her up, then if needed, the patient is immobilized and secured in an effort to avoid any further damage or injury. Placing a firm collar around the neck is first, and then strapping the patient to a hard backboard is next. Any body part that can get bumped or dislodged when the helicopter takes off is taped down.

One final hurdle remains once the soldier is on board a helicopter. Vibration, decreased oxygen, g-forces, and low air humidity can add stress during air transport to the already impaired individual. Transport personnel are asked to do everything possible within their means to make patients comfortable and minimize adverse effects of air travel.

In conclusion, not all soldiers injured on the battlefield need to be immobilized to prevent further spinal injury. Evidence is lacking that these measures are needed and they can actually cause additional injuries. Anyone involved in the emergency care and transport of our wounded soldiers will find this article helpful in guiding assessment and management decisions. "Do no harm" and beyond that "Do no further harm" is the order of the day.

References:
Daniel G. Kang, MD, and Ronald A. Lehman, Jr., MD. Spine Immobilization: Prehospitalization to Final Destination. In Journal of Surgical Orthopaedic Advances. Spring 2011. Vol. 20. No. 1. Pp. 2-7.

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