[northshore08]

In the community hospital EDs I have worked in the US, removing the pt from the backboard signals freedom to move. No matter how clear you try to be with the pt and with ancillary personnel (read imaging) if you are not there physically with the pt in radiology (or back in the ED,) chances are the pt will not remain immobilized and straight, even with a collar in place. And if the board comes off, the blocks usually come off as well. End of immobilization, except maybe for the C-spine if the doc left the Stifneck in place. I think this is why doctors leave pts on the boards until films are cleared.

Applying straps to a pt lying on an ED stretcher constitutes applying restraint, and requires reams of documentation. A backboard and straps instituted by EMS do not require the same documentation. Go figure.

I'm not saying it is right to leave Granny strapped down. I agree completely with getting everyone off the board ASAP. But the practice/reality is different. I try to get the docs to all my backboard pts quickly, and all the ED nurses I know do the same, especially if the pt is at increased risk of skin breakdown.

I'm not sure how y'all do it north of the border; that's how it looks in my nursing world.

[northshore08]

Zippy, I read the whole paper at the link you posted for the British Orthopaedic Association. It was very interesting and is a great resource document for pts with documented spinal cord injury, from initial eval to transfer all the way to rehab, including lots of good info about skin breakdown in SCI patients on beds. But I couldn't find any information about the use of long backboards anywhere, including the transfer checklist. Strange.

Now you all have me curious about time limits. After a bit more googling to get specifics, here is what I found.

http://www.spineuniverse.com/pdf/traumaguide/1.pdf has a 34 page document titled: PRE-HOSPITAL CERVICAL SPINAL IMMOBILIZATION FOLLOWING TRAUMA; page 17 addresses initial onset of pressure sores directly by quoting Linares in the journal of Orthopedics (see the reference on pg 23 of the PDF.)

According to their study, we don't have a lot of time to get folks off that board--only 1-2 hours. That means we help to speed up the process, from MD assessment through radiology so we can get them off the board.

This is some of the Linares et al. study info from PubMed. It says enough for me: www.ncbi.nlm.nih.gov/pubmed/3575181

[ZippyGBR]

Originally Posted by northshore08

In the community hospital EDs I have worked in the US, removing the pt from the backboard signals freedom to move. No matter how clear you try to be with the pt and with ancillary personnel (read imaging) if you are not there physically with the pt in radiology (or back in the ED,) chances are the pt will not remain immobilized and straight, even with a collar in place. And if the board comes off, the blocks usually come off as well. End of immobilization, except maybe for the C-spine if the doc left the Stifneck in place. I think this is why doctors leave pts on the boards until films are cleared.

systems design/ education issue , not a reason to unnecessarily restrain patients and cause iatorgenic injury - as radiographer is accountable for his / her omissions and the mossions or actions of an UAPs in the radiology dept who assists him/her.

a stif -neck type collar is one part of an immobilisation strategy - even an aspen type collar doesn't provide full immobilisation unless it's used with a thoracic brace component


as for those who doubted the evidence base for timely removal i hope the existance of anational Clinical guideline (JRCALC), a position paper from a relevant professional organisation ( the BOA paper) and the underpinning references to those and the references northshore cited answer your concerns.

put it this way i catch you giving one of my patients a pressure sore , not only would I encourage them to sue i'd help them go after your registration

[Medic15251]

so you advocate the assault and battery of all patients in case someone who is intoxicated might possibly make an injury worse.

Not at all. It's hardly a & b. If a pt was adamant about getting of the board I would explain the possible consequences then let them off if they persisted.

is physically restraining a person on a hard surface and causng them discomfort and injury acting in their best interests?

Many times yes. If I was the pt, I would want to be immobilized on a lbb until I was cleared by a doctor.

so patient with a correctly fitted collar, with head blocks and base in place on a trolley ( with straps or remaining in a vac mattress if necessary) in a static building is not immobilised ....

Not as well as when the pt is immobilized on a lbb. The matress allows for more movement.

time to definitive care is impoortant, however i f patient is not time critical you can and should take the time to ensure that their extrication is managed as well as it can be.

