# Back boarding injures more people than it helps.



## ExpatMedic0 (Mar 13, 2013)

Most of the studies and literature I have read suggest less than %5 of all people need to be back boarded who are. However, (depending on the study you read) %40-80 of these people develop injuries from being back boarded. ( such as ulcers)

Who gets back boarded in your area and why?

Does your agency or hospital track stats on this?

Why is this still being done so much?

Any interesting studies or feedback anyone would care to share?


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## JPINFV (Mar 13, 2013)

schulz said:


> Why is this still being done so much?


[YOUTUBE]http://www.youtube.com/watch?v=gRdfX7ut8gw[/YOUTUBE]


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## Summit (Mar 13, 2013)

Seems timely:

NAEMSP's newest position on spinal immobilization for EMS
http://www.ncbi.nlm.nih.gov/pubmed/23458580


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## ExpatMedic0 (Mar 13, 2013)

man I really gotta start searching pub med more lol. I'll look that over


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## Tigger (Mar 13, 2013)

Summit said:


> Seems timely:
> 
> NAEMSP's newest position on spinal immobilization for EMS
> http://www.ncbi.nlm.nih.gov/pubmed/23458580



Hmm I can't get more than a brief summary, do you have access to the full paper?

Also I found this study fairly illuminating in regards to SMR in vehicle extrication though it looks like there is still some research to be done.


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## JPINFV (Mar 13, 2013)

Here's the one from 1999...
http://www.naemsp.org/Documents/POSITION%20IndicationsforSpinalImmobilization.pdf


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## Summit (Mar 13, 2013)

Tigger said:


> Hmm I can't get more than a brief summary, do you have access to the full paper?
> 
> Also I found this study fairly illuminating in regards to SMR in vehicle extrication though it looks like there is still some research to be done.



I had it pulled up, but right now my remote journal access no workee... I'll pull it at work tonight.

My brief recollection, but this is polluted by reading some drafts from 6 months ago:

Backboards don't have a proven benefit and are proven to cause harm.
Indications should be s/s (or altered) more than mechanism (although severe mechanism can still be used). 
Backboards are good for extrication, but get the patient off the backboard ASAP.
Long transports use a collar but no board.
Something like the nexus c-spine clearance criteria...


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## mycrofft (Mar 13, 2013)

For one, I would suffocate from positional asphyxia if forced to lay supine facing upwards. Just one datum.


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## WTEngel (Mar 13, 2013)

I can't get the full text of the NAEMSP position statement. Does anyone have a link that doesn't require a subscription? I'm on vacation, and can't use the hospital library.

I became fairly comfortable informing patients that there was a SMALL chance that they might have an injury which could become worse if they were not placed on a backboard, but the risk was minimal. Once they were informed of this, I let them make the decision, after telling them that they would likely be on the board for another 2 hours, until they could be cleared at the hospital. I used this method frequently when the patient was ambulatory on scene. It really fit the definition of "informed consent" quite well I thought.

The majority of patients opted to have a c collar placed and declined back boarding. When we got to the hospital and the doctor asked why they weren't back boarded, I simply stated the patient refused. From time to time they actually back boarded the patient in triage! I thought that was crazy...

It always seemed like cruel and unusual punishment to fully backboard an elderly patient who had simply bumped their head or the individual who was rear ended at low speed, or anyone else with low index for suspicion of injury.

This looks like promising news from the NAEMSP, and hopefully it will not require 20 years of reeducation in order to fix the mindset of first responders who have been indoctrinated to believe that back boarding patients saves lives. Was anyone ever told the anecdotal story of the person who was hit at low speed in a parking lot, sat down, turned their head to the side and became paralyzed? Seems like every EMT class is told this story, but I doubt its veracity.


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## Tigger (Mar 13, 2013)

Summit said:


> I had it pulled up, but right now my remote journal access no workee... I'll pull it at work tonight.
> 
> My brief recollection, but this is polluted by reading some drafts from 6 months ago:
> 
> ...



Yes, I remember those points from the draft and from an Eagles conference.  Just curious how strongly the statement will be written, I have hope!


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## ExpatMedic0 (Mar 13, 2013)

http://www.sensorprod.com/news/white-papers/rar/wp_rar.pdf


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## Summit (Mar 13, 2013)

Tigger said:


> Yes, I remember those points from the draft and from an Eagles conference.  Just curious how strongly the statement will be written, I have hope!



It won't let me in because it is ahead of print...


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## Tigger (Mar 13, 2013)

Summit said:


> It won't let me in because it is ahead of print...



Ah I see, well I hear it is soon to be released nonetheless.


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## Brandon O (Mar 13, 2013)

Please PM me if anybody wants a copy.

Edit: or just visit http://medicscribe.com/2013/02/in-praise-of-cemsmac/ , which has essentially the full text of the piece (no, there's nothing more), plus what it ALMOST became...


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## DrParasite (Mar 14, 2013)

schulz said:


> Who gets back boarded in your area and why?


anyone with traumatic neck and back pain.  because protocol says to, because the supervisors want us to, because we are trained monkeys who are taught in EMT school that everyone with neck and back pain needs to collar and backboard?  And if we don't, the hospitals have been rumored to call our supervisors who would investigate why we didn't board and collar patient a.b.c





schulz said:


> Does your agency or hospital track stats on this?


yes.  epcr has allowed us to get stats on how often we apply a LSB, provided the provider fills out the chart properly.





schulz said:


> Why is this still being done so much?


because, despite there being NO evidence that a LSB does ANYTHING, few medical directors and state protocol writers have the balls to actually do something progressive and remove such an archaic idea from our normal operations.  Not only that, but since we beat into the heads that every neck and back pain needs a LSB back in EMT school, then all the educators and educational materials would need to be updated.  After all, everyone involved is too scared for being sued, as using a LSB has become the standard of care, and there is plenty of anacdotal evidence of people who have almost died or required surgery following MVAs and weren't backboarded.  It's all about liability, and most policy writers would rather stick with what they know that transition to evidence based practices out of fear of being sued for not following what has been the standard of care for years.


