Spinal Immobilization & LUSAR

[Donut]

Recently the CF is running LUSAR (Light Urban Search and Rescue, bad acronym, though) tng, for Reg F ( I believe) and for Res F (I know).  This is being run in Esquimalt, and almost certainly other places as well.  There are also LUSAR exercises being run in conjunction with local FD, Emerg Social Services, Canadian Red Cross and possibly other agencies, too.

I've been tasked to teach the people from 39 CBG HQ and Lower Mainland units the pre-course spinal immobilzation skills, including c-collar application and KEDs.  It doesn't specify spine boards, ROS (scoop litters) or any other device, just collar and KED.  Keep that in mind.

I've taught one course so far, and I had a student who had just returned from one such exercise. When it became time to teach the KED application to a supine pt I asked him how they had done it on the exercise.  He indicated they, maintaining c-spine control, sat the pt up, applied (without strapping) the ked to the pts back, and returned the pt to the supine position. 

Earlier he had stated they were training to work in teams of 3, two primary rescuers, one backup outside the structure.  he stated they used KEDs because they were portable, more easily then other spinal kits.

If you do the math, that's going to be a hard manoever to accomplish with two rescuers in a confined or chaotic space.

For the clinicians, and I've gotten several opinions already, is that an acceptable means to package a patient? 

Is there an easier way that's more effective? 

Is the KED and a non-rigid stretcher acceptable pt transport?

Your thought, please.

DF

 

[Fraser.g]

I can see why they like the use of the KED in theory. Once a person is in the device it is great however it is slow to apply, and once on it is a pain in the butt to remove once in the ED. Those buckles cause allot of flexing of the thoracic and Lumbar spine during the log roll.

That being said I certainly grimmaced when I read that your student had been taught to lean the person forward to apply the KED and then place them back in the suppine position. If absolutely necessary to save life then by all means but I believe it would unnecessarily place or change loads on the thoracic and lumbar spines and therefore threaten to move an otherwise stable but tenuous fracture.

I do not have the pre-hospital experience that many on this board have and therefore am only speaking from my own POV.

I am working with the SME from the local amb tonight in the ED. I will ask him what protocol he follows. He is also a vet the Tsunami and the Pakistan quake disaster responce.

I will let you know what I find out.

GF

 

[old medic]

I cringed as well when I read that part about sitting the patient up.
It certainly doesn't fit the golden rule, minimize handling and movement, of spinal immobilization.

I would have thought a SKED sleeve would be better for use in a structural collapse. 
Kendricks are probably cheaper, but I would assume the straps and handles would be a problem
while working in rubble.  Perhaps they were told to sit the patient up if the straps were coming
tangled ?  My next question would be, how often do you have that kind of room in L/M/H USAR? and if
you do have it, why not just use a board? 

The KED is essentially a splint for a suspected spinal fracture. The famous phrase "Follow local protocols" comes in here.
Some places say you can use it in place of a spine board, other places say you have to lay the patient
onto a board once the extrication is done.

RN PRN:

Why log roll a patient to get them out of a KED?  Just put a slider board under the KED, unstrap it and
slide it up their back and off while the patient remains supine.

 

[Armymedic]

I've taught one course so far, and I had a student who had just returned from one such exercise. When it became time to teach the KED application to a supine pt I asked him how they had done it on the exercise.   He indicated they, maintaining c-spine control, sat the pt up, applied (without strapping) the ked to the pts back, and returned the pt to the supine position.  

Good question, time to think outside the box (or gold standard).

My choice would be KED as well, with c collar and copious amounts of 1 inch gun tape

My most likely context for equivilent use would be evac in OBUA. We are limited in what kit we have access to. In this case, where the areas that need to be traversed are too small for the standard 7 ft backboard, then the KED should work fine.

