Nurses taking patient's off backboards without doctor clearnce? - page 5

The place I am currently working takes their patients off the back bard before the doctors clear the pt. Dose anyone know or heard of this practice anywhere and what studies have done to backed this... Read More

  1. by   CraigB-RN
    http://www.ohri.ca/emerg/nursing-cspine.html
    http://www.aemj.org/cgi/content/full...pplement_1/S48

    Granted this was from a 30 sec Google search and not a detailed meta anysis.

    I'm working on a more extensive search using a couple of legal databases for cases of law suits involving c-spine clearence. These take a litle longer as the search critera needs to be specific and such.,

    I'll admit up front that some of my comfort level in removing patients from long boards (Notice I didn't say clear a c-spine) come from the fact that over the past 30 yeras I've practiced in some out of the box locations. Locations were I was the only provider and if I didn't take them of the back board they would have layed there for 7+ hours. I've been a trauma/Sicu nurse, a Flight Nurse, As well as a EMT-P instructor in an area that allowed paramedics the ability to choose NOT to imobilize patients and a trauma researcher. I participated in a stufy in the mid 90's that looked at medical records from Vietnam looking for cases of C-Spine injury.

    I think in looking at this whole problem area, we need to look farther. Establish some common language. ie clearence vs removing long board imobilization. and base education and competencies. There is a lot of fear, due to some early education and thoughts that havn't stood up to the test of time. But there are a lot of areas in medicine that we took as dogma and found were wrong. That is the nature of medicine. In some cases the things that we thought were a given, turned out to be BAD for a patient.

    Will I continue to take patient off back boards, (not clear c-spines) yes, I've got education, trainign and experience and a written policy that gives me guidlines. Will there be patients that I won't take off a back board, Yes. Will I shake my head at nurses who put c-collars on patients in triage, when the patient had their MVC 6 hours ago and have been walking around is turning their head, left and right in triage, Yes. Will I do it, Yes becasue our protocol says to.

    The one thing I do in all those cases is to document my you know what off. I document the patient M&S when I get them from EMS, I document my assessents, and I document the assessment after I take them off the board.
  2. by   ZippyGBR
    Quote from mmutk
    <snip>

    As to the above post, I see no problem if you take a pt off the backboard after xrays are performed, but if you do it before xrays, you are liable for the patient suing you saying when you took them off the backboard you may have caused an injury to the neck.
    rationale?

    given that even with gold standard extrication at scene there is far more movement of the patient at scene than there is doing a controlled move in the emergency department , - one which does not involve rolling if you use a scoop stretcher to remove the patient from the board if you are unable / unwilling to undertake an examination of the back at that point in time

    i am somewhat alarmed that people seem to be quite happy to leave patients on longboards or indeterminate amounts of time , yet suggest they are acting as thepatient's advocate by maintaining a course of action which is acknowledged to be harmful to the patient.
  3. by   ZippyGBR
    craig nice to see someone else who can look beyond the dogma, just a shame that others allow the dogma to be reinforced - especially when others have done the leg work and taken the 'risk' in developing and validating assessment tools such as the canadian C-spine rule

    i think you are correct in assuming that that some of the other posters i nthis thread have not differentiated between removing the long board once extrication and transport is completed versus the actual clinical clearance of the C-spine - which is where the CCR comes in...
  4. by   ERbunny
    I work at the same facility as CraigB, and we have very defined criteria for taking patients off of boards, one of which is that they must be sober and cooperative. We have been following our protocol for at least 5 years without problems. It requires a team approach of 4 people and alleviates a lot of pt discomfort. We do keep them boarded if there is any question of injury, until the MD ses them.
  5. by   mmutk
    Quote from ZippyGBR
    rationale?
    Well, for example see http://books.google.com/books?id=A59...tUsfOuYwtZGyzY

    notice paragraph 5 and 6 states the lawsuit against the doc was because the backboard was removed prior to radiological evaluation of the spine and IT WAS BROKEN. Luckily a doc took it off and he got sued. If you think this won't apply to you (nurse) when you take someone off a backboard with a broken back, think again.
  6. by   ZippyGBR
    Quote from mmutk
    Well, for example see http://books.google.com/books?id=A59...tUsfOuYwtZGyzY

    notice paragraph 5 and 6 states the lawsuit against the doc was because the backboard was removed prior to radiological evaluation of the spine and IT WAS BROKEN. Luckily a doc took it off and he got sued. If you think this won't apply to you (nurse) when you take someone off a backboard with a broken back, think again.
    you have failed dismally to demonstrate a rationale relying solely on an anecdote and misapplication of that anecdote ....

    1. the cord injury was dicovered some hours after the initial incident, so quite possibly after transfer to an inpatient unit where nursing and medical staff may have been under the impression that the neck and back were cleared.

    2. According to the anecdote there were failures in clinical examination and the determination of which and when plain films should be performed ...

    3. This scenario is very different from the situation where a correctly performed removal from the board and re-institution of spinal preacutions pending a complete physical examination by an appropriate provider and radiology as indicated by the findings of the clinical examination, this patient has been transferred from ED trolley (?to a bed) to an operating table and back to bed apparently without spinal precautions ...
  7. by   mmutk
    Well I'm not here to argue with you. It's just my opinion that every patient is different, but the one time you take a patient off a backboard with an acute C T or L spine fx, prior to xrays; you are most likely facing a lawsuit and you will have plenty of time to practice your legal aspects then.

    :spin:
  8. by   RN1980
    zippygbr i belive you have failed dismally to convience me as well as others on this board that the patient as well as the nurse has more to gain by taking it upon themselves to remove the back board before being medically cleared or given a verbal ok. you have your way of doing things with the evidence that you have and i and ohters have our way with our beliefs in the best intrest concerning the patient and ourselves. i believe we have all made our points many times though that they are different. so we might as well shut the post down...
  9. by   CraigB-RN
    I don't think he's failed at all, just like I don't think "the other side" made their case at all. It looks like an area that needs more study and probably more inmportatantly more education for all involved. The catastrophic results of spinal injuries can sometimes give us what I think is an unhealthy fear of these pateints.

