# Now what



## rescueman (Mar 25, 2009)

Ok... we all know the bathroom is the most common place in a home for the slip and fall. I'd like to ask for a consensus from the group about the best way to deal with this..... it's all hypothetical.

Middle of the night, 65 YOM  slip and fall in the second floor bathroom with altered loc, hx of seizures, possible head / neck injury. 16 step narrow stairs. OK.... stair chair isn't an option, what is? Reeves.... backboard... both... neither ?

Inquiring minds would like to know..... thanks !:unsure:


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## EMTinNEPA (Mar 25, 2009)

Backboard.  How narrow are we talking?


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## Sasha (Mar 25, 2009)

> slip and fall in the second floor bathroom with altered loc, hx of seizures, possible head / neck injury.



Backboard. And people who don't trip and fall easily while walking down stairs.


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## medic417 (Mar 25, 2009)

Narrow stairs why not use the KED.


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> Narrow stairs why not use the KED.



Altered level of consciousness and possible seizure activity would contraindicate the KED.  It'd be quicker (and safer) to just go with the backboard.  If you're worried about tripping going down the stairs and dropping the board, then whip out the reeves so you down have to bend over so much.  If you can't lift the patient, call the Fire Department. ^_^


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## medic417 (Mar 25, 2009)

Any turns in stair well or at top or bottom may make it impossible to turn with backboard.  Is this an open stairwell or walls on both sides?


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## Sasha (Mar 25, 2009)

A ked is not meant to carry someone down stairs!


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## rescueman (Mar 25, 2009)

*Continued*

Thanks....The points about not being able to turn on a stairway with a backboard and keds not really being appropriate are well taken.

I'll try to clarify a little.... let's make the stairs standard size and a straight run with a wall on one side and bannisters on the other. I'm interested in the best way to immobilize the pt as well as secure him to prevent / minimize movement as much as possible given the incline of the stairs. Never want the backboard to become a sliding board ! YIKES !!!!:unsure:


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## Sasha (Mar 25, 2009)

> Never want the backboard to become a sliding board ! YIKES !!!!



If you do the straps properly they shouldn't. And have lots of three inch tape on hand. But if you're still concerned, perhaps a scoop or basket stretcher would be an option for you.


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## AJ Hidell (Mar 25, 2009)

Not sure why a KED would be appropriate for extricating from a car, but not from a stairwell.  The purpose is to immobilize the c-spine, and it does that job on stairs as well as in a car.


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## EMTinNEPA (Mar 25, 2009)

If the patient has altered mental status and might have had a seizure, why would you waste time putting on a KED?  A KED is indicated only for possible cervical and upper thoracic injuries and when you have a lot of time to waste.

Given the type of stairs the OP described and the patient's situation, a backboard would be the optimum choice.  Possibly a backboard on a reeves, depending on the incline.


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## reaper (Mar 25, 2009)

KED to stairchair, stairchair to LSB,Transport. That's not that hard!


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## Sasha (Mar 25, 2009)

Retracted.


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## EMTinNEPA (Mar 25, 2009)

Or maybe just LSB to transport?


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## reaper (Mar 25, 2009)

EMTinNEPA said:


> If the patient has altered mental status and might have had a seizure, why would you waste time putting on a KED?  A KED is indicated only for possible cervical and upper thoracic injuries and when you have a lot of time to waste.
> 
> Given the type of stairs the OP described and the patient's situation, a backboard would be the optimum choice.  Possibly a backboard on a reeves, depending on the incline.



OP stated possible neck injury. Is the neck not Cervical in nature? Why would I need a lot of time to waste? Does not take long to apply a KED.

OP stated "narrow stairs", this means tight manuvers with a LSB. A KED is a perfect fit for the job. Then a staichair is the safest way to transport the pt.


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## EMTinNEPA (Mar 25, 2009)

reaper said:


> OP stated possible neck injury. Is the neck not Cervical in nature? Why would I need a lot of time to waste? Does not take long to apply a KED.
> 
> OP stated "narrow stairs", this means tight manuvers with a LSB. A KED is a perfect fit for the job. Then a staichair is the safest way to transport the pt.



It takes longer to apply a KED than to apply a LSB.  OP ALSO said altered LOC and history of seizures, or did you forget about that.  Did I say the neck wasn't cervical in nature, or was that a thinly veiled personal attack?  And it the patient can walk down the stairs, then they aren't too narrow to take a LSB down.  Unless the LSB magically makes the patient wider or the stairs more narrow.


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## Veneficus (Mar 25, 2009)

a consensus in medicine?

