Lifting and Moving Patients 8

The Wheeled Ambulance Stretcher

(also called an ambulance stretcher, gurney, or simply the stretcher) is the most commonly used device to move and transport patients. -->Weighs between 40 and 145 lb (18 and 66 kg), depending on its design and features - The stretcher should be pulled, pushed, and lifted by its main frame or handles only. - A second tubular frame made up of three sections is attached within or above the main frame. - A metal plate serves as the platform for the mattress and patient. - The head end of the stretcher is designed to be elevated or lowered only when a tilt control is released. - The frame and plates that lie from the hips to the foot end are divided into two hinged sections that bend upward under the patient's knees to elevate them. - Once the patient has been properly placed on the stretcher, the guardrail handle is drawn up and locked in an elevated position perpendicular to the surface of the stretcher. - The folding undercarriage is designed so that the litter can be adjusted to any height from about 12 inches (30 cm) above the ground, which is the desired height when the stretcher is secured in the ambulance, to 32 to 36 inches (81 to 91 cm), which is the desired height when the stretcher is being rolled. - The main frame must be slightly lifted to remove all weight from the undercarriage before it will fold, even if the control is pulled. - Controls for elevating and lowering most stretchers are located at the foot end and at one or both sides. - The mattress must be fluid resistant. - Patients must always be secured with straps on the stretcher.

At a minimum, you will have to:

- Lift and carry the patient to the stretcher - Move the stretcher to the ambulance - Load the stretcher into the patient compartment - Upon arrival at the hospital, remove the patient from the ambulance, wheel the patient into the emergency department (ED), and transfer the patient to the ED bed

Emergency Moves

- Use an emergency move when there is a risk of serious harm or death due to fire, explosives, hazardous materials, or other hazards, or when an injured patient prevents you from gaining access to others in a vehicle who need lifesaving care. A primary concern is the danger of aggravating an existing spinal injury. You can move a patient on his or her back along the floor or ground by using one of the following methods: - Pull on the patient's clothing in the neck and shoulder area. - If the shirt has buttons, the top two should be undone to prevent the patient from choking. - Place the patient onto a blanket, coat, or other item that can be pulled. - Rotate the patient's arms so that they are extended straight on the ground beyond his or her head --->Grasp the wrists and, with the arms elevated above the ground, drag the patient. Place your arms under the patient's shoulders and through the armpits and, while grasping your opposite wrist, drag the patient backward.

You must know:

- Where each EMT should be positioned - How to give and receive lifting commands so that all parties act simultaneously - How to properly use patient-moving devices and any other equipment your service may carry - Which device or combination of devices is appropriate for the current situation

Patient Positioning

A patient with a potential spinal injury should be fully immobilized. A patient with no suspected spinal injury who reports chest pain or respiratory distress should be placed in a position of comfort—typically a Fowler or semi-Fowler position—unless he or she is hypotensive. Patients who are in shock should be packaged and placed in a supine position. Patients in late stages of pregnancy should be positioned and transported on their left side if they are uncomfortable or hypotensive when supine. Place an unresponsive patient with no suspected spinal, hip, or pelvic injury into the recovery position by rolling the patient onto his or her side without twisting the body. Transport a patient who is nauseated or vomiting in a position of comfort, but ensure that you are positioned appropriately to manage and maintain a patent airway. Obese patients should be positioned the same as other patients with a similar condition; however, pay particular attention to ensure that their dignity is maintained.

Additional Patient-Moving Equipment

Bariatric stretchers: Pneumatic and electronic-powered wheeled stretchers: - Similar in appearance to conventional wheeled stretchers, electronic stretchers are battery operated and have electronic controls to facilitate raising and lowering of the undercarriage at the touch of a button. - A drawback to the powered wheeled stretcher is that the weight of the stretcher is increased, typically by 75 to 100 lb (34 to 45 kg). ----> Coupled with the weight of the patient on the loaded stretcher, this creates a potential hazard when transporting the patient over uneven terrain or up and down steps. Portable/folding stretchers: - A portable/folding stretcher is a stretcher with a strong, rectangular, tubular metal frame and rigid fabric stretched across it. - Portable stretchers do not have a second multipositioning frame or adjustable undercarriage. - Some models have two wheels that fold down about 4 inches (10 cm) underneath the foot end of the frame and legs of a similar length that fold down from the head end at each side. ---> The wheels make it easier to move the loaded stretcher. The legs should not be used as handles. - Some can be folded in half across the center of each side so that the stretcher is only half its usual length during storage. - A portable stretcher weighs much less than a wheeled stretcher and does not have a bulky undercarriage - Because most models do not have wheels, you and your team must support all of the patient's weight and any equipment along with the weight of the stretcher. Flexible stretchers: - Several types of flexible stretchers are available and can be rolled up across either the stretcher's width or length, so that the stretcher becomes a smaller, tubular package for storage and carrying. - A flexible stretcher forms a rigid stretcher that conforms around the patient's sides and does not extend beyond them. - When these stretchers are extended, they are particularly useful when you must remove a patient from or through a confined space. - Certain flexible stretchers can also be used if the patient must be belayed or rappelled by ropes. - The flexible stretcher is the most uncomfortable of all the various devices, but it provides excellent support and immobilization. --->The stretcher can be lowered by rope or slid down a flight of stairs by resting it on the front edge of each step.