    We all come from different backgrounds and experience and work in different places that lead us to different practices. That is one of the diffuculties of nursing. Way to much is dependent on experience and the location you work. I've been fortunate enough to have participated in some of the research that identified that the majority of patients don't need the backboards at all.

    Out of all this, my biggest fear isn't that some take patients off backboards or not, it's the mechanics of taking patients of backboards. With this discusion, I looked at people taking patients off backboards and the technigue is terrible. And the documentation worse.

    Open discusion is a good think, it's hard to keep it proffesional and not let it get personal when both sides feel so strongly about things.
  10. by   ZippyGBR
    as craig and ERbunny have stated there need be no issue with the decision to remove a patient from a longboard ( an extrication device) once they are in the Emergency department, even if theiry are not 'cleared' as long as all the other precautions remain in place and the removal is done in a safe and appropriate manner with respect to patient handling.

    there is no reason for CYA immobilisation when there is the evidence base from the international use of the canadian C-spine rule by a variety of providers physician and none -physician , incidentially the Canadain C-spine ruleis held in sufficient regard in the Uk for it to be incorporated in out National Pre-hospital care guidelines

    removing someoen fro mthe long board and reducing their risk of iatrogenic injury does not equal clearance of the spine - which the anecdotal report mmtuk posted is about - where inadequate care by physician providers lead to a disocntinuation of pinal precautiosn without the proper physicla ( and if indicated ) radiological examination.
  11. by   mmutk
    Quote from CraigB-RN
    I don't think he's failed at all, just like I don't think "the other side" made their case at all.
    I am not trying to argue "the other side" here, as I said before I am not going to argue with you all, someone asked for a reference to my point and I went on google for 5 min and posted the first thing I came across. I'm not trying to argue a case and point here. I am just stating my OPINION (as I said before).

    Which is ...if I was a patient and I rolled in to your ER with a broken neck, and you went through the process of rolling me off the backboard before xrays were performed, i would tend to sue you because you can't prove my neck wasn't broken before you MOVED me off the backboard. However xrays and subsequent CTs would show my neck was broken after you took me off the backboard.

    And if I was on a jury I would find for the defendant also.
  12. by   CritterLover
    i've been watching this thread for a while now, interested to see what kind of practices the rest of the country has.

    i spent the past few years working in a fairly small er. our docs had to clear pts from the spine boards, but it didn't seem as though there was much to the exam -- rarely, if ever, did i see the pt xray'd prior to removal of the board. usually just a pe; palpation/inspection/"does this hurt?"

    before that, however, i worked for a few years in the icu of a level-1 trauma center. sometimes, a patient came to me from the er with the spine board still in place, usually when the xrays hadn't been done yet. when this happened, we usually used it to move them to the bed, and then removed it (via log-roll).

    (we did, though, take the spine board to xray with us when the ctls were done -- better pictures, we were told.)

    however, there was one noteable exception:
    i came in one night to find i had been assigned a new admission. the patient had an unstable cspine fracture. neurosurgery hadn't been able to operate yet -- i don't remeber the reason, maybe they needed some equipment; maybe they needed staff, maybe the patient needed something by way of stabelization.
    at any rate, the patient was going to the or first thing in the morning to have his spine fused.

    he was still intact, and the fracture was unstable enough that neurosurgery was very worried about what could happen during the night. so, this is what they did: he was still on the spine board, ccollar in place. the clothes they had cut off him were still under him on the board. he was taped securly to the board -- close to a roll of silk tape had been used, with "do not remove" written in sharpie all over the tape (by the neurosurgeon). he was intubated, and on continuous infusions of versed, morphine, and norcuron.

    he went to surgery the next morning -- i sent him before i left. when i came in that night, he was gone. to the floor. surgery was successful, he no longer needed icu care (so the above precautions were due to his spinal instability; the rest of his injuries wern't that serious).

    it has been so long that i don't remember what the specific injury was., but i want to say it was an odontoid fracture.

    i'm relaying this instance to reinforce that the spine board is not just for transport.

    and i'm sure that his neck was very painful when he came in to the er, and i'm sure that no nurse posting here would have removed his ccollar. however, he was never even log-rolled in the er to have his back inspected. he had a portable cspine done in the trauma room that revealed the fracture, and the spine exam stopped there (except for further xrays).

    who knows -- maybe neurosurgery was being ultra-conservative (they were pretty aggressive in treating spines, much more so than ortho), and he would have been fine sitting up in bed with the ccollar in place waiting for surgery. they obviously felt it wasn't worth the gamble.
  13. by   CraigB-RN
    ANd that sounded like the best care this patient could have gotten! Sounds like the patient got great care.

    The point that this thread still brings to bear is how much of our practice isn't based on a scientific fact. Dogma tends to bring out very emotional responses.

    I do remember many times cussing at the ER staff for the condition of trauma patients when they made it to my SICU. Now I am one.

    I remeber at one point in my career were I was sure I knew everything there was to know and that I was the right one. Now I've discovered that in many cases I"m wrong. I learned to not take it personally and learn, and get pass the fear and the "you'll get sued" mentality, and the we've always done it this way mentality.

    I know they have been done, but I'd like to see a flouro study or something like that to establish the best form of imobilization, short of HALO for these patients.

    But like it was said before, we've definitly reached the point of well passed diminished returns. I've enjoyed the discusion, it met the purpose of havign to think about what I do on a day to day basis and evaluate my and my co workers practice.

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