# Back Boarding



## Sasha (Apr 13, 2009)

After the I'm Confused thread, I did a little bit of searching for articles on backboarding, and here's two articles I found interesting

Previously I was in the "What could it hurt?" camp. According to this article, it can hurt quite a bit!



> The act of immobilizing a cervical spine is not a completely benign process. It taxes the patient financially and physically.* Spinal immobilization is estimated to cost $15 or more per patient*, leading to more than $75 million a year in extra medical expenses.2
> 
> According to current ATLS teaching, a cervical spine is not immobilized properly unless the patient is placed in a semi-rigid collar, then strapped and taped to a rigid backboard.3This can be an uncomfortable and traumatic procedure in itself. *It has long been known that long-term exposure to a c-collar and backboard can lead to decubitus ulcers and pain.*
> 
> In a study of 21 healthy individuals placed in full spinal immobilization, *all were found to have immediate pain, with six patients complaining of delayed symptoms from the immobilization 48 hours later*.4 There also is the possibility of further damage to a spinal injury from manipulating it into a cervical collar.





> *The researchers found less disability (even in the patients with fractures) in the nonimmobilized *patients than the immobilized patients.5The study has limitations, but it certainly supports further investigation into the value of cervical immobilization in all trauma patients.



The article also refrences another study which uses five criteria to rule out the need for immoblization



> The five criteria are no focal neurologic deficits, no intoxication, alert and oriented times three, no distracting injury, and no midline cervical vertebral tenderness.



And the results:


> By using these criteria on 34,069 patients, 810 of 818 cervical spine injuries were identified and filmed appropriately. Of the eight missed injuries, only two were considered clinically significant. In addition, 240 of the total fractures were deemed clinically insignificant, occurring in either the spinous or transverse processes and having no risk of neurologic injury. Of the 34,069 patients enrolled in this study, it was estimated that by using these five criteria, 4,309 patients did not need to be evaluated with x-rays



And here's a study that there may be less benefit to backboarding than EMT texts lead you to believe.



> A 5-year retrospective chart review was carried out at 2 university hospitals. All patients with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal immobilization during transport, whereas all 334 patients seen at the University of New Mexico did.





> There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03; 95% CI 1.03-3.99; p = 0.04). This corresponds to a <2% chance that immobilization has any beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries (OR 1.52; 95% CI 0.64-3.62; p = 0.34). CONCLUSION: Out-of-hospital immobilization has little or no effect on neurologic outcome in patients with blunt spinal injuries.



And looking at it from a personal, non sciencey side... I, like many others, was backboarded (although only for a short time) in EMT school by practicing classmates. In the short time I was backboarded I found myself squirming around in the C-Collar, headblocks and straps trying to get comfortable and I was completely okay and cognizant of what was going on. I couldn't imagine having to in those for any length of time. Would you not think that a person is less likely to try and move laying down on a slightly more comfortable stretcher for a nice ride to the hospital, or immoblized in an uncomfortable, unanatomically correct position? Look at your spine, then look at a spine board. We have some natural spinal curvatures! We're not flat, and we aren't meant to be.


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## Mountain Res-Q (Apr 13, 2009)

For those that haven't read my profile, I am also an EMT Supervisor at a 60 acre snow park.  We specialize in snow tubing.  Speeds reach the 20-30.  You have no seat belt.  You have no breaks.  You have no helmet.  You have no control.  We see our fair share of wipe-outs.  Based on the MOI of most crashes you would almost wnat to backboard everyone.  Our policy is that when we witness a crash we walk (not run) to the scene.  The 90 seconds it takes to get there (versus 60 running on ice and snow) gives us time to evaluate the patients reactions.  Often they bounce right up and are laughing their butts off.  We still ask if they want to be evaluated to CYA, but we are nt going to force them onto a backboard because the MOI was there.  50,000 customers see our mountain a year and we only backboard a half dozen at most (actually none this year).  One of my duies is to train teh newbies (usually fresh out of EMT or FR and only with us for a season), and they are so inundated with "backboard, BackBoard, BACKBOARD," from class, that they don't understand that not everyone needs a backboard, any more than not every fracture needs traction.  There is a time a place for them, and you had better be sure that you use one when _needed_.  If we place a non-spinal muscle strain on a backboard, just because "they have some pain an were in a high speed crash", we are not getting them off until ALS Medics show up in 45-60 minutes.  On the other hand, I bette not see a 60-year-old woman who is in so much pain that she can;t stand up be told by one of my people that it is probably a strain, take a few minutes, and we will try to walk it off."  The point is that backboards have there place, like everything else, and shouldn't be slapped on every trauma patient just to CYA.


