Backboarding / C-Collar When Patient Refuses

[OnceAnEMT]

The studies I've found suggest the body's own inflammatory response to a spinal cord injury will be far more effective than a backboard and collar at stabilizing and preventing further injury.

That is actually a really good point, I've never heard of that approach. I'll look into it. And you are right, my question does kind of contradict itself.

@Flying , I completely agree, a board is great to have as an additional tool for extrication.

One thing I haven't heard is the types of lifts desired for the non-boarded patient. I assume y'all go 4 or 6 man lift and put the stretcher under?

 

[chaz90]

That is actually a really good point, I've never heard of that approach. I'll look into it. And you are right, my question does kind of contradict itself.

@Flying , I completely agree, a board is great to have as an additional tool for extrication.

One thing I haven't heard is the types of lifts desired for the non-boarded patient. I assume y'all go 4 or 6 man lift and put the stretcher under?

"Sir, you can walk? Why don't you take a seat right here on my stretcher. Head goes here, legs go up here."

Otherwise, we use a lot of stair chairs and do a lot of stand/pivot with assistance, or reeves underneath and carry. If we can get the stretcher right up close we'll do a 4 man lift onto the stretcher.

 

[Flying]

Lots of sliding, rolling, manipulating the reeves and good use of sheets.

Those air mattresses look cool, would like to have a go at those some time.

 

[RedAirplane]

I'm a bit confused

If there is an apparent spinal injury, wouldn't immobilization be safer than allowing the patient to move?

 

[RedAirplane]

I'm not as much concerned with once they're on the gurney, but getting them to there.

 

[Flying]

"Immobilization" is a farce. Think about what it really means: practically zero degrees of movement of the neck in three axes. How will we ever practically achieve that?

We also cannot feel the pain that the person is feeling. So letting the person move themselves onto the stretcher at their own pace while guarding their injury is a sound policy.

 

[Brandon O]

Not quite on topic here but not worth making a new topic. Given all of the evidence out there that opposes routine SMR, what about when spinal cord damage is already obvious? Pt head locked to one side, Pt apprehensive to move head, Pt has no motor or sensation of the lower extremities, Pt has clearly suffered spinal cord damage. Do you backboard? I haven't found much that talks about when the injury is truly present.

Most sources would say yes, but there's really no more data about this than in the larger cohort of undifferentiated patients.

 

[Underoath87]

An apparent spinal injury? Like someone who is experiencing paralysis? Obviously they're getting the board. We're mostly discussing patients with isolated back pain and other mundane complaints.

I'm a bit confused

If there is an apparent spinal injury, wouldn't immobilization be safer than allowing the patient to move?

 

[LACoGurneyjockey]

An apparent spinal injury? Like someone who is experiencing paralysis? Obviously they're getting the board. We're mostly discussing patients with isolated back pain and other mundane complaints.

Why? And "because protocol" isn't an answer that anyone can't figure out on their own.
Backboards aren't shown to better immobilize the spine than a gurney, break-away flat, or scoop? So what if they're paralyzed. Use a flat, use a sheet, if you're really jonesing for a backboard use that. But just to move them to the gurney. Paralyzed or not, obvious deformity or not, backboards don't work. They're just fancy extrication devices.
So again, why would you opt for a board for the paralyzed patient, but not the "mundane" complaints of neck/back pain?

 

[RedAirplane]

So you're suggesting removing the backboard after you strap them to it and transfer?

 

[Flying]

Sure, we don't want to increase their discomfort.

 

[LACoGurneyjockey]

So you're suggesting removing the backboard after you strap them to it and transfer?

Protocols aside, yes. Transporting them on a backboard will cause more movement of their spine and more discomfort to the patient. I'd much rather you never put them on a board to begin with. Break-away flats are just as easy to move someone with, far more comfortable, and can be removed without moving the patient.

 

[Bullets]

Honestly, if you understand that we opperate under the concept of informed consent, and you are doing you job informing the patient as to the risks and benefits of the treatments you wish to provide, then every patient should be refusing your backboard after you get done with them.


"Sir/Ma'am, due to your complaint, id like to place a collar around your neck and strap your curved spine to this straight board. Understand that there is no evidence this will actually help you and may actually lead to increased pain, discomfort, reduced blood flow, pressure sores, increased skull pressure, nausea and vomiting. However due to a poorly written study authored 40 years ago, this is still our official protocol. Do you wish to have this potentially debilitating procedure applied?"

 

[Brandon O]

The trouble is that if 90% of your patients start mysteriously refusing care, you are going to get some close scrutiny in most systems, the same as if 90% of your calls were mysteriously ending up as "no patient found." And most supervisors -- and probably medical directors -- will be deeply unimpressed to hear that one of their EMTs has been taking it upon themselves to "inform" patients as to the risks and benefits of spinal immobilization.

