Lecture 3 - Emergency Action Plan (EAP) & PPE

Moving the Injured Participant

1. Ambulatory assistance > Aid an injured individual able to walk > Must be around the same height, too small and it's not as good; ; individual drapes his/her arms across the shoulders of the assistants while their arms encircle the injured player's back; assistants then escort the player off the field —Implies that the injury is minor, and no further harm will occur if the individual is ambulatory 2. Manual conveyance > Individual unable to walk or distance is too great to walk —Individual continues to drape his or her arms across the assistants' shoulders, while one arm from each assistant is placed behind the individual's back and the other arm is placed under the individual's thigh; both assistants lift the legs up, placing the individual in a seated position; individual is then carried off the field 3. Transport by rigid immobilization device (spine boards) > Spinal motion restriction > Safest method

Preventing Sudden Death in Athletics

1. Asthma (Must know and make sure they have their medication and no sharing!!) 2. Catastrophic brain injuries 3. Cervical spine injuries 4. Diabetes mellitus (monitor and detect the symptoms) 5. Exertional heat stroke 6. Exertional sickling (from sickle cell anemia) 7. Lightning injury 8. Sudden cardiac arrest

Before the Athletes Hit the Field

1. Emergency Action Plan (EAP) 2. Pre-participation Examination (PPE)

Components of an EAP

1. Emergency Personnel > Describe the emergency team involved when the EAP is activated and the roles of each person 2. Emergency Communication > What communication devices are available, where, what number to call in an emergency, specific information and directions to the venue to provide to EMS response team. 3. Emergency Equipment Medical > Location of equipment should be quickly accessible and clearly listed. Equipment needs to be maintained on a regular basis. 4. Medical Emergency > Describe options and estimated response times for emergency transportation. 5. Transportation Venue Directions with a Map > (should be specific to the venue, and provide instructions for easy access to venue) 6. Roles of First Responders > Establish scene safety and immediate care of the athlete, activation of EMS, equipment retreival, direction of EMS to the scene

Primary Responsibilities of a First Responder

1. Ensure safety for self, your team, and any bystanders 2. Gain access to the person 3. Determine any threats to the persons life 4. Summon more advanced help as needed. 5. Provide needed care for the person 6. Assist advanced medical personnel as needed

4 Basic Roles

1. Establish scene safety and immediate care of athlete > Establish scene safety and immediate care of the athlete, activation of EMS, equipment retreival, direction of EMS to the scene 2. Activation of EMS > This may be necessary in situations where emergency transportation is not already present at the sporting event. 3. Equipment Retrieval >May be done by anyone on the emergency team who is familiar with the types and locations of the specific equipment needed. Athletic training students, managers, and coaches may be good choices for this role 4. Direction of EMS to the scene > Time is the most critical factor and this may be done by anyone on the team. However, the person chosen should be someone who is calm under pressure, communicates well, and is familiar with the location and address of the sporting event. > One of the members of the team should be in charge of meeting the emergency medical personnel as they arrive at the site. This person should have keys to locked gates or doors.

Assessing Emergent Conditions

1. On-site neurological testing 2. Vital Signs 3. Respiration 4. Blood Pressure 5. Temperature 6. Skin colour 7. Pupils

Benefits of Having an EAP?

1. Risk management strategy: lead to prevention of athletic injury 2. Readily prepared for emergency situations 3. Ensures that appropriate care is provided in a timely manner 4. Decrease chance of legal action taking place 5. Protects liability of therapist and school administration 6. Leads to more effective emergency response

Steps to Take in an Emergency

1. Scene Survey 2. Primary Survey 3. Secondary Survey 4. Ongoing Survey

Physical Examination (Dermatological exam and exam for heat disorders)

11. Dermatological exam > Identify contagious lesions, skin infections > Other lesions (e.g., warts, acne). Examples: Fungal infections, Secondary syphilis, Herpes (e.g., simplex, gladiatorum), Impetigo 12. Exam for heat disorders > Environment related: history of cramping, syncope, exhaustion, or heat stroke > Use of medications > Heat-related "red flags": - Cardiac disease - Uncontrolled diabetes - Hypertension - Drug use (e.g., amphetamines, cocaine, hallucinogens, laxatives, narcotics) - Medications (e.g., anticholinergics, diuretics, antihistamines, β-blockers) - Excessive muscle cramps in heat - Heat exhaustion - Heat stroke

