Backboarding question.

[Veneficus]

Hey guys,

Let’s keep this in perspective:

There is evidence backbarding is harmful or has no appreciable effect.
There is no evidence that it prevents any further injury.

So aside from anecdotes and dogma there is not any rationale to do it at all. Now just because a doc says to do it doesn’t make it suddenly a good idea. There are lots of docs that hold onto dogma that has been beaten into their brain too.

I am not saying suddenly stop this practice against protocol, but what I am saying is that maybe it is time that a fresh look has to be taken at the protocols for the benefit of the patient. I have not met anyone on this forum that can’t have an intelligent discussion with their medical director. Questioning a practice is the first step to get it changed. Plus you could always call med control.

I read something here about boarding people who fell less than 24 hours after the incident. Why 24? Why not 36? Did the insult heal?

Spinal injury is not just about fx bones. Please think and use clinical judgment based on your findings(educate yourself higher than what is expected by the DOT MINIMUM), not what if the sky was green when a jet crashed into the ground injuring the person it struck but all aboard were safe on Monday Feb 29th, during an earthquake right after a flood when gravity was temporarily reversed. These “what if” statements really are that preposterous and show a general lack of understanding which holds the EMS profession to a lesser wage than the manager at McDs.

 

[karaya]

There is evidence backbarding is harmful or has no appreciable effect.
There is no evidence that it prevents any further injury.

As a med student, you should know that citing your statements should be paramount. Your sweeping assertion that talking to a provider's medical director to apparently get protocols changed in an effort to abandon spinal immobilization I find a little premature. Especially since more thorough clear scientific studies are still absent.

I suspect that you may be citing the study and article, "The Evidence for Spinal Immobilization: An Estimate of the Magnitude of the Treatment Benefit"?

From what I understand from the article, and please bear in mind I have not seen the entire article, the effects of spinal immobilization (with what little studies that have been completed so far) conclude that there are in fact no published or unpublished scientific studies that supports the practice of spinal immobilization in the pre-hospital setting.

This is not a declaration that spinal immobilization should cease, but in fact an endorsement that scientific studies should be launched to better understand to what degree ( if any) spinal immobilization should be practiced.

Responses seem to indicate that such studies will at least yield a better understanding as to what point a patient is cleared in the field from immobilization.

 

[JPINFV]

Here's another review article.

Hauswald, M., Braude, D. Spinal immobilization in trauma patients: is it really necessary? Current Opinion in Critical Care 2002, 8:566–570

Conclusions
Like much of medicine, spinal immobilization is a concept that became the standard of care based on common sense rather than research. There are convincing biomechanical arguments and some preliminary research that suggest that spinal immobilization may not be necessary, even in many trauma patients with unstable injuries. Until further research clarifies which injuries, if any, truly benefit from immobilization, immobilization will remain the standard practice. The clinician’s goal should be to apply it only to those patients predicted to be at risk for unstable injury and to do as little harm from immobilization as possible.

There's really two ways to look at it. If the concept of spinal immobilization was being looked at to add to treatment plans today, would it be accepted? Alternatively, there is the current situation where we're now looking at evidence for a current intervention and finding it unsupported. How much lack of support will be needed to stop doing it?

 

[karaya]

There's really two ways to look at it. If the concept of spinal immobilization was being looked at to add to treatment plans today, would it be accepted? Alternatively, there is the current situation where we're now looking at evidence for a current intervention and finding it unsupported. How much lack of support will be needed to stop doing it?

Good points. Let's take this whole subject to a really simple view: EMS providers are taught to splint something that may be broken. That's it. Back might be broken? Splint it. Neck might be broken? Splint it.

That simple part of our training has been the educational standard since Moby **** was a minnow. Now there is new evidence to suggest that this concept needs further investigation. I haven't seen anything just yet that would indicate that any medical director would comfortably alter this very simple standard in the absence of better scientific studies; even though there are no studies to support its practice. Furthermore, I cannot find where any such studies are being conducted or in the works.

Lot's of chatter, but little scientific results.

 

[Veneficus]

As a med student, you should know that citing your statements should be paramount. Your sweeping assertion that talking to a provider's medical director to apparently get protocols changed in an effort to abandon spinal immobilization I find a little premature. Especially since more thorough clear scientific studies are still absent.

Yes I unerstand the citing the studies, but you must forgive me, I read about 4-5 (15 minutes to 1/2hour) of medical briefs a day, I see several studies, and I really don't have the ambition to look them up everytime I make a post here, particularly when I seem to be saying the same thing to new people every few months. I guess the people here will have to do some of their own research.

