Simple KED Question... or not?

[mycrofft]

Five is four

If the patient requires the immobilization offered by the KED, do it, and cause the least movement you can, which means padding dense enough to prevent laxness of the restraints. If the particular pt does not warrant a KED, don't do it unless your protocol dictates; then, do it right if the pt is safely helped. Can't hide behind protocol if on-scene conditions make it dangerous.

 

[AnthonyM83]

I think a pretty convincing case can be built, based on evidence, that routine immobilization of any sort is not called for vs an expert witness spouting dogma out of a text book written at a 7th grade level.

I disagree (legally speaking). To go against local and state protocols written by panels and MDs, standard of care, National Registry, all the paramedic books I've read (including those unpopular ones written at higher reading levels), just because of the latest studies....I wouldn't take my chances. To be clear, I'm not contesting the latest studies, rather I'm contesting the strength of that defense in court (realizing that if you end up in court, injury probably did happen).

Of course, you used the word "routine"...that could be used as an "out" since the definition/application of the word is a bit subjective (does it mean you cspine regularly or that you cspine everyone, etc etc etc)

 

[AnthonyM83]

Considering how infrequently it is used, it would be hard define it as a "standard of care". For something to be a standard of care, would not it have to be frequently employed for a given condition. In 8 years I've applied the KED once for an individual who couldn't tolerate a LSB. I've only seen it applied one other time. I know of few medics and EMTs that have used it more than once. Its most frequent use seems to be for off-label purposes - pelvic fractures, immobilization of pediatric patients, etc. It is in no way a standard of care. The book does not determine the standard of care, the sum of the end-users does. To state it as a standard of care in my area (and many many others) would be to tell a lie.

You're right, standard of care is affected by local practice. But why aren't you practicing what the book says on your own regardless of what your peers do?

Pretty much all of the providers where I work have mom hold infants and toddlers in their arms unbelted (mom sits on the gurney and holds baby)...they fare okay. They might be able to defend it as local "standard". But why would I partake in that instead of just using the pediatric restraint device we carry (especially for stable patients)???

 

[usalsfyre]

I disagree (legally speaking). To go against local and state protocols

No state protocols, and local ones don't mention the KED.

written by panels and MDs, standard of care, National Registry, all the paramedic books I've read (including those unpopular ones written at higher reading levels), just because of the latest studies....I wouldn't take my chances.

Here's why this doesn't fly. EVERY new treatment at some point goes against what text books, MDs, standard of care, ect says. If we went solely by this medicine would still be bloodletting.

To be clear, I'm not contesting the latest studies, rather I'm contesting the strength of that defense in court (realizing that if you end up in court, injury probably did happen).

The studies are actual hard, scientific evidence (granted some of it is stronger than other parts of it). The books and protocols are based on expert recommendations that may, or may not be based on misguided thinking, old standards, sacrificed chicken blood or any other number of things.

All in all, the KED, with a few small improvements would probably be a FAR superior to the LSB for patient immobilization. But using the KED the way we do now, in conjunction a LSB is overkill, uncomfortable for the patient, and stupid. The only reason we continue to do things the way we do is EMS providers have been convinced more than any other area of medicine that the lawyers are out to get them, and as such, we can't advance based on evidence.

 

[Veneficus]

I agree with you. What some of my co-workers were saying, is that if you bring the head to a neutral in-line position "correctly", you will NEVER need to use the padding, because the back of the head will make contact with the KED on its own. I've never heard of this before.

Wouldn't that depend on the size and shape of the patients head?

I actually wrote a paper once on the false science of using cranial vault volume as a measure of intelligence. Skulls are not all the same size or shape. The KED is.

 

[mycrofft]

KED is adjustable to a point, and I'm enjoying this exchange!

The KED limitation is inferior-superior length, since the head flaps have velcro which can be variably secured. If you are too tall or too short for the KED at hand, then you have to make it safe or do it another way. My experience IN a KED (as a demo) is that is it a truly effective tool of its sort; not a panacea.

I'm seeing pointed, reasoned exchanges as well as opinions being forwarded without ad hominum shin-kicking. Good deal!

BTW, a bunch of guys and gals sitting around the ambulance floor talking about how they might subvert safety protocols, if it results in an injury, could be possibly considered a conspiracy.

 

[medtech421]

No state protocols, and local ones don't mention the KED.

Google search produced a protocol for Detroit on the KED so there are a few areas that have protocol concerning this device.


Here's why this doesn't fly. EVERY new treatment at some point goes against what text books, MDs, standard of care, ect says. If we went solely by this medicine would still be bloodletting.

A lawyer will have the textbook in front of them when prosecuting you and MD's are your medical control that can pull your ability to use your certification if you dont follow their written protocols.


The studies are actual hard, scientific evidence (granted some of it is stronger than other parts of it). The books and protocols are based on expert recommendations that may, or may not be based on misguided thinking, old standards, sacrificed chicken blood or any other number of things.

Studies are adressed when reviewing protocols and writing textbooks. Studies are not what they teach you in school and arent what they test you on when you take your NREMT exams. Until those studies are regionally or nationally accepted standard, youre going to go to jail for using a study instead of your accepted practices.

