I posted this question in another thread about a nurse getting an MVC patient who had not been immobilized on a back board for transport to her ER, but I wanted to move it to it's own thread so I can get my question answered without hijacking that other post:
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Ok, I've looked through my TNCC book and my Emergency Nursing book, because I just hate to ask this question and risk looking like a total MORON! I've been in ER for a year now and SHOULD KNOW the answer to this question...but I've actually asked it of several people at work, and gotten different answers! (and the books just say HOW to immobilize using the backboard, not why).
So here goes: is the purpose of the backboard to immobilize the spine for transport only, or the entire time they're in the ER, until their spine is cleared via xray or CT?
I've had docs immediately take the pt off the backboard, based on their conversation and physical assessment, although they were pending results of xrays/CTs. I've had other docs insist that the pt stay on the backboard until the L-spine film is taken (but not read, just xrays have been shot) because the board helps get a better picture. But once the xray's been taken, they'll have the pt off the board, before the xrays have been read. And then I've got another doc who won't let us take the pt off the board until all films have been read and their spine has been cleared (could be an hour or two in the minor MVCs!).
We also have been told that one of the very important issues in the traumas is getting the pt off the board as quickly as possibly, because of the issue of skin breakdown.
So...what's the purpose of the board IN THE ER?
Oh, by the way, until their spine is cleared via xrays/CT, we do keep them lying flat, with the c-collar on, we log roll them off if we're taking them off the board, etc. But we very often put the pt on a soft bed before any xray/ct results have come back.
You can also do the easiest thing by asking the docs why they do what they do. I find that the progressive ones will tell you about the latest research and where to find it.
The ED I left late last year was the same as others listed on this thread; the docs gave a wide range of care, from those who left Granny on the board for hours while they CTed her from head to toe, to those who immediately did their prim/sec surveys and removed the board.
In the ED where I am now, the board comes off as quickly as possible. The collar is a different story, and usually stays in place until the neck is cleared.
I am a CT tech at night in a trauma center, and our docs are pulling patients off the boards right away, even when obvious damage is in the spine area. We have complained repeatedly about this, and are now being told that this is a "National Protocol." Anyone know anything about this? Being an ex-EMT, I have a huge problem with this, if this is the case, why have a backboard at all? Shouldn't the patient stay on the board until at least the x-rays/CT is done? Our standard answer to this is "the damage has already been done" ????????????????????
Would welcome any and all info for an upcoming meeting.
Thanks much:banghead:
How the heck do you do a CT when they are still on the bck board
The backboard is a great tool for keeping the patient still, and being able to not repeatedly move the patient back and forth until xray/ct is done. Otherwise, you are rolling them back and forth, trying to keep everyone on the same roll over and over, rather than a simple lift and over move for several exams. If the ER is on the ball, all radiology exams can easily be completed within 30-40 minutes, depending on what the ER doc orders done.
I was just wondering if anyone knows about a "national standard".
So here goes: is the purpose of the backboard to immobilize the spine for transport only, or the entire time they're in the ER, until their spine is cleared via xray or CT?
I've had docs immediately take the pt off the backboard, based on their conversation and physical assessment, although they were pending results of xrays/CTs. VS
YES! the board's purpose along with the C collar and other methods of cervical spine immobilization is to immobilize the spine until a medical provider clears the spine.
Clearing the spine does not need to be done with xrays and CT all the time. The provider might talk to the patient and realize they came in for a hurt thumb and EMS put them on a collar and backboard... at this point after assesing the spine and maybe the patient not having ANY symptoms or history or mechanism of injury that would or could suggest a spinal injury, the board can be removed. NO need to torture a patient, these things are hard and uncomfortable.
Anyway, I'm sure we all know, but never remove a backboard or collar until cleared by the MD.
As nurses, we can make sure the MD gets to that patient in timely fashion so that they are not lying on the board for hours before any diagnostics are done.
Good question, because we all know that EMS overuses the boards a bit. I don't want EMS to stop this practice because we need to make sure an injury is ruled out in the ED, but we can definitely advocate for our patients for a quick MD assessment.
Good question, because we all know that EMS overuses the boards a bit.
I disagree. It is the standard of care to back board any mvc patient that is being transported unless they make an informed decision to not be back boarded. We don't have xray vision. I would much rather be in court explaining why I back boarded someone as opposed to why I did not.
That being said, there are things we can do to make the experience less painful. Padding the voids is a big one. 9/10 it is not done though. Keeping the pt warm and encouraging the doctor to check them promptly is another. IMO protecting a pt from a paralyzing spinal injury trumps skin breakdown every time.
In the ED that I work at, we usually roll trauma/MVC type patients off of a hardboard onto our thinner sliderboards. It still keeps the pt flat and is useful for transport but can at least have a sheet on it and is a little more comfortable.
Also, I agree that protecting a pt's spine is superior to comfort, in the long run. I flipped a 4-wheeler this summer, and since I live in the country volunteer first-responders came to the scene before the county medics did. I knew my back was hurt, but as long as I was lying still my pain was controllable. As a result, no one thought that I had actually sustained any serious injury. Thankfully county medics still decided to put me on a board. My brother was the only one who knew me well enough to know that I wouldn't call EMS for the heck of it. It turned out that I had an L1 burst/compression fracture. So from personal experience, I'd prefer that EMS err on the side of caution.