The key thing in any sort of C spine immobilization is to minimize movement. My concern with the above statement is the returning of the pt to supine. To have the cas remain in a sitting posn (even if it means you have to bring the knees up once) would be acceptable as it would entail only moving the cas once. The KED, if properly applied, it will securely hold cervical and thorax spine in line, a small sacrifice in movement of the lumbar spine might have to be accepted if you are limited in manouver space. This will allow you to move the cas with 2-4 pers.   I have practiced with the KED in the extremely confined areas of armoured vehicles (both as the cas and rescuer). It worked as designed extremely well in those circumstance, so it should be more then adequate in the USAR role.

If you are using KED, then it should be used properly, with all staps tightened and secured.

As for the difficulties in the ER...isn't that what all you nurses and doctors there get paid the big bucks for?

 

[beach_bum]

Having been one of the students that ParaMed Tech taught, and then attending the LUSAR trg the next weekend, I found out why we used the KED.  There was NO room at all for a spine board until we extricated the victim from the buildings.  It was very confined, nor did we have room to have them sit up so that pretty much took away that option anyway.  As for the straps, we kept them buckled up until they were needed and they didn't really cause that much of a problem.

 

[medicineman]

I remember doing a confined spance entry and rescue course back in the early 90's in Calgary - it was really cool.  All pretty much done in the dark with SCBA's and such.  What we used to get people out of the tank (not an AFV - a fuel tank with very narrow manholes) was a SKED sled or a collar and wrap system with ropes - depending on which way the poor slob was going out and how much room was available (I had cosotchondritis for a month from being tied up small enough to go through an 18'' manhole :'( ).  Now I know SKED's aren't readily available in the system, so why not try to get some Ashton-Waters stretchers - the Navy use them all the time to get people through pretty small holes and packaged up nice and neatly and they are in the system.  Might be worth a try.

MM

 

[Fraser.g]

I cringed as well when I read that part about sitting the patient up.
It certainly doesn't fit the golden rule, minimize handling and movement, of spinal immobilization.

RN PRN:

Why log roll a patient to get them out of a KED?   Just put a slider board under the KED, unstrap it and
slide it up their back and off while the patient remains supine.

You answered your own question. We log roll to check the back, spine and rectal tone. If we slide the KED, then log roll for the spine board it is two moves while if we roll and do both it is one.

The fact is that once they get to the ER, the first thing we do is undo all the beautiful work that the Pre-hospital guys are so good at. It is just a fact of different applications for different parts of the chain.

GF

 

[Donut]

Thanks for your replies, everybody.  That was great, especially Beach Bum, thanks again.

I think a SKED drag may be the optimal item for this, but what the hell do I know.

My next class is tomorrow night, and I'll let everyone know what comes up.

DF

 

[Fraser.g]

I seem to recall seeing a collapsable sled like the SKED used for mountain rescue. From what I remember, it was made up of hard flexable plastic. When it unrolled it was curved at both ends and secured in the middle with three buckle fasteners.

DF the last time I saw one was at SMUR. Do you remember what I am talking about?

I will try and find a pic on line.

GF

 

[old medic]

Just a few USAR links. There are tons of team pages when you go looking. These ones seemed the most
relevent and useful.

A good Background page:    http://www.toronto.ca/wes/techservices/oem/husar/classification.htm

Toronto USAR:                  http://www.toronto.ca/wes/techservices/oem/husar/
LA County Fire USAR:          http://www.lacofd.org/usar.htm 
                                        http://www.lacofd.org/training.htm (lots of training pdf's when you start clicking photos)
Netherlands USAR:              http://www.usar.nl/page/english
New Zealand USAR:            http://www.usar.govt.nz/usarwebsite.nsf
Vancouver USAR:                http://vancouver.ca/usar/

Sked product line:                http://www.skedco.com/skedco-product.htm
Sked Hazmat Stretcher:        http://www.skedco.com/sk250.htm
half Sked patient drag:          http://www.skedco.com/sk220.htm

 

[Old Ranger]

Why stop at sitting the patient up, why not have them walk out and carry your bags as well. :
Sarcasm off.

I think the "sitting up" idea probably came from it's original intended use of the patient already in the sitting position i.e. car seat.

