# Board & Collar for Nursing Home Falls



## adamNYC (May 24, 2015)

Board & Collar for Nursing Home Falls

I notice depending on my partner I'm working with, we will just collar and sometimes we will board and collar. The main indication being if they hit their head. What I do most of the time is just collar if they hit their head. Recently my partner said "If you collar, you must board too" and we took a poor guy who was eating his lunch and in no apparent distress and did a standing takedown board and collar. Now that just agitated him on the whole ride to the hospital and the Doctor didn't seem to happy with it either.

Thoughts? Suggestions?

Thanks


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## CentralCalEMT (May 24, 2015)

First off, the normal disclaimer....Follow your local protocols.

That being said, it sounds like you are right to question backboarding. If he was eating lunch, he was obviously up and walking around after the fall and I would assume moving all extremities well. Here (Central CA) he would not have gotten anything other than transport to the hospital in the position of comfort. Did he have any neuro deficits, numbness or tingling? Did he have any mid line neck pain inhibiting movement? If the answer to all those questions is no, and if your local protocol allows it, transport in the position of comfort is generally the way to go. Possibly if the mid line neck pain inhibits movement, a collar can be used. We only use soft collars here, but I do not know if that is an option for you. It does no good to immobilize people who do not need it. Especially if they are weak and frail which most people in nursing homes are. If you lie patient with chronic COPD or CHF on his back, really bad things can happen, and it seems inhumane to c-spine elderly patients who can not tolerate it.  It sounds like he was minding his own business and EMS came up to him and threw him on a backboard. That would agitate anyone. We all have had that over zealous partner at times, and if that is the case, then it might be a good idea to take him or her aside and remind them we have to think in the best interest of our patient and not over treat patients if they do not need it.


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## 281mustang (May 24, 2015)

Neck pain upon palpation: C-Collar

Neck and back pain upon palpation: C-Collar/scoop stretcher(I also typically put a pillow under their head for comfort)

No neck/back pain upon palpation: Nothing

That's just my personal preference. Not a big fan of backboards, scoop stretchers technically are a form of SMR and circumvent many of the issues associated with boards. I typically only use backboards on MVCs(due to the fact that the slick flat surface makes it easy to transition the pt from a seated position to supine on the stretcher) and heavy unconscious patients(due to the fact that it's logistically typically the easiest way to get them from the floor to the stretcher.)


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## DrParasite (May 24, 2015)

adamNYC said:


> Recently my partner said "If you collar, you must board too" and we took a poor guy who was eating his lunch and in no apparent distress and did a standing takedown board and collar. Now that just agitated him on the whole ride to the hospital and the Doctor didn't seem to happy with it either.


maybe I'm missing something, but why did you board and collar him?  last I checked, eating lunch wasn't criteria for c-spine precautions....


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## adamNYC (May 24, 2015)

He fell, hit his head, and it was bandaged. Fall wasn't witnessed. Pt was found by us in the middle of lunch all bandaged up and ready to get checked out. 

Good points on the palpating the neck and spine. Will do on next fall as part of trauma assessment.


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## ERDoc (May 25, 2015)

NYS is at least a decade behind the literature and the providers are even more so.  The only real use for a long board anymore is to move a pt.  Once they are in the hospital we are taking them right off the board for a multitude of reasons (they serve no purpose, they interfere with xrays, they cause pressure sores, etc).  You are probably more likely to limit spinal movement by placing them on the stretcher mattress than you are on a long board because they will be much more comfortable and not move around as much.

As has been said, follow your local protocols but if you want to educate yourself, look up the NEXUS criteria and the Canadian C-Spine Rules.


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## NYBLS (May 25, 2015)

ERDoc said:


> NYS is at least a decade behind the literature and the providers are even more so.  The only real use for a long board anymore is to move a pt.  Once they are in the hospital we are taking them right off the board for a multitude of reasons (they serve no purpose, they interfere with xrays, they cause pressure sores, etc).  You are probably more likely to limit spinal movement by placing them on the stretcher mattress than you are on a long board because they will be much more comfortable and not move around as much.
> 
> As has been said, follow your local protocols but if you want to educate yourself, look up the NEXUS criteria and the Canadian C-Spine Rules.



I wouldn't generalize all providers as a decade behind the literature. NYS is in an awkward transition phase where the providers know whats best but the state doesn't allow it yet. It doesn't mean the providers don't know best or aren't ignoring common sense.


