Backboarding question.

[reaper]

Good for you, padding every patient.

This still does not alter the fact that i can stat that a cervical collar provides 35% restriction in movement, when applied with a KED, this incresed to over 85% immobilisation.

The same statistics cannot be given for the extrication device know as a spine board. I work alongside doctors who hate the fact that patients are bought in on them. Even when the patient is strapped to the board, there is still a range of movment that will allow the patient to slide & therefore have the possibility of increasing any damage already done.

As for the question of satfley removing a patient onto your stretcher, an effective log roll (I assume that there are more than 2 people on scene) with 1 person in control of the head will allow for this to happen. Remember the patient will have this done several times in hospital.

The incistance that we transpost on a spinal or long back board to prevent further injury is a nonsense with no evidence to support it.

Medicine, regardless of pre or in hospital MUST be performed on evidence based parctice. If the evidence is there, then we do it. For example, we used to, if we thought a pt was envenomated cut the wound & suck out the poison, or apply tourniquets, now, we know that these are not the most effective treatments & firm bandaging is proven to be the treatment. Similarly, the algorythm for cardiac arrest was changed world wide, why, because the evidence was there to support the change.

If you want to bring the evidence to the table to support you argument, then i will happily read it, but to say we do it cause it works does not wash in any prehospital environment any more.

Do I believe that backboarding is the best thing? NO!!!!! I have stated this over and over.

Have I debated with MD's over this? YES

We Got our MD to bend a little by putting a Spinal Clearance Protocol in effect. Is it everything I wanted? NO. But it is a start and we work on it.


Evidence based medicine is a great thing. But if you have any experience studying different studies, Then you know that a lot of them are crap. A lot of them are paid for by drug or equipment companies and they are swayed to prove the point that they want to make.

You can do a 3 year study on the negative affects of any thing in medicine and have it prove your point. I can do a 3 year study to prove that the same thing works like it should. Studies can be pushed in any direction that they want it do be pushed.

Yes, there are a lot of studies that are correct and prove the evidence behind it. But, do not take all studies to heart and think they are gospel because a Dr. did them.

There are studies that state that CPR is ineffective and we should abandon it. Do you think that this will happen? We use the best tools we have at the moment to deal with what we can. Medicine changes by the day and we change with it. When they produce a new way on backboarding that is shown to work better, we will all jump on it. Until then, we use what there is.

Unfortunately we are governed by the media and public opinion. Yes, we could go with not backboarding 90% of the pt's we do. But, it will be the one that is paralyzed by the medic that decided that it was not needed, that will be pasted all over the press and cause outrage in the public.

Well, sorry for the rant. Tail end of a 36 can cause the brain to fry!

 

[Wyoming Medic]

"A systematic review of the MEDLINE literature from 1966 to January 2006 Week 2 allows an estimate of the potential benefit of spinal immobilization. Multiple reports show that approximately 5% of trauma patients have a spinal fracture; only 20% of this 5% have a cord injury. There are 10 independent reports of secondary deterioration without spinal immobilization, many “suddenly” and temporally related to “inappropriate management” while not immobilized.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Three of these give precise data for calculations: up to 3% to 16% of these cord-injured groups had deterioration out-of-hospital.7, 9, 12 The product of these percentages indicates that 0.03% to 0.16% of all out-of-hospital trauma patients may be expected to have secondary injury and thus may be helped by immobilization. The minimum number of indiscriminately immobilized patients needed to prevent one secondary injury is thus likely between 625 and 3333 trauma patients. Admittedly, this indicates a small benefit per patient, but it is not insignificant in light of the catastrophic result of further cord injury and estimates that several million people are immobilized each year. Larger modern studies to define a rigorous number needed to treat (NNT) would not be ethical given the experiences shared above. The one case-control study of immobilization was elegant but unfortunately too small to refute a benefit.13 Not seeing deterioration in 13 cord-injured, non-immobilized patients is significant by the binomial exact test only if 25% or more of spinal-cord-injured patients are expected to deteriorate, and the above studies do not indicate this large of a rate of out-of-hospital secondary injury. This case-control study thus cannot discredit the multiple previous reports of small but non-zero numbers of late secondary spinal cord injury. Secondary deterioration is real, and immobilization is the best out-of-hospital intervention reported to date."

