Archives of Academic Emergency Medicine. 2021; 9(1): e3 https://doi.org/10.22037/aaem.v9i1.928 OR I G I N A L RE S E A RC H The Clinical Skills of Emergency Medical Service (EMS) Personnel Regarding Spinal Immobilization of Trauma Victims; a Cross Sectional Study Nasir Jadgal1∗, Malahat Nikravan Mofrad1, Maryam Jamsahar1, Malihe Nasiri2 1. Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Biostatics, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: October 2020; Accepted: October 2020; Published online: 10 November 2020 Abstract: Introduction: Spinal immobilization is the most important measure the Emergency Medical Service (EMS) has to take when facing the victims of traumatic events, especially those with confirmed or suspected traumatic spinal cord injury (TSCI). The aim of this study was to investigate the clinical skills of EMS personnel regarding the spinal immobilization of trauma victims. Methods: This cross-sectional study was conducted to examine the clinical skills of EMS personnel, regarding spinal immobilization of trauma victims during a 1-year period in 2019. EMS personnel were selected via convenience sampling method. Data collection tools were a demo- graphic questionnaire and a researcher-made checklist to assess clinical skills. The face and content validity of the tool was reviewed and approved by 10 experts. Also, the overall reliability coefficient for the skills was 0.98. Data were collected by the researcher through observing the skills performed, and filling out the clinical skills checklist accordingly. Results: The mean overall score of the clinical skills of the 120 participants regarding spinal immobilization of trauma victims in supine, prone, and sitting positions were 0.60 ± 1.44, 0.58 ± 1.42 and 0.65 ± 1.62, respectively. Most of the studied personnel had moderate clinical skills in spinal immobiliza- tion, and they had poor clinical skills required to correctly pull the trauma victims in the longitudinal axis of the body to put them on a long backboard and immobilize their torso, legs, and head using the Kendrick Extrication Device (KED). Conclusion: The studied EMS personnel had moderate clinical skills regarding the spinal immo- bilization of trauma victims. It is recommended that the EMS training programs focus more on the practical aspects of clinical skills in addition to theoretical aspects. Keywords: Advanced trauma life support care; Spinal cord injuries; Emergency medical services; Clinical competence Cite this article as: Jadgal N, Nikravan Mofrad M, Jamsahar M, Nasiri M. The Clinical Skills of Emergency Medical Service (EMS) Personnel Regarding Spinal Immobilization of Trauma Victims; a Cross Sectional Study. Arch Acad Emerg Med. 2021; 9(1): e3. 1. Introduction Traumatic spinal cord injury (TSCI) is a devastating injury re- sulting from traumatic events, which can affect many func- tions of the body and can be life-threatening (1). The an- nual TSCI incidence rate varies from 12.7 to 52.2 cases per million populations (2). However, this rate is about 40 to 50 people per million in Iran (3). TSCI causes lifelong disabil- ity in addition to devastating physical injury, TSCI can lead to long-term disability and place a heavy social and finan- ∗Corresponding Author: Nasir Jadgal; School of Nursing and Midwifery, Hashemi Rafsanjani Hwy, Tehran, Iran. Emails: Nasirjadgal@sbmu.ac.ir, nasirems7@gmail.com, Tel: 982188655366, Fax: 982188655366, ORCID: http://0000-0002-4785-4746. cial burden on patients, their families and the community (2). Despite the introduction of injury prevention programs and advances in vehicle safety systems, such as airbags and seatbelts, TSCI still has a profound effect on the healthcare system (4). The Emergency Medical Service (EMS) is respon- sible for providing care and treatment services to trauma vic- tims at the scene of the accident and during transportation to the hospital (5). Spinal immobilization is the most impor- tant measure that the EMS should take when facing victims of traumatic events, especially for those with confirmed or suspected TSCI (6). In the United States, more than 5 million patients per year are immobilized, mostly with a cervical col- lar and a backboard (7). EMS personnel use spinal immobi- lization on the field to maintain the normal anatomical align- ment and restrict the motion of the spinal cord (8). The in- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem N. Jadgal et al. 2 tent behind spinal immobilization is to reduce spinal move- ment and prevent further secondary injury, prevent nervous system deterioration, and facilitate the movement and trans- fer of a patient (9). It is estimated that 3 to 25% of TSCIs are secondary, which occur after a primary injury, due to inap- propriate management at the scene of the accident or dur- ing transport to the hospital (10). Therefore, it is very impor- tant to start TSCI-related