Again, we don't have as much diagnostic equipment in the field as in house. All pt's should be treated the same in regards to how long you stay on scene with a trauma pt. Simply put, you get them to the closest appropriate facility as quickly as possible.

put it this way i catch you giving one of my patients a pressure sore , not only would I encourage them to sue i'd help them go after your registration

That comment just shows what a small, ignorant, hateful person you are. It's no ones desire to cause a pressure sore to a pt, but if it means saving them from living in a wheel chair the rest of their lives, you bet I will. Of course, we should do everything in our power to get the pt off the board as quickly as possible, but that doesn't mean putting their life in danger to prevent the off chance of a pressure sore.

[ZippyGBR]

Originally Posted by Medic15251

Not at all. It's hardly a & b. If a pt was adamant about getting of the board I would explain the possible consequences then let them off if they persisted.

well

you have put them in fear of immediate harm without a lawful excuse ...

you have used physical force against a person without lawful excuse ...

Many times yes. If I was the pt, I would want to be immobilized on a lbb until I was cleared by a doctor.

would you ? or would the weeks if not months of pain and discomfort that you potential expose yourself to even if the immobilisation was completely unnecessary from a spinal bony injury point of view ?

Not as well as when the pt is immobilized on a lbb. The matress allows for more movement.

very much incorrect the easiest way to demonstrate this to climb aboard one of your ED trolleys with a sheet on the mattress get a colleague or two to push you about , now repeat hi with a long EXTRICATION board on the trolley as well - just to add to the fun don't use the straps ...

Again, we don't have as much diagnostic equipment in the field as in house. All pt's should be treated the same in regards to how long you stay on scene with a trauma pt. Simply put, you get them to the closest appropriate facility as quickly as possible.

incorrect

i'd rather wait 15 minutes with a stable patient for the fire and rescue service to do their worst to a Car or to secure me a path out , than risk exacerbating injuuries in a uncalled for mad dash

the RTC extrication instructors with the fire service tell all their students, firefighters, ambulance personnel, hospital medical team / immediate care scheme Nurses and Doctors you need 3 plans to get you patient out ...

plan a - the longest but safest way out - even if it means totally trashing a relatively undamaged car e.g. roof off or folded back, doors off, dash roll etc

plan b -an alternative if there is a problem in plan A or plan A simply isn't found to work in practice - sometimes this happens with a vehicle on it;s side or inverted ...

plan X - a rapid extrication for the time critical patient or if the patient becoms time critical during extrication

That comment just shows what a small, ignorant, hateful person you are. It's no ones desire to cause a pressure sore to a pt, but if it means saving them from living in a wheel chair the rest of their lives, you bet I will. Of course, we should do everything in our power to get the pt off the board as quickly as possible, but that doesn't mean putting their life in danger to prevent the off chance of a pressure sore.

a pressure related skin injury is a certainty in the immobilised patient if they are immobilised on a Long EXTRICATION board, the question is when and how bad ... again immobilise someone on a LEB leave them for 30 minutes then do a skin assessment

Along extrication board causes several points of high pressure and does not allow the spine to sit in its natural curves

exacerbating a bony injury and /or causing additional neurological symptoms is something which has a low probability if the patient is handled correctly ...

we do not nurse acute SCI patients on longboards once they are admitted to hospital even with unstable thoracic or lumbar fractures - they are nursed on flat bed rest with regular side to side turning/ 30 degree tilt as well as a alternating cell air mattress.

the attitudes displayed in this thread show extensive ignorance and a dogmatic patriarchial attitude towards patients.

[northshore08]

Zippy, you are not reading the posts that are responding to you. Your descriptions of pt care are centered in prehospital(read before the ED)and in spinal cord units. I think you don't get it. You are too busy looking for the next sentence you can use to denigrate other nurses.

I think the vampireslayer's original question was answered long ago. And I, for one, learned something from the research I did with my last response to Zippy. All the rest of his ranting is useless to me.

I'm done with this thread, y'all. BBFN and talk to you guys elsewhere.

