There is a longstanding human tradition, both inside and outside the world of emergency medicine, of accepting dangerous behaviors simply because they are the established norm.

In October 2017, JEMS published the article “Lifting and Moving: A Fresh Perspective on Safely Handling Patients”.1 This article demonstrated that the rate of musculoskeletal injury associated with lifting and moving patients is extremely high among prehospital health care providers.

This is true despite the fact that OSHA has created standards dedicated to safe patient handling.17 The shortcomings of the presented curricula stem from the lack of direct application to prehospital providers, leading to unnecessarily high and unacceptable rates of provider injury.

It was understood from the inception of the automobile that car crashes kill and severely injure people. Yet it was not until 1966 that the National Traffic and Motor Vehicle Safety Act formally addressed the problem and identified the real causes of injury in motor vehicle accidents on a national level.Since then, safety requirements and seatbelt laws enacted by the federal government have drastically reduced injury and fatality rates on the road (9).

Inside the health care world, there are numerous related examples. For years it seemed it was accepted that there was a higher rate of disease transference between healthcare professionals and patients carrying blood borne pathogens. Only recently did the Occupational Safety and Health Administration (17) move to require all healthcare agencies to write, maintain, and enforce an exposure control plan (8), leading to quite positive results.

Emergency Medical Services (EMS) providers understand the vast differences that exist in lifting and moving patients between inpatient and out-of-hospital settings. Away from the hospital, EMS providers frequently encounter awkward positioning, hazardous materials, and limited equipment/personnel support.

An additional major stressor that cannot be overlooked is the criticality of the patient and the importance of rapid, safe extrication.

With these factors in mind, it is disappointing, and readily apparent, that much less effort has been put into standardizing guidelines for the ways EMS providers move patients.

The prior publication has provided a framework to work towards successful changes made in the hospital environment.1 The previous article has missed an important point: there must be clear identification and delegation of responsibility in the EMS system, in order to decrease the rate of injury among those called upon first to help the injured.

Whose Job Is It Now

The lack of proficiency in lifting and moving often seen in the field originates in EMS education. Ideally, changes to fix the disconnect in the certification processes should be made, however, these changes cannot happen overnight. Therefore, it is imperative that employers act now to initiate change company by company.

The time spent teaching patient movement practices during certification programs is limited. An informal poll of students in their senior year of earning a Bachelor of Science (BS) Undergraduate Degree in Emergency Medicine (EM) shows just one day of instruction specifically in lifting and moving patients was provided during their EMT class.

This represents approximately 3.6% of the entire curriculum, which consists of a minimum of 110 instructional hours.15 This percentage of time in an EMT-B course is insufficient to prepare providers for working in the field. It is crucial that a formal study be undertaken of this issue, seeking data from EMS systems across the nation.

As opportunities expand for practicing medicine in the prehospital setting and our certification programs become more condensed, the emphasis of EMS education has shifted away from something equally important as the most complicated biochemistry—safe, practiced, strong lifting and moving techniques.

As the system stands today, employers rely on educators to ensure safe lifting and moving techniques are learned prior to students entering the workforce. Meanwhile, employers assume new hires have already acquired such skills and knowledge during their certification process.

Complicating the problem, once hired at an EMS service, the level of orientation differs significantly from service to service. Due to the vast amount of information required to be covered in EMT, A-EMT, and Paramedic curricula, instructors struggle to appropriately cover all the information needed to assure minimal mastery of requisite skills.

With this in mind, individual services must take the initiative to orient their employees on their respective lifting and moving equipment. Each service is unique, and so it is the responsibility of each and every service to develop and implement a training program that thoroughly instructs new employees on the equipment and techniques they have at their disposal.

Curriculum Overview

When looking at the more recent national EMS curriculum in comparison to prior editions, “lifting and moving” appears to have gone by the wayside in EMS education over the years.

Consider the 1994 Emergency Medical Technician-Basic: National Standard Curriculum, a revision of the 1984 Emergency Medical Technician-Ambulance: National Standard Curriculum.