Directions and Commands

Before any lifting is initiated, the team leader should indicate where each team member is to be located and rapidly describe the sequence of steps to ensure the team knows what is expected. If you must lift and move the patient through a number of separate stages, the team leader should first give an abbreviated overview of the stages, followed by a more detailed explanation of each stage just before it will occur. Orders that will initiate the actual lifting or moving or any significant changes in movement should be given in two parts: - A preparatory command - A command of execution --->Commands of execution should be delivered in a louder voice. - If using a countdown, the leader should always clarify whether "three" is to be a part of the preparatory command or whether it is to serve as the order to execute. - Repositioning usually requires lowering the backboard to the ground and lifting it again when all providers are in their proper places. - Plan ahead and select the methods that will involve the least amount of lifting and carrying.

Body Mechanics

Body mechanics is the relationship between the body's anatomical structures and the physical forces associated with lifting, moving, and carrying. When lifting, spread your legs about 15 inches (38 cm) apart (shoulder width) and place your feet so that your center of gravity is properly balanced between them. With the back held upright, bring your upper body down by bending the legs. Lift the patient by straightening your legs until you are in a standing position and curl your arms up to waist height. If you have still not reached the desired height, reposition your legs so they are closer together and repeat the process. Lifting by extending the properly placed flexed legs is the most powerful way to lift and is called a power lift. The power lift position is also useful if you have weak knees or thighs. Avoid lifting a patient with your arms outstretched. - Hold your arms so that your hands are almost adjacent to the plane described by your anterior torso. Keep the weight that you are lifting as close to your body as possible. Avoid placing lateral force across the spine and sideways leverage against the low back. Keep your arms approximately the same distance apart with the weight distributed equally and properly centered between them.

Principles of Safe Lifting and Carrying

Estimate how much the patient weighs before you attempt to lift. - Commonly, adult patients weigh between 120 and 220 lb (54 and 100 kg). - If you use the correct technique, you and one other EMT should be able to safely lift this weight. If you find that lifting the patient places a strain on you, stop the lift and lower the patient. - Obtain additional help before attempting to lift the patient again. Communicate clearly and frequently with your partner and other providers whenever you are lifting a patient. Do not attempt to lift a patient who weighs more than 250 lb (114 kg) with fewer than four providers, regardless of individual strength. Know the weight limitations of the equipment you are using and how to handle patients who exceed them. Special bariatric techniques, equipment, and resources are generally required to move any patient who weighs more than 350 lb (159 kg) to the ambulance.

Removing an Unresponsive Patient from a Vehicle

If you're alone and must remove an unresponsive patient from a vehicle: - First, move the patient's legs so they are clear of the pedals and are against the seat. - Rotate the patient so that his or her back is positioned toward the open vehicle door. - Place your arms through the armpits and support the patient's head against your body. - While supporting the patient's weight, drag the patient from the seat. - If the legs and feet clear the vehicle easily, you can rapidly drag the patient to a safe location by continuing this method. If the legs and feet do not clear the vehicle easily: ----> Slowly lower the patient until he or she is lying on his or her back next to the vehicle. ----> Clear the legs from the vehicle. ----> Use a long-axis body drag to move the patient a safe distance from the vehicle.

Moving and Positioning the Patient

Moving a patient should be done in an orderly, planned, and unhurried manner. Practice each technique with your team often so that when you must move a patient, you can perform the move quickly, safely, and efficiently. After each patient transfer to the ED, you and your team should: Evaluate the appropriateness of the technique used. Evaluate your technical skill in completing the transfer. Begin preparation for your next call by reviewing the positive points about the transport and discussing changes that would improve the next run. This process should help you identify: Procedures that need more practice Equipment that needs to be cleaned or serviced Skills that you need to review or acquire

Bariatrics

Over one-third of the adults in the United States (78.6 million people) are considered obese. The incidence of obesity is: 40% among adults aged 40 to 59 30% among adults aged 20 to 39 35% among older adults aged 61 years or older 17% among children and adolescents In 2008, the estimated annual cost of medical care for obese patients in the United States was $147 billion, or approximately $1,429 higher per obese person than a person of normal weight. Bariatrics is the branch of medicine concerned with the management (prevention or control) of obesity and allied diseases.

