Spinal Immobilization and the KED

[KYMEDIC]

Maybe it's just me, but it seems that I and all of my EMS brothers and sisters remember how and why to use a KED or other short board just long enough to get through testing for their EMT/Paramedic/BTLS/etc. class. Once we get paper in our hands the KED goes back to the back of the compartment.

Could it be that we know more than all of the MDs out there? Maybe it's our X-ray vision, spidey sense or intuition? I don't know, but I would like to see one of two things happen- either we all start using the things like we're supposed to ORRRR we all get off our duffs and do some real research that proves that they have no effect and we can do just as good a job manually.

I can't really think of a good way to set up a study re: this since there isn't a good way to immediately check to see how well we did right there in the field. It seems that in a time when all the scientific types are looking for things to study, someone would take on this problem. Look at what happened to MAST/PASG just based on a couple of studies and one loud voice. Could it be that we've assumed that Short Boards work just like we used to assume that MAST did?

Maybe someone with access to a cadaver lab could convince a reasearcher to break some C-spines and then X-ray them with and without rapid extrication. I would love to see us have facts to prove that the KED works or doesn't work, rather than the intuition that created it. It might also take some heat off me when I'm teaching EMT classes and the newbies ask why the "real" ambulance people don't use this equipment like the class teaches them to.

Any ideas?<br />(P.S. MAST/PASG do save lives! You've just gotta know how and why to use them and do some thinking instead of just "popping velcro".)

[ADSNWFLD]

In general I think too many medics are just LAZY! They are taking a gamble with our pt's lives. When properly applied the KED does a very good job. Their are instances where the KED takes too long, but many pt's that should have one don't get it.

Keep teaching the right way and do the right thing out in the field.

Just curious, what kind of assesment and findings would prevent you from placing a KED or for that matter not imobilizing a pt at all?

In one of the systems that I work in we clear c-spines in the field. The pt has to be reliable AO X 3, no mechanism of serious injury, no pain and a neuro assesment. If all findings are negative the pt doesn't have to be boarded.

[KYMEDIC]

Most people that I see not using the KED do it based on a LACK OF assessment findings. For example, even though the book says apply it if you have mechanism of injury, if the patient "looks OK" or doesn't have neck pain, they end up without it.

We also have a spinal clearance protocol, based on the one used in Maine, but note that it and the one published by BTLS don't allow for clearance if the patient has positive mechanism of injury (even if they don't complain of injury at that time). So in the scenario above it wouldn't be appropriate to clear them in the field and not use the KED.

Even if it was able to clear them from using the KED, why do they then frequently get an LSB? To me that's the same as putting on a collar and walking them to the truck to ride in on the squad bench. If you put the collar (or LSB) on, you're admiting you thought immobilization was needed, but then turn around and do it inappropriately (like not using the KED to get to the LSB).

I agree with you, it's laziness. Either they are lazy to get it out and have to pack it back up or they're too lazy to learn how to use it well, so it gets left on the truck to avoid embarassment.

Thanks for the reply.

[Resq14]

I was going to ask this very same question this week, so I was glad to see someone else take the initiative.

I always get the impression that "seasoned" EMS people don't use KED's.

Usually, the scenario goes like this. A minor MVC, such as a lower-to-moderate speed fender-bender, patient has no loss of consiousness, no obvious injuries, and is only complaining of neck discomfort. Patient has radial pulses, equal chest expansion, and denies dyspnea, chest discomfort, etc. There is no neuromotor or neurosensory deficit, and the patient is competent. In other words, the patient is not critical. The mechanism of injury is considered to be significant enough to warrant immobilization (along with the neck pain).

The popular thing to do: collar, slide a board under the patient, and "guide" them out and down.

I thought PHTLS said this technique was only for critical patients, and that all other patients were still to be treated using KED-type devices in addition to the above.

Now I'm not saying I like dilly-dallying with KED's... but when their use is indicated by all the training I've ever had, and it appears to be the standard of care, I'm going to use it.

