Home Uncategorized Everything You Know About EMS is WRONG, WRONG, WRONG, Backboard Edition

Everything You Know About EMS is WRONG, WRONG, WRONG, Backboard Edition

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Earlier in the week I posted a partial list of EMS myths that just seem to hang in there despite no evidence to support them. In fact, some of them hang in there despite evidence that they not only don’t help, but may cause harm. chiefjaybob was crushingly disappointed that I didn’t mention backboards. Since there was no disagreement among my friends, I didn’t feel the need to rehash the issue.

The problem is that outside my circle of friends, there is a lot of disagreement about this. A lot of paramedics have predicted The End Of The EMS World As We Know It if we stop using Middle Ages inspired devices to “help” our patients with potential spinal injuries.

Keep in mind my dicta that “It’s only help, if it helps”.

C spine immobilization on a long board doesn’t help. In fact, it probably hurts. Correction, it hurts. Not only is it uncomfortable and painful, it can actually cause permanent harm to the patient.

I know that this has been a difficult few years for the doesn’t like change in EMS crowd, but the essence of EMS is to continuously improve patient care. Part of that is discarding that which is proven not to work.

First we cut way back on Oxygen delivery, restricting it to the few cases where we know it helps. We know that high levels of O2 can actually cause harm and reduce survival rates for some patients. Still, it took a long time to convince EMS agencies to adopt the new approach.

That was jarring enough, but now we are on the verge of destroying yet another staple of EMS treatment… spinal immobilization.

Here are what I call some Spinal Immobilization fun facts;

The entire practice of immobilizing patients to reduce the risk of permanent spinal cord injury (SCI) is based on a single paper published in 1966. That’s not a typo, that’s almost 50 years ago. That year a paper was published documenting twenty nine cases of delayed paralysis in trauma patients transported by ambulance. The fault was laid on the ambulance crews, but it was anecdotal. There was no rigorous scrutiny of the care delivered, there were probably no patient care reports to review, it was just anecdote. Which should not be confused with fact or science. Another term for anecdote is “war stories”. So a level of evidence no better than a bull shit session over some beers lead to a nationwide (and probably international) treatment that had to be rigorously followed.

Based on that paper, the American Academy of Orthopedic Surgeons (AAOS) published an opinion that immobilization should be used for patients with signs and symptoms of spinal injury. Again, no evidence, just opinion.

So, from the mid 1970s, which was what we could term the “Modern era of EMS” forward that was the gold standard for treatment of suspected spinal injuries. Oh, bye the bye, no patient with a confirmed SCI has ever regained full neurological function. None. Nor is there any evidence that immobilization has prevented anyone from a SCI. None.  As it turns out, the  injury is caused at the moment of impact, even if the effect might be delayed. Energy against the spinal cord is what causes the injury.

Starting about 15 or so years ago some science slowly crept into the debate. Studies published in 1998, 1999, and then this year all demonstrated that putting a patient on a back board didn’t help. Not one bit. Nada, zilch. ixnay. Not only that, but even when done properly (when was the last time you padded voids?) immobilization still allowed significant (up to 4cm) of lateral movement.

Then the evidence that immobilization caused injury started to come out.

What kind of injury?

Respiratory distress. Older patients, patients with COPD and/or CHF, larger patients, all are at risk for suffering respiratory distress and failure from being laid supine on a backboard and then having straps tightened across their chests and abdomens. That’s real harm.

Pressure injuries/Decubiti. It takes about 20-30 minutes for patients placed on backboards to start developing skin injury from being placed on a hard board with straps… Elderly patients in particular, but even younger healthy patients can be affected.

Average time that patients spend on backboards in the Emergency Department before being cleared? Two hours.

That’s not to mention the aches and pains and possible nerve damage from being strapped down onto a hard board for extended time. A few years ago I suggested that every medical director in the country should be required to be immobilized on a back board in their home, driven to an emergency room, and then left to lie in a treatment room for about two hours before they were released. THAT would change protocols pretty quickly. Alas, it never happened, so it took a bit longer for this to change.

Need more convincing?

Patients with penetrating trauma had worse outcomes if they were immobilized. Yet, I know people who insist that all penetrating trauma above the level of the navel should be fully immobilized. I’d bet that there are EMS systems that still require that.

By the way, that includes patients with penetrating trauma to the head, including gun shot wounds. Actually, it’s even more significant with those patients as lying them flat and strapping them to a board increases there likelihood of death.

Intermediate devices, such as the KED or short backboard, increase movement, not decrease it. Patients who self extricate have less movement. No one has (yet) looked at rapid extrication, but my guess based on my experience (yes anecdote) is that movement is less than manipulating a patient into a KED or onto a short backboard, but probably a bit more than self extrication. So, all those nasty grams about letting patients get out of the car on their own and then sit on the stretcher are probably meaningless.

The new treatment recommendation is to put a Cervival Collar on the patient and then place them on the stretcher in a semi Fowlers position where they are comfortable. The patient will not only complain less about the transport, they are likely to have a better outcome.

One last head spinning bit of information. If for some reason you feel the need to use full immobilization, the backboard still is not indicated. It turns out that the scoop stretcher, long one of my favorite EMS implements, does as good a job immobilizing and is more comfortable (a relative term) than a backboard. Just make sure to keep the patient from directly contacting it on a cold day! The human shape just conforms to the shape of the scoop more readily than it does to a backboard.

Of course I expect it to be anywhere from 2-5 years before this becomes the accepted across the EMS world. One of the hardest things to do in EMS is to get people to abandon long cherished beliefs on what works. It took years go get medics to abandon the idea that Sodium Bicarb was beneficial in cardiac arrest despite the American Heart Association changing it’s guidelines.

Hopefully chiefjaybob is satisfied now. I strive to keep my reader base as happy as possible.

