When it comes to Lifting and Moving our main concern is to lift, move, and ultimately deliver the patient to a healthcare facility without causing any further harm to the patient, AND without injuring any of the providers involved.  It's a "common sense" operation.  In this section we will discuss the basics of lifting and moving a patient, and will review some extrication procedures.

Learning to move a patient without jeopardizing further injury requires a thorough understanding of any existing injury and what, if any, movement is allowable in the presence of that injury.  There will be times where the scene of this emergency will dictate that an urgent (immediate) move is necessary and, in such cases, it may be necessary to weigh the possibility of additional injury as a result of the move against the possibility of additional injury from the unstable scene.  If an urgent move is indicated every possible attempt must be employed to safeguard the patient, and again, a thorough understanding of any existing injury is a must. 

This tends to highlight the interaction of different skills learned during an EMT course.   In order to have an 'understanding' of the existing injuries, the provider must be able to perform a quick, thorough assessment of the scene, have a solid understanding of the possible injuries secondary to that scene assessment, be able to verify the presence (or absence) of the suspected injury by observing the patient, decide on a proper method for moving the patient, and ultimately be able to document the actions taken and justify them in a concise but complete written report.  So, the statement above about "common sense" is probably not so 'common' for the everyday man, but will become 'common' for the properly trained EMT.

More 'common' to the everyday man, are those techniques that we employ to protect the providers.  It's common knowledge that our legs are stronger than our backs, and with our backs properly positioned, that our arms are capable "lifting tools."  ALL lifting maneuvers MUST be started with a 'straight back,' and that 'straight back' posture MUST be maintained until the lift is completed.

When more than one person is involved in the lift, someone needs to coordinate the actions of the team.  That someone is usually the person closest to the patients head.  One person, "out of sync" with the rest of the team, can not only injure himself/herself, but may also cause the rest of the team to lose control of the patient and like a house of cards, the whole operation may come crashing back down to the ground.  This risks injury not only to the patient, but to the other providers as well.  The key here is good communication.  During your training, some of the suggestions that are made to help develop that communication skill, may seem foolish, but years of experience have gone into the training process and your instructors KNOW what they are doing.

When lifting a patient, the providers are encouraged to face each other.  For obvious reasons, this enhances the communication ability.

However, when moving a patient, providers are encouraged to face the direction of movement, whenever possible.  And, with rare exception, the patient will be moved 'feet first.'

The transition from one position to the next must be coordinated.  By that we mean that one person should be directing the movements of the others , NOT that all move at one time.

There may be times when "facing" the direction of movement is not a possibility.  Stairs are a perfect example.

In this case, it's advisable to have another member of the team "spot" the provider that is moving backwards.  Here, again, communication is the key.  The 'spotter' should advise the member of upcoming hazards, changes in terrain, the number of steps left to traverse, etc.

There are four basic tools used to move patients:

1. The Long Spine Board,

2. The Ambulance Cot,

3. The Stair Chair, and

4. The Scoop (Orthopedic) Stretcher

Some additional pieces of equipment include:

1. The Basket Stretcher,

2. The Flexible Stretcher,

3. The Short Spine Board (outdated,) and

4. The Kendrick's Extrication Device (KED)

When using these pieces of equipment, it is paramount that the patient be properly secured to the device prior to movement.  Demonstration of the proper technique for securing the patient to each device is best left to the classroom environment, where practice will perfect the procedure.

Once secured to the equipment, it's time to lift the patient.  It goes without saying that each 'piece' of equipment has hand-holds designed into it to properly lift the equipment with the patient 'aboard.'  With no intent to insult your intelligence, let's review some on the proper hand-hold positions.

If you are lifting the patient in a bed sheet, be certain to roll up the edges of the sheet creating a manageable grab handle.

When lifting an ambulance cot, be certain to grab the mainframe of the cot.  This is especially true for the provider at the 'head' of the cot, because there is a secondary frame at that end that is used to raise the patient into sitting (Fowlers) position.  Some cots also have a secondary frame at the 'foot' of the cot for establishing a Trendelenburg's  position.

Hand holds on long backboards offer locations from which the best control of the board can be achieved.

Enough of that...

We mentioned above that, with some rare exceptions, a patient is always moved feet first.  One of those exceptions is stairs.  When moving a patient down a flight of stairs, the patient is move feet first, but when taking a patient up a flight of stairs, the head is kept higher than the feet by moving the patient head first. You may encounter other situations where a "feet first" movement will orient the patient in a head down position, and under normal circumstances this is an uncomfortable, disquieting position for the patient.

Patient extricating is typically thought of as process of "removing a patient from a damaged automobile."  Although this is the scene where 90% of your extrication skills will be employed, we need to remind you that other situations exist which may require you to utilize the skills learned during this phase of your training, in order to assure that no further harm is done.

The basic concept in patient extrication is to remove the confining elements FROM around the patient, NOT to remove the patient from the confining elements.  In the case of a damaged automobile this concept is easily understood.  Cut the car away, then secure the patient.  But in a small bedroom, cluttered with furniture and personal objects, where the mechanism of injury indicates that further movement of the patient should be avoided, it might not be as apparent that the initial action might be to remove the 'clutter' from the room before attempting to move the patient.

A quick war story.