At last count I have seen 7 published studies citing ill effects of spine boards. The last was done by a physical therapy department. Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not? With the 10s of thousands of patients backboarded every year in the US, some evidence must be available. Of course then we should also look at our brethren in other countries who have ditched this practice. The more you look at the anatomy of physics of the matter, the more rediculous the intervention seems unless basic science is no longer a part of medicine, substituted for technology and the ignorant idea that all medicine in the US is somehow superior to everyplace else.

 

[karaya]

Yes I unerstand the citing the studies, but you must forgive me, I read about 4-5 (15 minutes to 1/2hour) of medical briefs a day, I see several studies, and I really don't have the ambition to look them up everytime I make a post here, particularly when I seem to be saying the same thing to new people every few months. I guess the people here will have to do some of their own research.

At last count I have seen 7 published studies citing ill effects of spine boards. The last was done by a physical therapy department. Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not? With the 10s of thousands of patients backboarded every year in the US, some evidence must be available. Of course then we should also look at our brethren in other countries who have ditched this practice. The more you look at the anatomy of physics of the matter, the more rediculous the intervention seems unless basic science is no longer a part of medicine, substituted for technology and the ignorant idea that all medicine in the US is somehow superior to everyplace else.

You are forgiven Veneficus!! My point was more in the area the impression one can leave to some of the forum members here. When I saw your thread, I could picture responses from bewildered and inexperienced medics who would consider the notion that maybe they don't need to immobilize anymore.

In my business I run into more anecdotal spinal immobilization methods than I can stomach. My photographs must meet the necessary current standards or my editors won't consider the images for publication. Tons of my images have been left on my editing room floor from half cocked medics who want to do it "their way". Hence the reason I take such a passionate few on this topic.

You bring up an excellent point about overseas studies. I'm curious now to see how these studies were conducted? Thanks for your input!

 

[BossyCow]

So, what is it the studies say is at fault? Is it the design of the board? Is it the material the board is made out of? Is it the method of strapping? I'm sure if we built a better mousetrap er.... backboard, it would sell. Something perhaps more along the lines of a vacu-splint that filled the voids better? Are the studies saying that spinal immobilization is bad or that the way we currently immobilize a spine is wrong?

We can argue all day long about it being right or wrong but what parts are right and what parts are wrong? And you can't dismiss the point that we operate under the license of our medical program director and its his call. Yes we should open a dialog regarding the efficacy of the current practice of spinal immobilization, but the wheels of change spin very slowly when personal injury lawyers are watching.

 

[Wyoming Medic]

At last count I have seen 7 published studies citing ill effects of spine boards.

Not trying to get into the mix too much but EVERY medical intervention has a risk or "side effect" associated with it.

It is very well published that IVs CAN cause severe problems (emboli, phelitis,infection, ETC) yet very few people will argue the necessity of IVs. We learn techniques to try to shrink the risk BUT it remains. The same can be said for almost every medication. Every one has a side effect of some kind. Usually the therapeutic dose is maintained and the side effects are outweighed by the benefits.

The same can be said of backboards IMO. They can cause problems but we can learn specific techniques (padding voids, knee freedom, etc) to minimize the hazard. We may never totally eliminate it but. . . . . .

I personally view backboards as fairly important. Not just because I was beat throughout medic school to "trust in the backboard" but because I really feel that it does some good. If you think about the mechanical injury associated with trauma then think about how to minimize the damage, you will always lean towards immobilization.

I know the backboard does not immobilize but it is as close as we can get in the field w/o resorting to RSI and an entire body vacuforming splint with a halo.

That being said, it also takes a special part on the ER staff to minimize the risk of backboarding. They really should strive to make sure that the patient gets off the board in an hour. I know this is not always possible (heck, some of our transport times are over an hour by themselves) but our local ER makes an attempt. Either cleared and off the board or into surgery within 1 hour of hitting the door.

I am not ready to write off the backboard just yet. A little evidence of possible side effects (just like everything else in EMS) does not scare me away when I think about how MECHANICALLY, the backboard makes sense. I am an amateur welder and mechanic on the side as well as a ham radio operator and rock climber. I feel that I have a pretty mechanically inclined mind and the backboard makes sense.

And last but not least, It is almost impossible to trump the med director. He says jump and I say HOW HIGH.

