# A fall that the hospital gave me grief about



## KyleG

70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved. 

My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.

On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.

Just wondering if I was in the wrong or right here.


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## DesertMedic66

What are your protocol for spinal immobilization?


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## firecoins

Was a RN questioning it or an MD?


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## Ackmaui

KyleG said:


> 70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved.
> 
> My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.
> 
> On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.
> 
> Just wondering if I was in the wrong or right here.



You are completely in the right. Unwitnessed fall, who knows what could have happened. Doesn't matter what the hospital staff says...it's your cert, not theirs. Good job


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## Aidey

KyleG said:


> 70+ y/o f unwitnessed fall in the bathroom while walking a bruise to right eye and orbit. Arrived on scene and she is still on the floor and has not moved.
> 
> My actions: assessed the patient for any other trauma pain located in hip neck and back. Placed pt in c collar and backboard. Transported to hospital access the street.
> 
> On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.
> 
> Just wondering if I was in the wrong or right here.



I can't tell from your post if the pt was complaining of hip, neck and back pain or not. 



Ackmaui said:


> You are completely in the right. Unwitnessed fall, who knows what could have happened. Doesn't matter what the hospital staff says...it's your cert, not theirs. Good job



WRONG! An unwitnessed fall is NOT a good enough reason to do anything to anybody. If the pt is reliable, and lacks the signs and/or symptoms of a spinal injury they do not need to be backboarded. I see you are still a student, have you taken PHTLS yet? 

Hell, they don't need to be backbaorded either way, but we're taking baby steps here.


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## JakeEMTP

KyleG said:


> On arrival the pt then claims no pain any were and the hospital staff the questions my spinal immobilization.



Since the patient was claiming no pain, the hospital staff may just have be asking what you saw in your assessment that warranted spinal immobilization. It might even be seen as a show of respect for your opinion before they remove the backboard.  Of course if you just say "that's what my protocols say to do" you could lose the chance to shine.


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## Anonymous

firefite said:


> What are your protocol for spinal immobilization?



That is what I am wondering... Were Medics on scene? Can they clear C-Spine?


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## DesertMedic66

Anonymous said:


> That is what I am wondering... Were Medics on scene? Can they clear C-Spine?



Even if their medics can't clear C-spine, I still want to find out what made them take the precautions.


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## KyleG

She did complain of pain onc. RN and MD were questioning it. 

In my opinion she really had the pain but once she knew how we reacted to that pain she flipped it around.


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## Handsome Robb

KyleG said:


> She did complain of pain onc. RN and MD were questioning it.
> 
> In my opinion she really had the pain but once she knew how we reacted to that pain she flipped it around.



So she had midline cervical/thoracic pain on scene? Or she didn't? Positive LOC? Altered? 

Like Aidey said unwitnessed fall =/= spinal motion restriction. Just like any other treatment there are indications as well as contraindications. Not saying it was contraindicated but it's one of the most overused tools in our toolbox IMO. 

It might just be me but I hate backboarding people, it makes everything more difficult except for moving people.


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## Anonymous

firefite said:


> Even if their medics can't clear C-spine, I still want to find out what made them take the precautions.



I hope I am not hijacking but I thought some agencies allow medics to transport without immobilization if certain criteria are met? I am still very new to EMS so I apologize if I am mistaken... Example:

*Assessment of spinal injury–Answer yes or no to each of the following clinical criteria:*

– Is patient reliable (calm, cooperative, awake, fully alert, oriented to           person, place, time and situation?
– Is there suspicion of ingestion or use of alcohol or drugs?
– Is there a language barrier?
– Is the patient < 12 years or > 55 years of age?
– Is the patient experiencing an acute stress reaction?
– Does the patient have an abnormal mental status?
– Does the patient have any distracting injuries?
– Is there a communications barrier?
– Does the patient have spine pain? Spine tenderness?
– Is the motor exam normal?
– Is the sensory exam normal?

If the patient is reliable and all other assessments have been answered “no”, the spine may be cleared and the patient transported without spinal immobilization


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## DesertMedic66

Yes systems do let medics clear C-spine. As to what all criteria needs to be met is agency/region specific.


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## Anonymous

firefite said:


> Yes systems do let medics clear C-spine. As to what all criteria needs to be met is agency/region specific.



I am an idiot. I read your "even if their medics" as "even if they're medics"


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## Arovetli

As for clearance of cspine, check out NEXUS and the Canadian C-Spine Rule on pubmed. Lots of good stuff on there.


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## Ackmaui

Aidey said:


> I can't tell from your post if the pt was complaining of hip, neck and back pain or not.
> 
> 
> 
> WRONG! An unwitnessed fall is NOT a good enough reason to do anything to anybody. If the pt is reliable, and lacks the signs and/or symptoms of a spinal injury they do not need to be backboarded. I see you are still a student, have you taken PHTLS yet?
> 
> Hell, they don't need to be backbaorded either way, but we're taking baby steps here.



An unwitnessed fall is absolutely a good enough reason. Yes I am a student, a paramedic student, I have been an EMT-b for 12 years. I am an on call EMT with my fire department for 12 years and I have been an ER tech for 11 years. Yes I have taken PHTLS.... So don't throw the student angle in my face. 
It is not hurting them to be on the board and do you want to be the one to tell their family that their loved one is hurt because you didn't take the time to put a collar on and board them? You don't know what they hit on the way down. Take the time to do the right thing and shame on the hospital staff who would have certainly complained if it were their family member on the call and you didn't do everything to insure their health.


