CE Article: Preventing Back Injuries in EMS

Paramedics Tonya and Zech have been waiting for an ED bed for nearly 45 minutes. Their patient, who fell at home and has a suspected hip fracture/dislocation, lies supine on their stretcher in significant discomfort. Finally they receive their bed and quickly move toward the vacant room. They are in a rush to turn over care—their shift ends in 15 minutes, and they’ve been out late for the past three nights. When Tonya suggests they wait for help lifting their 280-lb. patient, Zech laughs and says he can get the patient over if Tonya just pulls. Each partner grabs a side of the blankets, and Tonya pulls while Zech pushes the patient toward the ED bed. Three quarters of the way across, Zech grimaces in discomfort, and as he raises the bed rail, Tonya asks if he’s OK. Zech simply replies, “My back didn’t like that move.”

A Staggering Problem

Back injuries account for more than 20% of all workplace injuries in the United States and are a particular problem in EMS, where at any given time nearly 10% of the workforce is out of work from injury.¹ As a result, nearly 25% of all EMS workers experience career-ending back injuries within the first four years of their career.² To put this in perspective, from 2000–2010, FDNY EMS alone experienced 500 annual back injuries,³ and if a quarter of those resulted in careers ending, that’s 125 open positions each year from injury alone. The Centers for Disease Control and Prevention monitors EMS workers’ injuries, and in the most recent data set available, more than 27,000 EMS workers experienced on-the-job injuries and illnesses, and more than 21% of those injuries were to the lower back.⁴

The financial burden is not insignificant. Each year back injuries cost the economy nearly $50 billion in direct medical bills and lost revenue, and $20 billion of this cost is in injuries related to the healthcare profession. This exceeds the cost of back injuries in construction, mining and manufacturing.⁵ Each individual back sprain carries an anticipated direct cost of just over $18,000 in physician and medical bills, lost income and employer costs.

Back injuries not only affect employees but can have profound consequences on employers as well. An injury leaves the employee unable to perform routine duties. Staff may be restricted to light-duty work or left to recover at home. This time away is not vacation; back injuries interfere in nearly every aspect of daily living. On the employer side, there are workers’ compensation payments and open positions that must be backfilled with other staff, possibly in the form of forced overtime. Overtime shifts are not only expensive, they also drive up provider fatigue, increasing healthy staff members’ risk of injury. Table 1 summarizes the consequences of a single back injury for both the injured party and their agency.

More than half (62%) of all prehospital provider back injuries result from lifting patients.⁶ Our injuries are a consequence of three major factors: significant lifting forces (patient weight), repetitive movements and awkward positions. Prehospital back injury statistics have not changed significantly in the past decade despite the introduction of many safe-lifting devices (e.g., automatic-lift stretchers, slide boards, slide sheets, bariatric equipment). Our industrial partners have not failed to provide us adequate equipment; the opposite is true: EMS systems have been offered incredible and very effective tools to do their job. The truth is that back injury reduction requires more than a single strategy. A 2008 BMJ article supports this idea, finding there is little to no evidence that the introduction of training, lifting equipment and advice can prevent back pain or disability.⁷ The review’s author did not suggest that back injuries are unpreventable, but she concluded that single applications of training and the introduction of single devices for lifting fall short. A back injury-prevention program must be comprehensive and address prevention, training and monitoring.

How does this apply to EMS? Consider all the lifts that can occur on a routine patient transport—for instance, following a standing fall with a hip injury as presented in the introduction. On the typical transport, the minimum number of lifts that can be anticipated is five: 1) lifting the patient from the floor to the stretcher; 2) bringing the stretcher to waist height; 3) loading the stretcher into the ambulance; 4) unloading the stretcher from the ambulance; and 5) transferring the patient from the stretcher to the hospital bed. Each of these lifts puts unique forces on the provider’s body and presents opportunities for injury. A single device or training cannot effectively manage the physics of each of these lifts. Fortunately, even though each lift is unique, the basics mechanics of safe lifting can be applied.

