A culture of safety is a big thing for all first responders; in fact, it’s everything. As we all know, when exposure to risk is mitigated, life is easier for everyone. But-and there’s always a but-what do we do when a safety culture is broken? Even worse, what do we do when injury, pain and disability are shrugged off, as is common in many public safety departments, as just being part of the job?
Injury, disability and even death are risks that every first responder accepts when entering the profession. Back injuries alone account for more than 20% of all workplace injuries in the United States and are a particular problem in EMS and firefighting, where at any given time nearly 10% of the workforce is out of work from injury.1
The Centers for Disease Control and Prevention (CDC) monitors first responder injuries. In 2011, more than 27,000 EMS providers/firefighters experienced on-the-job injuries and illnesses, and more than 21% of those injuries were to the lower back.2
Data from the International Association of Fire Fighters shows that nearly 50% of early retirements are due to lower back injury.3 These injuries incur extreme costs, making staffing and budgeting challenging.
Interestingly, EMS has some of the best patient handling technology ever available to the industry, including power stretchers, loading systems, lifts, slides, etc.-yet injuries continue to increase in frequency.
Back pain is difficult for the injured provider to cope with as it affects every aspect of life. They’re in pain, at home or on light duty, and in many cases bringing home only two-thirds of their normal paycheck, creating both physical and financial hardships.
On the employer’s side, there are workers’ compensation payments and open positions that must be backfilled with other staff, possibly in the form of forced overtime. Overtime shifts aren’t only expensive, they also drive up provider fatigue, increasing healthy staff members’ risk of injury. Coupled with the fact that many providers have second EMS jobs, the injury risk increases even more.
There are a number of devices available that can change the lift height
and allow multiple responders to get their hands
on the patient. Photo courtesy Bryan Fass
Injury Factors & Forces
More than half (62%) of all prehospital provider back injuries result from lifting patients.4 Injuries are a consequence of three major factors: significant lifting forces (i.e., patient weight), repetitive movements and awkward positions. Prehospital back injury statistics haven’t changed significantly in the past decade, despite the introduction of many safe lifting devices like automatic-lift stretchers, slide boards, slide sheets and bariatric equipment.
In the prehospital and firefighting environments, ground responders must deal with three forces that affect the spine and can lead to injury: compression, shear and torque.
Compression forces push down on or squeeze the spine parallel to the spine’s axis. The intervertebral disks help us withstand compression forces.
Forces that impact the spine perpendicular to the axis are considered shear forces. Leaning over to the side by dropping one shoulder lower than the other and picking up a heavy pack is an example of a shear force. Shear forces also occur when you bend at the waist to pick up an object. The more round your back is when bending or the farther you reach away from your body, the higher the shear force.
Rotational forces are referred to as torque. Torque is calculated by multiplying force times distance, where distance is the space between the spine and the weighted object in motion. Significant torque forces can cause ligament and disk injuries as compression occurs unevenly; they can also occur when heavy objects are lifted with one arm.
To help protect workers, the National Institute for Occupational Safety and Health (NIOSH) established safe lifting limits for healthcare providers. The load limit set for single-person lifting is 51 lbs. and a spine compression force of 764 lbs.5
Using a soft stretcher will reduce both friction and trunk flexion angle
when transferring a patient from bed to cot. Photo courtesy Bryan Fass
Unfortunately for prehospital providers, many routine lifts far exceed the recommended compression limits. For example, pulling a 105-lb. patient via bedsheet between two beds applies between 832-1,708 lbs. of compressive force.
I can’t recall the last time I transferred a patient weighing less than 200 lbs. As obesity has increased, so has the occupational load that first responders must deal with.5
Interestingly, the bed-to-bed drag is a major cause of injury and it’s one of the few things we can control in the field. Using a bedsheet drag violates two of the three injury prevention principles that we champion. It increases friction and increases trunk angle (i.e., how much you have to lean forward), which creates a shearing force placed on the spine, neck and shoulders, thereby causing injury.
If “sheet drags are the way we’ve always done it” is a standard operating procedure, then your organization hasn’t invested in your career longevity.
Add to all of this compression, shear and torque, the fact that EMS and fire are two of the few professions left where it’s considered a normal (i.e., required) job task to pick up catastrophically heavy loads off the floor every day. This is akin to deadlifting 300 lbs. from the floor with the load shifting as you lift it. After it’s lifted, it must then be maneuvered down a hallway, downstairs and then onto the stretcher.
No other profession allows such injurious loads to be picked up from such a low position (i.e., hands on the floor), and that’s with the assumption that the patient isn’t wet and in a bathtub, which exponentially increases the shear, torque and compressive forces in the spine.
Almost all the responders I train across the country have deeply seated biomechanical patterns that inhibit deep, safe lifting. I teach hundreds of classes per year and less than 10% of our first responders can work safely from the floor. Of course, the easy answer is to not lift from the floor. There are techniques that can alter lift height and make it safer, but in extreme cases patients have to be lifted and no tool can help in all situations.
What we’ve learned, and what the data shows, is that most responders have similar patterns that can often be tied back to the job task. On top of that, many responders possess patterns that are both repetitive and static/chronic. Soft tissue traumas occur in the public sector from three major causes.
1. Overexertion trauma. Overexertion injury occurs when the external force that’s encountered produces torques and compressive loads that the tissue is unable to handle. When the soft tissue failure tolerance is met, the tissue can fail outright (i.e., injury) or sustain microtraumas that will weaken the tissue causing it to fail later. This is often manifested when a responder has to pick up a patient from a bathtub to move them into a hall where medical treatment can begin. The poor working environment and the weight of the patient causes the tissue to sustain forces that it cannot dissipate and the tissue fails as a result.