If the stiars are straight, why not whip out your trusty howd strap, (aka rope webbing) secure them to the board and carefully slide them down the stairs using the strap? (my first choice)

What makes you think spinal injury? Hx of osteoporosis? malnutrition? Or just the fact that he fell?

KED is an extrication device, if you could get it on in a timely manner, no reason not to use it. 

Personally I am partial to the reeves, I think it is the best piece of equipment ever devised for confined space rescue and this sounds like a confined space.


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## EMTinNEPA (Mar 25, 2009)

Veneficus said:


> a consensus in medicine?
> 
> If the stiars are straight, why not whip out your trusty howd strap, (aka rope webbing) secure them to the board and carefully slide them down the stairs using the strap? (my first choice)
> 
> ...



I'm not thinking spinal injury.  The OP is thinking spinal injury and questioning method of extrication.  I don't know if the patient actually told him their neck hurts or if he felt something abnormal upon palpation or if it IS just the fact that he fell.  Given the information I was, I went with the LSB.

LSB would be more timely than a KED.  You'd only have to roll the patient once to get them on the LSB where with the KED you'd have to roll one way, then the other.  Plus, the KED has the leg straps.

The Reeves would be great, except that it wouldn't provide immobilization.  Patient on LSB would be ideal or Patient on LSB on Reeves for safety.


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## Veneficus (Mar 25, 2009)

*Nepa*

sorry, didn't mean to imply you thought spinal injury, that was directed at the OP. My fault. 

I thought the new reeves allowed you to insert a LSB?

But we are in agreement, LSB would be my first choice. I am a big fan of sliding. Makes it harder to drop a pt. plus saves the back of the providers. 

But I also think a skillful provider would have no problem with a KED or a stair chair, just depends on if you really think there is a spinal injury. Not enough info as you pointed out to rule that out, but there would have to be a significant contributing factor to make me think somebody who fell fx any more than a transverse or spinus process. Babinski reflex and rectal tone (if there is incontinence with seizure hx that makes it a little tougher) should be a large indicator if the pt is breathing properly. 

a lot of unknowns, but the pt still needs to come out, and a head injury is a good assumption, but we could stipulate all day.


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## reaper (Mar 25, 2009)

EMTinNEPA said:


> It takes longer to apply a KED than to apply a LSB.  OP ALSO said altered LOC and history of seizures, or did you forget about that.  Did I say the neck wasn't cervical in nature, or was that a thinly veiled personal attack?  And it the patient can walk down the stairs, then they aren't too narrow to take a LSB down.  Unless the LSB magically makes the patient wider or the stairs more narrow.



Why does it take longer to apply a KED, then a LSB? Why are so many in EMS afraid of a KED? It is one of the best devices you have on your truck.

I did not forget about the ALOC or seizures. What do they have to do with the extrication of the pt?

Most EMS providers do not secure a pt to a LSB appropriately, so there is movement. As you maneuver the pt down the steps, they are sliding around on the LSB.

Even if it takes to 2-3 minutes to apply a KED, what is the difference. This is not a time sensitive extrication. Take the time to ensure pt safety. The KED will immobilize the head and neck. The stairchair will safely and comfortably transport the pt down the stairs. This will require a lot less effort and manpower then carrying a LSB or Reeves down the stairs.

I am not taking a shot at you, I am trying to provide a point of view that is often overlooked!


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## AJ Hidell (Mar 25, 2009)

reaper said:


> Why does it take longer to apply a KED, then a LSB?


Even if it did take longer, that is no excuse for not utilizing it when indicated.  This is not an ABC compromised or exsanguinating patient that warrants the ubiquitous and grossly overused "rapid extrication".  If the patient needs c-spine, he needs it.


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## EMTinNEPA (Mar 25, 2009)

reaper said:


> Why does it take longer to apply a KED, then a LSB? Why are so many in EMS afraid of a KED? It is one of the best devices you have on your truck.
> 
> I did not forget about the ALOC or seizures. What do they have to do with the extrication of the pt?
> 
> ...



I'm not afraid of the KED.  Hell, I _TEACH_ the KED.  KED does not intimidate me at all.  I'm looking at it this way... history of seizures, ALOC, the patient COULD be postictal or interictal.  And since the OP didn't mention anybody else in the residence, I'm guessing the fall was unwitnessed, so we don't know if the ALOC is related to the patient's seizure disorder, to the patient hitting his head, or to neither.  OP didn't mention any CVA symptoms, no diabetic history, no smell of ETOH on his breath, and I'm hoping the patient has a patent airway and is breathing adequately otherwise we wouldn't be worrying about immobilization yet.  So I would assume that patient could seize (again) at any time.  I'd rather go with the LSB, which takes a minute and a half to apply, than the KED, which would take 2-3 minutes.  While the extrication is not time-sensitive, immobilization is.  Correct me if I'm wrong, but I'm pretty sure that a non-immobilized patient seizing with a possible spinal injury would generally be considered a bad thing.  Plus, LSB by itself would be more comfortable than KED and LSB.  And if the patient _IS_ secured to the LSB appropriately, sliding shouldn't be a problem... I guess it depends how good you are at immobilization.


