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:
****************************************
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.
At least any medic in the states that has half a brain knows that immobilizing to a lbb is a higher priority than potentially causing a bed sore.
once again someone who proposes a course of action which is not justified and which will cause harm.
take you tunnel vision glasses off ...
the other factor is your 110 hour first aiders are immobilising according to their cookbook ... it's not as if it;s health professionals immobilising to a good decision support algorithm and using their clinical skills...
Sure we have. Have your "civilized" medics that you supposedly supervise immobilize you to a lbb with a c collar and head blocks. Next observe your range of motion.
Now compare this to you laying on a mattress with no straps or head blocks.
who said anything aobut removing collar, head blocks ( and base) or straps ...
the actual items that provide immobilisation for the C spine rather than the spatula that aids extrication and handling at scene
It's common sense. You have way more motion. All it would take is for someone to come in the room and the pt forget he is supposed to lay still and raises to greet them then boom, spinal injury or boom, previous spinal injury now much worse.
la la land ...
dogma and scare mongering , also who said anything about removinmg collar and head immobilisation until the c spine is CLINICALLY cleared whether that clinical assessment is aided by imaging or not.
No I advocate keeping the pt immobilized until either a doc clears them or the pt refuses medical treatment (specifically being immobilized to a lbb). At the end of the day I would much rather potentially cause a bed sore as opposed to potentially causing someone to live in a wheelchair. We will all have to answer for our actions sometime. If you sleep well at night knowing you are practicing dangerous medicine more power too you, but as for me, I will practice caution and common sense.
you are not practicing caution and common sense
you are practicing hugely negligent, none evidence based cook book 'medicine' which vastly over states the likelihood of a spontaneouis worsening in neurological condition and conveniently forgets aobut the patinet who fidgets and struggles during their prolonged imprisonment
this thread has shown a distinct lack of understanding of evidence based practice, of good basic nursing care, patient advocacy and a lack of understanding of the appropriate use of medical devices, aside from the fact that we have people advocating the misuse of a a device which DOES NOT provide any benefits beyond extrication and initial transport.
IF THE LONG EXTRICATION BOARD IS SO ESSENTIAL TO GOOD SPINAL IMMOBILISATION WHY ARE PATIENTS WITH UNSTABLE SPINAL FRACTURES NURSED ON FLAT BED REST ON AN ORDINARY DYNAMIC AIR MATTRESS?
Once again i challenge anyone to provide proof of their assertions vs the already quoted positions statements that advocate prompt removal from the long extrication board on arrival to the emergency department.
Again, the crux of this discussion should be based around getting somebody off the board as soon a possible. I would hope we could all agree on this point. I simply cannot understand why we continue to argue. This seems such a simple concept?
Everyone is saying that getting someone off the backboard as soon as possible is a good thing. There's just one individual who keeps arguing ...I've chosen not to give him/her the time of day as it lends to the "beating a dead horse" mentality that has been going on.
Specializes in Spinal Cord injuries, Emergency+EMS.
as soon as possible is NOT
i) after imaging or
ii) after a full documented medical plan is there
it is during the initial assessment process when 'inspect the posterior' is reached.
beyond that point in time there is no benefit, need or justification for the patient to remain on the long extrication board as it adds no benefit to immobilisation i nthe stable environment of the hospital emergency department.
IF THE LONG EXTRICATION BOARD IS SO ESSENTIAL TO GOOD SPINAL IMMOBILISATION WHY ARE PATIENTS WITH UNSTABLE SPINAL FRACTURES NURSED ON FLAT BED REST ON AN ORDINARY DYNAMIC AIR MATTRESS?
You can't compare apples to oranges. In the field and in the ED the extent of the pt's injuries are largely unknown. The key in these environments are keeping the pt immobilized until a definitive medical diagnosis in regards to spinal injury has been made. That said, this should be done as quickly and efficiently as the circumstances permit. These environments focus on identifying the problem, stabilizing the injury, and preventing further damage or death.
Contrast that to a nursing spine unit where the environment is very controlled, a definitive diagnosis has been made, and the goal is toward progressing the pt to wellness.
You can't compare apples to oranges. In the field and in the ED the extent of the pt's injuries are largely unknown. The key in these environments are keeping the pt immobilized until a definitive medical diagnosis in regards to spinal injury has been made. That said, this should be done as quickly and efficiently as the circumstances permit. These environments focus on identifying the problem, stabilizing the injury, and preventing further damage or death.
