EMS providers moving away from the use of longboards.

Mycroft H

So, again American EMS providers are forging a path here. There has being growing thought that religious the use of LSBs is based on no proven theory and is actually of no benefit to the patient in certain situations.

http://medicscribe.com/2013/02/in-praise-of-cemsmac/

The National Association of EMS Physicians and the American College of Surgeons Committee
on Trauma believe that:

• Long backboards are commonly used to attempt to provide rigid spinal immobilization
among EMS trauma patients. However, the benefit of long backboards is largely
unproven.

• The long backboard can induce pain, patient agitation, and respiratory compromise.
Further, the backboard can decrease tissue perfusion at pressure points, leading to the
development of pressure ulcers.

It lists the cases where a LSB may not be appropriate as an immobilisation device.

• Patients for whom immobilization on a backboard is not necessary include those with all
of the following:

o Normal level of consciousness (GCS 15);
o No spine tenderness or anatomic abnormality;
o No neurologic findings or complaints;
o No distracting injury;
o No intoxication.

• Patients with penetrating trauma to the head, neck or torso and no evidence of spinal
injury should not be immobilized on a backboard.

• Spinal precautions can be maintained by application of a rigid cervical collar and
securing the patient firmly to the EMS stretcher, and may be most appropriate for:
o Patients who are found to be ambulatory at the scene;
o Patients who must be transported for a protracted time, particularly prior to
interfacility transfer; or
o Patients for whom a backboard is not otherwise indicated.

So are there any thoughts on it from an Irish perspective? I've always thought they were overused and relied on far too much. Removing a lot of cases where a spinal board needs to be used and perhaps replacing it with other devices like an orthopedic stretcher seems like the way forward to me.

The effectiveness of the scoop stretcher to limit spinal motion in the destabilized spine is comparable or better than manual techniques currently being used by primary responders.

http://www.sciencedirect.com/science/article/pii/S0735675709001442

Bang Bang

The spinal immobilisation CPG and spinal rule-out decision is already based on some of the points you've raised so in fact has or should mean that the use of the long spinal board is greatly reduced. But I often see practitioners who appear to lack confidence when it comes to making that rule-out decision and instead 'collar & board' everyone, within reason of course.

The risk of poor perfusion from pressure points has been ruled out somewhat for quite a while now because those patients who are brought to the Emergency Department on a LSB no longer remain on the board through examination, onto x-ray etc. They are now examined quickly and the board taken away.

So we are seeing less and less use of the spinal board here in Ireland.

ForeRight

Bang Bang wrote: »

But I often see practitioners who appear to lack confidence when it comes to making that rule-out decision and instead 'collar & board' everyone, within reason of course.
.

There is no such thing as a rule out decision for a paramedic so once someone says they have neck or back pain they go on a board.

No matter how minor an incident unfortunately.

IMO it's up to certain mbers of joe public to cop on and stop acting the maggot in these incidents otherwise nothing can be done once they complain of pain as I said.

timmywex

ForeRight wrote: »

There is no such thing as a rule out decision for a paramedic so once someone says they have neck or back pain they go on a board.

No matter how minor an incident unfortunately.

IMO it's up to certain mbers of joe public to cop on and stop acting the maggot in these incidents otherwise nothing can be done once they complain of pain as I said.

Off the top of my head the paramedic CPG for spinal immobilisation can rule out spinal immobilisation? EMT's cannot

ForeRight

timmywex wrote: »

Off the top of my head the paramedic CPG for spinal immobilisation can rule out spinal immobilisation? EMT's cannot

Many people are taking this new cpg up wrong.

It's not a spinal rule out as it sounds.

If a mechanism of injury is there that would suggest a person could have spinal injury but they say they have no pain is when it cones into play. If they have no pain a few steps can be followed by the practitioner to rule out a spinal injury.

If the person says they have neck or back pain but we all know they are play acting unfortunately they still go onto a board.

There is no cpg that says if someone complains of neck pain a paramedic can rule out spinal injury on the side of the road when minimal impact even.

timmywex

ForeRight wrote: »

Many people are taking this new cpg up wrong.

It's not a spinal rule out as it sounds.

