Backboard or not?

thatJeffguy said:
People legally carry guns where you live? My god! You must have millions of murders! You should follow the lead of such peaceful places as New York, New Jersey and Los Angles and ban those darn murder-sticks!
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This is a back-boarding thread in regard to a gunshot patient. Let's not turn this one into another 200 something thread full of dribble about guns.
 
Paulie_G said:
I was doing a ride along a while back when we got a call for a suicide attempt at the fire station where we have our quarters. Apparently his father had found him and driven him to the fire station because he refused to go to the hospital. Upon our arrival firefighters were extricating a 40 year old male with a self inflicted gun shot wound to the chest from a truck. The pt. had an exit wound in line with the entrance wound to just below the left nipple. He still had CMS cause he was fighting with us as we tried to help. Long story short the guy ends up dieing. I was speaking with another medic just recently. Her take on it is that he was sitting up and blood was filling his abdominal cavity, when we back boarded him it began to fill up in his chest and caused his heart to stop. To her credit she admitted that she wasn't there so who knows. I would like to know what you think? Has anyone transferred a pt. to air care sitting up? Would it have delayed the pt. crashing? Your thoughts?
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mycrofft said:
Lots of vasculature as well as the lungs. Our active duty military medic members could shed more light, but I'm thinking O2, airway maintenance, IV large bore but only TKO until needed, be prepared to decompress enroute, and get thee to an OR.

I've seen my share of people crump as soon as they are placed supine, and long boards are pretty supine all right. Every treatment has it's negative effects and being unable to keep your airway clear versus potential for spinal injury in this scenario is a bad ratio. One field tx for penetrating wound to chest is place the pt on the affected side.
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Mycrofft is right. Let's go back over A&P. What else besides a lung is behind the left nipple? Anyone? Anyone? If you guessed the heart, you are correct. Even if the bullet didn't even touch the heart, it could still well have been effected by cavitation forces ripping all kinds of tissue and vasculature on it's way out the back.

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

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

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

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

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

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

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

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

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

Adam
 
From my arm chair.


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


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


Can someone tell me would sitting them up have such an effect as to kill them, based soley on whats going on in the chest?
 
sdadam said:
In fact regardless of the MOI the great myth of movement will worsen a spinal injury has exactly zero research to prove it. There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage.
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Zero research? Hardly.

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

What some prehospital providers fail understand is that there are many different types of spinal injuries. Some are to the bones, some are to the cord and some to the tissue surrounding the area. Thus, this is the reason why your neuro assessment can be very different from that done in a hospital 15 minutes later.
 
Scout said:
Can someone tell me would sitting them up have such an effect as to kill them, based soley on whats going on in the chest?
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That depends on what vessel or organ was damaged and the potential for hypotension.

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

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

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

I know, I want the mystery box! :rolleyes:
 
VentMedic said:
Zero research? Hardly.
Have you even seen how we move patients in the hospital with a highly suspected or confirmed C-spine injurie or the serious devices used to stabilize them?
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Actually yes, I have been working in ED's around the San Diego area for the better part of a decade now.

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

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

It's the lecture entitled Rethinking EMS Spine Immobilization.

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

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

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

As far as the patient crashing when he was laid supine... I would guess a coincidence.
 
sdadam said:
Actually yes, I have been working in ED's around the San Diego area for the better part of a decade now.

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

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

It's the lecture entitled Rethinking EMS Spine Immobilization.

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

Adam
Click to expand...

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

sdadam said:
In fact regardless of the MOI the great myth of movement will worsen a spinal injury has exactly zero research to prove it. There isn't even a single case study that has shown a PT with a spinal injury in which movement caused further damage.
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There has been tons of research out there which is why there are ASSESSMENT guidelines that can be instituted rather than blanket recipes concerning the use of a backboard.

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

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

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

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

http://scholar.google.com/

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

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

Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.
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Does this mean that all patients should be backboarded? Absolutely not. However, the Paramedic should have enough training to make an adequate assessment and transport the patient as appropriate for that patient. A backboard may not be required but good technique should be used to extricate and to limit the patient's movement somewhat. You probably would use an extremity carry on someone or have them walk into the ambulance either with a suspected spinal injury.

