# GSW and backboard?



## Raf (Jun 15, 2008)

I had my first GSW two nights ago. When we arrived at scene we found the pt. sitting on the sidewalk. He had one shot, into his back (a few inches from the most prominent vertebra), with no exit wound. The entrance wound was barely bleeding.

My partner wanted to longboard him but we decided not to. My question is, would it have been a good idea to backboard a GSW patient? It seemed kinda silly with so little time on our hands with internal bleeding a possible threat, but later I made the connection that the bullet came in pretty close to his spine and immobilization may have helped.


----------



## ffemt8978 (Jun 15, 2008)

Raf said:


> I had my first GSW two nights ago. When we arrived at scene we found the pt. sitting on the sidewalk. He had one shot, into his back (a few inches from the most prominent vertebra), with no exit wound. The entrance wound was barely bleeding.
> 
> My partner wanted to longboard him but we decided not to. My question is, would it have been a good idea to backboard a GSW patient? It seemed kinda silly with so little time on our hands with internal bleeding a possible threat, but later I made the connection that the bullet came in pretty close to his spine and immobilization may have helped.



I would have backboarded him because you don't know what path the bullet took, especially with no exit wound.


----------



## VentMedic (Jun 15, 2008)

I have 3 quadriplegic pts on vents in our rehab unit and one in the ICU whose entrance wounds were not right at the spine.  It depends on the angle of entry and what might deflect the bullet to determine its path.


----------



## traumateam1 (Jun 15, 2008)

What about packaging them lateral? You still get the C-Spine control, and access to both back, and front of patient.


----------



## fma08 (Jun 15, 2008)

like stated above, no exit wound, shot near the spine, ya, some immobilization was needed, like you said, it wasn't bleeding much, so i'd put a good dressing on it. keeping a close eye on CMS, and put him on a board.


----------



## VentMedic (Jun 15, 2008)

Lateral position if there is something pertruding from the body that could cause further damage.

In the ED, the patient will be rolled for assessment. The determination for intubation and an X-ray, usually supine, will be done immediately.  A CT Scan may also be done usually in supine position.


----------



## LucidResq (Jun 15, 2008)

Better safe than sorry. It shouldn't take all that long to board someone, and when you have a fairly significant MOI right to the back.... spinal immobilization should be a pretty high priority, I would imagine.


----------



## mikeylikesit (Jun 15, 2008)

i would board and strap... i have had a few GSW and they don't bleed bad unless they hit a artery remember cauterization? Just remember what the bullet hit in its path. Remember small calibers even from close can not lead an exit wound but rather cavitate and sever the spine...even if they were shot way off from it. Like said above better safe then sorry.


----------



## Hastings (Jun 15, 2008)

GSW is considered trauma, and all trauma - unless impossible - should have C-Spine precautions taken. Especially physical assault and stabbings.


----------



## MSDeltaFlt (Jun 15, 2008)

Know a medic who got *real* nervous for not packaging a GSW near the neck.  ...It was broken.


----------



## JPINFV (Jun 15, 2008)

Hastings said:


> GSW is considered trauma, and all trauma - unless impossible - should have C-Spine precautions taken. Especially physical assault and stabbings.



All trauma? So a broken arm needs to be backboarded? How about someone stabbed in the arm?


----------



## Hastings (Jun 15, 2008)

JPINFV said:


> All trauma? So a broken arm needs to be backboarded? How about someone stabbed in the arm?



I know that you know what I mean, and I know you're just asking that to cause me to reword what I said.

But I'll humor you.

Does everyone know where the spine is? Yeah, well, if anything hits the area around the spine (the core of the body, either front or back), or if the points of impact in an assault injury is unknown, the patient should be backboarded.

Should be. Textbook definition. Use common sense.


----------



## JPINFV (Jun 16, 2008)

Hastings said:


> I know that you know what I mean, and I know you're just asking that to cause me to reword what I said.
> 
> But I'll humor you.
> 
> ...










http://cat.inist.fr/?aModele=afficheN&cpsidt=15315716
http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus


----------



## Raf (Jun 16, 2008)

I can't come to a quick conclusion from the first two, but the abstract of the third one suggests that there is no point in backboarding a GSW pt.