If a mechanism of injury is there that would suggest a person could have spinal injury but they say they have no pain is when it cones into play. If they have no pain a few steps can be followed by the practitioner to rule out a spinal injury.

If the person says they have neck or back pain but we all know they are play acting unfortunately they still go onto a board.

There is no cpg that says if someone complains of neck pain a paramedic can rule out spinal injury on the side of the road when minimal impact even.

Ah yeh sorry, i took you up wrong on that! Me reading quick again I thought you were saying about people who had no pain.

Timewasters will always exist unfortunately and there just aint going to be a surefire way to rule anything out in a pre hospital setting i suppose

maglite

I would't say the Americans are forging a path, more like welcome to the party.

Bang Bang

ForeRight wrote: »

There is no such thing as a rule out decision for a paramedic

ForeRight wrote: »

If they have no pain a few steps can be followed by the practitioner to rule out a spinal injury.

Are you not contradicting yourself here?

A Practitioner can indeed make the decision to rule out the need for spinal immobilisation.
Perhaps you should look over CPG 5/6.6.3 Page 64 and the PHECC Field Guide
Page 20 Spinal Immobilisation Decision. It clearly shows when a spinal injury rule-out can be made.

ForeRight

Bang Bang wrote: »

Are you not contradicting yourself here?

A Practitioner can indeed make the decision to rule out the need for spinal immobilisation.
Perhaps you should look over CPG 5/6.6.3 Page 64 and the PHECC Field Guide
Page 20 Spinal Immobilisation Decision. It clearly shows when a spinal injury rule-out can be made.

Like I said.... If a person says they have any pain you cannot. Look at the decision tree.

Neck or back pain=yes=spinal board

Neck or back pain=no=practitioner can follow guide lines to establish there is no injury.

I may have worded my first post poorly but I did state that you cannot rule out spinal injury once a person says they have pain.

I think the thread was designed to say that spinal boards are going to be used less and less due to practitioners turning up and diagnosing no injuries no matter what a patient says. This is just not the case and the cpg clearly shows this.

irishrgr

When I worked for EMS here, we went through this change. For many years, as we used to say, we'd LSB people who once saw an accident just in case. We LSB'd everyone. About 15 years ago, we had a new Medical Director who allowed us, under certain circumstances in the field, to not use the LSB. Basically a common sense, no mechanism, no pain, etc. (sounds a lot like the PHECC CPG). Then of course, a crew made a bad decision, so naturally, we heard the sound of administrators kness hitting tables (which we then quickly rushed in and administered the LSB's :-) and we went back to "backboards for everyone".

I want to say there was a clinical study done that showed paramedics in the field had an abysmally bad rate of detecting otherwise asymptomatic patients whcih played into the above decision. Right now the needle seems to be swinging back towards allowing some discretion.

I will say on a critical patient, the LSB is a great way to move someone quicly and efficiently and is good for CPR. We do need more actual clinical studies of EMS, it will make for better patient care. So much of Emergency Medicine studies is as a result of hospital studies, not pre-hospital.

stretch00

Ah, back onto my old hobby horse. A back board is an extrication device, not a transport device, appropriate device for transport is a vacum mattress. It's a bit like choosing to use cobwebs instead of a bandage, kinda ok, but definitely not the best you could do for your patient. In regard to rule out ? Where to start, look at it more from the perspective of making a good decision to do something, rather than a bad decision to want to avoid something. There is little evidence, and I mean evidence not opinion, that imobilisation in the manner and circumstances you are discussing is useful or safe, and a scary amount of evidence that its not. Too long to go into here, but even simple searches of Pubmed or google scholar will provide the kind of evidence for and against that you seek.
Good to see discussion and debate it's the only way to advance medicine. Now where are my leeches ?

Vikings

I can't provide any insight but will explain an incident I witnessed and why I don't like the idea of back boards!

http://www.c-r-y.org.uk/gary_mcelkerney.htm

(Story from the patient)

I was refereeing the game above, one of the players got knocked unconscious and was put on a back board by ambulance staff. It took what seemed like an age when you consider having to carefully remove the helmet and cut off jersey/shoulder pads in a safe manner.

