# Another backboard scenario!!



## Sublime (Jan 31, 2013)

Alright so had a transfer today that rather bothered me. Taking a 75 y/o lady on a 1 hr transport to a more definitive facility out of a small ER. 

She has diabetic neuropathy and little feeling in her feet which causes her to fall. Today she fell and hit the back of her head on the night stand. Result was a C6 compression fracture and small subdural hematoma. 

BP was 210/100 when we got there and she was being given hydralazine by nurse, doc wanted BP down before leaving. BP comes down to 200/95 while we're getting report and the doc states she can now be transported. The crew who brought her in immobilized her, and at this point she has a collar on but board has been removed. Nurse says we need to get a backboard. I responded 

"wait you want to put her back on a backboard?" 

The doctor was behind me an gives me a annoyed sounding "yes". I go and assess patient and she is pain free while lying on bed. AOx4. Good CMS. BP 200/95, pulse 74, 98% on 2l, normal sinus on monitor. Pt states "I only hurt when I'm put on that board". I tell her I'm sorry but I have to since the doc wants it, but I'll provide her with pain medication. 

The nurse then goes on to me about how I shouldn't give her fentanyl because of her subdural hematoma and I need to be worried about that and not her pain. She ends by saying "seriously you shouldn't give her anything for pain"

I ignore her and don't say anything and take my patient after boarding her. By the time we're in truck she has 8/10 back pain. I gave her fentanyl on the way but needless to say she was miserable and in pain the entire transport.

Now my question: should I have stood up to the doctor and told him that the board would cause unnecessary pain and do nothing to stabilize her spine? Should I have offered to email him studies? 

Should I have told the nurse to go to hell (j/k). But seriously I feel like I should of stood up for my patient but didn't want to cause any trouble. My protocol states spinal immobilization is based on judgement of the medic. Not sure how that applies in a inter facility transfer situation like this though. 

Sorry for typing mistake and such... Wrote this on my phone.


----------



## Aidey (Jan 31, 2013)

1. Ask if the receiving MD wants her on the LSB.
2. Ask if the neurologist wants her on a LSB. 
3. Take her off of it in the ambulance.


----------



## Milla3P (Feb 1, 2013)

I'm under the opinion that a patient... Though I prefer to use the somehow lost term "person" still has a right to refuse any/all/some treatments if they don't like it. "Sorry, Doc, she doesn't want it."

If your small ED doc wants to push the issue, put it on, take it off in the truck. 

I guess I'm lucky that the local Docs I work with and the Level 1 are both ok with a person in a semi-fowlers and a collar. (When isolated injury to the head/neck) don't forget that your stretcher is essentially a padded, bendable LBB.


----------



## truetiger (Feb 1, 2013)

Hmm like Aidey said I would contact the receiving facility if you're concerned. However, arguing with a doc isn't going to get you very far. Did you think of padding the backboard with blankets? She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?  It is our job to do our best to mitigate pain, however sometimes there are contraindications to pain management, it sucks but thats life. Once again, I would contact the receiving facility for pain management, I would have not gone out on my own and given the fentanyl without orders. Something would of went south, you would have been hung out to dry.


----------



## Aidey (Feb 1, 2013)

truetiger said:


> She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?



*Hell no. *

Why? Explain to me, physiologically, how a LSB is going to stabilize a cervical compression fracture.


----------



## truetiger (Feb 1, 2013)

I'm not arguing the effectiveness of the LSB for the C6 fx. If his protocols are like most, he won't have a leg to stand on. If he doesn't contact the sending physician to omit the back board, then where is he going to get the authorization to remove the backboard? Certainly is protocols aren't going to support omission of the backboard.


----------



## Milla3P (Feb 1, 2013)

truetiger said:


> She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?



I don't subscribe to this theory at all. How will manipulating a person with a Fx a 3rd time (1st on scene, 2nd at the small ED... Probably a 4th time up north [how we describe our Lvl 1 trips]) benefit them? How will very carefully plopping them on a (probably) radiolucent piece of hard plastic improve their outcome?

Is causing somebody pain without scientific proof assault?

