Is a backboard for transport only, or immobilization while in the ER?

[vampireslayer]

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.

VS

[Medic15251]

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 -

That's stupid. What good does addressing a bleed first do when the pt has no airway and thus no breathing? Based on your other backwards logic it comes as no surprise that you would address a bleed before an airway problem.

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

You are wrong. It doesn't take a rocket scientist to understand that a mattress provides for more movement (and a greater potential for spinal damage) than a rigid backboard.

Long Extrication Board is the correct term for the device as described by the manufacturers and the majority of current Emergency care texts

Not the ones I have seen. A simple google search of long extrication board brings up only references to long spine boards or long back boards.

and the fact i train and act as a field based supervisor for Ambulance crew and other pre-hospital care personnel?

I really feel bad for anyone that you supervise. That being said, why don't you continue your a$$backwards practices and continue singing god save the queen and having your tea and crumpets. I think we will be just fine here in the US with taking a logical approach to medicine.:chuckle

[ZippyGBR, BSN, RN]

That's stupid. What good does addressing a bleed first do when the pt has no airway and thus no breathing? Based on your other backwards logic it comes as no surprise that you would address a bleed before an airway problem.

the point which you seem to be unable to distinguish is that reevaluation of 'accepted truths' is an important part of developing Medicla / nursing / pre-hospital care ...

maybe you'd like the argue the toss with Col. Hodgetts, the British Army's head of emergency medicine

http://emj.bmj.com/cgi/content/extract/23/10/745

http://www.ramcjournal.com/2007/mar07/tourniquet_debate.pdf

http://www.guardian.co.uk/technology/2006/nov/30/insideit.guardianweeklytechnologysection1

http://emj.bmj.com/cgi/content/abstract/24/8/584

or perhaps you'd like to tell Col. holcomb that his enthusiasm for controlling catastorphic heamorhage is over enthusiastic

http://www.combattourniquet.com/tourniquet-testimonials.php

You are wrong. It doesn't take a rocket scientist to understand that a mattress provides for more movement (and a greater potential for spinal damage) than a rigid backboard.

so why is the gold standard of immobilisation the vacuum mattress which aims to conform to and support the body as it lays rather than a hard board which does not conform to the body ? why are there a number of disposble adhesive pads etc available for Long extrication boards to attempt to address the pressure relief issues?

I really feel bad for anyone that you supervise. That being said, why don't you continue your a$$backwards practices and continue singing god save the queen and having your tea and crumpets. I think we will be just fine here in the US with taking a logical approach to medicine.:chuckle

sorry last time I looked the USA was going to war over the dogma of others , or is once a gain a case that Dogma is wrong unless it's Uncle Sam's ?

i think the evidence base is there to at least question practice if not suggest that practice based on outdated dogma needs to be changed,

I laso think those people advocating causing avoidable harm need to take a very long hard look at their personal standards of practice becasue causing avoidable harm is not acceptable in any location.

[ZippyGBR, BSN, RN]

so we've already seen one post deleted for missing the point and getting personal.

if you are going to tell people they are wrong please don't do so on the basis of dogma, have some kind of evidence base

to the person who questioned my right to question the practices of others , i'm fairly sure that 6 years of in hospital emergency care and 10 or more of pre-hospital emergency care experience plus training ,assessing and QA responsibilities in both ( not to mention a slew of alphabet soup certificates and a Nursing degree with a my dissertation about a pre-hospital care topic) means i have at least the same right as anyone else to give an opinion without being called Bass-ackwards for stating that the accepted truth can and does get turned on it;s head sometimes or being accused of being mentally ill and on being on psychiatric medication.

[traumaRUs, MSN, APRN]

I think we probably all need to agree to disagree on this subject. I will say that having 10 years pre-hospital experience as well as 10 years in a level one truama center that we do things differently. Much depends on the personal expertise and education of the provider, the protocols in place, the size and capability of the hospital where you transport the patient, etc..

[TraumaNurseRN]

...we all know what I'm, saying here.......:barf01:and here....:jester:90% of what is said in jest....is true!

[GilaRRT]

However, we have to at least admit there is allot of research that really does not support the prolonged use backboard. I do not expect any guidelines to change overnight; however, we simply cannot refuse to at least look at the current evidence base.

In addition, not everything we do in the USA is the best way and visa versa. We are very progressive in some areas and lacking in others. I would think the prudent provider would want to consider other modalities and look at other forms of evidence. Refusing to at least look at how things are done in other places and the evidence behind the different modalities is a very myopic way to approach medicine IMHO.