Other Carries

Place a backboard next to the patient and, after using a log roll or slide to move the patient onto the backboard, secure the patient and lift and carry the backboard to the nearby prepared stretcher. Assist an able patient to the edge of the bed and place the patient's legs over the side, helping the patient to sit up. - Move the stretcher so that its foot end touches the bed near the patient. - Help the patient to stand and rotate so that he or she can sit down on the center of the stretcher. - Lift the patient's legs and rotate them onto the stretcher while your partner lowers the patient's torso onto the stretcher. Use the draw sheet method or assist an able patient to the stretcher whenever possible. To move a patient from the ground or the floor onto the stretcher, use one of the following methods: - Lift and carry the patient to the nearby prepared stretcher using a direct body carry. - Use a log roll or long-axis drag to place the patient onto a backboard, and then lift and carry the backboard to the stretcher. --->Place both the backboard and the patient onto the stretcher. - Use a scoop stretcher. - Log roll the patient onto a blanket, centering the patient on the blanket and rolling up the excess material on each side. --->Lift the patient by the blanket, and carry him or her to the nearby stretcher. If a patient is sitting in a chair and cannot assist you, transfer the patient from the chair to a stair chair.

Draw Sheet Method

Place the stretcher next to the bed, making sure it is at the same height or slightly lower than the bed and that the rails are lowered and straps are unbuckled. Hold or secure the stretcher to keep it from moving. Loosen the bottom sheet underneath the patient, or log roll the patient onto a blanket. Reach across the stretcher and grasp the sheet or blanket firmly at the patient's head, chest, hips, and knees. Gently slide the patient onto the stretcher. When lifting a patient by a sheet or blanket, center the patient on the sheet and tightly roll up the excess fabric on each side. -This produces a cylindrical handle that provides a strong, secure way to grasp the fabric.

Principles of Safe Reaching and Pulling (continued)

Position yourself by kneeling just beyond he patient's shoulder and facing toward his or her groin. Extend one arm across and in front of your chest to grasp the armpit and, with your other arm extended in front and to the side of the patient's torso, the patient's belt. - When moving a patient, you may grab his or her belt to assist with the move. -->However, do not use pockets or belt loops that may tear with the patient's weight. Raise your elbows and flex your arms to pull the patient with the line of force at the minimum angle possible. When log rolling a patient onto his or her side, you will initially have to reach farther than 18 inches (46 cm). - To minimize this distance, kneel as close to the patient's side as possible, leaving only enough room so that your knees will not prevent the patient from being rolled. -->When you lean forward, keep your back straight and lean solely from the hips. -->Use your shoulder muscles to help with the roll. -->Roll the patient without stopping until the patient is resting on his or her side and braced against your thighs. -------->Pulling toward you allows your legs to prevent the patient from rolling over completely and from rolling beyond the intended distance.

Principles of Safe Reaching and Pulling (continued)

Rather than dragging the patient by his or her clothing, use the sheet or blanket under the patient. - Roll the bedding under the patient until it is about 6 inches (15 cm) wider than the patient. = Pull on the rolled bedding smoothly and evenly to glide the patient to the bedside. To transfer the patient from the stretcher to a bed in the ED: - With the stretcher at the same height as or slightly higher than the bed and held firmly against the bed's side, you and another EMT should kneel on the hospital bed and drag the patient in increments until he or she is properly centered on the bed.

Geriatrics When caring for a geriatric patient, be aware of:

Skeletal changes: Brittle bones (osteoporosis), rigidity, and spinal curvatures (kyphosis and spondylosis) present special challenges in packaging and moving older patients. Many patients cannot lie supine on a backboard or scoop stretcher without causing additional injury, such as fractures, pressure sores, and skin breakdown. Use special care and creativity in immobilizing such patients. - For example, a patient with spinal curvature may have to be placed on his or her side and immobilized in place with rolled towels and/or blankets to prevent exacerbating his or her injuries. Consult your local protocols and medical director about geriatric-specific devices and alternative ways of immobilizing such patients. Fear: A sympathetic and compassionate approach can go a long way in lessening the natural fear many older patients experience when interacting with EMS. Slow down, explain, and anticipate.