Will the anatomical position in the semi-fowlers somehow compromise the cervical area?

Why do they need to "go up on a board?"


----------



## Aidey (Feb 1, 2013)

truetiger said:


> I'm not arguing the effectiveness of the LSB for the C6 fx. If his protocols are like most, he won't have a leg to stand on. If he doesn't contact the sending physician to omit the back board, then where is he going to get the authorization to remove the backboard? Certainly is protocols aren't going to support omission of the backboard.



His protocols probably don't address the issue. My protocols talk about a suspected spinal injury. They say absolutely nothing about a radiologically confirmed one.


----------



## truetiger (Feb 1, 2013)

Aidey said:


> His protocols probably don't address the issue. My protocols talk about a suspected spinal injury. They say absolutely nothing about a radiologically confirmed one.



Exactly, so you're going to go against 2 different physicians, one being the accepting physician from a specialty resource center and your protocols do not address or support this. Sounds like a really bad idea to me. I'll keep my medic license, thank you very much.


----------



## Milla3P (Feb 1, 2013)

Patient choice, man. Have them sign the refusal form if you can. They don't want the board (as in the initial scenario) they don't need it. 

Screw the doctors. Document properly. 

What would you want done if it was your neck? Your 8/10 back pain?


----------



## Aidey (Feb 1, 2013)

What 2 physicians? The OP only mentions the sending doc. The last time I was in this exact situation I had them call the neurologist and ask if he wanted the pt transported on a LSB. His reply was "what the hell for?"

And what exactly are you going to be losing your license for? Last time I checked preventing harm wasn't grounds for disciplinary action in most places.


----------



## truetiger (Feb 1, 2013)

What exactly are you going to document? That you're smarter than 2 MD's? That'll get ripped apart in court. If it was my neck? And two different doctors confirmed it was necessary? I'll deal with the pain and not risk further injury.


----------



## truetiger (Feb 1, 2013)

If he didnt agree with the sending doc, he should of consulted with the receiving. If he said keep the back board too, then the backboard should stay.


----------



## Medic Tim (Feb 1, 2013)

truetiger said:


> Exactly, so you're going to go against 2 different physicians, one being the accepting physician from a specialty resource center and your protocols do not address or support this. Sounds like a really bad idea to me. I'll keep my medic license, thank you very much.



can you name even one instance anywhere where a medic has lost their cert/license because of this?

 It is common many places for the board to be removed on the pts arrival. the board then goes back to the ambulance. The ERs here do not have or use LSB's. the only time there is one there is if a crew forgets one.

Just because you don't have a protocol for something doesn't mean that you can't / aren't allowed to do it. 

It is common for us to transport pts with confirmed C#s (stable and unstable) with a collar and in a postition of comfort. How forcing your elderly pt into painful procedure with no plan for manageing it safer? especially if you are so worried about her ICP and BP?


----------



## Milla3P (Feb 1, 2013)

What would I document?

"Pt stated that she did not want to be placed on LBB. Pt stated that LBB caused significant pain. Advised pt that referring MD recommended LBB as precautionary measure, pt continued to refuse, advised of risks involved pt signed refusal form and moved to stretcher without LBB in place." 

Get the MD as a witness. At least the RN if the MD is too busy/angry. 

It's that easy. Just write the truth. Don't force anything on the unwilling.


----------



## truetiger (Feb 1, 2013)

It's very common for patients to be taken off the backboard if c spine is cleared, in this situation it sounds like it has not been cleared by the sending physician.


----------



## Milla3P (Feb 1, 2013)

"I don't want that procedure!"
"Too bad, this guy you just met told me to do it to you!"

=

Assault & Battery. 

Look back at your BLS education.


----------



## Medic Tim (Feb 1, 2013)

truetiger said:


> It's very common for patients to be taken off the backboard as soon as they arrive in the ER.



fixed that for you


----------



## Milla3P (Feb 1, 2013)

Medic Tim said:


> fixed that for you



^^^ This.


----------



## truetiger (Feb 1, 2013)

You'll be hard pressed to go against a patient's written orders without hard evidence.