The curriculum includes thirteen detailed pages of learning objectives based on lifting mechanics, techniques, and devices for every clinical field situation one could imagine, with the word “lifting” appearing a total of sixty times.12

The equivalent document for EMR education from 1995 includes the same lifting and moving content in identical format.4

The equivalent document for Paramedic education from 1998, while formatted differently, also includes the same lifting and moving content.3 Next is the National EMS Core Content released in 2004, which compiles the core knowledge and skills expected of any level EMS provider in the prehospital setting.10 This document features a single line on the subject of “Lifting and moving techniques.”

Finally, consider the National EMS Education Standards, published in January 2009. This document outlines the minimal competencies expected of any entry-level pre-hospital provider from EMR to paramedic. It contains the word “lifting” a mere total of three times and mentions “emergency moves” just once under the “Clinical Behavior/Judgment” section for the EMR level only.11

There are examples the EMS community can draw upon to directly confront this challenge. The instructor’s guide for a Volunteer Firemen’s Insurance Services (VFIS) boasts an extensive lifting and moving curriculum including anatomy of appropriate body mechanics, indications and contraindications of extrication devices, accompanying video material, and even a written test.6 Detailed pictures and diagrams delineate each step, from communication to hand grip techniques, of successful, safe moves utilizing various equipment.

However, VFIS’s most significant strength lies in its interactive videos. The media content shows providers demonstrating both safe and inappropriate lifting techniques. 6

Any modern EMS certification course should mimic the positive utilization of media in the classroom to ensure a multi-faceted education. Furthermore, VFIS acknowledges the importance of cognitive knowledge as pertaining to lifting and moving, in addition to the psychomotor knowledge. 6

The current EMR, EMT and Paramedic National Education Standards Instructional Guidelines released in January 2009 all include the same comprehensive outline of important lifting and moving techniques to be taught by the instructor, while the AEMT Instructional Guidelines omit patient lifting and moving altogether.

Overall, the guidelines provided to the EMS educators are sufficiently detailed. The problem is the lack of a verification method to prove these topics were taught and taught effectively. There is no psychomotor testing station in the certification of any level prehospital provider in which they must demonstrate their proficiency in this knowledge and skill set (Figure 1).

Figure 1
Method for moving a patient via a rigid device
Above left: A common technique taught to move a patient via a rigid device to the stretcher places excessive forces on the spine.

Above right: simple solution is to
slide the head onto the stretcher first while the partner provides a still point. Note the lack of spinal flexion and rotation.

Photos from the warrior slide, Injury Free Online, courtesy the Fit Responder Safety Course

Motivations

It is not solely the new or inexperienced EMS provider who risks injury to themselves or patients. These injuries are occurring across the board to all providers. It is critical that there are long-term, system-wide changes that continue to ensure provider safety.

It is widely recognized there is limited time in an EMT program to address all the needs surrounding lifting and moving. It is of utmost importance that lab faculty members take the time to integrate the various methods of routine and emergency lifts and moves into their lab sessions. Some EMT instructors are more motivated than others to address the follow-through aspects of the various patient simulated events. This most certainly includes the process of lifting and moving patients. Unfortunately, what is often stated by EMS faculty members is it is the responsibility of the EMS service to assure the provider will be prepared to meet all the needs of the many patient events concerning lifting and moving.  This is a continuous struggle with students, instructional faculty members and EMS services.

For example, the reaction of an EMT instructor who took interest in the topic of lifting and moving. The instructor claimed he tried his best to adequately cover lifting and moving mechanics in his lab sessions because of his awareness that this is a common struggle with entry-level EMS employees.

He worked to incorporate the skills into lab sessions as the students’ progress; however, they were allotted only a brief time to cover each device used to move patients directly. He attempted to allow students to fully simulate scenarios using relevant equipment, but it was difficult to compensate for time lost assembling and breaking down equipment in each scenario.

