# Backboard or not?



## Paulie_G (Nov 23, 2009)

I was doing a ride along a while back when we got a call for a suicide attempt at the fire station where we have our quarters.  Apparently his father had found him and driven him to the fire station because he refused to go to the hospital.  Upon our arrival firefighters were extricating a 40 year old male with a self inflicted gun shot wound to the chest from a truck.  The pt. had an exit wound in line with the entrance wound to just below the left nipple.  He still had CMS cause he was fighting with us as we tried to help. Long story short the guy ends up dieing.  I was speaking with another medic just recently.  Her take on it is that he was sitting up and blood was filling his abdominal cavity, when we back boarded him it began to fill up in his chest and caused his heart to stop. To her credit she admitted that she wasn't there so who knows.  I would like to know what you think?  Has anyone transferred a pt. to air care sitting up?  Would it have delayed the pt. crashing?  Your thoughts?


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## Shishkabob (Nov 23, 2009)

Why would you backboard for an moi inconsistant with spinal cord trauma?


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## spinnakr (Nov 23, 2009)

1.) The medic you talked to was 100% correct: we weren't there, so as the saying goes, "don't judge an operation from an armchair."  That said,

2.) I personally don't see a reason to board this patient, except potentially to make extrication from the vehicle easier.*  Can you give some more information?  I don't think there's really enough here to determine anything.

3.) The fact that the man's father did not immediately call 9-1-1 is reprehensible.  If the son didn't want to go to the hospital, what did the father think going to the station would do?!  Furthermore, he just shot himself...  clearly the father's interests and the son's are misaligned.  Ergo, 9-1-1.  Personally, if I were responding to that 9-1-1 call, I'd make sure LEOs beat me there to secure the scene, since it sounds potentially lethal to the responding crew.

*I have zero experience with this situation, and I haven't been in the field for very long, so take this with a grain of salt.

EDIT:  Linuss beat me to it.


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## Paulie_G (Nov 23, 2009)

*A little more info*

Well I suppose the fire crew used the backboard to extricate because it was a invasive injury to the torso and that's how they are trained to remove pts. from vehicles anyway. They were doing it while we were arriving so the medic didn't get a chance to assess inside the vehicle.  Not that any of us have an issue with them great first responders. Pt. was conscious, alert and oriented X3 on our arrival.  Pt. had a Hx of ETOH and drug abuse but we couldn't say either way if there was any use prior to shooting.  No head or neck problems that were visible.  Pt. was combative and just kept telling us to let me die.  Pt. cooperation was non existent.  But CMS was intact.


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## Paulie_G (Nov 23, 2009)

*911*

As for the dad not calling 911 right away.  he lived a block down from the station.  He had found the pt. some time after incident.  Pt. still had the gun.  I don't know about you but I'd be afraid to screw with someone holding a gun even if pt. wouldn't shoot you they could still turn the gun on themselves if you aggravate them more.


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## medichopeful (Nov 23, 2009)

Paulie_G said:


> As for the dad not calling 911 right away.  he lived a block down from the station.  He had found the pt. some time after incident.  Pt. still had the gun.  I don't know about you but I'd be afraid to screw with someone holding a gun even if pt. wouldn't shoot you they could still turn the gun on themselves if you aggravate them more.



If a patient or anybody on scene (besides LE) has a gun, EMS/FD shouldn't be going in in the first place.  Very easy way for somebody to get shot or killed.

Did the patient have the gun AT the FD?  If he did, the firefighters screwed up royally, and are lucky they lived.


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## spinnakr (Nov 23, 2009)

medichopeful said:


> If a patient or anybody on scene (besides LE) has a gun, EMS/FD shouldn't be going in in the first place.  Very easy way for somebody to get shot or killed.
> 
> Did the patient have the gun AT the FD?  If he did, the firefighters screwed up royally, and are lucky they lived.



Ditto that.
Also, that was exactly the reason I said if I were dispatched to that I would wait for LE to arrive and clear the scene.


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## Paulie_G (Nov 23, 2009)

*Scene Safety*

And you're right scene safety is the most important thing.  As far as I am aware the gun was left at the pts. parents home.  PD was on scene for the duration of the call.  I would also wait in the truck and let PD secure any scene with a weapon present.  So as far as scene safety goes it was run by the numbers.  It certainly makes it interesting though when a patient shows up at your front door rather than the other way around.


