GSW and backboard?

[Hastings]

LMAO agree to full back board????? I didn't realize they had to agree. Isn't that what Duct tape is for????????

...I actually don't forcefully restrain patients with a GCS of 15 - or any patient not an immediate threat to me and others - with duct tape or otherwise.

Call me a softie, but I like to explain the situation to my patients and, yes, get their verbal consent.

 

[LE-EMT]

Well sir if the individual is not cooperating and will not "agree" to a full back board then in my opinion they are a danger to themselves and coincidently ME. If I feel you need to be placed on a back board with full C-spine precautions then transporting you any other way would be endangering your well being. Any other way is a risk and a liability.
Oh and "softie" the duct tape was a joke and I figured you would probably gather that.

 

[Hastings]

Well sir if the individual is not cooperating and will not "agree" to a full back board then in my opinion they are a danger to themselves and coincidently ME. If I feel you need to be placed on a back board with full C-spine precautions then transporting you any other way would be endangering your well being. Any other way is a risk and a liability.

Actually, physically restraining an otherwise compliant individual is the risk and liability. There are other ways of protecting the C-Spine that you can negotiate with. I'd rather take a patient in with decent C-Spine immobilization willingly than one unhappy, possibly violent, in full C-Spine immobilization. At least, in this case. Critical car accident? A little different. But physically restraining a simple GSW victim is not worth it one bit. Plus it'll blow any chances of the patient letting you or the hospital staff do anything else to them.

 

[LE-EMT]

you will also have to take into account although it is not your job......... But why and by whom was this person shot. Maybe its just the former cop in me but the person may not just be a vic. Soooo you get the "boys in blue" to ride with you whether you like it or not. Possible flight risk and all that happy stuff. pt would need to be searched for fire arms or weapons of their own on their person. Generally speaking there is more to a GSW then it appears to be. I am going to want to question this individual after he is stabilized in the ER. So precautionary I am atleast going for a ride with you.
I also don't see any GSW as simple..... In my experience they tend to be very complex. depending on the caliber used, the kind of fire arm, and the type of ammunition. Study balistics and the effects of a bullet on human tissue. NEVER SIMPLE.

 

[Hastings]

you will also have to take into account although it is not your job......... But why and by whom was this person shot. Maybe its just the former cop in me but the person may not just be a vic. Soooo you get the "boys in blue" to ride with you whether you like it or not. Possible flight risk and all that happy stuff. pt would need to be searched for fire arms or weapons of their own on their person. Generally speaking there is more to a GSW then it appears to be. I am going to want to question this individual after he is stabilized in the ER. So precautionary I am atleast going for a ride with you.
I also don't see any GSW as simple..... In my experience they tend to be very complex. depending on the caliber used, the kind of fire arm, and the type of ammunition. Study balistics and the after math of a bullet on human tissue. NEVER SIMPLE.

Police are always on scene first in this area to search everyone. Otherwise, a patient isn't a danger to myself or others until he proves otherwise. And only once he does will force be used. However, forcefully backboard them, whether they were originally or not, will cause them to become aggressive.

I'm not a police officer. I'm 5'11 and 130 lbs. I'm going to take the diplomatic route.

 

[LE-EMT]

WOW and after that pt proves that he is a danger to you and or your crew by hmmmm knocking you out, using your equipment against you, Stabbing you with your sheers, strangling you with your stetho, putting your fancy little note taking pen into the side of your neck/eye.............How do you use force when you are dead or unconscious???? Not all pt are the little old man with heart problems...... not all weapons are the assumed guns and knives.

 

[JPINFV]

LMAO agree to full back board????? I didn't realize they had to agree. Isn't that what Duct tape is for????????

If I'm A/Ox4 and fully understand the impact of my refusal of certain treatment modalities and you force them on me anyways, you won't be in EMS, and probably public, for long. Yes, the patient essentially has to agree to being treated. Now most patients give tacit agreement, but if a patient refuses then yes, you can't force it on them.

 

[Ridryder911]

My unit, my patient, my treatment.. my way. Damn right they will be LSB if there is a real potential of risks or danger to the patient. Quick & to the point, don't want LSB then you don't want tx. .. Inform the risks, sign here for refusal AMA..