Patient was lifted and while being carried off the field, before they even got to the sideline I seen the backboard literally being dropped to the ground when they discovered he wasn't breathing. Now obviously getting the patient breathing is priority 1 but after spending approx 15 minutes carefully placing the patient on the back board - have they not just undone and made worse what they took so long doing in the first place?

Paulzx

Vikings wrote: »

I can't provide any insight but will explain an incident I witnessed and why I don't like the idea of back boards!

http://www.c-r-y.org.uk/gary_mcelkerney.htm

(Story from the patient)

I was refereeing the game above, one of the players got knocked unconscious and was put on a back board by ambulance staff. It took what seemed like an age when you consider having to carefully remove the helmet and cut off jersey/shoulder pads in a safe manner.

Patient was lifted and while being carried off the field, before they even got to the sideline I seen the backboard literally being dropped to the ground when they discovered he wasn't breathing. Now obviously getting the patient breathing is priority 1 but after spending approx 15 minutes carefully placing the patient on the back board - have they not just undone and made worse what they took so long doing in the first place?

*My antivirus has flagged that link as having a Trojan*

medic112

never did like them for transport especially in the elderly. we normally use for rapid extrication & transport of time critical status pt's, otherwise in non-time critical pt's its scooped on to a vac-mat & secured. The vac-mats are vastly under utilized.

19hz

LAS have been using scoops instead of board for a while now.. this is the new product from Ferno that they've just invested in..
http://www.ferno.co.uk/product/scoop-65-exl

Only using a board for extraction and rescue. Not as a spinal board.

im in two minds...I never liked using the scoop cause ya cant roll them when they vomit but this new ferno one is the best of both to be honest...loved using it..sturdy and easy to get on..

oscar2

Paulzx wrote: »

*My antivirus has flagged that link as having a Trojan*

Mine too

antichrist

ForeRight wrote: »

Like I said.... If a person says they have any pain you cannot. Look at the decision tree.

Neck or back pain=yes=spinal board

Neck or back pain=no=practitioner can follow guide lines to establish there is no injury.

I may have worded my first post poorly but I did state that you cannot rule out spinal injury once a person says they have pain.

I think the thread was designed to say that spinal boards are going to be used less and less due to practitioners turning up and diagnosing no injuries no matter what a patient says. This is just not the case and the cpg clearly shows this.

If you are a paramedic then you are expected to use your head. If the person complains of neck pain then you assess as to where that pain is. Checking if there is mid-line tenderness along the vertebra. The mid-line tenderness is the key issue.
In the UK there is a spinal "rule-in" as opposed to a rule out which is much better.

Long boards should NOT be used to transport a patient. The scoop if a short transport time or a vac mattress if prolonged transport time should be utilised.

At the end of the day CPG's are guidelines and if you can justify your actions based on current evidence based medicine then you should be fine. Its up to us as practitioners to look up newer research and take an active role in the development of our service.

antichrist

antichrist wrote: »

Its up to us as practitioners to look up newer research and take an active role in the development of our service.

So part of the job is looking up medical journals now?

I'm not one to say no to someone taking the initiative, but do you really think it's a good idea for all practitioners of all experience levels to start playing Sheldon Cooper with patients in front of them?

CPGs are there as a baseline, a go-to, a standard, not just a guide. If you can stand in front of a judge and answer for what you discarded from the CPG, fair enough, but you must accept that that is what will happen. It's a dangerous game moving away from your CPGs. This chop-and-change attitude you're on about really belongs with the more experienced Paramedics & APs, and would be dangerous for people like the voluntarys or inexperienced to try.

Edit: Seen that ferno scoop, I take back what I said about scoops not being good for transport. But a good point being that without a good suction kit, it has to be longboard to get them on their sides if dinner wants to come back up.

antichrist

SeaSlacker wrote: »

So part of the job is looking up medical journals now?

I'm not one to say no to someone taking the initiative, but do you really think it's a good idea for all practitioners of all experience levels to start playing Sheldon Cooper with patients in front of them?

