Walking Patients to the Ambulance

[J306]

As EMT's/Medics our backs are one our most important tools!!

I've just come back to work post a nasty back injury and I'm far more choosy about which patients I carry to the vehicle now.

You have to consider a number of factors I suppose - Complaint, Status, Weight, Extrication Difficulties, Distance to Ambulance......

I can think of examples where I've seen patients who are relatively sick being walked to the vehicle due to their weight or hazards in their home......

I don't think I've ever seen a written procedure here in New Zealand (Kiwi please point it out if I've missed it!!!) but I think anyone who's been around for a while knows who needs carrying and who doesn't!!

Yes yes I've heard the excuses before,

"I'm not using my back and lifting a patient unless I absolutely have to".

How about this, if your THAT concerned about your back, get in the gym, drop some weight, do some core exercises, improve your health and conditioning to the point that your obvious physical limitations DONT affect patient care. If your too old/fat/stubborn to do something proactive, how about you go find a nice relaxing 9-5 job that's not going to stress your back too much.

How hard is it to just grab the stretcher? Its right there, it takes ten seconds, and that's what its designed for so why not use it?

[paramedicmike]

Easy to say. Not so easy to practice.

The back is a complicated mass of muscles, tendons and ligaments. Sometimes, even the most toned, strengthened and consciencous back can become injured in even the most innocuous movements.

Will making an attempt to keep in shape help? Sure. But it won't prevent all back injuries. Add to it repetitive motion, repetitive lifting, repetitive odd angles and the stress and strain add up.

Health care workers have ridiculously high rates of back injuries. Some of that is from improper use of equipment and improper lifting technique. But a lot of it happens even when you do things right.

Some people can walk. Some people can't. Some people shouldn't. And sometimes you just can't use the stretcher. Each patient is a case by case evaluation. You do what you can.

That's not to say we shouldn't make an attempt to stay in shape and be healthy. But to argue that a healthy back will prevent injury so we should just use the stretcher regardless of the circumstances isn't the best argument, either.

[Richard B the EMT]

How hard is it to just grab the stretcher? Its right there, it takes ten seconds, and that's what its designed for so why not use it?

Easy to say. Not so easy to practice.

Here in NYC, buildings constructed after a certain year are supposed to have elevators, if they go higher than 5 storys tall. Then, I have a friend now living in an 8 story high building that is not even open for a full 2 years, and it seems she is always complaining that she has to walk up or down to her 6th floor apartment, as the elevator is out of order again. Worse, it has stalled with her IN THE ELEVATOR CAR, and she's a known cardiac patient with HBP.

Ever walk up 12 storys with the equipment, and then back down with the equipment and the patient in the carry chair, during a blackout? Did that (with the power returning about 5 minutes after effecting the carrydown assist with the Paramedics).

Remember that I am used to working in a big municipality, and await commentary from those in a more unpopulated area, where, obviously, experiences will be different.

[DwayneEMTP]

Yeah, I think that answer to this depends largely on where you practice. I walked less than 1% of the people that I was called to probably. But my call volume on the street has always been low, without old skyscrapers, etc...

I just don't like to walk sick people, and most of the people that I was called on were sick.

Some drunks I'd walk, the person with their suitcase packed got to walk, and most times carry their suitcase.

Sometimes patients that had me confused I'd walk if I thought it was safe so that I could see how confident their gait/balance was, if they seemed to have a sense of direction, how they'd breathe, what things drew their attention along the way, if they really needed support or were trying to pretend that they did, etc. I've found that there can really be a lot of information in a short walk...

Dwayne

[Kiwiology]

As EMT's/Medics our backs are one our most important tools!!

That is an absolute lie and I am ashamed you even suggested it ... the most important bits of kit we have are "no love you don't need to go to hospital right now" and the MySky HDI box that the social club pays for so I won't miss whatever has transpired on the telly while we were out.

Now that we have the ability to record what's on the telly it's probably best we transport them actually because they're liable to ring back at 1am and I'm just not into being blinded by the automatic lights that get flicked on when the station alarm goes off .... shucks I like my kip

[Bieber]

We don`t have a service policy. It`s more about general recommendations and your own clinical judgement.