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## JPINFV (Nov 23, 2009)

medichopeful said:


> If a patient or anybody on scene (besides LE) has a gun, EMS/FD shouldn't be going in in the first place.  Very easy way for somebody to get shot or killed.
> 
> Did the patient have the gun AT the FD?  If he did, the firefighters screwed up royally, and are lucky they lived.



What if you're treating someone with a valid CCW? Do CCW holders lose the ability to seek emergency care?


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## medichopeful (Nov 23, 2009)

JPINFV said:


> What if you're treating someone with a valid CCW? Do CCW holders lose the ability to seek emergency care?



If they have a weapon on them?  Yes.  I am not treating somebody until they are weapon free, unless they are a police officer, soldier, etc..  There is just too much danger.  Let them give their weapon to a police officer, or leave it in a different room, or unload it.  

The scene could just change too quickly.  Yes, they may have honorable intentions, but if they have a gun, they are just too much of a danger to my safety.  Once they are cleared, though, I will be more than happy to treat them.


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## medichopeful (Nov 23, 2009)

spinnakr said:


> Ditto that.
> Also, that was exactly the reason I said if I were dispatched to that I would wait for LE to arrive and clear the scene.



Oops, didn't catch that.  Well, it deserves repeating.


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## spinnakr (Nov 23, 2009)

JPINFV said:


> What if you're treating someone with a valid CCW? Do CCW holders lose the ability to seek emergency care?


You raise an extremely good point that I think merits discussion - but not in this thread.  We've already gotten off-topic from the OP.



medichopeful said:


> If they have a weapon on them?  Yes.  I am not treating somebody until they are weapon free, unless they are a police officer, soldier, etc..  There is just too much danger.  Let them give their weapon to a police officer, or leave it in a different room, or unload it.
> 
> The scene could just change too quickly.  Yes, they may have honorable intentions, but if they have a gun, they are just too much of a danger to my safety.  Once they are cleared, though, I will be more than happy to treat them.


I am hesitant to agree, solely because with a CCW permit holder, you probably will NOT know about the weapon until you are already on-scene.  But again, we digress.


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## Summit (Nov 23, 2009)

Backboard if you have time since the bullet theoretically could have fragmented internally unseen and a fragment then shattered a vertebrae leaving compromise with articulation a possibility.

However, with no s/s of spinal compromise, one should focus first on what is killing the patient now and how to solve it. If your patient has a bleeding issue in the chest, especially one headed towards a hemothorax, then that is gonna kill your patient and you can only treat that by getting them to an OR.

OK, maybe I misunderstood, but I think you need to thwack the medic on the head. She is suggesting a tension hemothorax killed the patient, but blood doesn't magically drain into the abdomen while sitting then into the thoracic cavity while laying down unless you blew one hell of a hole through the diaphragm and peritoneum.

Of course, as your medic friend said, I wasn't there.

Why don't you ask the hospital what killed your patient? Exsanguination? Tension hemo/pneumo?


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## Seaglass (Nov 23, 2009)

medichopeful said:
			
		

> If a patient or anybody on scene (besides LE) has a gun, EMS/FD shouldn't be going in in the first place. Very easy way for somebody to get shot or killed.



It's never become an issue, but I work in one of those areas where guns are really common. There's no real way of knowing who has one because everyone carries concealed, so we don't usually worry about bystanders with guns unless there's some reason to suspect the scene might turn ugly. If we found one on a patient, though, we'd remove it. 



Paulie_G said:


> It certainly makes it interesting though when a patient shows up at your front door rather than the other way around.



We get those pretty often. They don't want the cost of an ambulance, or to bother us (!), and they hope we can treat them there. Sometimes they really do have minor things that we actually can treat and release, although we always advise them to go to the hospital. More often, it's something that makes us wonder how the hell they managed to drive there, and then we have to argue with them about whether they should attempt to drive themselves to the ED.


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## medichopeful (Nov 23, 2009)

spinnakr said:


> You raise an extremely good point that I think merits discussion - but not in this thread.  We've already gotten off-topic from the OP.



Noted and started in EMSTalk


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## Paulie_G (Nov 23, 2009)

*Hemo or Pnemo*

It wasn't air a needle decompression was done and blood bubbled into the tube.  And your right the pt. needed an OR.


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## mycrofft (Nov 24, 2009)

*Left nipple area. Look up the anatomy of that area when sitting upright.*

Lots of vasculature as well as the lungs. Our active duty military medic members could shed more light, but I'm thinking O2, airway maintenance, IV large bore but only TKO until needed, be prepared to decompress enroute, and get thee to an OR. 

