A Short Take on Long Boards

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have made their Position Statement on spinal immobilization for EMS publicly available.  So, now what?

It is hard to argue with their findings:

  • Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients.  However, the benefit of long backboards is largely unproven.
  • The long backboard can induce pain, patient agitation, and respiratory compromise.  Further, the long backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.
  • Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.

I know that I have been torn in my own mind while strapping an octogenarian to a rigid long backboard when the only indication for such treatment was that she slipped on the floor of a rest home.  Neurologically she may appear completely intact with a normal level of consciousness (GCS of 15), no complaints of numbness, lacking any spinal deformation or distraction injury.  However, our protocols say she must be strapped to a rigid device without padding and subjected not only to the jolts of our handling, but every bump of a threshold as the stretcher is wheeled outside and then she continues to suffer the uneven pavement between the Emeritus Senior Living facility and the hospital.  If she wasn’t sore due to the fall, she will definitely feel it by the time she is seen by a physician.  I know I am protecting myself from any potential injury lawsuit, but am I really protecting my patient?

The Prehospital Emergency Care statement suggests criteria where use of a long backboard would not be indicated.  Part of that definition includes the following recommendation:

  • Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher…

While I can imagine the greater comfort for my patient and even see the potential for improved spinal protection, it remains just a thought until the concept is adopted by my Medical Director and written into our protocols before I can actually change my behavior.  While I applaud the new recommendations in this position statement, I feel powerless as I continue to apply a non “evidence-based” treatment to my patients.  The primary restraint to change is not medical evidence, however; it is a lack of confidence that the field EMS personnel can make proper judgement calls on when the treatment is indicated or not.  What I fail to understand is how it would be significantly different as we are already given specific latitude to make that call only it is constrained by a far more conservative set of criteria.  Here is hoping a change can happen soon.

 

17 Comments

  • RedHeadedStepChild says:

    Finally, progress out of the dark ages…. We have field clearance protocols at our service. The local hospitals remove LSB before the MD sees the patient under their protocols.

  • Gabriel says:

    My department has already adopted exceptions for spinal immobilization for patients who are victims of isolated trauma (e.g. gunshot wounds), wherein they expect us to NOT backboard our patients. It’s not comprehensive, but it’s refreshing to see my state moving in that direction (I’m in Maryland).

  • Joseph Roberts, NRP, CCP says:

    It’s about time a group stand up against the tourture we are putting our patients through. Backboards are archaic and have one minimal uses in a EMS setting as far as I believe. The empirical data is there to support the change why are we not adopting this? We accept findings from the AHA as if they are handed down from God himself. Why can’t we look at the research on backboards and come to the same conclusions. There are numerous study’s that show that backboards have limited benefits and hinder patient care and can cause further injury to the patient. There isn’t one study out there that says backboards are truly beneficial. It’s time for us to wake up and set a new standard of care so that those that flow in our footsteps, God help them, have an appropriate treatment protocol to care for patients wisely.

  • Pamela Cook says:

    As a paramedic on the street, I have often thought the same thing. Seeing this just confirms my thoughts. FINALLY others are starting to see the same!

  • Skip Kirkwood says:

    “….it remains just a thought until the concept is adopted by my Medical Director”

    So take the article, go to your medical director, and say “Hey Doc, time for a change! Your protocols are now out of date; your fellow physicians say so!”

  • John says:

    The EMS system needs to have a dynamic link to the most up to date information and the ability to implement these changes as they become known. The bottlenecks in the system keep this from happening. These bottlenecks keep us from being able to do what is best for the patient. The powers to be need to get together and help us to do our jobs instead of restricting us in it.

  • Chris Connolly says:

    I think that the use of backboards is still appropriate with certain patients. We need to remember, treat the patient. Use your professional judgement. Of you think the patient is better off without the LBB, then make sure that you are ready to defend your decision. Same for if you do backboard the patient.

  • daleloberger says:

    I learned long ago that EMS and Fire services are resistant to change for some very good reasons. We don’t want to chase fads that don’t work any better than “trusted” methods and changing protocols can be difficult for service providers to remember… BUT, when the evidence is so clear and the change so easy and beneficial to implement, I wish there was a reasonable fast track.

  • Jo says:

    Anyone ever considered the use of the KED in those situations where spinal motion restriction may be a consideration but the long backboard is inappropriate for a particular patient? Protocol is fine, but my best EMS instructor taught me that rigid adherence to protocol creates cookbook paramedics who are unable to respond appropriately when a situation falls outside expected parameters. Experience taught me that as long as I could present sound reasoning to support my actions, medical direction was amenable to adjustments in protocol as needed. Change is good…if we are not changing, we are not growing, and if we are not growing, we are dying. It’s the 21st century and evidence based practice is here.

  • Scot Lisman says:

    I’ve been an EMT for 2 years. While I understand that a lot of trauma patients may not necessarily need a LSB especially if the transport is lengthy, but if the spine is compromised, how would be the best method of getting the pt to the cot without further compromising the spine due to lifting?

  • Dan says:

    One less reason for all knowing, non EMA PERSON to find fault with and provide public criticism of EMS care.

  • We believe in the progress of medicine via clinical evidence and field observation. We have developed a very economical, true Cervical Splinting System that offers new improved capabilities to EMS responders. These capabilities address most of the shortfalls identified by the clinical community and scientific evidence, as well as, allows rescuers to utilize alternative methods to avoid the use of backboards, holding manual c-spine, moving the head into alignment prior to transport and more.
    Also, there there are other alternatives to conventional tools & methods used here in the USA. Never the less it is not without the action of the Medical Direction in every region that providers will be able to use improved techniques and innovative tools. There are several exaples of agencies that have taken action already and moved in the right direction. You too, contact us for more information: info@xcollar.com

  • Andrew d says:

    Check out the Canadian C-Spine Rules, they are similar to the Nexus guidelines for C-Spine immobilization. I teach both of these to Adv Care Paramedics and they are taught to utilize clinical judgement based on mechanism, patient complaints, hands on assessment, and patient feedback. If immobilization is deemed necessary, a long board can be utilized when absolutely necessary; however, I also encourage Lateral Trauma Positioning (similar to transporting a female trauma pt with gravid abdomen). Consideration should also be taken to remove buckles, belt loops and other pressure point causing items from between the patient and the board. When possible, the board should be padded with a flat blanket.

  • Josephine Nabulime says:

    Sounds perfect but what alternative is in place if a back boad is the best tool i have?

  • Jeremy says:

    This has been a common discussion over the years. We once had the ability to do field clearance however that was lost when we got a new medical director who does not work in any ER. In the years we have had him I think I have only seen him twice. Under his protocols everyone gets fully immobilized to include something like a GSW to the hand. Our service took a huge step backwards when he came on and it will take years before we can get it changed. We have other tools like KED’s and scoop stretchers that work better and are far more comfortable to the PT. We need the freedom to do what is best for the PT and that will only come when EMS is fully recognized for what we do.

  • LBB’s DO NOT immobilize the spine – they never have and never will. Get yourself a scoop and vacmat and do the job properly …

  • daleloberger says:

    Bryan Bledsoe debunks the religion of spinal immobolization http://www.emsworld.com/article/10964204/prehospital-spinal-immobilization

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