Physical Examination (CDV Exam and Pulmonary exam)

3. Cardiovascular exam usually by doctor > Auscultation of heart sounds > Check for cardiac abnormalities > History of loss of consciousness, syncope, dizziness, shortness of breath, heart palpitations, and chest pain during or after examination 4. Pulmonary exam usually by doctor > Auscultate for breath sounds > History of coughing or breathing difficulty > Ear, nose, and mouth may also be checked

Physical Examination (Musculoskeletal exam and Neurological exam)

5. Musculoskeletal exam > History of previous injury, including: - Nature of injury - When it occurred - Who evaluated it - Duration of treatment and rehab - Use of special protective equipment 6. Neurological exam > History of past head injury, loss of consciousness, amnesia, or seizures > Exam: pupillary examination and reaction to light, cranial nerve assessment, motor-sensory exam, deep tendon reflex testing > Baseline concussion testing

Physical Examination (Eye and Dental Examination)

7. Eye examination > Visual acuity > Peripheral vision and depth perception > Nystagmus > Pupil size 8. Dental examination > Determine number of teeth and last visit to dentist > Exam: gum condition and presence of cavities, dental appliances

Physical Examination (Gastrointestinal and Genitourinary exam)

9. Gastrointestinal exam (doctor exams) > Digestive system, eating habits, and nutrition > History of heartburn, indigestion, diarrhea, or constipation 10. Genitourinary exam > Kidney and genitourinary organs > Females: menstrual history, gynecological symptoms > Most females their ligaments during the luteal phase of the menstrual cycle as this is were the ligaments are less strong

Why do we Block the Head"

> A cervical spine that is positioned and maintained in neutral alignment should preserve the space within the spinal canal that normally surrounds the spinal cord. > Deviations from neutral alignment can decrease the diameter of the spinal canal and the space available for the spinal cord. > Once the spinal canal is compromised, compression of the cord can ensue, which can ultimately impair spinal cord function. ***This evidence supports the argument that the optimal position for the spinal cord is the neutral position. This implies that if at the time of injury, the athlete's head and neck are out of alignment, the cervical spine should be realigned to neutral during the emergency management process, a recommendation supported by the National Athletic Trainer's Association's Inter-Association Task Force for the Care of the Spine-Injured Athlete. If acute realignment of the cervical spine is necessary, this should be done gradually while observing the patient for any changes in neurologic status. In some cases, realignment of the cervical spine occurs during a log-roll maneuver in the prone athlete. If changes in neurologic status occur mid-roll, it is difficult to coordinate a change to the roll maneuver with multiple people involved in the transfer.

Exertion heat Stroke

> Among the top three causes of death in sports and occurs more often during the hotter months. > Core body temperature greater than 104°F to 105°F and CNS dysfunction. > Rectal temperature must be taken to assess core body temperature. > EMS should be activated immediately and patient should be immersed in cold moving water. Patient can be removed from immersion once core body temperature reaches 102°.

Scene is Safe

> Approach athlete from side they are facing - if they get nervous they may turn over and cause more injury > Stabilize the head in the position it is in. > Determine Responsiveness - Unresponsive: Activate EAP-EMS/911 - Assess CAB * Pulse - cartoid (First thing to check) * Open air way * Breathing look/listen/feel ***Cartoid - The fingers should be positioned between the larynx and the anterior border of the sternocleidomastoid muscle at the level of the cricoid cartilage

Diabetes Mellitus

> Blood sugar between 60 to 70 mg per dL is considered mild and can be treated on site. > Blood glucose levels below 40 mg per dL is considered severe hypoglycemia, and EMS should be activated.

Skin Colour

> Can indicate abnormal blood flow and low blood oxygen concentration in a particular body part > Lightly pigmented individuals - Red, white, and blue - Dark-skinned individuals Skin pigments mask cyanosis

Exertion sickling (from sickle cell anaemia)

> Can occur in athletes who have a sickle cell trait. > RBC shape changes from round to sickle. Cells then clump together, leads to decrease blood flow and a breakdown of muscle tissue and death. > May result in death of athlete.

