# Transition to new SMR protocol



## LACoGurneyjockey (Apr 7, 2015)

Our county just put out the draft for a new Spinal Motion Restriction protocol to take effect in June, in the past having collared and boarded any and everyone with any physical findings or ALOC in a setting of trauma. Grandma rolled out of bed and has some hip/femur pain? Well that's a distracting injury in a setting of trauma, let's put grandma on a backboard for the transport down a dirt road and up to 60min drive to the hospital. Billy bob has been drinking and got punched by Joe bob? Etoh and head trauma definitely needs a backboard. 
When the new protocol takes effect we will place them on the gurney, supine/position of comfort, with a c-collar. If they can walk, assist them to the gurney, or otherwise use a breakaway flat. The only indication for a board will be extrication, to be removed once they're on the gurney. I'll be finishing up medic school and starting my internship right around the time this new protocol takes effect, and now every time I hear my instructor telling us "we need to c-spine this and backboard that" I cringe a little inside. 
The reason I'm posting this isn't just to gloat that we are finally catching up to the rest of EMS, ever so slightly and a little late to the party. But I wanted to get input from others who have made the switch on how difficult it was to break the habit of backboarding everyone for anything.

How hard was it for the medics who had spent all their time in EMS backboarding every significant trauma to stop, and just put a patient on the gurney with a collar? Backboards have always been perceived as one of the more important interventions in any trauma patient. And now to see them effectively vanish, I just wonder how our experienced medics will make the switch.


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## NomadicMedic (Apr 7, 2015)

It's harder to break BLS of the habit. If I see a collar or board that are unneeded, I just take them off.


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## DesertMedic66 (Apr 7, 2015)

I ran into this issue a lot during my medic training. My FTO likes to backboard everyone. His reasoning is that "you don't want to find out that patient had a brain bleed and you didn't C-spine them". it was very hard to keep my mouth shut to get through training faster.


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## Flying (Apr 7, 2015)

Everyone around me just rolls their eyes when I try to stop Grandma from getting the board.
Or puts out the classic "It's part of protocol!".

CNJ's medics are hit and miss with SMR, some will take off the collar, some will ask why we didn't put it on. It all depends on the time of day and which hospital we are closer to.


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## DWR (Apr 7, 2015)

I think you'll still be ahead of the curve. I was always used to back boarding people that don't always need it. If you hang out in the trauma bay or whatever room you take your Pt too one of the first things they do to stable patients is take them off the board. Use judgement. Study the CDC criteria for trauma centers and then honestly think through the call. Also body size vacuum splints are a great alternative!


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## TRSpeed (Apr 7, 2015)

Not many places are actually completely removing backboards like kern is. So I am excited. Most use what we were using which was essentially NEXUS criteria aka
N-NEURO DEFICIT
S-SPINAL PAIN
A-ALOC
I-INTOXICATON
D-DISTRACTING INJURY

There has been lots of talk of the removing backboards but I can probably bet the vast majority of places still use them. 
We are to remove the backboards if used for extrication unless we can't because it will interfere with important procedures or tx.


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## LACoGurneyjockey (Apr 7, 2015)

I was trying to hide how excited I am for the new protocol. And no more calling for orders for pain meds, choice of seizure meds, and in defense of little old ladies everywhere no more verapamil. Maybe this will make up for all those years of stacked shocks...


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## TRSpeed (Apr 8, 2015)

I'm almost 99% sure we are the first and only county in socal to remove backboards .


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## LACoGurneyjockey (Apr 8, 2015)

Tulare beat us to it if I'm not mistaken. I believe it's soft collars and position of comfort now up there. But let's just say that's not so cal


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## TRSpeed (Apr 8, 2015)

Ya ccems beat us but yes that'd not socal lol


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## Brandon O (Apr 8, 2015)

DesertEMT66 said:


> I ran into this issue a lot during my medic training. My FTO likes to backboard everyone. His reasoning is that "you don't want to find out that patient had a brain bleed and you didn't C-spine them". it was very hard to keep my mouth shut to get through training faster.



Ah, the ol' hemostatic collar.


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## LACoGurneyjockey (Apr 8, 2015)

Hold on! You mean to tell me that putting a possible neck injury on a backboard doesn't help treat their injuries?!? That's absurd. We've been doing it forever, and look at how many of them ended up with spinal injuries. That's how you know it's working! Y'all are just stoopid...


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## TheLocalMedic (Apr 15, 2015)

The whole premise of fully backboarding and immobilizing patients was based on a poor understanding of body mechanics and anecdotal evidence.  I've always had a problem with it, and even before my county in Nor Cal adopted the new SMR protocol I was constantly taking flack for not putting people on boards....  It was a real blessing to have my decades-long philosophy of only boarding those with readily apparent neck (and neck only, not back) injuries or neuro deficits finally vindicated.  

Death to the backboard!!!!


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## NPO (Apr 24, 2015)

I talked to our new medical director for Kern and he had some exciting things to say about Ketamine and TXA, too.