All in all, the KED, with a few small improvements would probably be a FAR superior to the LSB for patient immobilization. But using the KED the way we do now, in conjunction a LSB is overkill, uncomfortable for the patient, and stupid. The only reason we continue to do things the way we do is EMS providers have been convinced more than any other area of medicine that the lawyers are out to get them, and as such, we can't advance based on evidence.

Overkill and uncomfortable? no disagreement here, but stupid to me is going against the standard in favor of a study before it is implemented as protocol. Smart is getting your medical control to read the study and listen to recommendations. Then you have a chance in court when the weasel in the suit asks why you went against what you were taught. Things change all the time; thats why CE is required instead of going back to school every 3 years.

 

[usalsfyre]

I'm not going against my treatment guidelines by not utilizing a KED.

I ask again, what evidence does the standard have to back it up?

 

[medtech421]

I'm not going against my treatment guidelines by not utilizing a KED.

I ask again, what evidence does the standard have to back it up?

Utilizing or not utilizing is at your discretion. I have seen your posts and you seem to be an intelligent person. You just have to say "would 12 other people say I did the right thing". Does the standard have to have evidence? Before you skewer me for that question think about it....Men and women with more medical education than we have sat down and said this is the standard and we will put it in the books. We will teach every EMT and Paramedic to do this to prevent injury. When the patient gets injured the very first thing the lawyer will say is "Were you taught how to use this device and told it may prevent injury?" I am not saying you are wrong, I am saying the system used to judge us is. Unless those very educated men and women sit back down and say "We have detailed reports showing this thing has no major benefit in this capacity." We have to sit back and wait. When i started in this field, MAST were the best thing since O2.

 

[Veneficus]

Unless those very educated men and women sit back down and say "We have detailed reports showing this thing has no major benefit in this capacity." We have to sit back and wait. When i started in this field, MAST were the best thing since O2.

I wouldn't hold my breath waiting for those very educated people.

Many of them I have met see little value in EMS.

The handful who do have interest seem absolutely impotent to effect change.

If things are ever going to change it will have to come from EMS.

 

[usalsfyre]

You just have to say "would 12 other people say I did the right thing". Does the standard have to have evidence?

I'll give you absence of evidence does not equal evidence of absence. However, when the evidence of harm starts to outweigh the evidence therapeutic value (where spinal motion restriction is getting might close to being), the "standard" starts to look might shaky legally. Not to mention I hate practicing based of being (unrealistically) scared of the legal system. I know it's beat into EMTs and paramedics, but how many cases have you heard of in your area that have centered around spinal immobilization?

Before you skewer me for that question think about it....Men and women with more medical education than we have sat down and said this is the standard and we will put it in the books. We will teach every EMT and Paramedic to do this to prevent injury.

Not trying to skewer you at all, very sorry if I came off that way. As you note below, those same educated people taught MAST, Isuprel, airway was more important than compressions, high dose epi, the list goes on and on. When the evidence piled up they were harmful, they were eliminated. The only reason spinal motion restriction continues in it's current form is....

When the patient gets injured the very first thing the lawyer will say is "Were you taught how to use this device and told it may prevent injury?" I am not saying you are wrong, I am saying the system used to judge us is.

...legal fears masquerading as good medicine. Legal fears that may, or may not be, unfounded. The US is the only first world EMS system that takes spinal motion restriction to the ridiculous level that we do. Our argument for doing so is either we're scared of lawyers, or we're too dumb to assess the patient (how many time have you heard "I don't have xray vision") The cynical side of me says certain providers push spinal precautions as so important because without it the EMT curriculum will look even more like a first aid class.

Unless those very educated men and women sit back down and say "We have detailed reports showing this thing has no major benefit in this capacity." We have to sit back and wait. When i started in this field, MAST were the best thing since O2.

The impetus is on EMS itself to drive change. We're probably still years away from a large trial, but we should be trying to push things that way. Waiting on "the smart people" is one reason why EMS is the redheaded stepchild of medicine.

 

[medtech421]

Now THAT is an intelligent debate my friends! Wish more posts would go that way.

 

[LucidResq]

To throw my quick, somewhat uninformed 2 cents in on this discussion -

After playing with the cumbersome KED again in my refresher class, and bearing in mind the general research consensus on the usefulness (lack thereof) of spinal immobilization, I'm not impressed. A special forces medic and former PA and I had a conversation about this, and agreed the KED has very limited practicality. He said he's only used it once in the field to extricate someone "from a hole." It takes too much time, it's too cumbersome, and spinal immobilization is not as critical as people think it is anyways.

However, I'd still like to have it available in my "toolbox." As has been mentioned, it does seem to have practical use in odd situations - pediatric patients, weird confined space rescues, etc.

And my final point - I thoroughly believe people are way too scared of legal liability. I know you've been taught from the get-go that YOU WILL GET SUED 800 TIMES SO YOU BETTER BE READY TO STAND TRIAL AT ALL TIMES!!! But, I really don't think it happens as much as people think. I think a solid argument for why you made the intelligent, evidence-based decision you did, will go a long way. But that's just theoretical I guess.