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## reaper (Mar 25, 2009)

EMTinNEPA said:


> I'm not afraid of the KED.  Hell, I _TEACH_ the KED.  KED does not intimidate me at all.  I'm looking at it this way... history of seizures, ALOC, the patient COULD be postictal or interictal.  And since the OP didn't mention anybody else in the residence, I'm guessing the fall was unwitnessed, so we don't know if the ALOC is related to the patient's seizure disorder, to the patient hitting his head, or to neither.  OP didn't mention any CVA symptoms, no diabetic history, no smell of ETOH on his breath, and I'm hoping the patient has a patent airway and is breathing adequately otherwise we wouldn't be worrying about immobilization yet.  So I would assume that patient could seize (again) at any time.  I'd rather go with the LSB, which takes a minute and a half to apply, than the KED, which would take 2-3 minutes.  While the extrication is not time-sensitive, immobilization is.  Correct me if I'm wrong, but I'm pretty sure that a non-immobilized patient seizing with a possible spinal injury would generally be considered a bad thing.  Plus, LSB by itself would be more comfortable than KED and LSB.  And if the patient _IS_ secured to the LSB appropriately, sliding shouldn't be a problem... I guess it depends how good you are at immobilization.



Well, since I am looking at this from a medic point of view. I am not worried about the seizures. I can control them. The KED is going to imobilize the head and neck just fine, normaly better then a LSB. The last line is where it all falls into place. You and I may imobilize a pt perfectly on a LSB, so there is no movement. Can you say that for every provider though? If you have plenty of man power on scene, then go with what ever feels right to you. If it is two of you on scene. The ked and stair chair will be the safest way to move this pt.


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## EMTinNEPA (Mar 25, 2009)

reaper said:


> Well, since I am looking at this from a medic point of view. I am not worried about the seizures. I can control them. The KED is going to imobilize the head and neck just fine, normaly better then a LSB. The last line is where it all falls into place. You and I may imobilize a pt perfectly on a LSB, so there is no movement. Can you say that for every provider though? If you have plenty of man power on scene, then go with what ever feels right to you. If it is two of you on scene. The ked and stair chair will be the safest way to move this pt.



Well, I'm looking at this from an EMT point of view.  I can't control the seizures.  The OP didn't specify whether, for this scenario, you (the provider) was an EMT on a BLS truck, an EMT on an ALS truck, or a medic on an ALS truck.  From the BLS point of view, where seizures cannot be controlled, immobilizing the patient ASAP would be the best course of action.  I'm also looking at this from MY point of view, as a provider who CAN immobilize a patient so there is no movement.  So, from my point of view, there are time constraints due to what might be going on with the patient (which I can't diagnose since there isn't enough information to rule anything out) that call for whichever immobilization method would be fastest, and I'm confident enough in my immobilization kung-fu ninja skills to limit movement.  Sure, the right answer differs from provider to provider.  As for myself, for safety and for patient care, an LSB on a reeves would be the best course of action.  But hey, diff'rent strokes...


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## BossyCow (Mar 25, 2009)

reaper said:


> Well, since I am looking at this from a medic point of view. I am not worried about the seizures. I can control them. The KED is going to imobilize the head and neck just fine, normaly better then a LSB. The last line is where it all falls into place. You and I may imobilize a pt perfectly on a LSB, so there is no movement. Can you say that for every provider though? If you have plenty of man power on scene, then go with what ever feels right to you. If it is two of you on scene. The ked and stair chair will be the safest way to move this pt.



I would go with the LSB. I mean there are those who will blow IV's, gut tube or otherwise mangle care... doesn't make the practice inappropriate, if we removed all skills that some people mess up, we wouldn't be able to do anything.  
My concern with this pt and the KED is what happens if the pt starts to seize again halfway down the stairs. Infinitely more manageable on the LSB than with the KED. KED leaves the extremeties loose, dangling and a possible issue in the tight stairway.

And didn't the OP state that stairchair wasn't an option?


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## medic417 (Mar 25, 2009)

Sasha said:


> A ked is not meant to carry someone down stairs!