Outright, the EMT instructor stated he would prefer having more time built into the schedule to focus directly on the mechanics of lifting and moving.7

Among EMT/Paramedic certification programs, a low attrition rate is very desirable. There is currently no test of proficiency in lifting and moving on the national registry exam at any level. It is currently acceptable for all lifting and moving actions to be can be voiced within scenarios.

This is an unintentional motivator to spend less time on lifting and moving and more on the aspects of medical decision making that are tested for certification.

In speaking with EMS providers from a variety of agencies in the greater Pittsburgh area, the majority stated they did not receive any lifting and moving training during their EMS curriculum, nor when they started working. It was simply assumed that these providers were proficient in appropriate body mechanics and equipment usage.

On the other hand, there were individuals who, upon employment, received thorough training on the operations of running a call, including lifting and moving.

Despite a difference in training methods, these employees all highlighted a similar point; someone from their company not only demonstrated operating the various pieces of equipment, but also oversaw them completing the operation before signing off their proficiency in the skill.

Paramedic students are required to complete a certain number of successful IVs and intubations. Similarly, this should be the case for all EMS providers concerning lifting and moving patients. In far too many cases of injury to either the patient or the provider, the mistake comes from an overestimation of abilities, or a lack of attention to detail that is required.

What We Need in the Future

EMS has a standard for providers who wish to drive an emergency vehicle such as an ambulance — EVOC certification. While an EVOC is not required to obtain a national EMT-B certification, most EMS services require their newly hired employees to be certified in either EVOC or an equivalent level of driver training.

A majority of pre-hospital providers would agree that an EMT’s ability to safely lift and move patients is equally important to, if not more important than, their ability to operate an ambulance.

For the future, it should be the responsibility of EMS leaders and employers on the regional, state, and even national stage, to develop, implement and enforce a certification that proves competency in lifting and moving techniques and protocols.

This certification would ensure the competence of entry-level providers who have minimal field experience to handle patients without adding the stress on instructors and the National Registry certification process.

The universal requirement of this certification by employers would benefit the provider, the company/agency they work for, and the patients they will encounter.

Similar to the American Heart Association CPR course, the lifting and moving certification process must include a written test paired with proficiency in psychomotor skills. Therefore, this certification process should ideally consist of 8 hours of hands-on, problem-based learning to help the provider excel in troubleshooting real-life patient extrication scenarios they may encounter working in the field.

By the end of the class, the student should be able to demonstrate for the instructor the appropriate body mechanics of the lifting and moving techniques discussed, as well as pass a multiple-choice test on when the use of each of these techniques and common lifting equipment is most appropriate (Figure 2).

Figure 2
Method for moving a patient via soft stretcher
Soft stretchers are not just for bariatric patients, they are for all patients. They allow you to slide, transfer and when configured properly turned into a rescue seat.

Source: Making the rescue seat, Injury free on-line. The Fit Responder course.

Upon demonstration of proficiency in these tasks, the student will receive their PMLC, or “Patient Lifting and Moving” certification (Figure 3). It is through continuing education and the recertification process that complacency and poor habits can be avoided.

Figure 3
Using sheets to move patient
Sheets are not an approved patient handling device. Use a device that reduces how far the provider leans, reduces friction and is weight rated.

Source: Bed to bed transfers, Injury free on-line. The Fit Responder course.

Conclusion

The majority of EMS providers can share stories, either their own or of coworkers’, concerning the tremendous fallout and risk that occurs when lifting and moving training is neglected. A new paramedic shared her story for this article, citing her preliminary experience with a stair chair involving a bariatric patient and a steep staircase. She found herself essentially immobile the next day, her physician prescribing strong muscle relaxants for her injured back and a note preventing her from working for the next three weeks. Such stories are much too commonplace in EMS–this can, and must, be changed.

Our recommendation is a two-tiered plan beginning with urging employers to take the initiative to ensure employees are proficient in their lifting and moving abilities. This plan extends further into the future by emphasizing the critical need for certification of lifting and moving skills, thus providing motivation for providers to engage with lifting and moving education.

EMS providers must learn and practice appropriate techniques to ensure lifting and moving safety for both themselves and their patients. By standardizing existing curricula into a teaching outline, a patient lifting and moving certification that all EMS employers require will bridge the gap between EMS education and workplace.