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## NEMed2 (Apr 13, 2009)

There has been "talk" for some time about giving EMT-B's in CT the ability to clear c-spine in certain circumstances.  I'm not going to hold my breath on that one, I'm still waiting for the new EMT-I criteria to be made effective.

I agree that not everyone needs to be boarded.  Putting 90 yo granny on a backboard can cause significantly more damage than allowing her to sit comfortably. But, for now I don't have the ability to clear c-spine and unless the pt is capable & refuses that care, it's required by my medical control.


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## medic417 (Apr 13, 2009)

Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically.  Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.


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## NEMed2 (Apr 13, 2009)

medic417 said:


> Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically.  Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.



Agreed.  It makes me cringe to know Basics aren't requried to take CEs.


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## JPINFV (Apr 13, 2009)

^
To be fair, a lot of EMT-B level CMEs are so watered down or generalized that they are next to useless anyways.


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## Mountain Res-Q (Apr 13, 2009)

NEMed2 said:


> Agreed.  It makes me cringe to know Basics aren't requried to take CEs.



By CE's I take it you are refering to Continuing Education Credits.  They don;t have to in your neck of the woods?  And out here in Calif, I've deen putting out good money every year.  I need to move to your state.

We all know Backboarding is overdone in general.  If beefing up training is what is needed, fine.  But too amny EMT's and Fr I know adhear so closely to following Step 1, Step. 2, Step 3" that they don't think for themselves.  If all it takes to run EMS is the ability to follow an instruction manual, then what good ar BLS level providers.  There should be criterial for backboarding, but not an overkill of everyhting gets a backboard, it is medically speaking irresponsible, and so may the training standards for certain levels of EMS in certain areas.


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## MSDeltaFlt (Apr 13, 2009)

Sasha said:


> After the I'm Confused thread, I did a little bit of searching for articles on backboarding, and here's two articles I found interesting
> 
> Previously I was in the "What could it hurt?" camp. According to this article, it can hurt quite a bit!
> 
> ...


 
There are those that need backboarding, and there are those that may not.  The key is assessment as you have referenced.  I don't mean a quick glance over.  I mean a detailed hands on assessment.

Ask yourself these questions.  Is his/her neck/back broken?  If yes, board them.  If not sure, follow protocols.  Assess and make a decision if allowed to do so.  

As far as MOI goes, it all refers to how much of a change in velocity and how many different changes in velocity your pt receives.  There are very few true mechanisms of injury.  A fall 3X pt's height and rollover MVC with ejection are two for sure.  As always you need to put your hands on your pt and assess them.

One more thing.  I've said this multiple times I know.  I aplologize.  It's just that this is one of my quirks.  But noone has their cervical spine truely immobilized until they have a halo placed on their skull.  Everything else is only restrictive.

Good article, Sasha.


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## downunderwunda (Apr 14, 2009)

I seem to remember bieing abused here 

http://www.emtlife.com/showthread.php?t=11148

for suggesting the same.

Maybe I am not as ignorant as people like to think.


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## lightsandsirens5 (Apr 14, 2009)

Sasha said:


> ........or immoblized in an uncomfortable, unanatomically correct position? Look at your spine, then look at a spine board. We have some natural spinal curvatures! We're not flat, and we aren't meant to be.



Sasha! There is a wonderful oppurtunity! 

1) Invent a new ridgid adjustable backboard the is shaped like a spine.
2) Patent it.
3) Sell patent or rights to manufacture to Ferno. (Or somone)
4) Retire and live happily ever after.


