# Backboarding question.



## emtfarva (Feb 3, 2009)

Lets say you were called on a response to a doctors' office for a Pt that fell earilier in the day. This Pt was prone to falls and syncope. The Pt was amb and went to his Dr's office for a checkup. (This was a scheduled appt.) The Dr called to have Pt evalutated at local ER for R/O head bleed due to coumadin tx. The doc reported that the Pt had no neuro defects. Pt, non-english speaking, is c/o neck pain. Would you collar and board this Pt?


Fyi: the Pt didn't get boarded and had a c2 fx from the fall eariler. When transported latter to a trauma center Pt still had no neruo defects.

And don't tell me that I should have boarded the Pt. I want to know in that case would you have boarded the Pt without knowing about the fx.


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## MSDeltaFlt (Feb 4, 2009)

How did the pt fall? Was there any ALOC?  How high was the fall?  Falling from a standing position and driving to the clinic for a scheduled appt and c/o neck pain will get a collar as long as there was no LOC.

Also, what exactly was broken on the neck?  Was it a vetebral body or a spinus process?  Was the spinal canal compromised?

I only ask because of my neck Fx.  I had a Hangman's Fx (C2 and Odontoid) involving the C2 vetebral body.  I also had a C7 lateral mass Fx.  The lateral Fx didn't necessarily need a Collr, but the vetebral body fx did.


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## sir.shocksalot (Feb 4, 2009)

The great backboard debate. In my opinion anyone c/o neck pain post fall gets backboarded regardless of how long ago it was. Is it probably nothing? yes it is probably absolutely nothing, but on the off chance it is something my buttocks is protected. On the other hand just because someone fell doesn't mean they need to be boarded, if they have no complaints, no LOC post fall, and physical exam finds nothing, then they don't necessarily buy a backboard. Ultimately its up to you and what treatment you feel comfortable with.


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## emtfarva (Feb 4, 2009)

MSDeltaFlt said:


> How did the pt fall? Was there any ALOC?  How high was the fall?  Falling from a standing position and driving to the clinic for a scheduled appt and c/o neck pain will get a collar as long as there was no LOC.
> 
> Also, what exactly was broken on the neck?  Was it a vetebral body or a spinus process?  Was the spinal canal compromised?
> 
> I only ask because of my neck Fx.  I had a Hangman's Fx (C2 and Odontoid) involving the C2 vetebral body.  I also had a C7 lateral mass Fx.  The lateral Fx didn't necessarily need a Collr, but the vetebral body fx did.



The Pt fell prob due to Syncope. I want to say the Pt has chronic A-fib. And I am not sure about what type of Fx he had. We didn't transport him to Boston. Yes he had +LOC. With That Info would you still board him. oh, it was a standing fall and he hit his head on something. ( that is how he broke his neck. he also doesn't remember how he fell.)


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## EMTCop86 (Feb 4, 2009)

If I got there and the patient had neck pain from a fall, no matter how long ago it was, I would more then likely collar and backboard. I rather over treat then under treat. As sirshockalot already stated, if it ends up being nothing then oh well, but at least I saved my butt in case it was something.


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## downunderwunda (Feb 4, 2009)

Firstly Backboards, AKA spineboards are an extrication device, not a transport tool.



> Lets say you were called on a response to a doctors' office for a Pt that fell earilier in the day. This Pt was prone to falls and syncope. The Pt was amb and went to his Dr's office for a checkup. (This was a scheduled appt.) The Dr called to have Pt evalutated at local ER for R/O head bleed due to coumadin tx. The doc reported that the Pt had no neuro defects. Pt, non-english speaking, is c/o neck pain. Would you collar and board this Pt?



is this not enough to say lets be carful? even with no neuro defecits. The fact that the pt is 





> non-english speaking


 with indications to cervical pain is enough to indicate a callar for precaution. 

emtfarva, let me ask you a question that is along similar lines. You are called to a motor vehicle accident. On arrival you see it was a High Speed single vehicle rollover. The patient is & has been walking around the scene. Questioning of bystanders indicate the accident occured 30-40 mins prior to your arrival. Would you collar this patient?


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## reaper (Feb 4, 2009)

downunderwunda said:


> Firstly Backboards, AKA spineboards are an extrication device, not a transport tool.
> 
> 
> 
> ]



How do you figure this? A KED is an extrication device. A LSB is for transport.


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## boingo (Feb 4, 2009)

You responded to a facility with a doctor on staff.  Did the doctor clear his c-spine?  Did you ask the sending physician what if any precautions the patient warranted?  This patient was already in the care of a licensed physician, If the doctor was comfortable transporting this patient without a board, then that is the doctors decision.  The patient clearly ambulated to his appointment and has no deficits.


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## Bosco578 (Feb 4, 2009)

boingo said:


> You responded to a facility with a doctor on staff. Did the doctor clear his c-spine? Did you ask the sending physician what if any precautions the patient warranted? This patient was already in the care of a licensed physician, If the doctor was comfortable transporting this patient without a board, then that is the doctors decision. The patient clearly ambulated to his appointment and has no deficits.


 
Ooooh, I'd be a little leary,some of the Med center Doc's I've delt with were pretty weak with trauma assessment. Infact some of them border on stupidity.:glare: Pluse with language barrier ( some times pt. AND Doc both ), he or she may have not been able to get a good hx.:sad:


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## JPINFV (Feb 4, 2009)

As much as I question the entire notion of c-spining everyone just because they suffered a a trauma (do we splint arms for no other reason than a patient fell on it? Do you call EMS every time you fall?), I have no choice but to agree with c-spineing patients with midline back/neck pain/tenderness and neurodeficits.

As far as the high speed roll over, 30-40 minutes post accident with the patient self-extricating and ambulating since the accident? As much as I'd like to say that it would depend on my assessment, I'd rather be a cook book practitioner than sit around debating the merits of spinal immobilization with people who can't see past their 110 hour advanced first aid course while throwing out platitudes about how "it doesn't hurt, why not do it?."


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## rescuepoppy (Feb 4, 2009)

MSDeltaFlt said:


> How did the pt fall? Was there any ALOC?  How high was the fall?  Falling from a standing position and driving to the clinic for a scheduled appt and c/o neck pain will get a collar as long as there was no LOC.
> 
> Also, what exactly was broken on the neck?  Was it a vetebral body or a spinus process?  Was the spinal canal compromised?
> 
> I only ask because of my neck Fx.  I had a Hangman's Fx (C2 and Odontoid) involving the C2 vetebral body.  I also had a C7 lateral mass Fx.  The lateral Fx didn't necessarily need a Collr, but the vetebral body fx did.



  I would have collared this patient if for nothing else just as a reminder for them to keep their head still. I know this is atypical but when I broke my neck C3 and C4 with C4 being completly shattered I had no pain or point tenderness or neurological defecits just the feeling that something was not right. The medics on the call wanted to clear me due to the fact that I met their criteria to clear in the field. Even the e.R. doctor was willing to clear me until after the X-Rays and C.T. Scan. After those he would not let me off the collar and board until a more stable collar was in place. Remember just because the typical symptoms are not there doesn't mean nothing is going on.


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## JPINFV (Feb 4, 2009)

Here's the page on EBM maintained by Halhousie University Department of Emergency Medicine regarding spinal immbolization. http://emergency.medicine.dal.ca/EHSProtocols/Protocols/LOE.cfm?ProtID=6295.01#378

They are currently rating the evidence underlining spinal immbolization as "There is poor evidence to support procedure or treatment."


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## rescuepoppy (Feb 4, 2009)

I can see the point that the studies are showing given the fact that the majority of injury is done during the accident. It is even probable that a patients neck muscles are strong enough to provide enough stability to prevent further injury during transport. However in my case I had more of a peace of mind just knowing that precautions were in place.


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## Wyoming Medic (Feb 4, 2009)

Someone here said it perfectly "midline neck pain".  That right there IMO makes the board justified.  In Wyoming, I as a medic can "clear" a patients C-spine on scene per our medical protocols.  That being said, I rarely do that for fear of litigation (i dont have x-ray vision).  I do clear if I have a very good feeling that it is NOT a spinal injury but remember, Walks like a duck,quacks like a duck, swims like a duck, IT IS PROBABLY A DUCK.

It is always safer to board than not to, HOWEVER (there is always a however with me ) the caveat is that placing a person on a board for longer than 1 hour can start to cause other problems.

In our system, several years ago I fell and broke up my t-12/l-1 area.  I was backboarded on scene and taken to the hospital.  I stayed backboarded for over 9 hours.  It cause some rather severe skin break down and some masking of symptoms that led to me having other complaints associated with muscle spasm.

This ended up being a waste of time and money for me.  

In the particular question, If the patient has midline point tenderness ANYWHERE along the spine, BACKBOARD.  And as was already pointed out, the c-2 area CAN be rather well supported by neck muscles.  Was this person an office jockey or a laborer?  Laborer may have pretty developed neck muscles.

Time since fall does not matter.  95% of the time nothing will be wrong.  But that other 5%, it pays to be careful.

Wy Medic


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## Sasha (Feb 4, 2009)

boingo said:


> You responded to a facility with a doctor on staff.  Did the doctor clear his c-spine?  Did you ask the sending physician what if any precautions the patient warranted?  This patient was already in the care of a licensed physician, If the doctor was comfortable transporting this patient without a board, then that is the doctors decision.  The patient clearly ambulated to his appointment and has no deficits.



Well what kind of doctor was it? Was it an optometrist or podiatrist clearing C-Spine? They all went through medical school, but they don't necessairly see enough spinal injuries to be up to snuff with their assesments.

He could have had no neural deficts now, but moving with a fractured C2... Couldn't fragments shift around and potentially damage the cord or  intervertebral fibrocartilage or something? After all he did have NECK pain.

The doctor turned over care to the responding EMTs. Therefore they're responsible for the care. Personally, I would have backboarded due to the c/o neck pain.


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## MSDeltaFlt (Feb 4, 2009)

emtfarva said:


> The Pt fell prob due to Syncope. I want to say the Pt has chronic A-fib. And I am not sure about what type of Fx he had. We didn't transport him to Boston. *Yes he had +LOC*. With That Info would you still board him. *oh, it was a standing fall and he hit his head on something. ( that is how he broke his neck. he also doesn't remember how he fell*.)