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## Aidey

No, it is not. Search Pubmed. MOI is NOT a good enough reason to do anything! I don't care how long you have been doing this, things change and backboarding is little more than snake oil. I'm not trying to throw anything in your face, I was trying yo give you the benefit of the doubt. Let me rephrase my question, have you taken PHTLS recently? Within the last year or two? 

It does hurt them to be on the board. There are multiple measurable negative effects of being back boarded and having a c-collar on. Do you want to be to the one to explain to their family why they now have bed sores because you didn't bother to assess your patient for actual injuries and not imaginary ones? 

I don't care what they hit on the way down. I care what they are complaining of and what my assessment finds. The right thing is to follow evidence based medicine and eliminate the unnecessary use of c-collars and back boards. The right thing is to assess your patient properly. The right thing is the educate yourself about the treatments you provide 

1. Motion in the unstable thoracolumbar spine when spine boarding a prone patient.
http://www.ncbi.nlm.nih.gov/pubmed/22330191

 2. Prehospital spine immobilization for penetrating trauma--review  and recommendations from the Prehospital Trauma Life Support Executive  Committee.
http://www.ncbi.nlm.nih.gov/pubmed/21909006

 3. Routine application of cervical collars--what is the evidence?
http://www.ncbi.nlm.nih.gov/pubmed/21752367

 4. Effects of spinal immobilization devices on pulmonary function in healthy volunteer individuals.
http://www.ncbi.nlm.nih.gov/pubmed/21644085

 5. Removing a patient from the spine board: is the lift and slide safer than the log roll?
http://www.ncbi.nlm.nih.gov/pubmed/21610441

 6. Cervical collars are insufficient for immobilizing an unstable cervical spine injury.
http://www.ncbi.nlm.nih.gov/pubmed/21397431

 7. Effectiveness of cervical spine stabilization techniques.
http://www.ncbi.nlm.nih.gov/pubmed/21358496

 8. Value of a rigid collar in addition to head blocks: a proof of principle study.
http://www.ncbi.nlm.nih.gov/pubmed/21335583

 9. Evaluation of the safety of C-spine clearance by paramedics: design and methodology.
http://www.ncbi.nlm.nih.gov/pubmed/21284880

 10. The presence of nonthoracic distracting injuries does not affect  the initial clinical examination of the cervical spine in evaluable  blunt trauma patients: a prospective observational study.
http://www.ncbi.nlm.nih.gov/pubmed/21248650

 11. Unintentional strangulation by a cervical collar after attempted suicide by hanging.
http://www.ncbi.nlm.nih.gov/pubmed/21183526

 12. Are scoop stretchers suitable for use on spine-injured patients?
http://www.ncbi.nlm.nih.gov/pubmed/20837250

 13. Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients.
http://www.ncbi.nlm.nih.gov/pubmed/20805776

 14. Motion in the unstable cervical spine during hospital bed transfers.
http://www.ncbi.nlm.nih.gov/pubmed/20699754

 15. Routine spinal immobilization in trauma patients: what are the advantages and disadvantages?
http://www.ncbi.nlm.nih.gov/pubmed/20569942

 16. Implementing traumatic cervical spine clearance clinical practice guidelines.
http://www.ncbi.nlm.nih.gov/pubmed/20539188

 17. Assessing the implementation of guidelines for the management of  the potentially injured cervical spine in unconscious trauma patients in  England.
http://www.ncbi.nlm.nih.gov/pubmed/20539187

 18. Clinical examination is insufficient to rule out thoracolumbar spine injuries.
http://www.ncbi.nlm.nih.gov/pubmed/20489662

 19. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department.
http://www.ncbi.nlm.nih.gov/pubmed/20457772

 20. Pre-hospital care management of a potential spinal cord injured  patient: a systematic review of the literature and evidence-based  guidelines.
http://www.ncbi.nlm.nih.gov/pubmed/20175667

 21. Clearance of the asymptomatic cervical spine: a meta-analysis.
http://www.ncbi.nlm.nih.gov/pubmed/20101134

 22. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury.
http://www.ncbi.nlm.nih.gov/pubmed/20093981

 23. Neurologic sequelae of penetrating cervical trauma.
http://www.ncbi.nlm.nih.gov/pubmed/19881402

 24. Prehospital spinal immobilization does not appear to be  beneficial and may complicate care following gunshot injury to the  torso.
http://www.ncbi.nlm.nih.gov/pubmed/19820585

 25. Cervical spine motion during extrication: a pilot study.
http://www.ncbi.nlm.nih.gov/pubmed/19561822

 26. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma.
http://www.ncbi.nlm.nih.gov/pubmed/19524236

 27. The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.
http://www.ncbi.nlm.nih.gov/pubmed/19394111

 28. Efficacy and compliance of a prehospital spinal immobilization guideline.
http://www.ncbi.nlm.nih.gov/pubmed/19390912

 29. Fatal child cervical spine injuries in motor vehicle collisions: Analysis using unique linked national datasets.
http://www.ncbi.nlm.nih.gov/pubmed/19375697

 30. A comparison of three cervical immobilization devices.
http://www.ncbi.nlm.nih.gov/pubmed/19291567

 31. A biomechanical comparison between the thoracolumbosacral surface  contact area (SCA) of a standard backboard with other rigid  immobilization surfaces.
http://www.ncbi.nlm.nih.gov/pubmed/19131824

 32. Cervical spine clearance: a review and understanding of the concepts.
http://www.ncbi.nlm.nih.gov/pubmed/19079406

 33. [Prevention of pressure ulcers--review of the evidence].
http://www.ncbi.nlm.nih.gov/pubmed/19039912

 34. Isolated transverse process fractures: spine service management not needed.
http://www.ncbi.nlm.nih.gov/pubmed/18849799


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## Veneficus

Ackmaui said:


> An unwitnessed fall is absolutely a good enough reason.