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## 281mustang (Apr 24, 2015)

Have you all ever run into issues with ER docs? I personally haven't had problems but I've known of others that have caught flack from old school Physicians that haven't adapted to the change.

A couple months I transported a pt from a level 1 trauma center to another level 1 trauma center for HLOC. The sending facility took pt off the board but the doc at the receiving facility was adamant that she be backboarded again prior to transport because she had a confirmed cervical fx. It's not just EMS that is stuck in the mindset...


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## DesertMedic66 (Apr 24, 2015)

NPO said:


> I talked to our new medical director for Kern and he had some exciting things to say about Ketamine and TXA, too.


We are supposed to be starting TXA trials next month (fingers crossed). There has also been talks about Levophed drips in my area.


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## GirevikMedic (May 9, 2015)

My area has been doing something similar for about a year and half or so. Breaking the habit was easy since I hated boarding patients who didn't need it. The discretion of collar only and self-extrication, when indicated, was an added bonus. I'm not such a huge fan of back boards being outlawed as I think they can still serve a purpose beyond extrication. Mainly in regards to time spent/wasted with extra procedures (the patient's being flown and we're still forbidden to use a long board for packaging purposes, instead we have to use the KED and collar and wait for air to land, bring their long board, etc, etc.). Overall, I'm still a bigger fan of our current policy.


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## Accelerator (May 13, 2015)

I never really was a fan of back boarding. I try to treat patient's how I would want medics treating my family and I would not want my mother placed on a hard board after breaking her hip. There are times when back boards are a must but I think we should have the understanding to admit that it is for our benefit mostly. Patients do benefit mostly from the time that the boards save.


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## Tigger (May 14, 2015)

When are backboards ever a must?


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## NomadicMedic (May 14, 2015)

Tigger said:


> When are backboards ever a must?


...and how do boards save time?


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## WildlandEMT89 (May 14, 2015)

Tigger said:


> When are backboards ever a must?


We use them more for working codes now.


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## Accelerator (May 14, 2015)

Tigger said:


> When are backboards ever a must?





DEmedic said:


> ...and how do boards save time?



I know of no better way to move unconscious unresponsive patients in houses where you can't get the cot into.


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## PotatoMedic (May 14, 2015)

Mega mover!


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## Tigger (May 14, 2015)

Accelerator said:


> I know of no better way to move unconscious unresponsive patients in houses where you can't get the cot into.


I prefer the scoop. Once they are on the cot you can remove the scoop, eliminating any risk of pressure sores or other uncomfortables.

As for codes, I prefer the floor. If we transport, a board or scoop will be used.


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## chaz90 (May 14, 2015)

Reeves! But yes, I do think backboards have their place as extrication tools.


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## Accelerator (May 14, 2015)

Tigger said:


> I prefer the scoop. Once they are on the cot you can remove the scoop, eliminating any risk of pressure sores or other uncomfortables.
> 
> As for codes, I prefer the floor. If we transport, a board or scoop will be used.



Sadly we lack scoops. A few of our local volunteer fire departments have scoops for wilderness rescue purposes. 

For codes unless it's a doa we pretty much have no choice but to transport. It's nearly impossible to get orders for cease efforts.


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## NomadicMedic (May 14, 2015)

I also vote Scoop or megamover. I'd never seen a reeves until I moved to DE.

As an aside, an unconscious, unresponsive person is going to get worked where they are. But, after that, they'll leave on a tarp or scoop. There's no way a narrow, slippery plastic board is the best way to move a patient out of a house.


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## LACoGurneyjockey (May 14, 2015)

Breakaway flats anyone...? Soft, secure, and don't require any patient movement to get them out.


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## COmedic17 (May 14, 2015)

There's (typically) two types of medics. The first ones will argue that any trauma needs to be backboarded because....well...its trauma. Then there's the other type who hates backboards, has read the articles that they aren't necessarily beneficial and don't want to backboard anyone. 

And then there's me. I'm kind of a pain in the butt that way.. But regardless....

There are times I say back boarding is an absolute must. Then there are times I have the patient walk to the cot. Theres another post where everyone was against back immobilizing a particular patient but I was all for it. I am very circumstantial. 

Yes, studies say backboards cause skin breakdown, don't completely immobilize the spine, put unneeded pressure on areas of spine, can cause pain, etc. but you know what sucks even more? A severed spinal cord. 

