Lift With Your Head

Participate: EMS Magazine's Back Injury Survey

We've all been told to lift with our legs and not our backs. That's good advice, but back injuries in EMS remain all too common. Let's consider a different approach: lifting with our heads.

     This article will look at several aspects of how to move a patient onto an ambulance stretcher and move that stretcher safely, without injury to the EMTs or the patient. It will require you to think outside the box and avoid the "But we've always done it that way!" mind-set. For purposes of this article, a stretcher and an ambulance cot and an ambulance gurney are all that same device in the back of the ambulance upon which the patient is placed.

     Is there an injury problem in EMS? Most certainly! In your own EMS organization, it's a safe bet that there are EMTs who have been out of work due to back injuries, shoulder problems or wrist pain. In my organization, there are three superb paramedics who will likely never work in the field again due to injuries associated with lifting. This is a terrible loss to the community, not to mention a massive disruption to these providers' careers and lives.

     There are other EMTs, though, who just never seem to have back injuries. I've the pleasure to work with an EMT whom I swear could not weigh any more than 100 pounds, yet she has a well-deserved reputation as being able to outlift many of our biggest and huskiest EMTs. You likely have some EMTs like this in your organization. What are they doing differently? Maybe they're lifting with their heads.

Heavy Is Our Burden
     First, let's accept that things have changed in the field. Patients are heavier, and they won't be getting lighter anytime soon. The amount and weight of equipment we carry in the ambulance has increased as well, and we often must carry it into a scene. Ask yourself, "How much training have I had in lifting and moving patients?" The answer is likely to be only a few minutes' worth, despite the fact that it's a major part of our jobs. We need to adapt to the situation at hand and reconsider how we lift.

     First, a quick review of the basics of lifting:

1. Stand close to the object to be lifted, feet shoulder-width apart.
2. Tighten your abdominal muscles before you start the lift (don't talk while lifting; you cannot do both at the same time).
3. Keep your back straight; bend with your knees, hips forward.
4. Lift the weight with your leg muscles, not your arm or back muscles.
5. Do not twist as you lift.
6. Push weights-do not pull them.

Other Input
     We've all been told we should lift with our legs and keep our backs straight, but are we really doing it? Think outside the box. Have a friend take a digital picture of you doing a practice lift and get another EMT to evaluate the picture. What you may think is the proper position could be incorrect. Look at your foot position and how far the weight to be lifted is from your body. Talk to those EMTs who never seem to have back trouble and observe where they put their hands and feet in relation to the patient.

     Have you ever read the owner's manual for the type of stretcher you use? It may instruct you in safe operation. When was the last time you were on the stretcher and had other EMTs load you into the back of the ambulance? You really need to do this to feel the change in anxiety level as you're loaded. It's critical that you realize what the injured or sick patient is thinking as they experience this, especially when their anxiety level might already be through the roof. Before you even load the patient onto the stretcher, you need to explain to them what you're doing. If you don't, you risk startling the patient and causing them to move suddenly, disrupting your balance. It goes without saying that all the straps and rails must be properly secured before you attempt any movement.

The State of Your Health
EMS is both a physical challenge and a mental test. You frequently attend training classes and seminars to keep your knowledge and skills sharp, but what are you doing to prepare for the physical challenges? Frankly, the days where you can just show up and work, then go home and kick back on the couch to watch television are gone. To stay in the game, just like any athletes, EMS providers have to train specific areas of their bodies. In EMS, not training for the "big game" could mean being benched-and out of a job.

    One of the best ways to strengthen the back is to strengthen the abdomen. Sit-ups can do this, but if they're not done properly, they can strain the lower back. Crunches, with or without the use of abdominal training devices, can be an effective replacement for sit-ups. These aren't fun, but both are key elements in training for lifting.

    Weight training for the arms and shoulders should not be ignored, and the legs, which provide the major muscles for lifting, require strength training as well. Improving the muscle tone of the legs and stretching the hamstrings can add the necessary stability to prevent injuries.

    We are not going to attempt to give you a list of specific exercises here; that will need to be tailored to your individual needs. Develop a program and follow it. Seek advice among your colleagues and from professional trainers.

Tips & Techniques
     Here's an example that will help illustrate some of the aspects of lifting with your head. Keep this thought in mind: If I don't have to lift the patient, so much the better.

