Another backboard scenario!!

[Sublime]

Alright so had a transfer today that rather bothered me. Taking a 75 y/o lady on a 1 hr transport to a more definitive facility out of a small ER.

She has diabetic neuropathy and little feeling in her feet which causes her to fall. Today she fell and hit the back of her head on the night stand. Result was a C6 compression fracture and small subdural hematoma.

BP was 210/100 when we got there and she was being given hydralazine by nurse, doc wanted BP down before leaving. BP comes down to 200/95 while we're getting report and the doc states she can now be transported. The crew who brought her in immobilized her, and at this point she has a collar on but board has been removed. Nurse says we need to get a backboard. I responded

"wait you want to put her back on a backboard?"

The doctor was behind me an gives me a annoyed sounding "yes". I go and assess patient and she is pain free while lying on bed. AOx4. Good CMS. BP 200/95, pulse 74, 98% on 2l, normal sinus on monitor. Pt states "I only hurt when I'm put on that board". I tell her I'm sorry but I have to since the doc wants it, but I'll provide her with pain medication.

The nurse then goes on to me about how I shouldn't give her fentanyl because of her subdural hematoma and I need to be worried about that and not her pain. She ends by saying "seriously you shouldn't give her anything for pain"

I ignore her and don't say anything and take my patient after boarding her. By the time we're in truck she has 8/10 back pain. I gave her fentanyl on the way but needless to say she was miserable and in pain the entire transport.

Now my question: should I have stood up to the doctor and told him that the board would cause unnecessary pain and do nothing to stabilize her spine? Should I have offered to email him studies?

Should I have told the nurse to go to hell (j/k). But seriously I feel like I should of stood up for my patient but didn't want to cause any trouble. My protocol states spinal immobilization is based on judgement of the medic. Not sure how that applies in a inter facility transfer situation like this though.

Sorry for typing mistake and such... Wrote this on my phone.

 

[Aidey]

1. Ask if the receiving MD wants her on the LSB.
2. Ask if the neurologist wants her on a LSB.
3. Take her off of it in the ambulance.

 

[Milla3P]

I'm under the opinion that a patient... Though I prefer to use the somehow lost term "person" still has a right to refuse any/all/some treatments if they don't like it. "Sorry, Doc, she doesn't want it."

If your small ED doc wants to push the issue, put it on, take it off in the truck.

I guess I'm lucky that the local Docs I work with and the Level 1 are both ok with a person in a semi-fowlers and a collar. (When isolated injury to the head/neck) don't forget that your stretcher is essentially a padded, bendable LBB.

 

[truetiger]

Hmm like Aidey said I would contact the receiving facility if you're concerned. However, arguing with a doc isn't going to get you very far. Did you think of padding the backboard with blankets? She's got a confirmed c spine fx, probably needs to go up on a board don't ya think? It is our job to do our best to mitigate pain, however sometimes there are contraindications to pain management, it sucks but thats life. Once again, I would contact the receiving facility for pain management, I would have not gone out on my own and given the fentanyl without orders. Something would of went south, you would have been hung out to dry.

 

[Aidey]

She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?

Hell no.

Why? Explain to me, physiologically, how a LSB is going to stabilize a cervical compression fracture.

 

[truetiger]

I'm not arguing the effectiveness of the LSB for the C6 fx. If his protocols are like most, he won't have a leg to stand on. If he doesn't contact the sending physician to omit the back board, then where is he going to get the authorization to remove the backboard? Certainly is protocols aren't going to support omission of the backboard.

 

[Milla3P]

She's got a confirmed c spine fx, probably needs to go up on a board don't ya think?

I don't subscribe to this theory at all. How will manipulating a person with a Fx a 3rd time (1st on scene, 2nd at the small ED... Probably a 4th time up north [how we describe our Lvl 1 trips]) benefit them? How will very carefully plopping them on a (probably) radiolucent piece of hard plastic improve their outcome?

Is causing somebody pain without scientific proof assault?

Will the anatomical position in the semi-fowlers somehow compromise the cervical area?

Why do they need to "go up on a board?"

 

[Aidey]

I'm not arguing the effectiveness of the LSB for the C6 fx. If his protocols are like most, he won't have a leg to stand on. If he doesn't contact the sending physician to omit the back board, then where is he going to get the authorization to remove the backboard? Certainly is protocols aren't going to support omission of the backboard.

His protocols probably don't address the issue. My protocols talk about a suspected spinal injury. They say absolutely nothing about a radiologically confirmed one.

 

[truetiger]

His protocols probably don't address the issue. My protocols talk about a suspected spinal injury. They say absolutely nothing about a radiologically confirmed one.

Exactly, so you're going to go against 2 different physicians, one being the accepting physician from a specialty resource center and your protocols do not address or support this. Sounds like a really bad idea to me. I'll keep my medic license, thank you very much.

 

[Milla3P]

Patient choice, man. Have them sign the refusal form if you can. They don't want the board (as in the initial scenario) they don't need it.

Screw the doctors. Document properly.

What would you want done if it was your neck? Your 8/10 back pain?

 

[Aidey]

What 2 physicians? The OP only mentions the sending doc. The last time I was in this exact situation I had them call the neurologist and ask if he wanted the pt transported on a LSB. His reply was "what the hell for?"

And what exactly are you going to be losing your license for? Last time I checked preventing harm wasn't grounds for disciplinary action in most places.

 

[truetiger]

What exactly are you going to document? That you're smarter than 2 MD's? That'll get ripped apart in court. If it was my neck? And two different doctors confirmed it was necessary? I'll deal with the pain and not risk further injury.

 

[truetiger]

If he didnt agree with the sending doc, he should of consulted with the receiving. If he said keep the back board too, then the backboard should stay.

 

[Medic Tim]

Exactly, so you're going to go against 2 different physicians, one being the accepting physician from a specialty resource center and your protocols do not address or support this. Sounds like a really bad idea to me. I'll keep my medic license, thank you very much.

can you name even one instance anywhere where a medic has lost their cert/license because of this?

It is common many places for the board to be removed on the pts arrival. the board then goes back to the ambulance. The ERs here do not have or use LSB's. the only time there is one there is if a crew forgets one.

Just because you don't have a protocol for something doesn't mean that you can't / aren't allowed to do it.

It is common for us to transport pts with confirmed C#s (stable and unstable) with a collar and in a postition of comfort. How forcing your elderly pt into painful procedure with no plan for manageing it safer? especially if you are so worried about her ICP and BP?

 

[Milla3P]

What would I document?

"Pt stated that she did not want to be placed on LBB. Pt stated that LBB caused significant pain. Advised pt that referring MD recommended LBB as precautionary measure, pt continued to refuse, advised of risks involved pt signed refusal form and moved to stretcher without LBB in place."

Get the MD as a witness. At least the RN if the MD is too busy/angry.

It's that easy. Just write the truth. Don't force anything on the unwilling.

 

[truetiger]

It's very common for patients to be taken off the backboard if c spine is cleared, in this situation it sounds like it has not been cleared by the sending physician.

 

[Milla3P]

"I don't want that procedure!"
"Too bad, this guy you just met told me to do it to you!"

=

Assault & Battery.

Look back at your BLS education.

 

[Medic Tim]

It's very common for patients to be taken off the backboard as soon as they arrive in the ER.

fixed that for you

 

[Milla3P]

fixed that for you

^^^ This.

 

[truetiger]

You'll be hard pressed to go against a patient's written orders without hard evidence.