Thursday, June 27, 2013

The backboard controversy.

This was NOT my call, but does bring up an interesting controversy. The following is a call that one of my avid followers has had recently... and his question was did he do the right thing?

"64yo male ran over by a tractor. On our arrival we had an alert 64 yo male laying in a right lateral recumbent position, in NAD, speaking full clear sentences, aox4, GCS 15. 

Pt said that the tractor ran over his right hip, denied pain upon palpation of his C Spine and spinal column. Negative for step off or deformity. Pt complained of right hip pain, 5/10. Negative for deformity or crepitus. Legs of equal length, negative rotation. Pelvis stable, negative crepitus.

Pt stated he did have a 5/10 discomfort in his lumbar region secondary to a fusion he had a year ago. This discomfort is not new. The pt was rolled onto a BB to lift him to the stretcher. He complained that his pain intensified on the BB. I opted to REMOVE him from the BB to avoid exacerbation of his pain and potential injury to his fusion. His pain resolved to a 0/10 in a supine pain on the softer surface of the stretcher.

The receiving physician was not happy and made it known. I defended myself and provided reason for what I did. He argued that all trauma pt should be BB and that the soft padding would cause flexion and injury. Both points he attempted to make I provided rebuttal.

Would you have placed this pt on a BB?"

Let me know what you guys think... Feel free to send me links to STUDIES showing the benefits OR harms of the backboard/immobilization use 


Here is what I wrote back to the provider... with some modifications after reading your comments.

Giving the described MOI, I would have kept him on the board. Reasoning being, the risk vs benefit.

In this case, the risk of a lumbar fracture is great particularly with pain... and particularly with an old fusion which is much more prone to fracture post trauma... even though the pt states that the pain feels "old" the body has no idea... the pain fibers are the same whether it is a fracture or an old fusion, the brain will receive the same impulse... pain.

Furthermore, do NOT forget the mechanism of injury (MOI). If I was rolled by a tractor I'm sure my adrenaline would be through the roof, further dulling any real pain that may actually be there. Such injuries occur in a split second... the tractor probably rolled over him... do NOT trust the pt to fully state that it was "Just over my hip." Recall of actual MOI by a patient under the stress of incurred trauma & excruciating pain should not be deemed reliable. Remember, an orthopedic injury will be VERY painful and distracting to the patient... his concern is PAIN in his hip... YOUR concern needs to be all the other stuff that COULD have occurred in the process. If you think about the mechanics of this MOI, it is virtually impossible for a tractor wheel to roll over SOLELY over a hip.

Think about the anatomy of the pelvis (immediately attached to the hip)... pelvis is a bowl attached to the sacral spine in the back... so the pressure from the wheel on the hip will transmit that pressure to the pelvis & hence the spine... where the old fusion is... the patient does NOT necessarily know that... but we as paramedics do... risk of lumbar fracture is GREAT.

But..... is backboard right here? I'm not saying it necessarily is or is NOT... let's think of the alternatives:

1) You backboard AND pain management - not the BEST option... but the risk of paralysis in his case is greater than the 5/10 pain that could have been successfully controlled by fentanyl/morphine/etc... remember until the precedent of backboarding changes, it is still the STANDARD of care.

2) Scoop stretcher - move the pt directly onto the soft stretcher with the scoop... would have been reasonable in my opinion.

Do I think that you were detrimental to his care or that you exacerbated his injury further? No, I sure as hell don't... but the problem is, a lawyer for this pt will see this in a whole different light... they will ignore the obvious fact that a damn tractor broke his f-in back, and instead blame it on the paramedic who didn't put him on a backboard... irregardless of mounting evidence against use of boards to begin with... but lawyers will use the slimiest way, not the up to date way.

Remember, crap rolls down hill... and EMS is at the bottom of that hill. You did not necessarily do anything blatantly wrong, probably actually helped him & his pain... but sometimes doing the right thing for the pt is not doing the right thing for yourself or your career... remember you are in a profession where there is no black & white... you are swimming in a murky sea of maybes... choose the path that is the best for everyone involved, your career being a priority... I wouldn't risk mine if I had a valid alternative of pain management. It would have been the wrong thing to do to just leave him there & not give him anything for pain, but I doubt that's what you would have done.

For example, I received a phone call from a fellow EMT a couple of years back asking me for advice. Their elderly relative was transported back from the hospital to the SNF that they were residing at... upon arrival, the staff called EMS back to transport the same patient back to the ED for "hip pain." The pt subsequently turned out to have a hip fracture... so how did this patient get a hip fracture between her hospital stay, EMS transport, and then SNF stay? Who the hell knows... but the hospital blamed the EMS crew for handling the patient "too rough" when moving them over to the stretcher... see @#$% rolls downhill.

It seems to me the ER doc was out of line in chewing you out in the matter that he did, but it is what it is... this won't be your last time getting chewed and that's OK... it just means you are thinking outside the box & doing your job.

Lastly, if you choose one option, then try to STICK with it... if you've backboarded this patient, then keep him on the board and manage his pain. Putting him on the board, then taking him off puts him at much higher risk for exacerbating his injury than if he was just left alone on it. I understand that every EMS call is dynamic, and always changing... and we have to be good at adapting... but in this case, stick with one option... it is easier to defend.

Hope this helped! Stay safe!