# Patient movement



## PeteBlair (Sep 14, 2008)

My question is this: "how would you move the following patient to the gurney?"  Here's the situation.

Female age 90 steps out of a door into an ally way.  A sizable gust of wind knocks her off her feet.  She is found on the sidewalk, on her left side, with her back firmly up against the wall.  Her left forearm is broken near the wrist and she has severe left hip pain.  (It was determined later that the hip was indeed broken.)

What equipment might you use to move her and how would you go about it?


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## KEVD18 (Sep 14, 2008)

heres the problem: the textbook/protocols cant possibly cover all possible circumstances. sometimes we have to use our best judgement and do the best we can.

to give you a really good play by play, id actually have to be there. i struggle with improvising in a theoretical environment. but anything is worth a shot

if they are pinned right up against the wall, you're not going to get out of this one without "excessive movement". the key would be to plan your movement so as to be effective across more than one axis. what i mean is, move in more than one direction. a simple solution could be to simply pick the woman up(at 90, she probably weighs about 13lbs) and place on a board. use one person to stabilize the legs. one for the noggin. two for the torso and abdomen. up, over and down. 

conversely, if they are perfectly squared against the wall meaning lying completely on their side, you could interpose a backboard between the patient and the wall. its doubtful you could adequately secure it in that position, but it would allow you to rotate 90 around the horizontal plane against _some_ stabilization.

its an odd presentation, true enough. it would be nice if there was a textbook answer for every problem. but alas that will never happen so we are required to think it through and improvise.


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## medicdan (Sep 14, 2008)

I'll mirror Kev here-- without being there, I can only see the scenario one way. As well, the EMTs all at the same scene will may do five completely different things- and none of them will be bad for the patient. Different people see the same situation differently and act differently. I dont want to "armchair medic"...

With all of that said, I am going to invoke some of my WEMT knowledge. Try to enlist several pairs of hands-- 3-4 people if possible. Each person takes a part of the body, and using clothing "beam" the pt away from the wall-- essentially, hold the patient in the same position you find them, and move them to a more convient location. 

With obstructions taken care of, consiter moving the patient "towards a position of function"-- never away. That is, for example, when shifting a patient on a board, shift in a "V" pattern rather then sideways. 

My last advice is to use "accessories". See if fitting a KED on the patient will help. If the KED doesnt work for it's labeled use, its also excellent for stabilizing a possibly fractured hip/pelvis. I wish I had a picture of it in this use, but essentially you put it upside down on a long board (with the head section where the patient's thigh would be), and the torso section where the hips are. You then secure the torso straps over the hip and the head section over the femur of the effected side.

Good Luck with the scenario, I look forward to reading more responses.

DES


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## PeteBlair (Sep 14, 2008)

This gal weighed around 130 - 140.  With the up over and down move would you be concerned about setting her down on that broken hip?  (Untill we actually had her on the gurney, we could not tell whether the hip was broken or not.)


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## PeteBlair (Sep 14, 2008)

Would you give any thought to moving her away from the wall with four sets of hands, rolling her to her back, and then using a scoop?   (Four sets would be hard to do since there are only three of us on the bus.)  Also, when suspecting a hip fracture such as this one, would you try to to support that part of the body with your hand directly under the hip, just above the hip, or just below the hip.  Remember this gal is on her side with the injured hip down.


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## KEVD18 (Sep 14, 2008)

PeteBlair said:


> Would you give any thought to moving her away from the wall with four sets of hands, rolling her to her back, and then using a scoop?   (Four sets would be hard to do since there are only three of us on the bus.)  Also, when suspecting a hip fracture such as this one, would you try to to support that part of the body with your hand directly under the hip, just above the hip, or just below the hip.  Remember this gal is on her side with the injured hip down.



again, why three seperate actions? if you're going to move her away from the wall, why not land at your end game and eliminate the middle man. to move her away from the wall, you're going to have to pick her up. cant drag her around with the injuries reported. if shes already in the air, why put her down, then roll her, then scoop? up, over, down onto the lsb. multiple people, mucho support, minimal movement possible.


