Ergonomics Issues In Paramedic Duties: A Case

Study

Steve MorrisseySteve Morrissey

Ergonomics ConsultantErgonomics Consultant

Oregon OSHA ConsultationOregon OSHA Consultation

Introduction

nn NonNon--binding binding ergonomic consultationergonomic consultationwithwith a large ambulance service in the a large ambulance service in the Pacific Northwest.Pacific Northwest.

nn Paper discusses thisPaper discusses this company and company and consultations with other specializedconsultations with other specializedemergency services I have worked with.emergency services I have worked with.

nnOregon OSHA is a State PlanOregon OSHA is a State Plan

nn Offers Consultation Offers Consultation ProgramProgram

uuFreeFree

uuNonNon--regulatory (nonregulatory (non--binding results)binding results)

uuConfidentialConfidential

uuOpen to ALL employers in StateOpen to ALL employers in State

nn Requires full cooperation of both employers Requires full cooperation of both employers and employeesand employees

Background

nn In early 2006, a large metropolitan In early 2006, a large metropolitan EMS service requested we help them EMS service requested we help them address: address:

uuBack injuries in the paramedic staff Back injuries in the paramedic staff whose source was not immediately whose source was not immediately apparentapparent

tt Shoulder injuries whose source was Shoulder injuries whose source was “understood:”“understood:”

Approach

nn Met with management, supervisory and safety Met with management, supervisory and safety committee committee members to setmembers to set goals for consultationgoals for consultation

nn ConductedConducted 5 5 –– 6 hour ride alongs with 6 hour ride alongs with crewscrews..uu Lots of conversations, question Lots of conversations, question –– answer periods, much answer periods, much

observation and “how come” discussionsobservation and “how come” discussions

nn Daily debriefings with supervisory personnel (how Daily debriefings with supervisory personnel (how can we help!)can we help!)

nn Reports and closing meeting(s) Reports and closing meeting(s)

Initial Findings-Observations

nn Two person crews,Two person crews, oneone qualifiedqualified paramedicparamedic

nn Shared driving and patient dutiesShared driving and patient duties

nn 1010--12 12 hour shifts,hour shifts, with the station approachwith the station approachuu Park at different locations until told to move or get callPark at different locations until told to move or get call

uu Read, study, do recordkeeping, sleep, talk when on stationRead, study, do recordkeeping, sleep, talk when on station

uu Stay in vehicle.Stay in vehicle.

nn Very differentVery different demand set during responsedemand set during response

Intermediate Discoveries

nn After meetings and ride alongs, I concluded After meetings and ride alongs, I concluded that there were a variety of issues contributing that there were a variety of issues contributing to reported musculoskeletal problems and a to reported musculoskeletal problems and a variety of variety of problemsproblems not well verbalized.not well verbalized.

nn Physical design issues (ambulance, equipment)Physical design issues (ambulance, equipment)

nn Task or mission profile specific issuesTask or mission profile specific issues

Basic Ambulance Design

nn Ambulance design is set by economics, Ambulance design is set by economics, perceived need and Federal Regulationsperceived need and Federal Regulations

uu Purchase E/FPurchase E/F--350/450 or Dodge equivalent 350/450 or Dodge equivalent frame which is finished by specialty company frame which is finished by specialty company for “normal” or special (bariatric) needsfor “normal” or special (bariatric) needs

uu Refurbish after about 250,000 miles of useRefurbish after about 250,000 miles of use

Ambulance Design, Cont.

nn Over the years, there has been an increase in:Over the years, there has been an increase in:

uu Engine sizeEngine size

uu Biohazard (general security) protection between Biohazard (general security) protection between patient area and crew cabpatient area and crew cab

nn Seats are “higher” end SUV typeSeats are “higher” end SUV type

nn Patient area has bench seats on one side, Patient area has bench seats on one side,

gurney in centergurney in center

Personnel and Task Factors

nn Shifts are 10Shifts are 10-- 12 hours and 12 hours and crews rotatecrews rotatebetween locations when not on callbetween locations when not on call

nn Driving and patient care duties are Driving and patient care duties are sharedshared

nn Meals are usually eaten in vehicleMeals are usually eaten in vehicle

nn Crews stay in vehicle for Crews stay in vehicle for safetysafety and to listen and to listen for callsfor calls

nn When waiting, crews sit and read, do paper When waiting, crews sit and read, do paper work, talk or try and sleep in chairswork, talk or try and sleep in chairs

Observations and Comments

nn Increased engine size has moved the firewall Increased engine size has moved the firewall backwards backwards

nn IncreasedIncreased biohazard protection has moved the patient biohazard protection has moved the patient area partition forward.area partition forward.uu Paramedics are in the middle, or what is left of itParamedics are in the middle, or what is left of it

nn 1010--hours of sitting is hours of sitting is an issue (pain)an issue (pain)

nn Reduced cab space makes any chair less effectiveReduced cab space makes any chair less effective

nn No one singleNo one single “silver bullet“silver bullet” to solve problems” to solve problems