----------



## Ridryder911 (Jun 16, 2008)

Raf said:


> I had my first *GSW* two nights ago. When we arrived at scene we found the pt. sitting on the sidewalk. He had one *shot, into his back (a few inches from the most prominent vertebra), with no exit wound*. The entrance wound was barely bleeding.
> 
> My partner wanted to longboard him but *we decided not to*. My question is, would it have been a good idea to backboard a GSW patient? It seemed kinda silly with so little time on our hands with internal bleeding a possible threat, but later I made the connection that the* bullet came in pretty close to his spine* and immobilization may have helped.



Your honor I rest my case! 

The only problem was your partner listened to you, so now they may suffer the consequences. Ever heard of tumbling effect of a GSW? Are you sure it did not hit the bones or spine at all? 

Sorry, not to be rude but I would start reviewing projectory & blasting injuries; and the care of trauma patients. As others stated, even laying them laterally would be accepted and possibly even better. One can immobilize multiple ways.

Again, study & rehearse, practice difficult immobilization scenarios. It is amazing how one can stabilize and immobilize patients. It would be far better than for an attorney to read just what you posted.. 

R/r 911


----------



## CAOX3 (Jun 16, 2008)

I would have to agree.  This seems like a pretty easy one to me.


----------



## traumateam1 (Jun 16, 2008)

Ridryder911 said:
			
		

> Are you sure it did not hit the bones or spine at all?


That's exactly it. We are not doctors, we do not have x-ray vision, we simply do not know. We can make very good educated guesses *based* on what we see and have been told, but we just do not know. If the bullet was a few inches from the spine, then that should be a full package. I mean we have to use common sense at every call, but this should of been a no brainer. Package and go. It's always better to roll him into ER, and get the x-ray results and see that it totally missed anything vital, then to roll him in, get the x-ray results and find out it, or a part of it hit his spine and now he can't move his legs or something.
Now being your first GSW, it was a new experience, but we are trained to deal with whatever we see.. so hopefully next time if your partner doesn't want to package you will know it should happen.


----------



## LE-EMT (Jun 16, 2008)

Since I am the dumb or ignorant pre-student I have a few questions and well they are probably going to seem .........well rather stupid but these are just my observations....

Ok if I read the original post correctly the individual doing the care is a basic....( insert fun commentary from my other threads)  
My first question is why is a basic making any decisions on a GSW is that not ALS?????  Not to mention the nature of the GSW BLAH BLAH medical jargon it was freaking close to the spine if nothing else that seems Like and ALS call to me....... 
It also seems funny to me if you are questioning whether you should back board or not shouldn't you back board just to be safe???????? 
Ok so no exit wound which logically would lead me to think well the bullet obviously didn't come out so its in there some where.  what else did it tear up??? all those good little organs in there that make us work properly........Yeah ummmmm again ALS call.  
If you are on an ALS unit then why was the medic asking you???  If the medic was asking your opinion because he doesn't know then I think its time to find  a new medic..
Really I could go on forever questioning this.... my point is as far as your question goes back board the fool throw him in the truck rendezvous(sp) with ALS or get him to the ER.


----------



## Hastings (Jun 16, 2008)

traumateam1 said:


> That's exactly it. We are not doctors, we do not have x-ray vision, we simply do not know. We can make very good educated guesses *based* on what we see and have been told, but we just do not know. If the bullet was a few inches from the spine, then that should be a full package. I mean we have to use common sense at every call, but this should of been a no brainer. Package and go. It's always better to roll him into ER, and get the x-ray results and see that it totally missed anything vital, then to roll him in, get the x-ray results and find out it, or a part of it hit his spine and now he can't move his legs or something.
> Now being your first GSW, it was a new experience, but we are trained to deal with whatever we see.. so hopefully next time if your partner doesn't want to package you will know it should happen.



