Re: Nurses taking patient's off backboards without doctor clearnce? Originally Posted by NativeSundance 
Hell will freeze over before I de-board a fully immobilized patient without a doctors order to do so. I work in a trauma center and it would be completely inappropriate for any nurse to randomly decide to deboard someone. Depending on mechanism of injury, the patient will not be de-boarded until the c-spine is cleared. In any case, the patient will not be de-boarded until the doctor states or writes the order to do so.
is there something magical that happens to a doctor's hands during the course of their professional education which makes it less risky for them to undertake a clinical examination than oany other suitabley educated, competent Health professional ...
no -one who has been immobilised should be un-immobilised until their neck is cleared whether that be clinically or radiologically where clinical clearance is inappropriate... the question which some respondents seem to be unable to see beyond is
1. what is the most appropriate Spinal immobilisation methodology for the ED vs pre hospital - specifically what the rationale behind keeping someone on a longboard once they have been transferred to the stable environment of a Emergency Department trolley and are in a clinical area of the ED.
2. are the definite risks for the average patient to remain boarded for potentially several hours commensurate with the very small additional potnetial risk that one additional handling procedure poses - given the majority of patients immobilised by EMS have no bony spinal injury and fewer still have lasting , or any cord symptoms.
In our ER, all immobilized patients are seen quickly by the MD to assess for board removal, so it really has never been an issue.
define quickly as the suggestio nfrom some sources i nthe uk is that patients should not remain on a long board for more than 20 -30 minutes - hence the reason some providers routinely carry vacumm mattresses and /or use split spine boards such as combicarrier so they immobilised directly to a conforming surface rather than a slipperly rigid 'spatula'
Certainly, no-one would argue that there are problems assosiated with prolonged boarding, but I think it could also be said that early board removal to avoid these problems takes the back seat to c-spine protection.
there is an element of throwing the baby out with the bathwater here, adequate C spine immobilisation does not depend on the presence or absence of a long board - as after all some peopel would support the statement that the best spinal immobilisation is manual control ... look at the phtls methodology of the 3 person rapid extrication and the emphasis this places on effective manual spinal control ...
look at theorthodoxy of none time critical extrication from RTCs again a lot of emphasis on manual inline immobilisation and the long board is used as a 'spatula'
Given the choice between a pressure ulcer and paralysis from my fractured c-spine...I'll take the pressure ulcer every day of the week!
chance of skin integrity damage from poor spinal management - approaches 1 even if you are completely uninjured
application of Spinal immobilisation by EMS or triage and actually bony or cord injury considerably less
Given the option of retaining my license or risk losing it over early board removal, I'll opt to retain my license every day of the week!
given that you risk losing your licence over your gross negligence in causing an iatrogenic wound ....
how do you justify not removing a device which is not longer required and is actively causing harm to your patient
In my ER, the trauma team is all experienced, TNCC certified, ACLS, PALS and NALS certified, and most are CEN certified. I personally have 24 years of ER experience and would not consider for one moment de-boarding a patient prior to MD eval. Policy or no policy, in the end it is
do you collar and board everyone who presents to triage with 'neck pain' and a possible MoI or do you undertake a clinicla examination and selelctively immobilise?
does your 'supplying' EMS provider(s) have a selective immobilisation guideline / protocol ?
MY license...and the patients future!
BTW: our policy clearly states that board removal is done ONLY after MD eval and either verbal or written order for removal. Some of the new "hot shot" "I'm so smart" "I'm just as competent as any doctor" "I want total autonomy" nurses will never understand this approach. We see them in our ER all the time. They don't last long.
and your evidence base for this ?
Please God...If I am EVER in a situation where I find myself boarded and collared, PLEASE PLEASE PLEASE let me awake to find myself in a trauma center where nurses are not making the "educated" decision to deboard me!! They don't have xray vision or the training to make that decision.
you don't need x ray vision to decide to remove a long board
you don't need x ray vision to decide to remove immobilisation
you do need appropriate physicial examination skills to justify your decision to irradiate someone
I have a very busy life God, and I need to be able to walk and move my body freely in order to perform my job and care for my family and farm. Please God, if I develop a pressure ulcer or experience any discomfort associated with the "big bad nasty uncomfortable board" I will ignore it and not hold you or anyone else responsible for it.
however a painful and time lost iatrogenic injury especially if you didn't have any bony , nevermind cord injury / symptoms is a big deal ... a triumph of pointless dogma with no evidence base over critical thinking and sensible analysis of the risks.
a signficant and /or infected pressure sore could result in some one being off work for siginficant amounts of time as it is healed / surgically repaired , those with existign cord injuries are a special case but it can involve hospitalisation and total bed rest for several months
- this could also be the delay in rehabilitation of an 'acute' patient with a cord injury who has been mismanaged in the early stages following their injury .
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