Backbreaking Work

     Geraldine did not look very heavy, but she was wedged between the toilet and bath-tub. She had slipped while getting out of the tub and was complaining of severe hip pain. The room was only big enough for me, my partner and Geraldine, who needed to be lifted up and out of the room to the cot in the hallway. The question at hand was how to keep Geraldine as pain-free as possible while protecting our own backs during the lift and move. Nearly every patient contact involves lifting and carrying equipment and patients, which applies forces that can potentially injure your back. In this article, we explore lifting and back safety for EMS providers.

     You probably have at least one coworker who is absent from work or seeing a doctor for a work-related back injury. A survey of 1,300 National Association of EMT members found that 47% of respondents had sustained a back injury while performing EMS duties.¹ Unfortunately, back injury is a common workplace injury for all healthcare providers. A 2002 study of back injuries in British Columbia, Canada, reported that healthcare workers had the largest number of time-loss injuries in the province.² Another study of 90 EMS providers found that 39% of participants had sustained a back injury performing EMS duties; 13% of the injuries led to work absenteeism and 52% interfered with daily activity.³ The study authors concluded that "EMS providers in our sample were significantly overweight …and may lack sufficient back strength and flexibility for safe execution of their duties. This group of professionals may be at risk for occupational injury and should be targeted for interventions to improve strength and flexibility."

     Back injuries and back pain are not unique to EMS. They account for a significant amount of human suffering, loss of productivity and economic burden on compensation systems.

• 90% of Americans will experience low back pain.
• Nearly 100 million days of work are lost each year due to back pain.
• Back pain is the most common and expensive work-related injury.
• Nearly $50 billion is spent annually on treating back injuries.^4,5
• Back pain is the single most common cause of disability for persons under age 45.⁵

     Unfortunately for 85% of back pain sufferers, the pain is idiopathic (without an identifiable cause).⁶

BACK ANATOMY AND INJURIES
     If you reach around and feel your back, you feel bones, muscles and connective tissue. Injuries can occur in muscles, ligaments, bones, vertebrae and disks, either alone or in combination.

     The vertebral column, or spine, is strong and flexible. It supports the weight of the head, is an attachment point for the ribs and encases the spinal cord. Back pain and injury can occur anywhere along the spinal column, but low back injuries are most common.

     Each spinal column vertebra is separated by a disk that acts as a shock absorber. The task of the intervertebral disk is to support the column of vertebral bones and maintain elasticity to allow movement. Problems to vertebral disks cause 85% of back pain. Disk problems are caused by sudden compression that causes a disk to protrude and impinge a spinal nerve, or from age-related weakening and loss of elasticity.^7,8 After age 20, spinal disks begin to degenerate and thin. As it thins, the jelly-like disk, the spinal column's shock absorber, bulges out and impinges nerve roots.⁶ The most common cause of disk herniation is improper lifting.⁹ Symptoms of a herniated disk include numbness, weakness and reflex loss. Disks at lumbar vertebrae 4 and 5 and sacral vertebra #1 are the most commonly herniated.¹⁰

     Adjacent vertebrae move as a synovial joint. The disk and synovial fluid allow the flat surfaces of the vertebrae to glide across each other. The joint properties of vertebrae allow us to bend forward, backward and sideways, and to rotate.⁷ Over time, the vertebrae surfaces degenerate and enlarge, causing pain.⁸

     Thirty-one pairs of spinal nerves exit the spine.^5,7 The nerve splits to innervate its joint before continuing to its peripheral destination.⁵ Nerve root impingement and/or inflammation cause acute and chronic low back pain.⁸ Many causes, such as spine changes or disk herniation, can impinge on the nerve roots.⁵

     The largest nerves in the body are the sciatic nerves, which are about as wide as your little finger. The two sciatic nerves exit the low spinal column, pass behind the hip joint, and travel down the back of each leg to the feet.¹¹ Sciatica is the result of an impingement, pinching or stretching of the sciatic nerve.⁶ Disk herniation is the leading cause of sciatica.

     Many ligaments support the connections between vertebrae. When the capacity of connective tissue is exceeded, it begins to tear. Twisting and turning, poor muscle tone and pre-existing conditions can lower the capacity of connective tissue.⁵ Strains and sprains are typically from lifting, repetitive motion, or turning and twisting.⁹

BACK INJURY CAUSES
     Three general factors put EMS providers at risk for back injury: force, awkward positions and repetition.¹²

     Force is the amount of physical effort required to perform a task or maintain control of equipment. For example, lifting a backboarded patient, guiding the cot down a gravel driveway, and returning equipment to storage compartments all require force.