No it is not. That is what is taught to EMTs because they are not given enough formal education to make decisions. 

They have simple instructions that do not allow deviation due to their limits. That is very different than being medically a good reason.




Ackmaui said:


> Yes I am a student, a paramedic student, I have been an EMT-b for 12 years. I am an on call EMT with my fire department for 12 years and I have been an ER tech for 11 years. Yes I have taken PHTLS.... So don't throw the student angle in my face..



None of this conerns me. A student who is right in a particular case is greater than any provider who is wrong. 

I do not think you are right in this case though. Not because you are a student, but because you have a very limited perspective that was a reinforced behavior for more than a decade.



Ackmaui said:


> It is not hurting them to be on the board and do you want to be the one to tell their family that their loved one is hurt because you didn't take the time to put a collar on and board them?.



I respectfully disagree. Elderly people have decreased chest wall expansion and decreased ability to compensate for it even without pathology. Even worse if they do have something like CHF.

Additionally, compression that can result in skin breakdown can occur in less than an hour. Again which can be worsened by underlying pathology. 

I don't want to tell a family I gave them a painful nonhealing wound either.

A stress response from being painfully strapped to a board or restricted in an unfamiliar environment can cause a host of deletorious effects. Increasing HR, BP, etc in a patient with various underlying conditions could be a problem. 

Furthermore, if you take a patient with an actual spinal pathology from their self splinted position of comfort and manipulte them to a flat position, you may worsen inflammation which may occlude spinal arteries resulting in secondary paralysis. 

Moreover, if you cause pain in said injured patient, they will move around so much trying to find a position of comfort, you restriction attempt actually increases motion. (which is not nearly as problematic as the inflammatory response above.)

If the patient is osteoporitic, kyphotic, and has osteomalacia with remodeling, you may actually cause an injury where none existed prior to your "treatment."



Ackmaui said:


> You don't know what they hit on the way down



Maybe Voldemort got them with a spinal injury curse...

Sorry, but examine the patient. If they are capable of answering and reliable, ask. Rather than play "What if?" be a sound clinical provider. 



Ackmaui said:


> Take the time to do the right thing



Examine your patient and make a decision where the benefit outweighs the risks.



Ackmaui said:


> and shame on the hospital staff who would have certainly complained if it were their family member on the call and you didn't do everything to insure their health.



They may have been complaining because they worry you might erroneously put their relative on a board because you didn't know it could result in harm?


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## FourLoko

I just think back to 2010 when I was T-Boned on the driver side of my little two door car. Passenger space intrusion was present but not terribly excessive. My only complaint at the time was a numb right hand which was from the airbag.

Now that I think back I don't recall if the FF put a C-Collar on but they did break out the backboard. They stuck it in the passenger door so I climbed over the center console and pushed either the door or console with my feet to get onto the thing. 

That's my not so scientific tale about backboard usage and how they do it just to do it.


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## Veneficus

FourLoko said:


> I just think back to 2010 when I was T-Boned on the driver side of my little two door car. Passenger space intrusion was present but not terribly excessive. My only complaint at the time was a numb right hand which was from the airbag.
> 
> Now that I think back I don't recall if the FF put a C-Collar on but they did break out the backboard. They stuck it in the passenger door so I climbed over the center console and pushed either the door or console with my feet to get onto the thing.
> 
> That's my not so scientific tale about backboard usage and how they do it just to do it.



A backboard can be a very useful extrication device. Nobody disputes its role in that. 

The problem is it is not benign as once thought, so it can cause injury when used as a motion restriction device inappropriately.

I also seriously doubt that it actually prevents secondary spinal injury. Unless there is a mechanism I am not aware of, I would wager a lot it may actually worsen spinal injury.


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## CCNRMedic1982

I am fairly new to all of these post but like a lot of what I read. A lot of very intelligent and dedicated people in this profession. With that being said here is my two cents. I think that with the given information it was appropriate to restrict spinal movement. There are a lot of things that could cause potential harm or discomfort to certain pt. types. But when spinal motion restriction is indicated based on a good strong assessment and unfortunately what some services protocols will allow you to do. I think it is in yours and your pts best interest to do so. From what I recall paralyzed pt. can have pressure sores as well. The service I work for has very short transport times. So the pts we have on backboards aren't on them for very long. But if someone works in a place where they have longer transports that is some to think about operationally to advocate for your pt. and provide the best care possible.


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## Medic Tim

I would not have boarded this person. A fall from standing height DOES NOT = a board automatically.