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## KellyBracket (Mar 14, 2013)

Tigger said:


> ...
> 
> Also I found this study fairly illuminating in regards to SMR in vehicle extrication though it looks like there is still some research to be done.



The authors followed that study up with Cervical spine motion during extrication. 

No full text available, but I did a review with pictures and witty commentary at  In order to protect the c-spine, should we stop helping?


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## ExpatMedic0 (Mar 14, 2013)

KellyBracket said:


> No full text available, but I did a review with pictures and witty commentary at  In order to protect the c-spine, should we stop helping?


Haha it was your blog post that inspired me to post this in correlation with the recent discussion on submissive hypoxemia. Just "got the old wheels turning up there"


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## Brandon O (Mar 14, 2013)

schulz said:


> Most of the studies and literature I have read suggest less than %5 of all people need to be back boarded who are. ...
> 
> Any interesting studies or feedback anyone would care to share?



The literature is pretty clear that adult blunt trauma patients with head or neck involvement (fell and bonked the head, MVA, etc) have around .6-3% incidence of significant C-spine injury. The definitions matter -- that number usually excludes trivial injuries, but doesn't necessarily mean that all those injuries are unstable or compromise the cord.

Even if 100% were "unstable" in the sense that a spine doc will eventually want to stabilize it with a halo or a plate or something, how many have a real potential to suffer further harm PRIOR to arriving at the hospital -- at least, harm that wasn't inevitable, since a fair number of cord injuries will deteriorate due to swelling or bleeding that can't be avoided? This number isn't really clear. It's never been reported from a reliable source, so possibly the answer is 0%. Patients who deteriorate usually do so a few days after the injury.

The exception may be anyklosing spondylitis patients, who are incredibly high-risk for catastrophically deteriorating. But we may not be able to prevent that; in fact, there's at least one report of a C-collar making it worse due to the distracting force.


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## Veneficus (Mar 14, 2013)

DrParasite said:


> anyone with traumatic neck and back pain.  because protocol says to, because the supervisors want us to, because we are trained monkeys who are taught in EMT school that everyone with neck and back pain needs to collar and backboard?  And if we don't, the hospitals have been rumored to call our supervisors who would investigate why we didn't board and collar patient a.b.cyes.  epcr has allowed us to get stats on how often we apply a LSB, provided the provider fills out the chart properly.because, despite there being NO evidence that a LSB does ANYTHING,* few medical directors and state protocol writers have the balls to actually do something *progressive and remove such an archaic idea from our normal operations.  Not only that, but since we beat into the heads that every neck and back pain needs a LSB back in EMT school, then all the educators and educational materials would need to be updated.  After all, everyone involved is too scared for being sued, as using a LSB has become the standard of care, and there is plenty of anacdotal evidence of people who have almost died or required surgery following MVAs and weren't backboarded.  It's all about liability, and most policy writers would rather stick with what they know that transition to evidence based practices out of fear of being sued for not following what has been the standard of care for years.



Somebody gets it...


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## mycrofft (Mar 14, 2013)

It probably does do something in extrication, but leaving the backboard on or applying it every stinking time is like forcing a neonate to wear the umbilical clamp until junior high school. 

I take that back. It simply reflects the perception of administrators, lawyers and MD's that field responders (EMTs etc) are not taught nor competent to evaluate whether or not a spineboard is necessary; it became the gold standard for extrication around 1970 and has never been displaced; so, it's no skin off their administrative noses as long as it is not proven to iatrogenically injure patients. 

If they are right about inconsistent competency, and that is a case by case instance nowadays, then universal boarding is called for. _Have we been taught a specific protocol etc. for evaluating whether or not immobilization of the spine is necessary?  _ Until then, technical competency is not assumed and can't be cited.


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## katgrl2003 (Mar 14, 2013)

We just received new protocols that have us very rarely using a backboard. Only with major trauma and altered mental status will we use it. If a patient is alert and oriented, c-collar only, unless a backboard is deemed necessary by the EMS crew.


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## mycrofft (Mar 14, 2013)

I remember before stiff collars when they were getting rid of cervical collars. Soft collars were worthless. But the antecedent procedure was pull them out of the wreck any way you could


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## lightsandsirens5 (Mar 14, 2013)

katgrl2003 said:


> We just received new protocols that have us very rarely using a backboard. Only with major trauma and altered mental status will we use it. If a patient is alert and oriented, c-collar only, unless a backboard is deemed necessary by the EMS crew.



That is very nice.


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## EpiEMS (Mar 14, 2013)

katgrl2003 said:


> We just received new protocols that have us very rarely using a backboard. Only with major trauma and altered mental status will we use it. If a patient is alert and oriented, c-collar only, unless a backboard is deemed necessary by the EMS crew.



Any idea which group (say, the medical directors, the service chiefs, the state OEMS, etc.) prompted the change?


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## Brandon O (Mar 14, 2013)

mycrofft said:


> I remember before stiff collars when they were getting rid of cervical collars. Soft collars were worthless. But the antecedent procedure was pull them out of the wreck any way you could



Nobody would ever do that now, of course...


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## wanderingmedic (Mar 14, 2013)

katgrl2003 said:


> We just received new protocols that have us very rarely using a backboard. Only with major trauma and altered mental status will we use it. If a patient is alert and oriented, c-collar only, unless a backboard is deemed necessary by the EMS crew.



That's a really good idea. Unfortunately most systems are still giving vitamin O to every patient even if they dont need it.


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