Doczilla

Eeeeexcellent. Now with EMS Doc and ERDoc, we shall begin your board examination for practice privileges. :twisted: 'zilla

Yes. I agree. It's a simple thing to do, but plenty of folks don't do it. 'zilla

Not to interrupt a good tar-and-feathering, but did the BLS crew/driver know that the ALS crew was there? Did they understand that they were expected in 1 minute, or did they misinterpret what they were told over the radio? Still -5pts for not waiting 1 minute for necessary higher level of care to arrive, but I'm not sure this is as bad as the paper would have us believe. 'zilla

"Patient Unable to Sign" is no longer acceptable. I'm not sure if this has been covered here recently (a search was not helpful), but the law has recently changed regarding obtaining signatures. If the EMS "Assignment of Billing" (consent to bill insurance, frequently on the EMS run report itself) isn't signed by the patient or a proper representative, Medicare will not pay for the transport. If the patient is unable to sign, you must document why. This applies particularly to emergency runs. http://www.pwwemslaw.com/content.aspx?id=321 If you wanna get paid, lifesaver, you gotta get it signed. 'zilla

I'm sure this is going to tick some people off. I've gone and re-read the article now after much of the debate on the ACEP listserv, and can't really find any meaningful inaccuracies. None of those interviewed outright says it "doesn't belong in the hands of EMS", except maybe the doc from Kentucky. They all emphasize the need for close oversight and extensive and ongoing training, which we all here seem to agree with. They also emphasize the importance of EtCO2 monitoring, which I also agree with. Yes, they use tragic cases to illustrate it, but I think the writer did a good job of laying out what is a very complex topic, and probably will continue to be within my lifetime, a key controversy in EMS. 'zilla

That's a scary man-chick. 'zilla

Before anyone is too hard on Dr. Wang, they should know that he authored the NAEMSP's original position paper on prehospital RSI [Prehosp Emerg Care. Jan/Mar 2001; 5(1):40-8], which encompassed much of the evidence I presented (up to it's publication date of 2001). This paper presented very strong evidence in favor of the use of RSI in the field. 'zilla