Specializes in Spinal Cord injuries, Emergency+EMS.
Once the pt is place in full precautions, only the ERMD can d/c it. If you roll the pt off the board, you are d/c-ing precautions. Leaving the collar on is fine and dandy, but if there truly is a spinal fx, would you want to risk movement before an MD exam? Logrolling is good.....but what happens when the x-rays are done? Not all ER gurneys are set up to hold x-ray plates underneath and the pt must be rolled repeatedly for plate placement.
as an Emergency Care ( ED, assessment unit and pre-hospital) background Nurse who currently works on a regional Spinal injuries Unit
get the patient off the damn EXTRICATION board ASAP! if someone has got an SCI you may prolong their rehabiliation by weeks for every extra hour you leave them on the board unnecessarily. some people recommend 20 -30 minutes on a long board maximum - if transports are longer then a vac mattress should be used
removing the board is NOT NOT NOT discontinuing immobilisation - removing collar blocks, and telling the patient they are free to move as they please is dscontinuing immobilisation.
on the SIU we routinely nurse patients with unstable thoracic or lumbar fractures with NO immobilisation - they are 30degree tilted and on air mattresses for pressure relief ... ICU will nurse patients with cervical fractures unimmobilised when they are anaesthetised - vs halo or Aspen collar if they are up and awake
the log roll is useful as part of a proper trauma assessment but on the SIU we use a scoop hoist to transfer patients with unstable fractures from bed to ambulance/ theatre/ MRI trolley and back again ... in my pre-hospital practice the gold standard for a none time crtical transfer to a board will be to scoop the patient - time critical either log roll or the drag techniques that PHTLS faculty are now teaching
there is also the background issue of is your EMS a proper professional service with health professional providers or does it rely on physcian extender model with cook book medics and 'mother may i ?' protocols via 'on line medical control' - how many of your patients who come in boarded especially from RTCs walk out of the department an hour or later with a whiplash injury leaflet some ibuprofen and paracetamol !
the canadian C spine rule provides a good guideline for selctive immobilisation and is widely used i nthe UK both i nthe emergency department and a similar tool is in the JRCALC pre hospital guidelines and used by Registered Paramedics ( yes UK paramedics are a registered Health professional and are banded on the same AFC pay bands as RNs) and UK Qualified Ambulance Technicians
Specializes in Spinal Cord injuries, Emergency+EMS.
Thought-provoking post.
Related question: any tips for managing the the intoxicated, unruly or just plain uncooperative patient who refuses to remain flat? Other than documenting my butt off, which I do ...
I went in to a patient room last weekend to find my MVA patient who had multiple injuries standing at the bedside.
reove all restraints other than the Collar and document your clinical justification for doing so, alternative get a senior doctor to anaesthetise them and send them for a CT scan of head and C spine becasue they are 'cerebrally irritated'
restraining a combative patient is more likely to make their injury worse
Specializes in Spinal Cord injuries, Emergency+EMS.
As a general rule in my ER, we keep C/S trauma patients on the board until we see a negative CT/MRI result. It's really better to be safe than sorry, and while it is uncomfortable for the patient, it sure as shootin' beats being paralyzed from the neck down.
except it is dangerous and clinically negligent
what benefit does the patient remaining on the Long EXTRICATION board have above a patient with correct immobilsation applied on a modern Emergency department pressure relieving trolley mattress ?
as part of the trauma assessment the patient's p[osterior surfaces will have been inspected - the board should be removed at this point assuming that it has not already been removed for tissue viability reasons
a wound caused or exacerbated by poor pressure management will adversly impact on the rehabiliation of the patient whether they have an SCI or not and if you can't move and handle a patient with an actual or suspected Spinal bony inury you really need to think aobut your practice and /or the practice of the team you work in
in my ed we remove the longboards immediately -clarify dr removes longboard.pt will remain collared if has point tenderness or if md feels they can't clear spine w/o xrays and ct scans.we never leave our pts on long board .we use log roll and when pt goes to xray /ct md pa-c or rn has to assist with pt move .
removing the board is NOT NOT NOT discontinuing immobilisation
Tell that to the lawyer and watch him eat you alive!
some people recommend 20 -30 minutes on a long board maximum - if transports are longer then a vac mattress should be used
This is not logical. First, many services don't have this equipment due to cost. Second, they take longer to apply. As a trauma nurse you should know how precious those first minutes are.
get the patient off the damn EXTRICATION board ASAP! if someone has got an SCI you may prolong their rehabiliation by weeks for every extra hour you leave them on the board unnecessarily.
I would love to see the research and the journals that say this. I am certainly glad I am not a patient at your hospital. You are dead wrong about this.
northshore08
257 Posts
Quick pubmed search:
http://www.ncbi.nlm.nih.gov/pubmed/11310463
http://www.ncbi.nlm.nih.gov/pubmed/16246337
http://publicsafety.com/article/article.jsp?id=3437&siteSection=7 (this is a good one!)
You can also do the easiest thing by asking the docs why they do what they do. I find that the progressive ones will tell you about the latest research and where to find it.
The ED I left late last year was the same as others listed on this thread; the docs gave a wide range of care, from those who left Granny on the board for hours while they CTed her from head to toe, to those who immediately did their prim/sec surveys and removed the board.
In the ED where I am now, the board comes off as quickly as possible. The collar is a different story, and usually stays in place until the neck is cleared.