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## PeteBlair (Sep 14, 2008)

referring to your last post, would your intent be to place her on the LSB (or gurney) on her side or her back?


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## KEVD18 (Sep 14, 2008)

yeah, they bought a board. you didnt mention anything about cervical involvement, but thats irrelevant. this patient definatley needs to be boarded. so of course that means supine, not lateral recumbant.


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## Epi-do (Sep 14, 2008)

KEVD18 said:


> this patient definatley needs to be boarded



Ok, maybe I am just not getting something since I am currently exhausted, but why does she definately need to be boarded?  Granted, I would consider boarding her, but I don't think it is necesarily a given.  I think it would all depend upon how she landed and if she hit anything else as she was falling.  

She is 90, so she is going to break more easily than a younger person.  Along with that, given the fact that she has less muscle mass, less body fat, etc, etc, why put her on a hard board if you don't have to do so?

If circumstances allowed me to be able to clear her c-spine and avoid the backboard, why not put a folded sheet across the cot in the hip area to tie around the pelvis/hips once the patient is on the cot and then simply pick her up by lifting underneath her arms and knees.  Have a third person support her hips, and put her on the cot.  If she is in alot of pain, premedicate her prior to moving her.  Here we are able to give fentanyl intranasally, so it isn't necesary to start an IV prior to moving her.  (I am not saying that she may not ultimately need an IV, she just doesn't need one for me to administer pain meds prior to moving her.)

I am not against putting a patient on a backboard when they truly need it, but I just am not convinced that this patient fits that description based upon the information the OP provided.


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## AnthonyM83 (Sep 14, 2008)

Wouldn't there be a highish index of suspicion for spinal fracture based on age / brittle bones and possible hip fracture? Would the hip pain be a distracting injury masking back pain?


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## KEVD18 (Sep 14, 2008)

you're assuming i meant boarded in the sense of cervical spine precautions. while that wouldnt be a bad idea give the patients age and moi, thats not precisely what i meant.

the presentation is consistent with a hip fx. this needs to be stabilized. now, some places carry fancy pieces of kit for this. ive never had the luxury. all ive ever had at my disposal is a board, and i suppose the ked as well. but every suspected hip fx that i can remember off the top of my head has been boarded. maybe not collared and blocked and what not, but secured to a long board to stabilize the fracture.


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## Epi-do (Sep 14, 2008)

Thanks for clarifying for me KEV, like I said, I am pretty exhausted right now so I am not thinking as well as I normally do.


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## KEVD18 (Sep 14, 2008)

no problem. im currently fighting of my first round of either bronchitis or pneumonia of the year so i had to re-read my posts to make sure _i'm_ making sense.


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## mycrofft (Sep 14, 2008)

*Do we have ANY tools at our discretion, or are any banned?*

If I were near a hardware store I'd get a small blue tarp, insinuate the slippery thing between her and the wall and then between her and the ground. Maybe some Armorall on it. Then you have your choice of things to slide under or behind her since the clothing and boney projection-drag issues are mooted. Lifting with it alone would be uneven, but if enough do it at once, and only as needed (a couple inches up?) you could get her onto a board, the cot mattress on the ground, etc. As a side benefit, it would block the presumably continuing wind. Then you slip it out from under her.
There's no way to do this like magic if she is "firmly" wedged.
PS: Long ago some services would transport patients as they lay as long as intubation was not needed. Hmmm. Especially considerong a number of cases where the pt was ticking right along, then went to hades the second they were make supine.


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## JPINFV (Sep 15, 2008)

The first thing I'd do would be to have someone (really anyone, it can be done while preparing for the move) splint her forearm [assuming no providers on scene have the ability to premedicate]. The next goal would be to see if there was any way, even if it required minor movement, to get a sheet under the hip. Get a sheet under her hip and tie it off. What this does is provide some splinting for the hip and allow the hip to be moved and supported as a unit by having providers lift using the sheet in addition to the legs and trunk. Since the hip can be supported in any lift as an independent unit, the pain associated with lifts should be greatly decreased. From there, move the paitent onto a flat/breakaway which can then be transfered to the cot. The breakaway would also make transfer at the hospital easier.