I believe (when I say "I believe" it's my personal opinion) that most "trauma" patients do NOT need full spinal immobilization. I believe there are some circumstances where it's borderline neglectful not to immobilize to some degree. My protocols allow a type of "wiggle room" where I can substitute scoop style boards for a backboard. I LOVE SCOOPS. Part of the reason backboards are being questioned is the logrolling moves the spine more then previously thought. With the scoop- you avoid that. There's also less "voids" to pad. But I determine who needs immobilization based on a large amount of factors. Age- do they probably have some degree of osteoporosis? Are they on drugs/etoh that might minimize pain? Previous injury- is part of their spine "fused" from a previous surgery? Location of pain,vitals, etc. but there has been times I have immobilized  when others may not of. But in the rural areas of my county, I trust the fire people moving the patient on a scoop as opposed as moving them by any other means ( a lot aren't even EMTs). The scoop doesn't put pressure on the spine (unless scoliosis or kyphosis is present. But that's not the "average" patient).I board(scoop) when I have a reasonable belief that they have legitimate trauma to their spine/vertebrae and I am concerned that movement might cause injury to the cord. If I'm not concerned with that, then I won't. 


There's an argument that back boarding (scooping) takes time- when you have 6 firefighters, an EMT, and yourself, it lakes less then 60 seconds (even less with a scoop, again, I love scoops) 


Just use common sense. You don't have to " pick a side". You can choose what you believe is best for the given for the situation. 


Would I immobilize a pt with no neck back pain who self extricated after an MVA and is strolling around and was wearing a seat belt? No.
Would I immobilize a or with multiple GSW, not alert and orientated, poor vitals, and I can't guarantee one bullet didn't clip the spine? Then they would probably get the scoop.

But 99% of my patients who are immobilized get taken off on the cot because I feel movement is minimal on a cot. I will bring a scoop into the hospital to use it to move them to the hospital bed though. 


*shrugs*

I am comfortable with a happy median between the two.


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## COmedic17 (May 14, 2015)

****i do backboard( using a longboard) during cardiac arrests. It's easier to move them (especially down stairs) and it's a great CPR board.


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## PotatoMedic (May 14, 2015)

I do not believe backboards have ANY use for spinal immobilization.  I believe full body vaccume splints are good for spinal immobilization.

I do believe extrication boards ("backboard") can be useful in other situations.


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## RocketMedic (May 14, 2015)

COmedic17 said:


> Would I immobilize a pt with no neck back pain who self extricated after an MVA and is strolling around and was wearing a seat belt? No.
> Would I immobilize a or with multiple GSW, not alert and orientated, poor vitals, and I can't guarantee one bullet didn't clip the spine? Then they would probably get the scoop.


COmedic17, the first patient certainly doesn't need a scoop, but the second patient is actually actively harmed by immobilization. Bullets don't "clip" the spine and cause "poor vitals", they hit anatomically-vital centers like the descending aorta and punch holes.


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## gotbeerz001 (May 15, 2015)

I use a variety of immobilization techniques including:
- nothing
- collar only
- collar + half vacuum splint
- half vacuum splint only
- KED only
- KED + collar
- collar + scoop
- vacuum splint + scoop
- collar + long board
- vacuum splint + long board

These are all determined by methods of extrication, pt anatomy, time and extent of injury / presence of deficits. 

I like options.


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## COmedic17 (May 15, 2015)

RocketMedic said:


> COmedic17, the first patient certainly doesn't need a scoop, but the second patient is actually actively harmed by immobilization. Bullets don't "clip" the spine and cause "poor vitals", they hit anatomically-vital centers like the descending aorta and punch holes.


My "gangbanger" who was running, most definitely got hit on the spine and severed his spinal cord. This was comfirmed by the hospital. The BP was in the 80s. After two liters unchanged. Passed a week or so later. Aorta was not hit. But liver was ( several GSWs). Also GSW to side of head.


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## RocketMedic (May 15, 2015)

And how, pray tell, did a spine board help in that situation?


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## Tigger (May 15, 2015)

Here's the thing. NOTHING we do in the field besides telling someone to lie still and not move around a whole bunch has any effect on so called spinal immobilization. Nothing. Nada. Zilch. Spine boards do nothing. KEDs generate more movement getting them into it. C collars are usually poorly fitted but even when done right have little to back them up. Vacuum mattresses work in theory, but have no evidence supported them. Guess what else was used because of that reasoning, long backboards. 

If the patient has a spinal cord injury, it's done. It's not going to get worse because you touched them. Be careful moving them, but let's stop pretending that we have any evidence of benefit from any of these techniques, because we don't and they've been well studied. 

And so help me god if someone comes in and pulls the whole "I had a patient who turned out to have a C5 fx and thank god I boarded them cuz they'd be messed up now." NO. You affected that injury in no way. None.


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## highglyder (Sep 13, 2015)

DesertMedic66 said:


> I ran into this issue a lot during my medic training. My FTO likes to backboard everyone. His reasoning is that "you don't want to find out that patient had a brain bleed and you didn't C-spine them". it was very hard to keep my mouth shut to get through training faster.



Soooo...hemorrhagic CVA = possibke spinal injury?  If that's one's mentality, c-collars and LSBs should bd as available as public defibs.  Just think how messed it is that normal day to day occurences suddenly mean spinal injury the second we are in the picture.  Kid fell from monkey bars, boxer boxing, trip and fall.... we should all be paralysed!!


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