What is the most dangerous piece of equipment your crews use? Is it the endotracheal tube or the trocar used to create a hole in a patient’s trachea? Could it be the ambulance, certainly a contender. Possibly, but we don’t have injury rates in the frequency with ambulances as we do with what we are going to discuss here.
I would argue that the most dangerous piece of equipment is none of those, but is in fact the stretchers we use.
A recent paper stated each patient transport required a minimum of nine (9) movements of the stretcher. What defines a movement, or the actual number is not the focus of this article. What is of concern, however, is the fact that there are not many devices in our toolbox which can harm both EMT and patient and has the frequency of use that the common stretcher does.
It is likely that you have heard the acronym HALO. For my military friends I am not referring to High Altitude Low Opening. I am referring to High Acuity Low Occurrence. These are instances which have a high likelihood of injuring or killing someone but do not happen frequently. A good example is a surgical airway or a trench rescue. There are numerous trainings for the placement of advanced airways and special rescue operations, but these are relatively rare occurrences. The operation of a stretcher is far more likely to hurt your patient and staff member and we use them frequently; on just about every single patient we have.
When I trained new EMS providers years ago, stretcher operations were part of the EMT program. This training was not included as a part of the prescribed DOT curriculum, but as an additional module the program chief added. It is critical that the first time a new provider interacts with a stretcher and their partner, it should not be when it has a patient on it. How often does that occur? When two new field providers are working together, do they practice lifting the stretcher before heading out on shift? Can you and your team confirm that this practice is incorporated as a ‘start of shift’ protocol? It is wonderful if it is, but in my experience, it does not happen often or often enough.
Recently while reviewing the case files for a stretcher tip lawsuit, I noticed that the new hire EMT had been placed on the foot of the stretcher with another EMT at the side, but the preceptor was still inside the ambulance. Without dissecting the details of “how it happened”, basically a ‘drop and tip’ resulted in a patient injury outcome. This is concerning, but what troubled me the most was that the preceptor was still in the truck. During the investigation process it was found the new hire had completed the didactic training and a hands on with the stretcher but had not actually performed loading or removing an occupied stretcher from the ambulance prior to the incident that led to the lawsuit.
The investigation identified several gaps in their training program and procedures. These centered around both initial and ongoing training as well as the overall culture of safety at the company. They identified that all field providers required more training, including reinforcing that preceptors or field training personnel need to be close enough to counsel and intervene during the loading and removal process if necessary. What was most concerning, and likely a significant factor in why this accident occurred, was the culture of the company regarding new hire onboarding. The goal of the training program was to get the new hire out the door and working as soon as possible. The attitude was to simply “check the box” on the stretcher training and not to make it harder or more time consuming than it needed to be.
In performing the background research for this article, I searched the internet for available “stretcher trainings” that were available for EMS agencies. Included in the ‘Beyond the Stryker’ or ‘Ferno’ resources, I noted there were numerous insurance companies who hosted articles on stretcher training. This is likely due to the number of claims they had processed.
The training should include a theory or didactic portion, which covers the manufacturers guidelines, state regulations (if any), and the company policy. Not every state has a stretcher policy or regulation. However, some states, such as Massachusetts, do include regulations that require movement of a patient-loaded stretcher to be at transport height or lower. These regulations often reference failure on the part of the crew for not complying with the manufacturers recommendations of proper patient-loaded stretcher height as a significant factor in patient injury.
The hands-on component of all field provider training should include the basics; raising and lowering, loading and unloading from the ambulance, all following the manufacturer’s recommendations. It should also include some best practices including loading and unloading with a weighted mannequin or other weight simulated stretcher. Adding some fail safes into the procedure such as pushing the stretcher back against the ambulance after the undercarriage has come down to ensure it is still clipped in the mount or caught on the hook.
Remember that the overwhelming frequency with which we perform patient movements on stretchers may result in field providers becoming complacent, substantially increasing the opportunity for significant injury to both staff and patients.
The first time a new field provider operates a stretcher should not be the first time they have had a patient on it. Because of the rarity and high consequence associated with HALO events, it is critical that we train them well and train them often.
Brandel, Robert, "EMS Safety, Stretchers, and Stretcher Handling" (2016). Student Writing.