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## adamNYC (May 25, 2015)

I was just glad the hospital was 5mins away so he wasn't too uncomfortable for too long


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## ERDoc (May 26, 2015)

NYBLS said:


> I wouldn't generalize all providers as a decade behind the literature. NYS is in an awkward transition phase where the providers know whats best but the state doesn't allow it yet. It doesn't mean the providers don't know best or aren't ignoring common sense.



I wasn't trying to imply that all providers are that way, but most in the areas I am familiar with are.  I also wouldn't generalize all providers as knowing what's best, since the OP has shown this is not true.  I know lots of providers who want to provide better care but are limited because of the antiquated system but there are also a lot of the old guard who say, "This is the way we have always done it so why change it," and unfortunately they are the ones that run the system. Again, this is based on the parts of the state I am familiar with so your mileage may vary.


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## adamNYC (May 26, 2015)

Keep in mind I'm a December EMT school  grad and been working txp two months


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## Trauma Queen (May 26, 2015)

Connecticut has recently updated it's spinal immobilization protocols. ALS can clear c-spine under certain circumstances. If there is any altered mentation, intoxication, distracting injuries, etc, the patient requires a LBB. Otherwise, they can be cleared of everything. BLS, if we arrive on scene and the patient is ambulatory, we don't need to put the patient on a LBB. So goodbye to the nonsense standing takedown. 

We're definitely moving in the right direction.


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## RedAirplane (May 26, 2015)

DrParasite said:


> maybe I'm missing something, but why did you board and collar him?  last I checked, eating lunch wasn't criteria for c-spine precautions....



Many fast food sandwiches cause multi-system trauma...


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## NYBLS (May 26, 2015)

ERDoc said:


> I wasn't trying to imply that all providers are that way, but most in the areas I am familiar with are.  I also wouldn't generalize all providers as knowing what's best, since the OP has shown this is not true.  I know lots of providers who want to provide better care but are limited because of the antiquated system but there are also a lot of the old guard who say, "This is the way we have always done it so why change it," and unfortunately they are the ones that run the system. Again, this is based on the parts of the state I am familiar with so your mileage may vary.



Agreed, I shouldn't have generalized. Hopefully science and quality clinicians can pave the way (and knock the old guard) to providing better care.


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## ERDoc (May 26, 2015)

The problem is that the old guard is creating the new providers the same way.


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## TF Medic (May 26, 2015)

adamNYC said:


> Keep in mind I'm a December EMT school  grad and been working txp two months



From one new guy to another, when you get conflicting information from partners:

1.) Read the protocol
2.) Ask someone who has proven trustworthy
3.) If #2 is unavailable, see #1

What do your protocols say?


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## NYBLS (May 26, 2015)

TF Medic said:


> From one new guy to another, when you get conflicting information from partners:
> 
> 1.) Read the protocol
> 2.) Ask someone who has proven trustworthy
> ...



Protocols are guidelines for treatment. We are talking about people following guidelines on here too strictly and hurting patients.


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## TF Medic (May 26, 2015)

NYBLS said:


> Protocols are guidelines for treatment. We are talking about people following guidelines on here too strictly and hurting patients.


Guidelines, exactly. And without knowing them, we have no idea how close or how far his partners are to following said guidelines.


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## Chewy20 (May 26, 2015)

adamNYC said:


> He fell, hit his head, and it was bandaged. Fall wasn't witnessed. Pt was found by us in the middle of lunch all bandaged up and ready to get checked out.
> 
> Good points on the palpating the neck and spine. Will do on next fall as part of trauma assessment.



That should already be apart of your trauma assessment.


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## EMTinCT (May 26, 2015)

Longboards are a good way to cause a lot of damage, especially to the elderly. Be kind to your patients and never use them for anything other than moving a PT. If you fear c-spine damage then use a collar but place them on the stretcher without a longboard. 

Longboard=not supported by the literature


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## RocketMedic (May 27, 2015)

They are great for adding table space, and the collar can make a good salad-bowl holder.


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## NomadicMedic (May 27, 2015)

EMTinCT said:


> Longboards are a good way to cause a lot of damage, especially to the elderly. Be kind to your patients and never use them for anything other than moving a PT. If you fear c-spine damage then use a collar but place them on the stretcher without a longboard.
> 
> Longboard=not supported by the literature




Or, *follow your protocols*. If his protocol says "LSB/collar" that's a better idea and he'll stay out of trouble. It's certainly better than saying "some guy on the internet says "never use a longboard for anything than moving a patient". 

This forum tends to attract more educated (and opinionated) providers, but at the end of the day you've got to DO WHAT THEY TELL YOU TO DO, until you have the experience and education to defend your position.


