# To BB or not to BB



## Medico (Jun 12, 2013)

We were toned out for a 64yo male who had been ran over by a tractor. 

On our arrival we had an alert 64 yo male laying in a right lateral recumbent position, in no apparent distress, speaking full clear sentences, aox4, GCS 15. Pt said that the tractor ran over his right hip. Pt denied pain upon palpation of his C Spine and spinal column. Negative for step off or deformity. Pt complained of right hip pain, 5/10. Negative for deformity or crepitus. Legs of equal length, negative rotation. Pelvis stable, negative crepitus. Pt stated he did have a 5/10 discomfort in his lumbar region secondary to a fusion he had a year ago. This discomfort is not new, and has the discomfort when laying on his side or standing.  The pt was rolled onto a BB to lift him to the stretcher. He complained that his pain intensified on the BB. I opted to remove him from the BB to avoid exacerbation of his pain and potential injury to his fusion. His pain resolved to a 0/10 in a supine position on the softer surface of the stretcher. 

He was being transported from a rural area. He had an hour transport on bumpy roads. Something else to keep in mind. 

The receiving physician was not happy and made it known. I defended myself and provided reason for what I did. He argued that all trauma pt should be BB and that the soft padding would cause flexion and injury. Both points he attempted to make I provided rebuttal. 

Would you have placed this pt on a BB? 

Please excuse my brevity, I'm typing this on my phone.


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## Medic Tim (Jun 13, 2013)

Would have used a board or scoop to get the pt to stretcher then position of comfort for the transport.

No smr


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## Aidey (Jun 13, 2013)

The pt was clearable under both Nexus and the Canadian C-Spine Rule.


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## DesertMedic66 (Jun 13, 2013)

Medic Tim said:


> Would have used a board or scoop to get the pt to stretcher then position of comfort for the transport.
> 
> No smr





Aidey said:


> The pt was clearable under both Nexus and the Canadian C-Spine Rule.



Bu..Bu...But MOI!!!!!!


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## Arovetli (Jun 13, 2013)

Aidey said:


> The pt was clearable under both Nexus and the Canadian C-Spine Rule.



Vetebral disease was an exclusionary criteria for the Canadian study and age 65 is the recommended mandatory for imaging. Nexus isn't really regarded as the best in some circles.

Those factors may have led to some of the difficulties the OP encountered.

I don't really have the full picture if what happened but isolated crush injury from a tire to the hip/lower extremity doesn't exactly scream concern for a head or neck injury, unless there was some other type of injury involved. Position of comfort seems appropriate for the situation described.


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## Aidey (Jun 13, 2013)

The pt was 64, not 65 and the published criteria for using the CCSR doesn't mention vertebral disease at all. At least, none of the versions I've seen mention it. People with very specific types of vertebral disease were excluded, but the CCSR doesn't list them as a caveat to using the tool. Pregnant patients were excluded too, but we still apply the CCSR to them. Plus the CCSR studies only excluded people with a history of cervical surgery, not lumbar.


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## J B (Jun 13, 2013)

Can we let the patient make the choice, and have him sign a refusal of care if he wants to go without backboard?

"My protocols say I'm supposed to put you on a backboard and that's what I must officially recommend... However, there is a lot of evidence that shows backboards are overused and not as beneficial as was once believed.  

We have to consider that getting run over by a tractor is a pretty serious accident.  However, it's not clear that you need the backboard, or that it would be beneficial for you.  In fact, it could even be harmful.  

You have the right to refuse any aspect of care.  Personally, I would prefer to not be backboarded if I was in your situation.  But again, officially, as an EMT/paramedic and employee of _____ ambulance company, I must recommend that you go on the backboard.  

If you want to go without a backboard, you'll have to sign this refusal form which basically says you won't sue us if an injury arises that the backboard would have prevented."


This seems to cover our bases pretty well.  We avoid getting sued if something goes wrong, and we make the patient more comfortable and informed.  I just have this sneaking suspicion that giving a spiel like this would probably get you fired for some reason?


