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Wed Jun 7 12:19:58 BST 2006

Easy Phil - you know not the practice environment nor the resources
availability (durable, disposable, and personnel) in the areas in
question.  if that is all they have available at any one time, should
they NOT transport all that need transport?  And if so, then who are
they going to leave behind?  Are you going to suggest that military
triage be brought to the civilian world in a very hard core fashion,
leaving potentially viable patients in the field when the resources
lacking are not at the hospital, but in the pre-hospital arena?

If you were talking about downtown Manhattan or Hartford, then perhaps
one could site negligence - or better, just plain stupidity.  But
elsewhere, where resources are scarce, and the prehospital personnel
have been tasked with doing the most they can with the least available
resources, it might be looked at as "resourceful".  

Common sense sometimes gives way to desperation.

Take care,
Ron

>>> "Phil Hoffman" <phoffman at charlevoixmfg.com> 6/6/2006 1:34 PM >>>

Not a lot of new information on the spinal immobilization discussion. 
We've
been doing the "tilt-the-board" thing for several years here in
northern
Michigan on the advice of a gnarly old medic who said: "No one throws
up...
If you look, they all throw down...".  

However, I am surprised that no one questioned the following
statement:

"... we work in a situation where there may be more than two or three
patients in a vehicle at a time. How does the EMT working alone deal
with on
[sic] aspirating patient whilst controlling arterial bleeding on
another
patient?"

Are there not laws, if not common sense, governing the number of
patients
vs. the number of providers?

The above situation seems to border on negligence.

Phil Hoffman
EMTP

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Ronald Gross
Sent: Tuesday, June 06, 2006 1:03 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Spinal immobilization

Pret,

It is almost scarey, for in a few moments, a post that I penned a few
moments will have ceased flying through cyberspace, and land square in
front
of your eyes - and it beginns "OK Johann and Tim".

It seems that you and I are thinking along the same wavelength.  That
should
really worry you!!!

Take care,
Ron

>>> "Bjorn, Pret" <pbjorn at emh.org> 6/6/2006 12:59 PM >>>
Okay, I'm gonna demonstrate my ignorance: "Local is Lekker" is
completely
lost on me.  Can some patient soul let me in on the joke?

The rest of Johann's missive invokes the perennial/perpetual Trauma
List
dialogue over the nature and process of spinal immobilization, to which
my
responses are dog-eared and predictable: 1) a spine board is nothing
more or
less than a big frigging splint; 2) iatrogenic cord injury among even
casually prudent providers is so infrequent as to flirt with urban
myth; and
3) wherever airway and breathing priorities collide with a suspicion
of
spinal injury, it is worth remembering that a dead guy is by
definition
quadriplegic.

I'll politely defer my equally fatiguing commentary on vacuum
mattresses.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Johann Mc Dermott
Sent: Tuesday, June 06, 2006 12:14 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Spinal immobilization

Dr Hardcastle 

I nearly fell off my chair when I read: 'local is lekker' phrase. Home
sweet
home. 

In South-Africa we have quite a high incidence of suspected spinal
injured
patients and this has been a widely debated topic for a while on all
ALS
courses. 

My experience on these are such that all patients on a traumaboard will
move
to some extent when turned lateral. It's what movement that should be
the
concern

What I have found to work for me and what I encourage my colleagues to
do is
when you have a confirmed cervical injury and the patient is GCS 15/15,
keep
the patient supine and sit next to the patient. Immobilize patient
properly
and place added padding in areas where you could have movement when
turned
lateral. Any sign of vomiting - the patient goes lateral with minimal
movement. It should be the crews responsibility to make sure that he is
not
distracted. Reason being is that the most movement is of the superior
torso
and thus movement of the neck. Risk vs benefit.

Now with traumaboard supine transport pressure sores starts to develop
after
20 minutes. Transport time often are longer than 20 minutes. Weigh up
risk
versus benefit to the patient. 

Any other patient will go in the lateral position with proper
immobilization
and padding. Intubated patients go immobilized and supine in the ambo.

As Dr Hardcastle said with our long transport times to hospital or
interfacility transfers I opt for the use of a vacuum mattress. More
comfortable (supine and lateral) and less instances of pressure sores.

Looking forward to hear other comments.  

Johann Mc Dermott
South-Africa 

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Hardcastle Tim, Dr <tch at sun.ac.za>
Sent: Tuesday, June 06, 2006 1:00 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Spinal immobilization

Brendan

Local is "lekker". The additional reason for the lateral board is to
relieve
the pressure on the patient from the long-board. It is for more than
just
airway - this technique was recommended after some of the pressure sore
on
spine board studies. Remember that unlike the USA / UK we often have
long
road transfers (3 - 6 hours) so pressure necrosis becomes a reality on
the
road.