I don't really know that you need X-Ray vision when the patient is shot _in the back_ (That's where the spine is). I know it's just about impossible to get a patient who is sitting on arrival to agree to full backboard C-Spine precautions, but as suggested, simply taking care in position and moving can do wonders.


----------



## LE-EMT (Jun 16, 2008)

Hastings said:


> I don't really know that you need X-Ray vision when the patient is shot _in the back_ (That's where the spine is). I know it's just about impossible to get a patient who is sitting on arrival to agree to full backboard C-Spine precautions, but as suggested, simply taking care in position and moving can do wonders.




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


----------



## Hastings (Jun 16, 2008)

LE-EMT said:


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



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

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


----------



## LE-EMT (Jun 16, 2008)

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


----------



## Hastings (Jun 16, 2008)

LE-EMT said:


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



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


----------



## LE-EMT (Jun 16, 2008)

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


----------



## Hastings (Jun 16, 2008)

LE-EMT said:


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



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

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


----------



## LE-EMT (Jun 16, 2008)

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


----------



## JPINFV (Jun 16, 2008)

LE-EMT said:


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



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


----------



## Ridryder911 (Jun 16, 2008)

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

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

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

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

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

R/r 911


----------



## boingo (Jun 16, 2008)

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


----------



## mikeylikesit (Jun 16, 2008)

boingo said:


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


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


----------



## boingo (Jun 16, 2008)

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


----------



## Ridryder911 (Jun 16, 2008)

boingo said:


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



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

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

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

Just glad I am not your malpractice carrier... 

R/r 911


----------



## boingo (Jun 16, 2008)

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


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

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

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

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


----------



## Ridryder911 (Jun 16, 2008)

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

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

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

R/r 911


----------



## Hastings (Jun 16, 2008)

Interesting, completely unrelated comment.

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


----------



## fma08 (Jun 16, 2008)

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


----------



## LucidResq (Jun 16, 2008)

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


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

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

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


----------



## traumateam1 (Jun 17, 2008)

LucidResq said:
			
		

> Now correct me if I'm wrong here, but in the field you're not checking for sphincter tone and deep tendon reflexes and full motor function, so how positive can you be that the patient does not have a neuro deficit? I would think that the relatively simple AVPU, AAOx3, GCS and CSM assessments are not comprehensive enough to truly rule out neuro deficit to the point that I would feel comfortable neglecting to backboard someone with a penetrating injury so near the spinal column just because they show no neuro deficit in my quick field assessments.
> 
> 
> And I do believe that there are patients who may not have neuro deficits now, but once they get moved around a lot and that bullet/bone fragment/whatever is bumped, they will have a deficit, and as a provider you'll be in deep... poop. I know that this may be an extremely rare circumstance, but why risk exacerbating that circumstance when the consequences are so grave, preventing that problem is so easy, and in the field you can never prove that the patient is not in that circumstance? You just can't.
> ...



I agree *110%*.


----------



## boingo (Jun 17, 2008)

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

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

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


----------



## Ridryder911 (Jun 17, 2008)

boingo said:


> There is no National Standard, hell, there is no standard across county lines, let alone across the nation (US).  How many systems do you think still advocate w/o fluids for hypotensive trauma patients?  MAST trousers?  Hyperventilating head injuries?  Studies have shown that what we once believed helpful was actually not.  How long should a system wait until they change the way they approach patient care?  Do we need Dr. Pepe to tell us when?  Seattle Fire department?  Department of Transportation, god forbid?
> 
> I am not telling anyone to change the way they do business, they should follow local guidelines, however there is good data out there that would suggest to elect not to board the patient with a penetrating injury to the torso is not negligent, in fact, it is based on sound medical research.  Deviating from protocol on the other hand could get you into trouble.  As I have stated, I am not required to board this class of patient, and don't.  I utilize tourniquets on vascular injuries by department guidelines, and good evidence based medicine.  The vascular surgeons who lecture for us are 100% in favor of this.
> 
> Look at therapuetic hypothermia for ROSC in the medical arrest patient.  If someone were to pack their patient in ice based on the research, yet against protocol they would be in a world of trouble.  Systems that choose to utilize TH do so because of good science.  It is certainly not a National Standard, and probably won't be for some time.  Doesn't mean it isn't the right thing to do.