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## Arovetli (Jun 13, 2013)

Aidey said:


> The pt was 64, not 65 and the published criteria for using the CCSR doesn't mention vertebral disease at all. At least, none of the versions I've seen mention it. People with very specific types of vertebral disease were excluded, but the CCSR doesn't list them as a caveat to using the tool. Pregnant patients were excluded too, but we still apply the CCSR to them. Plus the CCSR studies only excluded people with a history of cervical surgery, not lumbar.



I'm not arguing with you, but if you take the time to read the paper you will see that it was excluded from the study. That just means there was no data available. Reasonably, it's not that big of a deal.

The point isn't that anyone is wrong. The point is that there is room for expert judgement. Nothing magic happens from day 364th of your 64th year to the 1st day of your 65th. There's always questions about data.

I'm not of the 'dunk the patient in Elmer's Glue until the get to the ED' mentality, but some are. So before everyone gets all hackled up, I'm on your side.

But There's room for physician opinion in this case, you just ended up with two different ones (attending vs. ems medical direction/protocol, or perhaps your own, if you can claim that) in this case. Or the attending could have just been ignorant or a jerk.

You can't complain about paramedics being forced into cookbook medicine by following protocols and unable to use judgement and then get mad when a physician doesn't practice cookbook medicine and uses judgement instead. 

Id say there's room to reason, so long as the reason is guided by science and your in compliance with protocols/guidelines enough to make the suits happy.

Obviously, the best thing for the OP is to be in compliance with his protocols, and should a separate physician not like them they can address it appropriately with the medical director.


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## Handsome Robb (Jun 13, 2013)

Aidey said:


> The pt was clearable under both Nexus and the Canadian C-Spine Rule.



Yea. What she said.

Did the doc tell you he needed a NRB at 15 lpm for his traumatic hip pain as well? 

Sounds like a rural doc who's no comfortable with current trauma/spinal motion restriction practices or used to EMS being clinicians rather than technicians.


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## Aidey (Jun 13, 2013)

Arovetli said:


> The point isn't that anyone is wrong. The point is that there is room for expert judgement. Nothing magic happens from day 364th of your 64th year to the 1st day of your 65th. There's always questions about data.



The point is that he was still clearable under both of those protocols.


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## Arovetli (Jun 13, 2013)

Aidey said:


> The point is that he was still clearable under both of those protocols.



Of course he is, no one ever said otherwise or that any course of action by the OP was incorrect.

The point of my post was to point out some of the rationale which may have led to the disagreement, and that while it may be exceedingly picky, it certainly doesn't automatically make the doctor a rural unqualified buffoon. (Which he may very well be)

Just because I told the OP why the MD might have taken issue with his treatment doesn't mean that he was right to get mad with it.


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## Akulahawk (Jun 13, 2013)

Well, let me see, tractor ran over his right hip, not his back, pelvis, spine or neck. No need for the spine board. Unless he somehow needed a full body splint, I just don't see any need for the spine board. I wouldn't have put him in spinal restrictions because the MOI told me that there wasn't likely any spinal impingement. 

MOI is important. It tells me where to look. It also tells me where injury is very unlikely to occur.


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## Arovetli (Jun 13, 2013)

While ill reiterate that I agree with the consensus of the thread, and Aideys post, for the sake of depth to the discussion:

 an additional take home point about NEXUS is that it really isn't a decision tool in and of it self, and more of an empirical validation that the prevailing clinical judgement of the day was accurate. It doesn't change much for physicians, or at least knowledgeable physicians, so that's (among a few other esoteric points) is why there can be some consternation to its use as a clinical decision tool.

 "If it is a tool you need, perhaps you shouldn't be in the position to need it", so to speak, from certain points of view perhaps.

Though for the level of a paramedic, it does help to guide the thought process, I think, it just may not win brownie points to name drop NEXUS.

Also, under a strict technical reading of the Canadian literature, you can make a case for saying preexisting vertebral injuries can preclude application of the tool. 

Just an encouragement to all to actually read the literature and think critically.