 

What about pediatric patients? Same risks and still no benefit.

 

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After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it? I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs. I still write about EMS, but I'm adding more and more non EMS subject matter. Thanks for visiting.

13 COMMENTS

  1. Sorry, I had to do it.

    I have felt this way about backboards for some time. It’s starting to creep this way; the neighboring EMS system has finally gone to scoop stretchers as the preferred immobilization method.

    I must say, however, as a provider of nearly 25 years, it is intensely frustrating to be told– ORDERED– by doctors who KNOW BETTER (’cause they’re, ya know, doctors), that Treatment X is the gold standard and you WILL DO TREATMENT X, only to be instructed years later that Treatment X is in fact, detrimental and must not be done. I was very glad you touched on oxygenation in your argument above, as I think it’s the most egregious example. For years it was pounded into us: HIGH FLOW O2!!!!!1!!!! Now we’re being told something diametrically opposed to that. How many times have various drugs been brought in as the NEW GREAT LIFESAVER, only to have them pulled later as causing more deaths than lives saved. I fully understand that study and examination of efficacy are crucial parts of medical care, but more than one complete reversal is, as I say, eternally frustrating. That is all. BACKBOARD!

    • I feel your pain, but the truth is that we mostly don’t know what works and what doesn’t. EM and EMS (not the same things) were until recently outside the main stream of medicine. Science in EMS is a recent thing and some people still fight it tooth and nail. Unlike Rogue Medic, I don’t feel the need to slavishly follow every new study that comes out.
      The Oxygen thing came from the 1994 EMT Basic curriculum where we were told the EMTs, and by extension paramedics, were too dumb to know when a patient was hypoxic. As said then, and now, it wasn’t us, it was the doctors that couldn’t figure it out. The same basic assessment skills I learned over 30 years ago are still valid. Respiratory rate, ability to speak, breath sounds, work of breathing, are far more accurate than Pulse Oximetry for assessing respiratory function. I fought the stupid high flow O2 rule for years and was using flow rates based on my assessment (including ETCO2) for a few years before the protocols changed. Actually, I started right when the AHA did, back in 2005. The protocols still called for high flow O2 unless the patient wouldn’t tolerate the mask. It was amazing how many of my patients didn’t tolerate the mask, but got better on a nasal cannula.

      Hmmm, I guess I was the real Rogue Medic! 😉

      Most of the ACLS drug changes were really the evolution of actually doing scientific studies and finding out that drugs we used really didn’t work. At first the studies showed that high dose Epi increased survival. Then, once we figured out what “survival” really meant, it turned out that high does Epi was useless.

      It’s science, I guess.

    • Not according to the study that was cited in the presentation. Now, I don’t know if that was referring complete cord transection or some other degree of injury. My experience has been that injury is pretty apparent when it happens. It’s very apparent to the patient, who will tell you that they have paralysis and loss of sensation.

      • It happens. (Changes during EMS care are less common because we don’t watch them for very long, of course.) Here’s a couple of references:

        http://www.ncbi.nlm.nih.gov/pubmed/9657541
        http://www.ncbi.nlm.nih.gov/pubmed/3771035

        (shoot me an email for fulltexts)

        Improvement or deterioration is not an uncommon feature in the hours/days/weeks after injury. There’s a lot of contusion, inflammation, etc going on that can make things worse and then possibly resolve. (Plus we can treat people and maybe make them better… not that anything seems to work very well, but I’ll let the neurosurgeons argue over that one.)

        You’re probably correct for complete transection, but fortunately that’s not as common outside of the Saw movies…

        • I have only a partial citation from Injury in 2009. Vanderen, et al. The article seems to be mostly about increased mortality across the board for penetrating trauma patients immobilized. I don’t have access, but if someone does maybe they can find the entire article.

          • Yep, I have that one… it’s http://www.ncbi.nlm.nih.gov/pubmed/19524236. No mention that I can see of neuro improvement though.

            At this point there seems to be little question that penetrating trauma suffers rather than benefits from immobilization… most of the current debate surrounds blunt trauma. (Not to say that there aren’t systems out there still boarding the crap out of GSWs and stabbings, but there’s enough variation in the US prehospital world that you can probably still find bretylium too if you look hard enough…)

          • I think all of the Bretylium trees died or something. That’s why they stopped making it. Well, not trees, but some other component became scarce. Not that it matters because I never saw it work. I would bet that you will still find some systems using IV Verapamil. Or as a medic I know calls it “Verapidkill”.

            Yeah, there are still a lot of systems still insisting on killing their patients by treating non existent occult cervical injuries related to GSWs. Some medics (and their medical directors) are hopelessly stuck in late 1980s/early 1990s treatment modalities.

  2. That American Academy of Orthopedic Surgeons opinion was shoved down our throats in the 70’s… EVERY training meeting with both rescue and fire personnel that was pushed for extractions and any kind of ‘transport’ like moving patients down stairs…

    • And opinion was all it was. It was semi informed opinion, but in truth they could have flipped a coin or thrown a dart at a board and got pretty much the same level of scientific validity.

  3. Thought of you and this post as I forced by protocol to place my 1st-trimester LOC fall patient in a c-collar and on a backboard…and oh yeah, she complained of head pain AFTER we did this to her.

    I know “gut feelings” aren’t very scientific, but I’m pretty sure that she would have been just fine without the damn thing, considering I’m reasonably sure what the origin of the chief complaint was.

    Adding to the irony: guess who had to proctor a Nat Reg backboard station?

    • There is as good amount of science now showing that immobilization hurts and doesn’t help. Penetrating trauma patients, especially head wound patients, do much worse when they are immobilized supine. The entire “industry of immobilization” is based on gut instinct and anecdote. Which means that it’s wrong.

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