measures and care from the scene of the accident (4). Providing high-quality, timely, and stan- dard services for victims and emergency patients in the early moments of traumatic events can reduce mortality and in- crease patients’ trust in and satisfaction with EMS (11). As- sessing the clinical skills of EMS personnel may provide an appropriate reflection of the training programs. A number of studies have been conducted to examine the clinical skills of EMS personnel regarding spinal immobilization of the in- jured persons lying in the supine position (12-14); however, no studies have been conducted on the victims lying in prone position. Therefore, the aim of this study was to evaluate the clinical skills of EMS personnel regarding spinal immobiliza- tion of trauma victims lying in supine position, lying in prone position, and placed in the sitting position. 2. Methods 2.1. Study design and setting This cross-sectional study was conducted to examine the clinical skills of EMS personnel of Iranshahr University of Medical Sciences, Iranshahr, Iran, regarding spinal immo- bilization of trauma victims during a 1-year period in 2019. Sampling was performed in 43 emergency stations located in five cities of Iranshahr, Chabahar, Konarak, Rask, and Qasr Ghand. The clinical skills of EMS personnel regarding spinal immobilization of victims of traumatic events were assessed using a researcher-made questionnaire checklist. The study protocol was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences with the ID: IR.SBMU.PHARMACY.REC.1398.262. 2.2. The study participants The study population consisted of all EMS personnel work- ing in Iranshahr University of Medical Sciences, Iranshahr, Iran, 120 of whom were selected using convenience sam- pling based on the sample size formula. Having a high school diploma, nursing assistant certificate, associate degree or bachelor’s degree in nursing, medical emergencies, or op- erating room and experience of working in the pre-hospital emergency unit were among the inclusion criteria. Personnel working in the administrative unit of pre-hospital emergency or the dispatch unit were excluded from the study. Table 1: The baseline characteristics of the participants Variable Number (%) Age (year) 20-30 65 (54.2) 31-40 48 (40.0) ≥ 40 7 (5.8) Field of study Pre-hospital Emergency 69 (58.5) Operating room 5 (5.0) Others* 45 (37.5) Level of education High school diploma 45 (37.5) Associate’s degree 67 (55.8) Bachelor’s degree 8 (6.7) Place for EMS work Urban station 37(30.8) On roads station 83(69.2) Work experience(year) 0-10 101 (84.2) 11-20 18 (15.0) ≥ 20 1 (0.8) Type of employment Under –a-contract 41 (34.2) Temporary 18 (15) Casual 5 (4.2) Contractual 28 (23.3) Temporary to Official 22 (18.3) Official 6 (5.0) Participation in training program Yes 47 (39.2) No 73 (60.8) *A high school diploma in natural sciences or a nursing as- sistant certificate. Data are presented as frequency (%). 2.3. Data collection The data were collected using a demographic questionnaire and a clinical skills checklist consisting of the three checklists used for the assessment of the clinical skills of EMS personnel regarding spinal immobilization of trauma victims in three positions: supine, prone and sitting. For the face and con- tent validity, the tool was evaluated by 10 experts. The relia- bility of the tool for overall clinical skills was 0.98. The partic- ipants’ demographic characteristics such as age, level of ed- ucation, field of study, type of employment, work experience, place for EMS work, and history of participation in a training program for the spinal immobilization over the last year were assessed. The data were collected by a senior nursing expert. In order to collect data, the researcher referred to the EMS of Iranshahr University of Medical Sciences, Iranshahr, Iran, after coordination with the relevant authorities. He guar- anteed the participants confidentiality after explaining the study purpose to them. The clinical skills of EMS personnel were assessed by the researcher in the EMS stations. Written informed consent was obtained from the participants. For This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e3 Table 2: Mean scores of clinical skills for studied EMS personnel regarding spinal immobilization of trauma victims lying in supine position Clinical skills Score Mean± SD 2 1 0 Separation of body secretions 62.5 25.0 12.5 1.50 ± 0.71 Keeping head in a neutral position with hands 73.3 18.3 8.3 1.65 ± 0.63 Picking the correct cervical collar 55.8 31.7 12.5 1.43 ± 0.70 Applying cervical collar 83.3 13.3 3.3 1.80 ± 0.47 Placement of the long backboard next to the victim 19.2 80.0 0.8 1.18 ± 0.40 Transfer of the injured person on the long backboard 45 53.3 1.7 1.43 ± 0.53 Pulling the injured person in the longitudinal axis of the body to put him/her on a long backboard 14.2 77.5 8.3 1.05 ± 0.47 The