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## Melclin (Jun 13, 2013)

I'll have to disagree with you Aidey,

I think its probably a bit grey but I wouldn't agree outright that this pt can be cleared under Canadian c-spine.



> Patients were excluded if they: (1)
> were younger than 16 years; (2) had minor
> injuries, such as simple lacerations,
> and did not fulfill the first 2 inclusion
> ...



I find it hard to imagine the injuries sustained when a tractor rolled over you wouldn't be distracting and I'm having a hard time picturing this patient. That said, nexus wise, there is an argument to be made from a distracting injury point of view. 

So all in all, I don't think this pt can be cleared but I also don't think the SMR should be considered in the first place, so I don't think they _need to be cleared_. 

I wouldn't feel inclined to board this person. There is a lot to be said for positions of comfort and I think anyone who reckons that less movement occurs during an hour spent on a long board probably hasn't ever sat with a patient on a long board for an hour. Especially with actual injuries. The only alert unstable fractures I've ever taken in had to be taken off the board because it was too painful and the patient felt inclined to leap out of the ambulance.

Of course then there are all those arguments about force deposition which I completely agree with. Out with back board all together I'd say. 

*For the OP, how much morph/fent/whatever did he get?*


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## Medic Tim (Jun 13, 2013)

Melclin said:


> I'll have to disagree with you Aidey,
> 
> I think its probably a bit grey but I wouldn't agree outright that this pt can be cleared under Canadian c-spine.
> 
> ...


I agree that is c spine rule out does not really need to be used here. I can see it being grey area if his existing back pain was worse than usual.
 I have had a few pts rn over by tractors before and they were all relatively unharmed . They were in a field so they mostly were pushed into the soft ground .


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## Carlos Danger (Jun 13, 2013)

Arovetli said:


> *Vetebral disease was an exclusionary criteria* for the Canadian study and age 65 is the recommended mandatory for imaging. Nexus isn't really regarded as the best in some circles.
> 
> Those factors may have led to some of the difficulties the OP encountered.
> 
> I don't really have the full picture if what happened but isolated crush injury from a tire to the hip/lower extremity doesn't exactly scream concern for a head or neck injury, unless there was some other type of injury involved. Position of comfort seems appropriate for the situation described.



"Vertebral disease" wouldn't include a lumbar fusion though, would it?


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## Arovetli (Jun 13, 2013)

Right. That's why a think there's a little room for judgement here. It would be why the spine was fused, if there was any widespread underlying degeneration or stenosis or something else discovered by exam/hx.

I don't think it's that big of a deal, but it's something to take into account with him being elderly, all things considered perhaps it may increase the suspicion, or just fall in a tiny little grey area that the study didnt examine, but I mean really...we all know how rare these types of injuries are, especially given the presentation.

If I understand right, there was no rollover of the tractor knocking him around  just a tire went over his leg, right? I don't think you can get too concerned over head/neck injuries in the first place if that's the case. 

I suppose at best it may just confound an ironclad application of the rules, leaving a little more room for judgement.


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## Carlos Danger (Jun 13, 2013)

Arovetli said:


> I suppose at best it may just confound an ironclad application of the rules, *leaving a little more room for judgement*.



Well you know we can't have that....


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## Aidey (Jun 13, 2013)

Melclin said:


> I find it hard to imagine the injuries sustained when a tractor rolled over you wouldn't be distracting and I'm having a hard time picturing this patient. That said, nexus wise, there is an argument to be made from a distracting injury point of view.



It sounds like this individual had very localized injuries, and was able to fully participate in his assessment. If both his legs were crushed, and when you asked his past history all he would say is "It hurts too much to think" I would agree that he has distracting injuries. 



Halothane said:


> "Vertebral disease" wouldn't include a lumbar fusion though, would it?



No, it doesn't. At least not according to all of the full text versions of the CCSR validation studies I have copies of. They specify previous cervical surgery, not any spinal surgery at all. 