I would like to see something conclusive that says it works, or it doesn't work. Or, solid indications for use that we can all agree with.

[ADSNWFLD]

Another reaso that the KED isn't used is the type of car involved. Their are many cars that once a KED is applied their is no way of getting the pt. out.

I think the best thing to do is document why or why not. If the KED isn't on a pt. but you can provide good documentation as to why you'll better protect yourself and your department.

Do what is best for the pt. I think most medics know, down deep, what the correct thing to do is.

Good Luck

PS if the pt really needs a KED, obvious injury, I have no problem having a car's roof removed. Again do what is best for them, not what is convienient.

[joejoe33]

I've used the KED and the XP-1. We carry the KED in our MICU's. I would have to agree and say that the KED does not get utilized as much as it probably could be used.

We had a MVC less than a month ago involving a 55 year old male who was a unrestrained front seat passenger in a vehicle that t-boned another vehicle. The windshield was shattered from the patients head striking it. His chief complaint was inability to move and numbness from the shoulders down. We immobilized the c-spine, applied a c-collar, applied the KED, immobilized the patient on a backboard with straps, and immobilized the patients head. This was crucial packaging to extricate the patient through the rear hatchback.

Upon extricating the patient from the vehicle he experienced difficulty breathing.

During the extrication our engine company set up a LZ for the helicopter ambulance to set down.

The helicopter ambulance was on-scene quickly and the patient was transferred by our MICU. The patient was treated per protocol and loaded in the helicopter for a quick flight to the trauma center.

I think if you want c-spine immobilization in suspected c-spine injuries with packaging for extrication, the KED is the way to go. <img src="rolleyes.gif" border="0">

[WHFD322]

I have never seen a study that proves that a ked helps any body. It does put handles on the patient and makes them move for some people. I do put them on every one that is in a sitting position because it is a national standard. Most of the people in this area forget to put the leg straps on.

[firecadetak]

We just used our's today at an MVA, first time I have ever used it on an actual call and it worked great!!!

[EMT135864]

When my agency rolls up on an MVA, anyone still in a vehicle and c/o pain gets a KED and then extrication to a LBB. Exceptions would be a critical pt that gets a rapid extrication instead. Anyone stable enough, though, gets a KED. No reason not to, other than laziness or indifference.

[littlemissemt]

In my EMT class we were taught how to use KED's and we were tested on it at National Registry. I never had the oppourtunity to use one on my ridealongs but if I were at the scene of an MVA and a pt was sitting in a vehicle with a possible spinal injury I would put on one them unless there were extenuating circumstances that prevented me from doing so. If I had a pt in a MVA with a sig MOI, I would be putting one on them. Better to be safe than sorry.

[ESDA-20]

Don't forget, lawyers would love to eat it up should you ever find yourself at the wrong end of a law suit.

"So, Mr. EMT. You have this device called a KED that helps immobilize the spine. Why didn't you use it again?"

Better to be safe, then sorry. Take the extra 45 seconds.

[tlfd600]

The problem I have with it is I have seen many people use it as the sole back boarding devise in pediatric patients. I totaly hate this practice because their feet stick out the botttom, allowing movent and void any effort you have used to make thier bodies imobile. As for me I have only used it a few times, most of the time we are the first responding ambulnace on a wreck with 2 or more patients and we only have one on the MICU so we just Board them while trying to minimize back movement. Also we get alot of Layer pains, where there is a low speed impact and they are out of the car standing and talking on thier cell phone and after talking to them they finally decide their back hurts, (mainly when the police show up or a BMW is involved).

[medic3401]

My personal experience with the KED is that the patient is manipulated more trying to apply it than if you take your time and move a patient out onto an LSB without it. It works great in a classroom while the "patient" is sitting in a chair with nothing else around him or her. I have used a KED once in the last three years. It was with a patient with neck pain and a possible step-off at C4/5. The reason we used it and why it worked so well is that the FD removed the roof and we were able to take the patient straight out of his seat and out the back of the car. To try to remove someone out of the door with a KED in place is difficult at best. I prefer to collar someone and manually stabilize their c-spine and then CAREFULLY move them to a LSB. My humble opinion.