As said, if I suspect any diagnose which would make it possibly harmful for them to walk, like AAA, etc following your abdomnial example., they don`t - otherwise they can.

I really see no need to carry every bloke down to the ambo if there`s no validable evidence to do so, especially with an onset of pain (for example) of some time during which they have walked around independently - they can make the short walk to the ambo then, too.

A lot of the "carry-everyone-down-to-the-ambo"-attitude is mainly ass-covering, which is surely understandable to some point, but in the end ìf it`s not needed, there`s no point to ruin your back.

Vorenus, I agree with you a hundred percent and think that that is more than reasonable. Thanks for expanding more on your practices.

By-and-large the vast majority of patients who require immediate referral to ED and for whom ambulance transport is the most appropriate method walk themselves out to the ambulance..

Exceptions include things like cardiac chest pain or pain of any kind which we've had to treat (exceptions are isolated upper limb injuries), anybody who's been spinally immobilised or anybody who is reasonably "sick"

If you're not walking then most times the patient will be put on the stair chair or the stretcher if it can easily access where the patient is ... if not then the scoop stretcher is a wicked bit of kit, we threw out long spinal boards a few years ago.

Kiwi, if you would please, do you care to clarify what you mean when you say "sick"? I'm assuming you reserve that to strictly those patients for whom walking may be detrimental to their care (or who are unable to ambulate due to their condition)? Also, good on you to get rid of the spine boards.

Yes yes I've heard the excuses before,

"I'm not using my back and lifting a patient unless I absolutely have to".

How about this, if your THAT concerned about your back, get in the gym, drop some weight, do some core exercises, improve your health and conditioning to the point that your obvious physical limitations DONT affect patient care. If your too old/fat/stubborn to do something proactive, how about you go find a nice relaxing 9-5 job that's not going to stress your back too much.

How hard is it to just grab the stretcher? Its right there, it takes ten seconds, and that's what its designed for so why not use it?

J306, while I appreciate and agree that we should all do our best to remain in good health and capable to do our job, you have to concede that back injuries are by no means unique to paramedics and EMT's who are in poor shape, and that reducing unnecessary lifting is the best way to prevent injuries to providers.

Also, I feel I should point out that the cot is hardly designed to endure the kind of enviroments we drag it through, and that there are even times where moving patients via stretcher poses a much greater hazard to them (i.e. the cot tipping over due to rough terrain, stairs, etc) than ambulation.

Finally, I'd like to ask, do you believe that all patients should be moved by stretcher? To what benefit? If everyone should be moved by stretcher, should we then also give patients other forms of care when it's not indicated?

I just don't like to walk sick people, and most of the people that I was called on were sick.

Some drunks I'd walk, the person with their suitcase packed got to walk, and most times carry their suitcase.

Sometimes patients that had me confused I'd walk if I thought it was safe so that I could see how confident their gait/balance was, if they seemed to have a sense of direction, how they'd breathe, what things drew their attention along the way, if they really needed support or were trying to pretend that they did, etc. I've found that there can really be a lot of information in a short walk...

Dwayne

Dwayne, you surprised me with your answer. You say you don't like to walk sick people, do you care to elaborate?

Good discussion, guys.

-Bieber

Edited January 28, 2012 by Bieber

[DwayneEMTP]

...Dwayne, you surprised me with your answer. You say you don't like to walk sick people, do you care to elaborate?...

Edit: Why were you surprised?

Sure. For example in Mongolia I was called to the quarters of a woman that reportedly took an overdose of some drug that I was unfamiliar with and the Dr and Nurse were unable to explain to me. She was obtunded, groaning, when I tapped her eyelid I seemed to get a retarded response, yet she seemed to adjust herself very slightly a couple of times, as if to get more comfortable.