And here is the lead up to that "Cochrane Database systematic review of spinal immobilization.1 The study selection criteria included only randomized controlled trials (RCTs) of patients with suspected spinal cord injuries. None were found, so the Cochrane authors justifiably state that the effects of immobilization remain uncertain. However, the EBEM commentators’ conclusion that there is “no published or unpublished scientific evidence justifying the practice of spinal immobilization in the out-of-hospital setting” is too extreme. While emergency medicine practitioners are wise to understand the evidence underlying their interventions and the magnitude of the likely effects, the lack of RCT evidence should not lead to therapeutic nihilism about interventions that other types of studies indicate may lower morbidity."

Well, Here is what I HAVE seen and done studying on throughout my schooling. I have more references but it would take me longer to find them. This one is pretty compelling however. It pretty clearly states how (while small) backboarding is justified and how,at least this group, feels that it does reduce further spinal cord injury. The numbers of people that it really helps is small compared to the ones that are boarded un-necessarily, but I am not ready to be the one to tell the occasional person that they will not get boarded because of the "greater good". I will do my job and what is best for the patient. I will risk the decub (and try my best to counter with padding and such) for the sake of preventing POSSIBLE further spinal compromise.


I also want to address this
Veneficus-- "I have seen ~7 studies that says no benefit or harm."

Where? I re-read all of your posts on this topic and I cannot find you providing a link to any of these studies (perhaps I missed them but I don't think so) nor the text associated with any. I can find studies citing the dangers of wearing underwear and ALSO some saying that it is dangerous NOT to wear underwear.

http://www.associatedcontent.com/article/7987/health_dangers_more_serious_than_terrorists.html


http://jhorna.wordpress.com/2007/01...ng-underwear-is-detrimental-to-your-sex-life/

Now, are these studies anything that are serious? I dunno , I take them with a pretty large grain of salt. HOWEVER, do note that I found "studies" to support both of my claims. I also found a reference to TPS (tight pants syndrome) and a doctor claiming that belts were far more dangerous than suspenders


Veneficus-- "Why do I try to raise the respect for EMS providers with other health care practicioners?"

I dunno why you do any of what you do, only you know that

http://www.cwnsurgery.com/CWN/About/doctors.html (look at that link and run your mouse over their names to get some background)

These are the local folks that deal with the trauma patients that I bring in every day. They are the same ones that say "backboard" and the same ones that I feel have a pretty mutual respect for me. I hate to say it but you coming on here writing that you have read 7 studies about how backboarding is bad, has not come anywhere near what these folk have taught me and shown me with regard to the benefits that backboarding has.

As I have been saying all along, I agree that backboards are not the solution but for in the field care, I think they are the best that we have right now. I can think of no way that my partner and I can move a trauma patient BY OURSELVES without compromising some form of spinal movement limitation unless we use the backboard. Maybe in a magical world you have 25 people on a scene but here in Wyoming we have 2. My partner and I and the occasional rancher.

Along with me agreeing that boarding is not the perfect solution, I will also agree that sufficient evidence is around to support doing an in depth study. This is becoming a pretty hot topic in forums across the internet and I am shocked at how little data there really is. I respect your interpretation of the little evidence that is around and I respect mine. However you have not convinced me to "fight the good fight" as you put it and I doubt that I will convince you of my thoughts. I think that we must continue to use what our medical directors mandate, try to come up with better solutions, educate ourselves on new techniques and try to do our best to "clear" patients in the field and reduce our numbers of grossly un-necessary boarding.

Thank you for the green mega man, you may now all have ice cream, cake and pie.

Wy medic

 

[Veneficus]

I also want to address this
Veneficus-- "I have seen ~7 studies that says no benefit or harm."

