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In a sling: An integrated review of pelvic binders as a best practice

The risk of treating can be significant if your have equipment and don't use it

By Nicolas Hall, RN, BSN, CRFN, CEN, EMT, and David J. Givot, JD

Most emergency medical services carry pelvic binders and protocols call for their use. But too often the patient arrives at the emergency department without a binder in place. Are we opening ourselves up to risk?

Managing pelvic fractures: Best practices
Timely stabilization of pelvic fractures is now a standard of trauma care. Pelvic fractures are usually the result of high energy transfer situations such as long falls and motor vehicle crashes.

The geriatric and bone diseased populations can sustain a fracture with as little as a ground level fall. Due to potentially devastating hemorrhage associated with such fractures, mortality rates can be as high as 50%4. Trauma protocols throughout the nation call for applying a circumferential compression binder around the patient’s pelvis to stabilize such fractures.

Many peer reviewed articles have indicated the use of a pelvic binder, stating that “a Pelvic Circumferential Compression Device (PCCD) can effectively reduce pelvic ring injuries. It poses a minimal risk for over-compression and complications as compared with reduction alternatives that do not provide a feedback on the applied reduction force.”1

Results of this clinical trial suggest that the PCCD can “rapidly reduce and stabilize open book type pelvic ring injuries, without causing complications if applied to a range of pelvic ring injuries, including internal rotation type injuries that are prone to internal collapse.” 2

Albeit confined to a relatively small patient group, these findings suggest that the PCCD can be applied by paramedics at the crash scene to provide early stabilization within the 'golden hour' and before patient transport, as well as by physicians at the time of hospital admission."3

In another study, Ross concludes that "EMS crews should assess major mechanism trauma patients for pelvic injuries and, if thought to be present, should apply a compressive sling to assist in the stabilization of hemodynamics." 4

Bleeding is the major concern with unstable pelvic fractures. Many large vessels, both arterial and venous, run very close to the pelvis and are easily lacerated. Exsanguination is a distinct possibility with an unsecured and unstable pelvis.5

Let’s look the following scenario: As you arrive on scene of a motorcycle versus tree, another unit has already back boarded the patient and is preparing to intubate. Your assessment reveals an unstable pelvis with blood at the penile meatus, but no pelvic binder has been applied. If the patient died of pelvic instability complications during transport, are you liable? The short answer is, you could be.

Legal liabilities
Negligence exists where one owes a duty, breaches that duty, and that breach is both the actual and proximate cause of some damage or harm. To be guilty criminally or liable civilly for medical negligence, the responder must have a duty to act; they must breach that duty, and that breach must directly cause some harm.

Breach of duty occurs when a provider fails to uphold the established standard of care. Most people think that “breach” means to do something the wrong way. In fact, it is very common for a breach to be found where, the provider did not do something that he or she could have and should have done. In legalese this type of breach can be referred to as an omission or as “nonfeasance.”

In the case of a pelvic fracture, failure to use a pelvic sling where one is indicated and available could result in legal action based on breach of duty by nonfeasance if even only the slightest harm comes to the patient as a result.

As a matter of law, linking the breach to damage requires two conditions: actual cause and proximate cause. To determine actual causation, simply ask the “…but for or without…” question: But for (without) your act or omission, would the damage have resulted how and when it did? If the damage would still have resulted given your conduct, there is no actual cause.  If the answer is no, that would mean the damage would not have resulted without your conduct.

However, when considering negligence, it’s not enough to be just an actual cause; you must also be the proximate cause. Proximate causation, very simply, means that based on your act or omission, the damage was foreseeable. In the present context, if you suspect a pelvic fracture and you have the proper equipment to support and stabilize the pelvis, but don’t use it, then it is completely foreseeable that the injury would be exacerbated and complications could arise; if they do, you have just committed negligence.