2. Repetitive motion disorder. Repetitive movements will ultimately lead to tissue failure from countless repetitions of faulty and dangerous movements.
A common pattern we see is how responders enter and exit their vehicles. Years of rapid entry and exit-often weighted down with gear or simply poor mechanics-will fatigue the tissue to the point of failure.
We see the same effect from faulty lifting. In EMS, we often see repetitive rotator cuff strain after lifting the 40-lb. ECG monitor from the floor toward the cot in a swinging motion. The repetitive traumas of the job add up over time.
3. Prolonged static positioning. As children, we went to school and sat at little tables, hunched forward. As adults, we essentially do the same thing except now it’s hunched over a computer, phone or a steering wheel. Repetitive static postures like sitting, standing and desk work will “program” the body over time to believe the faulty postures to be normal. It’s not normal to have a forward head posture and a rounded back!
First responders often display tightness in the calf, foot and ankle, from standing on concrete floors, hours spent in duty boots, training and working in boots and gear, and hours of climbing in and out of trucks and up and down stairs. We also see that the way first responders enter and exit their apparatus affects the foot and ankle. We know that when the ankle joint is tight and/or restricted, the ability to squat or climb steps is altered, causing both knee and back pain.4
So how do we fix it? First and foremost, as a profession we must stop thinking of the first responder as the ultimate multi-tool and lifting device. Yes, you can get away with doing it all for a while, but eventually the loads, positions, extreme trunk angles and chronic fatigue will break your tissue down and injury will occur. Repeat after me: “Use a tool; don’t be the tool.” When we do root cause analysis of why most injuries in the field occur, they almost always occur from doing a seemingly normal task.
1. Change the lift height.
Instilled in every first responder is a duty to act, serve and help. The consequence is that we often use ourselves as the tool to get the job done, in order to serve and be a strong, caring patient advocate. So, we end up picking up the patient or the gear in awkward positions or from a height that’s below the knees.
Instead, use a commercially made device to change the lift height and allow multiple responders to get their hands on the patient. Devices like the Titan from Taylor Medical, the MegaMover from Graham Medical, the HILT Human Injury Limiting Tool or the Binder Lift allow the lift height to change from floor to knee height. They also reduce friction and trunk angle when transferring a patient from stretcher to hospital bed.
2. Reduce friction.
Friction can be a big deal, especially when tasked with transferring a 500-plus-lb. patient from bed to bed or a patient of normal weight from an air mattress to the cot. Common techniques include moving the patient on a bedsheet or blanket, which will add resistance to the transfer due to the coefficient of friction. Add to this the extreme trunk flexion angle that must be achieved to lean over the bed to grasp the sheet, and that some responders will have to either stand on or kneel on the bed, and we have the trifecta for spinal disaster: shear, compression and torque.
Simply using a soft stretcher as mentioned above will both eliminate the friction issue while reducing the trunk flexion angle. These devices have built-in handles and are made of high-strength materials that also reduce friction. Plus, the lift height is more like that of a dead lift with greater hip involvement and less lumbar spine load.
3. Master the hip hinge and reduce trunk angle.
Perspective is an interesting thing. As a paramedic, athletic trainer and a certified strength and conditioning specialist, I’ve noted that very few responders possess the ability to use a good hip hinge to spare the spine and reduce compressive and shear forces. This is from poor hip mobility and a lack of coaching/awareness on the importance of the hip hinge.
A very common pattern prevalent in all first responders is that the hip flexors become very short and tight. As they tighten they cause an anterior pelvic rotation that inhibits the abdominal wall (i.e., the guts and butts posture). As the abdominal wall weakens, the spine takes additional loads. This results in the glutes become tight and weak and the hamstrings tighten in an attempt to pull the pelvis back into place.6 As this pattern becomes more and more severe (i.e., lower crossed syndrome), the EMT loses the ability to lift properly.
Despite training first responders to lift with their legs, hip flexor tightness and gluteal weakness results in an inability to do so, forcing them to use the back as a lifting device and not the hips.
As a first responder, you need to understand some truths. First, dangerous lifting techniques are handed down from generation to generation; we need to break this cycle. Next, safe patient and equipment handling must be constantly trained and retrained-it’s too easy to fall back into old habits. We must teach proper mobility allowing us to be fit for duty: “You have to move well before you can move objects well.” EMS and fire departments must also conduct an annual physical abilities test to ensure providers maintain fit for duty status. Finally, there must be a blend of engineered solutions and awesome ergonomics.
It amazes me how many departments invest in new tools and technology, like powered cots or lift devices, yet injury rates still rise due to poor training and a misunderstanding that most provider injuries come from moving the patient on and off of the cot.
1. Studnek JR, Ferketich A, Crawford JM. On the job illness and injury resulting in lost work time among a national cohort of emergency medical services professionals. Am J Ind Med. 2007;50(12):921-931.
2. Centers for Disease Control and Prevention. (June 21, 2013.) Emergency medical services workers injury and illness data, 2011. Retrieved Aug. 5, 2017, from www.cdc.gov/niosh/topics/ems/data2011.html.
3. Death and injury survey. (2000.) International Association of Fire Fighters. Retrieved Aug. 5, 2017, from www.iaff.org/hs/PDF/2000%20D&I.pdf.
4. Hogya PT, Ellis L. Evaluation of the injury profile of personnel in a busy urban EMS system. Am J Emerg Med. 1990;8(4):308-311.
5. Kincl L, Hess J, Hecker S. (n.d.) Firefighter and emergency medical services ergonomics curriculum. Oregon OSHA. Retrieved Aug. 5, 2017, from http://osha.oregon.gov/OSHAGrants/ff_ergo/index.html.
6. Janda’s crossed syndromes. (n.d.) The Janda approach. Retrieved Aug. 5, 2017, from