I've seen my share of people crump as soon as they are placed supine, and long boards are pretty supine all right. Every treatment has it's negative effects and being unable to keep your airway clear versus potential for spinal injury in this scenario is a bad ratio. One field tx for penetrating wound to chest is place the pt on the affected side.


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## Lvillemedic (Nov 29, 2009)

*Yes..LSB the Pt.*

Yes the pt should be placed on a LSB due to possible spinal compromise for one and two it will make restraining the pt easier, But remember to restrain to the LSB and not to the stretcher. Also you could stuff pillows, blankets, sheets or what ever under the one side of the LSB to try and keep the injuried side down and hopefully keep one lung somewhat usefull. Good BLS before ALS...Don't get tunnel vision thinking there's only the one GSW. You gotta look for other GSW's....


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## thatJeffguy (Nov 29, 2009)

Seaglass said:


> It's never become an issue, but I work in one of those areas where guns are really common. There's no real way of knowing who has one because everyone carries concealed, so we don't usually worry about bystanders with guns unless there's some reason to suspect the scene might turn ugly. If we found one on a patient, though, we'd remove it.



People legally carry guns where you live?  My god!  You must have millions of murders!  You should follow the lead of such peaceful places as New York, New Jersey and Los Angles and ban those darn murder-sticks!


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## VentMedic (Nov 29, 2009)

Linuss said:


> Why would you backboard for an moi inconsistant with spinal cord trauma?


 
The backboard is a great device to restrain a combative patient, roll patient for exam, position patient for injury and with a GSW to the chest, CPR may be only minutes away. Log rolling a patient is also a nice way to place the patient on a board then to the stretcher and maneuver them where the patient doesn't get the providers all bloody. As well, if one was not certain of the path of the bullet, the spinal cord is in the chest. Several of our para and quadriplegics in LTC and Rehab were GSWs to the chest. 

Without vital signs, breath sounds, and heart sounds it is difficult to know what all happened but the patient probably had a pneumothorax, hemothorax and maybe a cardiac tamponade. The heart or one of the pulmonary vessels may have been severed. 

What the Paramedic could have meant is the patient lost his BP (hypotensive) by sitting him up which diverted the blood toward the lower body instead of the head and chest. Remember the MAST days of autotransfusion or the principles of what trendelenburg is supposed do? 



> It wasn't air a needle decompression was done and blood *bubbled *into the tube.


 
If the blood "bubbled" there was air mixed in there.


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## karaya (Nov 29, 2009)

thatJeffguy said:


> People legally carry guns where you live? My god! You must have millions of murders! You should follow the lead of such peaceful places as New York, New Jersey and Los Angles and ban those darn murder-sticks!


 
This is a back-boarding thread in regard to a gunshot patient.  Let's not turn this one into another 200 something thread full of dribble about guns.


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## thatJeffguy (Nov 29, 2009)

karaya said:


> This is a back-boarding thread in regard to a gunshot patient.  Let's not turn this one into another 200 something thread full of dribble about guns.



Fair enough.


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## MSDeltaFlt (Nov 29, 2009)

Paulie_G said:


> I was doing a ride along a while back when we got a call for a suicide attempt at the fire station where we have our quarters. Apparently his father had found him and driven him to the fire station because he refused to go to the hospital. Upon our arrival firefighters were extricating a 40 year old male with a *self inflicted gun shot wound to the chest* from a truck. *The pt. had an exit wound in line with the entrance wound to just below the left nipple*. He still had CMS cause he was fighting with us as we tried to help. *Long story short the guy ends up dieing*. I was speaking with another medic just recently. Her take on it is that he was sitting up and blood was filling his abdominal cavity, when we back boarded him it began to fill up in his chest and caused his heart to stop. To her credit she admitted that she wasn't there so who knows. I would like to know what you think? Has anyone transferred a pt. to air care sitting up? Would it have delayed the pt. crashing? Your thoughts?


 


mycrofft said:


> *Lots of vasculature as well as the lungs*. Our active duty military medic members could shed more light, but I'm thinking O2, airway maintenance, IV large bore but only TKO until needed, be prepared to decompress enroute, and get thee to an OR.
> 
> I've seen my share of people crump as soon as they are placed supine, and long boards are pretty supine all right. Every treatment has it's negative effects and being unable to keep your airway clear versus potential for spinal injury in this scenario is a bad ratio. One field tx for penetrating wound to chest is place the pt on the affected side.