On-site neurological testing

> Critical to prevent a catastrophic injury > Areas - Cutaneous sensation - normal protocol - Motor Function (complete a cranial nerve assessment or ask the athlete to wiggle the fingers and toes on both hands and feet; compare grip strength in both hands - Reflexes

Primary Survey

> Determines level of responsiveness > Identifies immediate life-threatening situations (ABCs) > Dictates necessary actions

Approaching the Scene

> Location of the emergency > Extent of the emergency > Apparent scene dangers > Apparent number of ill or injured people > Behavior of the person (s) and bystanders

Sudden Cardiac Arrest (SCA)

> Many factors may result in sudden cardiac arrest. > Must be prepared to recognized; assess and initiate the EAP if sudden cardiac arrest occurs.

Asthma

> Mild acute asthma exacerbation (or asthma attack) occurs when the patient has mild dyspnea during activity. Wheezing or coughing, peak expiratory flow is equal or greater than 70% baseline. > Moderate acute asthma exacerbation presents with more pronounced wheezing, coughing, decreased ability to speak, inability to continue participation, and a PEF that is between 40% and 69% of the baseline. > Severe acute asthma exacerbation is experienced with a PEF of less than 40% of baseline. The patient may be unable to speak and coughs frequently.

Lightning Injury

> Most can be prevented by having a lightning policy and following it. > Most deaths are result of cardiac arrest.

Treat CABD

> No pulse - AED!!!!!! > Begin chest compressions (CPR) - Once AED arrives it becomes priority and apply it. - Don't mistake SCA for a seizure - 50% of SCA athletes had a brief seizure - like activity following collapse *** SCA = sudden cardiac arrest

Examples of PPE

> Prepubescent child (6-10 years of age)—identify previously undiagnosed congenital abnormalities > Pubescent child (11-15 years of age)—center on maturation and establishing good health practices for safe participation > Postpubescent or young adult group (16-30 years of age)—the history of previous injuries and sport-specific examinations are critical; the more strenuous activities and those involving contact or collision sports for this age group require a more extensive examination > Adult population (30-65 years of age)—high incidence of overuse injuries; these individuals need an examination based on the nature of the activity in which they intend to engage > Older than 65 years of age—often begin or increase activity to prevent a major medical illness; these individuals need an extensive examination based on individual needs, taking into consideration not only their physical needs but also possible medications they may be taking and possible side effects

Set up of EAP

> Preseason preparation - Meet with representatives from local EMS agencies to discuss, develop, and evaluate plan - Written plan for each activity site - Practice the emergency plan > Responsibilities of medical personnel (usually meet with doctor b4 season starts) - Team physician * Prior to season, delineate responsibilities of all personnel * On the field - Athletic trainer * Event setup * Home versus away (ask for EAP when away and who is doctor) * Presence or absence of physician

Blood Pressure

> Pressure or tension of the blood within the systemic arteries > Changes in BP are very significant —Reflects the effectiveness of the circulatory system —May be affected by gender, weight, race, lifestyle, and diet —Measured in the brachial artery with a sphygmomanometer and stethoscope Systolic blood pressure —Measured when the left ventricle contracts and expels blood into the aorta —Approximately 120 mm Hg for a healthy adult and 125 to 140 mm Hg for healthy children aged 10 to 18 years Diastolic blood pressure —Residual pressure present in the aorta between heart beats —Averages 70 to 80 mm Hg in healthy adults and 80 to 90 mm Hg in healthy children aged 10 to 18 years

What Is An EAP?

> Process that activates the emergency health care services of the athletic training facility and community to provide immediate health care to an injured individual  > The team physician, athletic therapist and coach have a legal duty to develop and implement an emergency plan to provide health care for participants.

Equipment Considerations

> Removal of any athletic helmet should be avoided unless individual circumstances dictate otherwise. "DEPENDS ON SPORT" (there is debate in the research on this!) > Face mask removal - Should be removed prior to transportation, regardless of the current respiratory status > Helmet removal (Usually the ATs know the best how to remove gear) - Requires two trained individuals > Shoulder pad removal - Should not be removed unless life is in danger, and the threat outweighs the risk of a possible spinal cord injury from moving the athlete

Shockable?

> SCA is an arrhythmia called ventricular fibrillation (v-fib). > In v-fib, the ventricles don't beat normally. Instead, they quiver very rapidly and irregularly. > Another arrhythmia that can lead to SCA is ventricular tachycardia. This is a fast, regular beating of the ventricles that may last for a few seconds or much longer.