CPGs are there as a baseline, a go-to, a standard, not just a guide. If you can stand in front of a judge and answer for what you discarded from the CPG, fair enough, but you must accept that that is what will happen. It's a dangerous game moving away from your CPGs. This chop-and-change attitude you're on about really belongs with the more experienced Paramedics & APs, and would be dangerous for people like the voluntarys or inexperienced to try.

Edit: Seen that ferno scoop, I take back what I said about scoops not being good for transport. But a good point being that without a good suction kit, it has to be longboard to get them on their sides if dinner wants to come back up.

Sorry, I was referring to paramedics and advanced paramedics. Although the vols do provide a service, check I wasn't factoring them in when it came to EMS as the OP described.

As professionals we should be looking up articles relating to our field. We can't just say "ah sure it's up to the TDO to train me" we should show an active interest in our jobs. I understand this isn't the most popular idea in the current economic climate but we are no longer ambulance drivers, the more we educate ourselves the better we do for our patients.
I'm not saying that we become cowboys and practice whatever we read but we can use the knowledge to make better decisions regarding the current lines of treatment for our patients.

And as I mentioned before..... Long boards are an extrication device, not a transport device. Our problem is paramedics here cannot administer an anti-emetic as of yet.

Sounds good to me, but the sweeping longboard statement's up for debate really. It *can* be transport if you're stuck, and I mean Armageddon mass casualty stuck. The sooner you can get the patient onto an ambulance stretcher & transported that way, the better. Sometimes longboard's all you can use, other times it's as you call it. Best indicator is what you see in front of you on-scene, and what equipment you've got in the back.

RiderOnTheStorm

It seems that the correct & proper use of spinal boards is beneficial (pro's outweigh the con's) .... but it seems that overuse or misuse of them negates the benefits, and so its worse than not using them at all. Would ye agree? (I am inexperienced EMT and have only used boards in classroom and training ex)

ForeRight

antichrist wrote: »

If you are a paramedic then you are expected to use your head. If the person complains of neck pain then you assess as to where that pain is. Checking if there is mid-line tenderness along the vertebra. The mid-line tenderness is the key issue.
In the UK there is a spinal "rule-in" as opposed to a rule out which is much better.

Long boards should NOT be used to transport a patient. The scoop if a short transport time or a vac mattress if prolonged transport time should be utilised.

At the end of the day CPG's are guidelines and if you can justify your actions based on current evidence based medicine then you should be fine. Its up to us as practitioners to look up newer research and take an active role in the development of our service.

So you are saying that if someone says they have a pain in their neck you are not going to put them straight onto a board as per the cpg's but instead you are going to assess if the pain is mid line?
If its not mid line are you deciding not to board them?

What about overwhelming referred pain that may be detracting from the serious issue.

Any paramedic that decides not to put a patient on a board after they complain of neck pain in a trauma incident is asking for trouble. You can say that the cpg's are guidelines as they are of course but at the end of the day they are the bible when you are on the stand answering questions.

If you can explain that you somehow x-rayed someone on the side of the road and ruled out any spinal injury and decided to go against the guidelines well then best of luck to you. Especially after the initial complaint is neck pain.

antichrist

ForeRight wrote: »

So you are saying that if someone says they have a pain in their neck you are not going to put them straight onto a board as per the cpg's but instead you are going to assess if the pain is mid line?
If its not mid line are you deciding not to board them?

What about overwhelming referred pain that may be detracting from the serious issue.

Any paramedic that decides not to put a patient on a board after they complain of neck pain in a trauma incident is asking for trouble. You can say that the cpg's are guidelines as they are of course but at the end of the day they are the bible when you are on the stand answering questions.

If you can explain that you somehow x-rayed someone on the side of the road and ruled out any spinal injury and decided to go against the guidelines well then best of luck to you. Especially after the initial complaint is neck pain.

If a patient has pain to their calf muscle after a fall...with no signs and symptoms of any fracture...would you apply a leg splint?

Pain to the lateral aspects of the neck is usually muscle damage, its up to the practitioner on-scene to use their clinical judgement, factoring in MOI, to decide if their patient needs a cervical collar.

If you don't feel confident enough in your ability to properly assess your patient and collar them just to cover your ass....so be it, but you have to ask....am I doing this for the patients well being or for my own.

