Patient Transfers
	Date: 06.02.97 15:55 From: Shane Curran [scurran@tpgi.com.au] How does the list transfer patients from an ambulance stretcher to a bed in a case of trauma? patient is a 32 yo man involved in a 70 -80 km/hr rollover on a straight stretch of road.wearing a seatbelt.car rolled 3 times little memory for teh event but can remember people talking to him in the car Trapped by confinement with loss of 500 ml of blood from a scalp wound Arrives in dep't supine on an ambulance stretcher c/o shoulder pain and renal angle pain hemodynamically stable said to be confused at scene not obviously so now able to move all limbs to quick command how would you move this patient to the bed in your trauma area? there was some spirited discussion later as to the appropriate method between medical nursing and ambulance staff i look forward to input (off to medline I go) Dr Shane Curran Staff Specialist Emergency Department Wagga Wagga Base Hospital Wagga Wagga NSW 2650 Australia
	Date: 06.02.97 16:36 From: robert b palmer [robp@unm.edu] Shane: In a roll-over accident such as you describe, sufficient mechanism exists for significant injury. Therefore, the patient should be placed in full C-spine restraint (C-collar, long backboard, secured straps, "headbed" or other device to prevent later movement, etc.)by the ambulance personnel at the scene. In this circumstance, the matter of moving from the ambulance bed to the hospital bed involves simply lifting the backboard. That would be my vote, anyway. At least until the neck and back have been radiographically cleared of significant injury. Rob ******************** Dr. R. Palmer University of New Mexico Health Sciences Center Albuquerque, NM 87131-1066
	Date: 06.02.97 18:35 From: Jean.Proehl@Dartmouth.EDU (Jean Proehl) Dr. Curran, With prehospital care being what it is in the U.S. we always get these patients on a backboard and thus just lift the backboard over to the ambulance stretcher. It seems that the place to start is with your ambulance personnel so that patients are boarded in the field -- I'm surprised Anne Hawkins hasn't already done that! (Please tell her hello for me) If they arrive without backboard anyway my thought would be to either: 1) logroll the patient onto a board and then transfer to bed 2) four person lift/slide onto board which is on the bed I don't know of any official reference addressing this situation and the decision on which of the above options depends on a lot a situational variables. Jean Proehl Emergency Clinical Nurse Specialist Dartmouth-Hitchcock Medical Center
	Date: 07.02.97 00:49 From: Keith Wesley [drwesley@primenet.com] re: moving patient onto bed It is the standard of care in our system that such a patient would have been placed in c-spine immobilization with a rigid c-collar because of the head injuury and affixed to a KED board which is a short wrap around extication divice which would immobilize the head and c-spine down to the waist. He would then have been placed on a long backboard and secured with straps or seat belts. The entire package (patient, c-collar, KED, and longboard) would then be transfered to the hospital strecther for evaluation. Should a patient arrive only a cot. We would apply the c-collar and log-roll the patient onto a long board then move them to the stretcher. Keith Wesley, MD, FACEP Director, EMS Education & Trauma Care Sacred Heart Hospital Eau Claire, WI
	Date: 07.02.97 04:30 From: "Huub.T.M. ter Beek" [htmtbeek@worldonline.nl] The nature of this trauma makes the patient an ideal candidate for trauma to the spine (car roll over). As long as injury to the spina has not been excludede, this patient should be moved, with immobilisation if the total spine, especially the c-spine. There is a technique for this transfer, described in the manual of the Advanced Trauma Life Support Course for physicians, page 214. called the Log-roll Technique. Basically you need four persons, and a long spine board for this job. ******************************* Huub T.M. ter Beek St.Antonius Hospital Nieuwegein The Netherlands
	Date: 07.02.97 10:26 From: "Jose A.Acosta" [miguel@mwr.is] Ideally this patient should be in full spine precautions with c-spine collar and long spine board. If the patient arrives without the precautions to the trauma room then he should be placed in them before any transfer occurs. You should use the log-roll technique during the placement of the above. Jose A. Acosta, M.D., F.A.C.S. Keflavik, Iceland
	Date: 09.02.97 02:57 From: Tim Coats[t.coats@dial.pipex.com] Moving the casualty from an ambulance stretcher to hospital trolley can involve two situations: 1) Patient already on long backboard. Here we would lift the backboard on to the hospital trolley then cut the patient's clothing, perform primary survey and critical interventions then do a "mini log-roll" of about 20 degrees to each side to insert a 'scoop' stretcher under the patient (over clothes). The casualty would then be lifted on the scoop stretcher and clothes and backboard removed. The scoop is then removed with counter-pressure on hip and shoulder. This allows high quality radiographs without artifact from clothes or backboard. 2) Patient on ambulance trolley without backboard. In this situation we would perform 20 degree mini log rolls in each direction to place a 'scoop' stretcher under the casualty on which they can then be lifted to the hospital trolley. We have evolved these methods as simply log rolling the patient often does not move them off the backboard. In the same way log rolling the patient on the ambulance stretcher would leave them off to one side of a long backboard. Our methods seem to be different from others suggested - Any comments? Tim Coats Mr. T. J. Coats FRCS. Senior Lecturer in Accident and Emergency / Pre-Hospital Care. Royal London Hospital.