Where? I re-read all of your posts on this topic and I cannot find you providing a link to any of these studies (perhaps I missed them but I don't think so) nor the text associated with any. I can find studies citing the dangers of wearing underwear and ALSO some saying that it is dangerous NOT to wear underwear.

somewhere in this post I mentioned that I have no intention on searching up where I saw these. The last one I saw was done by the department of PT/OT at MetroHealth medical center. Between medscape, BMJ, JAMA, NEJM, Lancet, and every other source that people email me I really just don't plan to go through years of briefs on this topic. At one point I decided they did not contain enough bias to be discounted. Taken togeether that is significant in my mind.

When I look at MAST, aggresive fluid resuscitation, golden hour, the focus of intubation during CPR, and other EMS dogma that has been the staple of EMS for more than 2 decades, just accepting spineboarding is not something I am prepared to do. In addition since I know that penetrating trauma is one of the leading causes of spinal injury and mechanism is not always reliable I am thinking it may be impossible to prove that a backboard does help. How could anyone say it was the board and not the manipulation itself that was the deciding factor in whether a pt suffered a secondary injury?

These are the local folks that deal with the trauma patients that I bring in every day. They are the same ones that say "backboard" and the same ones that I feel have a pretty mutual respect for me. I hate to say it but you coming on here writing that you have read 7 studies about how backboarding is bad, has not come anywhere near what these folk have taught me and shown me with regard to the benefits that backboarding has.

I would not think for a moment that anything I could say here would change your mind. I don't even hope to try, what I do hope to do is point out that medicine is a larger world than your or my local area, and maybe people reading this will be ambitioius enough to start calling practices into question instead of mindlessly performing them or spouting the anecdotal benefit.

As I have been saying all along, I agree that backboards are not the solution but for in the field care, I think they are the best that we have right now. I can think of no way that my partner and I can move a trauma patient BY OURSELVES without compromising some form of spinal movement limitation unless we use the backboard. Maybe in a magical world you have 25 people on a scene but here in Wyoming we have 2. My partner and I and the occasional rancher..

I am very well experienced in having only 2 people and the occasional sheriff. I also think a board helps make extrication easier. What I am against is boarding every patient because of wild "what if" statements.

Along with me agreeing that boarding is not the perfect solution, I will also agree that sufficient evidence is around to support doing an in depth study...

EMS in my experience does not like to take a hard look at what it does because it wants somebody to tell them what to do instead of using critical thinking skills. Which i would venture guess is why none of this data has ever been called upon. If I have a choice of getting involved in a study of the next greatest blood substitute or backboarding, I probably wouldn't even consider backboarding, if other people wth a high interest in trauma and the average opinion of EMS that I see in trauma surgeons it doesn't surprise me at all nobody has done more.

I think that we must continue to use what our medical directors mandate,

This is exactly the problem. EMS cannot rely on people interested in grander things to keep telling them what to do. Most medical directors I know have so much on their plate already, reviewing this stuff will fall on EMS providers, who don't seem interested.

try to come up with better solutions,,

but we have to admit what we are doing is not good enough before that can happen. You may admit it, I may admit it, but look at EMS across the US. You may pad the board regularly, but I can tell you that is not the average. Infact I would wager if you go by call volume, less than 1% of all patients put on a board are padded at all, much less properly.

educate ourselves,

That is the key phrase right there. The more you know about anatomy, pathophysiology, and biophysics, the more you will be able to recognize or even clear people who do not need a board. But without namng names, there are very large lobbyists who have worked very hard to keep EMS education as low as possible.

 

[Wyoming Medic]

I am very well experienced in having only 2 people and the occasional sheriff. I also think a board helps make extrication easier. What I am against is boarding every patient because of wild "what if" statements.

And I respect that. I also feel like while we may argue certain points, we do have a lot of the same views. Like I have said in several past posts, I believe that the field clearing of C-spine injuries is in our protocols and needs to be taught and encouraged more.

