We try to avoid putting personal stuff on this blog, but my personal observations from being a trauma patient fits too well with Thomas D’s righteous rant about logrolls a few days ago. He wrote about how the logroll, as a diagnostic tool, is mostly useless for finding relevant injuries. He told us, with the possible exception of penetrating trauma, it misses most of the injuries it is intended to find. Injuries that are found on the trauma CT scan anyway.
This becomes obvious if one considers what a nasty pelvic fracture looks like on a scan. Consider the open book fracture on the right. It is easy to see how any kind of rolling the patient could result in fractures shifting, clots bursting and severe pain.
What it feels like to be logrolled with a pelvic fracture
A few years ago I got to experience this first-hand. I had a nasty skiing accident where I fell down a rock ridge when skiing off-piste. Coming to a stop, after hitting every rock on that ridge on my way down, I immediately knew I wasn´t walking away from that. My friends called for the rescue helicopter.
It was bad. I had pelvic fractures and central dislocation of my femur through my acetabulum into my abdomen. Despite that, the pain wasn’t too bad as long as I didn’t try to move. That was about to change. The rescue services were on their way, and simply by adhering to standard protocols for patient handling and prehospital analgesia they, and the nearby trauma hospital, were about to put me through hours of torture. I do believe they tried to kill me too.
It all started with them using a spineboard. Getting me on the spineboard involved a 90 degree logroll. They grabbed my clothes and gently rolled me on my fractured pelvis. It was incredibly painful! Pain of the scream-out-loud-sensory-overload type of pain. The 90 degree roll back was as bad. Despite a good dose of IV morphine.
I was extricated and loaded onto the helicopter and then transported for half an hour lying on the spineboard until our arrival in the ED. After hand-over, the HEMS crew wanted their spineboard back…This resulted in another two logrolls, then a fifth logroll for the primary trauma assessment.
Every time, despite high doses of fentanyl, the pain was so immense it completely shut down my brain. Not only that, I could also clearly feel how my pelvic fractures and femur shifted inside me every time I was log-rolled. If any clot had formed up during transport, there was just no way it was still holding after me being rolled over and over directly on my broken pelvis.
I was logrolled several times during the first hours. Coming on and off the spineboard, for the trauma assessment, for cutting away the clothes, for the x-rays, coming of the trauma transfer mattress and what not. As long as they left me alone I was actually fine, but every time they moved me or rolled me the pain was absolutely mental, and every single time I could feel the fracture surfaces shifting and grinding inside me.
While I’m sure there are better ways to learn trauma than actually becoming a trauma patient yourself it is fair to say I came out a better, at least different, trauma doctor than I was before. The whole thing from wiping out on the mountain to the frustrating, tedious year of getting back in shape taught me invaluable lessons.
One of those lessons, as you might have guessed, is how we do patient handling poorly. We need to minimise patient handling and moving. The logrolling as a diagnostic procedure is, as Thomas D, pointed out mostly useless. Logrolling as a diagnostic tool as well as a means of handling our patients is potentially dangerous, and in some patients extremely painful.
For the love of God, use a scoop stretcher.
Thankfully, there is progress. The ambulance services awareness of the importance of careful patient handling is increasing. A nice example of this is the UK-HEMS SOP for patient packaging. You should probably read it.
Another great example is, as mentioned in a previous post, how the UK faculty of prehospital care no longer recommends using the spineboard for transporting patients.
Instead they recommend using a scoop stretcher. With the scoop stretcher a gentle 5-10 degree roll is all that is required to apply the halves of the scoop stretcher. By consistently using the scoop stretcher from the trauma team reception all the way to the wards, most patient rolling can be eliminated.
Finally, as you can tell from the scoop stretcher design, there is even a gap between the stretcher blades so that the asshole surgeon can perform his digital rectal exam without rolling the patient.