Yes, full C-Spine precautions (or restrictions) would be performed on this guy if he were my pt.  Notice I didn't say "immobilization".  That comes with halo placement.  But, yes.  I would go the whole 9 yards on him.


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## BossyCow (Feb 4, 2009)

Wyoming Medic said:


> Someone here said it perfectly "midline neck pain".  That right there IMO makes the board justified.
> In the particular question, If the patient has midline point tenderness ANYWHERE along the spine, BACKBOARD.  And as was already pointed out, the c-2 area CAN be rather well supported by neck muscles.  Was this person an office jockey or a laborer?  Laborer may have pretty developed neck muscles.
> 
> Time since fall does not matter.  95% of the time nothing will be wrong.  But that other 5%, it pays to be careful.
> ...



Don't forget that if the pt is the better or worse for recreational chemcials or alcohol ingestion, their perception of pain can be skewed. Feeling no pain may have nothing to do with the seriousness of the injuries in those cases.


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## Airwaygoddess (Feb 4, 2009)

*C-spine precautions*

I will be the first to backboard a patient with the complaint of neck and or back pain, and MOI.  I do think part of the problem is how long patients are on these boards when they arrive to the ED, for the most part most folks that have worked in an ED have never worked in the field or have been a patient themselves.


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## Wyoming Medic (Feb 4, 2009)

BossyCow said:


> Don't forget that if the pt is the better or worse for recreational chemcials or alcohol ingestion, their perception of pain can be skewed. Feeling no pain may have nothing to do with the seriousness of the injuries in those cases.




Very good point.  

Wy medic


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## frogtat2 (Feb 4, 2009)

*To board or not to board*

I would much rather err on the side of caution and have it be unneccesary.  In this situation, I would go ahead and collar and board the patient.  There is a hx of fall, and c/o neck pain.  That is enough for me.


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## downunderwunda (Feb 4, 2009)

reaper said:


> How do you figure this? A KED is an extrication device. A LSB is for transport.



Ambulance stretchers, well ours at least, are designed for minimal movment to allow the pt to be removed from the spine board. Have you ever been strapped to a LSB & driven around? I would suggedt that you do before you respond further.

The LSB was originally designed to assist with extrication, to provide further immobilisation of the spine, however, i would suggest that you have a real good look at a  person lying on a LSB, then look at all of the naturla hollows. If we are trating this patient as suspected with spinal injuries, should we not be trying to make them more comfortable & dont try to lie & tell me you fill in those hollows for patient comfort.


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## Sasha (Feb 4, 2009)

> Ambulance stretchers, *well ours at least*, are designed for minimal movment to allow the pt to be removed from the spine board.



I have yet to see a stretcher, here, that allows you to remove the patient from the backboard and still maintain spinal percaution/restriction. So very sorry they're uncomfortable, but I'd take a little bit of uncomfortablness over a lifetime of paralysis any day.


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## Veneficus (Feb 4, 2009)

downunderwunda said:


> The LSB was originally designed to assist with extrication, to provide further immobilisation of the spine, however, i would suggest that you have a real good look at a  person lying on a LSB, then look at all of the naturla hollows. If we are trating this patient as suspected with spinal injuries, should we not be trying to make them more comfortable & dont try to lie & tell me you fill in those hollows for patient comfort.



Welcome to the good fight my friend, I have been trying to bring the uselessness of spineboards to light for years. But despite the the mounting evidence they are useless for their prescribed task and can actually cause harm, providers in the US have been programmed to believe they alone solve the spinal immobilization issue. Never mind the anatomy or physiology of paralysis. It's all about the board. 

What makes it even better is if you did what was best for your Pt. and not put him on the board, you would surely lose the lawsuit filed against you, because the unyielding standard of care in the US is the LSB. So come hell or high water, we will bend the curves of the back, inhibit breathing, comprimise airways, cause cutaneous lesions, and make the patient as uncomfortable as possible so they squirm around to boot.

The US is quite ethnocentric, go over to studentdoctor.net and listen to them babble on for hours how any physician not trained at a US school is second rate. Look at how many CISD teams exist, despite the fact the British proved that is harmful. If you figure out a way to get people to stop mindlessly performing skills they have embraced like the true faith religion please let me know.


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## rmellish (Feb 4, 2009)

downunderwunda said:


> Ambulance stretchers, well ours at least, are designed for minimal movment to allow the pt to be removed from the spine board. Have you ever been strapped to a LSB & driven around? I would suggedt that you do before you respond further.
> 
> The LSB was originally designed to assist with extrication, to provide further immobilisation of the spine, however, i would suggest that you have a real good look at a  person lying on a LSB, then look at all of the naturla hollows. If we are trating this patient as suspected with spinal injuries, should we not be trying to make them more comfortable & dont try to lie & tell me you fill in those hollows for patient comfort.



Plus the precursors to decubitus ulcers form in as few as 10mins in healthy, younger patients placed on the LSB. Imagine the elderly.


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## rmellish (Feb 4, 2009)

Sasha said:


> I have yet to see a stretcher, here, that allows you to remove the patient from the backboard and still maintain spinal percaution/restriction. So very sorry they're uncomfortable, but I'd take a little bit of uncomfortablness over a lifetime of paralysis any day.



How often is a LSB responsible for actually preventing paralysis? I would assume the number is rather low.


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## JPINFV (Feb 4, 2009)

Less than 2% according to one study.
Out-of-hospital spinal immobilization: its effect on neurologic injury.
http://www.ncbi.nlm.nih.gov/pubmed/9523928


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## JPINFV (Feb 4, 2009)

Veneficus said:


> Welcome to the good fight my friend, I have been trying to bring the uselessness of spineboards to light for years. But despite the the mounting evidence they are useless for their prescribed task and can actually cause harm, providers in the US have been programmed to believe they alone solve the spinal immobilization issue. Never mind the anatomy or physiology of paralysis. It's all about the board.




As I said earlier in regards to the high speed accident scenario (assuming no complaints from the patients in terms of pain, neurodeficits, etc). The logical side of my head would say probably not while the part of my brain that doesn't want to listen to my coworkers clamor on about how it doesn't hurt anyone, the patients aren't on it that long, how we don't have x-ray vision (but apparently the physician does when he medically clears the patient instead of radiologically clearing the patient), and liability concerns (because it's better to induce an injury in fear of a phantom than just ignoring the phantom). 

Just remember, EBM in EMS stands for emotionally based medicine, not evidence based medicine.


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## fortsmithman (Feb 4, 2009)

Sasha said:


> Was it an optometrist or podiatrist clearing C-Spine? They all went through medical school, but they don't necessairly see enough spinal injuries to be up to snuff with their assesments.


I thought it was Opthamologist's who were MD's and Optometrist's are non MD's.


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## Sasha (Feb 4, 2009)

fortsmithman said:


> I thought it was Opthamologist's who were MD's and Optometrist's are non MD's.



Tomatoe tomatoe. You know what I meant.

Edit:You know... that really looses it's meaning when posted instead of spoken.


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## Veneficus (Feb 4, 2009)

JPINFV said:


> As I said earlier in regards to the high speed accident scenario (assuming no complaints from the patients in terms of pain, neurodeficits, etc). The logical side of my head would say probably not while the part of my brain that doesn't want to listen to my coworkers clamor on about how it doesn't hurt anyone, the patients aren't on it that long, how we don't have x-ray vision (but apparently the physician does when he medically clears the patient instead of radiologically clearing the patient), and liability concerns (because it's better to induce an injury in fear of a phantom than just ignoring the phantom).
> 
> Just remember, EBM in EMS stands for emotionally based medicine, not evidence based medicine.



HVLA is not injurious.  sorry, couldn't resist. 

EMS providers are focused more on subluxation rather than all the mechanisms of paralysis. I cannot recal a subluxation that didn't present with deficit. (and I have seen quite a few) The amount of musculature holding the spine in place is considerable. A lot of it has evolved specifically to. Can anyone realistically say putting somebody on a board stopped a potential paralysis? How about cause paralysis when it limits the potential space for swelling shutting off circulation to the cord? (inquiring minds want to know)

BTW, that is my favorite spineboard study.
I am still waiting for my xray vision, I haven't gotten it yet. But I have had a healthy dose of anatomy that reminds me how pathetic LSBs are.


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## reaper (Feb 4, 2009)

downunderwunda said:


> Ambulance stretchers, well ours at least, are designed for minimal movment to allow the pt to be removed from the spine board. Have you ever been strapped to a LSB & driven around? I would suggedt that you do before you respond further.
> 
> *How do you move your pt once at the hospital? Yes. I have been on plenty of LSB! So I do know how it feels.*
> 
> ...



*Yes, I do pad my pt's on the LSB. I have been on to many and know what is needed to make them more comfortable.*



The LSB was designed to imobilize, not extrication. Does it do a perfect job, NO. Do we need them as often as they get used, NO. Until the MD's step up and put an end to imobilizing every mvc or fall, we have no choice. So you must do the best with what you have.

We can argue the use of them all day long on here. It makes no difference. The MD's are the ones that make that decision and I don't see them changing it as a standard, any time soon. They are all worried about the liability issues involved.


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## 911cwgrl (Feb 4, 2009)

Even in our area, a call like that would have me backboarding and collaring.  We even have to go into the state penn infirmary ready to do all that even though there's a doc there.  But our hospital is small enough that the clinic is right there and the docs are our trauma docs.  Both of them would have the pt "packaged".  I know it seems sometimes like a hassel, but there is always that off chance,,,


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## JPINFV (Feb 4, 2009)

911cwgrl said:


> but there is always that off chance,,,



Hate to jump on you since you're new, but phrases like this gets thrown around all too often in EMS. The off chance of what, the patient may be a zebra and have an injury? Again, do we splint limbs just because a patient fell on that limb even if there is no sign ir symptom of injury? Do we wear N95 masks on all patients on the off chance that they have TB? At what point do we make the decision that no signs/symptoms just means that there's nothing wrong?


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## emtfarva (Feb 4, 2009)

*Thanks for the Help*

You guys told me what I already knew, We should have took c-spine precautions. My partner and Discussed this in length and have decied that anyone within a 24 hour period will get c-spine precautions s/p a fall. Maybe longer if they are c/o pn. As far as the MVC with Pt amb at scene, I may want to lbb the Pt, but that is the Pt decision, not mine. Refusal is what this person will sign if they don't want a board.
 Thanks with the help.