Physiology of the Spine and Lifting

Appreciating the forces and mechanics of lifting requires a brief anatomical review. The cervical, thoracic and lumbar spine sections gain strength and flexibility from being curved rather than straight. The cervical and lumbar spine regions are convex, while the thoracic spine is concave. Safe lifting requires the individual to maintain these curves to ensure proper core strength and spine protection. In particular, maintaining the natural curve, or lordosis, of the lumbar spine is important, as its loss can rapidly contribute to spine injury.⁸

Within the spine, the vertebral bodies are the load-bearing structures and are separated by shock-absorbing intervertebral disks that also permit motion within the spine. Muscles run the length of the spine’s posterior aspect and provide strength and protection to its entirety. There are ligaments on all sides between the vertebrae that contribute to the spine’s strength.

Three forces affect the spine and can lead to injury: compression, shear and torque. Compression forces push down on or squeeze the spine parallel to the spine’s axis; for instance, gravity is a constant compressive force. The intervertebral disks help us withstand compression forces. Forces that impact the spine perpendicular to the axis are considered shear forces. Leaning over to the side by dropping one shoulder lower than the other and picking up a heavy pack is an example of a shear force. Shear forces also occur when you bend at the waist to pick up an object. Rotational forces are referred to as torque. Torque is calculated by multiplying force times distance where distance is the space between the spine and the weighted object in motion. Significant torque forces can cause ligament and disk injuries as compression occurs unevenly; they can occur when heavy objects are lifted with one arm.

To help protect workers, the National Institute for Occupational Safety and Health (NIOSH) established safe-lifting limits. The load limit for single-person lifting is 51 lbs. and a spine compression force of 764 lbs.⁸ Unfortunately for prehospital providers, many routine lifts far exceed the recommended compression limits. For example, pulling a 105-lb. patient via bedsheet between two beds applies between 832–1,708 lbs. of compressive force, while carrying the same patient down a set of stairs compresses the spine with 1,012–1,281 lbs.⁸

Mechanics of Lifting

When lifting a patient, heavy equipment or even just a bulky object, the use of proper mechanics can reduce your chance of injury. Remember to follow these basic principles:

• Size up the load. If you feel you and your partner cannot safely handle the lift, request help, regardless of the nature of the patient’s emergency. Being honest with your own personal limitations can save a lifetime of problems.

• ?Establish firm footing. Plant your feet shoulder-width apart with one foot slightly in front of the other. Rest with your weight back on your feet, as rocking your weight onto your toes tilts your center of gravity forward.

• Keep a straight back. Imagine two parallel steel rods running from your shoulders to your hips and into the ground at a 90° angle. Try to maintain this position as you squat and lift to minimize torque on your spine.

• Bend slowly at the knees. Lowering and lifting slowly promotes a safer lift than a fast and jerky move. Allow the leg muscles to do the work rather than the back muscles, which are actually weaker.

• Keep the load close to your body. It’s reasonable to have the stretcher, backboard or any object supporting the patient within inches of you; keeping space pushes the center of gravity away from your core and strains the back.

• Keep your chin up. Raising the head brings the back forward and keeps it in line.

• Pull your shoulders back. This limits the temptation to lean over to lift.

Figures 1a and 1b illustrate the differences between proper and dangerous body mechanics. Note that with improper mechanics (1b) the back leans forward, allowing the spine to come out of alignment and creating excessive torque and shear forces.

Traditional lifting techniques work well when lifting a patient on a backboard from the ground to a lowered stretcher. Contrary to popular belief, it is not safe to lower the stretcher to its lowest position when lifting a patient off the floor. It is a better practice to lift the patient to waist height and then have the stretcher at the same height to lift onto. This allows you to make two moves in safe body positions. When the stretcher is lowered to the ground, the result is a partial lift and then twisting to move the patient onto the stretcher from a relatively unstable back position.