Contrast that to a nursing spine unit where the environment is very controlled, a definitive diagnosis has been made, and the goal is toward progressing the pt to wellness.
So...in the end there is more than anecdotal evidence to remove the spinal immobilization as soon as possible. Sometimes its not even necessary to apply. Let's try to keep this civil and on topic please. thanks everyone....
As far as EMS and hospital differences, I agree and disagree. The environments may differ; however, many of the techniques can be utilized from one environment to the other. In fact, some of the techniques and devices that started out in the hospital are now common place in the field. I go back to my prior post that talks about the LMA. I really think we should at least consider the evidence and perhaps approach our medical director's and and challenge them to ensure we have guidelines consistent with current evidence based practice.
Could we not start utilizing vac mattress devices in the pre-hospital environment? I am not talking about placing somebody flat on an air bed like the hospital. The devices we use in Iraq, Afghanistan, and UAE are quite portable and allow for head blocks, c-collar, and the full immobilization techniques we all know and love.
So, I challenge you to look outside of your box and at least consider what you can do to change your current practice and practice at your facility or EMS service. I know when I go home and start flying again (hopefully), I will be talking to our medical director and clinical director about training in the use of these devices and placing these devices on our aircraft.
Perhaps I will fail; however, I owe it to my profession, my service, and my patients as a professional to constantly advocate for practice that will lead to better patient outcomes.
Could we not start utilizing vac mattress devices in the pre-hospital environment?
Maybe. The vacuum mattress is a good product to some degree although it does have significant drawbacks. The first one being cost. A vacuum mattress costs around $700. A traditional long back board (or long extrication board for those of us who are uneducated on proper medical terms) costs around $100. As we know many ems systems are either volunteer or taxed based. Do we really expect these services that already have problems with funding to take on the exuberant cost of more expensive equipment. Also, the services will still require a regular lbb to use under the vac mattress. You also have to look at the limited amount of space on an ambulance.
The list goes on and on. It just doesn't seem feasible at this current time. Until this option or others are more feasible, I again will say that the use of lbb in a prehospital setting is the gold standard for potential spinal injuries. Additionally, as others have mentioned numerous times, the goal in the ed should be to get the pt off the backboard as quickly and safely as possible. To me this means when the pt is cleared by a doctor after films are done and/or an assessment by a doctor. That is why they make so much more than a nurse. They carry more responsibility and liability. Perhaps if UK zippy wants the added responsibility she should spend more time going to medical school and less time arguing on the internet.
When I was on staff at a hospital in FL- It was not allowed until we trauma-rolled the pt and checked pt for tenderness. If the er doc had any doubts-we would xray stat then remove the board given there are no serious injuries seen on xray.
Now that I am in NY I see things are sometimes done differently. I see NURSES do trauma roll and remove the boards themselves(without assistance from a physician at times
I don't know if this is a facility specific policy or practice, but I leave it to immobilize the pt until the xrays confirm absence of injury. Pts usually understand.
Medic, I understand the issues; however, why not push for changes? We pay thousands of dollars for cardiac monitors and such, why not $1,000 for a couple of vac-mattress devices? As far as space, throw out the MAST/PASG pants?
Again, if we have alternatives that will prevent complications why not push for changes? $500 for something that can prevent a complication resulting in life altering effects and thousands of dollars if not more in monetary resource utilization is definately something to consider.
Push for changes, you can always find money. Trust me, my class in nursing school had to pay for it's own trip to state legislative days. In a matter of weeks, we easily raised $1,000.
When you use the phrase "gold standard" to define something, I think of the words definitive and nothing better. Clearly, alternatives that may produce better results exist. Clearly, evidence exists that demonstrates many negative consequences associated with back board use. I cannot agree that a back board is the "gold standard" for spinal immobilization. Do not dismiss a concept simply because it may be difficult to implement. If this was the case, we would still be hacking off limbs with hand saws on blood stained carts and anesthesia providers would be providing liberal doses of alcohol as their primary induction agent.
Not to say a vac-matterss is the end all to spinal immobilization. However, why should we not consider other devices and techniques?
Maybe. The vacuum mattress is a good product to some degree although it does have significant drawbacks. The first one being cost. A vacuum mattress costs around $700. A traditional long back board (or long extrication board for those of us who are uneducated on proper medical terms) costs around $100. As we know many ems systems are either volunteer or taxed based. Do we really expect these services that already have problems with funding to take on the exuberant cost of more expensive equipment. Also, the services will still require a regular lbb to use under the vac mattress. You also have to look at the limited amount of space on an ambulance.