There is a brisk discussion on this very topic online right now among the docs in the ACEP EMS Section. I will post here what I sent there. I have performed a number of intubations in the field with RSI with my squad. Few have been trauma patients; most were respiratory failure due to medical causes such as CHF that did not respond to therapy. Perhaps it's our patient population of morbidly obese chain smoking hypertensive type II diabetic vasculopaths with CHF that prefer to call 911 only when there is a large hooded figure with a scythe standing in the corner of the room, but we get some sick folks. We are in the process of training the medics for RSI to see if we can sustain the skill retention through training and periodic retesting before we implement it. On our SWAT team, the medics are trained and authorized to use RSI (easier to implement, since this is a small cadre of very experienced medics with dedicated monthly training time). One important thing to consider when looking at those studies is the fact that they include intubation of patients who are incompletely relaxed, the "cowboy tube" that is undertaken with nothing but a laryngoscope and Brutane. Not only do the paramedics get the really bad airways, as pointed out, but we ask them to intubate patients that we as physicians would never consider intubating without RSI. By asking them to do so, are we not setting them up for failure? What would our intubation success rate be as physicians without RSI? Several studies have demonstrated the value of RSI in prehospital settings. Whether by improving intubation conditions, or improving training, improved airway decision-making, periodic skills reassessment, or improvement of conditions for intubation by use of the drugs, RSI (with appropriate oversight and training) seems to improve intubation rates. A 2004 study by Jones et al found that rates of unrecognized esophageal placement of endotracheal tubes was as high as 6%. The standard for placement verification was auscultation by the receiving emergency physician. This rate was lower (3% vs. 9%) when a confirmation device, such as Esophageal Detector Device or end-tidal CO2 detector was used. Small study size limits the scope of this study, but the results are concerning nonetheless. An analysis of failed intubations revealed that of the 10% of patients who had failed intubation attempts in the field, nearly 50% were attributable to inadequate relaxation, 20% to poor anatomy, and 10% to obstruction..[iii] Of these that could not be intubated in the field, 41% were successfully intubated after RSI in the Emergency Department. The estimate of “truly difficult” airways, defined as requiring 3 or more intubation attempts in the ED, was 0.8-1.6%. A 2003 study from the University of Pittsburgh showed an overall intubation success rate of 90%. Patients with vital signs were successfully intubated only 72% of the time, while patients in cardiac arrest were successfully intubated 93% of the time. Factors attributed to failed intubation which may be remedied through RSI include clenched jaw (30%), combativeness (11%), inadequate relaxation (25%), intact gag reflex (38%).[iv] A 2005 study from Wake Forest University utilizing an air transport service compared etomidate only intubation (EOI) to RSI.[v] This small study, with younger (mean 38 years) mostly trauma patients (90%) used a subjective scale to rate “adequate” conditions for intubation. EOI produced these conditions only 13% of the time, while RSI produced them 80% of the time. Intubation success rate was 25% in the EOI group and 92% in the RSI group. Studies from Dickenson et al and Wang et al showed limited success with midazolam (Versed) as a single-line agent to facilitate intubation, citing success rates of 62-75%.[vi],[vii] This mirrors our experience with our "sedate to intubate" protocol, which allows use of versed or etomidate to facilitate intubation. Alicandro reported RSI success in a paramedic air transport system to be 90%, compared with conventional ETI success rate of 69%.[viii] A study by Hedges et al recounted 95 occurrences of RSI in a ground ALS system, which showed an overall success rate of 96% and no misplaced tubes or cricothyroidotomies performed.[ix] Pace and Fuller found success rates of 92% vs. 66% with conventional intubation.[x] Krisanda et al reported a 94% success rate with RSI in seven ground ALS services.[xi] Pearson’s 2003 study in the Air Medical Journal examined the impact of implementation of an RSI protocol on number of intubation attempts and time to successful intubation. The study, though small (140 patients) found that both the number of attempts and the time to intubation decreased significantly once succinylcholine was added to the drug box.[xii] A study by Ochs and Davis from San Diego enrolled 114 patients with head injury who underwent RSI. 84% were intubated successfully, the rest were managed with combitube. There was only one airway failure.[xiii] Wayne and Friedland’s 20 year review of RSI with succinylcholine in a ground ALS service found a success rate of 95% in their analysis of 1657 patients. Only 3 of the 74 patients where intubation was unsuccessful required cricothyroidotomy.[xiv] This study seems to suggest 2 things: paramedics CAN successfully perform RSI, and paralysis + failed intubation do not necessarily equal surgical cricothyroidotomy. If the patient can be managed with a rescue airway or oral airway and BVM, then they don't need to be cut. This study I think shows the value of training: medics had 20 OR intubations, and were required to get OR time and a minimum number of tubes per year. Some recent studies have questioned the use of RSI on specific populations in the prehospital environment. RSI has been associated with worse outcomes in patients with severe head injury in a landmark study by Davis, Hoyt et al from San Diego.[xv] A follow-up analysis of these patients suggested the association between increased mortality and hyperventilation.[xvi] I agree completely that RSI is a potentially disastrous tool to have without proper training and oversight. Our currently planned regimen involves monthly skill time on the mannekin, quarterly retesting (written and practical), tracking of individual paramedic intubation rates with quarterly minimums (to be made up on mannekin testing if inadequate), and QA review of all intubation cases. Currently, run sheets are kicked to my inbox automatically for advanced airways, arrests, AMI, "significant ALS care", pediatrics, obstetrics, refusals, and any other issue as seen fit by the QA supervisor. Two other important factors I think must be in place when allowing RSI: confirmation of tube placement, and backup airway devices. We've already touched on the use of capnography, which I think is an invaluable tool for confirming and monitoring intubation. Despite what the studies suggest regarding the EDD, I don't think anything else yet matches EtCO2. As far as backup airways and adjuncts go, I'm a big believer in the Airtraq, the Glidescope (though right now we can't afford to put them on the trucks, this is on the wish list), the bougie, and the King LT-D. As a matter of disclosure, I have no financial or other conflicting interests in these products whatsoever. Medics have to have them and be comfortable with them. The real question we need to be asking is, how can we get our medics into the OR to practice intubation? Many anesthesiology groups here are shut down tight when it comes to paramedic intubation time, and unfortunately, concerned about the liability of having a less experienced provider perform the intubation. This leaves cadaver labs as the most accessible solution. So to summarize (everyone wake up, lights are coming on again, powerpoint is coming to an end, urinals and coffee urns await you...) 1) I think that RSI does belong in the field under the right conditions. 2) That said, training and oversight are crucial and are the difference between a successful RSI program and one that is dangerous. 3) Medics should have the right tools. That includes not only the tools to intubate successfully but the tools to manage the patient when they can't. We can't set them up for failure and then complain that their skills are inadequate. 'zilla Jones JH, Murphy MP, DicksonRL. Emergency Physician-Verified Out-Of-Hospital Intubation: Miss rates by paramedics. Acad Emerg Med. 2004 Jun;11(6):707-709. [ii] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7) 717-724. [iii] Wang HE, Sweeney TA, et al. Failed Prehospital Intubations: An analysis of emergency department courses and outcomes. Prehosp Emer Care. 2001;5:134-141. [iv] Wang HE, Kupas DF, et al. Multivariate Predictors of Failed Prehospital Endotracheal Intubation. Acad. Emerg. Med. 2003 Jul;10(7) 717-724. [v] Bozeman WP, Kleiner DM, Hugget V. A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emer Care. 2006;10:8-13. [vi] Wang HE, O’Connor RE, Megargel RE, et al. The utilization of midazolam as a pharmacologic adjunct to endotracheal intubation by paramedics. Prehosp Emerg Care. 2000;4:14–8. [vii] Dickinson ET, Cohen JE, Mechem CC. The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics. Prehosp Emerg Care. 1999;3:191–3. 84. [viii] Alicandro JM, Henry MC, Hollander JE, Johnson S, Kaufman M, Niegelberg E. Improved success rate of out-of-hospital intubation with rapid-sequence induction . Acad Emerg Med. 1996; 3:408. [ix] Hedges JR, Dronen SC, Feero S, Hawkins S, Syverud SA, Shultz B. Succinylcholine-assisted intubations in prehospital care. Ann Emerg Med. 1988;17:469–72.36. [x] Pace SA, Fuller FP. Out-of-hospital use of succinylcholine by paramedics. Acad Emerg Med. 1996;3: 407–8. [xi] Krisanda T, Eitel D, Cooley M, et al. Succinylcholine-assisted intubation by responding advanced life support ground units: results of a four-year pilot study for the state of Pennsylvania. Acad Emerg Med. 1997;4:460. [xii] Pearson S. Comparison of intubation attempts and completion times before and after the initiation of a rapid sequence intubation protocol in an air medical transport program. Air Med J. 2003 Nov-Dec;22(6):28-33. [xiii] Davis DP, Ochs M, Hoyt DB, Bailey D, Marshall LK, Rosen P. Paramedic-administered neuromuscular blockade improves prehospital intubation success in severely head-injured patients. J Trauma. 2003 Oct;55(4):713-9. [xiv] Wayne MA, Friedland E. Prehospital use of succinylcholine: a 20-year review. Prehosp Emerg Care. 1999 Apr-Jun;3(2):107-9. [xv] Davis DP, Hoyt DB, Ochs M. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003 Mar;54(3):444-53. [xvi] Davis DP, Stern J, Sise MJ, Hoyt DB. A follow-up analysis of factors associated with head-injury mortality after paramedic rapid sequence intubation. J Trauma. 2005 Aug;59(2):486-90.