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## EMTinCT (May 27, 2015)

DEmedic said:


> Or, *follow your protocols*. If his protocol says "LSB/collar" that's a better idea and he'll stay out of trouble. It's certainly better than saying "some guy on the internet says "never use a longboard for anything than moving a patient".
> 
> This forum tends to attract more educated (and opinionated) providers, but at the end of the day you've got to DO WHAT THEY TELL YOU TO DO, until you have the experience and education to defend your position.



OK here are the protocols and they say no longboard. If you use one for anything other than moving a patient then you've done bad.


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## LACoGurneyjockey (May 28, 2015)

EMTinCT said:


> OK here are the protocols and they say no longboard. If you use one for anything other than moving a patient then you've done bad.


Except the OP is not in CT...


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## RedAirplane (May 28, 2015)

Side question: wouldn't a back board be needed for a patient like this?


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## LACoGurneyjockey (May 28, 2015)

Ishan said:


> Side question: wouldn't a back board be needed for a patient like this?


I'll just start quoting DE on all my responses. 



DEmedic said:


> Or, *follow your protocols*. If his protocol says "LSB/collar" that's a better idea and he'll stay out of trouble...
> 
> ...DO WHAT THEY TELL YOU TO DO, until you have the experience and education to defend your position.



Why do you think that would require a backboard more than another call?


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## RedAirplane (May 28, 2015)

LACoGurneyjockey said:


> I'll just start quoting DE on all my responses.
> 
> 
> 
> Why do you think that would require a backboard more than another call?



He can't move, there is visible spinal injury, loss of distal CSM, and I (perhaps wrongly) am afraid that moving him any other way will just snap whatever is left of his spinal column.

Since he is seated I might argue the KED if I had one.


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## RedAirplane (May 28, 2015)

And yes, I follow protocols. This question is just for my knowledge/understanding.


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## LACoGurneyjockey (May 28, 2015)

Once our new protocols take effect, I would slide him onto a backboard and use that to move him to the gurney. In terms of transport, his spine is more secure seat belted to the padded gurney than strapped to a hard plastic board. So no, the only patient I want to transport on a board is CPR in progress.
The issue isn't whether or not we're sure he has a spinal injury. It's that a board isn't more secure for a spinal injury, whether that's a major trauma or a ground level fall doesn't matter.


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## Brandon O (May 28, 2015)

Ishan said:


> And yes, I follow protocols. This question is just for my knowledge/understanding.



It's a good question. Your reasoning is the reasoning that most folks are using nowadays. In other words, it's predicated on the idea that "unstable spinal injuries" (those with the potential to neurologically deteriorate due to movement occurring after the initial trauma) are rare, but they do exist. Since they're rare most folks are starting to move away from prophylactically immobilizing every Tom, ****, and Harry who sneezes -- the NNT is too high -- but since they're real, patients with clear spinal injury or especially those ALREADY exhibiting neurological compromise have a much better risk/benefit. So they buy the plastic stuff.

That's the most common thinking at this point, anyway. Whether this phenomenon is actually real remains something of a mystery, and whether we can prevent it remains wholly so.


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## TF Medic (May 28, 2015)

LACoGurneyjockey said:


> his spine is more secure seat belted to the padded gurney than strapped to a hard plastic board.



Do you have a link to a study confirming this? I am not doubting you, just would like to read the data. Thanks.


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## Jim37F (May 28, 2015)

The tractor patient would definitely have been collar and boarded here (I'll imagine a construction accident with one of those big cable spools here due to lack of farms)....but there is a big difference in being crushed by a hay bail with multiple trauma complaints over a ground level slip and fall in a nursing home where the patient is calmly eating lunch upon arrival


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## EMTinCT (May 28, 2015)

LACoGurneyjockey said:


> Except the OP is not in CT...



This is just the CT adaptation of the national standards.


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## LACoGurneyjockey (May 28, 2015)

EMTinCT said:


> This is just the CT adaptation of the national standards.


Umm, no. As much as it should be, a c-collar and position of comfort for traumatic neck/back pain is not the national standard. CT may be spot on, but that doesn't mean everywhere else is.


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## EMTinCT (May 28, 2015)

LACoGurneyjockey said:


> Umm, no. As much as it should be, a c-collar and position of comfort for traumatic neck/back pain is not the national standard. CT may be spot on, but that doesn't mean everywhere else is.



It definitely is the national standard. If individual states choose not to be on board then that's them abrogating the standards.


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## LACoGurneyjockey (May 28, 2015)

Show me where the NREMT says that. Or whoever you're choosing to use as your national standard. More relaxed c-spine criteria, maybe. But as you said earlier, using a backboard for patient movement only and transport on a board was always contraindicated? I'd love to see a source to that national standard.