Farva


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## Sasha (Feb 4, 2009)

Hate to result down to the "It's in the protocol" answer, but be honest. It doesn't matter how much you despise backboarding every trip and fall, but if it's in your protocol to backboard patients with MOIs that have the potential to cause neck/back injury even without a complaint of neck or back pain, are you going to go against it? Are you ready to accept all responsibility and libaility that comes with violating your protocol?

If your protocol allows you to clear C-Spine, however, by all means, clear it 'til your heart's content.


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## JPINFV (Feb 4, 2009)

As amazing as it might sound, Orange County, CA did not (and, for the most part, currently do not) have written protocols for EMT-Bs and there is no automatic criteria for C-Spine restriction in Mass (there is a list following this clause though "When evaluating for possible spinal injury and the need for immobilization, consider the following factors as high-risk:"). As much as I find a lot of what Massachusetts does bass aackwards, their protocols have a significant amount of wiggle room if you (generic "you") are willing and able to justify your actions. 

Let's be honest, though, you can't enact the Nuremberg defense ("I'm just following orders") in terms of treatment. Providers accept responsibility for their treatments regardless of if they are following protocol (strict reading or liberal reading) or blatantly ignoring protocols. Every treatment and omission should be able to be justified by the provider, regardless of what the protocol says.


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## Sasha (Feb 4, 2009)

JPINFV said:


> As amazing as it might sound, Orange County, CA did not (and, for the most part, currently do not) have written protocols for EMT-Bs and there is no automatic criteria for C-Spine restriction in Mass (there is a list following this clause though "When evaluating for possible spinal injury and the need for immobilization, consider the following factors as high-risk:"). As much as I find a lot of what Massachusetts does bass aackwards, their protocols have a significant amount of wiggle room if you (generic "you") are willing and able to justify your actions.
> 
> Let's be honest, though, you can't enact the Nuremberg defense ("I'm just following orders") in terms of treatment. Providers accept responsibility for their treatments regardless of if they are following protocol (strict reading or liberal reading) or blatantly ignoring protocols. Every treatment and omission should be able to be justified by the provider, regardless of what the protocol says.




It is easier to justify your actions if you have protocols to support. I'm not saying to blindly follow them with no question. Of course. If you have a patient who forever reason cannot be backboarded, refuses, can't breathe lying down, etc. don't go strapping them to a backboard, but don't use "Well.. They weren't complaining of pain!" as an excuse to blatantly ignore your protocol every time. You might get away scratch free for a long time, but if and once you have a patient who may not have been complaining of pain but backboarding could have made the difference for, you don't have a leg to stand on.


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## JPINFV (Feb 4, 2009)

...now we're back to the old debate, though, of what constitutes an injury that justifies c-spine restriction and how recent that event needs to be absent of any clinical signs indicating a potential c-spine injury.


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## 911cwgrl (Feb 4, 2009)

It's ok to jump on me,,, just don't sqwish me.    We do have protocals in place for a reason here.  The doc used to be a paramedic in colorado and had found where many a times the pt shoulda been under c-spine precautions.  To this day she still will say "there's that off chance where something might have happened".  I do what I'm told by her for a reason.  BUT, I don't see the protocals as a ceiling of care that I give my pt, I see it as a base to build on.  We may not be in a vastly populated area, but we take what we do to heart.  We work with QRU's and they are the same way.  We all have our own opinions, listening to each other should help us all.  :blush:


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## Sasha (Feb 4, 2009)

JPINFV said:


> ...now we're back to the old debate, though, of what constitutes an injury that justifies c-spine restriction and how recent that event needs to be absent of any clinical signs indicating a potential c-spine injury.



It's a vicious circle :]


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## Veneficus (Feb 5, 2009)

Hey guys,

Let’s keep this in perspective:

There is evidence backbarding is harmful or has no appreciable effect.
There is no evidence that it prevents any further injury.

So aside from anecdotes and dogma there is not any rationale to do it at all. Now just because a doc says to do it doesn’t make it suddenly a good idea. There are lots of docs that hold onto dogma that has been beaten into their brain too.

I am not saying suddenly stop this practice against protocol, but what I am saying is that maybe it is time that a fresh look has to be taken at the protocols for the benefit of the patient. I have not met anyone on this forum that can’t have an intelligent discussion with their medical director. Questioning a practice is the first step to get it changed. Plus you could always call med control.

I read something here about boarding people who fell less than 24 hours after the incident. Why 24? Why not 36? Did the insult heal?

Spinal injury is not just about fx bones. Please think and use clinical judgment based on your findings(educate yourself higher than what is expected by the DOT *MINIMUM*), not what if the sky was green when a jet crashed into the ground injuring the person it struck but all aboard were safe on Monday Feb 29th, during an earthquake right after a flood when gravity was temporarily reversed. These “what if” statements really are that preposterous and show a general lack of understanding which holds the EMS profession to a lesser wage than the manager at McDs.


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## karaya (Feb 5, 2009)

Veneficus said:


> There is evidence backbarding is harmful or has no appreciable effect.
> There is no evidence that it prevents any further injury.


 
As a med student, you should know that citing your statements should be paramount. Your sweeping assertion that talking to a provider's medical director to apparently get protocols changed in an effort to abandon spinal immobilization I find a little premature. Especially since more thorough clear scientific studies are still absent.

I suspect that you may be citing the study and article, _"The Evidence for Spinal Immobilization: An Estimate of the Magnitude of the Treatment Benefit"_?

From what I understand from the article, and please bear in mind I have not seen the entire article, the effects of spinal immobilization (with what little studies that have been completed so far) conclude that there are in fact no published or unpublished _scientific _studies that supports the practice of spinal immobilization in the pre-hospital setting.

This is not a declaration that spinal immobilization should cease, but in fact an endorsement that scientific studies should be launched to better understand to what degree ( if any) spinal immobilization should be practiced.

Responses seem to indicate that such studies will at least yield a better understanding as to what point a patient is cleared in the field from immobilization.


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## JPINFV (Feb 5, 2009)

Here's another review article.

Hauswald, M., Braude, D. Spinal immobilization in trauma patients: is it really necessary? Current Opinion in Critical Care 2002, 8:566–570



> *Conclusions*
> Like much of medicine, spinal immobilization is a concept that became the standard of care based on common sense rather than research. There are convincing biomechanical arguments and some preliminary research that suggest that spinal immobilization may not be necessary, even in many trauma patients with unstable injuries. Until further research clarifies which injuries, if any, truly benefit from immobilization, immobilization will remain the standard practice. *The clinician’s goal should be to apply it only to those patients predicted to be at risk for unstable injury and to do as little harm from immobilization as possible.*



There's really two ways to look at it. If the concept of spinal immobilization was being looked at to add to treatment plans today, would it be accepted? Alternatively, there is the current situation where we're now looking at evidence for a current intervention and finding it unsupported. How much lack of support will be needed to stop doing it?


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## karaya (Feb 5, 2009)

JPINFV said:


> There's really two ways to look at it. If the concept of spinal immobilization was being looked at to add to treatment plans today, would it be accepted? Alternatively, there is the current situation where we're now looking at evidence for a current intervention and finding it unsupported. How much lack of support will be needed to stop doing it?


 
Good points. Let's take this whole subject to a really simple view: EMS providers are taught to splint something that may be broken. That's it. Back might be broken? Splint it. Neck might be broken? Splint it.

That simple part of our training has been the educational standard since Moby **** was a minnow. Now there is new evidence to suggest that this concept needs further investigation. I haven't seen anything just yet that would indicate that any medical director would comfortably alter this very simple standard in the absence of better scientific studies; even though there are no studies to support its practice. Furthermore, I cannot find where any such studies are being conducted or in the works.

Lot's of chatter, but little scientific results.


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## Veneficus (Feb 5, 2009)

karaya said:


> As a med student, you should know that citing your statements should be paramount. Your sweeping assertion that talking to a provider's medical director to apparently get protocols changed in an effort to abandon spinal immobilization I find a little premature. Especially since more thorough clear scientific studies are still absent.


 
Yes I unerstand the citing the studies, but you must forgive me, I read about 4-5 (15 minutes to 1/2hour) of medical briefs a day, I see several studies, and I really don't have the ambition to look them up everytime I make a post here, particularly when I seem to be saying the same thing to new people every few months. I guess the people here will have to do some of their own research.

At last count I have seen 7 published studies citing ill effects of spine boards. The last was done by a physical therapy department. Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not? With the 10s of thousands of patients backboarded every year in the US, some evidence must be available. Of course then we should also look at our brethren in other countries who have ditched this practice. The more you look at the anatomy of physics of the matter, the more rediculous the intervention seems unless basic science is no longer a part of medicine, substituted for technology and the ignorant idea that all medicine in the US is somehow superior to everyplace else.


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## karaya (Feb 5, 2009)

Veneficus said:


> Yes I unerstand the citing the studies, but you must forgive me, I read about 4-5 (15 minutes to 1/2hour) of medical briefs a day, I see several studies, and I really don't have the ambition to look them up everytime I make a post here, particularly when I seem to be saying the same thing to new people every few months. I guess the people here will have to do some of their own research.
> 
> At last count I have seen 7 published studies citing ill effects of spine boards. The last was done by a physical therapy department. Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not? With the 10s of thousands of patients backboarded every year in the US, some evidence must be available. Of course then we should also look at our brethren in other countries who have ditched this practice. The more you look at the anatomy of physics of the matter, the more rediculous the intervention seems unless basic science is no longer a part of medicine, substituted for technology and the ignorant idea that all medicine in the US is somehow superior to everyplace else.


 
You are forgiven Veneficus!! My point was more in the area the impression one can leave to some of the forum members here. When I saw your thread, I could picture responses from bewildered and inexperienced medics who would consider the notion that maybe they don't need to immobilize anymore. 

In my business I run into more anecdotal spinal immobilization methods than I can stomach. My photographs must meet the necessary current standards or my editors won't consider the images for publication. Tons of my images have been left on my editing room floor from half cocked medics who want to do it "their way". Hence the reason I take such a passionate few on this topic.

You bring up an excellent point about overseas studies. I'm curious now to see how these studies were conducted? Thanks for your input!