Arovetli said:


> Right. That's why a think there's a little room for judgement here. It would be why the spine was fused, if there was any widespread underlying degeneration or stenosis or something else discovered by exam/hx.
> 
> I don't think it's that big of a deal, but it's something to take into account with him being elderly, all things considered perhaps it may increase the suspicion, or just fall in a tiny little grey area that the study didnt examine, but I mean really...we all know how rare these types of injuries are, especially given the presentation.
> 
> ...



Again, technically under the CCSR he isn't elderly. He is 64, not 65. And the published CCSR flow chart does not include a list of patients that it doesn't apply to. Yes. I know I am being pedantic, but they are the ones who picked a hardline age cut off. And they are the ones who neglected or chosen not to publish a list of patients the rule doesn't apply to. 

 I am all for allowing judgement to be used, but the CCSR draws some lines in the sand. As much as I would prefer that we were thoroughly trained in physical assessment, evaluating risk factors, and able to use judgement there doesn't seem to be much room for that with the CCSR.


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## Arovetli (Jun 13, 2013)

im really not in the mood to get an internet argument, but you seem hell bent on it.

What do you think vertebral disease is, and does it not occur to you that a spinal fusion may be a process by which to treat said disease? Not that it really matters, its just something to throw into the mix when you are thinking, especially if you subscribe to a conservative approach. In assessing this patient I want to know why he had the procedure and how, if at all, it effects anything. That to me is of more value that simply knowing he went under a knife. I get it that it may be lumbar vs. cervical, i get that it is a minor splash of grey...but its still an item we want to explore.

Your right, when they designed the methodology, they picked 65, because thats a commonly used number. They could have analyzed the data out to age 64, 4 months, and 3 days. It really doesn't mean anything more than that. Do you really think that between the morning of your 65th birthday and the time you blow your cake candles out that magic sauce sprinkles from heaven, drips in your ear, and undermines the strength of your cervical spine? Its a freaking number to aid the data analysis. Again, something to think about when deciding on a treatment plan.

The "rule" is just a tool. Its not a be all end all to ruling in or out injuries. Nothing is. No tool we have is perfect. No data, no machine, no diagnostic. We use clinical judgement and the best of science, and a little artistry to treat our patients. One paper, one flow chart, does not necessarily become the gold standard in all things treatment, and allow you to send your brain out to lunch because your MDCalc app on your iphone can just make decisions for you. (As an interesting aside, MDCalc includes the hx of vertebral disease as exclusionary critera.... damn conservatives)

This is why EMS cant have nice things....


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## Arovetli (Jun 13, 2013)

Aidey said:


> As much as I would prefer that we were thoroughly trained in physical assessment, evaluating risk factors, and able to use judgement there doesn't seem to be much room for that with the CCSR.



Right. Im not talking about paramedics, Im talking about physicians, who are trained and educated and bear the responsibility to make clinical judgements. The OP seemed inquisitive as to why there may have been some consternation from the attending as to his treatment. Not a comment on what paramedics can or cant do, or how the canadian rule should or shouldn't be applied by EMS.


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## Melclin (Jun 13, 2013)

Aidey said:


> It sounds like this individual had very localized injuries, and was able to fully participate in his assessment. If both his legs were crushed, and when you asked his past history all he would say is "It hurts too much to think" I would agree that he has distracting injuries.
> 
> 
> 
> No, it doesn't. At least not according to all of the full text versions of the CCSR validation studies I have copies of. They specify previous cervical surgery, not any spinal surgery at all.



The point of the OP's question seemed to be getting at why the doctor took the approach that he did. 

You stated categorically that the pt could be cleared under nexus and CCR. All I was saying was that I can see how it might be a bit more grey than that. I suggested the grey area because it might be useful to the OP in determining why the dr disagreed with the management. Thats all.


