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Spinal Restriction

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8 hours ago, ERDoc said:

Backboards are great for getting the ambulance out of the sand that is up to the rear bumper when you are at the beach, so I hear.  Otherwise they aren't too useful.

i hear that phone call to the supervisor isn't very fun though.  

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You know I worked for a 911 service on the beach and they didn't carry backboards...I wonder if this is why. It only takes one crew getting caught using backboards to get unstuck to ruin the beach for the rest of us. Lol

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There was video floating around a few years back of a crew in Massachusetts if I recall correctly using one as a sled towed behind the ambulance during a snow storm.  I just did a quick search and couldn't find it.  I don't think it ended well for anyone involved.  One of the early lessons of "not everything needs to wind up on the internet".

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It just so happens my doctoral dissertation was on this exact subject.  The literature since the early 1980s demonstrated that the LSB increases pain, causes respiratory compromise, leads to tissue breakdown, and is ineffective.  Yet, the practice continued until 2013 when the NAEMSP released a position paper that called for the limited use of the LSB.  ACEP followed in 2015.  Using it as an extrication device is warranted and the services in my area have stopped using it except for the entrapped patient with multi system injuries (multiple fractures) but we have transport times to the trauma center of less than 10 minutes.  

My dissertation showed a 60% decrease in the use of the LSB in the first six months after implementing a spinal motion restriction protocol by the state.  Additional service QA indicates the decrease continued the next year to the point use of the LSB is the exception and not the rule.

If anybody wants a copy of my references, let me know and I would be happy to send them.  They date to 1966.  

Spock

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It's funny how things change.  In my days, early to mid 90s, long boards and c collars were gospel.  We drilled on standing take downs constantly.  Then again, MAST pants were still in use also.  Look at us now.

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When I started we did standing take downs every day...I haven't done one in probably the last 5 years. 

I'm curious, are they still taught how to do a standing take down?

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Spock,

Nice to see you're still here and contributing to the discussions.  Did your research look at negative outcomes associated with LSB usage?  How about any change in the frequency of those outcomes associated with reduced usage?

Hope your defense went well... or goes well if you haven't done it yet.

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I certainly remember teaching and using the standing board take down but it is gone.  The new Pennsylvania (July 2015) spine injury care protocol specifically states the standing take down should not be used.  We also used to put the MAST trousers on every trauma patient although actually inflating them was rare.  

Finished my Doctor of Nursing Practice (DNP) degree from Carlow University in May 2016.  It is my fifth college degree and I think I can safely say it will be my last.  The negative outcomes from LSB use was a given based upon the literature.  The question is:  Will a change to spinal motion restriction cause injury by missing significant spinal injuries and causing more harm by movement?  Morrissey et al. (2014) found only two missed spinal injuries after switching to SMR from using the board in a patient population of 5800 in a service area population of 1.5 million.  Both of these "missed" spinal injuries were insignificant (spinal process fractures).  My work looked at three services in suburban Pittsburgh and had no missed injuries in patient population of 543 and a service area population of 143,000.  

Since Eyre (2006) reported an estimated 13 million people seek care in emergency departments each year with an incidence of significant spinal injure of 0.3%, one would need a very large patient population in order to achieve power when looking for spinal injuries made worse by SMR.  Getting follow up information from hospitals is very difficult as both the Morrissey and my study found.  So the jury is still out on SMR and it is interesting that spinal immobilization was instituted by consensus and not evidence just as SMR is being instituted by consensus.  Ten years from now we may look back and say how stupid we were to use SMR and cervical collars but only time will tell.  Considering we used the LSB for almost 50 years before moving away from it, if we recognize problems with SMR in only ten years we have learned something.  Don't get me started on the effectiveness of cervical collars.  

I bet ERDoc will agree with my next statement.  Ask any ED physician about the worst spinal injury they ever saw and they will probably tell you the patient walked into the hospital under their own power and not on an ambulance stretcher.   

Bottom line is that changing to SMR from SI resulted in an initial decrease in the use of the LSB by about 60%,  Unpublished data indicates use of the LSB has dropped almost 95% since changing protocols.  Are there still times when a LSB should be used?  Yes, but as I mentioned previously, it should be the exception and not the rule.  Never say never!

Spock 

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Just think of how much money the C-collar manufacturers stand to lose if we go away completely from C-collars.  

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19 hours ago, ERDoc said:

It's funny how things change.  In my days, early to mid 90s, long boards and c collars were gospel.  We drilled on standing take downs constantly.  Then again, MAST pants were still in use also.  Look at us now.

I think with the evolving understanding of crystalloid volume resuscitation and permissive hypotension in trauma, the MAST should get a second look, imo.....

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