Field amputation in the scenarios provided are feasible, and I agree that the chances of doing it are incredibly low. Entrapment with immediate threat to life or entrapment without the possibility of extrication means the limb has to come off. What any surgeon will tell you is that it doesn't really matter how you do it in the field, since they will be going to surgery to do a proper job of it once the patient gets to the hospital. Apply a tourniquet, go as distal as possible, cut through everything you can with the scalpel, then cut bone (if necessary) with a saw of any kind. There is always some discussion in (remote, wilderness) field medicine texts regarding cutting of the bone, soft tissue, and skin at varying lengths to ensure good stump healing. This is crap, since the surgeon will take care of that in the OR. Just save them as much tissue and bone as you can. If it's a leg, make every effort to save the knee if possible (this makes a big difference to the patient as far as function with prosthetics). Same thing with the elbow. Hesitate before making the determination if a limb is salvageable or not. With external fixators, wound vacs, grafts, microsurgical techniques, and other technologies, you will be amazed at the regaining of function. Much of the time, you won't be able to predict this in the field. If you've ever wondered if you can do it with your pocket knife... Aaron Ralston Sampson Parker For the field c-section, I remember some discussion in Virginia back in 2003 that they were adding an "extreme measures" protocol to the peninsula's EMS protocols to allow it on a gravid pulseless patient. Field c-section in this setting is not really that complex a concept: vertical incision from the umbilicus to the pubis, cut until you get uterus, then cut until you get amniotic fluid. Finish the uterine incision with scissors, and try not to cut the baby. Deliver through the incision, clamp and cut the cord as usual, and resuscitate the baby per protocol. Whether or not you really want to face the regulatory consequences later is up to you. It had better be an iron-clad decision. 'zilla