One of the most dangerous lifts performed by prehospital providers is sliding a patient from a bed onto the stretcher, and vice versa. Most EMS teams have two crew members, and when presented with the need to slide a patient between two beds, the natural tendency is to have one person on each side. While reaching and pulling the patient toward you is relatively safe, lifting and pushing the patient away from your core is extremely dangerous and creates significant strain for the spine. Reaching across the bed to slide the patient causes 700–1,000 lbs. of compressive forces at L4/L5. Kneeling on the bed reduces this lift to 670 lbs., and standing on the bed to lift for a lateral patient slide reduces it to 367 lbs.⁸

The ideal lift to move a patient between two beds is to lift from the head and feet. While this is feasible when the patient is on a long spine board, patients on soft mattresses are difficult to move in this manner. The best alternative is to use a slide board/sheet and gather the assistance of as many additional persons as necessary to safely move the patient. Placing a slide board/sheet beneath the patient doesn’t take much additional time and reduces the load on a provider’s spine.

Reducing Risk

Published evidence is not always necessary to know that something is beneficial. Gordon Smith and Jill Pell demonstrated this in 2003 when they published their parachute research in the British Medical Journal. In a somewhat satirical article, they sought empirical clinical evidence that parachutes prevented traumatic injury from gravitational forces. Despite searching all available published clinical research, they could not find one study demonstrating that using a parachute when jumping from any height will help prevent injury.⁹ Common sense, however, tells us that if we jump from an airplane without a parachute, we will suffer serious injury or death. This same principle can be applied to many of the lifting devices available to prehospital providers. Many lifting tools are effective, yet lack the studies to prove they are beneficial. While the authors of this column favor evidence-based medicine, we feel it is important to remember that any lifting support and aid is better than none.

The study of fitting workplace conditions and job requirements to the abilities of the working population is the science of ergonomics. Developing a good ergonomics program improves worker satisfaction, safety and productivity.¹⁰ Proper ergonomics takes into consideration the worker’s capabilities, the job at hand and the work environment (Figure 3). In EMS, developing a strong ergonomics system modifies the job to fit the provider’s capabilities and requires improving the strength and health of providers as well as the proper introduction of and education on lifting equipment appropriate for the system’s scope of care. EMS ergonomics requires implementation of proper training and fitness programs to teach safe lifting as well as the addition of and training in the use of safe-lifting devices.

An EMS Ergonomics Program

A comprehensive ergonomics program encompasses initial assessments, ongoing training, staff evaluations, established procedures and plans for high-risk lifting and maneuvers, and approved medical management for identified weaknesses and injuries. While the size and scope of each agency will define how many of these aspects can be used, it extremely important to build a program that meets staff needs. There are many aspects to consider when implementing strategies to reduce back injuries in EMS. Begin with hiring practices. Several organizations have outstanding prehire or interview lifting tests that can help.

Prehire screening—An effective prehire lifting evaluation need not be used to eliminate job candidates. Rather, consider it an opportunity to identify needs for improved training in staff you feel is clinically qualified to work within your system. Eliminating employees because they cannot lift safely could sell your department short. Instead, develop a lifting evaluation and a post-hire training program designed to train staff on their lifting weaknesses. For example, have candidates 1) climb out of the ambulance, 2) open up a side cabinet and obtain a heavy bag, 3) carry that bag 50 feet and set it down, 4) lift a manikin on a backboard with a partner onto a stretcher, and 5) load the same stretcher into an ambulance. These realistic lifts can be monitored by a trainer who can help design necessary fitness programs to help otherwise-talented candidates be successful. Candidates who pass the exam likely have safe-lifting practices, while those who do not could be identified as needing additional training during orientation. You might just save a peer’s career by offering them training rather than pointing them to the exit door!

