Protocols regarding extrication of potential spinal injury patients from POV's showin

  1. Protocols regarding extrication of potential spinal injury patients from POV’s showing up at your ED.



    I need some assist. I need to present a protocol to be established for our ED for extrication of injured patient’s from their POV’s (Privately Owned Vehicles) which show up at our ED Door.

    Obviously, the ideal situation would be for the driver to have simply phoned EMS and allow those with expertise in Pre-Hospital Management to work their magic. (We have an excellent and well trained EMS system in the county in which our hospital is located! There are generally at least a couple of trucks at the ED, but not when always…)

    We serve a 5-6 county region, and some patients, their family and friends, just simply load & go…it’s a mountainous area, and MVC’s & ATV injuries occur frequently.

    We are fortunate in that most of our ED Techs are EMT Basics, we have a couple of RNs that are also working Paramedics, and have a couple of Flight Paramedics that work in our ED.

    I am current in PHTLS and TNCC , as are a few of my co-workers. btw I personally feel that it would benefit all of us to be proficient in extrication skills.

    I am saying all of this, because I realize that having professional EMS to handle these situations would be ideal, but sometimes care simply cannot, nor should not, be delayed.

    We obviously have C-collars on hand, a backboard with appropriate straps, and Multigrip Head Immobilizer or CID’s on hand.

    I plan to add a KED, or Kendrick Extrication Device to our gear.

    Also in the planning is instruction related to the above. One of the Paramedics that work in the Ed was also my PHTLS Instructor.

    The bottom line is that we are trying to Proactive , not just Reactive .

    So please lend me a hand. If you have any insight, or any Protocols regarding extrication, or just your qualified opinions, I’d appreciate hearing them.

    Feel free to PM or e-mail me, if you’d like.

    Thanks in advance.

    Regards,

    JJ
    Last edit by JJEDRN on Nov 23, '07 : Reason: to include total heading of thread
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  2. 14 Comments

  3. by   CraigB-RN
    Don't reinvent the wheel If your EMS has good protocols, just adapt them to your environment. Don't forget to iclude competency requirments.
  4. by   JJEDRN
    Craig;

    I appreciate the input. Good points and I definitely plan on utilizing the resources at hand.

    My apologies for not being more clear in my original post. My primary interest is in current Hospital Protocols, Policies and Procedure that cover Nursing Personnel and out of "physical department" C-Spine Immobilization.

    Credentialing will be an integral portion of the process. I don't foresee much of an issue with the backing of our ED Medical staff...but this has got to pass muster with Risk Management.

    So I'm just putting out feelers as to how other ED's are dealing with the actual or potential problem of having someone arrive at their ED door requiring C-Spine Immobilization.

    I am in the process of contacting other area ED's to see how they deal with the situation.

    Thanks again Craig.

    And Thanks to all viewing this and giving your input.


    Later,

    JJ
  5. by   Medic/Nurse
    Hey there JJEDRN-

    Craig has a good point --

    * No matter how many ways you try to reinvent a wheel - it's gotta be round to roll. (That is be able to roll into your ED)

    I think the big thing here is standard of care. There have been multiple studies (and opinions!) on the value of spinal immobilization of all MVC patients. I'm not sure how you will know who/what unless someone that is accompanying the patient comes into the ED in advance of the patient just walking in. A patient that walks in - well, that is a "easy" immobilization.

    All the equipment/policy in the world is nice to have, but marginally useful in the best of hands and disastrous in the unskilled. C-collar, in line manual stabilization, concerted removal to LSB with enough folks to do the job, secure to LSB - has to be done and done perfectly. I do like vacuum splints of all sizes for a variety of applications - including this one. I hate KED's though, I am confident that they are among the worst devices to immobilize a c-spine effectively that has ever existed. I will admit that the KED does give you some handles to hold and most have pretty straps - so it "looks good" but I would challenge anyone to try and "immobilize" me with one. I'd bet my life that I can move everything. The reason I "witness" on this is simple - my life could depend on someone getting it right.

    I have seen varying degrees of proficiency/competencies of responders that "immobilize" patients. (And most of the folks that I encounter do it on a regular basis!) So, whatever method you choose - CBO is gonna be essential. I'm not suggesting a course that goes through the motions - but being able to "do it" many times. You do play the way you practice.

    A word of caution: If "one" does not know "how" to effectively remove a patient from a POV - they should not do it.

    So, where does this leave you? Not sure.

    If I knew that a patient was in a POV and had neuro/sensory/motor deficits r/t injury or was unresponsive - I have called EMS to direct the removal of the patient from the POV. I have had times where the ED did NOT have the equipment and well trained staff to accomplish the removal of the patient in an optimal manner! After all, we are all in the same business. I'm not suggesting abusing the EMS system - but, I will do the best thing for the patient - regardless.

    This is a low stakes skill in the uninjured and a massive liability procedure in the patient that has a SCI - so, when in doubt, always just choose to do that in which your patients best interest is paramount.

    Heck, I have had times that I could not find enough well trained staff to log roll a patient in a optimal manner - thankfully that is rare.

    Good Luck


    Practice SAFE!
  6. by   NewRN2008
    I am on a rsq squad in my county, volunteer, and we actually are considered #1 in extrication. Sorry, had to start with that, VERY PROUD of what i and we do.

    When i went in they already had the protocols, but i did take part in revising them. You can find protcols online a lot of times from other departments. But i really agree with finding "someone" in your area and having them do teaching and adopt their policies. At least then you have somewhere to start, you are making an effort to make things a Community Wide Effort to help people, and you wont have to start from scratch!
    If you cannot find anything online, i will see if i can find our policies, but being in school, i do not get much time at our HQ.