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## Ackmaui

Veneficus said:


> No it is not. That is what is taught to EMTs because they are not given enough formal education to make decisions.
> 
> They have simple instructions that do not allow deviation due to their limits. That is very different than being medically a good reason.
> 
> 
> 
> 
> None of this conerns me. A student who is right in a particular case is greater than any provider who is wrong.
> 
> I do not think you are right in this case though. Not because you are a student, but because you have a very limited perspective that was a reinforced behavior for more than a decade.
> 
> 
> 
> I respectfully disagree. Elderly people have decreased chest wall expansion and decreased ability to compensate for it even without pathology. Even worse if they do have something like CHF.
> 
> Additionally, compression that can result in skin breakdown can occur in less than an hour. Again which can be worsened by underlying pathology.
> 
> I don't want to tell a family I gave them a painful nonhealing wound either.
> 
> A stress response from being painfully strapped to a board or restricted in an unfamiliar environment can cause a host of deletorious effects. Increasing HR, BP, etc in a patient with various underlying conditions could be a problem.
> 
> Furthermore, if you take a patient with an actual spinal pathology from their self splinted position of comfort and manipulte them to a flat position, you may worsen inflammation which may occlude spinal arteries resulting in secondary paralysis.
> 
> Moreover, if you cause pain in said injured patient, they will move around so much trying to find a position of comfort, you restriction attempt actually increases motion. (which is not nearly as problematic as the inflammatory response above.)
> 
> If the patient is osteoporitic, kyphotic, and has osteomalacia with remodeling, you may actually cause an injury where none existed prior to your "treatment."
> 
> 
> 
> Maybe Voldemort got them with a spinal injury curse...
> 
> Sorry, but examine the patient. If they are capable of answering and reliable, ask. Rather than play "What if?" be a sound clinical provider.
> 
> 
> 
> Examine your patient and make a decision where the benefit outweighs the risks.
> 
> 
> 
> They may have been complaining because they worry you might erroneously put their relative on a board because you didn't know it could result in harm?



The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
. By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.


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## DesertMedic66

Ackmaui said:


> The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..



I fell a month ago and got a bruise around my eye. No one witnessed my fall. I didn't get boarded and a collar....

Since it was an un-witnessed fall how do you know that the bruise was caused by the fall? How do you know the patient hit their head?

I fall all the time. Just because I fell doesn't mean I hit my head or injured my spine.


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## Aidey

Ackmaui said:


> The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
> . By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
> ..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.



There is a difference between a stable and unstable fracture. A "fractured vertebrae" doesn't tell us anything since there are types of fractures that need little to no treatment. 

Read some of the links I posted. The idea that backboards are unnecessary and harmful in some cases wasn't started on this forum. There are doctors who have been questioning their efficacy for years.


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## Handsome Robb

Ackmaui said:


> The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared..
> . By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
> ..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.



No she shouldn't have. I still fail to see how spinal motion restriction is indicated. She's A&O, denies LOC unless I read something wrong, is without painful distracting injuries and does not complain of midline cervical or thoracic pain. There's nothing that says this patient should be placed on a back board.

Citing a single case hardly supports your point.


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## DesertMedic66

NVRob said:


> No she shouldn't have. I still fail to see how spinal motion restriction is indicated. She's A&O, denies LOC unless I read something wrong, is without painful distracting injuries and does not complain of midline cervical or thoracic pain. There's nothing that says this patient should be placed on a back board.
> 
> Citing a single case hardly supports your point.



But everyone knows a fall = trauma. And any kind of trauma = full rapid trauma assessment, hi flow O2 via NRB, and full spinal immobilization


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## Veneficus

Ackmaui said:


> The patient had bruising around her eye..found on examination.. Meaning she hit her head... She should be boarded and collared...



I am not so sure where her hitting her head alone puts her at risk for a spinal injury, but isn't that is what assessment is for?

I am not so sure the totality of findings were presented here. It seems extraordinarily vague.

But I will stipulate that since she was alert and oriented, that if she did not have an obvious distracting injury, had no neuro deficits, no midline pain, a full range of motion, and no history of bone disease or cancer, this patient would recieve no benefit from spinal immobilization.

I still very seriously doubt a flat board is spinal immobilization anyway.

I would not have put her on a board under the circumstances stipulated. Afterall, if she had bone disease and was kyphotic, I wouldn't put her on a board anyway, even if I did suspect a vertebral body fracture.



Ackmaui said:


> By the way.. 5 years ago, EMS answered a call for 83 year old male, found on floor in nursing home...Unwitnessed fall. Vitals were normal, pt only complaint of slight pain in right arm. The patient was assessed thoroughly by EMTs. EMTs did not board and collar patient.
> ..the patient had 3 cracked vertebra and fracture of the left hip. But I'm sure that you all still don't want the patient to be boarded and collared.



Even though this case is unrelated completely, I will comment on it.

An unwitnessed fall in a nursing home? Must be a reason the patient was in a nursing home. I am guessing health so poor he is unable to care for himself. Did the patient fall from standing? From bed? Dropped by staff who didn't see anything?"

On to treatment.

Cracked vertebrae, doesn't sound like an unstable body fracture. Was it a spinal or transverse process, or the body? 

Moreover, what was done for it? I am somehow doubting he was refered to ortho or neuro surg to fix it.

But that is still secondary.

Was the patient made worse by not being boarded and collared? 

Because if he wasn't, that would sort of support the point that it doesn't really make much difference doesn't it?

I would be most interested in hearing why you think a board is indicated and what theraputic benefit it derives. Forget studies and crap, would you just tell me how you think it works and what it does?