Fitness program—Consider helping to develop a fitness program for your agency’s new-hire orientation program. During training academies and orientations, practice calisthenics and weight training and proper lifting strategies, and encourage or offer a gym membership. Fitness encourages both safe lifting practices and healthy lifestyles. Refer new employees who demonstrate improper lifting strategies to a physical therapist for strength training and training on proper lifting techniques. Acquiring access to fitness facilities and allowing staff 2–4 hours per week to work out and perform core-strengthening exercises like curl-ups, side bridges, lunges and push-ups will reduce injury risk, relieve stress and improve the department’s overall physical health. A small investment such as a fitness program can actually reduce overall healthcare costs for the system; for one department’s example, see www.emsworld.com/news/11300500.

Annual lifting evaluations—Once orientation is over, it is imperative to continue to emphasize safe lifting practices and good body fitness. Without regular reevaluation and practice, we all develop bad habits, including in how we lift. There are several options in evaluating lifting. Regardless of the option selected, train as a team. Since we don’t lift patients alone, lifting practice and evaluations shouldn’t be done alone either.

Similar to prehire screenings, select a series of lifts that are realistic for the department’s environment. Consider using an athletic trainer, physical therapist or fitness expert rather than department staff to evaluate lifting. We don’t often see the small errors when we all live in the trenches together. If an outside evaluator is not available, consider filming the lifting evaluation to permit peer and self-debriefing in a controlled setting. When we watch ourselves on film, small opportunities for improvement often become obvious. Consider an annual lifting evaluation that goes beyond a dead lift of some predetermined weight. Figure 4 is an example of one lifting evaluation that uses a series of lifts in succession. Other lifting elements that might be considered are movement of a patient via stair chair down a flight of stairs, carrying stocked bags up/down stairs, helping a patient up from the ground and dragging a patient to safety.

Safety management system (reporting)—One of the most effective back injury-prevention strategies is the development of a standardized reporting system for incidents, including work-related injuries. Often called a safety management system (SMS), this allows leadership to summarize and review patterns and frequency of safety events. With a well-developed reporting system, common injury patterns may become apparent, allowing them to be addressed and corrected. When utilizing an SMS, have a multidisciplinary team review reported events. These should include front-line providers as well as department leadership.

Establish patient-lifting practices—Standardized safe-lifting practices promote consistency within a system, enable staff to ask for help and protect the agency should an injury to a patient or staff occur during a lift. Beyond having standardized practices written within a policy, all staff must understand and adhere to these practices. Consider developing practices that set a maximum patient weight for a two-person lift, as well as a patient weight that results in automatic dispatch of additional lifting resources. While we are not exploring bariatric patient lifting in this article, it is reasonable to always dispatch an additional crew to addresses where the resident is known to exceed 500 or 600 pounds. Also consider requiring the utilization of specific safe-lifting devices such as a Mac’s Lift when loading large patients or a slide board when moving a patient who cannot slide between two beds on their own.

Besides policies regarding equipment and assistance, establish standard expectations for patient lifts. Standardize who leads and directs lifts (e.g., the person at the head), and always plan the start and endpoint of a lift—for example, “We are lifting the patient up and carrying them over to the stretcher and setting them on it.” Ensure patients are lifted as short of a distance as practical in a single lift.

Never be afraid to ask for help lifting on a scene. You are your own best advocate, and if a patient’s weight exceeds your abilities to lift, don’t force it. Asking for help and waiting for a lift assist will protect your patient and your back. It doesn’t help to try to rush a lift or patient carry because there will be a long wait for help. While there was a time in EMS when asking for lifting help was a sign of weakness, those days need to be over. Work together to create an environment where the accepted standing is asking, and waiting, for help.

Complete a lift hazard assessment on each scene. Every call where patients are moved has body stress requirements that may be physical, environmental or psychosocial. Break down each patient move into its basic elements. Determine the necessary equipment to complete each task before beginning the entire series of lifts. Most important, don’t attempt the job if the right resources are missing. We often ignore or underappreciate the impacts environmental and psychosocial stressors have on lifts.