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

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

R/r 911


----------



## Clibby (Jun 17, 2008)

As Rid has been saying, he should have been back boarded, not because it necessarily would have done much good, but to cover your own behind. Everyone will give the, "he could have had a spinal injury" or "this treatment works better" and there is always a possibility of that, but an even bigger reason is that if he turns out to have some neurological injury, and you didn't backboard, the court is not going to side with you unless he refused. It shouldn't take you more than 2 min to backboard even the most difficult pt except during an extrication, so if it is taking you 5 min or more you should pull out a board at the station and practice a bit.


----------



## CAOX3 (Jun 17, 2008)

I am new here and I enjoy the discussions, so I figured I would chime in.

I am an EMT in a tiered ALS/BLS system. Urban with a high call volume.

As far as the GSW.  Why wouldnt you board him, unless he refused then he can sign AMA.

Second, You wouldnt be boarding him just to protect against possible c-spine damage, you are also immobilizing him due to the fact that he has been shot in the torso with no noted exit wound, which could mean that the jagged little piece of shrap-metal is resting nicely on one of his major arteries, or perhaps lodged in his ventrical, and any sudden movement will cause irreversible damage, up to and probably including death.   

By the way LE your question about why EMTs still respond to EMS calls in the US is simple, my thoughts aside, its financial.  I dont believe that every call requires a paramedic, however with what they are pumping out today in these so called educational institutions.  Some who at leats slept through night medic school is probably a little more prepared to handle some calls then most EMTs.

Another thought EMTs nor paramedics save gunshot wounds surgeons do. These calls are time sensitive, I have done a few  ha ha.....and sitting around on scene with these pts is completely in excusable, at the ALS or BLS level.  

About the pt refusing c-spine immobilization.  Usually a conversation about what it would be like to spend the rest of his life seated in a chair with his wife and children feeding him supper through a staw will usually do the trick.


----------



## mycrofft (Jun 17, 2008)

*Hmmmm...general instructions versus clinical findings*

Re the comment above from an uncited fellow poster, a BLS may be making the decision on a GSW because all you have is a BLS, or even a bystander if there is no one else there.  Also, if you are ALS but your BLS-buddy can't throttle back and follow your lead; or, since the BLS is right (imagine that), you go for it. Trick is, the right decision gts made and the right course followed, whether it's Gilligan, the Skipper, or Mrs Howell.

Don't get dogmatic. Your policis and procedures are hopefully good ones, so follow them unless something doesn't make sense, then you have to act on your observations.

If the pt's gonna fight, skip it and get em in. If the pt shows clinical symptoms and will cooperate, board em and go. Just be damn sure you can manage airway and you rule out or "treat-out" a pneumothorax from that little gsw you are about to lay the pt upon. While you might paralyze them through movement, you can lose them entirely if they are bleeding or a frag is moving about doing damage. There isn't much more to be done at the entrance wound, so if it's inaccessible but covered by an occlusive dressing or Heimlich valve (am I dating myself again?), fine, press on.

Folks like to hypothesize about the physics of projectiles, but after learning the basics, medical treatment short of the O.R. (or "House, MD") is still dependent upon what you see, feel hear and smell. I'd be worrying about bleeding; bullets don't significantly "cauterize" _per se_ (no, not even tracers), they stretch vessels so that the vessels retract and close themselves by clotting, but the large dangerous vessels don't and you can even wind up with a frag IN a major vessel. Small cal will not cavitate much unless it has a big powder charge (ala the M-16*), and then it will tumble, too; it takes energy to cavitate, and to make up for small mass you gotta accelerate, but as far as treatment, it's academic. Round and round, in and out, but defintive care demands a hospital, so _didi mau_.

Triage may be affected, though. 

*Yes, I know, but technically speaking a M-16 round is a small caliber (diameter); it just has a pretty high mass versus a .22, plus that walloping powder charge.