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## EMTinCT (May 28, 2015)

LACoGurneyjockey said:


> Show me where the NREMT says that. Or whoever you're choosing to use as your national standard. More relaxed c-spine criteria, maybe. But as you said earlier, using a backboard for patient movement only and transport on a board was always contraindicated? I'd love to see a source to that national standard.


NREMT doesn't make the standards. They are simply a testing agency.


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## LACoGurneyjockey (May 28, 2015)

EMTinCT said:


> NREMT doesn't make the standards. They are simply a testing agency.


Let me say it again, 


LACoGurneyjockey said:


> Or whoever you're choosing to use as your national standard. More relaxed c-spine criteria, maybe. But as you said earlier, using a backboard for patient movement only and transport on a board was always contraindicated? I'd love to see a source to that national standard.


 
Where did you find that "National standard" then? Please show us some sources so we can be so enlightened. 
I'm not arguing that backboards are the way to go. But you can't just say...


EMTinCT said:


> no longboard. If you use one for anything other than moving a patient then you've done bad.


And...


EMTinCT said:


> It definitely is the national standard. If individual states choose not to be on board then that's them abrogating the standards.


And then not have any sources to back that up. I'm not talking about your state protocols, you wanted to call it a national standard.


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## EMTinCT (May 28, 2015)

You seem pretty convinced. Gramma told me to never fight with someone who knows they're right.


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## Flying (May 28, 2015)

EMTinCT said:


> NREMT doesn't make the standards. They are simply a testing agency.


From page 30 of the NHTSA "National Scope of Practice Model".





What our "national standard" mandates as the necessary minimum is behind the times.


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## LACoGurneyjockey (May 28, 2015)

EMTinCT said:


> You seem pretty convinced. Gramma told me to never fight with someone who knows they're right.


Hey, I'm ready to be shown I'm wrong. But you don't want to do that.
No ones saying it's not behind the times and the evidence. But national standards aren't just what you want them to be because gramma said so.


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## DrParasite (May 28, 2015)

EMTinCT said:


> It definitely is the national standard. If individual states choose not to be on board then that's them abrogating the standards.


I must agree, I can't find any national standard saying what you are claiming.  In fact, I would argue that the national standard is still to board and collar more than they should, and certain individual states are changing their individual standards, not the nation as a whole has not changed.

If you can cite a source, I would gladly accept it as the national standard, and admit that you are correct.


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## ERDoc (May 29, 2015)

How can anything be called a "national standard" when there is a paucity of literature on the subject?  We can all say what we think is best but where is the evidence?


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## RedAirplane (May 29, 2015)

The "national standards" are available on the NHTSA website. Of course, they are just guidelines and have no direct legal applicability.


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## Bullets (May 30, 2015)

Maybe he means the national position paper from NAEMSP and ACS-CoT?


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## Tigger (May 30, 2015)

Certainly not the national standard, sadly. Slowly that will change, but the national standard is more of a consensus than anything else.


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## NomadicMedic (May 30, 2015)

If you're looking for a national standard, shouldn't we be  looking at what's taught in the DOT standard curriculum?

Last I saw, that included a board and collar. Of course, each state is welcome to add or subtract as they, and the medical directors, see fit... But let's not confuse consensus with curriculum.


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## ERDoc (May 31, 2015)

My point was that there is really no "standard" since there is very little evidence.  It is more recommendations based on small studies looking at other things and opinion.  I also get the feeling that CT doesn't realize that the protocols in CT don't necessarily apply across the board, especially in areas where there is this much controversy and lack of evidence.  I remember my CFR/EMT classes, we were taught that our protocols were gospel and infallible.


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## DrParasite (May 31, 2015)

ERDoc said:


> I remember my CFR/EMT classes, we were taught that our protocols were gospel and infallible.


I must admit, I was taught the same.  Even when stuff didn't make sense, and I questions the instructors on it, the fuddled their way through an explanation that didn't make much logical sense, but when I was going to be evaluated on it, and told "this is the standard of care, and if you get called into court, they will bring in your text book and ask you why you didn't do what your text book said," I decided that maybe the best defense should be "that's what i'm taught, that's what my boss wants me to do, and that's what my medical director wants me to do... if you disagree, you should take it up with someone higher up the food chain."


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## TimRaven (Jun 8, 2015)

My county recently adopted NEXUS like standard for field personal, even EMR in SAR teams.
So OP's patient in here would be simply put on position of comfort and transport.


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