A fall that the hospital gave me grief about

[Medic Tim]

I would not have boarded this person. A fall from standing height DOES NOT = a board automatically.

 

[Ackmaui]

No it is not. That is what is taught to EMTs because they are not given enough formal education to make decisions.

They have simple instructions that do not allow deviation due to their limits. That is very different than being medically a good reason.




None of this conerns me. A student who is right in a particular case is greater than any provider who is wrong.

I do not think you are right in this case though. Not because you are a student, but because you have a very limited perspective that was a reinforced behavior for more than a decade.



I respectfully disagree. Elderly people have decreased chest wall expansion and decreased ability to compensate for it even without pathology. Even worse if they do have something like CHF.

Additionally, compression that can result in skin breakdown can occur in less than an hour. Again which can be worsened by underlying pathology.

I don't want to tell a family I gave them a painful nonhealing wound either.

A stress response from being painfully strapped to a board or restricted in an unfamiliar environment can cause a host of deletorious effects. Increasing HR, BP, etc in a patient with various underlying conditions could be a problem.

Furthermore, if you take a patient with an actual spinal pathology from their self splinted position of comfort and manipulte them to a flat position, you may worsen inflammation which may occlude spinal arteries resulting in secondary paralysis.

Moreover, if you cause pain in said injured patient, they will move around so much trying to find a position of comfort, you restriction attempt actually increases motion. (which is not nearly as problematic as the inflammatory response above.)

If the patient is osteoporitic, kyphotic, and has osteomalacia with remodeling, you may actually cause an injury where none existed prior to your "treatment."



Maybe Voldemort got them with a spinal injury curse...

Sorry, but examine the patient. If they are capable of answering and reliable, ask. Rather than play "What if?" be a sound clinical provider.



Examine your patient and make a decision where the benefit outweighs the risks.



They may have been complaining because they worry you might erroneously put their relative on a board because you didn't know it could result in harm?

The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
. By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.

 

[DesertMedic66]

The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..

I fell a month ago and got a bruise around my eye. No one witnessed my fall. I didn't get boarded and a collar....

Since it was an un-witnessed fall how do you know that the bruise was caused by the fall? How do you know the patient hit their head?

I fall all the time. Just because I fell doesn't mean I hit my head or injured my spine.

 

[Aidey]

The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
. By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.

There is a difference between a stable and unstable fracture. A "fractured vertebrae" doesn't tell us anything since there are types of fractures that need little to no treatment.

Read some of the links I posted. The idea that backboards are unnecessary and harmful in some cases wasn't started on this forum. There are doctors who have been questioning their efficacy for years.

 

[Handsome Robb]

The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
. By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.

No she shouldn't have. I still fail to see how spinal motion restriction is indicated. She's A&O, denies LOC unless I read something wrong, is without painful distracting injuries and does not complain of midline cervical or thoracic pain. There's nothing that says this patient should be placed on a back board.

Citing a single case hardly supports your point.

 

[DesertMedic66]

No she shouldn't have. I still fail to see how spinal motion restriction is indicated. She's A&O, denies LOC unless I read something wrong, is without painful distracting injuries and does not complain of midline cervical or thoracic pain. There's nothing that says this patient should be placed on a back board.

Citing a single case hardly supports your point.

But everyone knows a fall = trauma. And any kind of trauma = full rapid trauma assessment, hi flow O2 via NRB, and full spinal immobilization

 

[Veneficus]

The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared...

I am not so sure where her hitting her head alone puts her at risk for a spinal injury, but isn't that is what assessment is for?

I am not so sure the totality of findings were presented here. It seems extraordinarily vague.

But I will stipulate that since she was alert and oriented, that if she did not have an obvious distracting injury, had no neuro deficits, no midline pain, a full range of motion, and no history of bone disease or cancer, this patient would recieve no benefit from spinal immobilization.

I still very seriously doubt a flat board is spinal immobilization anyway.

I would not have put her on a board under the circumstances stipulated. Afterall, if she had bone disease and was kyphotic, I wouldn't put her on a board anyway, even if I did suspect a vertebral body fracture.

By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.

Even though this case is unrelated completely, I will comment on it.

An unwitnessed fall in a nursing home? Must be a reason the patient was in a nursing home. I am guessing health so poor he is unable to care for himself. Did the patient fall from standing? From bed? Dropped by staff who didn't see anything?"

On to treatment.

Cracked vertebrae, doesn't sound like an unstable body fracture. Was it a spinal or transverse process, or the body?

Moreover, what was done for it? I am somehow doubting he was refered to ortho or neuro surg to fix it.

But that is still secondary.

Was the patient made worse by not being boarded and collared?

Because if he wasn't, that would sort of support the point that it doesn't really make much difference doesn't it?

I would be most interested in hearing why you think a board is indicated and what theraputic benefit it derives. Forget studies and crap, would you just tell me how you think it works and what it does?

 

[mycrofft]

I wasn't happy with my reply.Disregard

 

[94H]

Even though the MOI might not be cause for backboarding under your protocols, it still is for most EMTs around the country.

Good job to the OP for following his protocols. Whether or not spinal immobilization is a correct treatment is not the issue here, since most people are bound by their protocols, however outdated they may be.

For my last skills review at my company, the backboarding station was a pt who fell from a standing height.

FYI The Med-Director took away Medics ability to clear C-Spine at my company

 

[mycrofft]

94H good reply. Cut to the chase.