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## PeteBlair (Sep 15, 2008)

As it turns out, I did not suspect spine trauma and did not backboard. 

From my perspective, pain medication was not an option because I am 
BLS.  ALS was on scene (They called us, but the patient was within 150 yards of our building so we got there first).  The pain level was not high enough for them to initiate pain control.  They put the patient on our gurney, but not as gently as I would have liked to have seen done.


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## BossyCow (Sep 15, 2008)

I agree with JP. Use either a sheet or the new SAM stabilizer to stabilize the hip. Splint the arm. Then I would go for our soft stretcher. We use this a lot on our little old ladies. Since they generally weigh next to nothing. Used correctly the pt is moved in a seated position with 2 to 4 people doing the lifting depending on the weight of the pt and the room around her. I would be concerned about using a KED with the crotch straps with a possible hip fx. I  think that would be extremely painful on the hips. We can generally work the soft stretcher under the pt with minimal movement, it acts like a big sling and allows for fairly rapid, smooth transport to the gurney, especially if the suspected fxs have been splinted or stabilized first.


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## PeteBlair (Sep 15, 2008)

JPINFV, I just read your post and I like what you said.  In this particular case, it would have been a struggle to get that sheet under her left hip because her back was "tight" against a wall.  

In any event, you all have given me a few ideas on how to approach this type of situation.  I live in a zip code area where the average is 75 so I have no doubt that I'll see a lot more broken hips than most other EMT-Bs will see.

Thanks to all!

In your post you mentioned a "flat break-away."  Is that another term for a scoop stretcher?


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## PeteBlair (Sep 15, 2008)

I'm not familiar with "soft stretcher," at least not by that name.  Is there some place (URL) where you could direct me to a picture of it?

Thanks,


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## BossyCow (Sep 15, 2008)

PeteBlair said:


> I'm not familiar with "soft stretcher," at least not by that name.  Is there some place (URL) where you could direct me to a picture of it?
> 
> Thanks,



Here ya go... http://www.drmass.com/rescue-soft-stretcher.html


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## JPINFV (Sep 15, 2008)

PeteBlair said:


> In your post you mentioned a "flat break-away."  Is that another term for a scoop stretcher?








I used flat/breakaway because I've heard it referred to as both. It's set up so that you can place it on a gurney and there are lockable joints in the middle that allows the patient to be put in a sitting position when on the gurney. A big advantage when using them (same advantage as a scoop, though) is that you can remove the plastic strip holding it together and then pull it apart to leave the patient on the hospital gurney.


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## KEVD18 (Sep 15, 2008)

PeteBlair said:


> The pain level was not high enough for them to initiate pain control.



i dont armchair quaterback other peoples treatment very often, but i take issue with this statement. the patient was in pain, therefore there was enough pain to manage it. plain and simple. they had the ability to make the patient more comfortable and they didnt. bad patient care in my book.

im willing to bet that they dont push narcs often because they are a pain. especially in system where the replacement of used narcs is complicated or time consuming. ive seen this before with two services ive worked for. one service had a cumbersome system for narc. when you used something, you had to do the paperwork, go to the pharmacy, draw your replacements and log them in. the medics at this company hardly ever used narcs, especially on the night shift when all that time could be spent sleeping. another service ive worked for had several full and tagged narc boxes in the safe in dispatch. if you broke a seal, you went to dispatch, turned in your used narcs kit and drew a fresh one. they also had one or two spares at some of the sub stations. the next day, one of the supers would round up all the opened kits, take them to the pharmacy and replenish them. with such an easy system, i saw much more agressive treatment.


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## flhtci01 (Sep 16, 2008)

I haven't seen the mention of a whole body vacuum splint.  I have used those with hip fractures and they seen to stabilize the hip rather well.  There is still the issue of movement to the splint.  Without actually seeing the pt,  location and manpower available it is hard to say which route to go.  With a goal of as little movement as possible, I would look at a possibly a lift of 4-5 inches and slide the splint under the pt and then lower the pt back down.  Again this would depend on a number of factors.