Work Phase Analysis

nn To To understand the various problemsunderstand the various problems, need to look , need to look at work at work withinwithin each work stage or activity.each work stage or activity.

uu Sit on stationSit on station

uu Respond to callRespond to call

uu Arrive and handle patientArrive and handle patient

uu Transport to hospitalTransport to hospital

uu Transfer patient at hospitalTransfer patient at hospital

tt RepositionReposition

Sit on Station

nn Crew sits in ambulance until told to move to Crew sits in ambulance until told to move to new station or call comes in.new station or call comes in.

uu 1010--12 hour days rotating between sites12 hour days rotating between sites

uuLocations selected and need to be close to Locations selected and need to be close to radios minimizes crew leaving vehicleradios minimizes crew leaving vehiclett Meals in vehicle.Meals in vehicle.

uuRead, do paperwork, talk, sleepRead, do paperwork, talk, sleep

Comments and Observations

nn Cab space is not particularly largeCab space is not particularly large

nn Duties create poor posturesDuties create poor postures

nn Lack of storage spaceLack of storage space

nn Lack of leg roomLack of leg room

Concerns: Cab Area

nn Long periods of sitting in chairs with restricted leg Long periods of sitting in chairs with restricted leg room, inability to adjust chairroom, inability to adjust chair

nn More leg room on driver’s sideMore leg room on driver’s side

nn Larger persons have difficulties on paramedic side:Larger persons have difficulties on paramedic side:

uu Some crew cannot sit in paramedic seat.Some crew cannot sit in paramedic seat.

nn Limited storage space for personal items, computer Limited storage space for personal items, computer and keyboardand keyboard

nn No room for use of computerNo room for use of computer

nn Computer does not always work (wireless) in every Computer does not always work (wireless) in every locationlocation

Basic Recommendations

nn Increase cab space Increase cab space uu Original purchase, Original purchase, orderorder frames frames 88” to 12” ” to 12”

longer.longer.

uu During retrofit, add 8” to 12” spacerDuring retrofit, add 8” to 12” spacer

nn Improve seats after more space is availableImprove seats after more space is available

nn Mandate walkMandate walk--aa--rounds by crews, free rounds by crews, free lunch timelunch time

nn Device to hold computerDevice to hold computer

Respond to Calls/Switch Locations

nn When When assigned to aassigned to a call, significantcall, significant increase in increase in activity/stress as the route is planned, the type of call activity/stress as the route is planned, the type of call determined and time of arrival considered (coordinate determined and time of arrival considered (coordinate with cowith co--responders)responders)

nn Drive to the site can be very stressful and postures Drive to the site can be very stressful and postures may be far from idealmay be far from ideal

nn Arrival on site results in (rapid) climbing out of cab, Arrival on site results in (rapid) climbing out of cab, going to back of ambulance, lifting and pulling going to back of ambulance, lifting and pulling gurney from back of ambulance and pushing it to gurney from back of ambulance and pushing it to patient.patient.uu Surfaces and routes can be far from goodSurfaces and routes can be far from good

Comments

nn Going from a sedentary Going from a sedentary postureposture to to a tensea tenseand often staticand often static posture, then immediately posture, then immediately beginning a variety of light, but demanding beginning a variety of light, but demanding physical activities, physical activities, cancan stress the back, stress the back, knees and upper body in general. knees and upper body in general.

Patient Contact-Handling

nn This is the most demanding and unpredictable This is the most demanding and unpredictable part of the paramedics dutiespart of the paramedics duties

uu Assess state of patientAssess state of patient--determine action plandetermine action plan

uu CoordinateCoordinate with patient, cowith patient, co--responders, familyresponders, family

uu Move patient to gurney Move patient to gurney

tt Hopefully clean lift and carry to gurneyHopefully clean lift and carry to gurney

tt May require lift, carry, twist, move round corners, May require lift, carry, twist, move round corners, up and down steps, ramps before getting to up and down steps, ramps before getting to gurneygurney

uu Move gurney and patient Move gurney and patient toto ambulanceambulance

Hazards, Concerns

nn The unpredictability of the location and patient status The unpredictability of the location and patient status creates creates anan environmentenvironment with high potential for injurywith high potential for injury

nn Coordination with other responders and family may be an Coordination with other responders and family may be an issue that can lead to injury issue that can lead to injury

nn Additional Issues/Problems:Additional Issues/Problems:

uu Obesity Obesity

uu Resisting, Resisting, struggling, or medically fragilestruggling, or medically fragile patientpatient

uu NeedNeed for speedfor speed

uu Very difficult locations: Stairs, turns, cluttered roomsVery difficult locations: Stairs, turns, cluttered rooms

uu Lack of proper patient transport devicesLack of proper patient transport devices