[EMT135864]

ESDI is exactly right. On a stable pt, there is no reason not to immobilize using the KED or the good ol' short board. You go to court and it comes out that you have a KED on your truck but your answer to not using it is because you didn't want to or you didn't like it? If it wasn't a good thing, then why would it (or a shortboard in lieu of a KED) be required for ambulance licensure in many states?? And if it is in your local protocols, you better hope you don't get caught not using it, unless your pt is critical... Just like when writing the tripsheet, you gotta cover your a**!

[littlemissemt]

Like I stated before, I would rather play it safe than sorry. Also, KED is a required skill station at National Registry. So, if it's a skill that is required to be taught and we have to demonstrate it at practicals, then what is the point of not using it? I would rather take the extra minute or so that it takes to apply it and make sure that my pt's spine is stable than not apply it and have my pt's spine get messed up and possibly get my hind end sued off. I would hate to have my license revoked because I didn't make the effort to apply the KED and help maintain the patient's c-spine.

For those that don't know how to use it, just ask a fellow EMT or medic to show you how to properly use it. The time will be well worth it.

[JEMS-RB-ALS]

Is it really called the KID? Do you mean you want to put a KID on someone? A Kendrick Immobilization Device? No wait...that's not it. Its a Kendrick EXTRICATION Device. For Extrication I guess, right? I am sorry, but putting a ked on someone properly does everything but immobilize them. It encourages excessive movement, it requires contorting and putting pressure on the pelvis and lower spine, and then, if it was on tight enough, the movement promoted by releasing the groin straps should really serve to move the spine in wonderful ways. It works great for extrication when you need to lift a patient out of a compartment before making the same movements you would if you just ease the patient onto a longboard. It is much more movement if used uneccessarily however. I imagine that the good people at Kendrick must put some money into the NREMT, since it is the only product we test with by brand name exclusively.

Lets think progressively please.

My Opinion here folks, does not neccessarily make it right.

Jim

[KYMEDIC]

Looks like most of us are in agreement...we all hate it/think it's worthless, but we all either recognize the need to use it for CYA or we don't use it based on our feelings (rather than documented and standardized research.

So, like I mentioned in the original post, does anyone have any ideas re: how to research this to PROVE it wrong?

I think it has usefullness every once in a while, but not enough to be THE standard of care. Besides, I'd love to drop that testing station so that we could test something that we use daily that newbies don't know when they get out of class. Something like lifting, raising and lowering a stretcher, talking to soemone that's about to beat the hell out of you, etc.

Jim

[JEMS-RB-ALS]

AMEN KYMedic!!

Maybe something like getting the leads positioned right for a 3 lead monitor would be good too.

I have used a KED in a few instances, I stress a few. But, as you said, not the standard of care to be sure.

Take it easy,<br />Jim

[EMT135864]

First of all, I do agree with KYMEDIC about ineptitudes of current classes. Recently had a new EMT graduate that didn't know you could call medical command to deviate from spinal immobilization protocols on the little old lady that fell and went boom and got back up. But that's another story...

JEMS-RB-ALS (and the rest, too!), the KED is a brand name by Ferno. Before you spout off about it, do a little research. Remember, BLS before ALS... Short spinal immobilization is taught in EMT classes for anyone stable and still seated in a vehicle. It is TAUGHT... not SUGGESTED. Since it is also tested for NREMT, could failure to use it when not contraindicated by pt condition be considered negligence?? Who wants to go down that road?? <img src="eek.gif" border="0"> <br />And Ferno's model isn't the only option. Probably the most used I'll agree, and KED has become synonomous with all such devices, but Ferno's is not the only one. There are also the XP-1, LSP Halfback, and a Gall's Dyna-Med version. The one your company buys is a choice. Just like those CIDs that say FERNO all over them. <br />Also, "extrication" isn't just cutting the car into tiny, unrecognizable pieces that fit neatly into a zip-lock bag. Removing someone that is still in a vehicle from their position in that vehicle is extrication. Hence the E in KED. Removing someone's stuck finger from the opening of a beer bottle is extrication. You might also want to check the instructions that came with the device, whatever be the manufacturer, about using the handles as lifting devices, to hoist the pt up out of a vehicle.