 
Mycrofft is right.  Let's go back over A&P.  What else besides a lung is behind the left nipple?  Anyone?  Anyone?  If you guessed the heart, you are correct.  Even if the bullet didn't even touch the heart, it could still well have been effected by cavitation forces ripping all kinds of tissue and vasculature on it's way out the back.

Of course he was combative.  He was dying.  Just not as fast as he wanted, but he still achieved his goal.  Thus negating the suicide attempt and confirming suicide.

Would I have boarded him?  From what I'm picturing in my mind as an armchair quarterback miles and miles away, I probably wouldn't.  However it is a moot point.  This pt's pain and bleeding has stopped.


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## sdadam (Nov 30, 2009)

Ummm, 

A GSW to the chest is for sure an indication to cspine.

Now in reality the odds of the PT having an unstable spinal injury which any amount of movement would exacerbate is one in a million. 

In fact regardless of the MOI the great myth of movement will worsen a spinal injury has exactly zero research to prove it. There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage. 

So should you? Yes, but is it anywhere near the top of the :censored::censored::censored::censored: you need to do for that PT, probably not.

Now I'm a million miles away, but the description of blood filling the abdomen till you laid them down, and then filling the chest and killing the PT makes just about no sense at all to me. 

It does however sound like a medic trying to knock what other medics did and justify it with some made up shady A&P and pathophysiology.

Maybe it's just me, but I think what killed him was most likely the loosing of the blood, rather than where it went. I also agree with the high degree of possible direct or indirect cardiac injury already posted, good thinking.

Adam


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## Scout (Nov 30, 2009)

From my arm chair.


GSW to chest opens the possibility for spinal.
KED anyone.. Now there is your beloved immobilisation in a seated position. 
I'm going to be impressed if he managed to get a bullet throught his chest under his left nipple and not hiteith the heart or some major pipework. 


I'd probible have used the coard for easy of movement if nothing else. Pt on board, easy to lift, easy to pad under board for tilting.


Can someone tell me would sitting them up have such an effect as to kill them, based soley on whats going on in the chest?


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## VentMedic (Nov 30, 2009)

sdadam said:


> In fact regardless of the MOI the great myth of movement will worsen a spinal injury has exactly zero research to prove it. There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage.


 
Zero research?  Hardly.

Have you even seen how we move patients in the hospital with a highly suspected or confirmed C-spine injurie or the serious devices used to stabilize them? 

What some prehospital providers fail understand is that there are many different types of spinal injuries.  Some are to the bones, some are to the cord and some to the tissue surrounding the area.  Thus, this is the reason why your neuro assessment can be very different from that done in a hospital 15 minutes later.


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## VentMedic (Nov 30, 2009)

Scout said:


> Can someone tell me would sitting them up have such an effect as to kill them, based soley on whats going on in the chest?


 
That depends on what vessel or organ was damaged and the potential for hypotension.

Princess Diana is a good case study if you want to surf her death up.


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## MrBrown (Nov 30, 2009)

Hmmm lets see .....

Door A:  A patient with severe internal bleeding and trauma to multiple major organs and blood vessels who requires several surgeons to fix it.  Yes, let's piss around putting him on a board and strapping him down, he clearly has a spinal injury!

Door B:  Put patient on stretcher (perhaps in the semi-fowlers position, yes, lets try that for starters) and take him to the hospital while adhering to the principles of airway care, stopping external bleeding and permissive hypotension.

I know, I want the mystery box!


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## sdadam (Nov 30, 2009)

VentMedic said:


> Zero research?  Hardly.
> Have you even seen how we move patients in the hospital with a highly suspected or confirmed C-spine injurie or the serious devices used to stabilize them?



Actually yes, I have been working in ED's around the San Diego area for the better part of a decade now. 

If you have any research, please post the research, not just you scoffing about what you think you know.

Here is a link to a lecture by spinal surgeon Dr. John Burton who has been researching and teaching the emergency physician community for over ten years about this very topic, and discusses in depth the only two studies on this issue, including  NEXUS Low-Risk Criteria.

It's the lecture entitled Rethinking EMS Spine Immobilization.

Considering one of his best points is the history of c-spine and the complete lack of research proving any of our hypothesis about spinal injuries, if you do have some research to back up your claims, you should probably email it to him too.