I'm not saying we should be out there walking every patient after an RTA, but newer evidence should be looked into, don't be surprised if you see a change to the CPG's.

ForeRight

antichrist wrote: »

If a patient has pain to their calf muscle after a fall...with no signs and symptoms of any fracture...would you apply a leg splint?

Pain to the lateral aspects of the neck is usually muscle damage, its up to the practitioner on-scene to use their clinical judgement, factoring in MOI, to decide if their patient needs a cervical collar.

If you don't feel confident enough in your ability to properly assess your patient and collar them just to cover your ass....so be it, but you have to ask....am I doing this for the patients well being or for my own.

I'm not saying we should be out there walking every patient after an RTA, but newer evidence should be looked into, don't be surprised if you see a change to the CPG's.

I won't be surprised if their are changes either but you must have amazing abilities to be capable of ruling out spinal injuries and diagnosing it as muscular pain when someone complains of neck pain after an accident.

Nothing to do with confidence at all. It's about following protocols. Following what we are trained to do as per cpg's.

If someone has neck pain after an incident they go on a board according to the guidelines. At no point does it say you look for midline tenderness or the likes.

If they have no pain well then you can do your tests to rule out spinal injury.

Very naive to believe that if you deviate from this that your judgement as a practitioner will hold up in court over the cpg's IMO.

antichrist

As I stated in a previous post, the UK is moving away from the traditional 'rule-out' and moving toward a 'rule-in', so don't collar anyone unless the listed criteria is met.

The CPG states that you should use clinical judgement but if in doubt immobilise. It also states to look for midline tenderness.

Upon arriving at the ED, a log roll is usually performed and a doctor assess for midline tenderness along the vertebra, the doctor is trying to isolate where the pain is coming from. If there is back or neck pain but it is not along the midline the board and collar are usually removed (unless intoxicated) as this is more a sign of muscular damage.

As for the comment about me being very naive, you do not know me nor my abilities on the road let alone my clinical level.
At what stage will I find myself dragged into court over this?
As I said, I'm not advocating that we simply discard spinal protocols, but what I am saying is that we are no longer ambulance men, we have moved away from that and should practice to our abilities using our clinical judgement.


(oh.....this topic is covered quite well on the last number of AP courses and I think it should be rolled out to paramedic level as the lecture is quite interesting)

ForeRight

antichrist wrote: »

As I stated in a previous post, the UK is moving away from the traditional 'rule-out' and moving toward a 'rule-in', so don't collar anyone unless the listed criteria is met.

The CPG states that you should use clinical judgement but if in doubt immobilise. It also states to look for midline tenderness.

Upon arriving at the ED, a log roll is usually performed and a doctor assess for midline tenderness along the vertebra, the doctor is trying to isolate where the pain is coming from. If there is back or neck pain but it is not along the midline the board and collar are usually removed (unless intoxicated) as this is more a sign of muscular damage.

As for the comment about me being very naive, you do not know me nor my abilities on the road let alone my clinical level.
At what stage will I find myself dragged into court over this?
As I said, I'm not advocating that we simply discard spinal protocols, but what I am saying is that we are no longer ambulance men, we have moved away from that and should practice to our abilities using our clinical judgement.


(oh.....this topic is covered quite well on the last number of AP courses and I think it should be rolled out to paramedic level as the lecture is quite interesting)

True I do not know you or your level so if you are a consultant rightly so you can do checks to rule out spinal injury if pain is felt by a patient.
This is about medics on ambulances though.

If pain they go in board.

That's the cpg at the moment.

I refer to being naive in terms of thinking that if you decide after someone says they have neck pain to do a few checks and rule it out as spinal injury. A parameduc cannot do that as per the cpg. It's as simple as that.

Your judgement may be excellent and we all know when someone is play acting but if you rule something out and go against your cpg it would not hold up in court if they indeed did have an injury.

I used my clinical judgement but deviated away from the guidelines and my training will only end one way if on the stand.


At no point in the cpg does it allow a paramedic to rule out spinal injury once they complain of pain. It simply says immobilise.

If no pain you can check for tenderness, pain upon movement, csm's etc to rule out injury if the mechanism is there.


The new cpg is very clear on this.