Emergency Action Plan (EAP)

> Serves as a blue print on how to respond to emergencies Plan should identify: 1. Personnel and qualifications 2. Equipment (where they are, an inventory of what is present) 3. Mechanism of communication (how we are going to comm. in case of an emergency) 4. Facilities (Document where all the AEDs are at the facilities) 5. Documentation verifying the implementation and evaluation of EAP (should practice this every year before the season opens) 6. Documentation of annual review and rehearsal (to call in people you want to work with EHS)

Catastrophic Brain Injuries

> Steps in treating: recognize TBI, immediate activation of EAP, patients with a Glasgow Coma Scale of less than 9 and SpO2 level less than 90%, provide supplemental oxygen. Monitor ABCs and treat for shock.

Flexibility

> The total ROM that occurs pain-free in each of the planes of motion > Measured with a goniometer, flexometer, or tape measure  > Hypermobility versus hypomobility

Respiration

> Varies with gender and age > Count for 30 seconds (and double it) or 15x4 > Normal ranges - Adults: 10 to 25 breaths per minute - Children: 20 to 25 breaths per minute

Cervical Spine Injuries

> When cervical spine injuries are suspected, the cervical spine should be immobilized in a neutral position and neck motion controlled in preparation for transport to an emergency facility. > A catastrophic cervical spine injury is defined by Banerjee et al as "a structural distortion of the cervical spinal column associated with actual or potential damage to the spinal cord." > Catastrophic cervical spine injuries in sports have the potential for permanent loss of neural function (ie, hemiplegia, quadriplegia) or even a fatal outcome. ***Try and get the head into neutral position and "block it" but if can't move it as it is stuck, don't force it.

Vital Signs

> When warranted, assess to establish a baseline information about the health status of the individual > Indicate the status of the CDV system and CNS Pulse > Variety of factors influence pulse > Count carotid for 30 seconds (and double it) > Normal ranges - Adults: 60 to 100 beats per minute - Children: 120 to 140 beats per minute —Usually taken at the carotid artery because a pulse at that site is not normally obstructed by clothing, equipment, or strappings —Aerobically conditioned athletes may have a pulse rate as low as 40 beats per minute.

Suspect a Spinal Injury

> Witnessing mechanism of injury > Witnessing athlete who remains down or motionless after play > Abnormal neurological findings (can't feel feet/tingling in fingers) > Loss of motion in extremities > Cervical spine pain with or with out palpation > Cervical spine deformity

Determination of LOC (Level of Consciousness)

A - Alert (person, place, time, event) V - Verbal (respond to verbal stimuli) P - Painful (respond to pain stimuli) U - Unresponsive > Ask -What happened? > Tell - Open your eyes!! - No response, pain stimuli > Ask - where does it hurt > Tell - move your fingers! > Painful stimuli - triceps/nailbed

Agility, Balance and Reaction Time

Agility > Ability to change directions rapidly when moving at a high rate of speed Balance > Body's coordinated neuromuscular response to maintain a defined position of equilibrium in response to changing visual, tactile, or kinesthetic stimuli Reaction time > Ability to respond to a stimulus > Agility and balance tests are often measured by time or accuracy (e.g., correct two out of three) and should be developed to be sport specific. > Examples of agility, balance, and reaction tests include run-and-cut drills, carioca steps, shuttle runs, pivoting drills, front-to-back and side-to-side hops, figure-of-eight running drills, kicking a stationary or moving target, and beam-walking tests. ***Want to be watching their biomechanics when testing the athletes

Cervical Spine Injuries (in preventing sudden death)

Athletes who complain of unprovoked neck pain or who are tender upon palpation of the cervical vertebrae should be treated for a potential spinal cord injury. > Immediate activation of EAP. > In-line stabilization of the cervical region should be administered without applying traction.