Adam


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## redcrossemt (Nov 30, 2009)

I would have quickly backboarded this patient out of the car. From the OP's scenario, he is combative and resisting assistance, and may need CPR in the next few minutes. The backboard is easier to restrain to, easier to transfer to the stretcher and ED bed, and may be indicated for a possible spinal injury.

I don't think backboarding this patient out of the car would have taken any longer than carrying him, tarping him, or other methods of moving him to the stretcher and then restraining him.

As far as the patient crashing when he was laid supine... I would guess a coincidence.


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## VentMedic (Nov 30, 2009)

sdadam said:


> Actually yes, I have been working in ED's around the San Diego area for the better part of a decade now.
> 
> If you have any research, please post the research, not just you scoffing about what you think you know.
> 
> ...


 
First I find it difficult to believe someone who states to have all of this experience would even make a statement like this.



sdadam said:


> In fact regardless of the MOI the great myth of movement will worsen a spinal injury has *exactly zero research* to prove it. *There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage. *


 
There has been tons of research out there which is why there are ASSESSMENT guidelines that can be instituted rather than blanket recipes concerning the use of a backboard.    

If you happen to look up a few lawsuit cases, some of which have been highly publicized especially in CA, you will find there have been more than A SINGLE CASE where further injury has been caused by movement especially those who are clueless about assessment and moving patients.   I can not believe you would even make such a statement. 

As far as MOI, this is highly researched and IF you actually worked in an ED that reciped trauma patients you would know the data on SCI is well tracked by many different persons/companies with a vested interest. 

Neurosurgeons, Neurologists, Physiatrists, Sports Medicine Physicians, Exercise Physiologists, Ergonomics Specialists, Insurance companies, workmen's comp insuring agencies and manufacturers of motor vehicles, helmuts, sports equipment and spinal immobilization equipment for both in the hospital and prehospital all have an interest in spinal movement before, during and after an event for both the prevention and treatment. 

If you do not have access to any medical search engines although there are many that are free, here is a generic link for you:

http://scholar.google.com/

Here's a good article by Dr. Bledsoe for those who get a little cocky and fail to follow the "guidelines".

Danger at the Door
http://www.ems1.com/ems-products/consulting-management/articles/426350-Danger-at-the-Door/



> Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.


 
Does this mean that all patients should be backboarded?  Absolutely not.  However, the Paramedic should have enough training to make an adequate assessment and transport the patient as appropriate for that patient.  A  backboard may not be required but good technique should be used to extricate and to limit the patient's movement somewhat.  You probably would use an extremity carry on someone or have them walk into the ambulance either with a suspected spinal injury.  

However, for the patient in this scenario, a code was in this person's future and a backboard is a nice device to have under the patient rather than a soft stretcher for compressions.


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## JPINFV (Nov 30, 2009)

Correct me if I'm wrong Vent, but aren't most to all of the studies validating SSI criteria looking at what assessments correlate to spinal fractures and not whether prehosptial immbolization prevents secondary injury? In fact, are there any studies that show that spinal immobilization with a long back board prevents secondary spinal cord injuries?

Doing a quick search, there's this bit of correspondance between two researchers in Annals of Emergency Medicine [PDF file] discussing what's been reported. While no randomized controlled studies have shown the effectiveness of spinal immobilization, based on case reports over a 40 year period, the number needed to treat is somewhere between 625 and 3333 trauma patients. Additionally, the number of people who "may" benefit makes up a small percent of a small percent of trauma patients (0.03-0.16% of trauma patients may develop secondary injury out of the hospital). The original authors reply discusses some of the issues with such a large NNT and complications vs the drastic side effects of secondary injury.

Dalhousie University's database for evidence based EMS protocol lists spinal immobilization as having C level of support (Recomendation Summary: There is an insufficient amount of evidence available to determine if this intervention should be used or not.) http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=214#Spinal Immobilization

In contrast, selective spinal immobilization ("C-spine clearance")  is listed as having B level support (Recomendation Summary: There is a fair amount of evidence to support the use of this intervention.).



What may need to happen to prove benefit, given the tiny number of people who might be helped, is to finally complete the paradigm shift from trauma=spinal cord injury=immobilize to signs and symptoms of spinal cord injury=spinal cord injury=immobilize. As long as people involved in 5 mph accidents are being immobilized because there's "trauma" involved, the people who actually have spinal column and spinal cord fractures who might be helped by immobilization is going to be drowned out.