You misunderstand me. I meant the report on arrival in the ED. 'zilla

I agree with the other statements about it possibly being a locum doc, or someone moonlighting in that facility, or new to that facility, etc. Having a good charge nurse in the code is a Godsend. I prefer them to be recording (though they often want to be "doing") because they can keep another set of eyes on the room and catch things that get missed. The doc is looking at the big picture. Having an experienced nurse alongside can help avoid issues like ordering drugs when there is no IV access, or changing assignments, etc. Another thing that I tell students rotating through the ED is this: codes/traumas where a lot of things are going on appear to be chaotic. You have to look past the noise and the movement to see what is truly going on, what issues are being addressed, etc. It is possible that although it looked like a cluster, things were happening more smoothly than apparent. It's easy to say that a code is going well once the airway and IV are established and everything is happening consecutively rather than simultaneously. When you have multiple staff doing multiple things at once, this is where it can be overwhelming to people not used to it, or inexperienced providers. This is what truly separates emergency medicine from all other specialties. A good paramedic or physician is looking past the immediate interventions and anticipating the next. "give 1mg epi" is easy enough at the provider level. "Draw up the amiodarone" and "order blood up here" are looking one step beyond what is going on. It's possible that the physician was asking for the next drug in anticipation of the IV being established shortly. Or not. Difficult to say when I wasn't there. Let's not forget the importance of a good prehospital report on arrival at the ED. Maybe one wasn't given, or the doc wasn't listening, but the IV and airway issue should be known on arrival with a good report. "Down time...yada yada yada... attempted intubation unsuccessfully, so placed a King airway... attempted IV unsuccessfully.... put a 20g IV in on this side but I'm not sure if it's working....summary of drugs that have been given...last drug given....time since last epi..." These things will set the priorities for the physician and let him know what to address immediately and where we are in the ACLS protocols. First things out of my mouth to the ED staff: "How's the tube?" (to the Respiratory Terrorist) "How's the IV access?" (to the nurses) I will recheck these periodically. This is ensuring the ABCs are addressed and rechecked. The King Airway, like adult IO, is one of those things that really started out in EMS, so they aren't as well known in the hospital setting. King airways are still pretty much relegated to EMS, so ED staff aren't familiar with it. IOs are known in the ED, but they are unknown in the rest of the hospital (with the exception of pediatrics). 'zilla