The vest-style extrication device, or a short-board in lieu of it, might not be the easiest piece of equipment to apply, but when in doubt, wouldn't you rather err on the side of what could potentially be best for the patient? I thought that's why we were all here.... <img src="eek.gif" border="0">

<br />*contains only personal views.

[JEMS-RB-ALS]

Actually, do some further research. Kendrick is the brand name, and the ownership by Ferno came much later.

You bring up extrication. Yes- I know this, all too well. But, by the same token, this discussion is whether or not it is appropriate to teach immobilization with an extrication device. I feel that it is not. I have worked many accident scenes. MANY. I do not know where using a KED is considered to be only a BLS skill, but remember, the wrong skill, can kill your patient, whether or not it was a BLS or ALS skill. Just because the NREMT has it on their recommended flow sheet does not make it right in every real world scenario you see. Textbooks and paperwork cannot do my job. If I had put a KED on every patient that the textbook said I should, I would have been considered to be a Cookie Cutter EMT, and I would have caused undue delays in transport, uneccessary discomfort for the patient, and uneccessary moving of their lower spine into abnormal contractions. Like I said before, it is an extrication device, and at times, can immobilize in the perfect situation, but it is not something I use first line every day.

I see plenty of new EMTs wanting to grab it right away, as well as First Responders that do not see a whole lot of call volume. The first things out of their mouth is "The book said" or "In class they said..." Cookie Cutter medicine does not work in the field.

Back to the topic though, the question is, Is it appropriate to teach the KED as an Immobilization device still?

My answer- No. It was never even designed to be an immobilization device. It was designed as an extrication device, and it has certain qualities that lend itself to assisting with immobilization in the right situation, but those situations are so few and far between in the field. That is what KYMedic's question is all about.

Now, take a look at the NREMT's Check sheet for sitting spinal immobilization, and it says either with the Short board, or with the KED. By Name. No other device. I am fully aware that there are other devices of the same type, and others of similar design, and I have used them. But this discussion is about the KED as taught by the DOT approved curriculum and endorsed by the NREMT.

My opinion here again, right or wrong, its mine. But I will share>

Take Care,<br />Jim

[Resq14]

great discussion

[EMT135864]

Well I agree on many of your points. First and foremost, I strongly agree about the "cookie-cutter" EMTs. Before I took my EMT class, I had the benefit of having ridden along as a third person (go-for) on our trucks for over a year. So when I went through the class, I was also very aware of what happens in the real world, moreso than many of the others in the class (probably including the instructor too, but we won't go there! <img src="tongue.gif" border="0"> ). Thus, the class wasn't that "instructional." Most instruction had come from experience, and continues to be that way today. The problem is, like I said before and I'm sure you'll agree, that EMT classes are now really only teaching one way to do most things. The thought process and adaptation isn't always there, unfortunately. Therein lies the problem.

I will also agree that the devices that we are discussing, including the good old short board, are extrication devices and not immobilization devices, to a point. They stabilize the pt so they can be removed from the seat of the car to the awaiting LBB. That is their purpose, nothing more. They are for SHORT-TERM stabilization, only for as long as it takes to get from the seat to the board. Notice I didn't say short-term immobilization, because I am not defending the ability of them (or lack thereof). But they are the best device that we have at the present time, for better or worse I suppose. The LBB and CIDs don't FULLY immobilize a patient and prevent further jarring, etc, either. But for now, its the best we can do. So I guess that's what we have to do on the patients that are stable enough!