----------



## Ridryder911 (Jun 17, 2008)

I am concerned that some would think that it would take time to "board" someone. Seriously folks if it takes you more than a minute (non extrication), then something is wrong. Think about it, turn the patient on the side as a unit, observe the back.. look, listen and feel, then back over..if they were in a sitting position, even more simple: secure & up. How hard or time consuming? Actually, usually faster than attempting to grab ahold of someone, or lifting them.. 

Let's not make it any harder or difficult than it is folks...

R/r 911


----------



## tydek07 (Jun 17, 2008)

Raf said:


> I had my first GSW two nights ago. When we arrived at scene we found the pt. sitting on the sidewalk. He had one shot, into his back (a few inches from the most prominent vertebra), with no exit wound. The entrance wound was barely bleeding.
> 
> My partner wanted to longboard him but we decided not to. My question is, would it have been a good idea to backboard a GSW patient? It seemed kinda silly with so little time on our hands with internal bleeding a possible threat, but later I made the connection that the bullet came in pretty close to his spine and immobilization may have helped.



I would have backboarded him for the same reasons that have been stated multiple times ahead of me: Close to spine, No exit wound. Better to be safe then sorry.


----------



## traumateam1 (Jun 17, 2008)

Agree with the last three posts. It really isn't that hard to board someone (unless scene isn't safe or p/t is fighting) but other than that.. you should board them and go. In all honesty, if it takes "to long" to board someone, you better practice.

I think we've beaten this to death pretty well... ^_^


----------



## mycrofft (Jun 18, 2008)

*Agreed. Scene safety is good for another thread, though.*

The question of "Who shot john?" gets personal.


----------



## CAOX3 (Jun 18, 2008)

Just to clarify, in my opinion a backboard should be a for gone conclusion in this instance. 

Im not a big fan of monday morning quarterbacking, I wasnt there.  With the information that was given I would have immobilized this gentleman.  

Do I backboard all gunshot victims? No. 

Have I gotten a little heat for not doing so? On occasion. Be prepared to explain your reasoning. If its logical you shouldnt have a problem.

One other thing, I dont do this job not to get sued or caught in a review board.  I do whats best for my patient, if that means we deviate from the plan, then so be it. This isnt cookie cutter stuff, every situation is different and should be assessed that way.  

Thats why protocols bother me some at any level, you cant conform every pt to a certain protocol it just does not work that way, as a guide sure Im fine with that, as a rule not so much.

If you dont do something that you should have done, what ever the case may be, you better have a damn good reason to back it up, as my medical director would say.


----------



## boingo (Jun 18, 2008)

tydek07 said:


> I would have backboarded him for the same reasons that have been stated multiple times ahead of me: Close to spine, No exit wound. Better to be safe then sorry.




What if it wasn't "close to the spine?"  What if it was in the abdomen, or anterior cx?  If your working under the "what if" theory, then you should be boarding them too.  An abdomenal GSW could very well end up in the spine, you don't know.  Either board them all with the possibility it "could be" in the spine, or don't.  Having a wound "near" the spine is pretty subjective.  What is near, 2 cm, 10 cm, more?  

No one will fault you for boarding a patient, the question is should you be faulted for not.  If you are working with the assumption that a wound without exit (determining exit vs entrance in the field would be another thread) could be in the spine, then proximity to the spine should be irrelevant.  Above the groin, below the head should be boarded.  

Placing a patient supine on a board can make them easier to move, and it doesn't take much time.  Placing a patient flat on a board can also increase anxiety and air hunger.  Follow your protocols/guidelines.  I wouldn't advise using the "close" arguement trying to defend why you did or didn't.  Just my humble opinion.


----------



## Ridryder911 (Jun 18, 2008)

Again, no one thought of the scoop.. which could be used to lift & broke apart if need be...

R/r 911


----------



## traumateam1 (Jun 18, 2008)

Ridryder911 said:
			
		

> Again, no one thought of the scoop.. which could be used to lift & broke apart if need be...


Scoop Stretcher? Clam Shell by Ferno? That's what I would of used...


----------