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## redcrossemt (Nov 30, 2009)

So if we applied selective spinal immobilization to this patient... I would say that there is a mechanism consistent with possible spinal injury, as well as a distracting injury and uncooperative patient that would make a spinal assessment unreliable. So, spinal immobilization is indicated.


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## boingo (Nov 30, 2009)

Neurological damage from penetrating trauma is done at the time of injury, not after the fact.  If the patient had no neuro deficit on your primary, the odds of him getting them from you not boarding them is slim to none...the research in this subset of patients supports this.  With that being said, restraining someone is easier on a board, as is delivering effective cx compressions, although in the case of a traumatic arrest secondary to gsw to the cx, cpr is  likely to be ineffective at best.


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## Summit (Nov 30, 2009)

^I thought arrest due to penetrating trauma had one of the higher save rates (versus due to cardiac or due to blunt trauma).


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## redcrossemt (Nov 30, 2009)

Summit said:


> ^I thought arrest due to penetrating trauma had one of the higher save rates (versus due to cardiac or due to blunt trauma).



GSW to the left chest that results in arrest... I guess it depends on the cause. If you have a dissected aorta, then your chances are not good. If it's a hemothorax and you have a short transport time or can insert a chest tube, cool beans. Or cardiac tamponade... again, can you do pericardiocentesis, or get them to a trauma bay quickly? 

But the chances seem better than those for blunt traumatic arrest, that's for sure.


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## VentMedic (Nov 30, 2009)

JPINFV said:


> Correct me if I'm wrong Vent, but aren't most to all of the studies validating SSI criteria looking at what assessments correlate to spinal fractures and not whether prehosptial immbolization prevents secondary injury? In fact, are there any studies that show that spinal immobilization with a long back board prevents secondary spinal cord injuries?


 
JP, go back and read my post.  I did not advocate backboards but I did mention proper assessment and immobilization appropriate for the patient. 

Immobilization can be a broad category and if you have ever seen what is done in the hospital once the patient arrives, you would be amazed as how we can stabilize a patient for transport to many tests.   

The person I was responding to seems to be under the impression that the spinal cord can not be further damaged if it survived a crash by moving a patient or that MOI plays no part in the damage.   

The patient in this scenario was about to code. Are you in the habit of working your codes on a soft cot?  Some do and some don't in EMS.  I still work codes on a harder surface than the bed or cot.  Maybe that is wrong also but it is still taught to move or place the patient on a harder surface for compressions.


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## VentMedic (Nov 30, 2009)

redcrossemt said:


> If it's a hemothorax and you have a short transport time or can insert a chest tube, cool beans. Or cardiac tamponade... again, can you do pericardiocentesis, or get them to a trauma bay quickly?


 
Most Paramedic in the U.S. can no longer insert chest tubes or do pericardiocentesis.  30 years ago, these skills were routinely taught in the Paramedic curriculum.   However today,  few remote services still have both in their protocols.  Some flight and specialty also can do both.


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## sdadam (Dec 1, 2009)

Vent, I think we are having a miscommunication.

You didn't address anything from my post.

I said;


sdadam said:


> Now in reality the odds of the PT having an unstable spinal injury which any amount of movement would exacerbate is one in a million.
> 
> In fact regardless of the MOI the great myth of movement will worsen a spinal injury has exactly zero research to prove it. There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage.



You then said that you were right because there are lots of examples in law which prove so;


VentMedic said:


> If you happen to look up a few lawsuit cases, some of which have been highly publicized especially in CA, you will find there have been more than A SINGLE CASE where further injury has been caused by movement especially those who are clueless about assessment and moving patients.   I can not believe you would even make such a statement.



Please provide an example, substantiated by a medical authority if possible.

Then you explain to me how MOI is heavily researched, which I agree with.

I also agree that there are many devices for immobilization, and many professions which are concerned with the care of spinal injuries, or general back care as your list points out. So we are on the same page there I guess.

Now thank you for taking the time to research and post supporting material that will allow other people to better understand the issues we are all discussing in your link "google scholar".

It's obvious that you took the time, and gave my point of view some respect by listening to the lecture I posted. And didn't immediately assume that you know better off the top of your head than anything I could possibly post. 

As that lecture is given by an expert in the field of spinal immobilization, and he is discussing some of the exact issues we are talking about it wouldn't make sense to ignore it. Unless you're sure you just know better than that physician of course.

I'll be sure to go to "google scholar" and read up on where you got the information that allowed you to form your opinions about all this. 

