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Quick intro + why this matters

• AJ brings a “hot topic” from a highly downloaded 2025 NAEMSP publication in Prehospital Emergency Care (NAEMSP’s journal).
  
  

• The paper sparked broad discussion (including roundtable-style podcast conversation with state EMS leaders) because it challenges long-held assumptions about spinal immobilization and cervical collars in trauma.
  
  

• Framing: this is the “next logical step” after the major shift away from routine long backboard use (post-2018 position paper).
  
  

The big context: where we’ve been

The old paradigm (1990s–early 2000s)

• “One movement and they’ll be paralyzed” mindset drove full-body immobilization:
  
  

  • backboard + straps + collar + aggressive packaging
    
    

• Panel agrees: it’s easy to see how this could create harm (comfort, breathing restriction, pressure injury, etc.).
  
  

The 2018 inflection point

• NAEMSP guidance helped push EMS away from routine backboard use.
  
  

• Backboards became deprioritized and used more as a tool for extrication than a transport surface.
  
  

• Many systems moved toward vacuum mattresses and other alternatives—though this newer paper raises concerns about potential harms there too.
  
  

What the 2025 paper actually says (and what it doesn’t)

What it is

• A broad review of the available research (not a formal meta-analysis).
  
  

• Core conclusion (as boiled down by the group):
  
  

  • No existing data clearly demonstrates that spinal motion restriction “saves lives” or prevents delayed neurologic injury.
    
    

  • Meanwhile, harms associated with immobilization (including collars) have been identified.
    
    

What it is not

• Not an official NAEMSP directive changing the standard of care.
  
  

• Not a “burn the backboards” or “throw away collars” mandate.
  
  

• Not proof that SMR is useless—rather, that the evidence hasn’t demonstrated benefit, while harm signals exist.
  
  

The tension: benefit vs harm vs “no evidence”

• The team highlights a key nuance:
  
  

  • “No evidence of benefit” ≠ “evidence of no benefit”
    
    

• Similar theme to other EMS controversies this year: people sometimes conflate “not proven” with “harmful” (or with “remove it entirely”).
  
  

The patient groups where this matters most

1) Awake, alert, low-risk patients

• If a patient is:
  
  

  • alert/oriented
    
    

  • no neuro deficits
    
    

  • can control their neck
    
    

  • no midline tenderness
    
    

  • no distracting injury
    → many protocols already allow no collar (aligned with NEXUS/Canadian C-spine concepts).
    
    

Clinical reasoning discussed:

• An alert patient generally won’t keep putting themselves into positions that worsen an unstable injury.
  
  

2) The obtunded / unreliable exam patient (the “big takeaway” zone)

• Strong consensus: if obtunded, neuro deficit present, unreliable exam, or providers have doubt → collar + careful SMR still makes sense.
  
  

• This is the population the team most wants to see better data on before changing practice dramatically.
  
  

3) Airway-first conflicts (collar vs airway management)

• Practical field reality:
  
  

  • Collars can limit access and positioning for airway procedures.
    
    

• The paper’s implications (and modern EMS thinking):
  
  

  • If the collar impairs airway management, airway wins.
    
    

  • Remove/loosen collar as needed, maintain alignment as best as possible, then reapply.
    
    

Related parallel mentioned:

• Similar modern logic in airway opening: if jaw thrust isn’t effective, escalate—don’t let “perfect C-spine precautions” block lifesaving oxygenation/ventilation.
  
  

Identified harms (what the paper + discussion emphasize)

Harm themes

• Pressure injury / skin breakdown risks (especially frail/geriatric patients with little padding over bony prominences)
  
  

• Alignment mismatch: collars may force patients into an anatomic position that’s not their neutral (degenerative disease, prior injury, body habitus)
  
  

• Breathing restriction / comfort limitations:
  
  

  • even vacuum mattresses may restrict chest wall excursion or comfort/mobility
    
    

• Downstream effects:
  
  

  • Collar placement may unintentionally “signal” severity and drive more imaging (CT/radiology creep), even when clearance criteria are met.
    
    

“Are we using the wrong tool?”

• Contrast discussed:
  
  

  • EMS rigid extrication collars (“plastic”) vs Aspen collars (padded, adjustable, better fit).
    
    

• Question raised: are harms partly device-related rather than concept-related?
  
  

Practical operations + equipment talk (very on-brand)

Backboards: still a tool—but not a transport surface

• Clear agreement:
  
  

  • Backboards remain useful for rapid extrication, water rescue flotation, and as a protective “shield” during certain extrications.
    
    

• Practice shift emphasized by Scott:
  
  

  • Even if used for extrication, he’s now more likely to take the extra minute to remove it once on the cot.
    
    

Vacuum mattresses

• Appreciated for handles and comfort compared to boards.
  
  

• Still: remove early in ED when feasible; paper suggests even these may carry harm signals.
  
  

MegaMover vs sheet (and “right tool for the right job”)

• Sheet: fine for lateral transfers, but dangerous for carry extrications (sheet tears → patient falls).
  
  

• MegaMover/Reeves: purpose-built devices for moving/carrying in constrained spaces.
  
  

KED

• KED use is discussed as largely “legacy” and often repurposed for off-label stabilization needs.
  
  

• Not required on Ohio ambulances anymore (per discussion).
  
  

• Some agencies keep one for specific extrication scenarios (tight vehicle access).
  
  

Case discussion: blunt traumatic arrest with high C-spine fractures

• Dr. Hill shares a memorable case:
  
  

  • blunt traumatic arrest → ROSC after airway/oxygenation
    
    

  • imaging showed high cervical fractures (including dens) + cord edema
    
    

  • no massive intracranial bleed; brain death by exam rather than dramatic radiographic catastrophe
    
    

• Takeaway tied to paper theme:
  
  

  • much of the injury occurs at impact; “secondary injury from EMS movement” is harder to prove and may be overstated—while oxygenation and hemodynamics are consistently critical.
    
    

What might change tomorrow vs later

What changes now (individual practice “nudges”)

• Be more intentional about using devices only as needed and removing them early once their job is done.
  
  

• Don’t let collars/SMR interfere with airway, resuscitation, access, and transport priorities.
  
  

• Avoid “default collar” in clearly low-risk, reliable exam patients (consistent with protocols).
  
  

What needs more evidence

• The obtunded population, neuro deficit patients, and high-risk mechanisms where EMS errs on the side of caution.
  
  

System-level next steps

• “Talk to your people” approach:
  
  

  • medical director
    
    

  • trauma program
    
    

  • neurosurgery stakeholders
    Align expectations and reduce confusion/friction when EMS arrives without a collar in a cleared patient.
    
    

Take-home points

• The 2025 NAEMSP paper doesn’t “ban collars”—it highlights a lack of demonstrated benefit and presence of harm signals in the literature.
  
  

• Modern protocols already reflect a selective approach: collar/SMR for unreliable exams, deficits, doubt; avoid routine use in low-risk, reliable patients.
  
  

• Biggest near-term improvement: don’t leave people on devices longer than necessary—especially backboards.
  
  

• Airway and oxygenation remain king—don’t let “perfect immobilization” compromise lifesaving care.

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