     You are called to a residence for a 50-year-old male who needs to be transported to a doctor's appointment. He has difficulty walking more than a few steps. The patient weighs about 140 kilograms. Normally you'd drive to the scene, park and bring the stretcher inside. You'd lower the stretcher to the perfect sitting height, secure the patient with straps and rails, gather his personal belongings, lift the stretcher up and proceed to load him into the ambulance.

     Let's consider a different approach. You respond to the scene and are advised by dispatch of the patient's weight. You could consider calling for additional help, but today you decide to size up the situation first. The call is nonurgent, so as you arrive at the address, you position the ambulance to lower the back close to the ground. Two ways to do this are to back partway into a sloped driveway or up against a curb. This could lower the rear bumper, relative to the ground, by 4-6 inches. (Consider traffic safety and lane blockage before you do this.) You could also load the patient onto the stretcher, then have your partner move the ambulance to the best available loading spot.

     As you arrive on scene, discuss with your partner how you can best take advantage of the terrain. Plan and discuss the lift before you even get out of the ambulance. What does the ground cover look like? Is your access route a narrow concrete walkway with a dropoff on each side? This could easily catch a wheel and cause the stretcher to tip. Even a smooth surface could have an obstacle like a rock or small branch that could overturn the stretcher if a wheel gets caught. If you're not looking for it, you won't see it.

     Do not engage the wheel locks when loading a patient or while a patient is on the stretcher. This is because the stretcher may tip when the brake is applied or when you first move it. Use the brake only to prevent the stretcher from rolling when unattended.

     Another option is to remove the empty stretcher from the rig and set it at a height where it will roll back into the unit, or where you might need to only lift the front of the stretcher a little bit. This may be a little higher than the optimum height for a patient to sit on the stretcher, but here's the benefit: Once the patient is on the stretcher, you can roll them directly into the ambulance without lifting them. Each stretcher is different, and you might have one that must be in the fully raised position for loading. Adapt to your own equipment. Some ambulances are even hydraulically equipped to lower closer to the ground for loading. This is a thing of beauty.

     Getting the patient to the stretcher can require creative thinking when you can't get the stretcher close to the patient. A "soft" stretcher (a canvas draw sheet with sturdy handles) allows you to lift using handles, rather than pulling on the patient. How about a patient in a chair who can't stand up? This situation can be high-risk because you could find yourself lifting and twisting at the same time. The risk can be reduced by using the soft stretcher to lift from behind without twisting.

     What if the stretcher's height is too great for the patient to get on? Again, lift with your head: Is there a step down outside the front door where you can position the stretcher for easier access? Can the patient step up on something to get onto the stretcher? Could you carry a small, sturdy step stool in the ambulance for the patient to stand on? How about loading the patient from the first step of a stairway? Be safe, creative and flexible. After securing the patient on the stretcher, ask yourself, "Do I really need to lift this patient higher?" Often the answer is no. The lower the stretcher is, the more stable it becomes, so lifting is not inherently better. This might be a hard habit to break.

Tools Of The Trade
     There are devices available to help you move patients. Use what you have and adapt what's available. A canvas patient mover with handles will be much easier on your back than just pushing and pulling on the patient. Is there a draw sheet available, or can you make one? I've often used the entire sheet under the patient to move them, with excellent results. A stair chair is a wonderful device but must be used with caution. The person who can keep their back straight should be doing the lifting, not the person who's bent over. It is nearly impossible for the EMT at the bottom of the stair chair to keep their back straight and lift.

     Have you used that aluminum scoop stretcher recently? That's certainly an option that gives you a handle to lift with. Just about all ambulances have KEDs that can be adapted for patient movement even when you're not at a motor vehicle crash.

     There are newer devices available as well. Both Ferno and Stryker manufacture battery-powered stretchers that can lift up to 700 pounds.

Planning Smart
     If you answered a call for a patient weighing 250 kilograms, you'd certainly want to plan the lift carefully. Plan each and every lift in this same manner! Do not underestimate your potential for injury even with a tiny, frail grandmother. Use the right technique on every patient, every time. Break your planning down into steps:

1. How are you going to get the patient to the stretcher? What are the problem areas?
2. How are you going to load the patient onto the stretcher and get them secured? What are the problem areas?
3. How are you going to get the stretcher to the ambulance? What are the problem areas?
4. How are you going to unload and transfer at the destination? What are the problem areas?