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## mycrofft

I wasn't happy with my reply.Disregard


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## 94H

Even though the MOI might not be cause for backboarding under your protocols, it still is for most EMTs around the country. 

Good job to the OP for following his protocols. Whether or not spinal immobilization is a correct treatment is not the issue here, since most people are bound by their protocols, however outdated they may be.

For my last skills review at my company, the backboarding station was a pt who fell from a standing height. 

FYI The Med-Director took away Medics ability to clear C-Spine at my company


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## mycrofft

94H good reply. Cut to the chase.

You know, we all forget that spineboarding is designed to protect the pt from iatrogenic exacerbation to spinal injury by EMS responders. Just as initial prehospital splinting is designed to minimize exacerbation of medical conditions by movement or transport. NEITHER is a "treatment", it's more of a safety measure to allow transport to definitve care.

OK if theoretically we could suspend the protocols, what would the best course of prehospital management be for the OP's initial presentation?


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## Veneficus

mycrofft said:


> 94H good reply. Cut to the chase.
> 
> You know, we all forget that spineboarding is designed to protect the pt from iatrogenic exacerbation to spinal injury by EMS responders. Just as initial prehospital splinting is designed to minimize exacerbation of medical conditions by movement or transport. NEITHER is a "treatment", it's more of a safety measure to allow transport to definitve care.
> 
> OK if theoretically we could suspend the protocols, what would the best course of prehospital management be for the OP's initial presentation?



Have her sit on the cot in the position of comfort or anatomical position.

Nobody lays on a spineboard in the hospital.

edit: with a c-collar if you suspect an unstable body fracture.


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## Arovetli

mycrofft said:


> protect the pt from iatrogenic exacerbation to spinal injury by EMS responders.



A bit off topic but I recall years ago when I read through Bledsoe's paramedic text (Brady books) he quoted a study where prehospital providers caused ~50% of spinal injuries by moving patients or something to that effect. (which I thought at the time to be voodoo and still do)

 I no longer have the books and have never been able to find the study. Maybe I am making it up in my head, but does anyone recall reading this or stumbling across this paper?


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## d_miracle36

I never see a pt boarded in the er besides when preparing for transport. Is it appropriate for ems to apply a c-collar without full spinal motion restriction?


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## Veneficus

Arovetli said:


> A bit off topic but I recall years ago when I read through Bledsoe's paramedic text (Brady books) he quoted a study where prehospital providers caused ~50% of spinal injuries by moving patients or something to that effect. (which I thought at the time to be voodoo and still do)
> 
> I no longer have the books and have never been able to find the study. Maybe I am making it up in my head, but does anyone recall reading this or stumbling across this paper?



I looked in 2 editions of paramedic care I have, didn't find it in the trauma volumes or the index.

I recall hearing very early in my career something similar.(usually as somebody was trying to scare us into immobilizing every patient we saw just in case) I don't know if there was ever a study or a paper on it?

Given that we now know that compartment compression causes more secondary injury than other mechanisms I would question if there is such a study, if they erroneously attributed secondary injury to EMS providers because of lack of knowledge of the actual cause of the injury?


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## Veneficus

d_miracle36 said:


> I never see a pt boarded in the er besides when preparing for transport. Is it appropriate for ems to apply a c-collar without full spinal motion restriction?



Spinal motion restriction does not automatically mean a rigid spineboard.

In the hospital setting, having a patient lay flat in a c-collar on the hospital bed (without a pillow) is considered spinal mption restriction.

The same as with the full body vacuum splints.

I know of several agencies that permit the use of the splint.

In my past EMS employs I have put elderly people on the cot with a c-collar and at the hospital and on the PCR explained why I chose not to put the patient on a spineboard for various reasons. I never had any problems in those instances.

In fairness it was more of an exception than a rule.


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## Arovetli

Veneficus said:


> I looked in 2 editions of paramedic care I have, didn't find it in the trauma volumes or the index.
> 
> I recall hearing very early in my career something similar.(usually as somebody was trying to scare us into immobilizing every patient we saw just in case) I don't know if there was ever a study or a paper on it?
> 
> Given that we now know that compartment compression causes more secondary injury than other mechanisms I would question if there is such a study, if they erroneously attributed secondary injury to EMS providers because of lack of knowledge of the actual cause of the injury?



Yeah I remember questioning the methods in my head and I seem to recall the study was old. Speaking of my head, I must be remembering things wrong. Paramedic school was awhile ago, alot of things have come and gone since then and I probably got mixed up on where I heard about that. Thanks for checking.


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## d_miracle36

I agree with that but most of our patients are up walking around with a c-collar. If the only thing they are complaining of is neck pain is it okay to just apply c-spine precautions. With most of my patients if I put a collar on they usually get a board also but I have had elderly patients who I only put a c-collar on. What instances in ems will a collar only suffice?


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## Arovetli

d_miracle36 said:


> I agree with that but most of our patients are up walking around with a c-collar. If the only thing they are complaining of is neck pain is it okay to just apply c-spine precautions. With most of my patients if I put a collar on they usually get a board also but I have had elderly patients who I only put a c-collar on. What instances in ems will a collar only suffice?



For the science read what Aidey provided. If you finish those and still want more PM me as my bookmarks and pubmed favorites are full of that stuff.