It stabilizes back and neck while you get patient out to a more secure location.  If you can not use backboard as happens in many older rural homes, you at least have provided some support for possible spinal injury.


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## medic417 (Mar 25, 2009)

EMTinNEPA said:


> It takes longer to apply a KED than to apply a LSB.  OP ALSO said altered LOC and history of seizures, or did you forget about that.  Did I say the neck wasn't cervical in nature, or was that a thinly veiled personal attack?  And it the patient can walk down the stairs, then they aren't too narrow to take a LSB down.  Unless the LSB magically makes the patient wider or the stairs more narrow.



Based on OP saying you could not use a stair chair anyone that has been in EMS very long would know that also would mean you could not use a back board, a scope stretcher, etc.  If you can use the backboard you can use a stairchair.


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## BossyCow (Mar 25, 2009)

medic417 said:


> Based on OP saying you could not use a stair chair anyone that has been in EMS very long would know that also would mean you could not use a back board, a scope stretcher, etc.  If you can use the backboard you can use a stairchair.



Um... unless maybe they don't have a stairchair???


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> Based on OP saying you could not use a stair chair anyone that has been in EMS very long would know that also would mean you could not use a back board, a scope stretcher, etc.  If you can use the backboard you can use a stairchair.



Negative, ghostrider.  An LSB isn't as wide as a stair chair, so the LSB can fit in narrow stairwells that a stair chair couldn't.  And don't talk about turns in the stairwell because the OP ruled those out as well.  Plus, what if you're on a chase truck or a QRS and you don't HAVE a stairchair?  Or what if your service are a bunch of cheap idiots and didn't buy a stairchair for every bus?

By the way, thanks for the condescending "anyone that has been in EMS very long would know" thrown in there.  Upset that BossyCow ruined your master plan by pointing out that stairchair wasn't an option?  Your certification number has nothing to do with your knowledge.


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## medic417 (Mar 25, 2009)

BossyCow said:


> Um... unless maybe they don't have a stairchair???



Then they should be fired for failing to do a proper check of the ambulance.  If the service does not provide a stair chair they need to find a new service.  

But the way I took OP's statement was it would not work on theses stairs so I took his statement as a hint that you could not use backboard either then.  You apperently felt he meant they had forgotten it at the station or something like that.


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> But the way I took OP's statement was it would not work on theses stairs so I took his statement as a hint that you could not use backboard either then.  You apperently felt he meant they had forgotten it at the station or something like that.



Well then there's NO way to get down the stairs, or for you to get upstairs, so I guess you'd better call the fire department.


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## medic417 (Mar 25, 2009)

EMTinNEPA said:


> Negative, ghostrider.  An LSB isn't as wide as a stair chair, so the LSB can fit in narrow stairwells that a stair chair couldn't.  And don't talk about turns in the stairwell because the OP ruled those out as well.
> 
> By the way, thanks for the condescending "anyone that has been in EMS very long would know" thrown in there.  Upset that BossyCow ruined your master plan by pointing out that stairchair wasn't an option?  Your certification number has nothing to do with your knowledge.



LOL, you so don't get it.  Actually most styles are same width as most backboards.  And OP did not specify no turns or widen stairwell till after I brought that into play.  

And bossy did not ruin my statement she just interpeted OP differently.  So no I am not upset because even if she had pointed out something where I was wrong I would happily accept the correction, but she didn't so no problem.


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## medic417 (Mar 25, 2009)

EMTinNEPA said:


> Well then there's NO way to get down the stairs, or for you to get upstairs, so I guess you'd better call the fire department.



You really have not done this very long.  I have been in many old houses that you climbed stairs sideways or with both shoulders touching outer walls and turns at the top and bottom.  Poorly designed but thats poor people construction with no building code.


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> LOL, you so don't get it.  Actually most styles are same width as most backboards.  And OP did not specify no turns or widen stairwell till after I brought that into play.
> 
> And bossy did not ruin my statement she just interpeted OP differently.  So no I am not upset because even if she had pointed out something where I was wrong I would happily accept the correction, but she didn't so no problem.



Really?  Because I actually measured, and at every service I run with (all five of them) the stairchairs are wider than any LSB we have

Regardless of when he specified it, he specified it.  He ruled out stairchair, he did NOT rule out LSB.  He didn't give a reason for ruling out stairchair, all he said was that stairchair wasn't an option.  Until he rules out LSB or Reeves, my plan still stands.


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## medic417 (Mar 25, 2009)

With updated info from OP you could use a backboard.  Heck with his update you could set up a rope lowering system and lower over the rail if you wanted to.   That change changed the whole scenario.


