Purpose: Standard prehospital practice includes frequent immobilization of blunt trauma patients, some based solely on mechanism. Unnecessary cervical spine (c-spine) immobilization does have disadvantages, including morbidity such as low back pain and splinting, increased scene time and costs, and patient-paramedic conflict. Emergency physicians (EPs) use clinical criteria to clear trauma patients of c-spine injury. If paramedics were able to apply clinical criteria in the out-of-hospital setting, then unnecessary c-spine immobilization could be safely avoided. We designed a prospective, randomized, simulated trial to determine the level of agreement between paramedic and EP assessment of clinical indicators of cervical spine injury. We hypothesized that there would be substantial agreement between paramedic and EP evaluation of standardized patients.
Methods: A convenience sample of ten paramedics and ten attending EPs participated. Ten standardized patients, with various combinations of positive and negative findings, were examined simultaneously by EP-paramedic pairs. Each pair evaluated five randomly assigned patients for six clinical criteria, which were: 1) alteration in consciousness, 2) evidence of intoxication, 3) complaint of neck pain, 4) cervical tenderness, 5) neurologic deficit or complaint, and 6) distracting injury. If any criterion was positive, that was considered an immobilization decision. The kappa statistic was utilized to determine level of agreement between the two groups for each individual criterion and for the immobilization decision. A kappa of 0.40 to 0.75 denotes good reproducibility and >0.75 denotes excellent reproducibility.