No vest will deflect all bullets. Every bullet will meet a type of armor that it can't penetrate. Decisions to make when buying body armor: Threat level: This usually means an NIJ level of certification, most practical for soft armor being (from least protection to most protection) class IIa, class II, and class IIIa. Anything higher than that (class III, class IV) will involve plates (steel, ceramic, or compressed laminate fiber), and is likely impractical for the civilian EMS environment. Threats faced in your area are typically handgun, so you won't need a system to protect you from rifle shots (SWAT medics are a different story). A good idea is to wear what the police wear in your area. Class II is fine, but you won't go wrong with IIa or IIIa. There is a minimal difference in comfort between the three levels. IIIa is the highest level of protection in a soft vest, and this is what I would recommend based on your budget. The FBI has just released a new body armor testing standard, which goes beyond the "test shot at 16 feet on a square of material" that the NIJ currently does. The new FBI standard does test shots on the edges and center of the vest, as well as test shots on vests that have been heated, chilled, or wet. They also do contact shots. This will be the new standard of armor testing, and will likely expose some issues in current materials and influence design. Carrier. 2 main directions here: external carrier and concealable carrier. There are practical trade-offs of each. External carriers can be adorned with patches, pockets, reflective strips, etc. They are immensely practical for tactical teams for obvious reasons, as well as the ability to upgrade or scale threat protection based on the mission. Concealable carriers are less expensive and lighter. My recommendation for civilian EMS is a concealable carrier. There is a practical reason for this: if you have an external carrier, you will be tempted to take it off, and (worse) wear it only on certain calls. Police officers don't tend to get shot on shooting calls, they get shot on domestics and traffic stops where they have no expectation of getting shot. If wearing a concealable vest, the wearer is less tempted to take off the uniform shirt, remove the vest, etc. between calls and will instead simply wear it all the time. "Tails". These are fabric (not ballistic) panels that trail down from the carrier front and back and are designed to be tucked into your pants. They are an option on any concealable carrier. I recommend them on any concealable vest. They shouldn't cost you anything. Coverage/wrap around. Vests come in various levels of side protection. A typical defensive posture is to present one arm to ward off the bad guy, and this can expose the area between the vest panels (I worked on a cop who was shot and killed this way). So I encourage side coverage. Fit. Go to a police uniform shop and try it on. It should cover from the suprasternal notch to the beltline. When applying, pull it over your head and adjust the shoulder straps for the height. Then grab the velcro waist straps. Breathe out (normal breath), and simultaneously attach the waist straps from both sides (bottom ones first) with just enough tension to hold the straps straight; don't stretch them. Materials: Kevlar: aramid fiber. Reliable, heat resistant, predictable in its degredation. Twaron: Like kevlar, but a little bit lighter. Spectra: Aramid fiber laminated between sheets of plastic Zylon: aramid fiber. Unreliable in its degradation. Pulled from the market after officers lost their lives as a result. Woven vests are made of layers of kevlar or twaron woven into a sheet, and the sheets are piled one on top of another. Increasing threat level protection is achieved with more layers of the sheets. Laminate vest are made of spectra or other fibers layered in between sheets of plastic to hold them together. "Gold flex" is one brand of laminate which uses kevlar in this manner. Laminate materials have been used to make vests that are lighter and thinner. I don't know if I'd call them any more comfortable. Their chief drawbacks are this: they are vulnerable to contact shots (30% of officer shootings), which melts the laminate and allows the fibers to separate. The panels can delaminate at the edges with time and use, leaving incomplete protection there. Creases in the vest from wear will allow the fibers to migrate, leaving gaps of decreased protection in the vest. The laminate also have higher evaporative resistance than woven vests, and are therefore subjectively perceived as being hotter than woven vests. Trauma plate. This is a plate of added protection that goes in a pocket in the center of the front panel. There are hard and soft trauma plates. I'd go with the hard plate, simply because of the improved blunt trauma protection. Stab protection. Some vests are designed and manufactured to provide stab protection from things like ice picks manufactured by prisoners. Unless you are a corrections officer or work exclusively in that environment, I don't recommend this. All body armor will provide some protection from stabs and slashes. If a 3 time violent felon has an ice pick and a grudge with you, this protection might be worthwhile. Bottom line for civilian EMS: I recommend an all-woven kevlar concealable vest, and I recommend you wear it all the time. I have a bone to pick with Armor Holdings after some of their dealings (like the Zylon), so I'd put a plug in here for the US Armor Eagle Enforcer. Get a Cool-Max, UnderArmour, or other moisture-wicking shirt to wear under the vest. Care and feeding of your vest: Allow it to dry flat after every use. Remove panels from carrier and wipe with a damp cloth. Do not use any chemicals, though a mild soap is acceptable. Do not hang in your closet by the shoulder straps or you'll be replacing the carrier soon. Check panels monthly for wear, delamination, creases, or other signs of wear. Do not "soak" the panels or wash them in a washing machine. Particularly important to a laminate vest: don't leave in your hot car trunk on a regular basis. 'zilla