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> You really have not done this very long.  I have been in many old houses that you climbed stairs sideways or with both shoulders touching outer walls and turns at the top and bottom.  Poorly designed but thats poor people construction with no building code.



OP already ruled out turns.  If you have to go up with both shoulders touching the outer walls, you could still get a LSB on a reeves through.  LSBs are NOT that wide, and the reeves was designed for confined space rescue.  If you have to climb the stairs sideways, there is no way to get the patient down.  Both of our ideas are ruled out, so now what?  How about instead of getting your jollies off by trying to assert yourself as an authority figure over the youngins based solely on how long you've been in EMS, which could be 20 years of experience or one year of experience over and over for 20 years, you propose a new idea?


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## EMTinNEPA (Mar 25, 2009)

medic417 said:


> With updated info from OP you could use a backboard.  Heck with his update you could set up a rope lowering system and lower over the rail if you wanted to.   That change changed the whole scenario.



Thank you.


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## Veneficus (Mar 25, 2009)

AJ Hidell said:


> Even if it did take longer, that is no excuse for not utilizing it when indicated.  This is not an ABC compromised or exsanguinating patient that warrants the ubiquitous and grossly overused "rapid extrication".  If the patient needs c-spine, he needs it.



I think the term "rapid extrication" maybe over used, but I have been on record for several years now doubting that a LSB can actually immobilize a pt. 

I wish there was some data that shows the KED does a better job at immobilizing, most of what I have heard anecdotally comes from AU EMS with the device. 

I do think that a fall from standing may create a head injury, but I very much doubt a significant spine injury that is not grossly apparent without a comorbidity. I know everyone (including me) has seen walking taking c spine fx, but the body does a very good job at self spliting, and there is absolutely no evidence I have ever heard of, demonstrating that these patients benefit from immobiliation. I am sure you know (but for others benefit) we yank boards in the ED immediately if not sooner. If that doesn't aggrivate an occult injury I seriously doubt a reeves, KED, or stairchair will. 

We need to refine the spinal criteria to exclude more.


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## medic417 (Mar 25, 2009)

Veneficus said:


> but I have been on record for several years now doubting that a LSB can actually immobilize a pt.



It seems like a few years ago there was a report of a sevice in another country basically doing away with backboards.  They would use scoop stretcher to lift them onto the cot and then just secure them to the cot because they felt that if more comfortable they would move less thus creating less injury.  I can not find that for the life of me though.


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## Veneficus (Mar 25, 2009)

medic417 said:


> It seems like a few years ago there was a report of a sevice in another country basically doing away with backboards.  They would use scoop stretcher to lift them onto the cot and then just secure them to the cot because they felt that if more comfortable they would move less thus creating less injury.  I can not find that for the life of me though.



That's how it's done here


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## ffemt8978 (Mar 25, 2009)

medic417 said:


> Then they should be fired for failing to do a proper check of the ambulance.  If the service does not provide a stair chair they need to find a new service.



Hmm, we didn't get our stair chairs until two years ago, and the private IFT I worked for did not have them at all.  Last time I checked, they were not a requirement for an ambulance in WA state.  I'm not even sure they're required on an ambulance in ANY state, but I don't know for sure.


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## medic417 (Mar 25, 2009)

ffemt8978 said:


> Hmm, we didn't get our stair chairs until two years ago, and the private IFT I worked for did not have them at all.  Last time I checked, they were not a requirement for an ambulance in WA state.  I'm not even sure they're required on an ambulance in ANY state, but I don't know for sure.



Required or not they are a vital part of equipment and any 911 service w/o is lacking.  IFT 's may have no need but 911 should as they can be used to move patients from places you could never get a cot, backboard, or scoop stretcher.  Much safer than carrying patient.  Not just for stairs but hallways with turns.


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## AJ Hidell (Mar 26, 2009)

medic417 said:


> It seems like a few years ago there was a report of a sevice in another country basically doing away with backboards.  They would use scoop stretcher to lift them onto the cot and then just secure them to the cot because they felt that if more comfortable they would move less thus creating less injury.





Veneficus said:


> That's how it's done here


As it should be.  Besides vehicle extrication, there are just few scenarios where I find a legitimate need for the backboard anymore.  In fact, that has been my practice for around fifteen years.

About twenty years ago, I unfortunately got stuck with an "experienced" EMT-B partner for a shift.  I sent him out to the ambulance specifically for a scoop stretcher.  He came back with a backboard.  I calmly reminded him that I asked for a scoop stretcher, not a backboard.  His response was to loudly declare, "BACK INJURIES GO ON A BACKBOARD!"  He was relieved of duty at the hospital and sent to the unemployment line.


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