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## LucidResq (Apr 14, 2009)

This discussion brings to mind the use of full body vacuum splints for immobilization. Does anyone use them? A few other SAR teams out here are in love with them. We have one, but it's a piece of junk and I refuse to use it. I'd like to try out a newer one that works correctly, however. 

Here's a study on their use.



> In conclusion, the vacuum splint is an effective and more comfortable alternative to the backboard for cervical spine immobilization.



A few other studies I've seen generally agree.


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## EMT007 (Apr 14, 2009)

> There has been "talk" for some time about giving EMT-B's in CT the ability to clear c-spine in certain circumstances. I'm not going to hold my breath on that one, I'm still waiting for the new EMT-I criteria to be made effective.





medic417 said:


> Sorry basics should not have selective spinal immobilization protocols until the education requirement increases drastically.  Basics and sadly many Paramedics do not get enough A&P to have any clue as to what is going on.



Well thats the beautiful thing about the NEXUS criteria. You don't really need to know much A&P to use them, and they have been shown to be 99.8% sensitive for spinal cord injury. Studies have shown that EMT-B's trained to use the criteria are just as accurate with proper clearance as paramedics.

And selective spinal immobilization protocols are already in use by basics all over the country (I did a lot of research about this, as I proposed to get this protocol approved for my BLS agency). 

Here are the references, if you're interested...

__________________

_Domeier, et al: Prospective Performance Assessment of an Out-of-Hospital Protocol for Selective Spine Immobilization Using Clinical Spine Clearance Criteria. Ann Emerg Med. 2005; 46: 123-131

Domeier, et al: The reliability of pre-hospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury. Prehosp Emerg Care. 1999; 3: 332-337

Dunn, et al: Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol?: a preliminary report. Prehosp Emerg Care. 2004; 8(2): 207-211

Sahni, Menegazzi, Mosesso: Paramedic evaluation of clinical indicators of cervical spinal injury. Prehosp Emerg Care. 1997; 1: 16-8 

Hoffman, et al: Validation of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000; 343: 94-99

Stroh, Braude: Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization. Ann Emerg Med. 2001; 37: 609-615._


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## Veneficus (Apr 14, 2009)

LucidResq said:


> This discussion brings to mind the use of full body vacuum splints for immobilization. Does anyone use them? A few other SAR teams out here are in love with them. We have one, but it's a piece of junk and I refuse to use it. I'd like to try out a newer one that works correctly, however.
> 
> Here's a study on their use.
> 
> ...



You use them here, pt is extricated with the board, then transferred to the splint before transport. They seem to be a better alternative used this way, but I haven't seen an actual spinal injury pt with cord compromise on one yet. Just a lot of transverse and spinous process fx. (which doesn't require a board either)


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## Scout (Apr 14, 2009)

L&S that wouldt work becuase you would have trouble rolling and sliding the board in and out.

As for the vacume splints They are great its like a snug roll of silk in comparison to a slab of plastic. But they are massive and take up loads of room.

I did see a concept thing a while back, it was a sheet of foam that was vacume sealed in a bag the lenth of a board, you opened it somehow and then it inflated about an inch or so and relieved the pressure like a spunge. Duno why it did't make it further.


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## Sasha (Apr 14, 2009)

> 4) Retire and live happily ever after.



That sounds like way too much work.

My future plans still include marrying rich and widowing early.



Just kidding!


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## Sasha (Apr 14, 2009)

More Vacuum Splint Reading. 

http://cat.inist.fr/?aModele=afficheN&cpsidt=3180275


> The vacuum splint was judged to be significantly more comfortable on a 10-point scale than the rigid backboard after subjects had been lying on each device for 30 minutes (P <.001). It was also taster to apply : 131.6 ± 24.3 seconds versus 154.6 ± 22.2 seconds (P <.001). Various measures of immobilization were similar for the two devices. The vacuum splint provided better immobilization of the torso and less slippage on a gradual lateral tilt. The rigid backboard with head blocks was slightly better at immobilizing the head.



http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1323441


> We found that the Cervical Vacuum Immobilizer limited cervical spine range of motion in forward flexion, extension, and lateral flexion. The Cervical Vacuum Immobilizer can be easily placed on an injured, fully equipped football player and serves to limit cervical spine range of motion while the athlete is immobilized and transported. Future research should determine how the Cervical Vacuum Immobilizer limits range of motion with the athlete immobilized to the spine board.