----------



## Medic Tim (Feb 1, 2013)

truetiger said:


> You'll be hard pressed to go against a patient's written orders without hard evidence.



Where is the hard evidence for it? (because they said so and because that is the way we have always done it is not evidence)


----------



## truetiger (Feb 1, 2013)

Where's the hard evidence against it? You're going to have to have some to disregard a physicians order.


----------



## Handsome Robb (Feb 1, 2013)

I don't recommend removing the board in the rig. Like tiger said, you're directly violating a physician's order and that wont end well for you. Will it cost you your license? Probably not but it's not a risk I'm willing to take. Plus that's going to make your life more difficult during future interactions with that physician. I'm all for being a patient advocate, but I also love my job and like to be able to make my truck payment, pay my bills and pay for parts, oil and gas to go out and play on my sled. You have options in this scenario but boarding the patient in the ER *then taking her off of it in the ambulance* is not, in my opinion, one of them. Also, you're adding yet another manipulation to a patient with a confirmed spinal fracture. If the MD is wanting you to use it for patient movement offer up the option of a scoop stretcher. Scoop her, move her, remove the scoop then rinse and repeat at the receiving facility if that's what they'd like you to do. 

As far as the nurse goes, I would have politely asked if I ever told her how to do her job. When she said no, I'd politely respond with, "then please don't tell me how to do mine." Increased ICP is a caution in for fentanyl, not a contraindication. Fentanyl really doesn't have too many absolute contraindications. https://online.epocrates.com/u/1031692/fentanyl/Contraindications+Cautions

The sending physician is responsible for the pt until they reach the receiving facility but I don't see why a consult with the receiving physician about using the LSB during transport would be out of line. Yea they both have MD or DO after their name but who sees more injuries of this type? Band-aid station MD or Trauma Center MD?

If I'm not mistaken ATLS recommends removing patients from a LSB soon after they arrive at the ED. I know that even in patients with spinal abnormalities on palpation and/or neurological deficits still come off the board with the collar left in place almost immediately after moving them from my gurney to the trauma table. That's anecdotal but it's pretty common practice here. Removing the board =/= equal "clearing" their c-spine. Removing the collar, yes. The board, no.

Edited to fix a giant typo that was quoted, it's in bold.


----------



## Aidey (Feb 1, 2013)

truetiger said:


> Where's the hard evidence against it? You're going to have to have some to disregard a physicians order.



There is a lot actually. Especially when you consider the pts age and the very high risk of skin break down.


----------



## Handsome Robb (Feb 1, 2013)

Aidey said:


> There is a lot actually. Especially when you consider the pts age and the very high risk of skin break down.



What about the whole flat board, curved spine thing? Along with the fact that we're one of the last countries to routinely use LSBs for spinal motion restriction...

FWIW every IFT I've taken with confirmed spinal fractures have been in a collar and a collar only. Anecdotal again, sorry.


----------



## shfd739 (Feb 1, 2013)

Robb said:


> FWIW every IFT I've taken with confirmed spinal fractures have been in a collar and a collar only. Anecdotal again, sorry.



I so wish we could do this. 

The trauma hospitals insists the person be placed back on a board. So we have to reboard, secure etc. 

I thought I caught a break the other night with a 10yo with a compression fracture w/ no deficits and no pain. Receiving trauma hospital said no board. Then the nurse badgered the sending doc into having board the kid- he went in pov and had never been on a board. I was so pissed.


----------



## Sublime (Feb 1, 2013)

Aidey said:


> 1. Ask if the receiving MD wants her on the LSB.
> 2. Ask if the neurologist wants her on a LSB.
> 3. Take her off of it in the ambulance.



I thought about #3, but decided not to. I was afraid of possible repercussions... although the receiving facility would most likely have never asked about her being on a board and the sending would probably never know.

As a side note... she came of the board immediately after being transferred to the trauma bed at the receiving facility.




Milla3P said:


> I'm under the opinion that a patient... Though I prefer to use the somehow lost term "person" still has a right to refuse any/all/some treatments if they don't like it. "Sorry, Doc, she doesn't want it."