General Recommendations

nn The extreme unpredictability of this phase The extreme unpredictability of this phase requires excellent training and coordinationrequires excellent training and coordination

nn Chain of command training for coChain of command training for co--respondersresponders

nn Improved availability of transport devices such Improved availability of transport devices such as sheets, boards, chairs in a range of sizesas sheets, boards, chairs in a range of sizes

Moving Patient-Gurney to Ambulance

nn Moving the gurney and patient to the ambulance Moving the gurney and patient to the ambulance can be a significant issue if there are steps or can be a significant issue if there are steps or ramps, irregular or soft surfaces (gravel, lawns), ramps, irregular or soft surfaces (gravel, lawns), ice, mud, rain or hills or the ambulance itself is not ice, mud, rain or hills or the ambulance itself is not on flat, stable surfaces.on flat, stable surfaces.

nn HeavyHeavy patients can create additional additionalpatients can create additional additionalstresses stresses on theon the back and shouldersback and shoulders

Moving Gurney Into Ambulance

nn Lift gurney head into ambulance, catch lock Lift gurney head into ambulance, catch lock

nn Manually fold up undercarriageManually fold up undercarriage

nn Lift and push gurney into ambulanceLift and push gurney into ambulance

nn MultiMulti--stepstep, coordinated , coordinated activityactivity which may which may requirerequire awkward postures.awkward postures.

uu Bariatric patients Bariatric patients

uu Lack of flat, stable surface at ambulance doorLack of flat, stable surface at ambulance door..

nn This activity has significantThis activity has significant potential potential forfor injuryinjury

Recommendations

nn Winch on top of ambulance door frame to help Winch on top of ambulance door frame to help lift head of gurney into ambulancelift head of gurney into ambulance

uuEliminate lift, hold and fold of wheelsEliminate lift, hold and fold of wheels

nn InstallInstall winch/ramp systems winch/ramp systems usedused in bariatric in bariatric ambulancesambulances

Transport to Hospital

nn The paramedic in the back begins treatment and The paramedic in the back begins treatment and

interacts with the patient and the hospital.interacts with the patient and the hospital.

uu Sit on bench seat and lean forward (16” between seat Sit on bench seat and lean forward (16” between seat and edge of gurneyand edge of gurney), or), or

uu KneelKneel on floor next to gurney and on floor next to gurney and twisttwist to the sideto the side

nn BothBoth postures have potentials for back and knee postures have potentials for back and knee injury injury andand safety issuessafety issues

Concerns

nn Sitting and leaning Sitting and leaning forward forforward for extended extended periods of timeperiods of timeuu No back support and seat itself is poorNo back support and seat itself is poor

uu Vibration and sway from vehicleVibration and sway from vehicle

nn Kneeling and twisting about waist Kneeling and twisting about waist uu Knee stressesKnee stresses

uu Twisting about Twisting about back, vibration, sway from floorback, vibration, sway from floor

nn No crash protectionNo crash protection--seat belts are poorseat belts are poor

Recommendations

nn Regular breaks to straighten upRegular breaks to straighten up

nn Knee Knee padspads

nn Cautions about lifting and patient handling Cautions about lifting and patient handling after extended periods of back flexion after extended periods of back flexion and/or twistingand/or twisting

nn InvestigateInvestigate safety harness systemsafety harness system

Processing at Hospital

nn Remove patient and gurney from ambulanceRemove patient and gurney from ambulanceuu Same issues as putting gurney into ambulanceSame issues as putting gurney into ambulance

nn Push into emergency roomPush into emergency room

nn Transfer to exam table/bed with lateral transferTransfer to exam table/bed with lateral transferuu VeryVery high potential for back high potential for back injury, and hospital injury, and hospital

staff may not (be able to) helpstaff may not (be able to) help

nn Transfer equipment and hospital staff should be Transfer equipment and hospital staff should be available to help.available to help.

Reposition-Regroup

nn After the patient is released to the hospital, After the patient is released to the hospital, the crew cleans up/sets up the ambulance the crew cleans up/sets up the ambulance for next call then goes to next duty station.for next call then goes to next duty station.

nn Little time to stretch, walk around.Little time to stretch, walk around.

nn Ideally, should be allowed to take some Ideally, should be allowed to take some time and stretch, walk around.time and stretch, walk around.

Global Recommendations

nn Increase cab space by 8”, preferably 12”Increase cab space by 8”, preferably 12”

nn Crews must get out and stretch on regular basisCrews must get out and stretch on regular basis

nn More patient handling equipment More patient handling equipment

nn Powered system to load gurney into ambulancePowered system to load gurney into ambulance

nn Hospital staff assistance in transferring patientsHospital staff assistance in transferring patients