# Ground level fall and the Backboard



## Rhyse (Jul 3, 2012)

I few days ago i went on a call for a ground level fall, where a woman tripped in a parking lot and she fell to the ground.  She did not have any LOC, didnt hit her head, etc.. she only complained of arm pain (which we splinted), a twisted ankle which was immobilized, and after a few minutes laying supine on a very hot parking she said her she had a few back spasms...

My question is...should she be boarded and collared?  

This is a hot topic in my service right now and i'm curious what people think.

Thank you


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## Chimpie (Jul 3, 2012)

Rhyse said:


> My question is...should she be boarded and collared?



What do you think and why?


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## Rhyse (Jul 3, 2012)

In my option we did not need to board and collar the patient because the patient did not have and pain, swelling or tenderness in the head, neck or back.  The fall was also witnessed and witness said that the pt didnt hit her head.  There was also no significant mechanism of injury that would suggest the use of the board and collar either.


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## medichopeful (Jul 3, 2012)

Rhyse said:


> There was also no significant mechanism of injury that would suggest the use of the board and collar either.



This.


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## Handsome Robb (Jul 3, 2012)

medichopeful said:


> This.



Agreed. 

I wouldn't have boarded her. In all honesty it probably would have made the "spasms" worse. 

How old was she? 

People could argue that she had painful distracting injuries but that's a pretty subjective thing. Is she screaming and freaking out about her arm and ankle or more "my arm and ankle hurt" but still answering questions and engaging you during assessment? You can argue any injury is distracting but unless they are so wrapped up in that injury that they are making assessment difficult then I wouldn't call them distracting.


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## Rhyse (Jul 3, 2012)

She wasn't freaking out about the injuries, she was more calm and saying "hey, my arm really hurts" and the ankle was even less than that...So as for distracting injuries, i considered that on scene.  And Pt, who was in her late 40s, was even joking around with us after we got her on the stretcher.


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## Veneficus (Jul 3, 2012)

This lady did not need a board.

if laying on the hard flat ground put her back in spasms, laying on a hard flat board would too. 

Do no harm.


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## mycrofft (Jul 3, 2012)

Agreed, but don't expect to see "swelling" in a cervical or other spinal injury case. Not to say a protrusion from a herniation or "slipped" disk, or local spasm in a small part of the paraspinals, is not _palpable,_ but these would require maneuvering the pt to palpate, and might still be unhelpful  especially if you don't know the pt's baseline. Not a good ratio of benefit to risk if spinal trauma is suspected.


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## NYMedic828 (Jul 3, 2012)

It takes a lot of convincing to get me to put someone in a board and collar if there is no serious MOI.

Boarding and collaring often makes people worse, or people who are fine uncomfortable.

Useless treatment and it should be abolished from EMS.


Collar yes board no. 

When's the last time you went in an ER and saw someone on a backboard? Hospitals don't even own backboards I'm sure it must be a really viable and proven treatment.


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## Rhyse (Jul 3, 2012)

Why a collar but no board?


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## NYMedic828 (Jul 3, 2012)

Rhyse said:


> Why a collar but no board?



I'm not saying I do that because unfortunate I am a mindless robot forced to follow a set of steps but this is how hospitals do it.

Collars do in fact limit neck movement. Backboards are just dumb. There's a reason ONLY EMS uses backboards. 

Flat board curved spine, uncomfortable constraining device. Almost none of our patients ever have a spinal injury and when they do it's probably cervical and we make it worse.


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## Melclin (Jul 3, 2012)

No collar or board. 

I don't know why anyone would consider immobilisation in this patient. 

The distracting injury part only applies if you are clearing the pt. If you don't suspect a spinal injury in the first place then distracting injuries are irrelevant.

If someone cuts their hand off with a power saw you don't say, "Oh dear a distracting injury, better collar them". You don't suspect spinal involvement in the first place. 

It used to be common practice here to only use a collar and if you did use the board, to remove it once the pt was on the stretcher. My understanding was that boards were only ever really an extrication aid. Then they came along with a guideline change that stated if we did it at all it had to be the whole lot. I don't know why. They said something about a collar not immobilising the whole spine. I suspect it probably has something to with motion restriction during transport. Honestly the amount people wiggle about on long boards thanks to discomfort, we'd be better off without them. I hate long boards. I've hated them ever since I was immobilised during university for practice. I very quickly realised how incredibly uncomfortable, and indeed pain producing, they are and how completely useless they are at motion restriction.