Body Position

Body posturing > Signs of traumatic brain injury - Increase in intracranial pressure > Decerebate - Extension in all four extremities > Decorticate - Extension of the legs and marked flexion in the elbows, wrists, and fingers

Pupils

Can indicate abnormal blood flow and low blood oxygen concentration in a particular body part Lightly pigmented individuals Red, white, and blue Dark-skinned individuals Skin pigments mask cyanosis Pupillary light reflex —Rapid constriction of pupils when eyes are exposed to intense light. —Assessed by holding one hand over one eye and then moving the hand away quickly, or shining the light from a penlight into one eye and observing the pupil's reaction —Normal response—constriction with the light shining in the eye and dilation as light is removed —Reaction is classified as brisk (normal), sluggish, nonreactive, or fixed. —Eyes may appear normal, constricted, unequal, or dilated. Testing eye movement 1) Ask the individual to focus on a single object Diplopia—individual sees two images instead of one; double vision; occurs when the external eye muscles fail to work in a coordinated manner 2) Ask the individual to watch your fingers move through the six cardinal fields of vision—assesses tracking ability 3) Place a finger several inches in front of the individual and ask the person to reach out and touch the finger—assesses depth perception (move the finger to several different locations)

Medical History

Comprehensive history: > General medical > Orthopaedic > Supplemental form for females ***A comprehensive medical history can identify nearly 60% to 75% of the problems affecting a sport participant. Options: — A written form is completed by the individual answering in a "yes/no" format. — A separate station at the start of the mass station screening—this station should have a knowledgeable examiner who can go through the questionnaire and ask detailed follow-up questions.

Management of Bone Injuries

Detection of fractures 1. Palpation - can detect deformity, crepitus (if feel a crunching), swelling, or increased pain at the fracture site. 2. Percussion - tapping motion of the finger over a bony structure. (in the ankle, can send a lot of pain in the injured bone) 3. Tuning fork - works in the same manner as percussion; vibrations travel through the bone and cause increased pain at a fracture site. 4. Compression - gently compressing the distal end of the bone toward the proximal end or by encircling the body part (e.g., a foot or a hand) and gently squeezing. 5. Distraction - tensile force, whereby the application of traction to both ends of the fractured bone helps to relieve pain.

Musculoskeletal Field Assessment

H - History O - Observation P - Palpation S - Special tests

Physical Fitness Profile

Identifies weaknesses that may > Hinder athletic performance or > Predispose the athlete to injury Establishes a baseline of data in the event an injury does occur It is critical to assess the physical fitness status of an athlete prior to the start of physical activity to determine whether the individual possesses the attributes, skills, and abilities necessary to meet the demands of the sport. A physical fitness profile can assess body composition; maturation and growth; flexibility, strength, power, and speed; agility, balance, and reaction time; and cardiovascular endurance. Important. Usually done before season Work with strengthening and fitness coach.

Red Flags

If at anytime during the assessment "red flags" are noted, the assessment process should be terminated and EMS activated. "Red flags" include: —Airway obstruction —Respiratory failure —Severe shock —Severe chest or abdominal pains —Excessive bleeding —Suspected spinal injury —Head injury with loss of consciousness —Severe heat illness —Fractures involving several ribs, the femur, or pelvis

Temperature

Normal = 36.5 but can fluctuate Methods = Orally, axillary, tympanic, rectal —Core temperature can be measured by a thermometer placed under the tongue, in the ear, in the armpit, or, in case of unconsciousness, in the rectum. Average oral temperature —Normal 37°C (98.6°F), but this can fluctuate considerably; early morning hours may fall as low as 35.8°C (96.4°F), and later afternoon or evening hours may rise as high as 37.3°C (99.1°F) Rectal temperatures —Higher than oral temperatures by an average of 0.4° to 0.5°C (0.7° to 0.9°F) —Considered to be a more accurate measurement of core temperature Axillary temperatures —Lower than oral temperatures by approximately 1°F —May take 5 to 10 minutes to register —Considered less accurate than other measurements Infrared tympanic thermometers (ITTs) —Measure infrared energy emitted by the tympanic membrane —Provide a rapid, efficient, and noninvasive method of measuring body temperature —Have failed to detect fever in some patients with aids, neonates, infants, and children —Not useful in hypothermic or significantly hyperthermic individuals

Pre-Participation Exam (PPE)

Objective—to ensure the health and safety of a physically active individual —Those at risk for injury, or those who have conditions that may limit participation, can be identified and counseled on health-related issues and steered into participating in appropriate activities. —Many states and sport governing bodies require some type of PPE for competitive athletes; however, states differ greatly regarding specific requirements. Focus—dependent on Specific age group Intended sport/activity