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## LucidResq (Apr 14, 2009)

One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.


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## Scout (Apr 14, 2009)

LucidResq said:


> One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.




get your suction unit on to it and give it a suck on a low setting.

not quiet but it did work,

edit, and duck tape!!!!!


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## Mountain Res-Q (Apr 14, 2009)

Scout said:


> get your suction unit on to it and give it a suck on a low setting.
> 
> not quiet but it did work,
> 
> edit, and duck tape!!!!!



Agreed Lucid, DUCK TAPE is the greatest thing in the wilderness setting.

You can role in you hands and use it for rappeling rope.
You can use it to patch up the hole in your Swiftwater Raft that has been there for 2 years.
You can fastened the tread back together on your snowmobile when it breaks.
AND you can use it to tape your victims mouth shut when you start the short haul. :unsure:

It's great.  How do you think NASA reattches those heat panels that keep falling off?


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## Veneficus (Apr 14, 2009)

LucidResq said:


> One of the concerns that has been raised with vacuum splints, especially in the SAR setting, is that if it gets torn somehow, you can kiss any immobilization goodbye.



vacuum in a stokes basket is a wonderful thing.


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## LucidResq (Apr 14, 2009)

Mountain Res-Q said:


> You can role in you hands and use it for rappeling rope.



I really hope you're kidding! Or that I've misunderstood you. But yes. Duct tape is fantastic. As far as blisters go, I prefer duct tape to any other type of dressing - mole skin, blister bandaids, etc. 



Veneficus said:


> vacuum in a stokes basket is a wonderful thing.



I've heard this too, and I definitely see the advantages. I know how awful it feels to be immobilized for 6 hours on a backboard in the comfort of the ER, and have been carried out on a backboard in a stokes or a thompson for 1-2 hours at a time in training. I can imagine it's much worse being on a backboard for a 6 hour carry out over rough terrain. I really wish my team had a nice one. We play with the one we have for training purposes, so people can learn to use one, but it does not go into the field.


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## Veneficus (Apr 14, 2009)

LucidResq said:


> I've heard this too, and I definitely see the advantages. I know how awful it feels to be immobilized for 6 hours on a backboard in the comfort of the ER,



I would have called a lawyer after 1 hour, and only because I am generous, there is no excuse at all for that.


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## Mountain Res-Q (Apr 14, 2009)

LucidResq said:


> I really hope you're kidding! Or that I've misunderstood you. But yes. Duct tape is fantastic. As far as blisters go, I prefer duct tape to any other type of dressing - mole skin, blister bandaids, etc.




Oh course I am!!!  Duct tape is thee greatest thing on the planet for anything wilderness related.  If it can't be done with duct tape, it can't be done.  We recommend that all team members keep it in their packs, which leads to some funny moments where newbies open their packs in teh field and out comes rolling a 500 foot role of industrial strenght stuff!


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## lightsandsirens5 (Apr 14, 2009)

Scout said:


> L&S that wouldt work becuase you would have trouble rolling and sliding the board in and out.



It _was_ just a joke.


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## CAOX3 (Apr 14, 2009)

Wasn't there a study conducted that found there was no benefit at all to pre-hospital immobilization?

I cant find it.


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## LucidResq (Apr 14, 2009)

Veneficus said:


> I would have called a lawyer after 1 hour, and only because I am generous, there is no excuse at all for that.



So here was the series of events - 

1. I fell about 10 feet out of a tree (I was 14 at the time) right onto my lower back/butt. At first I felt fine. 

2. Within an hour, I was in the worst pain I have ever experienced. Shooting pain from my waist down, extremely difficult to walk - nearly unable to, and weakness. 