Personal Considerations

Some questions to ask include the following: Am I physically strong enough to lift and move this patient? Is there adequate room to get the proper stance to lift the patient? Do I need additional providers for lifting assistance? The answers to these questions need to be evaluated prior to moving your patient.

Medical Restraints

There should be a minimum of five personnel to assist in the restraint of a combative patient, one for each extremity and one for the head. Establish one EMT as the team leader. Be direct. State your intentions, what you expect of the patient, what you are doing. Maintain good eye contact. Place the patient in the supine position. If the patient is placed in a prone position, positional asphyxia could develop. Apply humane restraint to each extremity, such as: - Triangle bandages - Roller gauze - Commercially available disposable restraints - Leather restraints Preferably the patient should be restrained onto a backboard, which allows for easy movement should the patient begin to vomit. -If this is impractical, secure the patient to the stretcher. Secure one arm above the patient's head and one arm at the patient's side. After securing the upper extremities, secure each leg. Ensure that you will be able to quickly remove the restraints during transport if necessary. After application of the restraints, assess the patient's ABCs, mental status, and distal circulation (pulse and motor and sensory function) frequently. Document your findings on the patient care report. - Include what types of restraints were used and why in the report, which is essential if the case is reviewed for medicolegal reasons.

Power Grip

Use the power grip to get the maximum force from your hands whenever you are lifting a patient. Whenever you grasp a stretcher or backboard, your hands should be at least 10 inches (25 cm) apart. Insert each hand under the handle with the palm facing up and the thumb extended upward. Advance the hand until the thumb prevents further insertion and the cylindrical handle lies firmly in the crease of your curved palm. Curl your fingers and thumb tightly over the top of the handle. - All your fingers should be at the same angle. The handle is fully supported on your curved palm with only the fingers and thumb preventing it from being pulled sideways or upward. Never grasp a stretcher or backboard with the hand placed palm down over the handle. - When lifting with the palm down, the weight is supported by the fingers rather than the palm.

Pushing a Wheeled Stretcher

When rolling the wheeled ambulance stretcher, make sure that it is in the fully elevated position. If you are guiding the stretcher from the foot end, make sure your arms are held close to your body and be careful to avoid reaching significantly behind you or hyperextending your back. -Your partner should control the head end and assist you by pushing with his or her arms held with the elbows bent so that the hands are about 12 to 15 inches (30 to 38 cm) in front of the torso. Never push an object with your arms fully extended in a straight line and the elbows locked. Push from the area of your body between the waist and shoulder. If the weight you are pushing is lower than your waist, push from a kneeling position. Do not push or pull from an overhead position.

Principles of Safe Reaching and Pulling

When you use a body drag to move a patient, your back should always be locked in a slight curve created by tightening your abdominal muscles. Avoid any twisting so that the vertebrae remain in their normal alignment. When you reach overhead, avoid hyperextending your back. Kneel to minimize the distance that you will have to lean over. Reach forward and grasp the patient so that your elbows are just beyond the anterior torso. When pulling a patient who is at a different height from you, bend your knees until your hips are just below the height of the plane across which you will be pulling the patient. Extend your arms no more than about 15 to 20 inches (38 to 50 cm) in front of your torso. Reposition your feet (or knees, if kneeling) so that the force of pull is balanced equally between both arms and the line of pull is centered between them. Pull the patient by slowly flexing your arms. Alternate between pulling the patient by flexing your arms and then repositioning yourself so that your arms are extended with your hands about 15 inches (38 cm) in front of your torso.

Loading a wheeled stretcher into an ambulance

Whenever a patient is on an elevated stretcher, you must ensure that it is held firmly between two hands at all times so that even if the patient moves, the stretcher cannot tip. Clamps are located in a rack on the floor or side of the patient compartment of the ambulance to hold the stretcher in place until they are released at the hospital. Ensure the intended travel path is free from debris and potential obstacles. If the patient must be moved over a lawn or other irregular surface, lift and carry the stretcher over the terrain. - A four-person carry is much safer if the stretcher must be moved over rough ground. If the loaded stretcher must be carried down a short flight of steps, retract the undercarriage. - This is not necessary when the stretcher must be lifted over a curb, a single step, or an obstacle of a similar height An IV pole can be unfolded or extended above the main frame to hold an IV bag above the patient while you move the stretcher to the ambulance. Some wheeled ambulance stretchers include a carrier to hold a cardiac monitor or AED and portable oxygen unit. - If the model you use does not include these features, secure the equipment to the top surface of the stretcher mattress at the patient's legs. --> Remove these items before lifting the stretcher to avoid the excess weight.