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## BossyCow (Feb 5, 2009)

So, what is it the studies say is at fault? Is it the design of the board? Is it the material the board is made out of? Is it the method of strapping? I'm sure if we built a better mousetrap er.... backboard, it would sell. Something perhaps more along the lines of a vacu-splint that filled the voids better? Are the studies saying that spinal immobilization is bad or that the way we currently immobilize a spine is wrong? 

We can argue all day long about it being right or wrong but what parts are right and what parts are wrong? And you can't dismiss the point that we operate under the license of our medical program director and its his call. Yes we should open a dialog regarding the efficacy of the current practice of spinal immobilization, but the wheels of change spin very slowly when personal injury lawyers are watching.


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## Wyoming Medic (Feb 5, 2009)

Veneficus said:


> At last count I have seen 7 published studies citing ill effects of spine boards.



Not trying to get into the mix too much but EVERY medical intervention has a risk or "side effect" associated with it.

It is very well published that IVs CAN cause severe problems (emboli, phelitis,infection, ETC) yet very few people will argue the necessity of IVs.  We learn techniques to try to shrink the risk BUT it remains.  The same can be said for almost every medication.  Every one has a side effect of some kind.  Usually the therapeutic dose is maintained and the side effects are outweighed by the benefits.

The same can be said of backboards IMO.  They can cause problems but we can learn specific techniques (padding voids, knee freedom, etc) to minimize the hazard.  We may never totally eliminate it but. . . . . .

I personally view backboards as fairly important. Not just because I was beat throughout medic school to "trust in the backboard" but because I really feel that it does some good.  If you think about the mechanical injury associated with trauma then think about how to minimize the damage, you will always lean towards immobilization.

I know the backboard does not immobilize but it is as close as we can get in the field w/o resorting to RSI and an entire body vacuforming splint with a halo.

That being said, it also takes a special part on the ER staff to minimize the risk of backboarding.  They really should strive to make sure that the patient gets off the board in an hour.  I know this is not always possible (heck, some of our transport times are over an hour by themselves) but our local ER makes an attempt.  Either cleared and off the board or into surgery within 1 hour of hitting the door.

I am not ready to write off the backboard just yet.  A little evidence of possible side effects (just like everything else in EMS) does not scare me away when I think about how MECHANICALLY, the backboard makes sense.  I am an amateur welder and mechanic on the side as well as a ham radio operator and rock climber.  I feel that I have a pretty mechanically inclined mind and the backboard makes sense.  

And last but not least, It is almost impossible to trump the med director.  He says jump and I say HOW HIGH.    

That is all for now  

Wy medic


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## JPINFV (Feb 5, 2009)

karaya said:


> Good points. Let's take this whole subject to a really simple view: EMS providers are taught to splint something that may be broken. That's it. Back might be broken? Splint it. Neck might be broken? Splint it.



That's over simplifying it, though. It's not simply that an arm may be broken. The arm has to show signs or symptoms (pain, swelling, tenderness, etc) to be splinted. Outside of the spine, mechanism isn't enough to justify splinting anything else. It's splinting AND signs/symptoms. 

On one hand, I agree that there isn't enough to completely abandond it. I thing there is enough evidence, though, to seriously implement selective spinal immobilization at all areas though. The big problem is what area is going to agree to a randomized c-spine trial and where are we going to get an IRB willing to accept it? I'd like to see more of the Malaysia style studies done to build up the literature.


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## JPINFV (Feb 5, 2009)

Veneficus said:


> Perhaps somebody could tell me why PT/OT are researching EMS interventions and EMS is not?



How many EMS providers have the education, inclination, and/or ability to run a controlled study? As I'm sure you know, it's not as simple as throwing a bunch of people on a backboard for 2 hours and writing up an essay on what you did and what you found.


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## JPINFV (Feb 5, 2009)

BossyCow said:


> So, what is it the studies say is at fault? Is it the design of the board? Is it the material the board is made out of? Is it the method of strapping?



For the most part it's the material that the board is made of. Simply put, it's too hard and is causing ulcers in patients on it for any significant period of time. There's also a question being raised on if the entire practice does any good at all. Backboarding currently is like fluid resuscitation in trauma patients.


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## BossyCow (Feb 5, 2009)

JPINFV said:


> For the most part it's the material that the board is made of. Simply put, it's too hard and is causing ulcers in patients on it for any significant period of time. There's also a question being raised on if the entire practice does any good at all. Backboarding currently is like fluid resuscitation in trauma patients.



I just think its pointless to argue about should we or shouldn't we when we aren't clear on what specifically is the issue. Instead of yes or no, we need to focus on the 'how'.


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## karaya (Feb 5, 2009)

JPINFV said:


> That's over simplifying it, though. It's not simply that an arm may be broken. The arm has to show signs or symptoms (pain, swelling, tenderness, etc) to be splinted. Outside of the spine, mechanism isn't enough to justify splinting anything else. It's splinting AND signs/symptoms.


 
My point about the simplification of splinting, such as in the example of spine and cervical, was meant to be overly simple to dove tail into my next paragraph about the mind set of this longtime standard.  I'm not a neophyte when it comes to signs a symptoms to justify splinting.

My point was, in a round about way, to point out that spinal immobilization is one of the the most prominent immobilization methods taught and used in EMS.  To just up and change the standard to a suggested example that no immobilization is required is one that will clearly take strong scientific study to support.

There does appear though more and more support for definitive c-spine clearance protocols based on what the current studies have yielded here in the States.


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## downunderwunda (Feb 5, 2009)

reaper said:


> *Yes, I do pad my pt's on the LSB. I have been on to many and know what is needed to make them more comfortable.*
> 
> 
> 
> ...




Good for you, padding every patient.

This still does not alter the fact that i can stat that a cervical collar provides 35% restriction in movement, when applied with a KED, this incresed to over 85% immobilisation. 

The same statistics cannot be given for the extrication device know as a spine board. I work alongside doctors who hate the fact that patients are bought in on them. Even when the patient is strapped to the board, there is still a range of movment that will allow the patient to slide & therefore have the possibility of increasing any damage already done.

As for the question of satfley removing a patient onto your stretcher, an effective log roll (I assume that there are more than 2 people on scene) with 1 person in control of the head will allow for this to happen. Remember the patient will have this done several times in hospital.

The incistance that we transpost on a spinal or long back board to prevent further injury is a nonsense with no evidence to support it.

Medicine, regardless of pre or in hospital MUST be performed on evidence based parctice. If the evidence is there, then we do it. For example, we used to, if we thought a pt was envenomated cut the wound & suck out the poison, or apply tourniquets, now, we know that these are not the most effective treatments & firm bandaging is _proven_ to be the treatment. Similarly, the algorythm for cardiac arrest was changed world wide, why, because the* evidence was there to support the change*.

If you want to bring the evidence to the table to support you argument, then i will happily read it, but to say we do it cause it works does not wash in any prehospital environment any more.


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## Veneficus (Feb 5, 2009)

*food for thought*



karaya said:


> My point was, in a round about way, to point out that spinal immobilization is one of the the most prominent immobilization methods taught and used in EMS.  To just up and change the standard to a suggested example that no immobilization is required is one that will clearly take strong scientific study to support.



Ok, I’ll bite. 

Splinting to reduce motion. When you look at the shape of the spine, how do you reduce motion and still maintain lordosis and kyphosis? If you force a patient flat on a board, you are bending the spine you are trying to immobilize out of its anatomical position. There are no other splinting techniques that cause pressure points. Would you do this to any other bone? I am not against splinting, but I doubt the board actually splints. It can’t possibly immobilize the joint above and below the fx. Especially since in a supine position the distance between vertebrae increases. In addition the musculature holding the spine is quite strong, so when you place a person on a board and you relax one set of muscles, the opposing pulls against it, causing further stress if not outright movement. 

 Then, you have other issues, decubs, reduction in chest wall expansion, maintaining airway etc. which causes agitation and further movement. You give some 80 y/o person with limited mobility and circulation a decub and you might as well have just euthanized them instead of boarding them. Even if they are healthy you may cause other health problems that will increase the amount of time/money, etc that recovery takes. 

I understand risk stratification, but spinal precautions in house do not include a board, how are principles of medicine somehow different outside the hospital?


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## Wyoming Medic (Feb 5, 2009)

Veneficus said:


> Splinting to reduce motion. When you look at the shape of the spine, how do you reduce motion and still maintain lordosis and kyphosis? If you force a patient flat on a board, you are bending the spine you are trying to immobilize out of its anatomical position.



The only way that I can see backboarding as "out of anatomical position" is if you use cargo ratchet straps and apply so much force that you actually force the spine flat.  With proper padding and packaging techniques, I see no difference in placing somebody supine on a board and them sleeping supine in bed.  Yes the board is more uncomfortable BUT is it really that different from a bed?

I also feel like your post indicates that the patient is MORE likely to see spinal movement due to being boarded.  I just cannot visualize this.  I have been boarded (as I am sure we all have) both in the classroom setting and for personal injury many times.  I can safely say without a doubt that it limits my movement.

It prevents me from having to use (or severely decrease the requirements)  my musculature to keep me from moving while the ambulance transports me down a bumpy road.  It makes it so that I do not have to support my own weight as I am being transferred from ambulance to ER to radiology ETC.  The straps provide a way for force that is applied to the board to be transferred to my skeleton in other places that it would not otherwise be possible.

I agree that backboarding a patient is NOT immobilization but it is the closest thing that we have in an ambulance.  And as I have stated before, I think that it does limit the movement of the spine and can make moving a patient easier and safer.  Once in the hospital they do not have to contend with the movement that an ambulance has.  They do not have to fear getting rear ended at a stoplight.  They have multiple people to move and control a patient while on the streets, we (as in many parts of the country) may only have 2 people on a scene.  They also have limitless time and space which we all know are both at a premium on an ambulance.

I am very open to new ideas but at the same time, I feel that I can secure a patient to a backboard and at least reduce the chance of further spinal compromise.  I understand the various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has and until I am introduced to a viable option THAT MY MEDICAL DIRECTOR APPROVES OF, I am going to continue using it.

Movement limitation is key in my book and boarding is as close as we can get in the field.  

Wy medic


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## Veneficus (Feb 5, 2009)

Wyoming Medic said:


> I feel that I can secure a patient to a backboard and at least reduce the chance of further spinal compromise.



