In Support of Backboards

ProperPlacement of LBB

“Proper Placement of Backboard”

One of my first really successful posts years ago was “A Short Take on Long Boards” where I found myself piling on the negatives regarding our habitual dependence on the Long Spine Board. I do not feel as though I can take any credit, however, for agencies such as the Palm Beach Florida Fire Department or the New York City Regional Medical Advisory Committee who have since chosen to abandon the practice of its use.  Many others have made their displeasure of the practice clear in endless commentaries on the topic. And the photo above on the “Proper Placement of Backboard” garnered many “Likes” on social media. It is the traditional reliance on the backboard, in an attempt to totally immobilize patients, based predominately on the MOI that has lead some to parody the practice in a clever cartoon episode. As a matter of fact, the only evidence I could find to support the use of the spine board as an immobilization device for transport was this randomized clinical trial setting it up against a vacuum mattress splint in a false dichotomy that I could only hope is a mocking satire. In an even deeper insult to our immobilization practice, Dr. Bryan Bledsoe, emergency physician and EMS textbook author, has also gone on to suggest limiting use of the rigid cervical collar as well. Suddenly, the topic of immobilization seems to be much more fluid.

Still, I fear some may have gone too far in calling for the removal of the LBB from ambulances everywhere. In general, we are often all too willing to jump from one bandwagon to another in an “all or nothing” dance to be more “evidence-based” than the next medic. I have heard colleagues suggest that the KED is the rightful heir to the immobilization throne, but in my mind that is like replacing the standard stretcher with a stair chair. In some cases one may be more appropriate than another, but the recognition that a tool has limitations does not mean it should be replaced in every instance. We simply need to become more aware of when to use it, not just remove the tool from the toolbox altogether. I feel we have done the same thing with response times, if they don’t ALWAYS matter, then they NEVER matter (but that is a topic for another post.)

The backboard remains a flexible extrication tool that is widely available and already well understood by first responders. Furthermore, it can be adapted for other uses. Another topic that is hot in EMS right now is High Performance CPR. While the basics of CPR have been around for decades, we are learning better ways to apply it and even understanding more about the science behind the mechanics of how it works. We know, for instance, that the patient must be on a firm platform for effective compressions and the backboard fits that need very well.  More recent research also suggests that tilting the compression platform to a semi-fowlers’ position decreases ICP for better brain perfusion. Instead of introducing a new device, the backboard can be adapted to this use by raising the head about the height of your bag.

It is great when we can improve the efficacy of our work without adding anything to the expense of it! The most difficult change is in our attitude.

22 Comments

  • Andrew Merelman says:

    Interesting stance. The reason that everyone is, “jumping from one bandwagon to another in an ‘all or nothing’ dance”, is because there have been no studies at all to support backboard use in any situation, even with confirmed spinal injury. If there were a proven beneficial use for the backboard I would gladly use it in those situations, but there is not. As is suggested, there are certain times when I would use it, but not for spinal injury. Those cases may be for restraint of combative patients, to immobilize the patient with multiple lower leg fractures, etc. The backboard was put into place many years ago with no evidence to support it. It was implemented simply based on theory. Now that we have evidence and research on the topic, we must change our practice to follow it.
    The CPR example you gave is vastly different than the backboard situation. We have a great amount of evidence on CPR and cardiac arrest care and we continue to obtain more data. We KNOW chest compressions work and have data to support them so therefore we continue to do them. However, if literature comes out suggesting ways to improve cardiac arrest survival rate we should absolutely change those practices as well. Scientific research is the only solid ground we have to stand on when it comes to deciding treatments. The industry must change with it and not treat patients simply based on theory or the “we’ve always done it this way” attitude.

  • I believe backboards have very limited use. In almost all of the situations another piece of equipment such as orthopedic (scoop) stretcher, reeve or KED can do the same job, most of the time better than to LSB. We have too much equipment on ambulances that have a single use in very limited situations, ie- traction splints.