My question (to keep this forum moving) is what is the better approach. I keep reading about how a cervical collar then placing the pt directly onto the cot is acceptable. Is that what "experts" are saying?

My next question is, how do we accomplish maintaining some form of spinal movement limitation without the board?

I have read various reasons why people believe that the backboard is not a viable option. So what are we to do? If people are recommending that we go to our medical direction with other ideas, What are those ideas?

I am not willing (at this point) to say that backboarding is archaic and "old hat". I have not seen any solid evidence to say that backboarding is specifically bad. I have however seen (as I posted before) some limited information that backboarding is beneficial in the long run.

I am convinced however, that there are enough professionals that are questioning the practice for me to open my mind and listen to other options.


Wy medic

Ps. and addressing the comments about being in a small part of the world, I have practiced EMS in Wyoming, South Dakota, Many places in Texas, West Virginia,Utah, Colorado, and Pennsylvania. I feel that I have a pretty good grasp at how EMS is performed in the USA. The rest of the world may do things differently but I feel that I am keeping within the standards that I see all over the U.S.

 

[Veneficus]

And I respect that. I also feel like while we may argue certain points, we do have a lot of the same views. Like I have said in several past posts, I believe that the field clearing of C-spine injuries is in our protocols and needs to be taught and encouraged more.

My question (to keep this forum moving) is what is the better approach. I keep reading about how a cervical collar then placing the pt directly onto the cot is acceptable. Is that what "experts" are saying?

My next question is, how do we accomplish maintaining some form of spinal movement limitation without the board?

I have read various reasons why people believe that the backboard is not a viable option. So what are we to do? If people are recommending that we go to our medical direction with other ideas, What are those ideas?

I am not willing (at this point) to say that backboarding is archaic and "old hat". I have not seen any solid evidence to say that backboarding is specifically bad. I have however seen (as I posted before) some limited information that backboarding is beneficial in the long run.

I am convinced however, that there are enough professionals that are questioning the practice for me to open my mind and listen to other options.


Wy medic

Ps. and addressing the comments about being in a small part of the world, I have practiced EMS in Wyoming, South Dakota, Many places in Texas, West Virginia,Utah, Colorado, and Pennsylvania. I feel that I have a pretty good grasp at how EMS is performed in the USA. The rest of the world may do things differently but I feel that I am keeping within the standards that I see all over the U.S.

In hospital a c-collar and a regular hospital bed (the one with the 4-5” mattress)without pillow is acceptable. Some Cots have an option for thicker mattresses that may be useful.

In this neck of the woods extricating with the board and then transferring to a full body vacuum splint on the cot is protocol. It works really well (cause all the voids are padded automatically) but the pt still has to be taken off of it for x-rays. It is supposedly capable of being x-rayed but the creases blur boarders making them tough to read. Many experts I know think that is quite acceptable. Anatomically it seems more effective than a flat board.

In addition to the above, careful manipulation instead of speed trying to meet arbitrary time limits. That may require more scene time, but that is better than the alternatives.

 

[Wyoming Medic]

In this neck of the woods extricating with the board and then transferring to a full body vacuum splint on the cot is protocol.

How do you accomplish this without excessive manipulation? Seems like an extra step that can cause problems.

The other problem is one that we have with any type of air or vacuum splint. We have varying altitudes from 3,000 feet to almost 14,000. In my experience, the splints cause many problems and are difficult to be used reliably.

Any thoughts?

Wy med

 

[Veneficus]

How do you accomplish this without excessive manipulation? Seems like an extra step that can cause problems.

log roll, it has to be done at the hospital anyway, a lot of hospitals have time limits a patient can be on a board. (in minutes) But even so the back has to be assessed.

If you are logrolling onto a board, if it was going to cause harm wouldn't it likely have already?

The other problem is one that we have with any type of air or vacuum splint. We have varying altitudes from 3,000 feet to almost 14,000. In my experience, the splints cause many problems and are difficult to be used reliably

Any thoughts?

some kind of fast setting spray foam?