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## STXmedic (Jul 3, 2012)

Melclin said:


> The distracting injury part only applies if you are clearing the pt. If you don't suspect a spinal injury in the first place then distracting injuries are irrelevant.


THANK YOU!! I've got in that argument more times than I can remember! "Oh, he got shot in the arm then fell on the ground; we should immobilize him because a gunshot wound is a distracting injury!" :glare:


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## Melclin (Jul 3, 2012)

PoeticInjustice said:


> THANK YOU!! I've got in that argument more times than I can remember! "Oh, he got shot in the arm then fell on the ground; we should immobilize him because a gunshot wound is a distracting injury!" :glare:



Standing height falls with no head strike in young healthy people. Honestly. Its like people's common sense goes out the window. Teaching spinal immobilisation, I give scenarios like this to FRs and FAs and they often jump straight to immobilisation. How many times has each one of them fallen over in their lives and gotten straight back up. Boggles the mind.


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## usalsfyre (Jul 3, 2012)

Melclin said:


> Standing height falls with no head strike in young healthy people. Honestly. Its like people's common sense goes out the window. Teaching spinal immobilisation, I give scenarios like this to FRs and FAs and they often jump straight to immobilisation. How many times has each one of them fallen over in their lives and gotten straight back up. Boggles the mind.



"But my instructor's cousin's brother-in-law's neighbor saw a guy that fell down and if he had moved his head this much...."


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## Veneficus (Jul 3, 2012)

usalsfyre said:


> "But my instructor's cousin's brother-in-law's neighbor saw a guy that fell down and if he had moved his head this much...."



4 years in one of the busiest surgical trauma centers in the US, I never saw a guy who would have been paralyzed if he moved this much. 

I saw a lot of people who came in with deficits and many who came in without.

I call urban legend.


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## usalsfyre (Jul 3, 2012)

Veneficus said:


> 4 years in one of the busiest surgical trauma centers in the US, I never saw a guy who would have been paralyzed if he moved this much.
> 
> I saw a lot of people who came in with deficits and many who came in without.
> 
> I call urban legend.



Agree completely, just illustrating the normal argument.


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## OSMedic (Jul 3, 2012)

My department uses an Assesment Based Spinal Immobilization protocol.  In which I can determine wheather or not my patient needs immobilized.

In this case I would not have backboarded this patient.  They did not meet the criteria that is in my protocol.


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## Doczilla (Jul 3, 2012)

Backboards are great for transferring from the stretcher to the ER bed  

Plus , Sam Jackson from unbreakable could have used one when he fell down those stairs! 

Plus..... Ketamine. 

Wait, what were we talking about?


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## mycrofft (Jul 3, 2012)

A spineboard is a splint (for transport or extrication). How many unpadded splints do we use?

Again and again and again, the national  Department of Transportation's Highway and Traffic Safety Administration (NHTSA) invented EMT's partially to get spineboards into use, around 1970. Provider organizations started boarding everyone to cover their butts and because field workers needed to be taught and directed for the lowest common denominator.


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## AnthonyM83 (Jul 4, 2012)

mycrofft said:


> A spineboard is a splint (for transport or extrication). How many unpadded splints do we use?
> 
> Again and again and again, the national  Department of Transportation's Highway and Traffic Safety Administration (NHTSA) invented EMT's partially to get spineboards into use, around 1970. Provider organizations started boarding everyone to cover their butts and because field workers needed to be taught and directed for the lowest common denominator.


 How do we know this?


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## Akulahawk (Jul 5, 2012)

Properly pad a spine board and they actually can do OK for restricting motion. The problem is, how many of us actually properly pad the spine board prior to, and during, applying it to the patient? I would wager that probably very FEW of us (including me) actually do. Use them for what they're designed for and as soon as you can, get the patient OFF the board. 

In this instance, a ground-level fall with a patient that recalls the entire event and states that she did NOT strike her head on the way down would NOT make me put her in any sort of spinal restrictions whatsoever unless during my evaluation I found evidence that such an action is needed.


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## MexDefender (Jul 5, 2012)

From the book's perspective you wouldn't have needed to do so because of the MOI but from what I was taught in class by my instructor, when in doubt take extra precautions.


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## the_negro_puppy (Jul 5, 2012)

No no no no no

the quicker American EMS moves away from cookbook medical care the better.

Do you not see how absurd it is to assume that anyone who trips  or falls over has a spinal injury?

If the patient was elderly, c/o  neck or back pain, with any neuro deficits then it would be another kettle of fish.

