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beanbean

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Looking for opinions on the KED extrication device and similar pieces of equipment.....

Do you use them or just extricate directly to a long-board? In theory they should be used unless rapid extrication is called for, but how often do you really use it? Around here people usually extricate directly to the long board. I find KEDs very cumbersome especially if the patient is obese and sometimes feel like you end up moving the patient more getting the KED on. Anybody have any thoughts on this?

My favorite use for the KED is to wrap it around the pelvis of someone with a possible hip fx. Great way to stabilize.
 

oudoc08

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Also nice to immob. a ped if you don't carry a pre-manufactured pedi-board.
KED's have their place, but I don't believe they should be mandatory in all situations. Obviously they are not indicated in cases where rapid extrication is indicated, but even in low-emergence cases, clinical judgement is warranted to weigh whether the patient will benefit. In other words, a grossly obese individual who the KED is improperly sized for, or where a unacceptable amount of "wiggling" motion in order to get the device in place, may be better served instead by careful extrication directly onto a LSB. Better yet, a spinal immobilization ruleout protocol serves to eliminate many of these cases, and allows for the trauma patient to be transported in position of comfort. Of course, each of these issues is best addressed under your local protocol and in consultation with your medical director and medical control if warranted.
 

InfiniumEtAl

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I've only used a short board in over 6 years. Never used the KED after I had been trained on it. This was in rural as well as urban with some very long transport times with trauma victims.
 
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beanbean

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What types of spinal immobilization ruleout protocols do you use? Here, its always board and collar. Only at the ED can the physician remove the collar if the patient has no pain upon palpation of the cervical vertebrae and no pain with full neck range of motion. This assumes no ETOH, drugs or painful distracting injuries that would negate the effectiveness of the evaluation.
 

OSUdoc08

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I use it anytime it is too difficult to pull the person out safely, especially if we have time to spare, such as waiting for the bird. The last time I used it, we had a peds pt with a door that would not open wide enought to get the backboard in and flat.

I'm glad I used it---he had an upper lumbar spinal fracture.

It is extremely difficult to hold c-spine well when dropping the pt onto the backboard, especially if you have poorly trained first responders helping you. The KED is a safeguard for this.

**Also, dont forget that it can be used as an outright backboard for your smaller peds pts.
 

oudoc08

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Originally posted by beanbean
What types of spinal immobilization ruleout protocols do you use? Here, its always board and collar. Only at the ED can the physician remove the collar if the patient has no pain upon palpation of the cervical vertebrae and no pain with full neck range of motion. This assumes no ETOH, drugs or painful distracting injuries that would negate the effectiveness of the evaluation.
The service I'm at now basically has none, except for obvious things like sizing difficulties, etc.

However, a service I worked at prior, had us doing the same evaluation that the ER doctor does. That is, basically what you described in your post. Upon negative findings, and no overriding suspicion by the paramedic, the pt. was deemed cleared. Recent issues of JEMS have highlighted the inappropriate usage of spinal immobilization, indicating that it is no longer considered by many to be the benign procedure once thought. (i.e. pain and injury caused by the devices themselves, etc.)
It was also determined that the vast majority of the "hidden spinal fractures" in A/O x4 pts w/o distracting injury, pain, tenderness, or any of the other inclusion criteria, were basically urban legend designed to get EMT-Basic students into the mode of immobilizing people.
Many services have this protocol. My current service is looking into it, and I forsee it being commonplace in the future. If an ER doc can do it, so can we, as we're basically replicating the skill in the field. This is similar to most any skill we have been designated to do in the past, be it defib., intubation, etc.
 

beanbean

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I agree the KED is great as a pedi device.

I also tend to use it only when I seem to see a strong benefit and feel it will provide better immobilization for a patient without causing further harm. I go back to the days before stiffnecks and KEDs when all we had were Philly collars and short boards!

I am familiar with the recent articles regarding spinal immobilization and hope that if evidence supports a benefit in changing of protocols the EMS community will respond.
 