If you keep the buckles "fan folded" and secured with their little Velcro straps, it is much easier to deploy them, and they don't get caught up in the application.  Once they are secure, they can be tucked into the sides of the KED.  The leg straps are to help keep the Lumbar area from moving around (and the person in the sitting position) until you get them on a backboard.  Obviously if your confined and can't use a board, the leg straps are used to keep the patient from sliding out of the KED.

If the patient is supine, practice sliding the KED from the head of the patient down, with good C-Spine control, there should be minimal spinal movement.

KED's are fast....if practiced, as with any Drill!

With the ED's log rolling, it is a Controlled environment with more hands for stability.

If the Carry handles are a problem, keep them down with a wide strip of Gun tape (end folded for easy removal) until you need to use them.

I'll try and get a picture of the "Fan Folding" with the buckle ready to deploy, so you know what I mean.

Of course our Civi KED's have nice bright different coloured straps for ease of remembering which strap goes first and to where.

Ben

 

[Armymedic]

Thanks for reminding me to post up again on this.

After we run a BTLS course here is Petawawa, we try to do an extrication/scenario day where we play with various types of Armoured and SMP vehs. 
The scenario I gave to see how this would work was that you have a person on the floor of the LAV 3 with obvious head/face injury as result of MVC. The MOI is an indication of C spine injury and would require control. Also just for the sake of being nice, I made the scene safe, with lots of time and resources so that the KED would be used. We also limited access to the back of the thru the air sentry hatches so that no spine board could be used, and the cas had to be lifted thru and out of the veh.

As I suspected and without my influence, the team leader had the team log roll the pt onto the KED and then bring up the knees into to attach the legs straps. The cas was then tightened into the KED using proper technique and lifted to, then hauled up thru the air sentry hatch.

So it is my professional opinion (and what a scary thing that is) that sitting the pt up induces more movement to the pt's torso and neck then is required and that just flexing the hips will allow legs straps to be secured and tightened and then allowing 2-3 pers to easily (within their physical capabilities) to lift and carry the casualty.

 

[Fraser.g]

Makes perfect sense to me as well.

Give kudos to the troop that used that technique.

DF, ya getting this??

GF

 

[old medic]

Ben,

Is this what you were after when you said fan folding? I just fan folded the red strap on the second photo. The others are rolled. Sorry, didn't have a camo-ked handy.

 

[Donut]

Again, thanks for the feedback.

Last class I had a couple of med techs and an ex-lifeguard in it, so we had a chance to try out some different approaches to this.

We tried log rolling (seemed no better or worse then on to a board, and the panels and straps were easily managed)

sitting up (definitely a lot of movement of the lumbar spine)

and we tried a five person vertical lift with the KED slid underneath(not bad, actually).

I would argue that flexing the hips induces a greater-then-desireable degree of movement to the lower back.  (note, desireable, not acceptable. YMMV)

As with all con-space techniques, you work with what you've got, space included.

It seems there are lots of pieces of equipment that will perform better then the KED in these situations, but it seems to do an adequate job for this roll.

Another question:  Do these teams have a medical director?

DF

 

[beach_bum]

The LUSAR teams themselves?  No.  The team is comprised of 3 people.  One is building safety (they maintain contact with the teams and outside) the other two are either searchers or rescuers depending on the task they have been given by the box comd.  Back at the E-Box there is a first aid station set up which hopefully will have medical pers manning it. 

Does that answer your question?

 

[Donut]

Thanks, BB,  but I was more thinking about the development of the TTP's the teams use, as opposed to the teams on the ground themselves.

DF

 

[Old Ranger]

Ben,

Is this what you were after when you said fan folding? I just fan folded the red strap on the second photo. The others are rolled. Sorry, didn't have a camo-ked handy.

Yes, absolutely the Red strap.  Just a simple, reach across the patient and pull toward you.  Glad you have the buckle out of the velcro.

Thanks Old Medic,

Ben