In other words, they're going to assume you don't have the knowledge to do so correctly, and frankly that you're probably doing so in a coercive fashion. And there's typically no defense to these kind of accusations except being right (morally) and unemployed (actually).

Depending on the sophistication and tolerance of your employer, your mileage may vary. But probably not by much. Even in a progressive system, your medical director is going to want to be the one to make decisions about risk and the evidentiary basis behind care, not having every random peon on a truck doing their own thing.

Sorry guys. Real life sucks.

 

[RedAirplane]

So you're suggesting removing the backboard after you strap them to it and transfer?

Ah. That's the NEVER EVER EVER thing we were told.

 

[LACoGurneyjockey]

And you should follow your local protocols, because evidence aside that's what EMS is mandated by. If you work in a system that backboards, then backboard. Feel bad doing it, but do it anyway

 

[Handsome Robb]

If someone has neurological deficits after a traumatic injury I'm going to use a scoop stretcher to scoop them off the ground and move them to the gurney. We can use our scoops (combi-carrier II) for SMR. Unfortunately per my protocol I'd have to leave them on it for transport however in the near future it'll be place a collar, scoop them, move them then "unscoop" them prior to transport.

As far as documentation. Hopefully you've already established their mentation and competency early on in your narrative but here's a sample of what my narrative in its entirety, minus the flow chart, H/A/M and vitals.

"Upon arrival we find the PT seated in the driver's seat of a sedan-type vehicle with minor damage to the rear bumper which was involved in a two vehicle collision. PT was the restrained driver, negative airbag deployment, intrusion into passenger compartment or damage to any windows near the PT. They state they were sitting at a stop light when they were rear-ended by another sedan-type vehicle which was travelling "1637281738737392 MPH". They are A&Ox4, GCS 15, with no evidence of intoxicants and complain of 8/10 "sharp" midline cervical pain which is reduced by maintaining POC and is exacerbated by palpation, manipulation and ROM movements. They deny any LOC, headache, striking their head, N/V, distal numbness and tingling or any other associated complaints. The PT refuses SMR and after an explanation of SMR, reasons for it and risks associated with refusal they are able to reiterate the risks which were explained to them and still refuse SMR however allow a c-collar to be placed. They request transport to XYZ hospital. They are assisted in standing and ambulating to the gurney where they are placed in their POC and moved to the ambulance. During transport their pain is reduced to 3/10 with positioning and ice packs. No other changes in assessment or complaint. Upon arrival they are assisted in standing and ambulating from the gurney to the ER bed, assisted to their POC and care is transferred to the ER RN."

We have a SMR refusal signature in our ePCR and technically are supposed to have them sign it before we move them.

 

[Handsome Robb]

One thing I'm interested to see what happens is when someone has a SCI and sues an EMS Agency who utilizes long spine boards and the professional witness comes from an agency who's kept up with evidence and no longer uses them?

What happens then? Yea, you followed your protocols so you're probably fine but what happens to the agency and the Medical Director?

Who knows, maybe a case like that is what it takes to finally stop the use of long spine boards for anything more than an extrication/movement tool.

 

[DesertMedic66]

I hope we don't fully remove the boards from our ambulances. Had a nice self inflicted GSW to the head the other day where the board became really handy.

 

[DrParasite]

One thing I'm interested to see what happens is when someone has a SCI and sues an EMS Agency who utilizes long spine boards and the professional witness comes from an agency who's kept up with evidence and no longer uses them?

What happens then? Yea, you followed your protocols so you're probably fine but what happens to the agency and the Medical Director?

Who knows, maybe a case like that is what it takes to finally stop the use of long spine boards for anything more than an extrication/movement tool.

honest answer? hopefully they pay through the nose, with punitive damages for ignoring all the evidence that says they are bad, and they willfully ignored the research when they said to continue to use these archaic devices.

EMS has relied on voodoo for a long long time, and that voodoo is passed on from EMS educator to a new generation of providers every year. "do this because we think atropine will help restart their heart once it stops......" finally the ACLS algorithm got rid of that... then again, the last thing I heard was ACLS doesn't improve people walking out of the hospital, so maybe the AHA has a financial investment in us continuing to practice voodoo..... but I digress.

It will take a medical director with a set of balls to say "no, we aren't doing this voodoo any more, and if you want to sue us for not doing the voodoo, well bring it on, because the research is behind us, and we are doing what is right for the patient." And you would need to call house keeping, because the heads of the risk management department and legal team just exploded, but if that's what it takes to make progress....