 

[Wyoming Medic]

If you are logrolling onto a board, if it was going to cause harm wouldn't it likely have already?

Not necessarily. Maybe the 2nd time is the charm. More manipulation also means more chance of unwanted movement. And our hospital tries to get patients off the board within 1 hour. Our physicians leave the patient on the board until radiology can "get the shots".


And what did you mean by "spray foam"? I am totally confused. The problem with any type of air containment splint is that the air pressure changes here RAPIDLY with altitude changes. How would I incorporate spray foam into that? I have my thoughts but the state would yank my cert so fast.

I am not sure how EMS works where you are at but Wyoming has STRICT rules regarding adherence. You would not believe the hassle of getting a "warm IV" study permit. MONTHS and MONTHS. And until somebody can provide ACTUAL data that unquestionably shows that there are better ways than boarding a patient, all that I can do is pee into the wind. And that is assuming that I agree with the "good fight". I have not turned over that leaf yet.

All of this idea is well and good but there are fewer than 70 working medics in Wyoming and I would like to stay one of them.


Wy medic

 

[Veneficus]

Not necessarily. Maybe the 2nd time is the charm. More manipulation also means more chance of unwanted movement. And our hospital tries to get patients off the board within 1 hour. Our physicians leave the patient on the board until radiology can "get the shots".


And what did you mean by "spray foam"? I am totally confused. The problem with any type of air containment splint is that the air pressure changes here RAPIDLY with altitude changes. How would I incorporate spray foam into that? I have my thoughts but the state would yank my cert so fast.

I am not sure how EMS works where you are at but Wyoming has STRICT rules regarding adherence. You would not believe the hassle of getting a "warm IV" study permit. MONTHS and MONTHS. And until somebody can provide ACTUAL data that unquestionably shows that there are better ways than boarding a patient, all that I can do is pee into the wind. And that is assuming that I agree with the "good fight". I have not turned over that leaf yet.

All of this idea is well and good but there are fewer than 70 working medics in Wyoming and I would like to stay one of them.


Wy medic

I mean a new spray foam that could fill voids after the patient was on the board.

sounds like Wyoming needs some more progressive people doing med control there. I doubt we will ever see conclusive evidence for many medical procedures.

One hour is entirely too long to be on a board. Especially for the elderly. I know of 2 places that require it to be yanked in 10 minutes. I have never worked anywhere in any country (3) that permits greater than 1/2 hour. (you only beat me by 1 state in the US ) I have heard of spine fx being missed as much as 20% on x-ray so are your hospitals CTing spines if there is that much concern? If they are relying on x-ray to rule out a fx, then somebody is going to be a VOMIT. (victim of medical imaging technology) A head,neck, chest, abd and pelvis with spine recons can take upwards of 40 minutes. add in scene, transport, ED time and you are easily over an hour. If they are delaying transport to a higher level of care to do a CT, they will probably catch hell in the next ATLS recert.

Who is your level I trauma center there?

 

[Wyoming Medic]

We have no level one trauma center in the state. We have several level 2 but the majority are level 4.

I know that many people say that they are rural EMS but Wyoming really does take it a step further (at least within the 48 states). We have 1 lifeflight in the state. Usually unavailable due to weather. We have very few hospitals anywhere. Most of our ambulances cover 6,000 ish square miles without any radio, cell, or backup available.

Our state EMS is archaic at best. They know EVERY medic by name and face. They treat each differently. EMT-Is are the gold standard. Medics are deemed "un necessary". There are fewer than 70 working medics within the state. There are hundreds of intermediates. Intermediates in Wyoming can do more than many paramedics in other states. Unless you live in one of the bigger cities (over 20,000 people) you probably will never see a paramedic.

Wyoming has completely dropped off the map and no longer accepts NREMT and has completely designed it's own standard for reciprocity. Not just basing it upon what state you are coming from but by what school you got your level of EMT, be it basic, intermediate or medic.