Some time ago, we were presented with a male patient (approximately 125 kilos, that's about 275 pounds,) who, while working on the flooring of the second floor, fell through to the first floor and came to rest in a doorway of a closet (the closet door had not yet been installed in this new construction.)  The patient's 'girth' literally filled the undersized doorway, he was not, however, 'wedged' in the opening.  We couldn't roll the patient, nor were we comfortable with the idea of dragging the patient from the location.  The absence of wallboard gave us access to both "ends" of the patient from an adjacent 'room.'  Our suggestion to dismantle the closet was met with furious disapproval from the patient, contractor, and the home owner.  In an effort to preserve 'public relations' we positioned each half of a scoop stretcher along the side of the patient, and slowly and carefully worked the two halves under the patient until reassembled and lifted the patient out of the doorway.  In some twenty years of field work, this is the only time we can recall where the patient was removed FROM the confinement, an apparent "violation" of the basic concepts of extrication and an indication that for every rule there is an exception.

Once "access" to the patient has been established, the position of the patient needs to be stabilized and maintained throughout the rest of the move.  (In the "apparent" violation [as related above] we were able to accomplish both "access" and "stabilization" without dismantling the confining structure.)  When the patient is found in a sitting position (as one might be in an automobile) the device of choice is the "Kendrick's Extrication Device" (KED.)  Simply described, it is a "jacket" with vertical spines, and an extended head support, which immobilizes the upper torso, cervical spine, and head.

It's proper application, again, is something best left to the classroom.  It is a device that requires about 15 minutes to properly apply.

There may be times when the instability of the scene, or the unstable condition of the patient, dictates that the patient be removed from confinement in a more rapid fashion.  To that end, there is a technique called, "Rapid Extrication."

This procedure requires four individuals to maintain different aspects of immobilization during the technique.  The below described procedure will require imagination and forethought to accomplish successfully.  Assuming that the patient is being extricated from a vehicle, be mindful that the vehicle could be a city bus (with lots of available room,) a four door vehicle (with plenty of available access,) or a two door vehicle, like a pick-up truck, where some creativity may be necessary to, 'create' necessary access points to the patient, and/or find the necessary space to accommodate the four individual team members.  One of the team members is going to have to act as a coordinator, directing the efforts of the other three and maintaining a constant communication string with those members, as well as monitoring the condition of the patient.  We have typically suggested that the provider maintaining head and cervical spine immobilization has the best "over view" of the situation and it is our opinion that this provider would be the most effective "coordinator."  However, some texts disagree.

First, Provider #1 applies manual in-line support of the head and cervical spine.  Maintaining the original position of the patient.

Provider #2 is responsible for the patient's torso and, when appropriate, will be rotating the torso.  This provider should be physically capable of performing this task.  His/her first effort should be to return the patient to a position of neutrality from the original position by placing hands on the anterior and posterior aspects of the torso in the thoracic region, and gently moving the patient into a sitting position.  During this move, Provider #1 must maintain the original relationship between head and torso.  Once the torso is in a neutral position, then Provider #1 can begin to move the head into a position of neutrality, provided that the patient experiences NO discomfort as a result of the move and/or Provider #1 encounters no resistance to the move.  If resistance or discomfort result, Provider #1 must maintain the head/torso relationship at such a point until the patient is secured to the back board.

Provider #3 is responsible for the patient's lower extremities.  It will also be his/her responsibility to decide if the patient is to be removed from the driver's side or passenger's side of the vehicle. Such things as the presence or absence of a center console, or the presence or absence of obstacles inside or outside the vehicle, might dictate the exit point.  His/her first action would be to approach the patient from the side of the vehicle opposite the exit point.  Then move the patient's 'near' leg laterally, without moving the patient's pelvis, until the leg is clear of the foot well.  Then bringing the second leg to a position that matches the first, again, careful not to rotate the pelvis.

At this point, all three providers rotate the patient, while maintaining the sitting position, maintaining the head/torso relationship, and maintaining the leg/pelvis relationship, until the patient has been rotated 90 degrees and is 'facing' Provider #3.  For the sake of simplicity, we will assume that Provider #3 approached from the passenger's side of the vehicle, Provider #2 from the driver's side, and Provider #1 from the rear seat.  It is imperative that this rotation be coordinated by one member, and that the rotation be accomplished in small segments, so that hand positions can be adjusted, and all members are moving at one time in a synchronized fashion.

Having accomplished the 90 degree rotation, Provider #1 will have to pass control of the head and c-spine to a fourth provider outside the vehicle.  Provider #1 will then exit the vehicle, retrieve a long backboard and position the foot end of the board at the base of the patient's spine.  The board, under normal circumstances, should be positioned between Providers #2 and #4 so that when the patient is extricated Provider #2 will be on one side of the board and Provider #4 on the other side.

Once Provider #1 indicates that the foot of the backboard is properly placed, and the head of the backboard is properly supported (by Provider #1,) the "coordinator" will direct Providers #2 and #4 to slowly lower the patient into a supine position, in small increments.  With the patient supine, Providers #2, #3 and #4 will synchronize their efforts, directed by the "coordinator" to slide the patient onto the backboard, again in small segments, with Provider #3 "following" the patient out of the vehicle.  When the patient is properly centered on the backboard, Provider #3 exits the vehicle and assumes support of the foot end of the backboard, while Providers #2 and #4 support the sides, and Provider #1 supports the head end.

The patient is then carried to the NEAREST safe location where the board is lowered to the ground, the patient properly secured to the backboard, the board (with the patient) is then secured to the ambulance cot, properly loaded into the ambulance and transported to the appropriate facility.

This section is far from being a complete dissertation of all the techniques of lifting and moving.  Your text and instructors will fill in the missing elements.  Look to those sources for guidance when dealing with patient's with 'special needs' such as pregnancy, shock, impaled objects, patients with additional medical hardware (Pumps, Tracheostomies, IV's, Endotracheal Tubes to mention a few.)  These patients will require special handling and you will need to be prepared to meet their needs.

Proper handling of a patient, and proper implementation of the devices provided for the movement and transportation of patients is something that requires training, repeated practice, and constant re-evaluation.  This is just the beginning.

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