Lifting and Carrying a Patient on a Backboard or Stretcher: Diamond Carry

between 68 and 78 of the body weight of a patient in a horizontal position is in the torso - more of the patient's weight rests on the head half of the device than on the foot half a patient on a back board or stretcher can be lifted and carried by four providers in a diamond carry

Extremity Lift

helpful when patient is in a narrow space and not enough room for the patient and several EMTs to stand side by side step 1: patient's hands are crossed over the chest. Graspt the patient's wriss or fore arms and pull the patient to a sitting position step 2: your partner moves to a position between the patient's legs, facing in the same direction as the patient, and places his or her hands under the knees step 3: rise to a crouching position. on command, life and begin to move

Backboards

is a long, flat board made of rigid, rectangular material. Also called: Long backboard Spine board Trauma board Longboard - Backboards are 6 to 7 feet long (approximately 2 m). Commonly used for patients who are found lying down - Parallel to the sides and ends are a number of long holes about 0.5 to 1 inch (1 to 2.5 cm) from the outer edge. -These holes form handles and handholds so that the board can be easily grasped, lifted, and carried. - Also allow the patient to be secured to the board using straps located at each side and end of the backboard

You and your team should

practice lifting and carrying techniques often.

Using a Scoop Stretcher

step 1: adjust the length of the stretcher step 2: life the patient slightly and slide the stretcher into place, one side at a time step 3: lock the stretcher ends together, and avoid pinching either the patient or your fingers step 4: secure the patient to the scoop stretcher and transfer it to the wheeled stretcher

Performing the One-Handed Carry

step 1: face each other and use both hands step 2: lift the backboard to carrying height step 3: turn in the direction you will walk; and switch to using one hand

Moving a Patient With a Stair Chair

step 1: position and secure the patient on the chair with straps. take your places at the head and foot of the chair step 2: lower the chair to roll on landings and for transfer to the stretcher

Diamond carry

step 1: position yourselves facing the patient step 2: the providers at each side turn the head-end hand palm down and release the other hand step 3: the providers at each side turn toward the foot end. the provider at the foor end turns to face forward

Moving a Patient on Stairs With a Stretcher

step 1: strap the patient securely. Make sure one strap is tight across the upper torso, under the arms, and secured to the handles to prevent the patient from sliding step 2: carry a patient downstairs with the foot end first, always keeping the head elevated

Rapid Extrication Technique

step 1: the first provider provides in-line manual support of the head and cervical spine step 2: the second provider gives commands, applies a cervical collar, and performs the primary assessment step 3: the second provider supports the torso. The third provider frees the patient's legs from the pedals and moves the legs together, without moving the pelvis or spine step 4: the second provider and the third provider rotate the patient as a unit in several short, coordinated moves. The first provider (relived by the fourth provider as needed) supports the patient's head and neck during rotation (and later steps) step 5: the first (or fourth) provider places the backboard on the seat against the patient's buttocks. ( use of a backboard may depend on local protocols.) step 6: the third provider moves to an effective position for sliding the patient. The second and the third providers slide the patient along the back board in coordinated 8-to- 12 inch moves until the patient's hips rest on the backboard step 7: the third provider exits the vehicle and moves to the backboard opposite the second provider, and they continue to slide the patient until the patient is fully on the backboard step 8: the first (or fourth) provider continues to stabilize the head and neck while the second provider and the third provider carry the patient away from the vehicle and onto the prepared stretcher

Loading a Wheeled Stretcher Into an Ambulance (continued)

step 1: tilt the head of the stretcher upward and place it into the patient compartment with the wheels on the floor and the safety bar latched on the hook step 2: the second EMT on the side of the stretcher releases the undercarriage lock and lifts the undercarriage step 3: roll the stretcher into the back of the ambulance step 4: secure the strecher to the clamps mounted in the ambulance

Direct carry

transfer a supine patient from a bed to the stretcher using the direct carry method step 1: position the stretcher parallel to the bed. secure the stretcher to prevent movement. face the patient while standing between the bed and the stretcher. position your arms under the patient's neck and shoulder. your partner should position his hands under the patient's knees step 2: life the patient from the bed in a smooth, coordinated fashion step 3: slowly carry the patient to the stretcher step 4: gently lower the patient onto the stretcher and secure with straps

Direct Ground Lift

used for patients with no suspected spinal injury who are found lying supine on the ground use this lift when you have to lift and carry the patient some distance to be place on the stretcher step 1: line up on one side of the patient, with one provider at the head, one at the waist, and one at the patient's knees. all providers should be kneeling place the patient's arms on his or her chest, if possible step 2: on command, life the patient to knee level step 3: on command, roll the patient toward your chest, and then stand carry the patient to the stretcher