Now to move back to the topic at hand after the WY EMS lesson.

I have been researching online this whole time, trying to find definitive answers regarding this "backboard VS Not" debate.

I cannot find much info. So let me lay it on the line, and describe how I am hearing what you are saying. Not picking on anybody BUT this is how I HEAR YOU.

You are basically saying that you have read 7 studies that bemoan the use of backboards. You cannot remember exactly where or when BUT you did read them and you are not going to post any links or text associated with them. It is up to us as the reader to figure it out. I then post an entire text associated with a study and it is not even mentioned in rebuttal. You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint". When told that vac splints are not so hot here you come up with "spray foam" yet you offer no attempt at how to use this and seem not to take into account the fact that it is not approved/studied/tested/within national standard practices.

That is what I am gathering from this whole conversation. Perhaps you have more knowledge or information, but you have not conveyed it to me in a logical sense that I can understand and try to believe in. From what I can tell (as I said above) you are making statements that are based upon something that I (as reader) cannot verify OR deny.

I have very much enjoyed this banter. I always believe that this type of discussion is great for keeping the mind sharp so I do thank you. I can tell that you are an intelligent individual and after this, I do respect what you say. I also can see that the answer is still out there and that more research needs to be done.

I hope we can keep up the verbal judo in other threads that we both encounter.

Thanks for the information


Wy medic

 

[Veneficus]

You are basically saying that you have read 7 studies that bemoan the use of backboards. You cannot remember exactly where or when BUT you did read them and you are not going to post any links or text associated with them.

sorry, truthfully it would take hours to track them down. Like I said, The last one I read was done At Metro, with Case Western Reserve University. There were 2 listed here by other posters so i wasn't going to repost them, so we are up to 3.

I then post an entire text associated with a study and it is not even mentioned in rebuttal.

I read the post, you decided that many patients are overtriaged and boarded, we agree, didn't think you wanted a comment on it.

You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint"..

It's what's done here, I think it is a good idea.

When told that vac splints are not so hot here you come up with "spray foam" yet you offer no attempt at how to use this and seem not to take into account the fact that it is not approved/studied/tested/within national standard practices..

I was trying to come up with an original, logical solution to the problem, could be the next billion dollar medical gadget, but I don't have time to make it as I have other ambitions. But I figure with all the other crap out there, somebody will seize on it.

I have very much enjoyed this banter. I always believe that this type of discussion is great for keeping the mind sharp so I do thank you. I can tell that you are an intelligent individual and after this, I do respect what you say...

Indeed it has been a great conversation.

I hope we can keep up the verbal judo in other threads that we both encounter. ...

for certain, thanks for the WY EMS lesson and the debate.

 

[karaya]

Whew! You guys done?

 

[Veneficus]

Whew! You guys done?

I thought it wasn't over till somebody won

 

[JPINFV]

You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint".

Wouldn't the treatment change if a treatment doesn't work be to abandon it? I guess you could call "permissive hypotension" a treatment, but it could also be considered removal of fluid resuscitation from all but the most extreme cases. In the 13 or so cases mentioned in that study where patients had secondary spinal injury, I would be interested to know if the physicians involved with those cases felt that the secondary injury would have been avoided with the use of EMS style movement restriction.

 

[downunderwunda]