  • Brian says:

    I find it interesting that you talk about people being top quick to adopt practices in an attempt to be more “evidence based” than others and then go on to endorse a practice based on a study of a dozen pigs.

    • daleloberger says:

      My point was not necessarily about how “quickly” opinions change, but about the “extremes” that our opinions often take. I like the quote from Dr. Suber below, “Be not the first to embrace the new, nor the last to leave the old.” In any case, I certainly see your point, however, about bringing in the research of what may only be a potential future practice. I appreciate the constructive criticism and only wish I have already had more experience to share. We do with what we have though.

  • Michelle Tonini says:

    I might take this article more seriously if it were written and researched by someone who has made emergency medicine their life and career like Dr. Bledsoe. Otherwise it’s just an op-ed from someone who does this for fun on the weekends but believes their opinion is just as valid.

  • Peter Burton says:

    The Queensland Ambulance Service (in Australia) changed back to soft collars a couple of months ago.. They are actually more comfortable, easier to apply and do a better job than the Stiffneck Collars. I used a backboard two weeks ago to get a patient off a roof of a house that was injured, one of the few times nothing else would have worked.

  • GT Surber MD says:

    “Be not the first to embrace the new, nor the last to leave the old.” applies here. Backboards have a long history with us. Leaving them will make many EMS and ER workers pucker hard. I experienced this this very morning with one of my Lieutenants. But with studies such as the review article in Trauma Journal, we are seeing them and c-collars as more harmful than helpful, it is time to rethink and apply logic and science. It is time to trust our Paramedics and allow them to apply the teachings for patient individualization that they have earned. Blind application of either backboard or c-collar is bad practice. Our biggest obstacle is the receiving trauma centers demanding both backboards and c-collars in all cases. The reference in “PreHospital Care” (To memory January of 2014 or 2015?) gives good guidance, but it needs to be cut and pasted some to make a good protocol.

  • RAE RAYMUNDO says:

    Gentlemen:
    If there are backboards your units don’t want to use, I’ll be more than glad and happy to solicit them all and send them to all my supported disaster and emergency rescue teams in the Philippines.
    As sending them over to the Philippines could cost me a lot, I’m now wondering, as I would appreciate it a lot, if your units could send them over here in Toronto where I reside. I would gladly give my residential addy if you could email me at reservecare2000@gmail.com. I would also welcome other life-saving equipment you may have for disposal that we could refurbish for our teams’ use. Thank you very much…!!!
    —RAE, RESERVECare Consulting

  • Eric Meier says:

    My thoughts on long backboards are as follows I agree we are too quick to dismiss or fall in love in extremes with fads. I think long backboards simplify transportation of injured individuals. Similar to a stair chair is it a necessity, no absolutely not. Is it a practical and effective tool, I believe it is. Most of what we use in ems is not necessary but makes our jobs easier and the and expedite patient care. Also similar to tcats not necessary but a good resource. I think as clinicians most of us should focus more on disease pathology and assessment rather than new toys, or in this case getting rid of old toys

  • Tom says:

    The use of back baords has been researched and is useful in “unstable” spine fractures. It is just that the incidence of an unstable spine fracture is very low when compared to not only stable spinal fracture but an unstable.

    • Tom Horne says:

      Did you hit the post button prior to being ready. It seams like your comment was cut off in mid sentence.