Sorry, patients have the right to refuse tx modalities, as well as I have the right to inform them that they are endangering themselves. Sorry, I don't cuddle nor ask the patient what they want.. They called me, not vice versa.

On the given scenario that was given the patient should & could had been immobilized using alternative methods.. hence, why EMT's & Paramedics have to have critical thinking skills.. (thinking outside the classroom & box). Learn to improvise & adapt.

The first thing the patient will say is that they were not fully aware of the risks if there was spinal injuries afterwards & one did not take precautions. Even informing them maybe worthless, as there is more and more descriptions that they... "were under distress at the time & could not make a reasonable decision"... Attorneys love that excuse, as well did you really inform them of all the risks & potential risks, as well as alternatives?

Again, the key to this scenario was that improper treatment was performed. A GSW to the thoracic cavity, even stating it was near bony prominences. Sorry, this is something that should had been taught from day one. Now that it has been discussed, we all make mistakes and now learn from that and glad nothing severe came from it and move on.. not to repeat the same mistake again.

R/r 911

 

[boingo]

There is no evidence to suggest a patient with a penetrating GSW to the torso should have spinal immobilization. If you protocol says to do it, fine, but the evidence doesn't support it. There are numerous studies on this subject, JP referenced a few. How many soldiers to you think get a back board for a GSW? None. If the patient doesn't present with neuro deficit, they won't. The neuro deficit associated with GSW's is present at time of injury or not at all. Do your patients a favor and spend the extra 3 or 4 minutes getting them to a surgeon.

 

[mikeylikesit]

There is no evidence to suggest a patient with a penetrating GSW to the torso should have spinal immobilization. If you protocol says to do it, fine, but the evidence doesn't support it. There are numerous studies on this subject, JP referenced a few. How many soldiers to you think get a back board for a GSW? None. If the patient doesn't present with neuro deficit, they won't. The neuro deficit associated with GSW's is present at time of injury or not at all. Do your patients a favor and spend the extra 3 or 4 minutes getting them to a surgeon.

soldiers don't get a backboard when their shot...but they get the mobile stretchers for sure if it is not in a hot zone. i can understanding maybe not using a LSB on a GSW with an entrance and exit wound no where near the spine with a large caliber gun. but if there is no exit wound and the caliber is small enough or fired from a distance far enough away to cavitate, then I'm using that LSB. that bullet could easily have bounced around and hit or nicked or even be logged in the spine, unless you have superpowers with X-ray vision, good luck telling me a sure answer.

 

[boingo]

I'm not telling you not to use one, you can board all the patients you like. What I am saying is the evidence doesn't support it. If the patient suffering from a penetrating injury doesn't present with neuro deficit, he won't. Has it ever happened in the history of mankind? Probably, but that isn't what we base our treatment on.

 

[Ridryder911]

I'm not telling you not to use one, you can board all the patients you like. What I am saying is the evidence doesn't support it. If the patient suffering from a penetrating injury doesn't present with neuro deficit, he won't. Has it ever happened in the history of mankind? Probably, but that isn't what we base our treatment on.

Seriously, you have evidence that a shrapnel or penetrated bullet near spinal cord should not be immobilized? Sure allow them to move around and penetrate through the sheath... see what happens.

I have read those studies and do understand them, as well as the point of different type of injuries occurring too. High velocity is much different.

Also, military does not really care about such a thing as malpractice.. until it is a standard of practice other than theory.. one better board them until it is a standard of practice.

Just glad I am not your malpractice carrier...

R/r 911

 

[boingo]

Your right, high velocity is much different, there is a far greater chance of spinal injury in a high velocity injury as opposed to a low one, however even in this group, the patient either present with deficit, or they don't have one.


We don't routinely immobilize penetrating trauma victims because we generally work within the guide of best evidence. Our medical director, and heads of trauma surgery at the area trauma centers are all in agreement on this topic. Even penetrating neck injuries without deficit don't get immobilized.

As far as the military and malpractice, I don't exactly follow. Are you suggesting that military health care personell forego spinal immobilization because the soldiers can't sue? That is rediculous. The best studies on trauma management come from the military because of sheer volume of cases, not for lack of proper care for wounded combatants.