"A systematic review of the MEDLINE literature from 1966 to January 2006 Week 2 allows an estimate of the potential benefit of spinal immobilization. Multiple reports show that approximately 5% of trauma patients have a spinal fracture; only 20% of this 5% have a cord injury. There are 10 independent reports of secondary deterioration without spinal immobilization, many “suddenly” and temporally related to “inappropriate management” while not immobilized.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Three of these give precise data for calculations: up to 3% to 16% of these cord-injured groups had deterioration out-of-hospital.7, 9, 12 The product of these percentages indicates that 0.03% to 0.16% of all out-of-hospital trauma patients may be expected to have secondary injury and thus may be helped by immobilization. The minimum number of indiscriminately immobilized patients needed to prevent one secondary injury is thus likely between 625 and 3333 trauma patients. Admittedly, this indicates a small benefit per patient, but it is not insignificant in light of the catastrophic result of further cord injury and estimates that several million people are immobilized each year. Larger modern studies to define a rigorous number needed to treat (NNT) would not be ethical given the experiences shared above. The one case-control study of immobilization was elegant but unfortunately too small to refute a benefit.13 Not seeing deterioration in 13 cord-injured, non-immobilized patients is significant by the binomial exact test only if 25% or more of spinal-cord-injured patients are expected to deteriorate, and the above studies do not indicate this large of a rate of out-of-hospital secondary injury. This case-control study thus cannot discredit the multiple previous reports of small but non-zero numbers of late secondary spinal cord injury. Secondary deterioration is real, and immobilization is the best out-of-hospital intervention reported to date."

And here is the lead up to that "Cochrane Database systematic review of spinal immobilization.1 The study selection criteria included only randomized controlled trials (RCTs) of patients with suspected spinal cord injuries. None were found, so the Cochrane authors justifiably state that the effects of immobilization remain uncertain. However, the EBEM commentators’ conclusion that there is “no published or unpublished scientific evidence justifying the practice of spinal immobilization in the out-of-hospital setting” is too extreme. While emergency medicine practitioners are wise to understand the evidence underlying their interventions and the magnitude of the likely effects, the lack of RCT evidence should not lead to therapeutic nihilism about interventions that other types of studies indicate may lower morbidity."

Well, Here is what I HAVE seen and done studying on throughout my schooling. I have more references but it would take me longer to find them. This one is pretty compelling however. It pretty clearly states how (while small) backboarding is justified and how,at least this group, feels that it does reduce further spinal cord injury. The numbers of people that it really helps is small compared to the ones that are boarded un-necessarily, but I am not ready to be the one to tell the occasional person that they will not get boarded because of the "greater good". I will do my job and what is best for the patient. I will risk the decub (and try my best to counter with padding and such) for the sake of preventing POSSIBLE further spinal compromise.

Well researched Wy, however it talks spinal immobilisation, not transporting on a LSB. there is a difference. No one has disputed the need for spinal immobilisation. Vac packs are ideal, but alas we do not all have access to them, however, you can still immobilise effectivley without a LSB, if not better.

My experience is that if we present a patient to an ER without being on an LSB, the the Dr usually will come straight over to begin the process of spinal clearnce & where appropriate, based on what our reports from scene & en route are, we may take the pt through to X-ray & have that done on our stretcher to reduce movment.

As has been stated, most hospitals want the patients off the LSB post haste. Why, because they are uncomfortable & as such the patient wants to move & you run more risk of damage.

As the study sited by Wy states, we are, in reality talking very, very low numbers of people who are actually effected, if my maths works out right is is about 200 in every 100 000 trauma patients. However, because we cannot clear in field in most cases, we need to treat for the worst & hope for the best.

There is general agreement that transport on a LSB is not really the most desireable position, so what is the solution? Reaper stated in a reply to me

Evidence based medicine is a great thing. But if you have any experience studying different studies, Then you know that a lot of them are crap. A lot of them are paid for by drug or equipment companies and they are swayed to prove the point that they want to make.

You can do a 3 year study on the negative affects of any thing in medicine and have it prove your point. I can do a 3 year study to prove that the same thing works like it should. Studies can be pushed in any direction that they want it do be pushed.

Yes, there are a lot of studies that are correct and prove the evidence behind it. But, do not take all studies to heart and think they are gospel because a Dr. did them

Unfortunatley, while you are correct, just look at the Dr's employed by the tobacco companie who told us smoking was actually good for us, it costs money to run these studies, money only available to those companies. There is however now some protection for those of us who read them where if a study is paid for by one such company, this has to be declared & made obvious to the reader. While this is not perfect, either is the transport of a pt on a backboard!