     Planning your arrival at your destination is just as important. You may be taking the patient to a hospital, a doctor's office, a nursing home or back to a residence. Ask yourself where you can park to allow easy offloading. Where could the stretcher be upset and tip over? Are other caregivers available to help?

When to Call for Help
     Generally, it is best to avoid using bystanders for lifting. A family member who's asked to help may have a bad back or, instead of lifting smoothly, may give the patient a "heave-ho" type of lift. Certainly, bystanders will not be familiar with your stretcher's operation or pinch points.

     Using able-bodied family members to help stabilize the stretcher during loading is also best avoided. Though they may be physically capable, their minds are on their loved one, not the stretcher. Consider making a second trip for personal belongings. Many companies have added a canvas shelf at the bottom of the stretcher for personal belongings and equipment. This also helps lower the center of gravity. Do not load all the extras onto the stretcher along with the patient before lifting-that's not lifting with your head.

     There will be cases where you will need to call for additional resources to move a patient. Don't let having other EMTs at the scene lull you into a false sense of security where you don't use proper technique.

     Consider calling for additional help in the following circumstances:

1. When the patient must be carried up a flight of stairs. Moving a heavy weight up is more difficult than moving it down. A stair chair is helpful, but the EMT at the bottom will not be able to maintain a good lifting position.
2. When you must carry the patient on a stretcher down three or more steps. A stretcher's wheels will usually span two steps. The weight of the stretcher can be borne by the back wheels as the front end is lifted, then by the front wheels as the back end is lifted.
3. When the terrain to traverse has obstructions. There might be debris in the way, or a steep slope.
4. When you must carry the patient out of the house on a backboard, such as after a fall. Lifting a heavy patient on a backboard from floor level can be high-risk for everyone. The patient is often frightened and can suddenly reach out, throwing your balance off.
5. Depending on the experience level of you and your partner. If my partner is well trained in lifting and we know each other's strengths and limitations, it will help guide our decision to request a lift assist. If you've never worked together before, additional hands are prudent.
6. With a heavy patient. By itself, this is not reason for a lift assist (if, for example, you do not have to lift the patient). However, a heavy patient who cannot move from the bed to the stretcher on their own should be a red flag. What is a heavy patient? That's in the eye of the beholder.
7. For patient comfort. An additional crew member can help minimize pain by providing support to the legs or head in a nonurgent transfer.

     Just because additional help has arrived doesn't mean it will be used effectively. It is critical that you take the time to brief your fellow providers on the patient's injury and your lifting plan. Discuss the route you'll be using to take the patient out of the house and to the ambulance. Where are the problem areas? Is there furniture that should be moved? Any suggestions for doing it better? Finally, involve all crew members in the lifting. One person should not be asking the family for a list of medications and allergies while the others are lifting the patient.

     A fundamental that must be stressed is that the stretcher is very unstable when it's loaded and being moved sideways. Even a small rock could catch a wheel and topple the stretcher. Recognize this situation and prevent it. When going around a corner, the front wheels may be going straight, but the back wheels have a sideways motion. When making a turn, reduce your speed, check the floor/ground for hazards and proceed. When you're moving a patient, stay focused on that, and don't try to do other things at the same time. This might also be a hard habit to break!

Conclusion
     There is both a reward and a penalty for lifting with your head. The reward is that you'll likely have fewer injuries. It has been my experience that I often do not need a second unit to respond for a lift assist because we can plan and execute the transfer without doing a heavy lift at all! The price to be paid is that your scene times could be longer. Instead of just lifting the patient, we first tell the patient what we're going to do and what they should do ("Give yourself a hug."). Don't multitask by asking for the medical history as you're moving the patient. Concentrate on the lift and move first. All of this might take a little extra time, but that's the price to be paid.

     Before and after the call, discuss the concept of lifting with your head so that your partner isn't totally confused when you don't want to lower the stretcher to allow the patient to sit more easily. Practice on routine calls when there's time and the patient isn't heavy. With practice, you may find that when time is critical, you can move a patient quickly and minimize your risk of injury.

     Hopefully, this discussion has sparked additional thoughts. Talk about it with the others you work with. Remember, lift with your head, rather than your legs, and certainly not your back.

• Survey: EMS Magazine's Back Injury Survey