3. Shuffled into the ER. Was backboarded in triage. 

4. Waited 6 hours for x-rays on a backboard. Staring at the ceiling.  

5. X-rays clear. Was discharged with a diagnosis of sacroiliitis and sent home with vicodin and instructions to rest. 

6. Improved over the next 48 hours. Normal within 72. 

7. Still occasionally dealing with pain from the incident, 5 years later. It's not a big deal. but I'm supposed to be in physical therapy for this (but I'm a bad girl and stopped going). 

I can't help but wonder if I'd be fine today had they not backboarded me and allowed me to be in a POC - which was definitely NOT lying supine, directly on the inflammed area on a hard surface. I would have rather been prone. It probably wouldn't matter long-term, but definitely in the short-term.


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## LucidResq (Apr 14, 2009)

CAOX3 said:


> Wasn't there a study conducted that found there was no benefit at all to pre-hospital immobilization?
> 
> I cant find it.



EMS Responder article about the Cochrane Review



> The readership is referred to the brief evidence-based emergency medicine report by Baez and Schiebel entitled, "Is Routine Spinal Immobilization an Effective Intervention for Trauma Patients?" which appeared in the Annals of Emergency Medicine in January 2006. The objective of this study was to quantify the effect of different methods of spinal immobilization (including immobilization versus no immobilization) on mortality, neurologic disability, spinal stability and adverse effects in trauma patients





> The authors searched all databases where peer-reviewed medical journal articles would be found, along with the Cochrane Controlled Trial Register for evidence of scientific trials. Then they contacted experts in the field and eight manufacturers of spinal immobilization devices to determine whether they were aware of any sound evidence for use of these devices that would not otherwise appear in the on-line search. The authors were unable to find a single randomized controlled trial of actual injured patients to support the efficacy and effectiveness of spinal immobilization strategies and spinal immobilization techniques. I*n other words, there has never been a study in the medical literature that proves that any form of spinal immobilization or any technique or device used during such immobilization actually prevents spinal cord injury or lessens morbidity from spinal column injury.*


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## CAOX3 (Apr 14, 2009)

Yes that was it thank you.


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## Foxbat (Apr 14, 2009)

I read that prolonged immobilization may increase the risk of formation of clots and subsequent pulmonary emboli. Can anybody comment on that?


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## Ridryder911 (Apr 14, 2009)

Foxbat said:


> I read that prolonged immobilization may increase the risk of formation of clots and subsequent pulmonary emboli. Can anybody comment on that?



Yes, any time the body is immobile or have the inability to circulate stasis occurs and clot formation can occur, if circulates can become an embolus. Remember, when pressure is applied even laying down there is pressure placed upon the capillary system and poor circulation can occur. 

R/r911


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## mycrofft (Apr 15, 2009)

*Wow, search this joint and you shall find lots on this.*

Spinal immobilization is the backbone (pun intended) of EMT-dom because MVA victims were being dragged into hearses and zoomed to hospitals with c spine damage, or at other levels. This was in the days with no shock absorbing steering columns, seatbelts were an option, and of course no airbags, safety designed interiors, crumple zones, and forty foot wide highway shoulders (fewer trees to smash into).
Sasha, I read most of those studies last year trying to convince my coworkers to stop unnecessarily or improperly using spine boards etc. It is a marketing problem not a training one here. There was a study also which showed that continuation of spinal immobilization in the hospital after _*inital*_ clarance by ED xray was not productive.
Folks need to remember that immobilization in the EMS sense and time frame is not a curative but a measure to prevent further exacerbation of a spinal injury during extrication and transport...in short, it is to protect the patient from US!!


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## Bullets (Feb 15, 2012)

After extensivly searching this site and coming up empty and combing though PubMed i come to you guys. I know this is an old thread. 

Myself and a few other providers, forward thinking EMTs and Medics have all approached our medical director individually  about revising our SMR protocols. His response was, "Show me the evidence and we will talk" and ive found lots of statements like "It has long been known that long-term exposure to a c-collar and backboard can lead to decubitus ulcers and pain." Which doesnt help me. 