For practice as an emt or medic you absolutely must follow local protocols. Do not deviate even if your protocols are not evidence based. I understand your concerns because it is difficult to spell out every instance in a protocol book and interpretation can be difficult and occasionally you have to work with people who are better suited to the inside of a toolbag than the back of an ambulance or in a hospital....but this is how EMS and medicine rolls sometimes. You should direct questions to an FTO, senior medic, or admin of your service. Practices vary widely so its hard to advise.


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## d_miracle36

My protocols do not say anything about c-collar only and i understand to use them. I was just wondering if this would be practical or may eventually be a standard of care. My fto's still think we should board every pt just to be safe even though we have a clearance protocol. thank you for the resources.


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## Arovetli

d_miracle36 said:


> eventually be a standard of care.



In some places it is. Some places are so risk averse you will never see it because they don't want to adopt the tiniest bit of liability.

Once you get some time in where your voice will be respected a little you can always tactfully suggest to senior personnel what the literature says. They may not be aware of it because, quite honestly, prehospital research was virtually nonexistent in the past.


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## mycrofft

The NHTSA decided prehospital extrication and care were to blame for many traffic deaths and so they invented EMTs...(P)aramedics and (A)mbulance.


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## johnrsemt

My old area was very liberal with medics not c-spining:

  The protocol basically read:

  --Patient 5 years old or older
  --Patient understands what you are asking:  (if they only speak spanish and you have someone who speaks spanish that can translate, etc)
  --No distracting injuries (that will take your or the patients mind off of what you are asking the patient
   --No point tenderness along spinal column (C1-about mid shoulder blades)
   --No neuro problems; (equal numbnes or tingling {takes care of the 1 numb hand from airbag}).
    --Medic discretion:  If you were concerned do it anyway.
    --If first responders had already placed a c-collar medics could NOT remove it.

    It was good,  it saved us from the old school of having to c-spine an isolated hand injury  (I was written up by fire LT for not c-spining a patient who ran his hand through a table saw).

     In over 10 years of doing this in a busy metro area they have never had one go wrong from not c-spining


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## Veneficus

mycrofft said:


> The NHTSA decided prehospital extrication and care were to blame for many traffic deaths and so they invented EMTs...(P)aramedics and (A)mbulance.



This is an interesting point. 

It probably has a lot to do with spinal immobilization techniques and the dogma that has perpetuated from it. 

Back in those days and the very early part of my career, cars were made of steel, seatbelt usage optional, and engineered safety features basically nonexistant.

A MVA (i refuse to adopt the insurance indusrty idea of MVC to establish liability) was sure to mean somebody was really messed up. (which I found quite exciting actually, still do, it just takes more to impress me)

Force transfer from metal to people was very large, even patients with no obvious injuries could, and often did, have severe occult ones.

People would often bounce off the windshield, even go through it twice. (once partially out, and then back in) Others would bounce around the inside of the car at all angles. 

As I stated above, there wasn't significant understanding of what caused secondary spinal injury. I strongly suspect (primitive)EMS caught an undue share of the blame. Delayed clinical onset of symptoms being attributed to provider mishap.

As this "secondary" mechanism was popularly accepted, it seems other attempts to equate it to various traumatic injuries such as falls were establised.

The more recent studies demonstrating mechanism as being unreliable, also do not seek to address why. Only correlation. (poor science)

EMS and its physician leadership haven't put a whole lot of effort in even exploring and refining what EMS does. (most of the evidence I see is usually antiEMS, from physicians seeking to point out its flaws rather than help.)

Everytime I read a reply about "but that is protocol and it is unyielding, we must follow,"  while certainly true, and i am certainly not advocating ignoring them, I really think that change in EMS practice is going to have to come from the providers, through the proper channels, and at the proper time.

Perhaps the new EMS fellowship trained physicians will create the required environment?

Because most EMS medical directors are less than useless, they directly impede progress, which detracts from quality patient care. 

Since there are already numerous threads that have devolved into discussions on professionalism, to avoid that, i will say only this:

Recognizing and admitting inadequecy, then finding ways to make it better is the mark of a professional. 

Claiming that a practice is right or must be good because somebody said so is not.


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## 94H

Arovetli said:


> In some places it is. Some places are so risk averse you will never see it because they don't want to adopt the tiniest bit of liability.
> 
> Once you get some time in where your voice will be respected a little you can always tactfully suggest to senior personnel what the literature says. They may not be aware of it because, quite honestly, prehospital research was virtually nonexistent in the past.



I took a Selective Spinal Immobilization course with my Squad's Captain when the protocols were amended in NYS. I asked him if we would backboard less people now, he told me "No way, thats too much liability"


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## Remeber343

I would just like to say that... your big brains are scaring these people off... I was looking forward to a reply from Ackmaui.  I am quite interested in his justification... Thats all, carry on!


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## Arovetli

Remeber343 said:


> I would just like to say that... your big brains are scaring these people off...



A little knowledge is a dangerous thing,
drink deep or taste not the Pierian spring

-Pope


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## mycrofft

H'as we were! Carry on!


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## Veneficus

Arovetli said:


> A little knowledge is a dangerous thing,
> drink deep or taste not the Pierian spring
> 
> -Pope



I like that.


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## zzyzx

Just to throw my 2 cents it, we do have to keep in mind that when the NEXUS criteria was developed, they didn't study an elderly population. I'm very careful about considering possible cervical spinal injuries in the elderly even when the MOI is pretty mild, like a fall from a standing position. A little old lady with osteoporosis can break a whole bunch of bones from just a little fall. That said, I won't argue that improper backboarding couldn't make things worse.