      Tom

  • Tim Tucker says:

    I have been having this debate for a while now. If these practices are so dangerous to our patients then why haven’t they been forever removed from our protocols. If we don’t use c collars then how are we supposed to prevent further damage to an already fractured c spine. Should we just go ahead and let them become paralyzed or worse sever the c-1 and stop breathing. I know that statement is dramatic but it has happened and to patients who.would have passed a Neuro exam The writer.asks why do we so quickly jump from one bandwagon to another. My answer is part.of the people jumping on this one is laziness. Some EMS crews are just too lazy to walk back to the truck and get the equipment to properly care for the patient. I understand that there are studies that suggest that the LSB should have limited use but let’s not just abandon a very useful piece of equipment just because we read a couple of articles

  • daleloberger says:

    The established historical standard for immobilization in transport has long been the long back board. Cautious medics everywhere have often used it according to protocols “just in case” because they knew it would mean less trouble if they did than didn’t. But now that the “emperor of immobilization” has been exposed as having no evidence-base for its use, how long do you think it will take before some agency is sued over the possibility of injuries inflicted as a result of actually using it.

  • Will says:

    many people ask “what do we do when backboards and c-collars go away”. Well, I don’t see backboards completely ever disappearing as they will have a place and purpose such as CPR and extrication. Soft collars have shown more promise than rigid collars. And the use of commercial movers such as we use with bariatric patients and/or bed sheets work well to move patients. Reciting the study in paraphrase by Dr Bledsoe, the Malaysian Hospital who was in the study had patients with possible SCI come in w/o any backboard or c-collar and still had more positive neurological outcomes than that of conventional prehospital spinal immobilization.

  • Charles Green says:

    A excellent discussion of a very current topic.
    Should you or should you not under varying conditions.

  • Richard says:

    How much room does a LSB take up in the ambulance?
    I know, no one ever properly immobilizes a trauma victim using padding in the curves of the spine and under the knees. Thereby, causing such misery making it more useful for the Salem witch trials and Spanish Inquisition.
    Same with that hard c-collar. It’s almost as if people are so anxious to inflict suffering with it that 12 inch falls from out of bed get incarcerated.
    However, I say keep the board for those just in case situations such as the earlier mentioned CPR.
    Consider the standing take down. A person walking around at a trauma scene, ie. building collapse, MVC. Neck and spine injury in question. Changing position to laying or even sitting exerts non axial forces to the spine.
    Standing take down is the safest way to get someone to a supine position, without applying lateral forces to the spin.
    Speaking of building collapse, the board can be used as a quicky sled, rather than grabbing a person by the shirt collar and dragging him through the debris. The slots on the board allow for more hands on to carry a person out of a difficult area.
    With a little imagination, the possibilities are endless.

    Just saying, don’t toss the LSB, not now, not ever

  • Karen Berlin Greene says:

    One of the best things about this article is the total absence of a “my way or the highway” attitude on the part of the writer. To me, the ability to express that tere is more than one way to look at a situation & encourage other viewpoints from all experience levels is the hallmark of a successful article. To that end, most of the comments and all of the responses to those comments were just as thought-provoking and informative as the original post and I learned much. It is encouraging to see people of varying degrees of experience in the field engage in a meaningful, respectful exchange of ideas rather than the grand-standing (or worse) outright rudeness that has become all to common in similar forums. I’m still considering all sides of the spine board issue and haven’t formed my own opinion yet, but when I do, it is nice to know there is a place it can be expressed without fear of ridicule or recrimination.

  • VickiG (@EMTP513) says:

    I don’t care, as long as it doesn’t harm the patient. I started my career as a witness of a person who had a medical trauma occur. I was 13 and she was 7, and I was watching her die in front of my face.
    I didn’t care what they did as long as it saved her life which, in this case, it did.
    I have no idea how I would have handled it if I’d been like someone I work with, who saw his brother lost in a fire. I don’t know if I would have felt a calling to the career. I felt it bc of my sister, whose life was saved by paramedics and EMTs when I was 13.
    That’s why I’ve never lost focus of doing the work for the ultimate benefit of the patient.
    For the record, I agree with the person who said KED’s, scoop stretchers and other equipment can do the job as well.

  • Dennis Dudley says:

    Don’t throw away the back board yet! You can have all the discussions regarding it’s validity but I am in favor of keeping it on board the rig. Scoop stretchers and Reeves are good and I have used them in place of the board, but I find the sturdy back board as a good way to get someone off a bed (until I can get them to the stretcher). I have found them to be very sturdy in child recreational areas. Any tool that is on the rig can be a great help, and sometimes you just need something that is super sturdy.

