Back Injuries in EMS - Angelfire



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Back Injuries in EMS

By Dennis Mitterer, MS, ASP, ARM, NREMT-P

You have worked on the streets for six years. Today, you're busy thinking about the three-day vacation that will begin right after your current tour of duty. In three hours, you'll be on the road to that vacation house and relaxation. Suddenly, the tones sound, bringing you back to reality with a call for a patient who is experiencing shortness of breath. This is a "routine call" that should be completed just when your shift ends. Arriving at the scene, you carry your medical bag, airway bag, monitor and oxygen into the house. The patient is on the second floor in the back bedroom. You evaluate the patient, treat her quickly, and prepare to carry her downstairs and into the waiting ambulance.

The patient is doing well as you prepare to lift her 130 lbs. into the rig. You and your partner bend over and grab the bars, just as you've done hundreds of times. As you raise the litter to place the patient in the ambulance, you suddenly feel a dull, burning sensation in your lower back, followed by a sudden, sharp pain that radiates down one leg. The pain causes you to abruptly stop the lift. In a trembling voice, you ask your partner to put the litter back on the ground. Upon releasing the bar, you moan in pain. As you attempt to straighten, you meet a wall of resistance and an urgent increasing pain. You are unable to stand. Routine call?

The Need for Injury Prevention

Business leaders and healthcare providers in both the public and private sectors are continuously searching for methods to contain costs and provide greater value. Unfortunately, every organization that employs people is subject to the costs relating to work-related personnel injuries. Large corporations have learned this lesson, and many have initiated programs that attack specific industrial problems. Small organizations don't experience the same magnitude of significant losses, so they are unprepared for the financial consequences of a sudden injury. One severe injury can place the organization in financial jeopardy. By establishing proactive methods to prevent injuries from occurring, an organization can reap the financial benefits of its actions.

The Back Pain Problem

Almost everyone experiences acute back pain at some time in their adult life. Back-related complaints are second only to the common cold as a reason for office visits to primary care physicians. How can EMS providers avoid becoming part of this staggering statistic? By reviewing the anatomy of the back and descriptions of specific injuries, you will understand the complexity of an injury. The end result of this article is to share with you how to avoid the harmful effects of an acute back episode--a situation that can change the direction of your life.

History of Study

In a study conducted at the Industrial Resource Center (IRC) at Memorial Hospital in York, PA, more than 1,100 patients were evaluated for work-related injuries. Approximately 299 (27%) were evaluated for work-related back injuries. The IRC is a hospital-based industrial medicine facility, established to help organizations identify, evaluate and eliminate hazards in the workplace. The staff treats and rehabilitates employees who have experienced a work- related injury.

This study focused on the causes of the most common complaint (back injuries), costs, recovery time and prognosis. The study looked at all industrial work-related back complaints. This article focuses only on the findings in prehospital or general healthcare providers.

There are four reasons why a back complaint is the most problematic to the injured person and/or his employer. First, back injuries are multifaceted. Considerations include: extent of injury (strain/sprain, herniated disk, etc.), age, preexisting conditions (DJD, scoliosis), cause of injury and psychological responses to injuries. Most people report low back problems at some time in their lives, and national statistics indicate a general yearly prevalence in the United States population of 15%-20%.1 We know that among the working population, 50% of employees admit to lower back pain each year.2,3 In the IRC study, of the 299 patients evaluated, 35 healthcare providers reported lower back complaints. This represents 12% of the entire study group.

Various studies have found that back symptoms are the most common cause of disability for persons under age 45. Clearly, most prehospital healthcare providers fall within this age group. The IRC study noted that 24% of the patients in the healthcare provider's category were in the 19-29 age group. In a subcategory, all prehospital providers fell within this age group.

Second, the cost to treat a "routine back injury" can be a financial nightmare for an organization. Back injuries are the most common reason for office visits to occupational medicine physicians, orthopedic specialists and neurosurgeons. Low back problems are expensive. Approximately 93 million workdays are lost each year in the U.S. due to back pain.4 According to the National Safety Council, the cost to treat back injury complaints ranges from $30-$50 billion annually. The direct costs are derived from payments to physicians, rehabilitation professionals, insurance carriers and attorneys. Other direct costs include compensatable salaries for lost work, employee replacement costs and transfer costs to patients.

When a person sustains an injury, no one can predict how much the injury will cost. Diagnosis is very difficult, due to the many potential causes, and testing to determine the underlying cause may be very expensive and fail to yield any objective information. We do know that the average cost for a "simple" sprain or strain of the lumbar spine is approximately $18,365. In our study, healthcare providers spent a total of $25,200. The average cost was $718, with the highest cost calculated at $5,353 of direct costs.

We also can't forget indirect costs, which may include the inability to function normally at home, loss of community service activities and spousal adaptation to the injury. Psychosocial factors also contribute to the overall costs of treating back injury. Indirect costs are usually calculated to be 15-40 times the out-of-pocket expense.