But wait, it would seem that you didn't listen to the lecture I posted, and instead chose to ignore it, and reply only by stating you are right because law cases support you, and post an unrelated article about EMS spinal immobilization, then were sure to call in to question my experience. I get more into the other two below.

Danger at the Door
http://www.ems1.com/ems-products/consulting-management/articles/426350-Danger-at-the-Door/

The point of this article is that EMS sometimes fails to immobilize PTs with spinal injuries, even though spinal immobilization was indicated. I agree, this article is true, I didn't realize that was the topic at hand.

And then of course you were sure to include these gems:


VentMedic said:


> First I find it difficult to believe someone who states to have all of this experience would even make a statement like this.
> 
> As far as MOI, this is highly researched and IF you actually worked in an ED that reciped trauma patients you would know the data on SCI is well tracked by many different persons/companies with a vested interest.



As you can tell, I must be lying about my experience and education, from here on out let's assume that I am a first responder student.

I have been a member, and frequent reader of this board since 2006, and have posted 58 times, the reason for that is exemplified in your response to my posts.


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## VentMedic (Dec 1, 2009)

sdadam said:


> Vent, I think we are having a miscommunication.
> 
> You didn't address anything from my post.
> 
> ...


 
Since you have stated there is not ONE single case where spinal injury is made worse by movement and since it appears from that statement you have not even read the reference section at the end of the JEMS articles, it would truly be a waste of time to point you toward any medical search engine or post a few thousand links. Again, you need to learn the many methods out there for immobilization. Some in EMS only believe there is one way of doing things.  If more were to attend EMS conferences they might see more than what is in their own agency.

A spinal injury is not ONE in a million especially if you work in a busy ED. You may see at least one each shift and sometimes many more. If you visit any hospital trauma or neuro ICU you will see many many more. If you pay attention to some of those BS calls from the NHs, you will see many more young people with SCIs. If you visit any acute rehab you may see as many as 100 in ACUTE rehab. Thus, these are recent injuries and due to the large numbers, medical professionals and researchers like to gather data to prevent the injury or improve care.


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## spinnakr (Dec 1, 2009)

VentMedic said:


> A spinal injury is not ONE in a million especially if you work in a busy ED. You may see at least one each shift and sometimes many more.



I'm staying out of this debate, but I would like to add one thing:  I've worked a grand total of 24 hours in an E/R (in 2 different shifts) while doing "clinicals" for Basic.  During that extremely short time I personally witnessed 3 x-ray-confirmed spinal fractures.  Admittedly, only one was in the cervical region, but that doesn't change the fact that they were certainly not one-in-a-million.  It's really going to depend on where you work.


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## zmedic (Dec 1, 2009)

You're talking about two different samples. One is the "911 was called for someone with some transfer of energy" vs "people presenting to the ED who were given x-rays (ie they couldn't clear them without imaging." Those are two very different population.

Also I'd note that there is a big difference between "vertebral fracture" and "spinal cord injury" 

Notice how people with spinal cord injury are treated in the hospital. They are in bed, maybe with a collar on, but certainly they don't live on a backboard. I think we're going to move towards people getting boarded and being removed from the backboard/uncsooped but with a collar until they can be cleared or imaged.


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## spinnakr (Dec 1, 2009)

zmedic said:


> You're talking about two different samples. One is the "911 was called for someone with some transfer of energy" vs "people presenting to the ED who were given x-rays (ie they couldn't clear them without imaging." Those are two very different population.



If that was a reference to my comment then I beg to differ: these were all patients brought into the ED by EMS crews - and in fact, 2 of the three were brought in by the SAME EMS crew.  Somewhere along the line, the former situation happened.


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## VentMedic (Dec 1, 2009)

zmedic said:


> Notice how people with spinal cord injury are treated in the hospital. They are in bed, maybe with a collar on, but certainly they don't live on a backboard.


 
Of course the hospital doesn't use back boards.  They have halos and tongs to stabilize before and after surgery.  Many are taken to the OR within a few hours upon arrival to the ED for surgical stabilization. Then, the patient may go to their room in a cervical collar of some type since that will also vary to the degree of stabilization required.  

A few nondisplaced fractures may go straight to a cervical collar which may be worn for 6 - 10 weeks for stabilization but that is only after a neuro consultant sees the patient and a few tests are done.