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## mycrofft

I think the indications are that there needs to be a better spinal immobilization armamentorium as well as protocols.


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## crazycajun

Wow!!!! So many complaints on here I do not know where to start. First of all to the OP.... You did the right thing. Geriatric PT's never seem to present with text book signs and symptoms. Many play off their pain as simply getting old or hide their pain in fear of needing surgery. All of the studies I have read never involve geriatrics in them. They also never follow up on the case to see if spinal issues presented later and if they could be tied to the original event. Now on to those who are complaining.... If this same PT did not fall but did have a CC of lower lumbar pain. What would your treatment be??? No other complaints just the back pain. And lastly to those that don't like boarding people because it is a pain and makes their job harder.... Please for the safety of my family and others FIND A NEW CAREER!!!!!!


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## Aidey

Did you even read any of the links I posted? It has nothing to do with laziness or making our job easier. It is about providing the best evidence based care possible. Back boards were introduced because someone thought they were a good idea without any proof they actually helped.


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## firecoins

you expect crazy cajun to read the thread?


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## crazycajun

Aidey said:


> Did you even read any of the links I posted? It has nothing to do with laziness or making our job easier. It is about providing the best evidence based care possible. Back boards were introduced because someone thought they were a good idea without any proof they actually helped.



Yes I have read the links as I have done plenty in the past as this is part of my job. You seem to fail to realize that most of the studies are done on healthy individuals in the 20 to 30 age group and on cadavers. The studies are also minimal on test subjects ranging from 5 to around 1600. With that said there is still not enough factual based evidence to rule out spinal precautions especially in a geriatric PT w/ unwitnessed fall. I will agree there are instances (combative PT not wanting to be boarded, PT refusal, PT CAOx4 walking w/ no complaint of Pain) that we should not board. I have also seen cases where the PT was cleared by the ER physician, taken off the board and out of C-collar only to find out later in x-ray there was in fact a spinal injury. And yes there are plenty on here that can't stand to backboard because it makes there job harder. Not saying you are one of them but read the post and you will easily see who made the statements.


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## crazycajun

firecoins said:


> you expect crazy cajun to read the thread?



If I want your opinion I will pull your chain


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## Smash

zzyzx said:


> Just to throw my 2 cents it, we do have to keep in mind that when the NEXUS criteria was developed, they didn't study an elderly population. I'm very careful about considering possible cervical spinal injuries in the elderly even when the MOI is pretty mild, like a fall from a standing position. A little old lady with osteoporosis can break a whole bunch of bones from just a little fall. That said, I won't argue that improper backboarding couldn't make things worse.



Both NEXUS and CCR did post-hoc sub-group analysis on the elderly population (age > 64) and both were found to be safe and effective.  There is of course the recognition that most elderly patients are at a higher risk for c-spine injury and SCIWORA, however this does not negate the various decision rules, but rather it makes one have to actually think about what one is doing rather than blindly following any protocol.




crazycajun said:


> Yes I have read the links as I have done plenty in the past as this is part of my job. You seem to fail to realize that most of the studies are done on healthy individuals in the 20 to 30 age group and on cadavers. The studies are also minimal on test subjects ranging from 5 to around 1600. With that said there is still not enough factual based evidence to rule out spinal precautions especially in a geriatric PT w/ unwitnessed fall.



You are absolutely correct that the studies refuting the efficacy of using long-boards and collars are small.  Perhaps though, you could post the large, multi-center RCTs that have established that long-boards and collars are effective and safe?

However slim the evidence against collars and boards is, it is orders of magnitude greater than the evidence in favour.  Yet we persist with something that has dubious biological plausibility, no hard evidence of good and mounting evidence of harm associated with it. 



> I will agree there are instances (combative PT not wanting to be boarded, PT refusal, PT CAOx4 walking w/ no complaint of Pain) that we should not board. I have also seen cases where the PT was cleared by the ER physician, taken off the board and out of C-collar only to find out later in x-ray there was in fact a spinal injury.



The plural of anecdote is not evidence.  These "spinal injuries" you have witnessed post clinical clearance: have any of them actually done any harm to the patient?  I'm pretty sure we aren't looking at a large population of high spinals because of clinical clearance.



> And yes there are plenty on here that can't stand to backboard because it makes there job harder. Not saying you are one of them but read the post and you will easily see who made the statements.



Strawman much?  Care to quote whoever is complaining about back-boarding making their life more difficult?


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## Epi-do

Would I board and collar this patient?  Absolutely not.  I could beat a dead horse and list all the same reasons for not doing it that have already been presented, but why bother.  

Instead, a little food for thought - Why is it that boarding/collaring a patient is just about the only thing we, as a whole, typically approach with the attitude that the need for it must be ruled out, instead of approaching it with the attitude that we need to assess and determine there is a need in the first place?

Think about it.  You don't show up on a scene and assume every patient is going to get oxygen, any sort of airway adjunct, any of the meds that are in your box, or 360j of electricity coursing through them.  Why should using a backboard and c-collar be any different?