That is all for now

Wy medic

 

[JPINFV]

Good points. Let's take this whole subject to a really simple view: EMS providers are taught to splint something that may be broken. That's it. Back might be broken? Splint it. Neck might be broken? Splint it.

That's over simplifying it, though. It's not simply that an arm may be broken. The arm has to show signs or symptoms (pain, swelling, tenderness, etc) to be splinted. Outside of the spine, mechanism isn't enough to justify splinting anything else. It's splinting AND signs/symptoms.

On one hand, I agree that there isn't enough to completely abandond it. I thing there is enough evidence, though, to seriously implement selective spinal immobilization at all areas though. The big problem is what area is going to agree to a randomized c-spine trial and where are we going to get an IRB willing to accept it? I'd like to see more of the Malaysia style studies done to build up the literature.

 

[JPINFV]

Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not?

How many EMS providers have the education, inclination, and/or ability to run a controlled study? As I'm sure you know, it's not as simple as throwing a bunch of people on a backboard for 2 hours and writing up an essay on what you did and what you found.

 

[JPINFV]

So, what is it the studies say is at fault? Is it the design of the board? Is it the material the board is made out of? Is it the method of strapping?

For the most part it's the material that the board is made of. Simply put, it's too hard and is causing ulcers in patients on it for any significant period of time. There's also a question being raised on if the entire practice does any good at all. Backboarding currently is like fluid resuscitation in trauma patients.

 

[BossyCow]

For the most part it's the material that the board is made of. Simply put, it's too hard and is causing ulcers in patients on it for any significant period of time. There's also a question being raised on if the entire practice does any good at all. Backboarding currently is like fluid resuscitation in trauma patients.

I just think its pointless to argue about should we or shouldn't we when we aren't clear on what specifically is the issue. Instead of yes or no, we need to focus on the 'how'.

 

[karaya]

That's over simplifying it, though. It's not simply that an arm may be broken. The arm has to show signs or symptoms (pain, swelling, tenderness, etc) to be splinted. Outside of the spine, mechanism isn't enough to justify splinting anything else. It's splinting AND signs/symptoms.

My point about the simplification of splinting, such as in the example of spine and cervical, was meant to be overly simple to dove tail into my next paragraph about the mind set of this longtime standard. I'm not a neophyte when it comes to signs a symptoms to justify splinting.

My point was, in a round about way, to point out that spinal immobilization is one of the the most prominent immobilization methods taught and used in EMS. To just up and change the standard to a suggested example that no immobilization is required is one that will clearly take strong scientific study to support.

There does appear though more and more support for definitive c-spine clearance protocols based on what the current studies have yielded here in the States.

 

[downunderwunda]

Yes, I do pad my pt's on the LSB. I have been on to many and know what is needed to make them more comfortable.



The LSB was designed to imobilize, not extrication. Does it do a perfect job, NO. Do we need them as often as they get used, NO. Until the MD's step up and put an end to imobilizing every mvc or fall, we have no choice. So you must do the best with what you have.

We can argue the use of them all day long on here. It makes no difference. The MD's are the ones that make that decision and I don't see them changing it as a standard, any time soon. They are all worried about the liability issues involved.

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.

 

[Veneficus]

food for thought

My point was, in a round about way, to point out that spinal immobilization is one of the the most prominent immobilization methods taught and used in EMS. To just up and change the standard to a suggested example that no immobilization is required is one that will clearly take strong scientific study to support.

Ok, I’ll bite.

Splinting to reduce motion. When you look at the shape of the spine, how do you reduce motion and still maintain lordosis and kyphosis? If you force a patient flat on a board, you are bending the spine you are trying to immobilize out of its anatomical position. There are no other splinting techniques that cause pressure points. Would you do this to any other bone? I am not against splinting, but I doubt the board actually splints. It can’t possibly immobilize the joint above and below the fx. Especially since in a supine position the distance between vertebrae increases. In addition the musculature holding the spine is quite strong, so when you place a person on a board and you relax one set of muscles, the opposing pulls against it, causing further stress if not outright movement.

Then, you have other issues, decubs, reduction in chest wall expansion, maintaining airway etc. which causes agitation and further movement. You give some 80 y/o person with limited mobility and circulation a decub and you might as well have just euthanized them instead of boarding them. Even if they are healthy you may cause other health problems that will increase the amount of time/money, etc that recovery takes.

I understand risk stratification, but spinal precautions in house do not include a board, how are principles of medicine somehow different outside the hospital?

