Backboards in the ED

EMS protocols have evolved to address this, although the newer EMT-B curriculum is more focused on cook-book answers than critical thinking in my opinion. We require a provider to clear the patient, but they get a higher ESI score and getting them off is a priority, especially if they are high risk for injury from the board.

No. We haven't seen this in the ATL. In fact, it seems the EMTs are back boarding more and more people based on protocoled order sets and increased pressure to adhere to protocols rather than employ critical thinking.

In terms of clearing them off the board, they are triaged and an MD (and only an MD in my hospital ), is immediately notified of the presence of a patient on backboard once they are triaged. They are then promptly removed from the backboard but because they continuously complain of illusionary (mostly) back and neck pain which shouldn't be present for another few hours, they remain in C spine precautions flat on their back whining and complaining for HOURS while they await a full assessment.

Afterwards, they complain of stiffness for reasons they find unfathomable.

(sorry for the extra dose of rant, about to leave on vacation and I definitely need it. lol)

EMS in our service area used to have a protocol that allowed us to not always collar and board patients in the field, but then they made protocols uniform statewide and we lost the protocol.

I wish there was a way to not board unnecessarily in the field because of the problems that can occur with boards, the least of which is discomfort. (Lots of dyspnea and you haven't lived until your boarded patient starts vomitting.)

I don't think I'm seeing a decrease in EMS use of backboards (will have to ask some medics ...) but in my ER we have a specific protocol to log roll patients off of backboards immediately after triage unless they have some very specific complaints -- and in that instance, getting an MD into the room to assess is considered a high priority.

We see a lot of backboards coming in. Some of the nurses feel comfortable clearing the spine, but I don't. I always let the doc do it.

I don't think I'm seeing a decrease in EMS use of backboards (will have to ask some medics ...) but in my ER we have a specific protocol to log roll patients off of backboards immediately after triage unless they have some very specific complaints -- and in that instance, getting an MD into the room to assess is considered a high priority.

Yes, that's what we're talking about and what I'm hearing about using an "evidence based" tool to at least get them off the spine board (again based on certain clinical/physical assessment criteria), BUT leaving the C-collar on if the neck is part of the presentation. The key is to also do it while EMS is at the BEDSIDE that's when you have the manpower to do it appropriately.

But again, if places are doing this, there should be an approved protocol with clear cut guidelines and a clear cut process that leaves nothing to guess.

Good post.

-Mark Boswell

MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P

"Support CEN certification and your local ENA"

No. We haven't seen this in the ATL. In fact, it seems the EMTs are back boarding more and more people based on protocoled order sets and increased pressure to adhere to protocols rather than employ critical thinking.

In terms of clearing them off the board, they are triaged and an MD (and only an MD in my hospital ), is immediately notified of the presence of a patient on backboard once they are triaged. They are then promptly removed from the backboard but because they continuously complain of illusionary (mostly) back and neck pain which shouldn't be present for another few hours, they remain in C spine precautions flat on their back whining and complaining for HOURS while they await a full assessment.

Afterwards, they complain of stiffness for reasons they find unfathomable.

(sorry for the extra dose of rant, about to leave on vacation and I definitely need it. lol)

Sounds like you could present the need for your facility to develop a policy to address this to decrease your patients whining and complaining. Look to the ENA for some guidelines and contemporary practice.

Keep up the tough work in the ATL.

Can you say where you work?

If not email me off list, got some info for you.

--Mark Boswell

MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P

"Support CEN certification and your local ENA"

One of the problems on the pre-hospital side is that every EMS service has it's own medical director and it's that medical director's overriding philosophy on how that system's medics will perform. Different services will have different protocols and standing orders. UNLESS, like the one poster said, they went to a state-wide universal protocol. The problem with that, is usually to get ALL the local medical directors on board (pardon the pun!) they will default to making the universal protocol the least common denominator (IE: the most restrictive effort - "board everyone")....quite a challenge to get some folks to start looking at evidence and resaerch.

-Mark Boswell

MSN FNP-BC CEN CFRN CTRN CPEN NREMT-P

"Support CEN certification and your local ENA"

as a paramedic I try to clear C-spine prior to using a spine Board. as someone who has been on a board for greater than an hour I know how much it hurts. with that said all the hospitals in my area need to have a MD clear the board, but they are usually good at getting that done while we are still there.

we have very selective spinal precautions criteria here is our protocol

It differs from quality of medic attending the call in some places, and in others it is a protocol issue.

My last agency I worked for had an awesome protocol for clearing c-spine. The medic could withhold immobilization or remove patients from boards as long as the patient met criteria. It was great because it gave the more experienced medics room to make their patients more comfortable, but wasn't mandatory so those who weren't comfortable could still immobilize prn.

I've also taken patients to hospitals that have strict criteria in having boarded patients evaluated by an MD within 10 minutes of arrival (even if holding for a bed) to have a determination made on clearance or immobilization. The agencies in this area didn't have c-spine protocol so even though there was a high number of non-sense immobilizations, the patients were off the boards pretty quick if not necessary.

I think either of these systems work as long as all parties involved understand the ramifications of prolonged immobilization. I remember seeing a paper in the last couple of years that put a significant increase in M&M on elderly patients who were immobilized for longer than 30 minutes and that the increase in severity was not correlated to their initial presenting condition.

There needs to definitely be more education and insight provided to not only the EMS providers but more importantly, the EMS medical directors.

1. No change that I have seen. The c-collar I can understand but the backboard baffles me.

2. Nurses in my ED don't clear boards - PAs/NPs/Docs do. Usually when someone comes in boarded, there is a comment note from triage on the tracking board alerting the fact that the pt. is 'boarded/collared'. If we're super busy, the RN assigned to pt./pod area will grab a mid-level/doc "hey, can we atleast clear the pt. off the board/collar?" - even if they haven't picked up the pt.

By and large however, our pts. are cleared (or remain immobilised post assessment) within about 10-15 mins. of arrival. There are very rare exceptions.

I am intrigued by this thread though and would like to research more! I'd appreciate more data. Given that we currently lack a protocol for 'clearing spinal immobilisation', I'm sure it would be of interest to the chaps running the department... and us nurses too :)

Check out ENAs website you say?

And on a side note:

*shudder* If there is one thing worse than board/collaring someone - it's board/collaring the chronic alcoholic combative due to "MoI".

Talking/reasoning with 'em is fruitless. Restraining 'em just riles 'em up more. *sigh*

cheers,