use of head immobilizers 60.8 20.8 18.3 1.42 ± 0.78 Immobilizing head on a long backboard using straps 44.2 35.8 20.0 1.24 ± 0.76 Immobilizing arms and legs on a long backboard using straps 81.7 10.0 8.3 1.73 ± 0.60 SD: standard deviation. The data are expressed as percentage for each score. * Score 2 if correct, 1 if incorrect, and 0 for not performing the clinical skill. Table 3: Mean scores of clinical skills for studied EMS personnel regarding spinal immobilization of trauma victims lying in prone position Clinical skills Score Mean± SD 2 1 0 Separation of body secretions 63.3 24.2 12.5 1.50 ± 0.71 Keeping head in a neutral position by hands 63.3 30.8 5.8 1.57 ± 0.60 Picking the correct cervical collar 20.0 80.0 0.0 1.20 ± 0.40 Applying cervical collar 23.3 76.7 0.0 1.23 ± 0.42 Placement of the long backboard next to victim 15.0 77.5 7.5 1.07 ± 0.47 Transfer of the injured person on the long backboard 62.5 26.7 10.8 1.51 ± 0.68 Pulling the injured person in the longitudinal axis of the body to put him/her on a long backboard 74.2 24.2 1.7 1.72 ± 0.48 The use of head immobilizers 61.7 22.5 18.8 1.45 ± 0.75 Immobilizing head on a long backboard using straps 43.3 40 16.7 1.26 ± 0.73 Immobilizing arms and legs on a long backboard using straps 80.8 10.8 8.3 1.72 ± 0.60 SD: standard deviation. The data are expressed as percentage for each score. *Score 2 if correct, 1 if incorrect, and 0 for not performing the clinical skill. Table 4: Mean scores of clinical skills for studied EMS personnel regarding spinal immobilization of trauma victims lying in prone position Clinical skills Score Mean± SD 2 1 0 Separation of body secretions 63.3 25.0 11.7 1.51 ± 0.69 Keeping head in a neutral position by hands 74.2 14.2 11.7 1.62 ± 0.68 Picking the correct cervical collar 63.3 27.5 9.2 1.54 ± 0.65 Applying cervical collar 80 19.2 0.8 1.79 ± 0.42 Placement of KED in the back of the injured person 53.3 45.8 0.8 1.52 ± 0.51 Tightening the straps of torso, legs and head using the KED 20.8 75.0 4.2 1.16 ± 0.47 Transfer of the injured person on the long backboard 40.0 57.5 2.5 1.37 ± 0.53 Pulling the injured person in the longitudinal axis of the body to put him/her on a long backboard 40.8 56.7 2.5 1.38 ± 0.53 The use of head immobilizers 61.7 21.7 16.7 1.45 ± 0.76 Immobilizing head on a long backboard using straps 40.8 40.8 18.3 1.22 ± 0.73 Immobilizing arms and legs on a long backboard using straps 81.7 9.2 9.2 1.72 ± 0.65 SD: standard deviation. The data are expressed as percentage for each score. *Score 2 if correct, 1 if incorrect, and 0 for not performing the clinical skill. KED: Kendrick Extrication Device. this purpose, first, the demographic questionnaire was given to the participants and then they were asked to use the clin- ical skills for the simulated patient in supine, prone, and sit- ting positions, in order to assess their clinical skills regarding spinal immobilization. The researcher recorded the scores of each skill in the clinical skill checklist. In this study, the sim- ulated patient was 32 years old, weighing 73 kg. The clinical skills of each member of EMS personnel were assessed sepa- rately without the presence of others. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem N. Jadgal et al. 4 Table 5: The relationship between the clinical skills regarding spinal immobilization and the demographic characteristics of the studied participants Variables Mean± SD P Age (year) 20-30 44.56 ± 8.22 31-40 46.70 ± 6.05 0.02 ≥ 40 38.42 ±10.98 Field of study Pre-hospital Emergency technician 46.59 ± 6.03 Operating room 38.00 ± 13.84 0.01 Others* 43.66 ± 8.59 Level of education High school diploma 43.66 ± 8.59 Associate’s degree 45.52 ± 7.38 0.15 Bachelor’s degree 49.12 ± 4.54 Place for EMS work Urban station 47.29 ± 7.86 0.03 On roads station 44.07 ± 7.59 Work experience (year) 0-10 45.63 ± 7.33 0.11 11-20 41.61 ± 9.61 Type of employment Under -a-contract 45.17 ± 7.35 Temporary 45.61 ± 8.08 Casual 32.20 ± 9.12 0.00 Contractual 44.67 ± 8.58 Temporary to Official 47.00 ± 5.03 Official 48.16 ± 4.95 Participation in training program Yes 48.27 ± 53.5 0.00 No 43.00 ± 8.35 *A high school diploma in natural sciences or a nursing assistant certificate. Data are presented as mean ± standard deviation. 2.4. Instruments After the simulated patient was put in the supine, prone, and sitting positions, the participants were asked to use the spinal immobilization based on the clinical skill checklist. The re- searcher recorded the scores of each skill in the correspond- ing checklist. The clinical skill checklist of the spinal immo- bilization in supine position contained 10 items or practical steps. The clinical skill checklist of the spinal immobilization in prone position contained 10 items or practical steps. The clinical skill checklist of the spinal immobilization in sitting position contained 11 items or practical steps. Each item or every step is scored on a 0 to 2 scale (2 if correct, 1 if incorrect, and 0 for not performing the clinical skill). The level of clini- cal skills was also evaluated as follows: 1.7-2 = good; 1.2-1.7 = moderate; lower than 1.2 = Poor. 2.5. Statistical Analysis All statistical analyses were performed using SPSS version 21. Mean ± standard deviation (SD) or frequency (%) was used to report the results. Analysis of variance (ANOVA) was used to examine the relationship between the clinical skills regard- ing spinal immobilization and demographic characteristics of the participants. P-value less than 0.05 was considered sta- tistically significant. 