Immobilization in Combative Patients

[jaksasquatch]

Hello all,

Wanting to start a conversation on combative patients and your local protocols. Mine have moved to not forcing full immobilization and simply placing a C-collar if we have to physically restrain them. Previous to this we had the dinosaur protocol where almost everybody who was even suspected of having an injury got board and collar. I felt like this resulted in many instances where it did more harm than good. I'm fairly sure most of us have seen that in the past as well. Anyone had experiences with medical directors/ER doctors reprimanding you for taking C-spine on an obviously combative patient?

On a side note have any of you every put a patient that had a seizure due to trauma in full immobilization? Had this call before at a prison with an epileptic patient who got sent into a string of 30 seizures after being involved in an assault. This particular patient was difficult to manage since we didn't have RSI but simply DAI at the time. My question is, would you have simply managed the patient with a c collar or gone through the process of fully boarding? My gut tells me not to force this on a patient who has already had seizures refractory to treatment.

 

[CANMAN]

Combative for what reasoning, in the setting of trauma or head injury, or just being difficult?

 

[jaksasquatch]

Mainly in the setting of trauma/head injury.

 

[CANMAN]

Mainly in the setting of trauma/head injury.

Well I would say utimately everyone is held to their programs protocols. In my service trauma + head injury + combative is likely buying RSI, and yes they would be boarded and collared, which wouldn't be an issue post RSI. If you don't have that option then yes it can be difficult, but I think you at least have to make an attempt with that level of injury.

My area has caught onto not boarding patients on long spine boards for the most part, but those aren't potential close head injury high mechanism patients. Those are the rear ended at 40 mph without complaints of pain players. Trauma centers here still want multi-system or head trauma patients boarded and collared until evaluated in the trauma bay.

 

[k9Dog]

Versed 5mg IM followed by c-collar only in semi fowlers position is what we would do in Bay Area northern ca

 

[FiremanMike]

Ketamine 1mg/kg IV (or 4mg/kg IM) and 2mg Versed. I don't really recall the last time I physically restrained someone.

I agree with canman, the totality of circumstances will dictate whether my patient is getting a sedation for combative behavior or an RSI for a deteriorating condition.

 

[highglyder]

. Trauma centers here still want multi-system or head trauma patients boarded and collared until evaluated in the trauma bay.

Aren't those people ITLS certified at a miminum? Which clearly states to not used a LSB.... I would expect more from a trauma centre! Just sayin....

 

[FiremanMike]

Aren't those people ITLS certified at a miminum? Which clearly states to not used a LSB.... I would expect more from a trauma centre! Just sayin....

I did an IFT flight once for an isolated tib/fib fracture but she was intoxicated, apparently her leg was run over by a car (long story). Patient was already off the backboard and c-spine films were already done and clear. Sending physician demanded that we put her back on a backboard and c-collar prior to transport. We tried briefly to convince him this was silly, but he stood by his position and we put her back in a collar and on the backboard..

 

[highglyder]

I did an IFT flight once for an isolated tib/fib fracture but she was intoxicated, apparently her leg was run over by a car (long story). Patient was already off the backboard and c-spine films were already done and clear. Sending physician demanded that we put her back on a backboard and c-collar prior to transport. We tried briefly to convince him this was silly, but he stood by his position and we put her back in a collar and on the backboard..

That's when I would place a call to my supervisor, and if that fails, to one of our base hospital physicians. It's our job to advocate for our patients and that physician clearly did more harm than good. I would have simply refused to do so on basis of medical evidence and ethics.

 

[STXmedic]

.

 

[CANMAN]

Aren't those people ITLS certified at a miminum? Which clearly states to not used a LSB.... I would expect more from a trauma centre! Just sayin....

The protocols in the few surrounding states we transport from all read pretty evenly. The use of backboarding hasn't gone away completely in any of these states, just decreased alot, however is called for in certain situations per protocol for scene runs. I am also not going to waste time in removing someone from it during a scene call if we arrive and they are already packaged due to the limited amount of time they will be on it. I have been in the same position as FiremanMike before, and most of the trauma MD's at our big center's are still not trusting outside hospital imaging 100% and often want certain patient's to be boarded.

End of the day protocols are protocols and if you don't want to follow them then you will be without a job, and potentially a state license. Not saying I don't agree, but I also enjoy being employed. The information and research behind the LSB is relatively new, and will take a couple years to catch on everywhere, just as most things do... There's research that shows balloon pump insertion does nothing to decrease morbidly or mortality but cardiologist's are still placing them because there is still money in it. You can't take on everyone in healthcare, so you can stand there and have your debate as you refuse to do something, which is ultimately delaying the patient getting to where they need to go even further, I will just take the patient to where they need to go and keep my job.

 

[highglyder]

The protocols in the few surrounding states we transport from all read pretty evenly. The use of backboarding hasn't gone away completely in any of these states, just decreased alot, however is called for in certain situations per protocol for scene runs. I am also not going to waste time in removing someone from it during a scene call if we arrive and they are already packaged due to the limited amount of time they will be on it. I have been in the same position as FiremanMike before, and most of the trauma MD's at our big center's are still not trusting outside hospital imaging 100% and often want certain patient's to be boarded.

End of the day protocols are protocols and if you don't want to follow them then you will be without a job, and potentially a state license. Not saying I don't agree, but I also enjoy being employed. The information and research behind the LSB is relatively new, and will take a couple years to catch on everywhere, just as most things do... There's research that shows balloon pump insertion does nothing to decrease morbidly or mortality but cardiologist's are still placing them because there is still money in it. You can't take on everyone in healthcare, so you can stand there and have your debate as you refuse to do something, which is ultimately delaying the patient getting to where they need to go even further, I will just take the patient to where they need to go and keep my job.

I guess that's the difference between our systems. As much as our directives exist, they are not considered to be written in stone. Sure, you still need to report a deviation, but if it was clinically justified, you're not going to get in trouble. The evidence regarding backboards is not all new, lots of in-hospital studies go back almost 20 years. And like I said, knowing the measured effects on healthy people, it's part of our job to advocate on our patient's behalf, something which I have no issues with. Will it delay transport? Yeah. And so what? If it means avoiding pain, tissue damage, and a better experience all around, a slight delay will not matter in the grand scheme of things.

Perhaps the fact that I've been down the road of justifying my actions in the past (without negative outcomes for myself or my patients) and holding many conversations with those who are in a position of influence and authority have allowed me to feel comfortable with my stated position.

 

[FiremanMike]

My scenario occurred about 2 years ago, when the back boarding changes were just hitting this area and still VERY new. It just wasn't worth getting into a battle with the sending physician to fight over a back board that would have been (and was) back off within 20 minutes.