If a football player got tackled an broke his wrist would you collar and board him?


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## NYMedic828 (Jul 5, 2012)

the_negro_puppy said:


> If a football player got tackled an broke his wrist would you collar and board him?



Absolutely.

Broken wrist is a distracting injury, obviously this means he has shattered atleast 3 vertebrae.


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## usalsfyre (Jul 5, 2012)

MexDefender said:


> From the book's perspective you wouldn't have needed to do so because of the MOI but from what I was taught in class by my instructor, when in doubt take extra precautions.



The problem is its pretty dubious if a LSB provides any "precaution" at all.


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## MexDefender (Jul 5, 2012)

usalsfyre said:


> The problem is its pretty dubious if a LSB provides any "precaution" at all.



I'm new but is it really for us to decide if a preventive care is necessary or not? giving all the possible care we can is what I was taught but from my clinicals I see its not always the case.


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## STXmedic (Jul 5, 2012)

MexDefender said:


> I'm new but is it really for us to decide if a preventive care is necessary or not?


It absolutely is your job to decide if a potential treatment will be helpful or harmful to your patient! Do some quick research on the efficacy of spinal immobilization and harmful effects associated.


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## EpiEMS (Jul 5, 2012)

MexDefender said:


> I'm new but is it really for us to decide if a preventive care is necessary or not? giving all the possible care we can is what I was taught but from my clinicals I see its not always the case.



It is for us to decide. We have to be educated. Yes, it's up to the medical director, but there is no reason why you shouldn't be a thinking provider of emergency medical care.

Is boarding necessary? Often, no. In fact, in isolated penetrating trauma, back boarding is contraindicated (http://www.ncbi.nlm.nih.gov/pubmed/20065766)!

According to the well-studied Maine spinal clearance protocols (http://www.ncbi.nlm.nih.gov/pubmed/16832265), there seems to be no reason to immobilize. Based on the data, we can say with a high level of confidence the the patient is unlikely to have a spinal injury. 

Don't forget about NEXUS, either, folks! It seems pretty adaptable.


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## Tigger (Jul 5, 2012)

MexDefender said:


> From the book's perspective you wouldn't have needed to do so because of the MOI but from what I was taught in class by my instructor, when in doubt take extra precautions.



Which is fine, but what exactly would have you "in doubt" here?


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## epipusher (Jul 5, 2012)

Tigger said:


> Which is fine, but what exactly would have you "in doubt" here?



Due to not trusting our QI committee, I would full cspine all day long.


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## MexDefender (Jul 5, 2012)

Tigger said:


> Which is fine, but what exactly would have you "in doubt" here?



if you are doubting whether or not you should immobilize you should just immobilize. at least that is what our instructor was saying. 

What I meant on for us to decide is that I have seen some paramedics not do something even though they should have according to the protocols. The protocols for spinal immobilization and other treatments were put their for a reason and yeah questioning them is to be expected but shouldn't you take that put with your superiors if you do have a problem with it?



epipusher said:


> Due to not trusting our QI committee, I would full cspine all day long.



This as well.


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## Veneficus (Jul 6, 2012)

the_negro_puppy said:


> No no no no no
> 
> the quicker American EMS moves away from cookbook medical care the better.
> 
> ...



America is moving towards cookbook medicine even for its physicians. WHich is probably why it is rated so low on the WHO list of quality medical care.

"We didn't do :censored::censored::censored::censored: for the patient, but at least we didn't get sued" is American medicine.


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## NYMedic828 (Jul 6, 2012)

MexDefender said:


> if you are doubting whether or not you should immobilize you should just immobilize. at least that is what our instructor was saying.
> 
> What I meant on for us to decide is that I have seen some paramedics not do something even though they should have according to the protocols. The protocols for spinal immobilization and other treatments were put their for a reason and yeah questioning them is to be expected but shouldn't you take that put with your superiors if you do have a problem with it?



A big problem with American EMS is the instructors. Many times we are looking at the blind leading the blinder.

If there is a question as to whether you should immobilize, than odds are you aren't at the level of experience, both classroom and clinical, that you need to be to be a truly competent provider. More often than not, especially in this case presented in this thread, the need for immobilization should be obvious. 

Did you ask those medics why they did something the way they did it? Yes people often do things out of laziness but other times they do it because it was warranted. Our protocols have a line in them that says "these protocols are not to be used in place of good clinical judgement."

Protocols are a guideline to what I CAN do, not what I have to do. I can't exceed their limitations without further approval but that doesn't mean I always need to work to the edge of their limits either.

