Three reasons why you should get excited to be a prehospital provider

“Contentment is the refuge of the boring and the uninspired” -Ralph Waldo Emerson

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Dr. John Hinds responding. (via Twitter)

Prehospital providers have always been particularly prone to complacency. Once the novelty of running code-3 wears off, routine transports and inglorious 911 responses threaten to demoralize providers and make them content with only the knowledge and skills needed for “the everyday.”

So let’s examine the extraordinary and apply it to the ordinary. Here are three incredible examples of prehospital FOAM that should get your blood flowing once again. Be inspired, share it with others, and bring your game face to each and every call

1) The First Prehospital REBOA— EMCrit chats with the first provider (registrar Jonny Price from London HEMS) to have performed a prehospital REBOA. What is REBOA? Essentially it inflates a balloon that occludes the aorta to stop bleeding at non-compressible points of hemorrhage. Why should you get excited? They did prehospitally what once only a full resuscitative thoracotomy and aortic clamp would. And a paramedic assisted with the procedure.

2) Making the Call— Again via EMCrit, Michael Lauria (@resuspadawan)–formerly of USAF Pararescue and then Dartmouth-Hitchcock Advanced Rescue Team (DART)–applies techniques and lessons learned during his time in the Special Forces to working as a prehospital provider. Why should you get excited? Mike speaks authoritatively on how providers can apply techniques used by Special Forces to improve their cognitive decision making under stress and keep a cool head in the inevitable cluster-call.

3) Motobike Mayhem— Dr. John Hinds (@DocJohnHinds) gives an incredible lecture outlining some of the traumatic injuries that result from high-speed motorcycle crashes. Listen to it and flip through the slides at the same time. No part of you will be disappointed. Why should you get excited? This team treats injuries similar to those that could be seen by any prehospital provider and have spectacular resuscitations. And it’s motobike EMS. Need I say more?

I recognize that not all of this is directly applicable to everyday-American-EMS, but that doesn’t mean that we discount it as irrelevant. All of these things are being done outside of the hospital by those who aren’t complacent with their everyday medicine. And I don’t see any reason why we can’t work our way there too.


LIT. ALERT–“EMS Spinal Precautions and the Use of the Long Backboard…”

Last year around this time, the National Association of EMS Physicians (NAEMSP) released a position statement on the prehospital use of the “long backboard” as an immobilization device.  In their statement, the NAEMSP outlines the type of patients that should be immobilized with a backboard; however, they also outline who should not be immobilized AND they make a potentially game-changing statement:

-Spinal precautions can be maintained by application of a rigid cervical collar and securing the patient firmly to the EMS stretcher [emphasis added], and may be most appropriate for: patients who are found to be ambulatory on scene; patients who must be transported for a protracted time, particularly prior to interfacility transfer; patients for whom a backboard is not otherwise indicated.

That was a year ago.  Last month they released a resource document providing more background and research supporting the position statement.  In the article, they provide supporting evidence for each of the points in the position statement.

If you can get your hands on it, it’s actually a pretty good read; they start at the beginning with the 1966 report by Geisler et al. that attributed “delayed onset of paraplegia” in hospitalized patients with spinal fractures to the “failure to recognize the injury and protect the patient from the consequences of his unstable spine.”  They touch on the study that took pain-free volunteers, strapped them to a backboard for an hour, and then had pain persisting for 24 hours afterwards, as well as the myriad studies showing just how rare unstable spinal fractures are (o.o1% of patients in one study had incomplete, unstable spinal injuries requiring operative fixation).

Finally, they get to the part that matters–what we can do differently.  To summarize: they recommend selective spinal immobilization protocols, they recommend (for appropriate patients) using a cervical collar and the stretcher as spinal precautions, and they recommend considering protocols that allow providers to consider removing patients from backboards if appropriate.  Very cool.

Some services have even started implementing these recommendations: the article mentions an Ohio fire department with protocols to transport with only a c-collar and stretcher as well as the State of Maryland, which recently changed its statewide protocols and will be eliminating the use of backboards for penetrating trauma.

As always, the change will be slow, but more supporting research is already on the way.  Currently in the “Early Online” section of Prehospital Emergency Care is a study that looks at Spinal Motion Reduction training program, and I’m sure other studies are on the way.

For now we’ll just have to keep following protocols, but this seems like a decently obvious change to make.  Are your systems taking steps in this direction?  And is anyone aware of additional recent studies?  This resource document may be the tipping point in taking more definitive action against the widespread use of backboards in the field, and I would encourage having that conversation with your peers and medical directors.

**RougeMedic did a post on the original position statement, which goes into details a little more than I do here.  I also borrowed his picture…