References

1. Eglitis, Niklavs, et al. “Lifting and Moving a Fresh Perspective on Safely Handling Patients.” Journal of Emergency Medical Services, Oct. 2017, pp. 40–46.

2. “EMERGENCY MEDICAL SERVICES WORKERS.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 6 Sept. 2016, www.cdc.gov/niosh/topics/ems/data.html.

3. “Emergency Medical Technician-Basic: National Standard Curriculum.” ems.gov, U.S. Dept. of Transportation, National Highway Traffic Safety Administration, 1994, www.ems.gov/pdf/education/Emergency-Medical-Technician/EMT_Basic_1996.pdf.

4.“EMT-Paramedic National Standard Curriculum.” ems.gov, U.S. Dept. of Transportation, National Highway Traffic Safety Administration, United States Department of Health and Human Services Maternal and Child Health Bureau 1998, https://www.ems.gov/pdf/education/Emergency-Medical-Technician-Paramedic/Paramedic_1998.pdf

5. “First Responder: National Standard Curriculum.” ems.gov, U.S. Dept. of Transportation, National Highway Traffic Safety Administration, United States Department of Health and Human Services Maternal and Child Health Bureau1995, https://www.ems.gov/pdf/education/First-Responder/FR_1995.pdf

6. Hendrickson, Kimberly A. “National Traffic and Motor Vehicle Safety Act.” Dictionary of American History, edited by Stanley I. Kutler, 3rd ed., vol. 5, Charles Scribner’s Sons, 2003, pp. 561-562. Gale Virtual Reference Library, http://link.galegroup.com/apps/doc/CX3401802875/GVRL?u=nm_p_elportal&sid=GVRL&xid=12aff58b.

7. Landolfi, Devin. Personal Interview. 19 March 2018.

8. Matin, Scott A. “When Lysol Isn’t Enough.” EMS WORLD, 3 Nov. 2010, www.emsworld.com/article/10319127/when-lysol-isnt-enough.

9. National Highway Traffic Safety Administration. Lives saved in 2015 by restraint use and minimum-drinking-age laws. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2016. Publication no. DOT-HS-812-319. Available at https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812319

10. Patient and Handling: Lifting and Moving Done Right!(2000). York, PA: VFIS.

11. “National EMS Core Content.” ems.gov, National Highway Traffic Safety Administration, 2004, www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-Approach/National_EMS_Core_Content.pdf.

12. “National Emergency Medical Services Education Standards.” ems.gov, NHTSA Office of EMS, Jan. 2009, www.ems.gov/pdf/National-EMS-Education-Standards-FINAL-Jan-2009.pdf.

13. “National EMS Education Standards: AEMT Instructional Guidelines.” Ems.gov, NHTSA Office of EMS, Jan. 2009, https://www.ems.gov/pdf/education/National-EMS-Education-Standards-and-Instructional-Guidelines/ADV_EMT_Instructional_Guidelines.pdf.

14. “National EMS Education Standards: EMR Instructional Guidelines.” Ems.gov, NHTSA Office of EMS, Jan. 2009, https://www.ems.gov/pdf/education/National-EMS-Education-Standards-and-Instructional-Guidelines/EMR_Instructional_Guidelines.pdf.

15. “National EMS Education Standards: EMT Instructional Guidelines.” Ems.gov, NHTSA Office of EMS, Jan. 2009, https://www.ems.gov/pdf/EMT_Instructional_Guidelines.pdf

16. “National EMS Education Standards: Paramedic Instructional Guidelines.” Ems.gov, NHTSA Office of EMS, Jan. 2009, www.ems.gov/pdf/education/National-EMS-Education-Standards-and-Instructional-Guidelines/Paramedic_Instructional_Guidelines.pdf.

17. “UNITED STATES DEPARTMENT OF LABOR.” Occupational Safety and Health Administration, www.osha.gov/SLTC/bloodbornepathogens/bloodborne_quickref.html.