Utilize lifting devices—Only use lifting equipment that is in good working order. Improper equipment might not have a good grip and could be cumbersome or too heavy to use safely.

Mechanical stretchers are significantly more expensive than traditional stretchers but far less expensive than the costs of a chronic back injury. It has also been demonstrated that using mechanical stretchers decreases the back injury frequency rate. At Austin-Travis County EMS in Texas, back injury rates decreased from 61% to 29% following the 2006 implementation of power stretchers. One study demonstrated that the introduction of powered stretchers reduced stretcher-related back-injury workers’ compensation filings by 41%.¹¹ In this study the powered model replaced all manual-lift stretchers in a large urban EMS system. The insurance company monitored workers’ compensation claims related to use of stretchers. Claim costs dropped by 49%, lost days by nearly 68%, and restricted days by 70%. This two-year reduction offset the costs of the initial stretcher purchases.

The redesign of stair chairs over the past decade has also revolutionized lifting. Manufacturers have added traction-control rails and all but eliminated the need to actually lift the stair chair and patient. The rail systems allow the chair to be slid down the stairs in a controlled manner, greatly reducing compression forces on provider spines. Several EMS systems, as reported on manufacturers’ websites, have reported that these stair chairs have dropped their house/apartment extrication-related back injury rates to near zero.

Slide boards and slide sheets are smooth devices designed to reduce the friction between a patient and a flat surface during lateral moves. They are typically made of smooth plastic or vinyl. Slide boards require at least two providers, as you must first roll the patient onto their side to place the device beneath them. When using a slide board or sheet, it is always safer to pull the patient toward you than to push them away.

Summary

Work-related back injuries remain an all-too-common occurrence in emergency services and all of healthcare. Reducing back injuries requires a holistic approach and investment by all interested parties, from front-line staff to leadership and supporting agencies. As a provider, take the time to ensure you are lifting and moving equipment and patients in a manner that protects both the patient and you. It only takes one jerking movement to cause an acute back injury.

References

1. Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in lost work time among a national cohort of emergency medical services professionals. Am J Ind Med, 2007 Dec; 50(12): 921–31.

2. EMS Back Injury Facts. www.mytactical.com.

3. Fitton M. Back Injury Reduction in the Fire Department of New York Emergency Medical Service. Fire Department of New York, www.usfa.fema.gov/pdf/efop/efo45457.pdf.

4. Centers for Disease Control and Prevention. Emergency Medical Services Workers Injury and Illness Data, www.cdc.gov/niosh/topics/ems/data2011.html.

5. Centers for Disease Control and Prevention, NIOSH Science Blog. Preventing Back Injuries in Health Care Settings, https://blogs.cdc.gov/niosh-science-blog/2008/09/22/lifting/.

6. Hogya PT, Ellis L. Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med, 1990 Jul; 8(4): 308–11.

7. Barclay L. Advice, Training in Lifting Techniques May Not Improve Prevention of Back Pain. Medscape, www.medscape.org/viewarticle/569657.

8. Oregon OSHA. Firefighter and Emergency Medical Services Ergonomics Curriculum, www.cbs.state.or.us/osha/grants/ff_ergo/index.html.

9. Centers for Disease Control and Prevention, NIOSH Publications and Products. Back Belts—Do They Prevent Injury? https://www.cdc.gov/niosh/docs/94-127/.

10. NIOSH. Elements of Ergonomic Programs, www.cdc.gov/niosh/docs/97-117/pdfs/97-117.pdf.

11. Fredericks TK, Butt SE, Hovencamp A. The Impact of Gurney Design on EMS Personnel. Proceedings of the XXIst Annual International Occupational Ergonomics and Safety Conference, 2009.

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for AirLink/VitaLink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail kcollopy@colgatealumni.org.

Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail.com.

Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. E-mail scottrsnyder@me.com.