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## zmedic (Dec 1, 2009)

What you are saying is "out of all the patients at a trauma center that I saw who were brought in by EMS backboarded and collared who got x-rays, 3 had fractures." Fine. But there is nothing in that statement says anything about how common spinal injuries are when EMS is called to a scene. For each of those patients you saw you have no idea how many people were not transported or who were transported and not boarded or who were  taken off a board with no x ray.


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## sdadam (Dec 1, 2009)

Did you actually read any of my posts vent?

I never said anything about the prevalence of spinal injuries. I have seen MANY they happen all the time, once again you have replied to a conversation that I didn't know we were having.

I said:


sdadam said:


> Now in reality the odds of the PT having an unstable spinal injury which any amount of movement would exacerbate is one in a million.



Meaning, not every spinal injury is unstable.

Not every unstable spinal injury causes further damage with movement.

Those that do fall into this category are EXTREMELY rare. This is the proposed reason that spinal immobilization studies repeatedly fail to show the benefit of immobilization. Which JPINFV took the time to post some examples of so I won't repeat work.

I read the article you posted.

Danger at the Door
http://www.ems1.com/ems-products/consulting-management/articles/426350-Danger-at-the-Door/

It had nothing to do with the point that I have clarified above.

You also said:


VentMedic said:


> ...it appears from that statement you have not even read the reference section at the end of the JEMS articles, it would truly be a waste of time to point you toward any medical search engine or post a few thousand links. Again, you need to learn the many methods out there for immobilization.



What JEMS articles are you talking about and what references? Or do you simply mean that I have not read EVERY JEMS article ever, and all of the associated references?

You have only posted one article, from EMS one, which has only one reference;

http://www.state.me.us/dps/ems/documents/spinal_assessment_book.pdf

Which is the state of Mains description of spinal assessment protocol. Which interestingly enough states:



> The prehospital care of the potential spine injury patient remains a subject of continued debate. This debate has evolved around the larger theories of spine injury processes. Two major theories abound regarding spinal cord trauma. One theory suggests that initial trauma to the spine is solely responsible for cord injury with subsequent care and treatment representing minimal risk of further injury – providing that major axial or rotational loading is minimized. Proponents of this theory have argued prehospital immobilization of the spine as unnecessary due to the relative insignificance of post- injury movement forces compared to initial injury.



Now obviously this is the school of thought that I belong to. Which is in the document that YOU referenced. Now the same document continues to talk about your point of view:



> The second theory suggests that energy from the initial traumatic insult is significant and that subsequent movements of the spine can result in injury exacerbation with secondary cord injury. The proponents of this view have frequently promoted immobilization as essential to prehospital secondary injury prevention.



So, since the document you posted seems to think that my school of thought has some merit, would it be possible for you to treat me like a professional with a valued opinion? 

Rather than the paradigm we have been using of I'm for sure wrong and lack education and experience, which you can tell based off my opinion. And that you are absolutely right in everything you say even though you continually fail to provide documentation of anything you say, just because you're in-hospital experience as a respiratory care practitioner (according to your Avatar label (RRT)) has made you the ultimate expert in all matters.

You closed starting with:


VentMedic said:


> A spinal injury is not ONE in a million especially if you work in a busy ED.



Who said that it was? Refer to my first quote of what I originally said. It is clearly NOT this.

Just out of curiosity, did you even bother to read my posts? Or are you just sure that there couldn't possibly be anything in there you don't already know?


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## sdadam (Dec 1, 2009)

zmedic said:


> You're talking about two different samples. One is the "911 was called for someone with some transfer of energy" vs "people presenting to the ED who were given x-rays (ie they couldn't clear them without imaging." Those are two very different population.
> 
> Also I'd note that there is a big difference between "vertebral fracture" and "spinal cord injury"
> 
> Notice how people with spinal cord injury are treated in the hospital. They are in bed, maybe with a collar on, but certainly they don't live on a backboard. I think we're going to move towards people getting boarded and being removed from the backboard/uncsooped but with a collar until they can be cleared or imaged.



Great points! I agree.


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## sdadam (Dec 1, 2009)

JPINFV said:


> Correct me if I'm wrong Vent, but aren't most to all of the studies validating SSI criteria looking at what assessments correlate to spinal fractures and not whether prehosptial immbolization prevents secondary injury? In fact, are there any studies that show that spinal immobilization with a long back board prevents secondary spinal cord injuries?



Yes!

Thank you  for bringing that up as well. I think you understand the point I was trying to make.

Great post, with good references! This was helpful and educational to everyone following the conversation.

Adam


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