    GL! have a blast!!! i LOVE all of that!

    -H-
  7. by   JJEDRN
    Good Advice and Much Appreciated!

    Fire & Rescue do the majority of extrication here...based on your recommendations I've contacted them and our local Search & Rescue and will work from that perspective.



    Quote from NREMT-P/RN
    Hey there JJEDRN-

    I think the big thing here is standard of care.
    Agreed!




    Quote from NREMT-P/RN
    All the equipment/policy in the world is nice to have, but marginally useful in the best of hands and disastrous in the unskilled. C-collar, in line manual stabilization, concerted removal to LSB with enough folks to do the job, secure to LSB - has to be done and done perfectly. I do like vacuum splints of all sizes for a variety of applications - including this one.
    Any particular vacuum device for this?




    Quote from NREMT-P/RN
    I hate KED's though, I am confident that they are among the worst devices to immobilize a c-spine effectively that has ever existed. I will admit that the KED does give you some handles to hold and most have pretty straps - so it "looks good" but I would challenge anyone to try and "immobilize" me with one. I'd bet my life that I can move everything. The reason I "witness" on this is simple - my life could depend on someone getting it right.
    LOL...Pretty much what I get from S&R, as well as Fire. They say the handles are great for thru the roof extrication, but that's about it...



    Quote from NREMT-P/RN
    I have seen varying degrees of proficiency/competencies of responders that "immobilize" patients. (And most of the folks that I encounter do it on a regular basis!) So, whatever method you choose - CBO is gonna be essential. I'm not suggesting a course that goes through the motions - but being able to "do it" many times. You do play the way you practice.
    Again, I agree. We tend to default to our level of training in times of stress.





    Quote from NREMT-P/RN
    If I knew that a patient was in a POV and had neuro/sensory/motor deficits r/t injury or was unresponsive - I have called EMS to direct the removal of the patient from the POV. I have had times where the ED did NOT have the equipment and well trained staff to accomplish the removal of the patient in an optimal manner! After all, we are all in the same business. I'm not suggesting abusing the EMS system - but, I will do the best thing for the patient - regardless.
    Given the opportunity, patient condition allowing, this is definitely my default plan. And I have discussed it with our primary EMS.

    Thanks again.

    JJ
  8. by   JJEDRN
    Quote from somedayrn2008
    I am on a rsq squad in my county, volunteer, and we actually are considered #1 in extrication. Sorry, had to start with that, VERY PROUD of what i and we do.
    +1 Good Work!




    Quote from somedayrn2008
    When i went in they already had the protocols, but i did take part in revising them. You can find protocols online a lot of times from other departments. But i really agree with finding "someone" in your area and having them do teaching and adopt their policies. At least then you have somewhere to start, you are making an effort to make things a Community Wide Effort to help people, and you wont have to start from scratch!
    If you cannot find anything online, i will see if i can find our policies, but being in school, i do not get much time at our HQ.
    Thanks for the advice and the offer.


    Stay Safe,

    JJ
  9. by   ZippyGBR
    interesting no one has mentioned the 'gold standard' of extrication , which involves firefighters and heavy machinery ....

    which given the amount of EMS based Fire services i nthe states is suprising ... given that our entirely seperate fire and resuce services here in right pondia have no problems with coming and smashingcars up for extrication...
  10. by   bigsyis
    With the c-collar, KED, a backboard, and a stretcher, you would extricate them just the way you are taught to do it in BTLS. No biggie, just time-consuming.
  11. by   EricJRN
    Quote from ZippyGBR
    interesting no one has mentioned the 'gold standard' of extrication , which involves firefighters and heavy machinery ....

    which given the amount of EMS based Fire services i nthe states is suprising ... given that our entirely seperate fire and resuce services here in right pondia have no problems with coming and smashingcars up for extrication...
    I think we're referring to times where the car is driven to the ER, so usually extrication tools won't be needed.
  12. by   ZippyGBR
    Quote from EricEnfermero
    I think we're referring to times where the car is driven to the ER, so usually extrication tools won't be needed.
    i'll see if i can find the picture of the new that week police vehicle which was roof and door chopped because a police officer was daft enough to sit someone from an RTC in his vehicle rather than back in their own or down on the ground ...

    the gold standard of extrication of a sitting patient in a none time critcal situation is out in a straight line - not out the side door given the spine board discussion where people are suggesting that the patient must stay o nthe board until radiologically cleared to then advocate an extrication method which involves deliberately twisting and turningthe patient is a somewhat illogical route to take
  13. by   bigsyis
    Quote from ZippyGBR
    the gold standard of extrication of a sitting patient in a none time critcal situation is out in a straight line - not out the side door given the spine board discussion where people are suggesting that the patient must stay o nthe board until radiologically cleared to then advocate an extrication method which involves deliberately twisting and turningthe patient is a somewhat illogical route to take
    In BTLS there is no twisting involved, especially if a KED is used.
  14. by   EricJRN
    Quote from ZippyGBR
    i'll see if i can find the picture of the new that week police vehicle which was roof and door chopped because a police officer was daft enough to sit someone from an RTC in his vehicle rather than back in their own or down on the ground ...
    But what makes that a funny photo is that the rescue personnel apparently went so far outside the standard of care (gold standard or otherwise) in cutting up the car. To me, sounds more like interagency strife than something that was done out of genuine concern for a patient.

    A graduate of a prehospital care/EMS program, or even someone who spent a weekend at BTLS, should be able to work with a team and move a patient as a unit to avoid twisting.

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