Why Should You Put Some Trauma Patients on Their Side?
Our practice in EMS for decades has been to strap trauma patients to a rigid longboard in a supine position. This has been thought to protect the spine from further injury. We’ve all gotten pretty good at performing that technique, so we’re comfortable doing it.
Unfortunately that comfort is not shared by the patient. Being secured to a longboard is not comfortable, it’s painful, and it can cause harm to the patient. Furthermore, there is no evidence that it actually makes a difference in patient outcome. So numerous EMS leaders are creating a sea change in EMS across the USA to stop using rigid longboards in the transport of trauma patients.
In 2014-2015 statewide protocols in several New England states took longboards out of the routine care for patients with potential or actual spine trauma. Anecdotal evidence to this point looks very good. However, did we give up anything useful by stopping the practice of transporting patients strapped to a backboard? Let’s think about airway management for a minute. Picture this, you’re in the back of the ambulance with a patient on a backboard. The patient starts to vomit. A lot. How did you manage that? Your suction device wasn’t going to help in this scenario, so as quickly as you could you undid the straps and rolled the patient and backboard up on its side. Gravity then saved the day.
Same scenario, but now we’re NOT transporting the patient on the backboard. How can you roll this patient up on their side and still maintain alignment of the spine? You probably can’t. However airway and breathing come before disability so you do the best you can.
Our state protocols recognize this potential scenario, and say if you think your patient is at risk for vomiting, you should transport them on their side. The language from the 2015 New Hampshire EMS Protocol 4.5 – Spinal Trauma says, “Patients with nausea or vomiting may be placed in a lateral recumbent position. Maintain neutral head position with manual stabilization, padding/pillows, and/or patient’s arm.”
But, but, but, I can’t do that… a trauma patient HAS to be transported supine. Right?
Dogma is defined by the Merriam-Webster dictionary as “a belief or set of beliefs that is accepted by the members of a group without being questioned or doubted”. Maybe the paradigm of transporting every trauma patient in a supine position is dogma that needs to be reconsidered.
The protocol cited above gives us the option to put a patient on their side while maintaining neutral head position in a situation involving nausea or vomiting. This means proactively doing so before initiating transport. THIS IS A VERY GOOD IDEA. There are clearly patients that you can anticipate that vomiting may be in their near future, and you should proactively take steps to deal with it. If endotracheal intubation with RSI is in your scope of practice that may be the path you take, but transporting the patient on their side may be just as effective and certainly less invasive.
So again, putting a trauma patient who is at risk for aspiration on their side for transport rather than transporting them supine is a very good idea. However we need to do this in a manner that still maintains an inline stabilization of the spine. How do you do that? Good question.
That’s the challenge this project seeks to address. We would like to have a technique that can accomplish that objective.
The Norwegian Lateral Trauma Position
Fortunately our EMS colleagues in Norway developed and have been utilizing a technique called the Lateral Trauma Position for over a decade, with success. What we seek to do here at the LateralTraumaPosition.org project is to take what the Norwegian EMS system started, and help our EMS colleagues in the USA develop this skill. We hope to provide you with information that can help you form your own clinical opinion and your own clinical practice.
This website includes a video that was produced by EMS providers in Norway illustrating the lateral trauma position (LTP) as they practice it. We’ve also included research studies that attempt to determine the effectiveness and safety of the technique. We believe that our practice in EMS should be based on evidence when possible. The current evidence on the LTP isn’t that strong, no randomized controlled trials. But the evidence is growing. This is thanks to the leadership of Dr. Per Kristian Hyldmo, a flight physician for the helicopter EMS system in Norway. We highly admire his work and hope to follow in his footsteps.
The demonstration videos in this website show the LTP as we have worked out the bugs for us. We wouldn’t presume to say this is the only way to do it. What we do say is that EMS providers need to practice a technique that accomplishes the goal, which is to transport a trauma patient who is at risk for airway compromise on their side while making reasonable attempts to maintain inline stabilization of the spine and minimize movement.
We suggest your team starts with our techniques, modifies the techniques to what works for you, then practice it. A lot.
Listen, for years and years we practiced the PHTLS technique of a standing takedown onto a long backboard, right? Well our evolving practice appears to be doing away with that technique, but we should practice the new LTP technique with the same fervor.
So we ask you to review our “how to” videos, practice them with your crews, modify them to suit your needs and your equipment, and get really good at it. We’d really appreciate your feedback and your modifications of the techniques, including photos and videos.
Finally, understand that we’re not holding ourselves out as experts on the topic of spinal immobilization. We are not researchers. We are simply partners in trying to develop an effective technique in the setting of changing protocols and clinical practices.
Oh, and don’t do things without authorization from protocols, medical direction, administration – you know, the legal stuff.
Be safe,
The LateralTraumaPosition.org Team