 

[Wyoming Medic]

Splinting to reduce motion. When you look at the shape of the spine, how do you reduce motion and still maintain lordosis and kyphosis? If you force a patient flat on a board, you are bending the spine you are trying to immobilize out of its anatomical position.

The only way that I can see backboarding as "out of anatomical position" is if you use cargo ratchet straps and apply so much force that you actually force the spine flat. With proper padding and packaging techniques, I see no difference in placing somebody supine on a board and them sleeping supine in bed. Yes the board is more uncomfortable BUT is it really that different from a bed?

I also feel like your post indicates that the patient is MORE likely to see spinal movement due to being boarded. I just cannot visualize this. I have been boarded (as I am sure we all have) both in the classroom setting and for personal injury many times. I can safely say without a doubt that it limits my movement.

It prevents me from having to use (or severely decrease the requirements) my musculature to keep me from moving while the ambulance transports me down a bumpy road. It makes it so that I do not have to support my own weight as I am being transferred from ambulance to ER to radiology ETC. The straps provide a way for force that is applied to the board to be transferred to my skeleton in other places that it would not otherwise be possible.

I agree that backboarding a patient is NOT immobilization but it is the closest thing that we have in an ambulance. And as I have stated before, I think that it does limit the movement of the spine and can make moving a patient easier and safer. Once in the hospital they do not have to contend with the movement that an ambulance has. They do not have to fear getting rear ended at a stoplight. They have multiple people to move and control a patient while on the streets, we (as in many parts of the country) may only have 2 people on a scene. They also have limitless time and space which we all know are both at a premium on an ambulance.

I am very open to new ideas but at the same time, I feel that I can secure a patient to a backboard and at least reduce the chance of further spinal compromise. I understand the various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has and until I am introduced to a viable option THAT MY MEDICAL DIRECTOR APPROVES OF, I am going to continue using it.

Movement limitation is key in my book and boarding is as close as we can get in the field.

Wy medic

 

[Veneficus]

I feel that I can secure a patient to a backboard and at least reduce the chance of further spinal compromise.

I have seen ~7 studies that says no benefit or harm. In addition, multiple countries have abandoned this practice based on the opinion of expert physicians. You have a feeling? Why do I try to raise the respect for EMS providers with other health care practicioners?

I understand the various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has.

Says who?

 

[downunderwunda]

various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has

I say again, evidence based practice. Where is your evidence?

Veneficus has sighted studies stating there is no benefit.

You state

various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has

so where is your evidence?

tTo hide behind the statment

until I am introduced to a viable option THAT MY MEDICAL DIRECTOR APPROVES OF, I am going to continue using it

in a foorum that has challenged yu to use your own mind, offer your own opinions shows the sad state of most EMS providors. You should have enough education to know the difference & when someone shows you, take that advice & look at how you can submit a proposal to your medical director. That is how we effect change. But do not hide behind a lame no brain excuse like that.

 

[fortsmithman]

My understanding is if it isn't approved by the medical director and something goes wrong and civil litigation follows then be prepared to lose everything to the pt and the pt's family in court. Civil juries are funny like that. If the medical director sys backboard then backboard it is if the medical director says no then don't. Simple as that.

 

[downunderwunda]

My understanding is if it isn't approved by the medical director and something goes wrong and civil litigation follows then be prepared to lose everything to the pt and the pt's family in court. Civil juries are funny like that. If the medical director sys backboard then backboard it is if the medical director says no then don't. Simple as that.

with all due respect, that isnt what i said in my last post.

I will, for clarity repeat myself.

This is a forum to challenge your thinking. To allow different ideas to permeate your mind. To see othe points of view.

Then it is up to you what you do with it. My challenge to Wyoming Medic was to not hide behind

THAT MY MEDICAL DIRECTOR APPROVES OF

but to look outside his little area that he works in, to see there are other points of view, that are as valid, and possibly more medically correct than the practice he currently employs.

If you think I am stupid enough to tell someone to stop doing what they are, rightly or wrongly, instucted & offered protection through protocols, that is your perogitive. However, the only way things will get changed is if the so called 'educated' among us use that knowledge, reseach topics properly & present findings to medical directors & protocol committees. I am not saying every change will be greeted with open arms, far from it. To sit on your hands and do nothing because

THAT MY MEDICAL DIRECTOR APPROVES OF

is tantamount to malpractice.

Since we are discussing spinal patients, 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?