Special Tests

On-site functional testing > When not contraindicated (if they don't want to move or if there is a fracture), the individual's willingness to move the injured body part > AROM (active range of motion), PROM (passive range of motion), RROM (resisted range of motion) - Always bilateral (might have limited range of motion - unique case) > Weight bearing (If they pass it all, they can weight bear on lower limb) On-site stress testing > Performed prior to any muscle guarding or swelling to prevent obscuring the extent of injury (testing ligaments to check their integrity) > Testing for ligamentous integrity is performed prior to any muscle guarding or swelling to prevent obscuring the extent of injury; typically, only single-plane tests are performed and then compared with the noninjured limb. > Muscle guarding - the muscles spasm to prevent the joint from moving as much

Secondary Survey

On-site history > Obtained from the individual or bystanders who witnessed the injury > Relatively brief as compared to a comprehensive clinical evaluation > Critical areas - Location of pain - Presence of abnormal neurological signs - Mechanism of injury - Associated sounds - History of the injury

Observation

On-site observation and inspection > Begin en route to individual > Critical areas - Surrounding area - Body position - Movement of the athlete - Level of responsiveness - Primary survey - Inspection for head trauma - Inspection of injured body part

Palpation

On-site palpation > General head-to-toe assessment > Determine - Abnormal joint angulation — identifies possible joint dislocation or fracture - Bony palpation — possible fractures can be detected with palpation, percussion, vibration, compression, and distraction; crepitus—associated with fracture, swelling, or inflammation - Soft-tissue palpation — swelling may indicate diffuse hemorrhage or inflammation in a muscle, ligament, bursa, or joint capsule; deformity (e.g., an indentation) may indicate a rupture in a musculotendinous unit; protruding firm bulge may indicate a joint dislocation, ruptured bursa, muscle spasm, or hematoma (feel for any deformity) Skin temperature —normally skin is dry, but certain conditions (e.g., cold, shock, or fever) can alter surface blood vessels; skin temperature is assessed by placing the back of the hand against the individual's forehead or by palpating appendages bilaterally (take with the back of your hand. Have to compare bilaterally)

When to Perform Special Tests?

Only performed when not contraindicated (e.g. you wouldn't use special tests if you suspect a fracture) or if the athlete is not willing to move the injured area. > Special tests are used to: - Find out what structure is injured - Find out how severe the injury is - What needs to be done to get the athlete off the field

Physical Examination (Vital signs and General medical problems)

Physical examination is not intended to be all encompassing . . . it is intended to focus on body systems of most concern relative to participant's sport/activity. 1. Vital signs > Establish baseline physiological parameters and vital statistics > Pulse—determine rate and rhythm > Blood pressure—hypertension standards vary relative to age—mild to moderate *Hypertension in the absence of organ disease or heart disease does not preclude sport participation, but this condition should be noted and evaluated on an individual basis. > Temperature—can fluctuate throughout the day; three types of thermometers are available: 1. Glass 2. Electronic 3. Infrared tympanic 2. General medical problems > Past surgery or hospitalisations > Medications (including OTC) > Use of alcohol, tobacco, ergogenic aids

Power and Speed

Power > Ability to produce force in a given time > Measures include throwing a medicine ball, vertical jump and reach, single- or two-legged hop for distance, and stair climbing Speed > Ability to move body mass over time > Can be assessed by timed sprints ***For power and speed, you want specificity for the test. Specific to the athletes.

Strength

Strength > Ability to produce force in one maximal resistance > Measures can involve isometric, isotonic, or isokinetic testing > The demands of a particular sport or activity will dictate the level of strength needed to perform the necessary skills of that sport. > Measures can involve isometric, isotonic, or isokinetic testing through manual muscle testing, grip strength, sit-ups, push-ups, pull-ups, or using a bench press or leg press. > 1 RM - one rep max. testing for strength need a lot of personnel for spotting

Transporting by rigid immobilization device

The Task Force on the Appropriate Prehospital Management of the Spine-Injured Athlete recommends the following criteria when considering using SMR Blunt trauma with altered level of consciousness Spinal pain or tenderness Neurological complaint (e.g., numbness or motor weakness) Anatomical deformity of the spine. SMR is also recommended when there is a high-energy mechanism of injury and with any of the following: (1) drug or alcohol intoxication, (2) inability to communicate, and (3) a distracting injury. —Due to potentially harmful effects of long spine board, it is recommended that an alternative immobilization device be used (vacuum mattress or scoop stretcher). —Eight person lift is recommended.