I have seen ~7 studies that says no benefit or harm. In addition, multiple countries have abandoned this practice based on the opinion of expert physicians. You have a feeling? Why do I try to raise the respect for EMS providers with other health care practicioners?



Wyoming Medic said:


> I understand the various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has.



Says who?


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## downunderwunda (Feb 6, 2009)

Wyoming Medic said:


> various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has



I say again, evidence based practice. Where is your evidence?

Veneficus has sighted studies stating there is no benefit. 

You state 





> various risks associated with securing a patient but those are GROSSLY outweighed by the potential benefit that the board has



so where is your evidence?

tTo hide behind the statment 





> until I am introduced to a viable option THAT MY MEDICAL DIRECTOR APPROVES OF, I am going to continue using it



in a foorum that has challenged yu to use your own mind, offer your own opinions shows the sad state of most EMS providors. You should have enough education to know the difference & when someone shows you, take that advice & look at how you can submit a proposal to your medical director. That is how we effect change. But do not hide behind a lame no brain excuse like that.


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## fortsmithman (Feb 6, 2009)

My understanding is if it isn't approved by the medical director and something goes wrong and civil litigation follows then be prepared to lose everything to the pt and the pt's family in court.   Civil juries are funny like that.  If the medical director sys backboard then backboard it is if the medical director says no then don't.  Simple as that.


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## downunderwunda (Feb 6, 2009)

fortsmithman said:


> My understanding is if it isn't approved by the medical director and something goes wrong and civil litigation follows then be prepared to lose everything to the pt and the pt's family in court.   Civil juries are funny like that.  If the medical director sys backboard then backboard it is if the medical director says no then don't.  Simple as that.


with all due respect, that isnt what i said in my last post. 

I will, for clarity repeat myself.

This is a forum to challenge your thinking. To allow different ideas to permeate your mind. To see othe points of view. 

Then it is up to you what you do with it. My challenge to Wyoming Medic was to not hide behind 





> THAT MY MEDICAL DIRECTOR APPROVES OF


 but to look outside his little area that he works in, to see there are other points of view, that are as valid, and possibly more medically correct than the practice he currently employs.

If you think I am stupid enough to tell someone to stop doing what they are, rightly or wrongly, instucted & offered protection through protocols, that is your perogitive. However, the only way things will get changed is if the so called 'educated' among us use that knowledge, reseach topics properly & present findings to medical directors & protocol committees. I am not saying every change will be greeted with open arms, far from it. To sit on your hands and do nothing because 





> THAT MY MEDICAL DIRECTOR APPROVES OF


 is tantamount to malpractice.

Since we are discussing spinal patients, does *EVERY* patient you treat as a suspected spinal get 1.Collar, 2. KED, 3. LSB, 4. Fluids, 5. Anti-emetic, 6. Nasogastric tube, or is it only the spine board, collar & KED that are important?


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## reaper (Feb 6, 2009)

downunderwunda said:


> Good for you, padding every patient.
> 
> This still does not alter the fact that i can stat that a cervical collar provides 35% restriction in movement, when applied with a KED, this incresed to over 85% immobilisation.
> 
> ...




Do I believe that backboarding is the best thing? NO!!!!! I have stated this over and over.

Have I debated with MD's over this? YES

We Got our MD to bend a little by putting a Spinal Clearance Protocol in effect. Is it everything I wanted? NO. But it is a start and we work on it.


Evidence based medicine is a great thing. But if you have any experience studying different studies, Then you know that a lot of them are crap. A lot of them are paid for by drug or equipment companies and they are swayed to prove the point that they want to make.

You can do a 3 year study on the negative affects of any thing in medicine and have it prove your point. I can do a 3 year study to prove that the same thing works like it should. Studies can be pushed in any direction that they want it do be pushed.

Yes, there are a lot of studies that are correct and prove the evidence behind it. But, do not take all studies to heart and think they are gospel because a Dr. did them. 

There are studies that state that CPR is ineffective and we should abandon it. Do you think that this will happen? We use the best tools we have at the moment to deal with what we can. Medicine changes by the day and we change with it. When they produce a new way on backboarding that is shown to work better, we will all jump on it. Until then, we use what there is.

Unfortunately we are governed by the media and public opinion. Yes, we could go with not backboarding 90% of the pt's we do. But, it will be the one that is paralyzed by the medic that decided that it was not needed, that will be pasted all over the press and cause outrage in the public.

Well, sorry for the rant. Tail end of a 36 can cause the brain to fry!


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## Wyoming Medic (Feb 6, 2009)

"A systematic review of the MEDLINE literature from 1966 to January 2006 Week 2 allows an estimate of the potential benefit of spinal immobilization. Multiple reports show that approximately 5% of trauma patients have a spinal fracture; only 20% of this 5% have a cord injury. There are 10 independent reports of secondary deterioration without spinal immobilization, many “suddenly” and temporally related to “inappropriate management” while not immobilized.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Three of these give precise data for calculations: up to 3% to 16% of these cord-injured groups had deterioration out-of-hospital.7, 9, 12 The product of these percentages indicates that 0.03% to 0.16% of all out-of-hospital trauma patients may be expected to have secondary injury and thus may be helped by immobilization. The minimum number of indiscriminately immobilized patients needed to prevent one secondary injury is thus likely between 625 and 3333 trauma patients. Admittedly, this indicates a small benefit per patient, but it is not insignificant in light of the catastrophic result of further cord injury and estimates that several million people are immobilized each year. Larger modern studies to define a rigorous number needed to treat (NNT) would not be ethical given the experiences shared above. The one case-control study of immobilization was elegant but unfortunately too small to refute a benefit.13 Not seeing deterioration in 13 cord-injured, non-immobilized patients is significant by the binomial exact test only if 25% or more of spinal-cord-injured patients are expected to deteriorate, and the above studies do not indicate this large of a rate of out-of-hospital secondary injury. This case-control study thus cannot discredit the multiple previous reports of small but non-zero numbers of late secondary spinal cord injury. Secondary deterioration is real, and immobilization is the best out-of-hospital intervention reported to date."

And here is the lead up to that "Cochrane Database systematic review of spinal immobilization.1 The study selection criteria included only randomized controlled trials (RCTs) of patients with suspected spinal cord injuries. None were found, so the Cochrane authors justifiably state that the effects of immobilization remain uncertain. However, the EBEM commentators’ conclusion that there is “no published or unpublished scientific evidence justifying the practice of spinal immobilization in the out-of-hospital setting” is too extreme. While emergency medicine practitioners are wise to understand the evidence underlying their interventions and the magnitude of the likely effects, the lack of RCT evidence should not lead to therapeutic nihilism about interventions that other types of studies indicate may lower morbidity."

Well, Here is what I HAVE seen and done studying on throughout my schooling.  I have more references but it would take me longer to find them.  This one is pretty compelling however.  It pretty clearly states how (while small) backboarding is justified and how,at least this group, feels that it does reduce further spinal cord injury.  The numbers of people that it really helps is small compared to the ones that are boarded un-necessarily, but I am not ready to be the one to tell the occasional person that they will not get boarded because of the "greater good".  I will do my job and what is best for the patient.  I will risk the decub (and try my best to counter with padding and such) for the sake of preventing POSSIBLE further spinal compromise.


I also want to address this  
       Veneficus-- "I have seen ~7 studies that says no benefit or harm."

Where?  I re-read all of your posts on this topic and I cannot find you providing a link to any of these studies (perhaps I missed them but I don't think so) nor the text associated with any.  I can find studies citing the dangers of wearing underwear and ALSO some saying that it is dangerous NOT to wear underwear.

http://www.associatedcontent.com/article/7987/health_dangers_more_serious_than_terrorists.html


http://jhorna.wordpress.com/2007/01...ng-underwear-is-detrimental-to-your-sex-life/

Now, are these studies anything that are serious?  I dunno ,  I take them with a pretty large grain of salt.  HOWEVER, do note that I found "studies" to support both of my claims.  I also found a reference to TPS (tight pants syndrome) and a doctor claiming that belts were far more dangerous than suspenders   


Veneficus-- "Why do I try to raise the respect for EMS providers with other health care practicioners?"

I dunno why you do any of what you do, only you know that 

http://www.cwnsurgery.com/CWN/About/doctors.html  (look at that link and run your mouse over their names to get some background)

These are the local folks that deal with the trauma patients that I bring in every day.  They are the same ones that say "backboard" and the same ones that I feel have a pretty mutual respect for me.  I hate to say it but you coming on here writing that you have read 7 studies about how backboarding is bad, has not come anywhere near what these folk have taught me and shown me with regard to the benefits that backboarding has.

As I have been saying all along, I agree that backboards are not the solution but for in the field care, I think they are the best that we have right now.  I can think of no way that my partner and I can move a trauma patient BY OURSELVES without compromising some form of spinal movement limitation unless we use the backboard.  Maybe in a magical world you have 25 people on a scene but here in Wyoming we have 2.  My partner and I and the occasional rancher.

Along with me agreeing that boarding is not the perfect solution, I will also agree that sufficient evidence is around to support doing an in depth study.  This is becoming a pretty hot topic in forums across the internet and I am shocked at how little data there really is.  I respect your interpretation of the little evidence that is around and I respect mine.  However you have not convinced me to "fight the good fight" as you put it and I doubt that I will convince you of my thoughts.  I think that we must continue to use what our medical directors mandate, try to come up with better solutions, educate ourselves on new techniques and try to do our best to "clear" patients in the field and reduce our numbers of grossly un-necessary boarding.

Thank you for the green mega man, you may now all have ice cream, cake and pie.

Wy medic


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## Veneficus (Feb 6, 2009)

Wyoming Medic said:


> I also want to address this
> Veneficus-- "I have seen ~7 studies that says no benefit or harm."
> 
> Where?  I re-read all of your posts on this topic and I cannot find you providing a link to any of these studies (perhaps I missed them but I don't think so) nor the text associated with any.  I can find studies citing the dangers of wearing underwear and ALSO some saying that it is dangerous NOT to wear underwear.



somewhere in this post I mentioned that I have no intention on searching up where I saw these. The last one I saw was done by the department of PT/OT at MetroHealth medical center. Between medscape, BMJ, JAMA, NEJM, Lancet, and every other source that people email me I really just don't plan to go through years of briefs on this topic. At one point I decided they did not contain enough bias to be discounted. Taken togeether that is significant in my mind.

