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.
Specializes in Spinal Cord injuries, Emergency+EMS.
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. :stone
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
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
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.
Specializes in Spinal Cord injuries, Emergency+EMS.
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...
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...
the physician (emd/trauma surgeon) is the person who clears the spine when a trauma patient is brought in fully immobilized. sometimes it's done during the primary survey and sometimes during the secondary survey. it's always done with the physician's order. perhaps if you have such issues with this you need to bring up the issue with them and tell them they are doing it wrong if you think that.....personally, i doubt you are that dumb, but who knows.
Specializes in Spinal Cord injuries, Emergency+EMS.
the physician (emd/trauma surgeon) is the person who clears the spine when a trauma patient is brought in fully immobilized. sometimes it's done during the primary survey and sometimes during the secondary survey. it's always done with the physician's order. perhaps if you have such issues with this you need to bring up the issue with them and tell them they are doing it wrong if you think that.....personally, i doubt you are that dumb, but who knows.
i see you didn't answer the question ref beds
the amount of proof by assertion and absence of evidence supporting prolonged immobilisation on the long extrication board on this topic is unbelievable, at least here in rightpondia we actually work as a team and exercise both advocacy for the patient and our professional competencies instead of hiding behind ' doctor's orders' as the answer to why poor practice is tolerated.
who is going to get in trouble when the patient gets a pressure sore?
who is going to get the blame when the patient stays extra days becasue of that pressure sore?
in case you failed to follow any of the links provided the clinical answer to the question is abundantly clear in that both the pre-hopital and in hospital clinical gudelines in the uk support early removal of the long extrication board ( both jrcalc andthe boa guidelines) and a the use of selective immobilisation guidelines by qats and pramedics - and consequently the same guidelines or canadian c-spine rule is in place in triage / initial assesment where it is used by 'ordinary' registered nurses ( as opposed to nps)
i don't have an issue with the clinical practice in the places i work becasue we follow the guidelines mentioend aobve and aim to remove patients from the long extrication board at the first appropriate opportunity, which is during the secondary survey - at their 'expose and examine' or 'inspect the posterior' depending on how the systematic approach is being used
the amount of proof by assertion and absence of evidence supporting prolonged immobilisation on the long extrication board on this topic is unbelievable, at least here in rightpondia we actually work as a team and exercise both advocacy for the patient and our professional competencies instead of hiding behind ' doctor's orders' as the answer to why poor practice is tolerated.
who is going to get in trouble when the patient gets a pressure sore?
who is going to get the blame when the patient stays extra days becasue of that pressure sore?
in case you failed to follow any of the links provided the clinical answer to the question is abundantly clear in that both the pre-hopital and in hospital clinical gudelines in the uk support early removal of the long extrication board ( both jrcalc andthe boa guidelines) and a the use of selective immobilisation guidelines by qats and pramedics - and consequently the same guidelines or canadian c-spine rule is in place in triage / initial assesment where it is used by 'ordinary' registered nurses ( as opposed to nps)
i don't have an issue with the clinical practice in the places i work becasue we follow the guidelines mentioend aobve and aim to remove patients from the long extrication board at the first appropriate opportunity, which is during the secondary survey - at their 'expose and examine' or 'inspect the posterior' depending on how the systematic approach is being used
that is exactly what i said, so if you weren't so quick to argue you would realize that. i did not answer the question about the beds because this was my first post. so, again....if you weren't so quick to argue....you would have realized that. sheesh!!!!! our hospital removes the board during the primary/secondary survey with a physcian's order. (level ii adult/pediatrictrauma center)
who is going to get in trouble when the patient gets a pressure sore?
No one if it occurred due to a potential spinal injury that was more important. It's the same reason you don't control a bleed before you have a patent airway. It's called prioritizing. As a nurse you should be familiar with this.
is abundantly clear in that both the Pre-hopital and in hospital clinical gudelines in the UK support early removal of the long EXTRICATION board
Then let them do it that way in the UK. Here in the US we realize that the potential for a spinal injury trumps the potential for a bed sore. Also, it's not a long extrication board. It is a long back board or a long spine board. Again, as a nurse you should know this.
I would recommend you take a class or two and educate yourself before you come to this board spewing flawed logic.
Ok then. Hopefully we can all agree that getting somebody off of a board as soon as possible should be a goal. Obviously, in a smaller facility with limited resources, people may need to stay on while waiting for medical evacuation to a facility with additional resources.
I understand the frustration associated with heated discussion; however, it would be foolish to discredit the treatment modalities of other countries. Remember, the LMA came from the UK. It is now frequently used in and out of the hospital within the USA. It even has the AHA golden seal of approval.
In fact, there is much research into this very topic. You can easily argue that traditional spinal immobilization can create additional problems and in fact may not provide the benefit of "spinal immobilization" that we have always thought.
As far as a Vac Mattress. I never saw one in the states. I recently used one on a medevac out of Iraq. I have to say, I am quite impressed. What a great tool.
I think we are all on the same page; however, it may take a little time before the policy makers make changes over here in the USA. I agree with you Zippy; however, things need to change before most of the RN's in the USA can take people off boards without orders.
Specializes in Spinal Cord injuries, Emergency+EMS.