     Awkward postures place stress on the body, such as reaching above shoulder height, kneeling, squatting, leaning over a bed or twisting the torso while lifting. Transferring a patient from the ambulance cot to a hospital bed is an awkward posture.

     Repetition is performing the same motion or series of motions continually or frequently. Kneeling at a patient's side to deliver chest compressions is a repetitive motion that can strain your back. Back injuries can also be the result of a single traumatic event like attempting to lift a load that is beyond your strength, or twisting or bending during a lift.⁴ Back injuries can also result from micro-trauma to muscles, tendons, ligaments and bones that occurs over months, years or decades.⁴

     Because many back injuries are idiopathic and have a slow and progressive onset, they are often ignored until the symptoms become acute, often resulting in disabling injury.⁴ While a back injury may seem to be caused by a single incident, the actual cause is often a series of single incidents with years of weakening from repetitive micro-trauma.⁴

     Back injuries result from exceeding the capability of muscles, tendons and disks, or the cumulative effect of these factors:₄

• Reaching while lifting
• Poor posture
• Stressful living and work activities
• Bad body mechanics
• Poor physical condition
• Poorly designed job or work station
• Repetitive lifting
• Twisting while lifting
• Bending while lifting
• Maintaining bent postures
• Heavy lifting
• Fatigue
• Poor footing
• Lifting with forceful movement
• Vibration.

     Signs and symptoms of a back injury include pain when attempting to assume normal posture, decreased mobility, and pain when standing or rising from a seated position.⁴ Other complaints include extremity numbness or weakness, decreased range of motion and decreased strength.

Strength and Flexibility Help Prevent Injuries
     Since 90% of us will experience back pain at some point in our lives, the purpose of prevention is to lessen the chance of on-the-job injury, reduce injury severity and speed up recovery. Although it does not guarantee a healthy back, regular exercise to increase cardiovascular capability, back and abdominal strength, and flexibility is always good. Work with your doctor to start a heart and back health exercise program.

     Strength and flexibility of the abdominal muscles and lower back are key elements to back-injury prevention. The muscles of the abdominals, lower back, hips and glutes make up the "core" muscles. Every movement or body action originates in the core. A strong core helps to prevent injuries and problems, especially in the lower back.

     By strengthening your core, you help to support and take the strain off of your lower back. Strong abdominals create a stable pelvis and hip area, which prevents injury caused by undesired movement of that area when we lift an object.

     To view demonstrations of a few simple exercises to do during downtime at work or home, visit RapidCE.com and view the lesson on lifting and back safety. Results from any exercise and stretching program take time, so be patient. With time, you will notice increased flexibility and improved range of motion, and the exercises will become easier.

LIFTING TECHNIQUES
     Glenda had lost the use of her arms and legs in a car accident a few years ago. She was cared for at home and was in a hospital-style bed when we arrived. Glenda had symptoms consistent with a urinary tract infection. Our treatment plan was simple: move Glenda to the cot and non-urgent transport to the hospital. Instead of manually lifting Glenda, we watched as the home health aide used a Hoyer lift to smoothly transfer her from her bed to our cot. The machine did all the lifting for us.

     Back injury prevention includes:¹²

• Modifying work practices by using proper lifting techniques
• Use of assistive devices and equipment for lifting and moving patients
• Elimination or reduction of hazards that may increase the risk of injury.

     Modification of work practices starts with EMS providers documenting and observing the types of lifts and other moves that increase the risk of back injury. For example, analysis of incidents showed a trend of injuries occurring for patients over 300 pounds. Therefore, the EMS service instituted a policy for two crews to respond to transfers of patients known to weigh more than 300 pounds. What patient lifting and moving work practices can be modified at your work sites?

     EMS providers have algorithms or treatment protocols for nearly everything. Does your service have algorithms for lifting and moving patients? Consider the sample algorithm in Figure 1 for lateral transfer of a patient from a bed to a cot.

     When available, use one of the many assistive devices like the Hoyer lift we used for Glenda to transfer and move patients. There is an increasing number of assistive devices and equipment to help EMS providers lift and move patients. For example, slider boards often seen in hospital and long-term care facilities are now available in a convenient size to be stored under the ambulance cot mattress. Slider boards are used for lateral transfer of the patient from bed to bed, bed to cot, or cot to bed.

     Hazard reduction is the process of removing hazards or obstacles that may increase the risk of or lead to a back injury. For example, we needed to lift Gordon out of his recliner and onto the ambulance cot. Before lifting him, we moved a table and lamp that were next to the chair and made sure there were no cords or rugs that we might trip on. Another hazard reduction is to park the ambulance on a firm, flat, dry, non-slip surface.