As far as using them, yes they are a pain. And they aren't a piece of equipment that gets used everyday by any means. If someone is still in the car upon EMS arrival, its probably because something more serious is wrong. In that case, they get the rapid extrication, no KED. If someone is still in the car, they are likely to be at least a potentially serious patient, whether that be because of true spinal injury or otherwise. In that case (spinal injury only), they need the KED or equivalent whenever possible, for their benefit. Those that are still in the car but aren't seriously injured are probably there for the insurance game that everyone is well aware of. They probably don't need it, or even to go to the ED, but they get it anyway because they are still seated. As long as the protocols are there, unfortunately we don't have much choice.

So, is it a true immobilization device? NO. But it is a short-term stabilization device, for that movement from the seat to the LBB. And its the best we can do now... So until the protocols are changed, or until we put our heads together and design a better device, I guess we're stuck with it, like it or not. <img src="frown.gif" border="0">

[JEMS-RB-ALS]

Hey EMT,

Well Said.

Jim

[Lewiston2Capt]

A little off topic. I dont know about anywhere else but in NY we also have a station on the Hare, or Sager traction splinting. That is how it was presented when I took my EMT-D.

Now a little more on topic. I personally do not prefer to use the KED for the reason that it does tend to cause more movement even when properly applying the device. Additionally if it is -10°F outside and your pt. has been waiting for you for 5 minutes, do you really want to take the time (1-2 mins.) to apply the device when you could have them in the back of the ambulance that much sooner?<br /> I agree that cookbook EMTs are ill prepared for the real world. I also agree that the KED is usually applied as a CYA. But, I personally look at it this way, the ambulance is one big toolbox, filled with tools. That doesent mean that you have to use all of the tools on all of the jobs, use the tool that fits the task in front of you. <br /> I hope I havent muddied the waters too much.

[ALSfirefighter]

I have to say you all have really good points. But now I'm going to play devils advocate. I do not see the KED as a burden or a piece of equipment like mast pants that have lost their place in the EMS world. I do have to say that I straight up disagree with those of you who list unnecessary movement of a patient to apply the device. JEMS you state that it puts pressure on the pelvis and lower spine. My question is what is the point. The majority of pressure is already on the pelvis and lower back. How many patients in your career have had lumbar spinal fractures from an MVA where you considered using a KED or its equivalent? And I still have to say how much contorting do you have to do to apply it properly. Are the pressures and contorting anymore then the twist that you have to perform to get the patient on a long board without it? How stable is the lower spine when the patients butt is twisting on a soft materialed car seat? Or could it be slightly better to have a device that attempts to maintain and "stablize" the spine in a postion?<br />I also do not like "cookie cutter" or what I call "cook book ems." However, I also am not and never want to be a "paragod." KED's are an general accepted practice. Just like NFPA,that is a general accepted practice of firefighting standards. And deviation from such in certain instances can cause you to be found negligable. Remember its not guilty or not guilty, but what percentage were you at fault. Can you or your dept afford 25% of a 10 million dollar lawsuit? <br />My point is this, no they are not always practical. But they have their place. While I see statements like, I've never seen anything that says they help people. I've never seen anything that says they hurt them. In my area its also seems that more seasoned EMT's use them then the lesser. That is because a well trained seasoned crew can get it on rather quickly. Also the KED is the last thing I look for when it comes to a pin job. Most of our pin jobs are either priority trauma's or unibody, crumple zone door pins, with airbag deployment. Want to talk about progressive, how about getting better c-spine clearance protocols, that allow us more freedom in using judgement. Especially with car manufacturing with the unibody construction. A 15 mph crash looks like 80 with many cars today. But they want us to still use vehicle intrusion as a guide to immobilization.

-------------------------------------------------<br />The above is my opinion only and doesn't reflect that of any dept/agency I work for, deal with, or am a member of. <img src="biggrin.gif" border="0">

[Resq14]

Good points.