No one if it occurred due to a potential spinal injury that was more important. It's the same reason you don't control a bleed before you have a patent airway. It's called prioritizing. As a nurse you should be familiar with this.
it's interesting you use that example especially when tactical teaching now uses a CABC approach approach where a catastrophic bleed is the first priority -
Then let them do it that way in the UK. Here in the US we realize that the potential for a spinal injury trumps the potential for a bed sore. Also, it's not a long extrication board. It is a long back board or a long spine board. Again, as a nurse you should know this.
can you prove your erroneous statements
1. A long Extrication board does not provide immobilisation above that of any reasonable surface whether that surface is the board, or a a trolley mattress or even the floor , certain surfaces may provide better immobilisation e.g. a vacuum mattress or even a properly applied Vest extrication device.
there is NO benefit to the person remaining on the board after the primary survey in the Emergency department, good handling techniques minimise the risks associated with moving someone with an unstable fracture - there is only one move you are possibly going to do betwee nthe primary survey and having an answer to whether there is a bony injury to the spinal column and that's onto the CT scanner bedplate AFTER plain film views whave been done on the trolley.
2. Long Extrication Board is the correct term for the device as described by the manufacturers and the majority of current Emergency care texts including JRCALC
3. In certain patient groups a long extrication board is a very poor tool particularly paeds - the younger the child the worse the it is and the elderly where aged realted problems such as kyphosis mens that a flat board offers little or no suport to the cervical spine and upper end of the throacic spine
I would recommend you take a class or two and educate yourself before you come to this board spewing flawed logic.
I would suggest that you review the literature, because by doing so you will note that my position is the one which is evidence based.
and what courses exactly do you wish me to take beyond TNCC, PHTLS and such alphabet soup and the fact i train and act as a field based supervisor for Ambulance crew and other pre-hospital care personnel?
the flawed logic here has come from the 'we leave people on a long Extrication Board until their neck is cleared' brigade and the people who associate extrication devices with appropriate and effective spinal immobilisation
Specializes in Spinal Cord injuries, Emergency+EMS.
Ok then. Hopefully we can all agree that getting somebody off of a board as soon as possible should be a goal. Obviously, in a smaller facility with limited resources, people may need to stay on while waiting for medical evacuation to a facility with additional resources.
or should they be transferred to a vacuum mattress by scoop stretcher in that scenario? not only does thevacuum mattress provide as good if not better spinal protec tion it substanially reduces the pressure damage risks and is not prohbitively expensive or hugely complex to use
Iatrogenic injury from prolonged use of the long extrication board has a probability of 1, and is none trivial , prolong use of certain immobilisation modalities has other adverse consequences as described earler i nthe thread - adverse events which will result in prolonged hospital stay are not acceptable and we need to consider how practice can be safely changed to minimise harm.
I understand the frustration associated with heated discussion; however, it would be foolish to discredit the treatment modalities of other countries. Remember, the LMA came from the UK. It is now frequently used in and out of the hospital within the USA. It even has the AHA golden seal of approval.
exactly
without adding further fuel to the fire the UK has a far more mature pre-hospital care community with much more buy in from Medicine and Nursing ... the attitudes and values aspired to by some of the more vocal about EMS Physicians in the USA fit much more with the Anglo-Australasian- canadian model of EMS provision than with the US model, where the education and autonomy of providers is far better developed.
US emergency care is certainly portrayed ( from within )as physician centric ( but not in the Franco-german model of physician field provider) and dogma based
In fact, there is much research into this very topic. You can easily argue that traditional spinal immobilization can create additional problems and in fact may not provide the benefit of "spinal immobilization" that we have always thought.
exactly
As far as a Vac Mattress. I never saw one in the states. I recently used one on a medevac out of Iraq. I have to say, I am quite impressed. What a great tool.
they are a very good tool and for prolonged management of the not cleared patient far more preferable especially if there is a transport dimension to the clinical picture
I think we are all on the same page; however, it may take a little time before the policy makers make changes over here in the USA. I agree with you Zippy; however, things need to change before most of the RN's in the USA can take people off boards without orders.
tis is not necessarily aobut policy makers , this is stuff that can be changed from the Emergency Department point of view relatively easily by adopting the position of the patient who comes in boarded gets immediate nursing and physician evaluation to determine the need to continue spinal precautions and to determine if the C spine can be clinically cleared - tools such as the canadian C -spine rule can be used here and do have an evidence base.
this is not necessarily about RNs taking people off boards it's two fold
1. advocating for a system which manages patients who come in boarded effectively - whether that's through prompt physician assessment or through a system of education training and supervised expereince to allow the Nurse to perform that evaluation
2. not unnecessarily immobilising self presenters through the use of a selective immobilisation guideline such as the canadian C-spine rule at triage / initial assessment
In a way it really is about changing overall hospital policy. In the defensive medicine based health care system within the US, it can be very difficult to change attitudes, policies, and ultimately physician practice. You are correct in that many modalities are simply "dogma based." I know many docs who would simply keep somebody on the board because that is how it has always been done. In addition, this is considered standard practice in many areas. Until we can get the physicians and people who make policy on board, many people are going to spend time on boards.
However, I agree with trauma nurse. Many facilities are pushing to remove the board following the primary survey and stabilization (Stabilisation for all you who speaks the queen's English. ) of life threats.
By the way, you would not happen to frequent one of the popular online EMS forums by chance? The name Zippy appears to stand out.
) of life threats.
ZippyGBR, BSN, RN
1,038 Posts
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