     We arrived to transfer Henry to another facility 20 minutes after he had fallen. Henry, an enormous man, was awake, lying supine on the floor of the hospital room and had no complaints. A gaggle of fretting nurses, aides and maintenance workers circled around him while my partner, Bill, a slight man at 5' 4? and 130 pounds, carefully analyzed the situation. Bill parted the crowd, leaned over Henry and asked, "Can you stand on your own?" "Sure, if you help me to a sitting position," Henry replied. Before lifting or moving any patient, determine what they can do on their own.

     The extent of injuries or illness, mechanism of injury, level of consciousness, strength and patient's ability to assist help determine the type of lift or move that is needed.

     First, have a reason to move a patient. Is an emergency move necessary? If it is not an emergent situation, wait for the proper equipment and personnel. For example, if the patient needs to be moved down a flight of stairs, wait for a stair chair.

     To reduce the risk of injury, whether lifting alone or with others, use proper body mechanics. Body mechanic principles include:

• Know your limitations
• Summon additional personnel
• Utilize equipment to make the job safer for you and the patient
• Keep the patient's weight close to your body and lift without twisting
• Stand with your feet shoulder width apart with knees flexed or bent
• If comfortable, place your dominant foot slightly forward
• During the lift, power up with your thighs
• Maintain normal back curvature during the lift
• Keep your stomach muscles tight.

     Follow local protocols for safe lifting techniques and posture. Seek out a physical or occupational therapist, industrial nurse or other specialist to deliver in-person, practical training.

     When lifting with the help of others, ensure one person is in charge and positioned at the patient's head. If you are in charge, clearly communicate with your lifting team what you want them to do.

     Small movements work best. Instead of lifting the patient from the toilet through the door and onto the cot in one motion, break the lift into several moves. First, assist the patient to a standing position. Second, rotate the patient toward the door. If possible, support the patient walking to the cot. Finally, assist the patient to a sitting position on the cot. Using small increments helps rescuers readjust their grip and body mechanics.

     Think ahead before moving. Where do you want this patient to end up and on what surface? If you have a possible spine-injured patient, making one move onto a backboard would be better than moving and lifting the patient several times.

     If time allows, explain the lifting and moving procedure to patients and tell them how they can assist. I often tell patients to relax, keep breathing during the lift, and hug their arms across their chest. A patient who reflexively twists or moves awkwardly during a lift puts me at greater risk of injury. Reassure them with your voice, a pat on the shoulder or a hand squeeze before, during and after a lift.

     One of the highest-risk moves for an EMS provider is lifting a loaded ambulance cot from the low to high position; therefore, know the weight limitations of the equipment. Most cots have a lower weight capacity in the raised position. Follow local protocols for lifting patients who exceed equipment weight limitations. Finally, it is best to lift with a partner or team of lifters of similar height and strength.

     To lift the cot, use a power-lift or squat-lift position that keeps your back locked into a normal curvature. During the lift, keep your feet flat and a comfortable distance apart, distribute your weight to the balls of your feet or just behind them, straddle the object, and stand as you lift, making sure you maintain normal back curvature and the upper body comes up before the hips.

     When lifting a cot, stretcher or backboard, make sure your palms and fingers come into complete contact with the object. As you prepare to lift, keep your elbows at your side or as close to your side as you can, and maintain a neutral wrist position. Oftentimes, the direction of our palms—up, down or side-facing—during a lift is dictated by the object we are lifting and the task we need to perform. When you have a choice, like when lifting a patient cot, face your palm up as you wrap your fingers around the cot handles.

     If you need to carry a patient on stairs, it is best to use a stair chair instead of a stretcher. During the lift and carry, keep your back in its normal curved position. As you navigate the stairs, up or down, flex at your hips, not the waist, and bend at the knees. Advise the patient to keep his arms in, folded across his chest.

     On many occasions, an EMS provider has to reach for equipment in a cabinet, across a bed to care for a patient, or across the ambulance to adjust lighting or temperature. When reaching, follow these guidelines:

• Keep your back in a normal curved position
• Avoid extending your back while reaching overhead
• Avoid reaching with a fully extended or locked elbow, maintain slight elbow flexion while you reach
• Avoid twisting your back while reaching
• Avoid situations where prolonged reaching (more than a minute) is necessary.