My driver had gotten the cot inside, but I pushed it aside and had him help me lift her a bit, still not really sure if she was bullshitting, partially bullshitting, or if I was missing something. After we got her standing she was allowing most of her weight to hang on our arms, so I kind of grunted and released my pressure, as if I was going to drop her...and she caught herself. Now I knew that she was at least partially bullshitting.

So we left the ambulance at the quarters and I walked her towards the clinic, her clumbsy gait seemed to be fake, so I just talked nicely to her, her eyes mostly closed, her head hanging, yet veered away from the clinic and could feel her kind of nudging me back in the right direction. At that point I was pretty confident that it was at least mostly bullshit.

Was it important that I know how much bullshit was involved? Yeah, in this case a larger clinic with an expat doc in it is several hours away and I have no idea what the drug is and have no way to find out. (it was a small bottle that the doc said came from prescription, but the writing was in Chinese, so no google! God damn it....)

Another time there was an older woman, a frequent flier that was always having a stroke or a heart attack, or was trying to be unresponsive. This time she was kind of confused, but not in any way that I wasn't used to. I was unable to do a stroke scale, as always, but her facial expressions/extremity movement was purposeful/equal/coordinated bilat. If I lifted her hand, she would groan and let it drop...you know the patient...

I could see her peeking at me, as if to see if I was buying the act this time. I had them leave the cot in the other room and told her I had to help her walk...I helped her up, she could always walk without issues, but as soon as her butt left the bed I could feel her fingers dig into my arm causing me to look at her face, which appeared genuinely afraid that she was going to fall. And this was really unusual. I lay her back on the bed and we loaded her up on the cot...I think that it turned out that she'd had some flavor of CVA or other.

So here we had genuine bullshit combined with genuine pathology...And I think that attempting to walk her gave additional information that fed my suspisions. In fact I don't think that she really even knew that she was sick until she tried to stand.

Was it important that I walk her to try and get more information? Not really...I was only about 5 minutes from the hospital, but I friggin' wanted to figure it out on my own. And I do think that trying to unravel every patient, every single one, makes us stronger providers in the long run.

In the end I still didn't predict a CVA, but at least I was able to develop a strong suspicion that I was wrong in my initial assessment, and though that didn't do shit for her, maybe it will do something for the next patient.

Anyway, it's probably not a good way to do it, but it's my way, and I find that gait, facial expression, body movements, anxiety levels, which details a patient pays attention to and whether they seem to make sense in that context or not, when they breathe, when they hold their breath, etc...are often as, or more, telling than a good set, or sets of vitals with many patients.

Dwayne

[zippyRN]

Yes yes I've heard the excuses before,

"I'm not using my back and lifting a patient unless I absolutely have to".

How about this, if your THAT concerned about your back, get in the gym, drop some weight, do some core exercises, improve your health and conditioning to the point that your obvious physical limitations DONT affect patient care. If your too old/fat/stubborn to do something proactive, how about you go find a nice relaxing 9-5 job that's not going to stress your back too much.

How hard is it to just grab the stretcher? Its right there, it takes ten seconds, and that's what its designed for so why not use it?

and mindsets like this is why EMS in the USA is such a low status job....

the Europeans will have a different mindset on this , and not just because of EUwide manual handling regulations that aim to reduce or eliminate manual handling takss , our tightly packed due to population density and available land private houses don't have room to get trolleys in and if if they do there is no assurance that you will be able to get to the patient ...

[chbare]

Zippy, your geography seems to be a bit off. No worries though, many of my European mates make that whole Canada = United States mistake.

[krumel]

@J306: Your post shows a big knowledge gap in the pathology of back injuries. Almost every study regarding the development of back injuries demonstrate that building up muscles can prevent certain kinds of back injuries (especially those from single capacity overload) but not all kinds of back injuries. Those developing by repeated load to a certain percentage can not be prevented by muscles......

But back to topic:

Personally I try to let "as much as possible" patients walk to the ambulance. Not because I'm lazy but I want to see how the patient reacts to walking. Especially in neurological patients this gives a huge diagnostical benefit.

Of course spinal-immobilized, (real) chest pain and those who are "really" sick get the stretcher/chair...But they are very rare...