	Date: 07.02.97 10:26 From: "Jose A.Acosta" [miguel@mwr.is] Ideally this patient should be in full spine precautions with c-spine collar and long spine board. If the patient arrives without the precautions to the trauma room then he should be placed in them before any transfer occurs. You should use the log-roll technique during the placement of the above. Jose A. Acosta, M.D., F.A.C.S. Keflavik, Iceland
	Date: 12.02.97 22:00 From: Trauma20@aol.com Shane: I have resently read your article about patient transfers. My view comes from two points of view. Being a paramedic on the streets I cannot see how this patient wasn't boarded, collared and administered oxygen. With a head injury, EMTs and Paramedics should immediatly suspect an accompianing neck injury. Being an Emergency Room Paramedic, I have seen such patients come into the ER without proper C-spine stabilization. I find that nurses in the ER are afraid to collar and board a patient if they are not presented to the ER with proper stabilization devices. In conclusion it is my opinion and is now a protocol in my hospital that if a patient is presented to the ER c/o neck, head, or back pain due to a significant trauma they are to be log rolled onto a backboard with a C-collar while on the ambulace stretcher. If the patient comes into the ER on their own they are to be boarded and collared right in the triage booth via rapid-takedown method. This protocol is hard for some nurses to swallow but has already proved to the administration effective in preventing further injury. ****************** Patrick Russo Emergency Room Paramedic
	Date: 07.02.97 02:42 From: TMcGuire@lanminds.com (Thomas J. McGuire) >Luc Tremblay wrote: >We are about to stop immobilising trauma patients on backboards when >possible and we will use the vacuum mattress. Hi: No personal experience, but here're two abstracts you might find useful. Another consideration (though hotly contested) is to allow paramedics more discretion in deciding IF spinal immobilization is necessary. The State of Maine and the Wilderness Medicine Institute seem to have the most sophisticated protocols for field c-spine evaluation. Good luck! Tom Title Comparison of a vacuum splint device to a rigid backboard for spinal immobilization. Author Johnson DR; Hauswald M; Stockhoff C Address New Mexico EMS Academy, University of New Mexico School of Medicine, Albuquerque 87106, USA. Source Am J Emerg Med, 1996 Jul, 14:4, 369-72 Abstract In this study, comparison of a vacuum splint device to a rigid backboard was made with respect to comfort, speed of application, and degree of immobilization. The study was a prospective, nonblinded comparative study conducted at a statewide emergency medical services (EMS) training facility and included a convenience sample of emergency medical technician (EMT) and paramedic students. The vacuum splint was judged to be significantly more comfortable on a 10-point scale than the rigid backboard after subjects had been lying on each device for 30 minutes (P < .001). It was also faster to apply: 131.6 +/- 24.3 seconds versus 154.6 +/- 22.2 seconds (P < .001). Various measures of immobilization were similar for the two devices. The vacuum splint provided better Immobilization of the torso and less slippage on a gradual lateral tilt. The rigid backboard with head blocks was slightly better at immobilizing the head. Vacuum splints offer a significant improvement in comfort over a traditional backboard for the patient with possible spinal injury. They can be applied in reasonable time frames and provide a similar degree of immobilization when compared to a standard rigid backboard. Title Pain and tissue-interface pressures during spine-board immobilization. Author Cordell WH; Hollingsworth JC; Olinger ML; Stroman SJ; Nelson DR Address Emergency Medicine and Trauma Center, Methodist Hospital of Indiana, Indianapolis, USA. Source Ann Emerg Med, 26: 1, 1995 Jul, 31-6 Abstract STUDY OBJECTIVES: Although spine boards are one of the main EMS means of immobilization and transportation, few studies have addressed the discomfort and potential harmful consequences of using this common EMS tool. We compared the levels of pain and tissue-interface (contact) pressures in volunteers immobilized on spine boards with and without interposed air mattresses. DESIGN: Prospective crossover study. SETTING: Emergency department of Methodist Hospital of Indiana, Indianapolis, Indiana. PARTICIPANTS: Twenty healthy volunteers who had not taken any analgesic drugs in the preceding 24 hours, were not experiencing any pain at the time of the study, and did not have history of chronic back pain. INTERVENTIONS: To simulate prehospital transport conditions, we immobilized volunteers with hard cervical collars and single-buckle chest straps on wooden spine boards with or without commercially available medical air mattresses. The crossover order was randomized. After 80 minutes, immobilization measures were discontinued and the subjects were allowed to get off the boards for a recovery period of 60 minutes. Subjects were then studied for a second 80-minute period with the opposite intervention. At baseline and at 20-minute intervals, the level of pain was rated with a 100-mm visual analog scale. Tissue-interface pressures were measured at the occiput, sacrum, and left heel. RESULTS: Mean pain on the visual analog scale was 9.7 mm at the end of the mattress period and 37.5 mm at the end of the no-mattress period (P = .0001). Although there were no significant differences in pain between the two groups at time 0, volunteers reported significantly more pain during the no-mattress period at 20 (P = .003), 40 (P = .0001), and 60 minutes (P = .0001). All 20 subjects reported that immobilization on the spine board with the mattress was "much better" (five-point scale) than that without the mattress. Interface pressure levels were significantly less in the mattress period than in the no-mattress period measured at occiput (P = .0001), sacrum (P = .0001), and heel (P = .0001). CONCLUSION: In a simulated immobilization experiment, healthy volunteers reported significantly less pain during immobilization on a spine board with an interposed air mattress than during that on a spine board without a mattress. Tissue-interface pressures were significantly higher on spine boards without air mattresses. This and previous studies suggest that immobilization on rigid spine boards is painful and may produce tissue-interface pressure high enough to result in the development of pressure necrosis ("bedsores"). Emergency care providers should consider the use of interposed air mattresses to reduce the pain and potential tissue injury associated with immobilization on rigid spine boards. ***************************************** Thomas J. McGuire (TMcGuire@LanMinds.com) Chabot College Paramedic Program Berkeley Fire Department (California) *****************************************