     Whenever possible, transport patients on devices that can be rolled instead of carrying or dragging them. It is better to push a cot than pull it. While pushing the cot:

• Keep your back in a normal curved position
• Keep the line of push through center of your body by bending your knees
• Keep weight close to your body
• Push from the area between the waist and shoulder
• If weight is below waist level, use squatting position
• Avoid pushing or pulling from an overhead position, if possible
• Keep elbows bent and close to the sides, or bend knees to keep natural curves in back.

     Practicing with the people and equipment in your system is critical to safe and efficient lifting and moving. Practice moving patients in the positions and situations that you encounter frequently. Practice and communication systems will help you make safe lifts with patients in common and uncommon situations.

Why You Need a Back Injury Reduction Program
     As statistics and research demonstrate, lifting is a high-risk activity for injury for EMS workers.

     Employers and employees should work together to protect workers from lifting-associated back injuries. Learning about back injury occurrence and prevention is just one component of an effective back injury reduction program.

     Other components include:

• Management support
• Employee involvement
• Problem identification
• Implementing solutions
• Injury reporting
• Initial and ongoing training
• Program evaluation.

     Potential benefits of a workplace back-injury prevention program include:

• Reduction in work-related back injuries and associated workers' compensation costs
• Reduced staff turnover and associated training and administrative costs
• Reduced absenteeism
• Increased productivity
• Improved employee morale
• Increased patient satisfaction.²

IF YOU ARE INJURED...
     If you do injure your back on the job, report it to your supervisor as soon as possible to initiate early evaluation and documentation of the injury. Early diagnosis and intervention, including alternative-duty programs, may limit the severity of injury, improve the effectiveness of treatment, minimize the likelihood of disability or permanent damage, and reduce the amount of associated workers' compensation claims and costs.²

     Injury reporting helps employers identify problem areas and evaluate back injury reduction program effectiveness. Remember, employees may not be discriminated against for reporting a work-related injury or illness.²

CONCLUSION
     Back injury is a leading cause of pain, disability and lost productivity. The length of your EMS career is heavily dependent on your ability to care for your own body, especially your back. Proactively maintain your health and fitness, identify and mitigate lifting hazards, and use appropriate lifting skills to minimize the risk of injury.

References

1. National Association of Emergency Medical Technicians. Four in Five EMS Workers Injured on the Job. 2006. www.naemt.org/forTheMedia/HarrisSurvey05.htm.
2. Davis PM, et al. Preventing disability from occupational musculoskeletal injuries in an urban, acute and tertiary care hospital: Results from a prevention and early active return-to-work safely program. J Occup Environ Med 46:1253–1262, 2004.
3. Crill MT, Hostler D. Back strength and flexibility of EMS providers in practicing prehospital providers. J Occup Rehab 15:105—111, 2005.
4. OSHA. OSHA Technical Manual. Osha.gov. 20 January 1999. OSHA Technical Manual. www.osha.gov/dts/osta/otm/otm_vii/otm_vii_1.html.
5. Mitterer D. Back injuries in EMS. Emerg Med Serv 28(3):41, 1999.
6. Fraser WR. Back Pain Overview. www.emedicinehealth.com/articles/4563-1.asp#.
7. Bledsoe BE, et al. Essentials of Paramedic Care. Brady/Prentice Hall Health: Upper Saddle River, NJ, 2003.
8. Lex R. Sciatica. www.emedicinehealth.com/articles/5626-1.asp#.
9. Deveraux MW. Low Back Pain. Primary Care Clinics in Office Practice 31: 33–51, 2004.
10. Perina D. Back Pain, Mechanical. www.emedicine.com/emerg/topic50.htm.
11. OSHA. "Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders". Osha.gov. 12 September 2005. Safety and Health Topics: Ergonomics: Guidelines for Nursing Homes. 20 January 2006. www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html.
12. Scott AS, et al. Functional Anatomy for Emergency Medical Services. Delmar Thomson Learning: Clifton Park, New York, 2002.

Greg Friese, MS, NREMT-P, is president of Emergency Preparedness Systems LLC, which helps clients rapidly deploy emergency education. Greg and EPS associates have authored and edited dozens of online education programs for first responders, EMTs and paramedics that are available at RapidCE.com. Friese is a paramedic, Wilderness Medical Associates lead instructor and EMS author. Contact him at gfriese@eps411.com.

Keith Owsley, MS, ATC, LAT, CSCS, EMT-P, is a career firefighter/paramedic working in southeast Wisconsin. He is also a nationally certified athletic trainer and president/CEO of MedEvent, Inc., which coordinates and provides medical staffing for sporting events and special events throughout the U.S. and internationally.

The authors appreciate the thoughtful review and comments they received from Deb Van Den Elzen, Occupational Therapist, SAINTS Health Services for Business, Stevens Point, WI.