Does anyone have links to actual studies which cite these kinds of claims?


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## TheGodfather (Feb 15, 2012)

Bullets said:


> After extensivly searching this site and coming up empty and combing though PubMed i come to you guys. I know this is an old thread.
> 
> Myself and a few other providers, forward thinking EMTs and Medics have all approached our medical director individually  about revising our SMR protocols. His response was, "Show me the evidence and we will talk" and ive found lots of statements like "It has long been known that long-term exposure to a c-collar and backboard can lead to decubitus ulcers and pain." Which doesnt help me.
> 
> Does anyone have links to actual studies which cite these kinds of claims?



have you searched studies focusing on the NEXUS criteria? that might be a start.

EDIT: are you only looking for studies related to decub ulcers? in that case, I'm not sure.


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## EpiEMS (Feb 15, 2012)

I can't help but wonder under what circumstances it might be appropriate (from a practical perspective, not so much a lawsuit perspective) for an EMT-B or FR to clear C-spine. Out in the woods, perhaps? In a military setting?


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## JPINFV (Feb 15, 2012)

Why would it ever be inappropriate for an EMT to utilize criteria such as NEXUS or the Canadian C-Spine Rule?


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## Handsome Robb (Feb 15, 2012)

EpiEMS said:


> I can't help but wonder under what circumstances it might be appropriate (from a practical perspective, not so much a lawsuit perspective) for an EMT-B or FR to clear C-spine. Out in the woods, perhaps? In a military setting?



You ever been strapped to a backboard for a long period of time? There's no reason to cause your patient unnecessary discomfort if we can clear their c-spine in the field.


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## Mountain Res-Q (Feb 15, 2012)

EpiEMS said:


> I can't help but wonder under what circumstances it might be appropriate (from a practical perspective, not so much a lawsuit perspective) for an EMT-B or FR to clear C-spine. Out in the woods, perhaps? In a military setting?



1.  Prolonged response time for the ambulance.  For comfort reasons, who wants to be on the board unnecessarily for that long?  Then there is the medical complications that we could be causing by doing so for hours on end (not everyone lives 5 minutes from a trauma center).

2.  Prolonged transport time.  Same reasons as above exist with the additional idea that you mentioned of "in the woods".  Do you know how hard it is to carry a 200lb person down a trail for hours?  If the neck can be cleared, the patient rested, and then assisted in walking out, then so much the better for us and for them.  Of course, the comfort of the rescuers is not more important that proper medical care, but when it is not needed, backboarding will cause more damage to patient and rescuers in this case.  Plus it ties up resources even in an urban setting. 

3.  Psychology.  The mind is as important as the body.  The result of a person being "immobilized" for hours on end lends itself to fear, anxiety, stress, and the belief that "the EMTs think something is wrong with me, my God, I might die!"  People who think they will die, tend to find a way to achieve their goal.

4.  "Because the protocol says so" should never be the standard for providing medical care.  I have a protocol that is very limiting when it comes to selective immobilization (even for medics), and I can tell you right now, I have refused to board people because _I KNEW_ it would cause more harm.  Later I discuss the case with Medics and ER Docs who agree that what I did was "EMSA Wrong", but Medically Right.  Had one like that 2 weeks ago.  Should have boarded him per protocol and MOI, but the end diagnosis was a exacerbation of a previous cord compression and boarding the overweight patient would have sent his 10/10 pain to a 20/10 pain.  That is bad medicine.  Oh, and medics were 45 minutes out from me and had a 60 minute transport time on mountain roads; not in the patients best interests to be boarded, so why do it?

5.  Patients in pain should not have more pain inflicted by EMTs just because the SOPs from the 1980's say "this is what you have to do or else they will all be paralyzed!"  I have know rock climbers to fall hundreds of feet and then be slammed into the wall without any injuries.  We have all seen the patient who rolls out of bed and breaks stuff.  MOI and protocol can cause more harm than good if imposed on the good and experienced provider.  That said, until standards are raised for certification and training, no EMT or EMR (in general) should not be granted the ability to think for themselves without their EMS Cookbook.  I shudder the thought when it comes to some of the newbies coming out of the local college.