If it ain't broke, don't try to fix it. Sometimes the best thing we can do for a patient is absolutely nothing. Just because an ambulance was called does not mean we need to find an emergency. If the patient just wants a ride to be checked out at the hospital, so be it atleast let them be comfortable and not unnecessarily straight jacketed to a plastic surf board.


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## Tigger (Jul 6, 2012)

MexDefender said:


> if you are doubting whether or not you should immobilize you should just immobilize. at least that is what our instructor was saying.
> 
> What I meant on for us to decide is that I have seen some paramedics not do something even though they should have according to the protocols. The protocols for spinal immobilization and other treatments were put their for a reason and yeah questioning them is to be expected but shouldn't you take that put with your superiors if you do have a problem with it?
> 
> ...



Protocols are meant to be applied in a clinically appropriate way. There are few "musts" in most protocols, it's all about using them with discretion. If after assessing a patient I find myself wondering if I should spinal, based on some murky results of the assessment, I probably will. But I'm not going to use an intervention just because the book says to consider it.


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## MexDefender (Jul 6, 2012)

NYMedic828 said:


> A big problem with American EMS is the instructors. Many times we are looking at the blind leading the blinder.
> 
> If there is a question as to whether you should immobilize, than odds are you aren't at the level of experience, both classroom and clinical, that you need to be to be a truly competent provider. More often than not, especially in this case presented in this thread, the need for immobilization should be obvious.
> 
> ...




I understand now, so there seems to be a big gap between newbies and experienced EMTs. My question now is do experienced EMTs help new EMTs from separating the book from real life events?


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## NYMedic828 (Jul 6, 2012)

MexDefender said:


> I understand now, so there seems to be a big gap between newbies and experienced EMTs. My question now is do experienced EMTs help new EMTs from separating the book from real life events?



The gap is not, or atleast should not, be so much based on experience as it should be on baseline education. The minimum standards to be an EMT or medic are substantially lower than they should be. It's a topic that comes up every day or so.


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## epipusher (Jul 6, 2012)

Or it should be: WWCQID?


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## EpiEMS (Jul 6, 2012)

MexDefender said:


> I understand now, so there seems to be a big gap between newbies and experienced EMTs. My question now is do experienced EMTs help new EMTs from separating the book from real life events?



I've never had a more experienced provider (EMT, AEMT, Medic, PA, or MD) not provide me help when I needed it. People are usually pretty good about answering questions.


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## jemt (Jul 6, 2012)

I work in a system with online medical control from a major regional trauma center, and our protocols state any kindof trauma gets full immolization.

This includes any blunt force trauma (punch to the face) fall from a standing position without hitting head.


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## STXmedic (Jul 6, 2012)

And one of my medical directors is one of the top trauma surgeons for the military who is speaking at this years world trauma symposium. He thinks spinal immobilization is highly overutilized. If your trauma center is telling you to immobilize everybody, then they likely lack confidence in your ability to distinguish who is at risk and who is not.


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## jemt (Jul 6, 2012)

I agree, it's way overused


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## med51fl (Jul 6, 2012)

I agree that the reason that a majority of immobilization takes place is the "CYA - possible lawsuit" protocol.  Departments and companies would rather backboard everybody to prevent that exceptionally small precentage of the "what if" cases from becoming lawsuits.  

I think another reason we backboard everybody is the lack of past evidence based medicine in EMS.  We have done so many things because it sounds logical, but is not proven.  I hope that as we look at the real data that studies our treatments, we as a profession will advance and change those treatments to better serve our patients.


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## Akulahawk (Jul 6, 2012)

the_negro_puppy said:


> No no no no no
> 
> the quicker American EMS moves away from cookbook medical care the better.
> 
> ...


Me personally? Not a chance... because if I'm out working at a game, you can bet I'm watching the players and not enjoying it... and most likely saw the injury occur. I've seen that happen. No, he didn't get put on the board. That day, the spine board _did_ get used... to carry equipment on and off the field...


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## Bullets (Jul 13, 2012)

I've used the LSB less and less since I became self educated on the effects of such. Now if I HAVE to apply SMR, I prefer the orthopedic scoop.  Not only is it more comfortable, it also throws the hospital staff for a loop, and I enjoy getting yelled at by nurses, only to have Docs compliment me for its use (then throw the nurse a sassy smile)

No pain or defecits, no board

The only thing i HAVE to do is use AED in cardiac arrest, the protocols are actually pretty current with ITLS/PHTLS science, NEXUS and the like


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