It’s important to know that the provider is not the only person exposed to liability. It is a legal fact that liability moves upward; under the proper circumstances, supervisors, training officers, supervising physicians, and managers can all share liability when a provider fails to perform to standards. Entire organizations can become responsible for the liability brought by a single provider who unilaterally decides or neglects to follow medical standards.

Summary
Even though this article focused on pelvic fractures and treatments, these principles of the law apply to all medical treatments. The bottom line is: protect yourself and your agency by following protocols, and relay information about new, emerging standards to your supervisors and overseeing physicians. You are on the front line, so take personal responsibility for minimizing your potential risk for liability.

References

1. Krieg JC, Mohr M, Ellis TJ, Simpson TS, Madey SM, Bottlang M. Emergent stabilization of pelvic ring injuries by controlled circumferential compression: a clinical trial. J Trauma. 2005 Sep;59(3):659-64.

2. Ross DW, Wichman C, Mackinnon M. Car versus bicycle: conclusion. Air Med J. 2009 Nov-Dec;28(6):268-71.

3. AAOS Now, Fracture management of unstable pelvic fractures, July 2009 Issue

4. Rice, MD. , & Rudolph, MD, (2007). Pelvic fractures. Emergency Medicine Clinics of North America, (25), 795-802.

5. Blackmore MD. , Jurkovich MD, , Linnau MD, , Cummings MD, , & Hoffer MD, (2003). Assessment of volume of hemorrhage and outcome from pelvic fracture. Journal of the American Medical Association, 138(5), 504-509

Disclosure: The authors are consultants to SAM Medical.
 

About the author:

Nicolas Hall works as an educator and flight nurse in the Pacific Northwest. He is a dually board certified in flight and emergency nursing as well as an EMT. His background is in urban and wilderness EMS and emergent critical care medicine. He presents on many topics with a focus on flight and wilderness medicine.

David Givot, Esq., graduated from the UCLA Center for Pre-hospital Care (formerly DFH) in June 1989 and spent most of the next decade working as a Paramedic responding to 911 in Glendale, CA, with the (then BLS only) fire department. By the end of 1998, he was traveling around the country working with distressed EMS agencies teaching improved field provider performance through better communication and leadership practices. David then moved into the position of director of operations for the largest ambulance provider in the Maryland. Now, back in Los Angeles, he has earned his law degree and is a practicing Defense Attorney still looking to the future of EMS. In addition to defending EMS Providers, both on the job and off, he has created TheLegalGuardian.com as a vital step toward improving the state of EMS through information and education designed to protect EMS professionals - and agencies - nationwide.

 

Comments
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Melinda Teaster Williams Melinda Teaster Williams Wednesday, February 06, 2013 5:05:56 PM Its called an upside down KED, works great from pelvic injuries.
Andrew Tucker Andrew Tucker Sunday, February 10, 2013 9:56:08 PM Mortality rates can be as high as "50%^4". Fifty percent raised to the power of four? There's no way to survive such an injury! LOL
Eric McCullough Eric McCullough Monday, February 11, 2013 7:20:33 AM I hope you're just kidding about the raise to the power of 4 thing....right?....
Andrew Tucker Andrew Tucker Monday, February 11, 2013 9:07:38 AM Yes, I am. Just making fun of the unfortunate placement of a superscript number over another number. And before you say you can't raise a percentage to an exponent, you can convert percentages to decimals and fractions as long as the value does not change. And 0.5^4=5,000. You'd die 50 times before you hit the ground :P
Josh Henke Josh Henke Monday, February 11, 2013 9:35:10 AM Any info on the incorrect placement of PCCD's and associated poor outcome as well as litigation. I know we've all seen both Pre hospital and especially hospital staff apply these devices as though they were ABD binders, not PCCD's
Nic Hall Nic Hall Monday, February 11, 2013 9:46:16 AM Hah, ABD binders. Nothing I found in my research gave any numbers for incorrect placement but it was mentioned as a "significant issue"
Howard Polden Howard Polden Saturday, February 23, 2013 7:15:09 PM Nice article Nic...