NEAR-MISS REPORT

The 400-lb. Patient in the Room: We must ensure safe operations during unique calls, like transporting the immobile, obese patient
By Deputy Chief John B. Tippett Jr.

The role of the fire service has expanded well beyond the original concept and ideals promulgated by early colonists Peter Stuyvesant and Benjamin Franklin. What hasn’t changed in the last 300 years: the tradition of rising to the occasion when called upon to assist a neighbor in need.

For years, many fire departments ran ambulances out of their stations or ran alongside separate EMS services. And in the 1970s, fire-based advanced life support systems experienced increasing attention with the premier of the TV show “Emergency.” All of this was followed by FireRescue’s founding publisher, James O. Page (aka, the Father of Modern EMS), who solidified the virtues of fire-based EMS. Today, depending on the location and type of department, EMS calls outpace fire calls by 3 to 1, 4 to 1 and sometimes even more disparate ratios.

This month’s featured near-miss report, No. 09-470, centers on an incident that fire personnel encounter with increasing frequency: the immobile, obese patient. Although it’s not as dramatic as the working fire call, it does represent another kind of risk and exposure to injury.

Event Narrative
“We were dispatched to a cardiac arrest and found a 400-lb. man on the second floor of a residence. The patient was placed on a stretcher and carried down a stairwell to the first floor by four personnel. While carrying the patient down the steps, the person opposite of me got caught in the stairwell and was unable to maintain the weight of the patient. I received the entire weight of the patient, causing me to suffer a back injury.”

Lessons Learned
“Train on moving obese patients. Train on good back posture while lifting.”

Comments
Moving 400 lbs. of limp, unconscious, non-breathing patient is a taxing situation for any crew. Take the fact that the patient is located on an upper floor and add in 1) the urgency of cardiac arrest and 2) having to maneuver down a stairway with the patient on a stretcher while maintaining life support, and you’ve got the links that complete the injury chain for this incident.

Stairways never seem to be wide enough—and patients never seem to suffer cardiac arrest on the first floor. Grips slip. Personnel get pushed into awkward positions. Knees and elbows get twisted, and discs slip. Rarely is there adequate training on heavy lifting and, in some cases, there’s just no way around muscling a patient down the stairs in the shortest time possible. When this happens, it’s very possible that someone’s going to get hurt. We just can’t predict how serious the injury will be.

Preparation
* Recognize that these incidents are a likelihood in your community.
* Because the obese patient is often chronically ill and a frequent EMS user, preplan the cardiac arrest event (e.g., know the patient’s address, the exit pathways, strategies for removing the patient, number of personnel and equipment needed).
* Share the information identified in the preplan with all agencies anticipated to be part of the incident, including the receiving hospital, EMS systems, fire companies, police, etc.
* Remember to brief the “rookie” or “detail” person about what they could encounter.
* Get to know your counterparts in fire, EMS and law enforcement. Whether you’re fire-based EMS or a third service, the more you work together, the better you will perform in taxing situations.
* Meet with the patient’s family to suggest how to make the patient and egress more accessible (e.g., move the patient to the first floor or widen doors and staircases).
* Determine whether there’s an alternate way to move the patient out of the structure. Crews have creatively moved large patients through sliding balcony doors or set up lowering systems.
* Stay in shape.

Prevention
* As noted above, injury prevention begins with preparation. A fitness program that incorporates stretching, strength training and focus on a strong core has been proven to prevent injuries and accelerate the healing process if an injury does occur. You don’t need to be muscle bound—just physically fit.
* Get help on the road early. The obese patient may require twice as many people as a regular patient. Call for additional crews when you’re responding or, better yet, have the address flagged in your 911 call center so extra help can be sent on the dispatch.
* Before any lift or carry takes place, ensure everyone is ready.
* Just as a fire scene needs an incident commander, the obese patient call requires one person to call the shots.
* Speak up if you’re losing your grip or feel any pain. The lift or movement should be stopped immediately to allow you to adjust position or be replaced.
* If possible, stage handoff personnel on landings so crews are not overtaxed. The handoff may be complicated, but it’s better to have fresh hands and legs to move the patient than have one of the carriers drop off halfway down the stairs.
* Consider disposing of traditional stretchers to bring the patient down. The patient may be more “cooperative” if they’re not strapped to rigid boards or stretchers. One effective alternative is to wrap the patient in a large blanket or bed comforter to “slide carry” them down the stairs.

Conclusion
One of the stimulating parts of emergency service work is preparing for the unexpected. For many of us, every time we pull into the station lot, the thought “What will I face today?” goes through our minds. Although we can’t prepare for every contingency, there is a map for maintaining operational readiness and vigilance. That map includes a focus on personal fitness, preparation through learning and remaining alert for future contingencies during operations in the present. We should not fear discussing the 400-lb. patient in the room. It’s the only way we can avoid being surprised.

John Tippett is the deputy chief of operations for the Charleston (S.C.) Fire Department. Tippett recently retired from Montgomery County (Md.) Fire and Rescue after 32 years, the last 7 as a battalion chief. He has served as project manager for the National Fire Fighter Near-Miss Reporting System since 2004. In 2007, Tippett was awarded the International Society of Fire Service Instructors’ George D. Post Instructor of the Year award.