The key is for the disserning reader to be able to read the report/study & look at it. I have seen studies that have based their findings on 100 people. That was their sample. Is this acceptable? No. Their findings were refuted not long after with a study using a sample of 5000. Similarly, if you are following the post on the Golden Hour, you will see that the basis for this was, to quote spisco85

The Golden Hour term was coined originally for medevacs in a WAR zone due to penetrating trauma. The major causes of death were "sucking chest wounds" and death due to extremity hemmorhage/amputation.

It has subsequently been refuted many times, but in many cases is still accepted as a rule in ems (please see the thread to continue this debate, this is meerly a reference not a point of argument here). Change has to begin somewhere, & the statment by Veneficus

EMS in my experience does not like to take a hard look at what it does because it wants somebody to tell them what to do instead of using critical thinking skills. Which i would venture guess is why none of this data has ever been called upon. If I have a choice of getting involved in a study of the next greatest blood substitute or backboarding, I probably wouldn't even consider backboarding, if other people wth a high interest in trauma and the average opinion of EMS that I see in trauma surgeons it doesn't surprise me at all nobody has done more.

is for the most part correct. However, having spent time as a member of the Australasian Trauma Society, the tide of change, at least here, is beginning. The recognition that ambulance services needs certain skills & drugs, recognition that we are capable of makeing decisions that will have positive effects on our patients, the ability to recognise when we should scoop & run or stay & play. The simple fact that we, through our professional bodies are being asked for our opinions & the walls are, slowly, being broken down, is a positive. This has been through persistence of officers & supporters over many YEARS. Many of which started as discussions, not unlike this one.

I would like someone to answer a question I did pose earlier which seems to have been lost, so I will ask again now.

does EVERY patient you treat as a suspected spinal get

1.Collar,
2. KED,
3. LSB,
4. Fluids,
5. Anti-emetic,
6. Nasogastric tube,
or is it only the spine board, collar & KED that are important?

I look forward to replies to this question

 

[Wyoming Medic]

I would like someone to answer a question I did pose earlier which seems to have been lost, so I will ask again now.

I look forward to replies to this question

I can say that here in the WY, we use the LSB, Collar, Zofran (that is just our choice) and fluids.

If the patients is to be kept on the board for any length (once in the hospital) then an NG is place. We don't have the ability to place field NG anyway.

The KED is used here very little. I have used it to "reduce movement" of c-spine of a guy that fell down a stair onto his face. He had serious epistaxis (sp) but had point tenderness in the c-3,4 area. It allowed us to transport him sitting up in a position that he could breath.

Wy medic

 

[downunderwunda]

I can say that here in the WY, we use the LSB, Collar, Zofran (that is just our choice) and fluids.

If the patients is to be kept on the board for any length (once in the hospital) then an NG is place. We don't have the ability to place field NG anyway.

The KED is used here very little. I have used it to "reduce movement" of c-spine of a guy that fell down a stair onto his face. He had serious epistaxis (sp) but had point tenderness in the c-3,4 area. It allowed us to transport him sitting up in a position that he could breath.

Wy medic

Wy,

it is interesting that you do not use a KED more when you have been very adamant about reducing spinal movment. A cervical collar only provides about 35% reduction in movment, but when combined with a KED this increases to 85%. Maybe it would be worth re evaluating your procedures & using a KED rather than a LSB for transport.

 

[Wyoming Medic]

That would definitely be worth looking at. I was unaware of the numbers that the KED provided.

I have always had problems with KEDs fitting correctly (we have LOTS of obesity here) and I never liked the fact that it really limited my access to the trauma patient.

Wy medic

 

[downunderwunda]

Obesity is a problem everywhere, a result of modern western society. I would suggest you get a couple of larger volunteers, explain the reason you have chosen them & practice on station. I believe there are extention straps available for the KED & other extrication devices.

 

[emtfarva]

Just to let you know:

LBB is just a splint that we just happen to use as a transportation device.
A scope or stokes stretcher are transportantion devices.
A ked or short spine board is an extrcation device.