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## EpiEMS (Feb 15, 2012)

[Stupid question]


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## TheGodfather (Feb 15, 2012)

EpiEMS said:


> Interesting stuff! What did you mean by clearing C-spine and then assisting walking? Wouldn't walking imply no C-spine problems? Or could they develop?


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## EpiEMS (Feb 15, 2012)

TheGodfather said:


>



Sorry. Wasn't thinking.


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## Handsome Robb (Feb 15, 2012)

EpiEMS said:


> Interesting stuff! What did you mean by clearing C-spine and then assisting walking? Wouldn't walking imply no C-spine problems? Or could they develop?



You can have spinal injuries that don't impinge on the cord thus causing none of the symptoms you would think. (numbness, tingling, weakness, paralysis, yadda yadda)

I had a high cervical fracture playing football in HS. Also had a wicked concussion so I don't remember much but according to the video I was doing plenty of fighting and moving even with a cervical injury. Needless to say I'm very, very lucky to have no deficits.


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## Mountain Res-Q (Feb 15, 2012)

EpiEMS said:


> Interesting stuff! What did you mean by clearing C-spine and then assisting walking? Wouldn't walking imply no C-spine problems? Or could they develop?



Not sure what you are asking...

If you have cleared the spine, then you have decided (based on an experienced medical evaluation) that there is no spinal involvement.  Therefore, if they can walk... then "Get off your *** and walk!  I am not a pack mule!"  :rofl:  Seriously, I don't care, if you are medically able to walk, then lets hold hands and frolic along the trail, but I am not carrying someone who does not need to be, for my safety and theirs!  If they 100% can't walk, then we move to plan B.  As far as c-spine issues developing... if their injury did not cause the problem, not sure how they could magically develop.  They were either there and were missed by the assessment or are not there; muscular problems, not spinal, which immobilization (by 2 CNAs overnight, in the middle of BF nowhere, until we could get there) will make worse..



EpiEMS said:


> Sorry. Wasn't thinking.



Welcome to the club... been that way for a few hours now...


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## EpiEMS (Feb 15, 2012)

Gotcha, I think I get it now. 

(My brain to finger filter was not operating properly.


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## TheGodfather (Feb 15, 2012)

Mountain Res-Q said:


> Not sure what you are asking...
> 
> If you have cleared the spine, then you have decided (based on an experienced medical evaluation) that there is no spinal involvement.  Therefore, if they can walk... then "Get off your *** and walk!  I am not a pack mule!"  :rofl:  Seriously, I don't care, if you are medically able to walk, then lets hold hands and frolic along the trail, but I am not carrying someone who does not need to be, for my safety and theirs!  If they 100% can't walk, then we move to plan B.  As far as c-spine issues developing...* if their injury did not cause the problem, not sure how they could magically develop.*  They were either there and were missed by the assessment or are not there; muscular problems, not spinal, which immobilization (by 2 CNAs overnight, in the middle of BF nowhere, until we could get there) will make worse..



really?

a seemingly "stable" and asymptomatic anterior subluxation could easily progress drastically worse from even the slightest passive ROM...


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## Bullets (Feb 15, 2012)

Ive looked for the nexus study, but ive come across two types of results. NEXUS v Candian, and WHAT the NEXUS is. Im looking for HOW NEXUS decided to put forth their standards.

Ive already got Cochrane

Ive also heard that is increases intercranial pressure, and i understand why, but does anyone have the reasons cited.