You better know what you're talking about with Dragonskin first. 'zilla

Pretty much. 'zilla

A Volvo. 'zilla

Personally I don't think body armor is a bad idea for EMS. Though not rated for it, it will provide some protection from stab wounds as well. I think I've posted on this topic here before, but to reiterate: - Avoid Zylon. Was recalled due to early failures, and some officers lost their lives to figure this out. - Avoid a used vest if practical - Avoid laminates like Goldflex, Spectra, and others. (as opposed to WOVEN vests made of Kevlar or Twaron) Laminates are fine in rigid armor (and are used to back ceramic plates and steel sometimes), but in soft armor, creases will cause fibers to migrate and gaps in coverage. Laminate is also more vulnerable to contact shots, which represent 30% of officer shootings. - All-woven Kevlar vests will provide excellent protection long past their "expiration" date. 'zilla

There's a whole lot of questions here. On your differential of abd pain and shock, the list is extensive, but there are some possibilities off the top of my head: AAA perforated gastric or duodenal ulcer pancreatitis strangulated bowel You also have to wonder if they meant epigastric pain, so also on your list: acute MI pulmonary embolus Another question is how accurate the SaO2 waveform was. You didn't mention his vitals on scene. This is one reason I am a fan of pulse ox that gives a waveform, so you can judge how accurate it is with some precision. 'zilla

This may be more geared for the (category 1 or 2) trauma patients. Here, the patient is on the board for the primary and most of the secondary survey. Initial chest xray and pelvis xray are shot in the trauma bay within the first few minutes, and if the patient is on the board during that time, it greatly simplifies placing the xray cassettes to shoot the xray. When we roll to check the back, the patient is taken off the board. I agree with CBEMT on the scoop issue. It may discourage the provider from log-rolling and doing a complete assessment. (I still think it should be used, just the point about assessing the back should be emphasized in training.) We see a similar issue with infants immobilized in place in car seats. Their back is rarely assessed, as evidenced by the broken glass they are laying on. 'zilla

Virtually anyone can issue such a certificate, since there is no regulating body or standard curriculum to define it. It doesn't mean much to have "EMT-Tactical". The only question is whether or not a SWAT team or educational program will recognize your basic 5 day TEMS course as a valid prerequisite for membership/advanced training/whatever. Schools offering a comparable program: Tacmed (www.tac-med.org) Global Operations Response Group (www.gorgrp.com) RTI (www.emtt.org) ISTM (www.tacticalmedicine.com) National Tactical Officer's Association (www.ntoa.org) Cypress Creek EMS (www.ccems.com/catt_team/class.html) 'zilla

Direct trauma to the lower back, such as from a direct blow with a baseball bat, is highly unlikely to cause c-spine injury. Global deceleration trauma, such as in an MVC, which causes a t-spine fx has a high rate of associated C-spine and L-spine fx (I forget the exact number, but it's double digit percentage). Therefore findings of thoracic or lumbar pain in a fall or MVC or something along those lines should prompt c-spine immobilization. Think of the t-spine as a "cage". From a structural standpoint, it's very strong, forming a complete circle with the ribs and supporting intercostal structures. This would therefore be the "strong" point in the spinal chain. The low cervical levels and high lumbar levels, being relatively weaker with less supporting structure (though the lumbar vertebrae are thicker and by themselves stronger than thoracic vertebrae), are the points where we are likely to see fractures, since this is the closest point to the thoracic vertebrae where force can be dissipated (and released, through fracture). Note also that severe pain, such as from a back fx, would be considered a distracting injury, and you would not be able to exclude them from c-spine immobilization if mechanism suggested the possibility of it. 'zilla

The Protective Medicine Branch of Immigration and Customs Enforcement has ceased to exist, and so went CONTOMS. There are efforts by some of the faculty to get it reinstated under another federal agency. There is interest on behalf of these agencies, but without funding, nobody's picked it up yet. No word on when this might happen. 'zilla