However, for the patient in this scenario, a code was in this person's future and a backboard is a nice device to have under the patient rather than a soft stretcher for compressions.
 
Correct me if I'm wrong Vent, but aren't most to all of the studies validating SSI criteria looking at what assessments correlate to spinal fractures and not whether prehosptial immbolization prevents secondary injury? In fact, are there any studies that show that spinal immobilization with a long back board prevents secondary spinal cord injuries?

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

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

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



What may need to happen to prove benefit, given the tiny number of people who might be helped, is to finally complete the paradigm shift from trauma=spinal cord injury=immobilize to signs and symptoms of spinal cord injury=spinal cord injury=immobilize. As long as people involved in 5 mph accidents are being immobilized because there's "trauma" involved, the people who actually have spinal column and spinal cord fractures who might be helped by immobilization is going to be drowned out.
 
So if we applied selective spinal immobilization to this patient... I would say that there is a mechanism consistent with possible spinal injury, as well as a distracting injury and uncooperative patient that would make a spinal assessment unreliable. So, spinal immobilization is indicated.
 
Neurological damage from penetrating trauma is done at the time of injury, not after the fact. If the patient had no neuro deficit on your primary, the odds of him getting them from you not boarding them is slim to none...the research in this subset of patients supports this. With that being said, restraining someone is easier on a board, as is delivering effective cx compressions, although in the case of a traumatic arrest secondary to gsw to the cx, cpr is likely to be ineffective at best.
 
^I thought arrest due to penetrating trauma had one of the higher save rates (versus due to cardiac or due to blunt trauma).
 
Summit said:
^I thought arrest due to penetrating trauma had one of the higher save rates (versus due to cardiac or due to blunt trauma).
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GSW to the left chest that results in arrest... I guess it depends on the cause. If you have a dissected aorta, then your chances are not good. If it's a hemothorax and you have a short transport time or can insert a chest tube, cool beans. Or cardiac tamponade... again, can you do pericardiocentesis, or get them to a trauma bay quickly?

But the chances seem better than those for blunt traumatic arrest, that's for sure.
 
JPINFV said:
Correct me if I'm wrong Vent, but aren't most to all of the studies validating SSI criteria looking at what assessments correlate to spinal fractures and not whether prehosptial immbolization prevents secondary injury? In fact, are there any studies that show that spinal immobilization with a long back board prevents secondary spinal cord injuries?
Click to expand...

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

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

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

The patient in this scenario was about to code. Are you in the habit of working your codes on a soft cot? Some do and some don't in EMS. I still work codes on a harder surface than the bed or cot. Maybe that is wrong also but it is still taught to move or place the patient on a harder surface for compressions.
 
redcrossemt said:
If it's a hemothorax and you have a short transport time or can insert a chest tube, cool beans. Or cardiac tamponade... again, can you do pericardiocentesis, or get them to a trauma bay quickly?
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Most Paramedic in the U.S. can no longer insert chest tubes or do pericardiocentesis. 30 years ago, these skills were routinely taught in the Paramedic curriculum. However today, few remote services still have both in their protocols. Some flight and specialty also can do both.
 
Vent, I think we are having a miscommunication.

You didn't address anything from my post.

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

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

You then said that you were right because there are lots of examples in law which prove so;
VentMedic said:
If you happen to look up a few lawsuit cases, some of which have been highly publicized especially in CA, you will find there have been more than A SINGLE CASE where further injury has been caused by movement especially those who are clueless about assessment and moving patients. I can not believe you would even make such a statement.
Click to expand...

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

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

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

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

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

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

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

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

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

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

And then of course you were sure to include these gems:
VentMedic said:
First I find it difficult to believe someone who states to have all of this experience would even make a statement like this.

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

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

I have been a member, and frequent reader of this board since 2006, and have posted 58 times, the reason for that is exemplified in your response to my posts.
 
sdadam said:
Vent, I think we are having a miscommunication.

You didn't address anything from my post.

I said;


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


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

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

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

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

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

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

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

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

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

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

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


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

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

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

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