The once-automatic use of long backboards to reduce spinal motion in patients transported by ambulance is now limited to a few patients for whom the equipment might provide some care. A statement by the National Association of EMS Physicians and the American College of Surgeons pulled no punches: The benefit of the boards is largely unproven. (http://bit.ly/190Q1A9.)
“At the time, the whole paradigm was based primarily on the reaction: ‘Boy! That was a bad accident.’ The EMS providers feared being wrong, and we immobilized everyone who possibly had any kind of spinal injury,” said Brian Clemency, DO, MBA, an assistant professor of emergency medicine and the EMS fellowship director at the Jacobs School of Medicine and Biomedical Sciences at the State University of New York-Buffalo.
Dr. Clemency, who was an EMT for many years, said he had seen many patients put on the backboard and, to put it simply, they were uncomfortable. “Increased pain leads to increased imaging,” he said. If there's pain, then emergency physicians order x-rays or CT scans to find out if there is a cause.
“In an old person with heart failure, you can cause respiratory distress by putting them on a long backboard. More and more, the literature is showing that backboarding is not a benign process. One of the big things that gave us pause was to look for a better way to handle this,” he said.
The process took two years in New York. Dr. Clemency and Joseph Bart, DO, also of SUNY-Buffalo, wrote the protocol and sent it to the state authorities. The approved protocol mirrors the national statement, which limits use of the long backboard to patients who have suffered blunt trauma and have an altered level of consciousness, exhibit spinal pain or tenderness, have a neurologic complaint such as numbness or motor weakness, an anatomic deformity of the spine, or whose injury results from a high-energy mechanism along with drug or alcohol intoxication, inability to communicate, or a distracting injury. Those who do not require a backboard include those with:
- Normal level of consciousness (Glasgow Coma Score 15)
- No spine tenderness or anatomic abnormality
- No neurologic findings or complaints
- No distracting injury
- No intoxication
Even patients with penetrating trauma to the head, neck, or torso and no evidence of spinal injury should not be immobilized on a backboard. A cervical collar and firm attachment to the EMS stretcher may be the most appropriate precautions for patients found walking at the scene, those who face a long transport or interfacility transport, or those for whom a backboard would not be indicated normally.
John Burton, MD, who began the process of changing backboard use while he was in Maine, is now the chair of emergency medicine at Virginia Tech Carilion School of Medicine and Research Institute in Roanoke.
“What had become commonplace in the late 1980s and early 1990s was to automatically do spinal immobilization,” he said. “The arguments from proponents were that there was no effective screening tool or process to accurately identify patients who did not have a spinal injury and, therefore, you had to immobilize everyone. A second shadow argument was that even if there was a device or decision rules or research to use to screen patients for an increased risk of spinal injury, prehospital providers could not use it consistently and accurately.”
The National Emergency X-Radiography Utilization Study (NEXUS) that used a protocol to screen people in the ED for a cervical spine injury and determine whether they needed x-rays or a CT scan and a couple of similar ones led many in EMS to question whether that protocol could be used in the prehospital study. (N Engl J Med 2000;343:94.)
The state of Maine, where Dr. Burton worked at the time as medical director for the state's emergency medical services, was interested in creating a prehospital spinal evaluation protocol that would allow EMS providers to immobilize patients selectively at increased risk and, conversely, not immobilize those at minimal risk. “That went live in 1993 or 1994,” he said. “As new research came out, the protocols were revised.”
They found that they were ruling out 40 to 60 percent of patients. He went on to collect the data to include more than one million hospital encounters in Maine.
“Once we published it, a lot of other states had already started making an algorithm for selective spine immobilization. Some states were battling it, but when they saw this research, they then came on board,” he said.
Dr. Burton said he estimated that 85 percent of states have some degree of active protocol in this area and are interested in creating protocols for selective spine immobilization for prehospital providers.
Douglas F. Kupas, MD, said he was surprised at how many in emergency medicine had taken on this protocol. Initially, EMS providers were concerned about pushback in the emergency department, according to Dr. Kupas, the Commonwealth EMS medical director for the Pennsylvania Department of Health.
“We know if we bring a patient in without being on a backboard, the trauma doctor, emergency physician, or emergency nurse will bite our heads off,” they told him.
“In Pennsylvania, we have put this out on the streets more than we had. It's OK to restrict spinal motion with a cervical collar and not transport them on a hard spineboard. For intrafacility transport, it's preferable to transfer them on the mattress or stretcher rather than transport on the board,” he said.
The backboard is sometimes used to extricate a patient, but that does not mean he has to be transported on a backboard, Dr. Kupas said. More and more emergency physicians tell him it's about time they do this, yet there are still times when a backboard is appropriate. One thing that's not appropriate, however, is using the term immobilization.
“We should be looking at backboards as an extrication device,” Dr. Kupas said.
As EMS providers and emergency physicians began to implement this, they strategized, considering who would be most strongly opposed. First, they consulted with emergency nurses and athletic trainers. The trainers have come to have their own position on this, but they do agree with EMS physicians in many areas.
Matt S. Friedman, MD, the associate medical director of prehospital care and the director of the EMS clerkship in emergency medicine at Maimonides Medical Center in Brooklyn, NY, said the decision to reduce use of backboards has been relatively recent. (Read Dr. Friedman's editorial on backboards on p. 5.)
“When I did a fellowship with the Fire Department of New York, one of the medicine residents was saying, ‘They are not using backboards now?’ It was met with complete shock. In some cases, they result in more harm than benefit. We are not saying, ‘Don't ever use them. Use them judiciously and don't use them blindly as to the reason why,’” he said..
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