Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Pennsylvania Eliminating Backboards for Potential Spinal Injuries

 
Medical directors should already have every EMS provider in Pennsylvania following the new Statewide BLS Protocols, but the procrastinators have until July 1, 2015 to get everyone to aggressively avoid using backboards.

We should not be manipulating the potentially injured spines of patients to get them onto backboards for no known benefit, while possibly causing permanent disabilities or other significant harms.
 

Excessive motion of the spine may worsen spine fractures or spinal cord injuries (especially in patients with altered consciousness who can’t restrict their own spinal motion), but immobilization on a long spine board may also cause pain, agitation, respiratory compromise, and pressure ulcers. Patients with the following symptoms or mechanisms of injury should be assessed to determine whether restriction of spinal motion is required:[1]

 


 

What are the full steps to be performed for someone suspected of having an unstable spinal injury?
 

Restrict Spinal Motion

Apply Rigid Cervical Collar[1]

 

We are beginning to realize that collars are probably also not be such a great idea,[2] but this is only one step to decrease the harm we cause for no apparent benefit.
 

If ambulatory,

Allow patient to move to stretcher mattress with minimal spinal motion3 [1]

 

This is just recognizing that people have been walking to stretchers without sudden onset of paralysis, so manipulating the patient’s spine onto a flat board for no known benefit was never a good idea. It was just dogma, that went unquestioned for too long.
 

If nonambulatory,

Use backboard, scoop/orthopedic stretcher, vacuum mattress, or other device to move patient to stretcher with minimal spinal motion4,5 [1]

 

We could use a sheet, since manipulating the patient onto a backboard, or other device, may result in much more movement of the spine than sliding a sheet under the patient and using the sheet to lift the patient.
 

Use CID may be used to further restrict spinal motion[1]

 

The typo is not important, but we can consider putting some sort of blocks next to the patient’s head to keep the head of an unconscious patient from flopping around.
 

Transport on stretcher mattress without backboard if patient ambulatory or if scoop/orthopedic stretcher can be removed with minimal patient motion.[1]

 

Again, the use of a sheet to move the patient may be the preferred method, since the use of the sheet may produce the least manipulation of the spine. We are trying to minimize the manipulation of the spine, not trying to defend some dogma that there is only one right way of doing things, regardless of outcomes. The patients’ outcomes are what matter, not adherence to the protocol at the expense of the patients.

The protocol clearly does not limit us to using backboards, scoops, orthopedic stretchers, or vacuum mattresses.

Using a sheet to move the patient, so that it does not produce more manipulation that would be produced by using these other devices appears to be encouraged, if not required. We are supposed to use the method that is least likely to harm the patient, which probably makes a backboard the least acceptable method.
 

This protocol also applies to assessment of patients before inter-facility transfer for injuries from a traumatic mechanism unless a medical command physician agrees that the patient may be transported without restriction of spinal motion.[1]

 

Any suggestion that a patient is going to be manipulated back onto a backboard should result in a firm, No, thank you.

I am not a lawyer, but I wouldn’t be surprised to see law suits against EMS agencies/providers who continue to cause harm with backboards, when there are less harmful alternatives available and no protocol/standard of care to defend this abuse of patients by placing them on backboards.
 

[youtube]0HAGMb_jAdU[/youtube]
 

Pennsylvania is the largest state (not all states have statewide protocols, so this is often only at the agency level) to do this and joins a growing list of EMS agencies that are putting patients ahead of superstition –
 
 

Agencies/EMS Systems Minimizing Backboard use –
 

Let me know if I should add your agency to this list.
 