When I look at MAST, aggresive fluid resuscitation, golden hour, the focus of intubation during CPR, and other EMS dogma that has been the staple of EMS for more than 2 decades, just accepting spineboarding is not something I am prepared to do. In addition since I know that penetrating trauma is one of the leading causes of spinal injury and mechanism is not always reliable I am thinking it may be impossible to prove that a backboard does help. How could anyone say it was the board and not the manipulation itself that was the deciding factor in whether a pt suffered a secondary injury? 



Wyoming Medic said:


> These are the local folks that deal with the trauma patients that I bring in every day.  They are the same ones that say "backboard" and the same ones that I feel have a pretty mutual respect for me.  I hate to say it but you coming on here writing that you have read 7 studies about how backboarding is bad, has not come anywhere near what these folk have taught me and shown me with regard to the benefits that backboarding has.



I would not think for a moment that anything I could say here would change your mind. I don't even hope to try, what I do hope to do is point out that medicine is a larger world than your or my local area, and maybe people reading this will be ambitioius enough to start calling practices into question instead of mindlessly performing them or spouting the anecdotal benefit.



Wyoming Medic said:


> As I have been saying all along, I agree that backboards are not the solution but for in the field care, I think they are the best that we have right now.  I can think of no way that my partner and I can move a trauma patient BY OURSELVES without compromising some form of spinal movement limitation unless we use the backboard.  Maybe in a magical world you have 25 people on a scene but here in Wyoming we have 2.  My partner and I and the occasional rancher..



I am very well experienced in having only 2 people and the occasional sheriff. I also think a board helps make extrication easier. What I am against is boarding every patient because of wild "what if" statements.



Wyoming Medic said:


> Along with me agreeing that boarding is not the perfect solution, I will also agree that sufficient evidence is around to support doing an in depth study...



EMS in my experience does not like to take a hard look at what it does because it wants somebody to tell them what to do instead of using critical thinking skills. Which i would venture guess is why none of this data has ever been called upon. If I have a choice of getting involved in a study of the next greatest blood substitute or backboarding, I probably wouldn't even consider backboarding, if other people wth a high interest in trauma and the average opinion of EMS that I see in trauma surgeons it doesn't surprise me at all nobody has done more.  



Wyoming Medic said:


> I think that we must continue to use what our medical directors mandate,



This is exactly the problem. EMS cannot rely on people interested in grander things to keep telling them what to do. Most medical directors I know have so much on their plate already, reviewing this stuff will fall on EMS providers, who don't seem interested.



Wyoming Medic said:


> try to come up with better solutions,,



but we have to admit what we are doing is not good enough before that can happen. You may admit it, I may admit it, but look at EMS across the US. You may pad the board regularly, but I can tell you that is not the average. Infact I would wager if you go by call volume, less than 1% of all patients put on a board are padded at all, much less properly.



Wyoming Medic said:


> educate ourselves,



That is the key phrase right there. The more you know about anatomy, pathophysiology, and biophysics, the more you will be able to recognize or even clear people who do not need a board. But without namng names, there are very large lobbyists who have worked very hard to keep EMS education as low as possible.


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## Wyoming Medic (Feb 6, 2009)

Veneficus said:


> I am very well experienced in having only 2 people and the occasional sheriff. I also think a board helps make extrication easier. What I am against is boarding every patient because of wild "what if" statements.




And I respect that.  I also feel like while we may argue certain points, we do have a lot of the same views.  Like I have said in several past posts, I believe that the field clearing of C-spine injuries is in our protocols and needs to be taught and encouraged more.

My question (to keep this forum moving) is what is the better approach.  I keep reading about how a cervical collar then placing the pt directly onto the cot is acceptable.  Is that what "experts" are saying?

My next question is, how do we accomplish maintaining some form of spinal movement limitation without the board?

I have read various reasons why people believe that the backboard is not a viable option.  So what are we to do?  If people are recommending that we go to our medical direction with other ideas, What are those ideas?

I am not willing (at this point) to say that backboarding is archaic and "old hat".  I have not seen any solid evidence to say that backboarding is specifically bad.  I have however seen (as I posted before) some limited information that backboarding is beneficial in the long run.  

I am convinced however, that there are enough professionals that are questioning the practice for me to open my mind and listen to other options.  


Wy medic

Ps. and addressing the comments about being in a small part of the world,  I have practiced EMS in Wyoming, South Dakota, Many places in Texas, West Virginia,Utah, Colorado, and Pennsylvania.  I feel that I have a pretty good grasp at how EMS is performed in the USA.  The rest of the world may do things differently but I feel that I am keeping within the standards that I see all over the U.S.


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## Veneficus (Feb 6, 2009)

Wyoming Medic said:


> And I respect that.  I also feel like while we may argue certain points, we do have a lot of the same views.  Like I have said in several past posts, I believe that the field clearing of C-spine injuries is in our protocols and needs to be taught and encouraged more.
> 
> My question (to keep this forum moving) is what is the better approach.  I keep reading about how a cervical collar then placing the pt directly onto the cot is acceptable.  Is that what "experts" are saying?
> 
> ...



In hospital a c-collar and a regular hospital bed (the one with the 4-5” mattress)without pillow is acceptable. Some Cots have an option for thicker mattresses that may be useful. 

In this neck of the woods extricating with the board and then transferring to a full body vacuum splint on the cot is protocol. It works really well (cause all the voids are padded automatically) but the pt still has to be taken off of it for x-rays. It is supposedly capable of being x-rayed but the creases blur boarders making them tough to read. Many experts I know think that is quite acceptable. Anatomically it seems more effective than a flat board.

In addition to the above, careful manipulation instead of speed trying to meet arbitrary time limits. That may require more scene time, but that is better than the alternatives.


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## Wyoming Medic (Feb 6, 2009)

Veneficus said:


> In this neck of the woods extricating with the board and then transferring to a full body vacuum splint on the cot is protocol.




How do you accomplish this without excessive manipulation?  Seems like an extra step that can cause problems.

The other problem is one that we have with any type of air or vacuum splint.  We have varying altitudes from 3,000 feet to almost 14,000.  In my experience, the splints cause many problems and are difficult to be used reliably.

Any thoughts?

Wy med


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## Veneficus (Feb 6, 2009)

Wyoming Medic said:


> How do you accomplish this without excessive manipulation?  Seems like an extra step that can cause problems.



log roll, it has to be done at the hospital anyway, a lot of hospitals have time limits a patient can be on a board. (in minutes) But even so the back has to be assessed. 

If you are logrolling onto a board, if it was going to cause harm wouldn't it likely have already?



Wyoming Medic said:


> The other problem is one that we have with any type of air or vacuum splint.  We have varying altitudes from 3,000 feet to almost 14,000.  In my experience, the splints cause many problems and are difficult to be used reliably
> 
> Any thoughts?



some kind of fast setting spray foam?


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## Wyoming Medic (Feb 6, 2009)

Veneficus said:


> If you are logrolling onto a board, if it was going to cause harm wouldn't it likely have already?



Not necessarily.  Maybe the 2nd time is the charm.  More manipulation also means more chance of unwanted movement.  And our hospital tries to get patients off the board within 1 hour.  Our physicians leave the patient on the board until radiology can "get the shots".  


And what did you mean by "spray foam"?  I am totally confused.  The problem with any type of air containment splint is that the air pressure changes here RAPIDLY with altitude changes.  How would I incorporate spray foam into that?   I have my thoughts but the state would yank my cert so fast. 

I am not sure how EMS works where you are at but Wyoming has STRICT rules regarding adherence.  You would not believe the hassle of getting a "warm IV" study permit.  MONTHS and MONTHS.  And until somebody can provide ACTUAL data that unquestionably shows that there are better ways than boarding a patient, all that I can do is pee into the wind.  And that is assuming that I agree with the "good fight".  I have not turned over that leaf yet.  

All of this idea is well and good but there are fewer than 70 working medics in Wyoming and I would like to stay one of them.     


Wy medic


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## Veneficus (Feb 6, 2009)

Wyoming Medic said:


> Not necessarily.  Maybe the 2nd time is the charm.  More manipulation also means more chance of unwanted movement.  And our hospital tries to get patients off the board within 1 hour.  Our physicians leave the patient on the board until radiology can "get the shots".
> 
> 
> And what did you mean by "spray foam"?  I am totally confused.  The problem with any type of air containment splint is that the air pressure changes here RAPIDLY with altitude changes.  How would I incorporate spray foam into that?   I have my thoughts but the state would yank my cert so fast.
> ...



I mean a new spray foam that could fill voids after the patient was on the board. 

sounds like Wyoming needs some more progressive people doing med control there. I doubt we will ever see conclusive evidence for many medical procedures.

One hour is entirely too long to be on a board. Especially for the elderly. I know of 2 places that require it to be yanked in 10 minutes. I have never worked anywhere in any country (3) that permits greater than 1/2 hour. (you only beat me by 1 state in the US  ) I have heard of spine fx being missed as much as 20% on x-ray so are your hospitals CTing spines if there is that much concern? If they are relying on x-ray to rule out a fx, then somebody is going to be a VOMIT. (victim of medical imaging technology) A head,neck, chest, abd and pelvis with spine recons can take upwards of 40 minutes. add in scene, transport, ED time and you are easily over an hour. If they are delaying transport to a higher level of care to do a CT, they will probably catch hell in the next ATLS recert.

Who is your level I trauma center there?


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## Wyoming Medic (Feb 6, 2009)

We have no level one trauma center in the state.  We have several level 2 but the majority are level 4.

I know that many people say that they are rural EMS but Wyoming really does take it a step further (at least within the 48 states).  We have 1 lifeflight in the state.  Usually unavailable due to weather.  We have very few hospitals anywhere.  Most of our ambulances cover 6,000 ish square miles without any radio, cell, or backup available.

Our state EMS is archaic at best.  They know EVERY medic by name and face.  They treat each differently.  EMT-Is are the gold standard.  Medics are deemed "un necessary".  There are fewer than 70 working medics within the state.  There are hundreds of intermediates.  Intermediates in Wyoming can do more than many paramedics in other states.  Unless you live in one of the bigger cities (over 20,000 people) you probably will never see a paramedic.  