Search the following Pubmed ID numbers: 12385610 Probably the strongest study to support this. Shows that immobilization creates false-positive findings for vertebral tenderness, and recommends immediate removal from LSB upon arrival at the ER. 8273958 Showed 100% of healthy volunteers had pain after immobilization for 30 minutes, half of which rated it as moderate to severe. 29% developed additional pain complaints over next 48 hours. 1877767 Immobilized healthy children and showed that their respiratory status was impaired by the immobilization as measured in FVC. 11446541 Showed that the LSB creates higher subjective pain scores that vacuum mattress splints. 15748015 A review of available literature on spinal immob. 10534038 Shows LSB restricts breathing in healthy adults 16023909 Shows that high and potentially ischemic pressures were created by immobilization, with the highest on the LSB. 7793717 Compared LSB with and without an interposed air mattress. LSB causes more pain. Also noted high tissue pressures with LSB. 7584752 Showed that adding closed cell padding to LSB caused less pain and didn't affect immobilization efficacy. 10488515 I don't know if this study refutes my assertion or not. It shows that if not strapped to a spine board, patients who want to move their neck will move it more. 16418091 study comparing the scoop stretcher with LSB. Shows that immobilization is better with scoop and comfort is improved as well. This helps us start thinking outside the box with spinal immob. Take it for what it's worth: it was sponsored by the manufacturer. A couple of notes: Our protocol for removal from the LSB upon ER arrival is universal for all EMS squads transporting to this particular hospital. After initial phase-in, it will be adopted at all hospitals. It is not in protocols because it does not need to be. The medics aren't clearing c-spines, and in fact are providing standard of care that the patient would receive if the physician were at the bedside. Upon arrival, medics are triaged to a room, where they give report to the receiving nurse. As long as the patient a) can follow directions and has no neuro deficits, they are unbuckled from the board and log rolled off in essentially the same manner that the board was applied. They are left to lie flat awaiting physician evaluation. I have never met a patient that wasn't grateful to get off the board. With this removal protocol, it happens much sooner. Again, we are still meeting the standard of care as it has been for years. Let me edit to add: There are no comparison studies on efficacy of immobilization with the ambulance stretcher to support my assertion that the stretcher immobilizes the patient just as well as LSB. I'll take this on the chin if someone wants to refute it. The ambulance stretcher mattress is a thin foam pad on a rigid backing, which contours to the patient's shape, providing some lateral support as well as the vertical support provided by the flat rigid stretcher backing. Properly secured with straps to the cot, I believe that in a compliant patient this will result in adequate immobilization. Vomiting will require the patient to be log-rolled again, which means unbuckling them from the stretcher to do so. Drunken raving lunatics may benefit from continued immobilization on the LSB. I also believe this would make an excellent study for those looking for a research project. Now when it comes to selective immobilization of the c-spine (c-spine clearance), there are several good studies which support the practice with very few "missed injuries" and no adverse events that I'm aware of. Another topic. 'zilla

A pressure ulcer and a bedsore are the same thing. It is thought to take about 2.5-3 hours to form a stage 1 pressure ulcer in a normal person, far less in someone who already has thin skin (elderly) or some amount of skin breakdown (bedridden or dependent, laying in the same place for a long time, etc.). Once that skin breakdown takes hold, it doesn't take much to continue it, and the pressure from the bed can go to work on the area after damage is done by the backboard. I've been on this soapbox before: we adhere strongly in EMS to a doctrine of spinal immobilization without evidence to support it. Most EMS providers I've run into don't seem to understand that standard treatment of spinal fractures, including c-spine fractures, is laying flat on the bed (with c-collar if it's a c-spine) until a brace is obtained, halo is applied, or fusion is performed. Long backboards have no role in spinal fracture treatment. I believe that securing the patient well to the gurney during transport with straps and no board will provide equivalent spinal immobilization to a LBB with a whole lot more comfort. The LBB should be reserved for getting the patient out of the car/house/grinder and to the gurney, particularly with long transport times. I think the discomfort caused by spinal immobilization is not a benign thing, and that we need to give our patients better care than a great big pile of suck-it-up. I have had numerous patients who got spinal x-rays based on spinal pain and tenderness, which evaporated after they were off the board for a while, and was caused solely by the board. Here we are implementing a protocol where medics transfer the patient to the ER gurney and immediately remove them from the backboard, leaving them in the c-collar laying flat on the bed before being seen by the physician. It is not c-spine clearance (in fact, most of these patients will ultimately undergo c-spine imaging), but goes far to improve their comfort. This also takes some of the pressure off (ha ha) us to interrupt our resuscitation of someone to take someone else off the backboard. This has met unanimous approval from the regional physicians advisory board as well as EMS providers who have been consulted. This does not apply to patients with neuro deficits or who cannot follow instructions, who must be seen immediately on arrival by the physician anyway. 'zilla

A great article on the subject from Mar08 issue of BMJ: BMJ Article 'zilla

SILENCE! I KEEL YOU!