[ZippyGBR]

Originally Posted by northshore08

Zippy, you are not reading the posts that are responding to you. Your descriptions of pt care are centered in prehospital(read before the ED)and in spinal cord units. I think you don't get it. You are too busy looking for the next sentence you can use to denigrate other nurses.

I think the vampireslayer's original question was answered long ago. And I, for one, learned something from the research I did with my last response to Zippy. All the rest of his ranting is useless to me.

I'm done with this thread, y'all. BBFN and talk to you guys elsewhere.

pre-hospital practice is emphasising the following

1. the long EXTRICATION board is an extrication tool and if transport time is prolonged a vac mattress should at least be be considered

2. that spinal immobilisation is the sum of all parts and the LEB is not the be all and end all , JRCALC also points out unnecessary immobilisation may be harmful

in the acute inpatient setting with SCI patients Long extrication boards are not used.

given caution is expressed by both pre-hospitla and the acute speciality over mis use of immobilisation and pressure damage is not an IF but a WHEN with the LEB - why do peopel consider it approrpaite for patient's to remain on it for prolonged periods ?

in terms of the OPs question - i'd support the practice of the deprtment they work in as a sensible compromise, once again i'm oncenred at the amount if radiation being dished out on the left side of the pond

[Medic15251]

you have put them in fear of immediate harm without a lawful excuse ...
you have used physical force against a person without lawful excuse ...

Wrong again. The pt consented to being placed on a lbb by ems. Again, I would explain the potential repercussions of them being taken off the lbb and if they persisted with wanting off I would take them off. No a & b. It's not hard to comprehend.

or would the weeks if not months of pain and discomfort that you potential expose yourself to even if the immobilisation was completely unnecessary from a spinal bony injury point of view ?

Yes I would. I would rather risk being sore for a while if it meant not living in a wheelchair the rest of my life.

very much incorrect the easiest way to demonstrate this to climb aboard one of your ED trolleys

I have been back boarded before. When it is done properly, it keeps the spine in an inline position where movement is greatly restricted to prevent further injury. A mattress allows for much more movement.

'd rather wait 15 minutes with a stable patient for the fire and rescue service to do their worst to a Car or to secure me a path out , than risk exacerbating injuuries in a uncalled for mad dash

Well of course! Don't put so much spin on my statements. In a trauma pt the goal is to get them to the closest appropriate facility as quickly as possible with out doing additional harm to them. I assumed you were educated enough to know not to hurt your patients. Forgive me for being wrong about that.

exacerbating a bony injury and /or causing additional neurological symptoms is something which has a low probability if the patient is handled correctly ...

I disagree. A pt can easily make a spinal injury worse or make only a spine injury into a spinal cord injury if not properly immobilized.

we do not nurse acute SCI patients on longboards once they are admitted to hospital even with unstable thoracic or lumbar fractures

Right, but we are not talking about a spine unit. We are talking about prehospital and the first little bit when they are in the ED. You can't compare apples to oranges. You have to compare apples to apples.

the attitudes displayed in this thread show extensive ignorance

Yes, namely ignorance on your part.

[veronicajr]

Zippy, you need to realize that your average ED does not have the advanced equipment needed to take care of spine pts the way that an ICU may have. I work in a 40 bed Level 1 trauma center/teaching facility's ER, and we have TWO trolley beds in the whole department. So no, not always an option.

[ZippyGBR]

Originally Posted by veronicajr

Zippy, you need to realize that your average ED does not have the advanced equipment needed to take care of spine pts the way that an ICU may have. I work in a 40 bed Level 1 trauma center/teaching facility's ER, and we have TWO trolley beds in the whole department. So no, not always an option.

what exactly do your other majors and resus patients get examined and cared for on ?

40 'bed' ED = 40 ( or more) ED trolleys surely unless you are counting 'consulting rooms' as a 'bed' and/or counting actual hospital beds on a CDU or observation unit as part of the the ED bed count

i'm worried if you don't have beds/trolleys with some kind of pressure relieving mattress top and some pillows.

someone who needs a halo or ORIF urgently needs to be either in theatre on on a vac mattress about to be transfered...