Wyoming has completely dropped off the map and no longer accepts NREMT and has completely designed it's own standard for reciprocity.  Not just basing it upon what state you are coming from but by what school you got your level of EMT, be it basic, intermediate or medic. 

Now to move back to the topic at hand after the WY EMS lesson.

I have been researching online this whole time, trying to find definitive answers regarding this "backboard VS Not" debate.

I cannot find much info.  So let me lay it on the line, and describe how I am hearing what you are saying.  Not picking on anybody BUT this is how I HEAR YOU.

You are basically saying that you have read 7 studies that bemoan the use of backboards.  You cannot remember exactly where or when BUT you did read them and you are not going to post any links or text associated with them.  It is up to us as the reader to figure it out.  I then post an entire text associated with a study and it is not even mentioned in rebuttal.  You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint".  When told that vac splints are not so hot here you come up with "spray foam" yet you offer no attempt at how to use this and seem not to take into account the fact that it is not approved/studied/tested/within national standard practices.

That is what I am gathering from this whole conversation.  Perhaps you have more knowledge or information, but you have not conveyed it to me in a logical sense that I can understand and try to believe in.  From what I can tell (as I said above) you are making statements that are based upon something that I (as reader) cannot verify OR deny.

I have very much enjoyed this banter.  I always believe that this type of discussion is great for keeping the mind sharp so I do thank you.  I can tell that you are an intelligent individual and after this, I do respect what you say.  I also can see that the answer is still out there and that more research needs to be done. 

I hope we can keep up the verbal judo in other threads that we both encounter.  

Thanks for the information


Wy medic


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## Veneficus (Feb 6, 2009)

Wyoming Medic said:


> You are basically saying that you have read 7 studies that bemoan the use of backboards.  You cannot remember exactly where or when BUT you did read them and you are not going to post any links or text associated with them.



sorry, truthfully it would take hours to track them down. Like I said, The last one I read was done At Metro, with Case Western Reserve University. There were 2 listed here by other posters so i wasn't going to repost them, so we are up to 3.  



Wyoming Medic said:


> I then post an entire text associated with a study and it is not even mentioned in rebuttal.



I read the post, you decided that many patients are overtriaged and boarded, we agree, didn't think you wanted a comment on it.



Wyoming Medic said:


> You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint"..



It's what's done here, I think it is a good idea.



Wyoming Medic said:


> When told that vac splints are not so hot here you come up with "spray foam" yet you offer no attempt at how to use this and seem not to take into account the fact that it is not approved/studied/tested/within national standard practices..



I was trying to come up with an original, logical solution to the problem, could be the next billion dollar medical gadget, but I don't have time to make it as I have other ambitions. But I figure with all the other crap out there, somebody will seize on it. 




Wyoming Medic said:


> I have very much enjoyed this banter.  I always believe that this type of discussion is great for keeping the mind sharp so I do thank you.  I can tell that you are an intelligent individual and after this, I do respect what you say...



Indeed it has been a great conversation.



Wyoming Medic said:


> I hope we can keep up the verbal judo in other threads that we both encounter.  ...



for certain, thanks for the WY EMS lesson and the debate.


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## karaya (Feb 6, 2009)

Whew!  You guys done?


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## Veneficus (Feb 6, 2009)

karaya said:


> Whew!  You guys done?



I thought it wasn't over till somebody won


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## JPINFV (Feb 6, 2009)

Wyoming Medic said:


> You also have no specific treatment changes other than "extricate on a backboard and THEN put them onto a body vac splint".


Wouldn't the treatment change if a treatment doesn't work be to abandon it? I guess you could call "permissive hypotension" a treatment, but it could also be considered removal of fluid resuscitation from all but the most extreme cases. In the 13 or so cases mentioned in that study where patients had secondary spinal injury, I would be interested to know if the physicians involved with those cases felt that the secondary injury would have been avoided with the use of EMS style movement restriction.


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## downunderwunda (Feb 6, 2009)

Wyoming Medic said:


> "A systematic review of the MEDLINE literature from 1966 to January 2006 Week 2 allows an estimate of the potential benefit of spinal immobilization. Multiple reports show that approximately 5% of trauma patients have a spinal fracture; only 20% of this 5% have a cord injury. There are 10 independent reports of secondary deterioration without spinal immobilization, many “suddenly” and temporally related to “inappropriate management” while not immobilized.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Three of these give precise data for calculations: up to 3% to 16% of these cord-injured groups had deterioration out-of-hospital.7, 9, 12 The product of these percentages indicates that 0.03% to 0.16% of all out-of-hospital trauma patients may be expected to have secondary injury and thus may be helped by immobilization. The minimum number of indiscriminately immobilized patients needed to prevent one secondary injury is thus likely between 625 and 3333 trauma patients. Admittedly, this indicates a small benefit per patient, but it is not insignificant in light of the catastrophic result of further cord injury and estimates that several million people are immobilized each year. Larger modern studies to define a rigorous number needed to treat (NNT) would not be ethical given the experiences shared above. The one case-control study of immobilization was elegant but unfortunately too small to refute a benefit.13 Not seeing deterioration in 13 cord-injured, non-immobilized patients is significant by the binomial exact test only if 25% or more of spinal-cord-injured patients are expected to deteriorate, and the above studies do not indicate this large of a rate of out-of-hospital secondary injury. This case-control study thus cannot discredit the multiple previous reports of small but non-zero numbers of late secondary spinal cord injury. Secondary deterioration is real, and immobilization is the best out-of-hospital intervention reported to date."
> 
> And here is the lead up to that "Cochrane Database systematic review of spinal immobilization.1 The study selection criteria included only randomized controlled trials (RCTs) of patients with suspected spinal cord injuries. None were found, so the Cochrane authors justifiably state that the effects of immobilization remain uncertain. However, the EBEM commentators’ conclusion that there is “no published or unpublished scientific evidence justifying the practice of spinal immobilization in the out-of-hospital setting” is too extreme. While emergency medicine practitioners are wise to understand the evidence underlying their interventions and the magnitude of the likely effects, the lack of RCT evidence should not lead to therapeutic nihilism about interventions that other types of studies indicate may lower morbidity."
> 
> Well, Here is what I HAVE seen and done studying on throughout my schooling.  I have more references but it would take me longer to find them.  This one is pretty compelling however.  It pretty clearly states how (while small) backboarding is justified and how,at least this group, feels that it does reduce further spinal cord injury.  The numbers of people that it really helps is small compared to the ones that are boarded un-necessarily, but I am not ready to be the one to tell the occasional person that they will not get boarded because of the "greater good".  I will do my job and what is best for the patient.  I will risk the decub (and try my best to counter with padding and such) for the sake of preventing POSSIBLE further spinal compromise.




Well researched Wy, however it talks spinal immobilisation, not transporting on a LSB. there is a difference. No one has disputed the need for spinal immobilisation. Vac packs are ideal, but alas we do not all have access to them, however, you can still immobilise effectivley without a LSB, if not better. 

My experience is that if we present a patient to an ER without being on an LSB, the the Dr usually will come straight over to begin the process of spinal clearnce & where appropriate, based on what our reports from scene & en route are, we may take the pt through to X-ray & have that done on our stretcher to reduce movment. 

As has been stated, most hospitals want the patients off the LSB post haste. Why, because they are uncomfortable & as such the patient wants to move & you run more risk of damage. 

As the study sited by Wy states, we are, in reality talking very, very low numbers of people who are actually effected, if my maths works out right is is about 200 in every 100 000 trauma patients. However, because we cannot clear in field in most cases, we need to treat for the worst & hope for the best. 

There is general agreement that transport on a LSB is not really the most desireable position, so what is the solution? Reaper stated in a reply to me



> Evidence based medicine is a great thing. But if you have any experience studying different studies, Then you know that a lot of them are crap. A lot of them are paid for by drug or equipment companies and they are swayed to prove the point that they want to make.
> 
> You can do a 3 year study on the negative affects of any thing in medicine and have it prove your point. I can do a 3 year study to prove that the same thing works like it should. Studies can be pushed in any direction that they want it do be pushed.
> 
> Yes, there are a lot of studies that are correct and prove the evidence behind it. But, do not take all studies to heart and think they are gospel because a Dr. did them



Unfortunatley, while you are correct, just look at the Dr's employed by the tobacco companie who told us smoking was actually good for us, it costs money to run these studies, money only available to those companies. There is however now some protection for those of us who read them where if a study is paid for by one such company, this has to be declared & made obvious to the reader. While this is not perfect, either is the transport of a pt on a backboard!

The key is for the disserning reader to be able to read the report/study & look at it. I have seen studies that have based their findings on 100 people. That was their sample. Is this acceptable? No. Their findings were refuted not long after with a study using a sample of 5000. Similarly, if you are following the post on the Golden Hour, you will see that the basis for this was, to quote spisco85 





> The Golden Hour term was coined originally for medevacs in a WAR zone due to penetrating trauma. The major causes of death were "sucking chest wounds" and death due to extremity hemmorhage/amputation.


 It has subsequently been refuted many times, but in many cases is still accepted as a rule in ems (please see the thread to continue this debate, this is meerly a reference not a point of argument here). Change has to begin somewhere, & the statment by Veneficus 





> EMS in my experience does not like to take a hard look at what it does because it wants somebody to tell them what to do instead of using critical thinking skills. Which i would venture guess is why none of this data has ever been called upon. If I have a choice of getting involved in a study of the next greatest blood substitute or backboarding, I probably wouldn't even consider backboarding, if other people wth a high interest in trauma and the average opinion of EMS that I see in trauma surgeons it doesn't surprise me at all nobody has done more.


 is for the most part correct. However, having spent time as a member of the Australasian Trauma Society, the tide of change, at least here, is beginning. The recognition that ambulance services needs certain skills & drugs, recognition that we are capable of makeing decisions that will have positive effects on our patients, the ability to recognise when we should scoop & run or stay & play. The simple fact that we, through our professional bodies are being asked for our opinions & the walls are, slowly, being broken down, is a positive. This has been through persistence of officers & supporters over many *YEARS*. Many of which started as discussions, not unlike this one.

I would like someone to answer a question I did pose earlier which seems to have been lost, so I will ask again now.