 

Alameda County
CA
 

Albuquerque-Bernalillo County Medical Control Board
NM
 

Bend Fire and Rescue
Bend, OR
 

Bernalillo County Fire Department
NM
 

CentraCare Health
Monticello, MN
 

Chaffee County EMS
CO
 

Connecticut, State of
CT
 

Durham County EMS
NC
 

Eagle County Ambulance District
CO
 

HealthEast Medical Transportation
St. Paul, MN
 

Johnson County EMS
KS
 

Kenosha Fire Department
Kenosha, WI
 

Macomb County EMS Med Control Authority
Macomb County, MI
 

Maryland, State of
MD
 

MedicWest Ambulance
NV
 

Milwaukee EMS
WI
 

North Memorial Ambulance & Aircare
Minneapolis, MN
 

Palm Beach County Fire Rescue
FL
 

Pennsylvania, Commonwealth of
PA
 

Pewaukee Fire Dept
Pewaukee, WI
 

Rio Rancho Fire Department
NM
 

SERTAC (Southeast Regional Trauma Advisory Council)
WI
 

Wichita-Sedgwick County EMS System
KS
 

Xenia Fire Department
Xenia, OH
 
 

Outside of the US –
 

NHS (National Health Service)
England (UK?)
 

St. John Ambulance
New Zealand
 

Norway
 

QAS
Queensland, Australia
 
 

Footnotes:

[1] Spinal Care
2015 Pennsylvania Statewide BLS Protocols
261 – BLS – Adult/Peds
pp 59 – 61
Protocols in PDF Download Format.

[2] Why EMS Should Limit the Use of Rigid Cervical Collars
Bryan Bledsoe, DO, FACEP, FAAEM, EMT-P and Dale Carrison, DO, FACEP
Monday, January 26, 2015
JEMS
Article

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Comments

  1. Pewaukee Fire Dept, Pewaukee WI.

    We’ve eliminated backboards, collars are optional

  2. The NHS restricts longboards to extrication tools and no one should be transported on one. Collars are still used but there’s a lot less importance attatched to them and it’s quite common for them to be omitted entirely now.

  3. Macomb County, MI goes live with a new spinal protocol I believe April 1:
    http://mcemsmca.org/?p=980

  4. Blacksburg Volunteer Rescue Squad in Blacksburg, VA now only uses backboards and/or c-collars when there are indications of spinal injury on exam (or the pt is unable to participate in the exam – altered LOC, etc.).

    The protocol is here (Google Drive shared link) if anyone is interested. This is an agency specific protocol replacing our regional authority’s protocol, which is more “rule-out” driven based on the NEXUS and Canadian systems.

  5. Centracare Health – Monticello
    Monticello, MN and surrounding areas. Limitations on use for the past 2 years.

  6. Toronto, Ontario, Canada – Toronto Paramedic Services

    Just started restricting our use for penetrating traumas.

    If the patient is GCS 15, sober, alert and cooperative, has no distracting injuries, and can move all four limbs with normal power and strength and has normal sensation in all limbs, then no backboard.

    Since we only just started it’s pretty limited, however I’m sure this is to expand further in the future.

  7. We use the Scoop EXL Strettcher, from 10 years from the TRAUMA PATIENS

    http://www.ferno.it/prodotti/97.49/immobilizzatoriestricatori/barella-scoop-exl

  8. Bend Fire has been following the position paper from Naemsp very similar to Pennsylvannia. While it has not eliminated backboards it has greatly reduced our usage over last year. Anecdotally I think we have seen a reduction in total pain meds given for longer transports especially from our local ski hill.

    Bend Fire and Rescue-Bend Oregon

  9. BC Canada has been on a scoop stretcher preference for years with spine boards being designated as extrication devices only. Canadian C-Spine rules are in place for clearance and there is talk of going to collar on a cot for conscious spinal pain but for now the scoop stays. My understanding is also that Alberta and Saskatchewan have gone to collar on the cot and ditched the back board except for extrication as well.

Trackbacks

  1. […] March 30, 2015 – In a relatively shocking (or perhaps not so shocking to those who keep themselves informed) move, the New York City Regional Medical Advisory Committee has released potential protocols on spinal immobilization that mostly eliminates backboards. This is right on the heels of Pennsylvannia doing something similar statewide. […]

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