3. Results 3.1. The demographic characteristics of the par- ticipants The mean age of the participants (n=120) was 6.14 ± 30.3 years (100% male). The demographic characteristics of the participants are shown in Table 1. 54.2% of the participants were in the 20–30 years age group. 69 (57.5%) had a degree in Pre-hospital Emergency Care and 67 (55.8%) had an asso- ciate degree. The majority of the participants (69.2%) pro- vided care on the roads station. 101 subjects (84.2%) had a work experience of 0–10 years. 73 participants (60.8%) did not participate in the training program for spinal immobi- lization over the last year. 3.2. The clinical skills of the participants regard- ing spinal immobilization The mean overall score of the clinical skills of the participants regarding spinal immobilization of trauma victims in supine, prone, and sitting positions were 0.60 ± 1.44, 0.58 ± 1.42, and 0.65 ± 1.62, respectively (Tables 2, 3, and 4). A significant dif- ference was observed between the participants’ scores based on their field of study (p = 0.01), place for EMS work (p = 0.03), type of employment (p = 0.00), and history of participation in the training program for spinal immobilization over the last year (p < 0.0001) (Table 5). 3.3. Discussion The results of the present study showed that the participants had moderate clinical skills regarding spinal immobilization. Regarding clinical skills of the participants in spinal immobi- lization of trauma victims lying in supine position, our find- ings showed that the highest score belonged to the use of cervical collar in the victims and the majority of participants applied it correctly, but they had poor clinical skills regard- ing pulling the trauma victims in the longitudinal axis of the body to put them on a long backboard and immobilize their torso, legs and head using the Kendrick Extrication Device (KED) and most of them applied it incorrectly. In 2018, Az- imi et al. showed that the majority of nurses had moderate clinical skills regarding spinal immobilization of the injured persons in traffic accidents, and they also had poor clinical skills regarding the injured person’s correct transfer to the long back board using the log roll technique and fixing arms and legs on the long backboard (12), which were consistent with our results. Correct transfer of the injured person from This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2021; 9(1): e3 the accident scene to the long backboard is a key step in im- plementing spinal immobilization of trauma victims, which requires precision, ability, and coordination of EMS person- nel to immobilize the spine in the longitudinal axis of the body, all parts of the injured body should be slowly trans- ferred to the backboard. Kumar et al. in 2008 examined the level of knowledge, attitude, and practice of three groups of health care providers about prehospital and emergency care. They reported that the level of knowledge and practice of par- ticipants regarding emergency and prehospital care was be- low average, and therefore ongoing training was required in this area (15). Regarding clinical skills of the participants on spinal immobilization of trauma victims lying in prone posi- tion, our findings demonstrated that the majority of partici- pants used cervical collar in the victims correctly. Also, most of them had correctly fixed arms and legs on the long back- board using straps, but they had poor clinical skills regard- ing pulling the trauma victims in the longitudinal axis of the body to put them on a long backboard. The total score in this skill was in the moderate level, which was not satisfac- tory. In 2016, Norouzinia et al., assessed the level of knowl- edge and clinical skills of pre-hospital emergency care stu- dents confronting trauma victims in their study, and the re- sults showed that 89.1% of the participants had good clini- cal skills for confronting trauma victims in pre-hospital set- ting (13). However, the results of the study by Dadashzadeh et al. in 2017 showed that despite the large number of per- sons with head and neck injuries, the cervical collar and long backboard has been merely used for the immobilization of a few traumatic patients, which requires further investigation and trauma