I believe this would of been the best option, and I actually thought of it afterward (hate when I do that). All I had to do was hint at the lady "Hey if you refuse then I legally can't put this board on you" ect. 



truetiger said:


> She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?



No I don't, although I used to think like that. There are a lot of papers and studies on this subject, and I didn't want this to turn into a "should she of been boarded / are backboards useful" because I KNOW she shouldn't have been boarded and I know they aren't useful. I wanted advice on how to handle a future situation like this. 

But here is one of my favorite papers on backboards. Another user posted this a while back.
Short version: http://www.ncbi.nlm.nih.gov/pubmed/22962052
Long version: attached





truetiger said:


> It is our job to do our best to mitigate pain, however sometimes there are contraindications to pain management, it sucks but thats life. Once again, I would contact the receiving facility for pain management, I would have not gone out on my own and given the fentanyl without orders. Something would of went south, you would have been hung out to dry.



I don't need orders from that facility to give pain meds (much less a questionable nurse). I have my own protocols that allow me to do that. I am going to ask you what I almost asked the nurse. What contraindication is the there for Fentanyl in a subdural hematoma? How is it going to harm her? Why wouldn't you treat her for pain? Why do you like hurting old ladies? You don't have to answer the last one 



Robb said:


> You have options in this scenario but boarding the patient in the ER is not, in my opinion, one of them. Also, you're adding yet another manipulation to a patient with a confirmed spinal fracture. If the MD is wanting you to use it for patient movement offer up the option of a scoop stretcher. Scoop her, move her, remove the scoop then rinse and repeat at the receiving facility if that's what they'd like you to do.



That is good advice, will definitely keep this in mind in a future situation like this.


----------



## Veneficus (Feb 1, 2013)

*arguing with doctors*

Is really not a good idea unless you are a doctor. Even if you are right, you will probably not come out the better for it. 

It sounds to me like this patient wound up in a community ED with a doctor not comfortable and probably not knowledgable about this type of patient. 

He was probably following guidlines he was familiar with and respected as best practice deferring his judgement to what he respects as expert. You certainly will not win that battle no matter what evidence you think you have. 

The only thing that will change that is a change in expert consensus.

The way to alter the order is by appealing to that doctor that the guidline does not fit this individual patient and suggest an expert consult. 

Don't leave it up to the doctor who to call, have that consultant be a doctor you know is likely to see your side of the story. (aka your medical director if you don't know anyone at the receiving facility) 

Then explain why you think the board will be a bad idea, don't take a confrontational stance.

Do not unilaterally take the board off in the ambulance. If you want to go that route you need to call a physician (like your medical direction) and have them change the order by presenting a change in the patient condition that would warrant that.

Dealing with nurses is an individual problem. Many of them have been taught just like you, they have a very strong opinion of right and wrong while not recognizing the limits of their knowledge. 

Anytime somebody tells you to leave a patient in pain, you need to consult with your medical direction prior to transport. In modern medicine there is no reason to leave somebody in pain. 

Generally when trasporting patients, they require higher levels of analgesia than laying in a hospital bed. Always diplomatically make that clear to the sending physician. If that order is not sufficent, always ask for a change in order. 

One of the easiest ways to get around most of this is to ask for the number for the receiving physician. 

The sending physician, while technically responsible, probably wants this patient gone more than anyone with as little fuss as possible. I cannot imagine he would not be amiable to the recieving doc giving out orders after accepting his patient.

At the completion of this call, set yourself up for success in the future. Bring it to the attention of your medical director who have multiple options to make sure it doesn't happen again in the future. 

Under no circumstances should you get into a pissing contest with anyone in front of the patient. 

You will also do more damage to your credibility than to anyone else by speaking poorly about any other care provider to the patient in private.


----------



## Handsome Robb (Feb 1, 2013)

Sublime said:


> That is good advice, will definitely keep this in mind in a future situation like this.



After reading your post and my post that you quoted I realized I had a very important piece of that statement that I had failed to type. Thought it, didn't type it. 

I bolded it in the original post and fixed it below for you. I think you picked up what I was trying to put down though. 