We are trying to write this proposal(and hopefully, protocol) to be easily accessible for some of our more...delayed providers. Not so much that we expect them to be breaking the sound barrier, but more for when our advanced (mentally) providers are working with them, we can show them the document and explain why we dont need to backboard every fall, MVC, ect


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## TheGodfather (Feb 15, 2012)

Bullets said:


> Ive also heard that is increases intercranial pressure, and i understand why, but does anyone have the reasons cited.



http://www.neurospineclinic.com.au/pdfs/journal-articles/hard-collar-icp.pdf

subnote: IMO,  I doubt you will be able to get your medical directer to budge even with this article due to the fact that if you have an unconscious patient with MOI significant enough to start getting you worried about the ICP, chances are you will need some type of cervical immobilization for the bumpy transport.


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## EMS123 (Feb 15, 2012)

It is a requirement in New York for RECERT or for the provider to take a refresher course... A LOT of training opp. are out there.



Mountain Res-Q said:


> By CE's I take it you are refering to Continuing Education Credits.  They don;t have to in your neck of the woods?  And out here in Calif, I've deen putting out good money every year.  I need to move to your state.
> 
> We all know Backboarding is overdone in general.  If beefing up training is what is needed, fine.  But too amny EMT's and Fr I know adhear so closely to following Step 1, Step. 2, Step 3" that they don't think for themselves.  If all it takes to run EMS is the ability to follow an instruction manual, then what good ar BLS level providers.  There should be criterial for backboarding, but not an overkill of everyhting gets a backboard, it is medically speaking irresponsible, and so may the training standards for certain levels of EMS in certain areas.


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## Bullets (Feb 15, 2012)

TheGodfather said:


> http://www.neurospineclinic.com.au/pdfs/journal-articles/hard-collar-icp.pdf
> 
> subnote: IMO,  I doubt you will be able to get your medical directer to budge even with this article due to the fact that if you have an unconscious patient with MOI significant enough to start getting you worried about the ICP, chances are you will need some type of cervical immobilization for the bumpy transport.



the issue myself and others have is that our protocols are written in such a way that MOI dictates when we provide SMR

"Spinal Immobilization should be provided to any patient experiencing a traumatic incident, including but not limited to: Motor Vehicle Incidents, Falls, Blunt Traumas, or other events that where the mechanism of injury could indicate a possible injury to the spinal column.  Spinal Immoblization should also be considered for patients who present with...(NEXUS criteria basically)"

We want to remove that first part, specifically the word "SHOULD". We also want to change the language to say "Spinal Motion Restriction" instead of Spinal Immobilization. We have suggested to basically apply the NEXUS formula and bump MOI consideration to secondary and only if a the provider can state why.


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## Mountain Res-Q (Feb 15, 2012)

TheGodfather said:


> really?
> 
> a seemingly "stable" and asymptomatic anterior subluxation could easily progress drastically worse from even the slightest passive ROM...



Progress being the operative word; the injury was already there and could become worse with or without backboarding.  Me?  I would prefer to not be strapped to a board with no control over what happens to me; but be allowed to walk or be assisted in walking with control over my actions.  Comfort and control play a role here.  Also, remember that my scenario was based on an "in the woods" idea without a known transport time, trail condition, or "the unknowns" that typically eff up the easiest of missions.

Yes, an "in the field" exam could miss many things if you forget you x-ray goggles (in my pack), but the oversimplified explanation I was making was that the chances of causing further injury because protocol says "BACKBOARD THE MOI" are far greater than the cases of not backboarding something that needed it.


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## DrParasite (Feb 15, 2012)

Can you ask him to show you the studies that say a person had a positive clinical experience when they suffered a spinal injury, which was mitigated because they were strapped to a LSB?

if he can't, maybe that should be enough justification for him to rethink their use.


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## JPINFV (Feb 15, 2012)

Bullets said:


> We also want to change the language to say "Spinal Motion Restriction" instead of Spinal Immobilization.



Is there any practical difference for this request? A duck by any other name is still a duck.


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## Mountain Res-Q (Feb 15, 2012)

JPINFV said:


> Is there any practical difference for this request? A duck by any other name is still a duck.



Truth in advertising.  Hard to call it immobilization and expect that from you when such a thing is impossible in the pre-hospital setting.  How about changing "Spinal Immobilization" to "Involuntary Spinal Restriction" and changing "Back Boarding" to "Water Boarding".  :rofl:


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