The U.S. experience mirrors that of the Israeli's on this topic. There is also civilian literature on the topic as well, and all tend to come to the same conclusion. If there is a deficit it is at the time of presentation, not some down stream phenomenon.

As far as my malpractice carrier, I wouldn't worry too much about it. I work under guidelines set forth by folks smarter than you and I combined.

 

[Ridryder911]

I realize that it will probably be a standard at one time. Just remember, one is judged on national standards, current curriculum, and "what others would have done" (peers) that are at the same or equal level as you.

As well, do I believe the military perform procedures that they know that the normal laymen/provider could be sued for? Oooh surely not?... .. That has never happened huh? Even look at V.A. centers for testing ground for medications...

I realize there will be plenty of changes that will occur. There will be as well many journal articles and hypothesis, but until they have been well founded in the civilian setting as a national standard of practice and published as such they will be just that. It takes a while for such to be a national standard to change after years of research and again many more articles.

R/r 911

 

[Hastings]

Interesting, completely unrelated comment.

We have an ER doctor here who, as soon as we bring in a trauma of any type that is backboarded (even MVA), unstraps the patient and sits them up first thing. I'm not a fan. I can't believe he's still around. We certainly make sure we document especially well the C-Spine precautions we took when he's on.

 

[fma08]

not to beat a dead horse here, but again... how do we know that the bullet is/isn't sitting right next to the spinal cord, or any number of nerves running through the body? i would think that until we know for sure (x-ray or such) that we don't want the patient moving excessively so as to agitate that. They may move in such a way that instead of having numbness, paralysis, or such, maybe they live in chronic pain due to a pinched nerve or such. It just seems to me that at a very least, we should keep a situation from getting worse. And to assure that in such a case like a GSW near the spine, that would mean have them immobilized. Not saying necessarily flat on their back on a long bored. I've been there and it sucks for any length of time. But like rid said earlier, get creative and come up with something else... just my lowly 2 cents.

 

[LucidResq]

Now correct me if I'm wrong here, but in the field you're not checking for sphincter tone and deep tendon reflexes and full motor function, so how positive can you be that the patient does not have a neuro deficit? I would think that the relatively simple AVPU, AAOx3, GCS and CSM assessments are not comprehensive enough to truly rule out neuro deficit to the point that I would feel comfortable neglecting to backboard someone with a penetrating injury so near the spinal column just because they show no neuro deficit in my quick field assessments.


And I do believe that there are patients who may not have neuro deficits now, but once they get moved around a lot and that bullet/bone fragment/whatever is bumped, they will have a deficit, and as a provider you'll be in deep... poop. I know that this may be an extremely rare circumstance, but why risk exacerbating that circumstance when the consequences are so grave, preventing that problem is so easy, and in the field you can never prove that the patient is not in that circumstance? You just can't.

The reality is, yes being on a backboard for a long time may suck. Been there, done that.... fell out of a tree, had numbness, tingling and intense pain shooting down my legs so I got to lay on a board and stare at the ER's ceiling for 6 hours only to find out that I bumped my sciatic nerve and I was fine. I lived. It was a little uncomfortable but it's really not that bad.

If done properly, what's the worst case scenario of backboarding someone? They get a decubitus ulcer? Complain about it? Sorry, but I don't believe that taking the extra 3-4 minutes to board a patient is going to affect their survival, even if they're bleeding like a stuck pig into their body cavities. As long as the patient isn't on the tracks about to get hit by a train or having major scary airway issues, I see no reason to completely abandon protection of their spine. Yes, they may need surgery. They may not. Either way, with this patient do you really think that they would have been risking his life by spending 3-4 more minutes on scene?

 

[traumateam1]

Now correct me if I'm wrong here, but in the field you're not checking for sphincter tone and deep tendon reflexes and full motor function, so how positive can you be that the patient does not have a neuro deficit? I would think that the relatively simple AVPU, AAOx3, GCS and CSM assessments are not comprehensive enough to truly rule out neuro deficit to the point that I would feel comfortable neglecting to backboard someone with a penetrating injury so near the spinal column just because they show no neuro deficit in my quick field assessments.