> does EVERY patient you treat as a suspected spinal get
> 
> 1.Collar,
> 2. KED,
> ...



I look forward to replies to this question


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## Wyoming Medic (Feb 6, 2009)

downunderwunda said:


> I would like someone to answer a question I did pose earlier which seems to have been lost, so I will ask again now.
> 
> I look forward to replies to this question




I can say that here in the WY, we use the LSB, Collar, Zofran (that is just our choice) and fluids.

If the patients is to be kept on the board for any length (once in the hospital) then an NG is place.  We don't have the ability to place field NG anyway.  

The KED is used here very little.  I have used it to "reduce movement" of c-spine of a guy that fell down a stair onto his face.  He had serious epistaxis (sp) but had point tenderness in the c-3,4 area.  It allowed us to transport him sitting up in a position that he could breath.   

Wy medic


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## downunderwunda (Feb 6, 2009)

Wyoming Medic said:


> I can say that here in the WY, we use the LSB, Collar, Zofran (that is just our choice) and fluids.
> 
> If the patients is to be kept on the board for any length (once in the hospital) then an NG is place.  We don't have the ability to place field NG anyway.
> 
> ...



Wy,  

it is interesting that you do not use a KED more when you have been very adamant about reducing spinal movment. A cervical collar only provides about 35% reduction in movment, but when combined with a KED this increases to 85%. Maybe it would be worth re evaluating your procedures & using a KED rather than a LSB for transport.


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## Wyoming Medic (Feb 6, 2009)

That would definitely be worth looking at.  I was unaware of the numbers that the KED provided. 

I have always had problems with KEDs fitting correctly (we have LOTS of obesity here) and I never liked the fact that it really limited my access to the trauma patient.

Wy medic


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## downunderwunda (Feb 6, 2009)

Obesity is a problem everywhere, a result of modern western society. I would suggest you get a couple of larger volunteers, explain the reason you have chosen them & practice on station. I believe there are extention straps available for the KED & other extrication devices.


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## emtfarva (Feb 6, 2009)

Just to let you know:

LBB is just a splint that we just happen to use as a transportation device.
A scope or stokes stretcher are transportantion devices.
A ked or short spine board is an extrcation device.


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## downunderwunda (Feb 7, 2009)

emtfarva said:


> Just to let you know:
> 
> LBB is just a splint that we just happen to use as a transportation device.
> A scope or stokes stretcher are transportantion devices.
> A ked or short spine board is an extrcation device.



Why do you use a LBB as a transportation device?

& I hope you know the difference between a KED & short spine board.


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## emtfarva (Feb 7, 2009)

downunderwunda said:


> Why do you use a LBB as a transportation device?
> 
> & I hope you know the difference between a KED & short spine board.



because, when I have a code on the third floor of a house and you have to bring the person down the stairs and cont. cpr, I use a LBB. Most other times when you are taking c-spine precautions it becomes a splint. Yes I do know the difference between a ked and a short spine board. A ked is a little easier to put on. and most of our short spine boards are used as cpr boards anyway.


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## chfite (Feb 8, 2009)

"non-english speaking,..." with the complaint of neck pain.  How could one not immobilize him?  A competent assessment is impossible and informed refusal incredible.

Chris


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## downunderwunda (Feb 12, 2009)

emtfarva said:


> Most other times when you are taking c-spine precautions it becomes a splint.



Have you read any of this thread & seen that it is not used as a spline effectivley? 

The effective spint is the KED used in combination with a c-collar.

not a C-Collar & attach to a spine board.


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## BossyCow (Feb 12, 2009)

downunderwunda said:


> Wy,
> 
> it is interesting that you do not use a KED more when you have been very adamant about reducing spinal movment. A cervical collar only provides about 35% reduction in movment, but when combined with a KED this increases to 85%. Maybe it would be worth re evaluating your procedures & using a KED rather than a LSB for transport.



A KED is not designed for transport. It is an extrication device only.


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## downunderwunda (Feb 12, 2009)

> A KED is not designed for transport. It is an extrication device only.




Actually, a KED is designed to remain insitu until the patient is in hospital, a LSB is an extrication device not a transport device.

To allow for transport with a KED, simply losten the leg straps, not that difficult & still provides 85% immobilisation to the entire spine.


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## Veneficus (Feb 13, 2009)

as just a thought, maybe we could all strap a KED on a volunteer, then strap another volunteer to a spine board and see what works better?


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## emtfarva (Feb 13, 2009)

A KED is not a transport device. It has only one purpose, to extricate someone from a vehicle or tight space. When you move them from the vehicle you have to place them on a LBB. It is not a splint because you have to place with a LBB. Which by the way is a splint. A LBB has many purposes. We used to take C-spine precautions, to immobilized the hip with possible fx, we have to use it with a traction splint to immobilize the hip also. I also use to move Pts from upper floors to the ground level. We use it for codes. And in the winter time we will use it for sleds or snowboards. A scope or stokes stretchers are transport devices.


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## CAOX3 (Feb 13, 2009)

I would have to disagree the KED remains in place until arrival at the hospital.  Therefore it is a transport device.

It also serves as a great immobilization device for children. Used it multiple times before we began getting pediatric immobilization equipment.


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## triemal04 (Feb 13, 2009)

Veneficus said:


> as just a thought, maybe we could all strap a KED on a volunteer, then strap another volunteer to a spine board and see what works better?


Quoted because this should be the end to the discussion on whether or not a KED can be used as a stand alone device.  If you really think it does not do a better job of immobilizing the spine that a longboard you have never used it right.  Period.


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## BossyCow (Feb 13, 2009)

Absolutely, just because it remains in place during transport doesn't make it a transport device. By that criteria, so would a bandage or dressing.


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## Veneficus (Feb 13, 2009)

triemal04 said:


> Quoted because this should be the end to the discussion on whether or not a KED can be used as a stand alone device.  If you really think it does not do a better job of immobilizing the spine that a longboard you have never used it right.  Period.



I figured since there was an intense debate on this matter that a scientific experiment would be in order.

I don't think a LSB immobilizes anything. It just makes the EMS provider feel like they are doing something.


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## downunderwunda (Feb 13, 2009)

emtfarva said:


> It has only one purpose, to extricate someone from a vehicle or tight space.




emtfarva, 

let me quote you some statistics again. Immobilisation with a c-collar provides *35% immobilisation to the spine*, when used in conjunction with a KED there is an *85% immobilisation of the spine*. To me this says it has more than one purpose, that is 





> to extricate someone from a vehicle or tight space.


 Does this not show that it has splinting (immobilisation) value also? 

No one has been able to show in this thread what level of immobilisation is provided using a long back board. Long Back Boards are uncomfortable & in reality, the discomfort caused on the patient is more likley to cause them to move to try to get comfortable.

The challenge is out there. I am not talking full studies, just show how, as I have shown, the level of immobilisation by using the equipment. I have tried & been unable to find any data on the reduction, or immobilisation offerred by a LBB. Put simply this is yet another myth that goes into the vault of EMS mythology - WE WILL TEACH IT BECAUSE WE HAVE ALWAYS DONE IT SO IT MUST BE RIGHT!


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## downunderwunda (Feb 13, 2009)

CAOX3 said:


> It also serves as a great immobilization device for children.




Turn it upside down & it is actually a good splint for bilateral femurs.

Oh wiat, let me quote someone else




> you have never used it right



Let me put that full quote in context



> Quote:
> Originally Posted by Veneficus
> as just a thought, maybe we could all strap a KED on a volunteer, then strap another volunteer to a spine board and see what works better?
> 
> Quoted because this should be the end to the discussion on whether or not a KED can be used as a stand alone device. If you really think it does not do a better job of immobilizing the spine that a longboard you have never used it right. Period.



triemal04, see my post above. I use it correctly.


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## triemal04 (Feb 13, 2009)

downunderwunda said:


> triemal04, see my post above. I use it correctly.


Ok...I have no clue what you are trying to get across in your last post.  KED=good, with or without a longboard.  KED=a piece of equipment that does not always need to be used in conjunction with a longboard.  In fact, it could be said that KED=better than a longboard.


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## CAOX3 (Feb 14, 2009)

BossyCow said:


> Absolutely, just because it remains in place during transport doesn't make it a transport device. By that criteria, so would a bandage or dressing.



See the second part of my post. 

A Ked can be used alone,  not in conjunction with another piece of equipment, therfore it is a transport device.


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## emtfarva (Feb 14, 2009)

#1 What does KED stand for?
#2 ok you are right you can consider the KED a splint.
#3 A KED is not a transport device. A stretcher is a transport device, an ambulance is a transport device. A LBB is a splint. We tend to use to transport a Pt from one spot to another but that is not what it is was intended to do. It was intended to be used a ssplint for spinal immobilization or whole body immobilization. I use it for unconscious and unresponsive Pts. I always suspect a spinal or head injury with these Pts. We use it for codes because our scoops are no good for codes. We have the old metal ones. While we are transporting the pt to the ambulance or stretcher we can continue CPR.

I don't care how effective a LBB or KED is at immobilizing. I am telling you what the devices are designed for. A long board and KEDs are splints. A KED is a extraction device. A scoop and stokes stretchers are transport devices.


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## CAOX3 (Feb 14, 2009)

I believe you stated earlier you carry codes down stairs on a back board,  Does that mean you were transporting someone with a splinting device?  

If you want to mince words here.  You can use a ked as a stand alone immobilization device.  I have been doing it for years.  Sometimes there is no right or wrong answer.


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## Veneficus (Feb 14, 2009)

What is the purpose of a driveway?
What is the purpose of a parkway?



Sorry, couldn't resist the play on words.


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## emtfarva (Feb 14, 2009)

CAOX3 said:


> I believe you stated earlier you carry codes down stairs on a back board, Does that mean you were transporting someone with a splinting device?
> 
> If you want to mince words here. You can use a ked as a stand alone immobilization device. I have been doing it for years. Sometimes there is no right or wrong answer.


yep, and yes i do use a splint as a transport device


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## CAOX3 (Feb 14, 2009)

OK im confused are we really arguing this point.


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## emtfarva (Feb 14, 2009)

CAOX3 said:


> OK im confused are we really arguing this point.


 not with you, Downunder


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## volff21 (Feb 14, 2009)

Neck pain usually means collar and back board,if the doc says not necessary get a signature and document


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