InfiniumEtAl

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Originally posted by oudoc08


........, were basically urban legend designed to get EMT-Basic students into the mode of immobilizing people.
Many services have this protocol. My current service is looking into it, and I forsee it being commonplace in the future. If an ER doc can do it, so can we, as we're basically replicating the skill in the field. This is similar to most any skill we have been designated to do in the past, be it defib., intubation, etc.
Keep it up.
This is my pet peeve. Any complete protocol/procedure CAN be taught to Paramedics/Tech's. Yet, so much is improperly focused in EMT-B courses that it gets difficult to continue teaching upper level algorithims and hueristics to paramedics.
(Read my post regarding research for more complete picture.)
 

oudoc08

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Originally posted by InfiniumEtAl
Keep it up.
This is my pet peeve. Any complete protocol/procedure CAN be taught to Paramedics/Tech's. Yet, so much is improperly focused in EMT-B courses that it gets difficult to continue teaching upper level algorithims and hueristics to paramedics.
(Read my post regarding research for more complete picture.)
Another is injudicious oxygen therapy. Cut toe=NRB mask in most EMT-Basic classes. Or at least it used to, not sure if things have changed or not.
 

SMW83

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I think the screw IV's you screw into the pt.'s leg into the bone marrow should be mandatory in every rig, because you just don't know when you'll need them....I read they are good for ped. pt's.
 

beanbean

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O2 therapy in the EMT-B curriculum has always been a little crazy! When I started in '86 we had NC's NRB's, partial-NRBs, face masks, and venturi masks - way to complicated ! Also, many patients were not getting any O2 even when they needed it because of misunderstandings regarding the hypoxic drive in COPD patients. I saw an EMT try to deny an asthma pt O2 because the EMT thought it would make her stop breathing!

Things then became almost too simple. NRB for everything and NC for pts who couldn't tolerate the NRB. Even though patients were getting the O2 they needed (and sometimes some they didn't need), EMTs were not taught to apply the O2 as part of the 'A' in ABC. In the old primary/secondary survey way of doing things O2 management was just something you did at some point. Although any good EMT in the field knew that O2 should be given immediately for pts in distress, it wasn't really being taught that way.

Now, O2 therapy is taught as an integrated part of the 'A' and 'B' of ABCs. I agree that NRBs still tend to get overused, but for the majority of patients a little too much is better than too little. I think in general EMTs have a bit better of an understanding of why O2 is important and do realize it is a drug and should not be used without just cause.
 

12R34Y

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I personally dislike the KED just because most people in fender benders DO NOT need C-collars and spine boards.

At my service if they are alert and oriented, no ETOH, drugs, distracting injuries, and have NO point tenderness over spine, no neurological symptoms (parasthesia, weakness etc...) then we do NOT apply c-spine precautions.

As you all know it makes for a much more cozy ride for patients NOT being a spine board because of the overkill philosphy of a lot of EMS systems that EVERYONE get c-spine precautions even if they ran up to you and hugged you upon arrival.

later
 

EMT036

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A few years ago, my service used to KED everyone that was involved in an MVA and had neck/back/head pain (except for pts whose condition necessitated rapid extrication.) We have gotten away from that now, and just basically immobilize straight onto a LBB. The KED is really too much of a pain, and I fail to see how it will lead to better outcomes in patients complaining of "Insurance pain."
 

trauma_junky

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I only use the KED for extended extrications.

We do field C-spine clearence so we only immobilize those that need it.
 

OSUdoc08

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Originally posted by SMW83
I think the screw IV's you screw into the pt.'s leg into the bone marrow should be mandatory in every rig, because you just don't know when you'll need them....I read they are good for ped. pt's.
Intraosseous needles are only for last resort if you can't find ANY veins whatsoever, and is only used for mainly CPR's in infants. It is also only to be used on unconscious patients, per my medical director.

Do you really want i piece of sharp metal shoved through your leg into your shin, unless you are about to die? I don't think so.