The list goes on and on. It just doesn't seem feasible at this current time. Until this option or others are more feasible, I again will say that the use of lbb in a prehospital setting is the gold standard for potential spinal injuries. Additionally, as others have mentioned numerous times, the goal in the ed should be to get the pt off the backboard as quickly and safely as possible. To me this means when the pt is cleared by a doctor after films are done and/or an assessment by a doctor. That is why they make so much more than a nurse. They carry more responsibility and liability. Perhaps if UK zippy wants the added responsibility she should spend more time going to medical school and less time arguing on the internet.
I work in a UK emergency unit and we practice in much the same was a Zippy does, the patient is log rolled off the long board as soon as possible usually prior to a full assessment by a medic. I don't think Zippy is trying to practice medicine but I wonder if our practices differ because on arrival to the EU the patient will be met by a team of people who are all singing from the same hymn sheet, this team will include nurses, EU doctors, radiographers, health care support workers. We work collaboratively with our medics rather than waiting for them to give us the orders. We don't need the docs to be saying to us, I give the order to remove the spine board because the patient comes through the door and we are all working together with the same goals in mind.
Specializes in Spinal Cord injuries, Emergency+EMS.
I have had two types of experience with this:
When I was on staff at a hospital in FL- It was not allowed until we trauma-rolled the pt and checked pt for tenderness. If the er doc had any doubts-we would xray stat then remove the board given there are no serious injuries seen on xray.
Now that I am in NY I see things are sometimes done differently. I see NURSES do trauma roll and remove the boards themselves(without assistance from a physician at times
I don't know if this is a facility specific policy or practice, but I leave it to immobilize the pt until the xrays confirm absence of injury. Pts usually understand.
the patient is immobilised with the board removed assuming that collar, blocks, base and straps remain in situ, the long extrication board is a useful 'spatula' which is is generally not practiable to remove on an 18 - 20 inch wide ambulance trolley with a limited numbers of pairs of hands vs 4 or more people available in the ED ( ambulance crew + nurse + doctor)
the log roll itself is the greatest potential problem in the emergency management of the patient who you have decied to immobilise - hence the empahsis on alternative methods of putting someone onto a the board / vac mattress for none - extrication transfer- however this must be tempered with the valid clinical need to undertake the following
1. inspect the posterior of the patient
2. clinically assess the spinal column for bony tenderness and the presence of sensation
3. check anal tone / sensation if clinally appropriate
4. assess the skin for the early signs of iatrogenic harm
in terms of those unwilling to roll the patient without a physician present - are you using 2 physicians ? or one as the person at the head controls movement , but i also assume you want the physician to be able to undertake 1-3 of the above mentioned interventions
ZippyGBR, BSN, RN
1,038 Posts
once again someone who proposes a course of action which is not justified and which will cause harm.
take you tunnel vision glasses off ...
the other factor is your 110 hour first aiders are immobilising according to their cookbook ... it's not as if it;s health professionals immobilising to a good decision support algorithm and using their clinical skills...
who said anything aobut removing collar, head blocks ( and base) or straps ...
the actual items that provide immobilisation for the C spine rather than the spatula that aids extrication and handling at scene
la la land ...
dogma and scare mongering , also who said anything about removinmg collar and head immobilisation until the c spine is CLINICALLY cleared whether that clinical assessment is aided by imaging or not.
you are not practicing caution and common sense
you are practicing hugely negligent, none evidence based cook book 'medicine' which vastly over states the likelihood of a spontaneouis worsening in neurological condition and conveniently forgets aobut the patinet who fidgets and struggles during their prolonged imprisonment
this thread has shown a distinct lack of understanding of evidence based practice, of good basic nursing care, patient advocacy and a lack of understanding of the appropriate use of medical devices, aside from the fact that we have people advocating the misuse of a a device which DOES NOT provide any benefits beyond extrication and initial transport.
IF THE LONG EXTRICATION BOARD IS SO ESSENTIAL TO GOOD SPINAL IMMOBILISATION WHY ARE PATIENTS WITH UNSTABLE SPINAL FRACTURES NURSED ON FLAT BED REST ON AN ORDINARY DYNAMIC AIR MATTRESS?
Once again i challenge anyone to provide proof of their assertions vs the already quoted positions statements that advocate prompt removal from the long extrication board on arrival to the emergency department.