management training programs for EMS person- nel (5). Also, the results of Mohseni et al.’s study in 2014 showed that the use of long backboard (12.2%) and cervical collar (15.6%) in the patients was the neurological care least provided by EMS personnel for trauma victims, which was not performed despite the necessity (16). The differences be- tween the results of studies can be attributed to the differ- ences in level of education and training for the EMS person- nel because graduates of various fields of study such as nurs- ing, pre-hospital emergency, operating room, nursing assis- tance, and even people with a high school diploma who were trained in this regard have been employed in the EMS set- ting. Regarding clinical skills of the participants in spinal immo- bilization of trauma victims placed in the sitting position, our results demonstrated that the participants had moder- ate clinical skills in this regard, but most of them had poor clinical skills regarding immobilizing the torso, legs and head using the KED. Given that spinal immobilization can be per- formed by tightening the straps of torso, legs and head us- ing the KED, more attention should be paid to the perfor- mance of this skill and training in this regard. Shakeri et al., in their study in 2012, evaluated clinical skills of medical emergency personnel in Tehran Emergency Center in con- fronting trauma and the results showed that 62.4% of the medical emergency personnel had good grades in trauma skill but had major skill deficiency in practicing two skills, namely seated patient’s spinal immobilization and traction splint, because these skills were less commonly used in the EMS setting (14), which were consistent with our results. Also, the study by Dunn et al. in 2004 examined the ability of basic emergency technicians in using the protocol of selec- tive immobilization of cervical spine in trauma patients and compared it with the performance of the paramedics. They showed that this skill is the same in both groups, and by pro- viding the correct training, the clinical skills of basic emer- gency technicians can be improved (17). The repetition of clinical skills during standard training programs is the most important factor in improving the clinical skill level of EMS personnel (18). In this study, the lack of a clinical skill center and the lack of proper access to them were considered as im- portant obstacles for the participants to achieve good clinical skills. 4. Limitation Fatigue among participants due to working 24-hour shifts and their specific job conditions, as well as the personal problems of the participants during the implementation of the clinical skills might have affected the results, all of which were beyond the control of the researcher. However, by con- ducting this study in appropriate conditions, in the EMS sta- tions, an attempt was made to reduce their impact on the re- sults. Additionally, observing the staff when implementing spinal immobilization skills might have influenced their per- formance. 5. Conclusion The EMS personnel had moderate clinical skills regarding spinal immobilization of trauma victims, and they had poor clinical skills regarding pulling the trauma victims in the lon- gitudinal axis of the body to put them on a long backboard and immobilizing their torso, legs and head using KED for the sitting patient. It is recommended that the EMS training programs focus more on the practical aspects of clinical skills in addition to training theoretical aspects. 6. Declarations: 6.1. Acknowledgements We would like to express our deep gratitude and apprecia- tion to personnel working in EMS in Chabahar and other pre- hospital emergency centers affiliated to Iranshahr University of Medical Sciences, Iranshahr, Iran. We would also like to This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem N. Jadgal et al. 6 thank Student Research Committee and the Deputy for Re- search and Technology of Shahid Beheshti University of Med- ical Sciences that provided financial support for this study. 6.2. Author contribution All authors met the four criteria for authorship based on guidelines of the International Committee of Medical Journal Publishers. 6.3. Funding/Support None. 6.4. Conflict of interest None. References 1. Hasanzadeh Pashang S, Zare H, Alipor A. The Efficacy of Stress Inculation Training (SIT) on Resilience, Anxiety, Depression and Stress Among Spinal Cord Injury (SCI) Patients. Pars Journal of Medical Sciences ( Jahrom Med- ical Journal). 2012;10(3):12-20. 2. Oteir AO, Smith K, Jennings PA, Stoelwinder JU. The pre- hospital management of suspected spinal cord injury: an update. Prehosp Disaster Med. 2014;29(4):399-402. 3. Khazaeli K, Hoseini E, Nasir AH, Amarloui M, Ganji MK. Relationship between level of injury and quality of life in spinal cord injury (SCI) patients. 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