Martyn/Adrian,
Further to my original posting on this (diagnostic v therapeutic log roll
etc.), the purpose of the long board IS primarily as an extrication device,
it is not designed appropriately to be a packaging/transfer device for
patients with serious injury. Once patients are secured on to it, however,
then yes it will facilitate transfer of patients from A to B but this is far
from ideal.
Considering the HEMS patient to which Adrian referred, the orthopaedic scoop
style stretcher, although potentially problematic with back pressure areas,
does help contribute to haemorrhage control by avoiding unnecessary log
rolling, IF the back has been examined at the scene and the findings
documented.
Accepting the current widespread use of long boards in prehospital care for
transfer purposes, the proposed (nurse/paramedic led spinal board removal)
protocol still holds good as this patient would have been admitted directly
to the resuscitation room for trauma team management. In this situation it
would have been inappropriate to have log rolled this patient without
(medical) clinical assessment at the time because of the potential for an
unstable pelvic injury, needless clot disruption etc would have been high.
If the back had not been examined in the field, then the log roll should
only be performed once.
It is also possible to rapidly and safely transfer spinally injured patients
extricated on a long board to a scoop stretcher in the field with minimal
patient movement.
However patients with such injuries are a relative rarity when compared to
the vast of majority of fully immobilised patients admitted to the ED. It is
these latter group patients who are most likely to languish inappropriately
on long boards.........
Your case also illustrates the importance of imaging the entire spine
patients with significant injury mechanisms in patients who are not only
unconscious, but also in my view, those with a persistent GCS <15, or who
are difficult to assess because of extremes of age, pre-existing disease
etc, irrespective of "clinical" findings upon log rolling.
John
-----Original Message-----
From: Adrian Fogarty [mailto:[log in to unmask]]
Sent: 11 September 2002 10:07
To: [log in to unmask]
Subject: Re: Nurse initiated removal from spinal boards
Interesting points Martyn, I agree there should be no problems with
nurse/paramedic initiated removal from boards, and this doesn't require any
"evidence", it's just plain common sense as you suggest. The only potential
drawback is that the doctor might have to repeat the logroll, for diagnosis,
several hours later, especially if the patient is complaining of back pain.
This of course depends on the scenario; I tend not to x-ray if it's a
whiplash situation but if it's a more direct injury such as a fall, then
there's no point in logrolling to examine, as you might as well go straight
for imaging. An example the other day, a HEMS patient who had fallen three
storeys (psyche case). No specific complaint of back pain and a normal back
exam when we logrolled her off the board. But I figured, as I do with all
"jumpers", let's image her spine anyway. She had nasty unstable crush
fractures of T10 and L3. The diagnostic yield of a logroll exam are highly
limited.
Adrian Fogarty
----- Original Message -----
From: "Martyn Hodson" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, September 10, 2002 9:41 PM
Subject: Re: Nurse initiated removal from spinal boards
> > -----Original Message-----
> > From: Adrian Boyle [mailto:[log in to unmask]]
> > Sent: 06 September 2002 16:38
> > To: [log in to unmask]
> > Subject: Nurse initiated removal from spinal boards
> >
> >
> > I am trying to reduce the amount of time our patients spend on spinal
> > boards. One solution that has been put forward is that the paramedics
and
> > nurses logroll the patient off the board onto the couch as soon as the
> > patient arrives (without the need for a doctor to be present) and then
> > maintains immobilisation. The other advantage of this is that the two
> > paramedics assist at arrival (and go away with their board) The triaging
> > nurse only needs to request one other person to give them a hand with a
> log
> > roll.
> > The present state is that a patient is left on the board by the triage
> > nurse, the paramedics go off to their next job and the patient is not
> taken
> > off the board until the SHO comes to see them, often these people are
> > medically fairly well and do not get high priorities so the wait can be
> > considerable. It can also be a hassle getting a 'log roll posse'
together.
> > What is practice in other departments? can nurses and paramedics log
roll
> > patients off spinal boards without a doctor being present? If anyone has
a
> > formal (evidence based protocol or guideline) I would be very keen to
have
> a
> > look at it.
> > Adrian Boyle
> >
>
> I've watched this debate for a while and feel that it is maybe time for me
> to throw by two pence into the ring ( thereby mixing my metaphors )
>
> i think what Adrain suggests of the 'therapeutic' log roll vs. the
> 'diagnostic' log roll has value, especially from somethign which is seen
as
> a 'nursing' issue that of patient comfort and of pressure area care.
>
> Firstly we have to consider what the purpose ofthe long board is - is it
to
> provide immobilisation until cleared / definite immobilisation is provided
> ( by whatever method, halo, traction, surgical procedures ...)
>
> or is it to aid immobilisation in the extrication and transfer to
definitive
> care parts of the patient 'journey'
>
> i would suggest that the second is closer to the truth as good
> immobilisation can be obtained off the board, on an A+E trolley or
similar -
> after all several Ambulance services used to immobilise on the ambulance
> trolley as they only carried scoop type stetchers as extrication aids .
>
> we have to consider what we want to achieve about this issue if it is to
> promote patient comfort and enable the crew to have their board back
while
> maintaining an appropriate level of immobilisation this is a desirable
aim.
>
> as for 'Can' of course you could teach primary school kids how to log roll
,
> 'should ' is the key question - and persoanlly even if the Nurse isn#t in
a
> position to clinically clear and /or request / interpret radiography there
> are potential benefits to be seen
>
>
> Martyn Hodson
> [log in to unmask]
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