And I do believe that there are patients who may not have neuro deficits now, but once they get moved around a lot and that bullet/bone fragment/whatever is bumped, they will have a deficit, and as a provider you'll be in deep... poop. I know that this may be an extremely rare circumstance, but why risk exacerbating that circumstance when the consequences are so grave, preventing that problem is so easy, and in the field you can never prove that the patient is not in that circumstance? You just can't.

The reality is, yes being on a backboard for a long time may suck. Been there, done that.... fell out of a tree, had numbness, tingling and intense pain shooting down my legs so I got to lay on a board and stare at the ER's ceiling for 6 hours only to find out that I bumped my sciatic nerve and I was fine. I lived. It was a little uncomfortable but it's really not that bad.

If done properly, what's the worst case scenario of backboarding someone? They get a decubitus ulcer? Complain about it? Sorry, but I don't believe that taking the extra 3-4 minutes to board a patient is going to affect their survival, even if they're bleeding like a stuck pig into their body cavities. As long as the patient isn't on the tracks about to get hit by a train or having major scary airway issues, I see no reason to completely abandon protection of their spine. Yes, they may need surgery. They may not. Either way, with this patient do you really think that they would have been risking his life by spending 3-4 more minutes on scene?

I agree 110%.

 

[boingo]

There is no National Standard, hell, there is no standard across county lines, let alone across the nation (US). How many systems do you think still advocate w/o fluids for hypotensive trauma patients? MAST trousers? Hyperventilating head injuries? Studies have shown that what we once believed helpful was actually not. How long should a system wait until they change the way they approach patient care? Do we need Dr. Pepe to tell us when? Seattle Fire department? Department of Transportation, god forbid?

I am not telling anyone to change the way they do business, they should follow local guidelines, however there is good data out there that would suggest to elect not to board the patient with a penetrating injury to the torso is not negligent, in fact, it is based on sound medical research. Deviating from protocol on the other hand could get you into trouble. As I have stated, I am not required to board this class of patient, and don't. I utilize tourniquets on vascular injuries by department guidelines, and good evidence based medicine. The vascular surgeons who lecture for us are 100% in favor of this.

Look at therapuetic hypothermia for ROSC in the medical arrest patient. If someone were to pack their patient in ice based on the research, yet against protocol they would be in a world of trouble. Systems that choose to utilize TH do so because of good science. It is certainly not a National Standard, and probably won't be for some time. Doesn't mean it isn't the right thing to do.

 

[Ridryder911]

There is no National Standard, hell, there is no standard across county lines, let alone across the nation (US). How many systems do you think still advocate w/o fluids for hypotensive trauma patients? MAST trousers? Hyperventilating head injuries? Studies have shown that what we once believed helpful was actually not. How long should a system wait until they change the way they approach patient care? Do we need Dr. Pepe to tell us when? Seattle Fire department? Department of Transportation, god forbid?

I am not telling anyone to change the way they do business, they should follow local guidelines, however there is good data out there that would suggest to elect not to board the patient with a penetrating injury to the torso is not negligent, in fact, it is based on sound medical research. Deviating from protocol on the other hand could get you into trouble. As I have stated, I am not required to board this class of patient, and don't. I utilize tourniquets on vascular injuries by department guidelines, and good evidence based medicine. The vascular surgeons who lecture for us are 100% in favor of this.

Look at therapuetic hypothermia for ROSC in the medical arrest patient. If someone were to pack their patient in ice based on the research, yet against protocol they would be in a world of trouble. Systems that choose to utilize TH do so because of good science. It is certainly not a National Standard, and probably won't be for some time. Doesn't mean it isn't the right thing to do.

I agree with you 99% and really understand and promote the care you are describing; however I disagree there is a so called national standard. Even physicians that are allowed to practice medicine upon their own discretion are judged against such standards. The reason any study has to be approved before hand by committees and boards as well as closely monitored.

Again, when one is in a courtroom, you will see such standards as the curriculum (even though antiquated) National publications and programs such as ACLS, PHTLS, ITLS, etc.. even though they maybe considered antiquated as well, but they are published and endorsed by organizations of respectable professionals. Again, I agree upon your statement, but that does not change what occurs.

R/r 911