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## KEVD18 (Sep 16, 2008)

flhtci01 said:


> I haven't seen the mention of a whole body vacuum splint.  I have used those with hip fractures and they seen to stabilize the hip rather well.  There is still the issue of movement to the splint.  Without actually seeing the pt,  location and manpower available it is hard to say which route to go.  With a goal of as little movement as possible, I would look at a possibly a lift of 4-5 inches and slide the splint under the pt and then lower the pt back down.  Again this would depend on a number of factors.



toys are nice, but not everybody has them.


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## flhtci01 (Sep 16, 2008)

KEVD18 said:


> toys are nice, but not everybody has them.



Wouldn't call it a 'toy' but a piece of equipment to be considered.  Not every company I have worked/trained with have it but the ones that do have it, utilize it.


Don't get me wrong, there are plenty of 'toys' out there, I just don't think this is one of them.


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## KEVD18 (Sep 16, 2008)

sorry, but i call everything above the minimum standard equipment a toy.


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## Oregon (Sep 16, 2008)

As we don't have a full body vac. splint, and our high-angle neighbors do, I too call it a toy.
Useful for them, and probably pretty useful in this case (they do a spandy job of total immobilization.)


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## BossyCow (Sep 16, 2008)

I've used the vacu-splints and I like them in some applications, but in this scenario, with a seated pt who is in pain from a hip fx, I don't think it would be my method of choice. If the pt is lying down and can be rolled onto the splint with a minimum of jostling, then sure, but with a seated pt in the position described, the movement it would take to work the vacu-splint under her rear end would cause some major pt discomfort. Also, the vacu-splints have to have all the filling equally distributed around the affected area in order to stabilize the fx properly. Moving the big one around and scooting under a seated pt would cause the filling to shift big time. Toy or not, wouldn't be my first choice.


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## mycrofft (Sep 16, 2008)

*Military's had those a long time, only green.*

A body bag will do if you can tape the patient to it.
Not real good unless you have stretcher bars of some sort, because the sides tend to come together, no matter how hard you pull them apart. This might be uncomfortable for a fx pelvis, hip, shoulder etc.
Get the SKED.


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## EMT-P633 (Sep 16, 2008)

KEVD18 said:


> yeah, they bought a board. you didnt mention anything about cervical involvement, but thats irrelevant. this patient definatley needs to be boarded. so of course that means supine, not lateral recumbant.



I agree with ya 100%, but since this is all hypothetical and all. would you still imobilize her supine if she is suffering kyphosis? just food for thought...


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## flhtci01 (Sep 21, 2008)

BossyCow said:


> I've used the vacu-splints and I like them in some applications, but in this scenario, with a seated pt who is in pain from a hip fx, I don't think it would be my method of choice. If the pt is lying down and can be rolled onto the splint with a minimum of jostling, then sure, but with a seated pt in the position described, the movement it would take to work the vacu-splint under her rear end would cause some major pt discomfort. Also, the vacu-splints have to have all the filling equally distributed around the affected area in order to stabilize the fx properly. Moving the big one around and scooting under a seated pt would cause the filling to shift big time. Toy or not, wouldn't be my first choice.



Don't see where it is a seated pt.  "on her left side, with her back firmly up against the wall."


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## BossyCow (Sep 22, 2008)

flhtci01 said:


> Don't see where it is a seated pt.  "on her left side, with her back firmly up against the wall."



Okay, I read 'back against the wall' as seated.  But still, without a lot of room to maneuver the vacu splint under the pt, my course of action would be probably to use the sam stabilizer first, then use the soft stretcher to move to the gurney and possibly use the vac-u splint by laying it on the gurney and lifting the pt onto it instead of trying to move the splint under the pt. 

This would all depend of course on the pain level of the pt, how they tolerated movement and how many people I had handly to lift and tote.


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