Boarding her in the ER *then taking her off of it in the ambulance* is not an option in my opinion.

Vene, I don't think anyone could've put that better. I tried arguing with a doctor once and I know I was right. I still ended up on the losing end of that argument not only in the doctor's eyes but also in the eyes of the agency I work for as well. They agreed with me "off the record" but I was still reprimanded for it. It wasn't a fun process to go through.


----------



## truetiger (Feb 1, 2013)

I don't want y'all think I'm some scrooge when it comes to pain medicine, but I also like covering my ***. In his situation I would of called the receiving facility and received orders. Head injury is not an absolute contraindication for the administration of fentanyl, but it is a caution, so why not be cautious and consult the expert facility? Also, upon arrival and getting the order signed, this would provide a great opportunity to pick the physician's brain on the subject.


----------



## Sublime (Feb 1, 2013)

Robb said:


> I tried arguing with a doctor once and I know I was right. I still ended up on the losing end of that argument not only in the doctor's eyes but also in the eyes of the agency I work for as well. They agreed with me "off the record" but I was still reprimanded for it. It wasn't a fun process to go through.



Exactly. Even if I was right, I would get in trouble if for nothing else, pissing off a facility that my company makes money off of.


----------



## shfd739 (Feb 1, 2013)

Robb said:


> I tried arguing with a doctor once and I know I was right. I still ended up on the losing end of that argument not only in the doctor's eyes but also in the eyes of the agency I work for as well. They agreed with me "off the record" but I was still reprimanded for it. It wasn't a fun process to go through.



I've been in this position twice. I was right, ERs (doctor and nurses)were wrong. Company backed me 100% all the way to the hospital president and chief doctor. Hospital took it as a chance to inservice their people. I think we're lucky. Not many places wouldve backed their people.


----------



## Handsome Robb (Feb 1, 2013)

truetiger said:


> I don't want y'all think I'm some scrooge when it comes to pain medicine, but I also like covering my ***. In his situation I would of called the receiving facility and received orders. Head injury is not an absolute contraindication for the administration of fentanyl, but it is a caution, so why not be cautious and consult the expert facility? Also, upon arrival and getting the order signed, this would provide a great opportunity to pick the physician's brain on the subject.



I wasn't trying to imply that you were, sorry if it came off that way. I agree calling the receiving doc is a good idea. I may be spoiled by my fairly liberal pain and sedation management protocol but I personally wouldn't call for this. 

Start my dosing low and see how she responds and then titrate it up to the desired effect.

If my understanding is correct the big worry with fentanyl in patients with increased ICP/head injuries is that they are predisposed to respiratory depression with the underlying pathology of their injury which could be worsened narcotic analgesia. 



shfd739 said:


> I've been in this position twice. I was right, ERs (doctor and nurses)were wrong. Company backed me 100% all the way to the hospital president and chief doctor. Hospital took it as a chance to inservice their people. I think we're lucky. Not many places wouldve backed their people.



I'm pretty sure now they would but back then I was a snot nosed rookie EMT-I who just happened to be in paramedic school :lol: Probably didn't go about my argument in the best way either.


----------



## Melclin (Feb 4, 2013)

I obviously can't speak for different places, but I've had several disagreements with doctors, none of them ending particularly badly. I think, like any conflict, how you have the argument is pretty important. 

I can only think of one time in which an argument didn't end well, but I would say had I managed the argument better, it would have ended a lot better. Sending doctor told me not to give pain relief to a pt with abdominal pain. I asked why, hoping it wouldn't be the old deal about the pain being diagnostic, but it was and I laughed at the doctor. Didn't mean too, it just popped out, and he stormed off. Didn't see him again and the pt got his pain relief but I was disappointed with myself for being so unprofessional. 

Other than that time, I usually ask for the rationale behind their decision/treatment/dx. Once I identify the concern and assuming I disagree with it, I assuage the concerns with a reasoned argument usually using some piece of literature. The reason for the disagreement usually seems to be that they're operating on obsolescent knowledge/practices and mostly I've found them eager to appear well informed by quickly assimilating the new information appearing well informed in a way that seems like they knew it all along.