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## Aidey

Epi-do said:


> Would I board and collar this patient?  Absolutely not.  I could beat a dead horse and list all the same reasons for not doing it that have already been presented, but why bother.
> 
> Instead, a little food for thought - Why is it that boarding/collaring a patient is just about the only thing we, as a whole, typically approach with the attitude that the need for it must be ruled out, instead of approaching it with the attitude that we need to assess and determine there is a need in the first place?
> 
> Think about it.  You don't show up on a scene and assume every patient is going to get oxygen, any sort of airway adjunct, any of the meds that are in your box, or 360j of electricity coursing through them.  Why should using a backboard and c-collar be any different?



It shouldn't, but for some stupid reason the myth persists. People have done a very good job of propagating the falsehood that backboards are beneficial and save lives. There are also all the threats of lawyers and lawsuits and people being paralyzed left and right.


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## Farmer2DO

Epi-do said:


> You don't show up on a scene and assume every patient is going to get oxygen



Actually, lots of people do.


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## Aidey

And those people deserve to be strapped to a backboard and beaten with a nonrebreather.


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## kindofafireguy

Farmer2DO said:


> Actually, lots of people do.



And along that vein is a great saying:

"You can't fix stupid, but you can sure as hell knock it down and tube it."
-anonymous


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## DesertMedic66

Aidey said:


> And those people deserve to be slapped with a backboard and beaten with a nonrebreather.



fixed that for you


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## firecoins

crazycajun said:


> If I want your opinion I will pull your chain



Who asked your opinion? Nobody.


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## Epi-do

Farmer2DO said:


> Actually, lots of people do.



What can I say.  There is way more stupid in the world than I have time to deal with.  When I precept students, that is often a topic we talk about.  We discuss how to pass the test "everyone gets high flow O2" but spend more time talking about how to determine who actually needs O2, how much, and what method of delivery is most appropriate.  If they are never taught, they will never learn how to figure it out.


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## Tigger

I wonder how many "providers" realize that spinal injuries do not automatically indicate nervous system damage and are really just another fracture. You could "break" every vertebra in your body and being walking around with no deficits whatsoever, though I bet you'd be in some pain.

A backboard does nothing for these fractures but make it more uncomfortable. It's not preventing them from getting any worse because short of another significant insult, the fractures are not going to get any worst. 

Here's my little spinal story:

I hit a tree skiing a few months ago and fractured my L4 and L5, there were no neuro deficits and I managed to convince the ski patrol to not immobilize me. Unfortunately once I laid down in the sled I could not get back up (too painful) and had to be transported to the hospital on a board sans collar and it was horribly uncomfortable and made the pain worse. When I asked the doc if I was a typical presentation he said absolutely and that the very fast majority of spinal fractures are quite stable.  

I have no studies, though I have read a few of the ones that Aidey posted as well as the the National Association of Athletic Trainer's position statement on spinal injury care and wholeheartedly agree that we do it far, far too much.


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## Veneficus

crazycajun said:


> Wow!!!! So many complaints on here I do not know where to start. First of all to the OP.... You did the right thing. Geriatric PT's never seem to present with text book signs and symptoms. Many play off their pain as simply getting old or hide their pain in fear of needing surgery. All of the studies I have read never involve geriatrics in them. They also never follow up on the case to see if spinal issues presented later and if they could be tied to the original event. Now on to those who are complaining.... If this same PT did not fall but did have a CC of lower lumbar pain. What would your treatment be??? No other complaints just the back pain. And lastly to those that don't like boarding people because it is a pain and makes their job harder.... Please for the safety of my family and others FIND A NEW CAREER!!!!!!



Actually, 

I'd like to think I know a little about trauma and the care of it. I have been to skule a few years. 

I seriously doubt the benefit of longboards.

They were an expert opinion based on a theory that has been discovered to have a lot of flaws in it.

The only reasons I can think of to use them at all is 

a. because you are obligated to follow a protocol. 
b. to help extricate somebody out of a space like a car, trench, etc. 

A pillow splint is a legitimate prehospital immobilization device.

What if that "pillow" was a 6 foot long cot matress? (sort of like a giant vacuum splint concept don't you think?)


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## Aidey

Bloody hell do I miss full body vacuum splints. Those things are amazing for hip patients.


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## Tigger

Aidey said:


> Bloody hell do I miss full body vacuum splints. Those things are amazing for hip patients.



We have one at my sports medicine job and I would like to see it get used more. However it is very large and would be a bear to get out on the ice. We also struggled to make it work for supine spinals, finding it pretty much a much to use the scoop to get them onto it, do you have a better technique perhaps?


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## ffemt8978

Veneficus said:


> A pillow splint is a legitimate prehospital immobilization device.
> 
> What if that "pillow" was a 6 foot long cot matress? (sort of like a giant vacuum splint concept don't you think?)



What about the old military litters that were two wooden poles with canvas between them?


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## Veneficus

ffemt8978 said:


> What about the old military litters that were two wooden poles with canvas between them?



Probably not much difference there either as long as you were not almost bouncing out of it as you were being carried.


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## mycrofft

We used the folding canvas stretchers by Ferno Washington that were always stretched laterally but folded in half longitudinally, and a short board (didn't have KED, 1981 midwest) if extrication was from/through a limited space. AND care, plus good coordination moving and positioning the pt., as well as a Philly collar. No ER complaints, and pt was not bouncing around thanks to care and having the ambulance litter (gurney/cot/bed whatever) as close at hand as possible.

I am greatly heartened to be reading here (and hearing in training materials) the reasoning process: splint to move, not treat. I am starting to hear more reasoning going into spine boarding. Hate to lose a potentially important tool just because it is more limited than we were and are taught.


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