Pret - I take your points too, but here it is one of the "suited to
specific
environment" issues, rather than one level-one evidence-based
guideline.

Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) ATLS 
instructor
and DSTC Cape Town Course Director Intern program Coordinator: Surgery
Program Manager: Emergency Medicine (SU) Clinical Head (Director):
Diana
Princess of Wales Trauma Unit Department of Surgery Room 4064
Tygerberg
Hospital / University of Stellenbosch PO Box 19063 Tygerberg 7505
Western
Cape South Africa
e-mail: tch at sun.ac.za 
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Bren
Sent: Tuesday, June 06, 2006 12:55 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Spinal immobilization

I must add to this... we work in a situation where there may be more
than
two or three patients in a vehicle at a time. How does the EMT working
alone
deal with on aspirating patient whilst controlling arterial bleeding
on
another patient? These are the realities of where we work, and the
environment we're in. our decision to train students in lateral
immobilization may be anecdotal to some extent. But how much gastric
content
is too much?
We give students the option of normal supine transport and in no way
force
them to use the lateral method but we've had so many people come back
to
us
with positive feedback that it makes it an interesting case for study.

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]On Behalf Of Bren
Sent: 06 June 2006 12:18
To: Trauma &amp; Critical Care mailing list
Subject: RE: Spinal immobilization

It's an interesting thought...
Our problem is that the injured or ill patient is inevitably nauseous
and if
he's been immobilized and strapped to a spine board he has no way to
protect
his own airway in the case of active vomiting. He can't just sit up
can
he?
He's strapped down! And just how quickly does a patient vomit? If we
take
into consideration that, in addition to being ill or injured, he
suffers
from motion sickness (tied down travelling head first in a large
diesel
ambulance, anxious, probably slightly shocked) how fast can the
ambulance
technician alone in the back with him lean over and turn him lateral
when he
does actively vomit?
In the case of a more serious injury with a patient with a decreased
level
of consciousness, he can't even tell you that he's feeling nauseous
and
may
give absolutely no warning that he's about to vomit.
Beyond that is the patient who has a seriously diminished GCS (6 - 12
out of
15) who may passively aspirate stomach contents into his airway. If
lying
supine... aspiration Pneumonia is a no-brainer.
If the EMT looks away for a second or (lord forbid) doesn't pick up
that
the
patient has aspirated... on top of that is the fact that a suction
unit
is
only effective if we leave the catheter in place and suction
constantly...
Our EMT-B equivalent have only Guedel Airway as an airway adjunct and
may
suction... beyond this it's manual airway manoeuvres. No more than
that.
And if there's no logic to it why is the "recovery position" so
strongly
advocated in non trauma patients with decreased level of
consciousness?
Thoughts please??

-----Original Message-----
From: trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]On Behalf Of p.bjorn
Sent: 06 June 2006 07:58
To: Trauma &amp; Critical Care mailing list
Subject: Re: Spinal immobilization

Bren,

I think this is an over-solution.  I doubt it's been studied, because
it's
of no logical benefit: if your spinal immobilization is adequate that
you
can turn the patient on his side for the entire transport, why not
just
let
him lie supine and turn him as needed?  Being strapped to a backboard
is
uncomfortable enough without hanging in a half-turn for the duration.
If
you must pursue this odd course, I'd suggest requiring that all
providers be
immobilized for twenty minutes both ways as part of their training.  I
think
you'll find the enthusiasm waning.

And by the way, secure airways can be properly maintained in a BLS
environment, if you're confident in your BLS.

Pret Bjorn, RN
Bangor, ME USA

----- Original Message -----
From: "Bren" <brendan at emstraining.co.za>
To: <trauma-list at trauma.org>
Sent: Tuesday, June 06, 2006 6:07 AM
Subject: Spinal immobilization

> Hey, we're having some really good arguments regarding the
pre-hospital
> immobilization of trauma patients.
> The big concern is one of airway management. Since most of our
ambulances
> run with primarily Basic Life Support crews (equivalent of EMT-B)
and
are
> not trained in advanced airway management, what methods do we have
of
> properly maintaining a secure airway?
>
> The argument seems to center around Immobilization on a long spine
board
> with full head immobilization, using a commercial head block device
and
then
> turning the board, patient and all, into a lateral position to
minimize
the
> chances of aspiration. Purely anecdotal perhaps, but it appears to
be
very
> effective if the pre hospital providers ensure that the
immobilization
is
> correct. We have come up with a method that prevents lateral
movement
of
the
> body and secures the patient to the board and allows little or no
lateral
> movement of Cervical Region. Does anyone on the list know of any
studies
> conducted in this regard? Currently we're training people to place
all
> spinal (or possible spinal) patients in the lateral position after
ensuring
> proper immobilization
>
> Your comments are awaited with baited breath!
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
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