There was a story locally about a famously incompetent Dr of Chinese heritage who, upon being questioned by the attending paramedic, yelled with a most unfortunate stereotypically poor command of English, "YOU WANT BE DOCTOR!? YOU GO ...DOCTOR SCHOOL!".

I've never heard of Fent being precautioned in ICP rises. Most strange. Is it an issue of not wanting to cloud the conscious state with an iatrogenic altered mental status? Also a silly reason to my mind but a common one around here.


----------



## Handsome Robb (Feb 4, 2013)

Melclin said:


> I've never heard of Fent being precautioned in ICP rises. Most strange. Is it an issue of not wanting to cloud the conscious state with an iatrogenic altered mental status? Also a silly reason to my mind but a common one around here.



That's the biggest argument I've heard for it. "Altered patients don't get pain management because it further alters their mental status and makes it difficult for the physician to ascertain if they're mental status is changing because of the advancing underlying pathology or if it's because you snowed them!". 

It wasn't until our most recent protocol update that we were allowed to provide analgesia to patients with an altered sensorium. Went from a absolute contraindication, per protocol, to "Pain management should be used with caution in patients with a GCS <14 or who are hemodynamically unstable". (It might be GCS <13, I can't remember and am too lazy to go look it up right this second.)

If you aren't able to do a proper neurological assessment prior to providing analgesia as well as continued neurological assessment in order to establish a trend/progression in changes to their mental status to pass on to the physician you probably shouldn't be providing narcotic analgesia anyways... that'd be the only caveat that I'd add.


----------



## ah2388 (Feb 7, 2013)

Veneficus said:


> Is really not a good idea unless you are a doctor. Even if you are right, you will probably not come out the better for it.
> 
> It sounds to me like this patient wound up in a community ED with a doctor not comfortable and probably not knowledgable about this type of patient.
> 
> ...



There is a TON to be learned from this post.

Thank you.


----------



## Melclin (Feb 7, 2013)

Robb said:


> That's the biggest argument I've heard for it. "Altered patients don't get pain management because it further alters their mental status and makes it difficult for the physician to ascertain if they're mental status is changing because of the advancing underlying pathology or if it's because you snowed them!".
> 
> It wasn't until our most recent protocol update that we were allowed to provide analgesia to patients with an altered sensorium. Went from a absolute contraindication, per protocol, to "Pain management should be used with caution in patients with a GCS <14 or who are hemodynamically unstable". (It might be GCS <13, I can't remember and am too lazy to go look it up right this second.)
> 
> If you aren't able to do a proper neurological assessment prior to providing analgesia as well as continued neurological assessment in order to establish a trend/progression in changes to their mental status to pass on to the physician you probably shouldn't be providing narcotic analgesia anyways... that'd be the only caveat that I'd add.



Haha always interesting to hear about the ways other people do things. 

I've never agreed that mild and predictable alteration in a person's conscious state really makes any difference in the management of head problems. I'd compare it to the abdo pain issue, although probably a bit more complex. If you've smacked you head and you're <GCS 15 on arrival at the hospital (by definition, a considerable time after the incident), you're getting a CT anyway. If you're combative or you airway is in question, you're getting a piece of plastic to chew on anyway. I don't really see how a slight alteration in mental status of a type and timing consistent with opiates really alters management. 

As far as neuro assessment being a prerequisite for opiate administration, I can't say I agree. I don't believe there is anything special about opiates. I just went down to the chemist and picked some up off the shelf and bought them and I didn't get a neuro exam from the pharmacist but I'll probably live  I don't think you need to be any kind of clinical guru to administer them safely with reasonable effect. My understanding is that our volly community emergency responders are getting IN Fent. They're really just first aiders and I don't see an issue.


----------



## wubbinz79 (Mar 12, 2013)

I was like to put myself in the patients position, a lot of the time patients don't know they can refuse treatment, I like to inform them of that, if I was the patient and u informed me of the risk and what not, I'd sign the AMA and go without the backboard. It's the patient's right to say what happens to their body. Informed consent.


----------