  • Gloria Bowman says:

    At a swimming pool, the use of a backboard is the most efficient and safest way for the lifeguards to remove an unconscious/submerged (non-spinal) victim from deep water. After the person has been rescued and brought to the side of the pool, the assisting lifeguard holds the victim in place while the primary lifeguard puts the board in the water. The person is not strapped on, merely flipped onto the board, and the two lifeguards pull the board with the victim from the water.
    In the less than 1% of cases where there is suspected head, neck or spinal injury in the water, Lifeguards are trained in both shallow and deep water to secure the victim on a backboard before removal from the water. No collar is used.
    In both cases, the backboard is the tool of choice.
    As an EMT for over 23 years, I’ve only considered using a backboard once when a patient collapsed and we initiated CPR. As a Lifeguard and Lifeguard Instructor Trainer, my staff train and practice with the board regularly. I won’t be removing this valuable tool from my arsenal anytime soon.

  • IF YOU HAVE EVER HAD THE MISFORTUNE OF HAVING A REAL MCI, BACKBOARDS ARE STILL AN ASSET.
    REMEMBER YOU MIGHT HAVE 15 AGENCIES WITH DIFFERENT LEVELS OF TRAINING, DIFFERENT FUNDING WHERE THEY MIGHT HAVE NEWER EQUIPMENT BUT NOT ENOUGH TO WORK AN INCIDENT. FIREFIGHTERS WILL BE ASSISTING, MOSTLY WITHOUT EXTRA TRAINING.
    A DOUBLE BUS CRASH ON AN INTERSTATE OR A COMMUTER RAIL INCIDENT WILL REQUIRE MORE CARRYING DEVICES AND A LOT OF HELP.
    WHAT IS EASIER TO USE WHEN VOLUME BECOMES AN ISSUE BUT A BACK BOARD.
    ALSO THEY ARE NOT MADE OF PLASTIC [ENVIRONMENT] AND CAN EASILY MAINTAINED. DON’T THROUW THEM AWAY YET.

  • Bill says:

    Good article. I’m stunned with the comments about “if a study exists showing backboards help” comment. You’ll never get an IRB board to approve such a study, but that’s where the methods of immobilizing the joint above and below the fracture come in. The comment about disregarding this post because the author is not like Bledsoe (DO, not MD). I actually appreciate the fact this author isn’t out trying to sell books, make a name on the speaking circuit, or uses studies that are so ludicrous, such as the Malaysian bus crash (yes, that’s the study that prompted Bledsoe’s movement against backboards and c-collars) to launch a crazed trend that will hurt patients. The studies that do exist regarding backboards show that they can cause more damage to patients, when prolonged use is applied. As with all splints (yes, we’re still splinting in the pre-hospital setting), you pad it and Vwalla! the injuries go away (yes, that was in all of the study’s conclusions, but left out during the big shakeup). Disregarding backboards and allowing field technicians to diagnose a spinal fracture in the field is not okay – ever. Have backboards been over used for non-spinal injuries – Hell Yes. That is what needs to stop – not throwing the baby out with the bath water. This fad is to a degree embarrassing. We know it’s neat to shake things up, but let’s get real about immobilizing a potential spinal fracture; turbulence during transport and the resulting inflammation will likely further the injury, if the damage hasn’t already been done. Rather than try to change an entire system because victims in a bus crash in Malaysia didn’t receive permanent spinal injuries, which the MOI indicated they could have, does not mean throw away a protocol that is consistent with immobilizing a fracture (immobilize above and below the fracture). Thank you for writing this article. It’s about time some common sense was brought forth on this subject, versus the arrogant position of “our idiot predecessors didn’t know what they were doing” agenda.

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