Patient Positioning

On October 23, 2002, 40 Islamist terrorists took 850 patrons hostages at the Dubrovka Theater in Moscow. The terrorists wired the auditorium, the hostages and themselves with bombs, so if attacked they could detonate the explosives, ensuring all would be killed. After a 2½-day standoff, Russian special forces came up with a brilliant strategy: They pumped fentanyl gas in through the ventilation system, rendering everyone inside unconscious, and successfully rescued all of the hostages. But then they made a simple but fatal mistake: The rescued hostages were either left or laid on their backs, which resulted in 130 of them dying from asphyxia due to obstructed airways or aspiration of vomitus. As a result, what otherwise would have been one of the greatest hostage rescue operations in history ended up being one of the greatest disasters, all because of something as simple as patient positioning.

More recently and closer to home, in New Jersey on July 31, 2010, EMTs responded to a fall victim. They arrived to find a 27-year-old man who presented with altered mental status and combative as a result of head trauma. The EMTs on the scene restrained the patient in the prone (face down) position on a Reeves litter, then carried him downstairs and out to their ambulance, where they then realized the patient was in cardiac arrest. Autopsy results confirmed the patient died from positional asphyxia.

Of universal significance for all of EMS, among the reasons cited by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons’ Committee on Trauma (ACS-COT) for the recent recommendation of less frequent and more judicious use of backboards was risk of respiratory compromise and aspiration, which in some cases has resulted in death.

Patient positioning is a component and decision point of every patient transport. In most cases, patient positioning is inconsequential, which may tend to lull some EMS providers into a state of indifference. But to not consider appropriate patient position or mindlessly assume or insist on a standard position that is convenient for EMS could result in patient discomfort and even death. The case histories above are two incidents that have been identified and publicized. There have obviously been many others.

In most cases, appropriate patient position will simply be the patient’s position of comfort. One of the greatest axioms in medicine has always been “listen to your patient.” If the patient tells you a position is uncomfortable or makes their pain or breathing worse, even if it’s contrary to conventional positioning, believe them and do not force them into that position.

Patients with any kind of difficulty breathing will generally prefer a sitting position to reduce the weight and pressure of their body’s habitus on their chest and lungs, thereby increasing the capacity of the lungs. So the best transporting position for patients with respiratory distress or shortness of breath would therefore be the full Fowler’s (sitting upright) position. If you opt to move a congestive heart failure patient with respiratory distress up or down stairs lying on a Reeves litter, you might as well just shoot them in the head. These patients should obviously be moved up or down stairs in a stair chair. Sometimes even minor variations of patient positioning can have a major impact on the patient’s condition. Most experienced EMS providers have probably noticed a CHF patient in mild distress who suddenly became worse within minutes of moving them to their litter. These are patients who are so cardiovascularly compromised that the added preload from simply raising their legs up from the normal sitting positon to the hip level on your litter is enough to push them over the edge and into full pulmonary edema.

Conversely, patients who are hypotensive or volume-depleted should be kept lying flat or supine. It obviously takes a higher blood pressure and more work of the heart to pump blood five or six feet vertically against gravity to the head to keep their brain perfused. It is much easier for the heart to pump blood horizontally to the brain of a person who’s lying flat. So, when extricating a hypotensive or volume-depleted patient up or down stairs, it’s much better to use a Reeves litter to keep them supine.

As far as other patient positioning, beyond listening to your patient, try to think of the patient and the unique circumstances of each call and not get mindlessly locked into habit or convention. This may sound so obvious as to not be worth mentioning, until you consider almost all of our patients are transported either supine or in Fowler’s. Is this really the best position for all patients in all cases? Maybe so, as long as you are totally dedicated and prepared to assume full control of their airway if necessary.

If you anticipate any difficulty with airway control, though, or especially if you have several altered or unconscious patients as in a mass-casualty situation like the Moscow theater, the recovery position is probably the safest position. If done properly, the recovery position is a quick and simple way to maintain an open and unobstructed airway while freeing up the medical resource to move on to other patients. All in the all, the recovery position may be the most underappreciated and underutilized treatment in all of EMS.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He serves as the quality coordinator for both of these midsize third-service agencies in Southeastern Pennsylvania. Joe has over 35 years experience in EMS. Joe is also the author of the book; CQI for EMS–A Practical Manual for QUICK Results and in 2014 founded the National Association of EMS Quality Coordinators (NAEMSQC). Contact Joe at jhayestpc@gmail.com.