You know, we all forget that spineboarding is designed to protect the pt from iatrogenic exacerbation to spinal injury by EMS responders. Just as initial prehospital splinting is designed to minimize exacerbation of medical conditions by movement or transport. NEITHER is a "treatment", it's more of a safety measure to allow transport to definitve care.

OK if theoretically we could suspend the protocols, what would the best course of prehospital management be for the OP's initial presentation?

 

[Veneficus]

94H good reply. Cut to the chase.

You know, we all forget that spineboarding is designed to protect the pt from iatrogenic exacerbation to spinal injury by EMS responders. Just as initial prehospital splinting is designed to minimize exacerbation of medical conditions by movement or transport. NEITHER is a "treatment", it's more of a safety measure to allow transport to definitve care.

OK if theoretically we could suspend the protocols, what would the best course of prehospital management be for the OP's initial presentation?

Have her sit on the cot in the position of comfort or anatomical position.

Nobody lays on a spineboard in the hospital.

edit: with a c-collar if you suspect an unstable body fracture.

 

[Arovetli]

protect the pt from iatrogenic exacerbation to spinal injury by EMS responders.

A bit off topic but I recall years ago when I read through Bledsoe's paramedic text (Brady books) he quoted a study where prehospital providers caused ~50% of spinal injuries by moving patients or something to that effect. (which I thought at the time to be voodoo and still do)

I no longer have the books and have never been able to find the study. Maybe I am making it up in my head, but does anyone recall reading this or stumbling across this paper?

 

[d_miracle36]

I never see a pt boarded in the er besides when preparing for transport. Is it appropriate for ems to apply a c-collar without full spinal motion restriction?

 

[Veneficus]

A bit off topic but I recall years ago when I read through Bledsoe's paramedic text (Brady books) he quoted a study where prehospital providers caused ~50% of spinal injuries by moving patients or something to that effect. (which I thought at the time to be voodoo and still do)

I no longer have the books and have never been able to find the study. Maybe I am making it up in my head, but does anyone recall reading this or stumbling across this paper?

I looked in 2 editions of paramedic care I have, didn't find it in the trauma volumes or the index.

I recall hearing very early in my career something similar.(usually as somebody was trying to scare us into immobilizing every patient we saw just in case) I don't know if there was ever a study or a paper on it?

Given that we now know that compartment compression causes more secondary injury than other mechanisms I would question if there is such a study, if they erroneously attributed secondary injury to EMS providers because of lack of knowledge of the actual cause of the injury?

 

[Veneficus]

I never see a pt boarded in the er besides when preparing for transport. Is it appropriate for ems to apply a c-collar without full spinal motion restriction?

Spinal motion restriction does not automatically mean a rigid spineboard.

In the hospital setting, having a patient lay flat in a c-collar on the hospital bed (without a pillow) is considered spinal mption restriction.

The same as with the full body vacuum splints.

I know of several agencies that permit the use of the splint.

In my past EMS employs I have put elderly people on the cot with a c-collar and at the hospital and on the PCR explained why I chose not to put the patient on a spineboard for various reasons. I never had any problems in those instances.

In fairness it was more of an exception than a rule.

 

[Arovetli]

I looked in 2 editions of paramedic care I have, didn't find it in the trauma volumes or the index.

I recall hearing very early in my career something similar.(usually as somebody was trying to scare us into immobilizing every patient we saw just in case) I don't know if there was ever a study or a paper on it?

Given that we now know that compartment compression causes more secondary injury than other mechanisms I would question if there is such a study, if they erroneously attributed secondary injury to EMS providers because of lack of knowledge of the actual cause of the injury?

Yeah I remember questioning the methods in my head and I seem to recall the study was old. Speaking of my head, I must be remembering things wrong. Paramedic school was awhile ago, alot of things have come and gone since then and I probably got mixed up on where I heard about that. Thanks for checking.

 

[d_miracle36]

I agree with that but most of our patients are up walking around with a c-collar. If the only thing they are complaining of is neck pain is it okay to just apply c-spine precautions. With most of my patients if I put a collar on they usually get a board also but I have had elderly patients who I only put a c-collar on. What instances in ems will a collar only suffice?

 

[Arovetli]

I agree with that but most of our patients are up walking around with a c-collar. If the only thing they are complaining of is neck pain is it okay to just apply c-spine precautions. With most of my patients if I put a collar on they usually get a board also but I have had elderly patients who I only put a c-collar on. What instances in ems will a collar only suffice?

For the science read what Aidey provided. If you finish those and still want more PM me as my bookmarks and pubmed favorites are full of that stuff.

For practice as an emt or medic you absolutely must follow local protocols. Do not deviate even if your protocols are not evidence based. I understand your concerns because it is difficult to spell out every instance in a protocol book and interpretation can be difficult and occasionally you have to work with people who are better suited to the inside of a toolbag than the back of an ambulance or in a hospital....but this is how EMS and medicine rolls sometimes. You should direct questions to an FTO, senior medic, or admin of your service. Practices vary widely so its hard to advise.

 

[d_miracle36]

My protocols do not say anything about c-collar only and i understand to use them. I was just wondering if this would be practical or may eventually be a standard of care. My fto's still think we should board every pt just to be safe even though we have a clearance protocol. thank you for the resources.

 

[Arovetli]

eventually be a standard of care.

In some places it is. Some places are so risk averse you will never see it because they don't want to adopt the tiniest bit of liability.

Once you get some time in where your voice will be respected a little you can always tactfully suggest to senior personnel what the literature says. They may not be aware of it because, quite honestly, prehospital research was virtually nonexistent in the past.