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Scenario Challenge

The Badly Sprained Ankle Upstairs

It's a windy winter day, and City Ambulance is called to an older section of town for a woman who's been injured in a fall. The responding crew arrives at a two-story walk-up apartment, and determines their caller is on the second floor. Her home is accessible only by a narrow staircase on the side of the building.

The crew climbs the stairs and knocks, and a distant voice calls, “Come in! I'm in back!” They open the door to enter a small, cluttered living area. A large, well-worn couch along one wall occupies what seems like half the room. Opposite it are a TV stand and small table. Between them are only a few feet of space. The hardwood floor is covered by a small area rug littered with cat toys.

The crew finds their patient in a small bedroom in the back. A moderately overweight woman in her 50s, she sits on the edge of her bed, right leg elevated. Her right ankle is visibly swollen. The woman, Mrs. Johnson, tells you it rolled on her as she stood, and she fell to the floor, landing hard on her right elbow. Both are now causing her significant pain. She climbed back up to the bed, but couldn't walk, so she called 9-1-1 from the phone on her nightstand. She asks to be transported for treatment.

The crew conducts its assessment. There is nothing to indicate an immediate life threat to Mrs. Johnson. But while her injuries may be minor, her removal for care won't necessarily be simple. Getting her out of her apartment and downstairs could pose several threats to this responding crew's safety. What are these, and how can they be reduced?

Safe Lifts & Moves
There are several important components to lifting and moving patients safely. Proper lifting technique is important. Careful advance planning of all patient movement, and identifying and reducing prospective hazards, is essential. And, when possible and appropriate, the use of assistive devices can greatly reduce the risk of injury to providers.

Decisions about the use of assistive devices should be influenced by a patient's size, location and the path to it. A case like Mrs. Johnson's may call for a pair of common patient-movement devices: a powered cot and a tracked stair chair.

Powered ambulance cots, like the Ferno Powerflexx+, combine the stability of standard x-frame cots with a powered lift. An electric motor and hydraulic system raise patient loads up to 700 lbs. without human assistance. This lets a single crew lift almost any size patient with greatly reduced risk of injury.

“When you have a patient who's really large, powered cots let the machine do the work,” explains EMS educator Greg Friese, NREMT-P, president of Wisconsin-based Emergency Preparedness Systems. “I've often worked with a partner who's stronger than I am, and with standard cots, we're frequently trading places because I want to be on the light end. That increases our risk. A powered cot would let us avoid that risk and raise the patient automatically.”

“When it comes to patient handling,” says Darrell Messersmith, MSPT, director of physical medicine at Platte Valley Medical Center in Brighton, CO, “if there's anything we've learned over the years in the hospital environment, it's that if you can take away that mechanical requirement of physically lifting the patient, you're going to make it a much safer environment for the worker. Anything that reduces the force required to lift is good, particularly if the lifting is repetitive.”

Tracked stair chairs, like the Ferno EZ Glide , convey patients in areas too difficult or hazardous for ambulance cots. With wheels and a more narrow profile, these chairs provide the maneuverability needed to get through tight spaces. And, tracked stair chairs feature a track mechanism that bears the patient's weight on stairs during descent. This eliminates the forces that would be faced by providers during a lift, and in turn helps them maintain better body mechanics.

“Tracked stair chairs are one of the best innovations I've seen,” says Bryan Fass, an athletic trainer, strength and conditioning specialist and longtime paramedic from North Carolina who writes regular fitness columns for EMSResponder.com . “You can just roll the patient down the stairs, versus having to hop them step to step.”

“The principles of lifting and moving are always to keep your back straight and use your legs,” says Steve Kanarian, a lieutenant in the Fire Department of New York's EMS Command and lead instructor for the paramedic program LaGuardia Community College in Long Island . “A benefit of these newer devices is that they help us to do that, and protect ourselves. Patients seem to be getting larger, and these devices can help.”

Determining the most appropriate means to transfer and transport a patient is part of a comprehensive assessment that should precede every patient move. Crews must identify and mitigate scene hazards. In this case, beyond the obvious trip hazards, the confined spaces of Mrs. Johnson's living and bedrooms represent an injury danger, as providers may not be able to lift, turn and move naturally. As well, Mrs. Johnson is moderately overweight, so anything to help providers from bearing her entire weight will reduce their risk as well.

A caregiver's impulse is to dive in and help. Approaching a patient move deliberately does more to keep you safe.

“Take the time to step back and develop a plan,” advises Friese, who has written on patient lifts and back safety for EMS Magazine. “Taking that few seconds to work out a patient move beforehand can do a lot to reduce your risk. Very rarely do we face true life-or-death lifts. Take your time and don't get hurt.”

Patient Removal
With their assessment complete and a plan in mind, Mrs. Johnson's crew sets about ensuring a clear path through the apartment, down the stairs and to the ambulance. The tight quarters in the apartment and narrow stairs accessing it place a premium on equipment maneuverability, so the crew uses their EZ Glide tracked stair chair. The maneuverability of the stair chair makes it easier to move through cramped and difficult scenes. One is brought to Mrs. Johnson's bedside.

The crew helps Mrs. Johnson sit up in her bed, and then helps her pivot from the bed to the stair chair. They secure her with the patient restraints, and convey her through the cleared living room.

In an open area by the front door, Mrs. Johnson's crew deploys the track mechanism, sets the foot-end and head-end handles to a comfortable height, and, working together with clear communication, takes her down the stairs. The tracks on the stair chair assume her weight, greatly reducing the risk of injury to City's crew.

On a level sidewalk at the foot of the stairs, the crew brings their powered cot next to Mrs. Johnson on the stair chair. Powered cots can be universally adjusted within a wide range of heights, so the crew adjusts the Powerflexx+ to the precise height of the stair chair, allowing for a safer lateral move. Mrs. Johnson's crew helps her pivot to the cot and lie down, secures her with patient restraints, and raises the cot with the powered lift for moving to the rig for transport.

At the back of the ambulance, the powered cot provides another safety benefit in loading: Instead of a single provider at the foot of the cot holding all the weight while their partner collapses the wheels, both members can support the weight as the wheels retract hydraulically.

Following a safe load into the ambulance, Mrs. Johnson is transported without event to the hospital, where she is diagnosed with a sprained ankle and badly bruised elbow. She is treated and released. City's crew, having completed the run successfully, moves on to their next call.

Conclusion
It was Mrs. Johnson's good fortune that she wasn't badly hurt in her fall, and good care by City Ambulance's crew that got her quickly and safely to definitive care. City's commitment to safety extended as well to its crews, and the training and equipment provided to them—they had the right tools and knew how to use them. Lifting and moving patients is among the most hazardous things EMS providers do. It requires the right resources to do the job safely.

“There's a preventative piece to it, the training and hazard reduction, and then there's the execution,” says Friese. “You can't just forget about all your training and try to grunt through it. Make a plan. Use the right equipment and use your training. And always ask for help when you need it.”

For additional help in training for safe patient handling, check out Ferno 's free CD based Operation Safe EMS program at www.OperationSafeEMS.com



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