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## Arovetli (Jun 13, 2013)

Arovetli said:


> im really not in the mood to get an internet argument, but you seem hell bent on it.
> 
> What do you think vertebral disease is, and does it not occur to you that a spinal fusion may be a process by which to treat said disease? Not that it really matters, its just something to throw into the mix when you are thinking, especially if you subscribe to a conservative approach. In assessing this patient I want to know why he had the procedure and how, if at all, it effects anything. That to me is of more value that simply knowing he went under a knife. I get it that it may be lumbar vs. cervical, i get that it is a minor splash of grey...but its still an item we want to explore.
> 
> ...



I was a little cranky. Rereading, I came off like a jerk. Apologies.


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## KellyBracket (Jun 13, 2013)

aust10n said:


> ... He complained that his pain intensified on the BB. I opted to remove him from the BB to avoid exacerbation of his pain and potential injury to his fusion. His pain resolved to a 0/10 in a supine position on the softer surface of the stretcher. ...



An ER physician's perspective: 

You started a therapy on the patient, and it hurt them. You changed the therapy, and the pain stopped. You continued this second therapy. This is wise medicine. 

Look, you did the right thing, but you have to make sure you document your findings, document the patient's wishes, and be proactive. Probably the doctor forgot about this 10 minutes later, but you never know. Approach your service chief/EMS coordinator/EMS medical director first, lay out your rationale. Be confident, but receptive. 

Good for you for doing the right thing - keep at it!


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## Handsome Robb (Jun 13, 2013)

KellyBracket said:


> Look, you did the right thing, but you have to make sure you document your findings, document the patient's wishes, and be proactive. Probably the doctor forgot about this 10 minutes later, but you never know. Approach your service chief/EMS coordinator/EMS medical director first, lay out your rationale. Be confident, but receptive



Very good point. If you ever have an issue with a coworker/co-responder/hospital staff or any sort of deviation from protocol it's in your best interest to bring it to the proper party's attention. If you wait for them to find out on their own it can be misconstrued that you were trying to hide something...then your integrity comes into question, it's not something you want to deal with.


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## Medico (Jun 14, 2013)

Sorry for this late reply. I'm located in Virginia and lost my power due to a string of storms.

I appreciate all the feedback and rational provided.

To answer a previous question, I did not give any Fent. as his pain was a 0/10 when off the backboard, and remained a 0 throughout transport. 

I've attempted to follow up on this patient, but have not yet received anything further.


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## MountainMedic (Jun 15, 2013)

It's these damn rural ER docs. Half of 'em are family practitioners playing around. Going to med school does not an ER physician make. You were 100% right. Just wait 5-10 years, when reasons NOT to backboard are taken more seriously than reasons to throw a pt on a piece of plastic with few proven benefits. 

Here's a little rural ED story. Hopefully an extreme:

MD: He's in cardiac arrest. Should we intubate?
Medic: Maybe you should start CPR first. 
MD: Right. How about some Versed?
Medic: Why?
MD: CPR's really traumatic, he shouldn't have to remember that. Can someone draw me up some sux? What's the dose?  

Swear to god. Saw it with my own eyes (won't say where).


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## Handsome Robb (Jun 15, 2013)

MountainMedic;485603Here's a little rural ED story. Hopefully an extreme:

MD: He's in cardiac arrest. Should we intubate?
Medic: Maybe you should start CPR first. 
MD: Right. How about some Versed?
Medic: Why?
MD: CPR's really traumatic said:
			
		

> All I can say is wow.


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## Medico (Jun 15, 2013)

MountainMedic said:


> It's these damn rural ER docs. Half of 'em are family practitioners playing around. Going to med school does not an ER physician make. You were 100% right. Just wait 5-10 years, when reasons NOT to backboard are taken more seriously than reasons to throw a pt on a piece of plastic with few proven benefits.
> 
> Here's a little rural ED story. Hopefully an extreme:
> 
> ...



Unbelievable.  

I do hope that those says come sooner rather than later. The BB has such a tight grip in the minds of many.


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## Codiaque (Jun 21, 2013)

It is obviously protocol driven.  Our Nexus is for over 75 years old in Pueblo County here in Colorado.  We also have a new protocol that allows for c-collar only immobilization due to new studies that are showing LBBs are doing more harm than good to the elderly.


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