It's nice (comforting?) for me to hear that someone thinks seasoned personnel are more likely to apply a KED.

I'm glad this is being discussed.

[Litch]

My medical director expects me to be able to assess a patient and determine the need for spinal immobilzation based on a number of factors. These include the mechanism of injury - falls from greater than the patient's height, speed and degree of damage to the passenger cabin of the vehicle (not just to the engine compartment or the trunk), the patient's mentation, and their complaint. (Yes, I operate with a C-spine clearance protocol). My medical director also expects me to be competent in using all of the tools available in my ambulance, including our vest style immobilization device. <br />If you are unable to apply your equipment without twisting the patient, perhaps you should get it out and practice with it rather than complaining about having to do your job. The treatment that is the best for my patient is not always the most convenient or easy for me to carry out. But then we aren't in the field for our own convenience, are we?

[medic3401]

I never do things to cover my a**. I do things because it is the right thing to do at the time for that particular patient. I learned how to assess a patient, determine a course of treatment and treat the patient accordingly.

I see the KED as a tool, no different than a non-rebreather mask. Do you put EVERY patient having respiratory distress on a NRB. I know I don't. I assess the patient and then determine the correct course of action and then treat the patient accordingly. If that means a NRB, then I place them on an NRB. If it means a NC, then I place them on a NC. If that means no oxygen therapy, then I don't place them on O2.

I feel sorry for providers who look at each patient encounter as an opportunity to be sued and do things to minimize their chances of losing a law suit. I don't see that as any way to function. If you do what is right for the patient and can back it up, there should be no cause for concern. I know this is a little off topic, but several of the posts mentioned CYA and EMT135864 has it in the signature line. Like I said, its no way to function.

[EMT135864]

You missed the first three words of the line... WHEN IN DOUBT. You could also read that as "When in doubt, call medical command." That is the safest way to protect yourself. If there is any question at all about the treatment of the patient, call the doc!

The right thing is that any stable patient still seated in a vehicle and complaining of pain gets a KED. That should have been part of the "learning how to assess a patient, determine a course of treatment and treat the patient accordingly." The pt. might not always want a KED because of one reason or another, but that doesn't make it "right". It is however, his/her wish. But you better get them to sign a valid refusal specifically documenting that they refused, because the first question you will hear when you walk into the ER is "Why isn't he/she properly immobilized??" If you have their signature refusing it, its no longer your problem. BEEN THERE (two weeks ago, as a matter of fact). But if you simply said it wasn't done because the patient didn't want it (and you don't have proof) or you felt it wasn't appropriate, better warm up your chair in the medical director's office. I likely would have, but I got the refusal to protect myself and my partner. Its part of protecting yourself, AND it is also part of thorough documentation.

[stretcherbearer]

One of the things that has to be weighed up when about to use The Ked is the patients injuries and accesibilty to the patient(in the case of an RTA or MVA as you people call them).<br />We like the rest of you hardly ever use it, but on our annual 2 day assessment it is pulled out of the store room and everyone is given a refresher on it and any other equipment that is hardly used, such as Trac3.<br />Quite often good c-spine management with colars and gentle movement can be a good substitute when time is of the essence.

When finished here why dont you visit our unofficial website (Scottish Ambulance Service) to say hi,

<a href="http://www.ambulancedriver.bravepages.com" target="_blank">www.ambulancedriver.bravepages.com</a>

[KYMEDIC]

My thanks to all that replied. Most people were in agreement re: the lack of KED (or similar device) use, which points out that there is either a problem with all of us not doing right OR a problem with the design/use/intent/appropriateness of the device.

Over the next few months I'll do some sniffing around to find where the origins of the short spine board and its offspring were and maybe we can figure a way to get the powers that be to take a renewed look at requiring their use, since we are in the age of scientifically proving everything!

Thanks again,
Jim