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As for O2, it doesn't hurt, and it helps the patient relax anyway. So why withhold it. You don't know what's wrong with them internally anyway. I put 02 on all trauma patients, because when the body is in distress, it requires all the help it can get, so the resources can be alotted for more essential purposes.
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As for C-collars, if the patient is ambulatory, then fine clear C-spine, but if the patient has not moved, it is not your call. Put it on the patient---their comfort is not important in this case. You are not a pararadiologist. They may not start feeling pain until later.
 

trauma_junky

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Originally posted by OSUdoc08


As for C-collars, if the patient is ambulatory, then fine clear C-spine, but if the patient has not moved, it is not your call. Put it on the patient---their comfort is not important in this case. You are not a pararadiologist. They may not start feeling pain until later.
If there is no point tenderness, no neuro defficits, and no distracting injuries, or EtOH then there is no need for CID. Pain that shows up later is soft tissue injury and does not require a c-collar.
 

OSUdoc08

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If your medical director trusts your judgement in this regard, then more power to you. I don't feel the training is there to clear c-spine in the field. Most paramedics don't know what distracting injuries are, or how to do a full neuro exam to determine deficits. And about the EtOH---do you carry a breathalyzer? I sure don't.
 

FoughtFyr

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Actually, we do clear c-spine in the field, and I have done research to validate it. I found an extremely high level of agreement between EMT-Ps and paramedics in this regard. My paper was presented at the World Congress on Trauma in 1999 where it won best clinical paper. So yes OSU, I think the training can be there.

Abstract:

Paramedics Performing Prehospital Spinal Clearance by Clinical Exam: Do Physicians Agree with their Findings?

Mell HK et al

Objective: Many EMS Systems have recently implemented or are considering implantation of protocols allowing prehospital spinal injury clearance. This study describes the implementation by a suburban Chicago EMS System of a protocol allowing paramedic level prehospital EMS personnel to clinically assess spinal injuries in the out-of-hospital environment and forego spinal immobilization based on that evaluation.
Methods: Retrospective patient record and EMS report review of patients transported by ambulance in 1997. The presence of spinal immobilization was measured against the presence of a physician?s order for a portable, cross-table, lateral c-spine radiograph in the receiving ED. Additional data characterizing each patient?s ED visit were collected. The setting was a Level-2 trauma center/EMS resource hospital serving a socio-economically mixed patient population.
Results: Of 1776 patients in the study, 1136 were immobilized prior to transport (63.96%). Of these patients, 486 received a portable, cross-table, lateral, c-spine radiograph (42.78%). 640 patients were transported without immobilization (36.04%). Of these patients, 1 received a portable, cross-table, lateral, c-spine radiograph (0.16%). Significant differences in the lengths of stay in the ED were noted between the immobilized and non-immobilized populations controlling for acuity and disposition.
Conclusion: The probability of disagreement between paramedics and ED physicians with regard to trauma patients transported to the ED without spinal immobilization when a protocol allowing prehospital spinal injury clearance is in effect was found to be 0.06%, which is significantly lower than previously published error rates concerning paramedics performing spinal immobilization. The use of a protocol of this type reduces the spinal immobilization of trauma patients by 36%. Injured patients transported without spinal immobilization experience shorter lengths of stay in the ED than similarly injured patients who were immobilized.
 

12R34Y

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AMEN!!

As stated in an earlier post my service routinely cleard c-spines.

definately can be done.

later
 

OSUdoc08

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Sounds good. Hopefully this knowledge can be applied.
 

Apollyon

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Originally posted by OSUdoc08
If your medical director trusts your judgement in this regard, then more power to you. I don't feel the training is there to clear c-spine in the field. Most paramedics don't know what distracting injuries are, or how to do a full neuro exam to determine deficits. And about the EtOH---do you carry a breathalyzer? I sure don't.
They're talking about NEXUS criteria. You don't need to do a full neuro exam. Also, in the ED, we don't breathalyze people or check the serum ETOH before clearing the c-spine without films. Remember, any question, and you just immoblize the pt (or leave them on the board).

Of note, the NEXUS study had 2 patients out of 30,000 that STILL had c-spine fractures, despite having no midline cervical point tenderness, no distracting injury, no intoxication, no focal deficit, and a normal mental status.
 
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