Just Say No

Attack One responds to a call for person who can’t breathe. The patient is a middle-aged woman having an asthma attack in her room on the second floor of her apartment. The crew starts her on a nebulizer treatment and begins moving her down the steps. Suddenly the patient sneezes, and as she does her weight shifts on the stretcher. The EMT at the foot of the stretcher immediately screams, and the rest of the crew scrambles to hold the stretcher steady as he loses his balance and falls to his knees. His colleagues move quickly to ensure stability of the patient on the stretcher and continue her nebulizer treatment, but the EMT, in obvious distress, can’t move out of the way on the steps.

The Attack One crew chief quickly decides to move the patient on her stretcher back up the steps, let her continue her treatment, and have the injured EMT evaluated and moved off the steps. The EMT is 42 years old and in good health, with no history of back problems. He complains of severe pain in his lower back, saying he “felt something tear” in his left lower back as the stretcher shifted. He says his entire lower back feels like it’s in spasm, and he doesn’t want to try to move, lest it get worse. He has no numbness in his legs, no abdominal pain and no other injury.

The crew chief calls for another ambulance and directs the first crew to continue care of the woman with asthma. She is upset that her movement caused injury to the EMT, and that’s worsening her shortness of breath. The crew chief reassures her that the EMT will be OK, and that she had no control over what happened. He asks if she will concentrate on her treatment, and assures her the rest of the team will take good care of the injured rescuer.

The crew finds a backboard and tries to get it under the injured EMT, but it seems like every movement causes him discomfort and spasming in his back. Finally they find a way to get him on the board, and then gently move him down the steps to a room on the first floor. There he asks if they will return to caring for the original patient, since he’s more concerned about her welfare than his injury.

The original patient is much improved after completing her nebulizer treatment, and she’s safely moved down the steps, where she gives her best wishes to the EMS and apologizes for hurting him. The remaining crew members then take her on to the ambulance and hospital. The second crew finishes evaluation of the injured EMT. He is in pain even at rest, and any movement makes his pain much worse. He has intact distal movement and sensation in his legs, and has not lost control of his bowels or bladder. He is very tender in his left lower back area. His position of greatest comfort is rolled slightly to the left side, so they prop him up with some rolled towels.

Fearing the movement of transport could worsen the EMT’s already-significant discomfort, the paramedic suggests giving him a shot of pain medication. But the EMT quickly refuses. “I know the policy, and I’ll need to have a drug screen at the hospital,” he says. “If you give me pain medicine, it will show up on the test, and I’ll never be able to get it explained. I’ve seen it happen to EMTs in other departments, and they lost their jobs. I can’t afford to lose my job or even have to take time off, so do not give me any medicine.”

The paramedic tries multiple times to explain the need for pain medicine, and that they will complete the paperwork to document the need for giving the narcotic, but the EMT won’t budge. He remains terrified that any medicine showing up on a drug screen will lead to suspension and loss of his job. An EMS supervisor who arrives at the scene also tries to get the EMT to accept medication, confirming that he will document the need for it, but there is no changing the patient’s mind. Consequently it’s very difficult to move him into the ambulance, and he remains in severe pain en route to the hospital.

Emergency Department Management

The ED nurses and physician are prepared for the EMT’s arrival. They first advise him that the original patient is much better and now receiving her second nebulizer treatment. Then they perform a rapid and thorough evaluation, and also suggest pain medication. When the EMT reiterates his concerns, the physician suggests they immediately collect and process the EMT’s urine and blood drug screen, then he can get the relief he needs. There is no delay in collecting the specimens, after which the patient has an intravenous line started and receives several medications to control his pain.

He is admitted for a short observation period, but at the time of release still has some slight discomfort. He is scheduled for follow-up with an orthopedic specialist, who will work with an occupational medicine specialist to help him get back to work. The EMT needs several weeks of therapy before can move easily or do any type of lifting. He is released back to full duty about a month after his injury. His drug screen is negative.

Case Discussion

EMS providers are at risk of a number of work-related injuries and illnesses. Back injuries are common in our line of work, and can cause long-term disability. Many departments now train members on back-injury prevention, but as EMS equipment gets heavier, and many patients do the same, the risk is ever present. Good work processes are very important; particularly in lifting on uneven surfaces, there should be adequate personnel to prevent injury to the patient and rescuers.

Many occupations now have mandatory drug screening following work injury. Injured workers in companies that utilize drug screens often have great concerns about taking any medication. They fear a positive test result could mean the loss of their job and the opportunity for further work in the industry. There is often a “street story” about an individual in a nearby company who lost their job and future employment because of a drug test result.

EMS personnel need to recognize that concern and be able to explain the need for any medication given to a patient. EMS personnel are not expected to know the specifics about drug screening, and even ED staffs have to request assistance in giving the tests to workers.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. He is also a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.