Those who have been sued for such an issue please stand up.

 

[medtech421]

I would love to live in a world where, reasonable,informed decisions keep people from liability. I would love to think that there is no sleazy lawyer just waiting for the case that will help pay off his student loans. I wish I could say that "it doesn't happen that often" would easily translate to "it wont happen to you"..Finally I would love to think that someone who orders a hot cup of coffee would never sue a restaurant for giving them a hot cup of coffee.

 

[mycrofft]

Anyone can be sued anytime.

It takes a good judge to throw out the trash suits, and good lawyers to decline to take them. Unfortunately, that isn't always the case, or a plaintiff has a point.

If you are busy doing the right thing for the pt and are not out there writing your own portocols as you work, then you are likely to come out ok, unless the legal bills kill you.

 

[Melclin]

I've been pretty vocal about only immobilising people who need it on this forum, so I'm the last person to bouncing about boarding every sore toe and finger ouchie.

Nonetheless, spinal immobilisation is still the standard of care. You can jump up and down all you want about spinal immobilisation probably not working, but if the spinal injury specialists still recommend immobilisation, then it should be done. We're not reading any special literature that they don't have and they have careers dedicated to the topic. We need to listen to them, just like EM docs in hospitals, ED nurses and the drs and paramedics on our advisory board and guideline working groups. The standard is the same in hospital as it is out, its nothing to do with some deficiency in pre-hospital education or literature.

I'm all for not putting collars on people who have low likelihood of spinal injury based on neuro exam, and some evidence based clearance criteria. But while immobilisation is a standard of care, its gotta be done for people in whom it is indicated. If it can't be with a board then, with whatever the next best option is. The KED is pretty useful to have available in my opinion, for some of those trauma jobs but especially for those, '89 year old nanna tripped over the bathroom mat, smacked her head, had an LOC of unknown length and osteoporosis, and is now wedged nicely behind the toilet and you wanna use a drag mat to move her out from the bathroom and around 2 corners' type jobs. They're not that uncommon.

 

[mycrofft]

Second that, Melclin.

Small studies get cited, but I want a large scale study comparing field immobilization, broken down by presentation to the responder and their evaluation, plus their protocols, and sequelae attributable in each case to use of a spinal immobilizer, and final in-house (hospital that is) diagnosis. Also, frequency of refusal. Make a matrix, follow these for a whole year, then do it again elsewhere.

KED is an effective tool if you are not excited and have practiced it a few times, and have half a brain; you have to use it appropriately.

Every single time you lay hands on a pt, the questions "What is probably wrong here?" and "What can I do to actually help that?" must be raised. Overtreatment starts everytime with failure to truthfully answer each of those questions, and maltreatment states by ignoring them or lying.

 

[Veneficus]

Small studies get cited, but I want a large scale study comparing field immobilization, broken down by presentation to the responder and their evaluation, plus their protocols, and sequelae attributable in each case to use of a spinal immobilizer, and final in-house (hospital that is) diagnosis. Also, frequency of refusal. Make a matrix, follow these for a whole year, then do it again elsewhere.

KED is an effective tool if you are not excited and have practiced it a few times, and have half a brain; you have to use it appropriately.

Every single time you lay hands on a pt, the questions "What is probably wrong here?" and "What can I do to actually help that?" must be raised. Overtreatment starts everytime with failure to truthfully answer each of those questions, and maltreatment states by ignoring them or lying.

Would have been nice to have that study before people decided spinal immobilization should be so pervasive.

Of course is long boards and KEDS work so well, why is nobody in the hospital on one? Hmmmm...

 

[mycrofft]

Vene, you should be an insructor! (Oh, yeah...)

( I'm about to preach to the choir and teach grandpa how to rustle cattle).

I'm always getting all "Five is Four" on other people, but we must remember the history.

When EMT's were invented, it was by NHTSA because wreck victims, in 1960's or earlier automobiles travelling up to seventy legal miles per hour, were being exacerbated in their injuries, including spinal ones, through the efforts of would-be rescuers. Since then, we have air bags, crumple zones, seat belts and shoulder harnesses, safer highway designs, and lower highway speed limits (stop laughing back there!). Also, EMS sees many times more non-MVA cases now than was anticipated when EMT's were devised.

The goal was to train as many people as quickly as possible to perform extrication, and to prepare and transport them, without a doctor physically looking over their shoulder. This was an outgrowth of the military experience with medics at forward positions during wartime doing so much for final outcome.

However, a condition for medical sign-off on standards was that certain universal standards needed to be in place to limit and guide the urge for self-direction in practitioners without adequate medical training/experience (or equipment in the field) to make a definitive diagnosis. Hence, spineboards.

People forget that splinting and spineboards are packaging for transport, not care. They are preventative, just like you donning gloves to prevent infection. They are there to prevent exacerbati0n of extant injury by the responders, or the exigencies of transport, like potholes.

Raise the level of training, and we should be able to dispense with universal anything except billing and safe driving.

(Paranoid ambulance company owners and medical controlers, take note).

5=4​