[TraumaNurseRN]

however, we have to at least admit there is allot of research that really does not support the prolonged use backboard. oh i agree......i do not expect any guidelines to change overnight;(exactly) however, we simply cannot refuse to at least look at the current evidence base. no-one here has refused to look at the current evidenced based data, as far as each post has indicated.

in addition, not everything we do in the usa is the best way and visa versa. (exactly...but i put our healthcare way above most)we are very progressive in some areas and lacking in others. i would think the prudent provider would want to consider other modalities and look at other forms of evidence.(sure.....$$$ needed though) .....i would have to consider the cost associated with an urban hospital funding mattresses for ems when they can't afford monitors for many of their ed rooms)refusing to at least look at how things are done in other places and the evidence behind the different modalities is a very myopic way to approach medicine imho.(exactly)

we have a brand new state of the art ed with 65 beds, 90% with monitors, 3 trauma bays with every gadget imaginable. my point is in our level ii trauma center....we base removal of the back board based the the c-spine safety.....there's a simple reason why ....c-spine safety, and a physician and only a physician can say removal is appropriate in the states. that's basically where this argument with everyone came from. the hospital's p&p....can you imagine removing a backboard or c-collar without a physicians orde?....oh my

[ZippyGBR, BSN, RN]

TraumaNurseRN

postings in this thread have not looked at the evidence, becasue quite simply anyone who does look at the evidence comes to the same conclusions as JRCALC which is that you cannot support the use of the long Extrication Board for any longer than is absolutely necessary.

in terms of USAn healthcare being 'way above' other places , take a look at some of the discussion on this site with regard to how healthcare is funded and some of the figures that show that USAn healthcare is a unwell animal bloated by the parasites that are fee for service driving clinical decision making ( why do you think so many USAn ED patients get CT scans - it's not clinical it's the fact a CT is a bigger profit generatorfor the facility that good old fadshioned clinical decision making, plain films or USS - also it seems that the USA doesn't have effective medical radiation legislation) and the insurers profits .

Another little anecdote a set of guidelines used in leftpondia to reduce the number unnecessary CThead doens by Emergency departments has doubled or triplled the numbers done in rightpondian EDs -

Have a look at some of the posts from ED nurses in leftpondia talking about ED 'holds' that run into days even for critical care patients and couch that against the UK picture of >98.5% of patients being discharged or transferred from the Emergency Department in under 4 hours.

in terms of 'c-spine safety' that's sounding awfully like none evidence based dogma ' - none evidenced based dogma has been 'killing' people with sudden cardiac arrest and catastrophic haemorrhage - whch is why the 'accepted truths' there are turned on their head by the latest research and guidelines ( continuous compressions, Single shocks vs. stacked shocks and 'protocol C' in the case of SCA and CABC doctrine in tactical EMS / military casualty care)

in terms of the assertions that 'only a doctor can' is this actually phrased in such a way in primary legislation or is it just Doctors playing power politicis and not being kept in check by the rest of the team ?

can i imagine ? i don't need to becasue i have a selective immobilisation guideline and so do my pre-hospital colleagues so the patients who are collared and boarded generally do actually need it DURING EXTRICATION and primary transport ... but they come off the board ASAP on arrival because the board provides no benefitsin the hospital setting and will cause harm.

[Medic15251]

called Bass-ackwards for stating that the accepted truth can and does get turned on it;s head sometimes or being accused of being mentally ill and on being on psychiatric medication.

:chuckle:yeah::chuckle:yeah:

[TraumaNurseRN]

abc has become established as the ubiquitous emergency care paradigm, reflected across the spectrum of advanced life support programmes. military practitioners have been intuitively uncomfortable with this, as experience and evidence indicate that external peripheral haemorrhage is the leading cause of combat casualty death. in the uk military, abc has now been replaced by abc, where stands for catastrophic haemorrhage. the rationale for this change is explained in this commentary, together with its relevance to civilian practice. military ballistic injury is different from civilian blunt trauma.

this is from one of the sites he offered.....all i have to say about it is......helllllllo....of course military ballistic injury is different from civiian blunt trauma..duh!!!!!!:banghead: the article does not talk about c-spine immobilization.....hmmmm isn't that what this thread is about? actually, all of those sites deal with military articles, and military ballistic injury is different from civilian trauma.

[ZippyGBR, BSN, RN]

This is from one of the sites he offered.....All I have to say about it is......helllllllo....of course Military ballistic injury is different from civiian blunt trauma..duh!!!!!!:banghead: The article does not talk about c-spine immobilization.....hmmmm isn't that what this thread is about?

the point about CABC is that the 'accepted universal truth' that airway always comes first is wrong in certain situations, there arecivilian andeven none trauma situations where a CABC approach is merited but that is a topic for a different thread.

so dogma based 'accepted universal truths' aren't allways the most appropriate course of action

no-one on this thread has been able to sustain an arguement for why someone should remain on a Long Extrication Board after extricationnd primary transfer , some have acknowledged that this is suboptimal practice but consider the barriers to changing practice too great for a 'mere RN' to challenge , others continue to recite the dogma and are reaching for the pitchforks and flaming torches to burn the 'mentally ill ' heretic ... while it hasn't quite reached it is 'god's word' it's getting there , unless of course you worship at the altar of the physician as deity.

[TraumaNurseRN]

:deadhorse

the point about CABC is that the 'accepted universal truth' that airway always comes first is wrong in certain situations, there arecivilian andeven none trauma situations where a CABC approach is merited but that is a topic for a different thread.

so dogma based 'accepted universal truths' aren't allways the most appropriate course of action

no-one on this thread has been able to sustain an arguement for why someone should remain on a Long Extrication Board after extricationnd primary transfer , some have acknowledged that this is suboptimal practice but consider the barriers to changing practice too great for a 'mere RN' to challenge , others continue to recite the dogma and are reaching for the pitchforks and flaming torches to burn the 'mentally ill ' heretic ... while it hasn't quite reached it is 'god's word' it's getting there , unless of course you worship at the altar of the physician as deity.

:deadhorse