A third reason why back injury is problematic is the increasing evidence that patients may be receiving less than optimal care. Regional variations for assessment, diagnosis, hospitalization and surgery imply a lack of consistency in appropriate care of low back complaints.5 In addition, some patients appear to be more disabled after treatment than before, indicating that patients may be receiving suboptimal care. What are the "best" methods for evaluating, diagnosing and treating the injured worker? There is a growing body of evidence that treatment for back-injured employees is more dynamic than previous treatment modalities.

The final reason for the IRC study is to alert you, whether you are a practicing provider or administrator, about the need to develop methods to reduce the possibility for this sort of injury to occur. Reducing costs, pain and suffering can occur through administrative actions, working with medical providers who are familiar with new thinking and developing provider-oriented training to reduce the risk of injury. Total cooperation is necessary when working toward preventing disabling back injury.

Anatomy

Low back pain may arise from one of many anatomical sites, including disks, facet joints, myofascial attachments and the sacroiliac joint. A brief review of anatomy will help explain the complexity of diagnosing a back complaint.

The spine is comprised of three distinct areas: cervical spine, thoracic spine and the lumbar-sacral spine, which is the area most commonly injured. The lumbar spine is comprised of five vertebral bodies. Each level is separated by a cushion called a disk--probably the site of most back pain and responsible for nearly 85% of all reported cases.6 Disks are shock absorbers for the spine. Disks are made up of two specialized tissues: the anulus fibrosa--a dense outer ring--and the interior area or nucleus pulposus.

Current evidence shows that disks have the potential to generate pain and inflammation, even though, historically, medical science has considered this area to be insensitive. Injury to the anulus fibrosa as a result of micro tearing allows for extrusion of the nucleus pulposus. The result initiates not only physical changes, but also chemical changes that may initiate an inflammatory process.

Nerve roots exit the spinal canal at the facet joints. Upon exiting, the nerve splits and innervates the facet joint and capsule. The capsule and synovial membranes of the joints are innervated with pain receptors. Structural changes in this area elicit discomfort. Changes in the structure of the spine, disk herniation, osteoarthritis, scar formation, bone spurs, etc., may cause narrowing of the neuroforamen that will impinge on the nerve roots.

The lumbar spine is held together by myofascial attachments. Damage to the myofascial structures surrounding the spine may also result in back pain. Lack of exercise reconditions the muscles that contribute to the act of lifting. Injury to these muscle groups can stimulate the sympathetic nervous system and cause the muscle spindles to spasm, which may manifest as painful nodules. Injury to muscle attachments may also lead to chronic inflammation.

Research shows that the back can handle about 1,600 lbs/in2 of axial loading before it begins to show signs of tearing. The connective tissue will show signs of weakness and microtrauma to the intervertebral disks may occur. You may say that you would never subject your spine to this trauma, but we do it every day.

As we age, the tensile strength of the back decreases. Other factors that contribute to the decrease in strength include: twisting and turning (displaced axial loading), preexisting spinal abnormalities (spinal degeneration, decreased disk hydration, fractures or other metabolic cause), and poor muscle tone. The 1,600 lbs/in2 tensile strength can rapidly decrease, at which time we increase our susceptibility to injury.

An Ohio State research group found that repetitive lifting contributes to the risk of a back injury. According to one researcher, most back injuries are probably a result of cumulative wear and tear rather than a sudden injury.7

The Injury

As in the opening case study, most injuries occur secondarily from forward flexion plus lateral twist. Our study showed that 26 out of 35 injured healthcare workers were injured as a result of bending forward or a combination of bending, twisting and lifting. Why does this occur? Think about your job. Lifting patients or equipment is what we do.

Imagine that you bend at the waist to pick up a 35-lb. equipment bag. Since the force on the lumbar-sacral region is approximately 10x the actual weight lifted, you are exerting approximately 350 lbs/in2 on the structures in the lumbar area. If you're thinking this does not even come close to 1,600 lbs/in2, you're correct; however, we did not add the entire weight of your upper body into this equation. Given that our upper body weighs approximately 100 lbs., a simple calculation shows that by lifting the bag, we are exerting approximately 1,350 lbs/in2 on the lumbar region.

Consider how injuries occur. The risk factors that contribute to the injury include: posture/technique, weight lifted, frequency/repetition of work performed, asymmetrical handling and space confinement. In the entire IRC study, 30% of the patients injured were lifting and/or lifting and twisting; 11% were bending and lifting; and 9% were pulling. For EMS providers, these three job functions comprise most of our patient-handling duties.

Injury Costs

A "simple" back injury will require initial evaluation. Suppose your salary is $10/hour. Since your injury occurred with three hours remaining on your shift, you will be paid $30 for nonproductive time. If the organization calls in another provider to cover the remaining 3 hours at an overtime premium, add $45 dollars (assuming same hourly rate, plus time and a half). Depending on your organization's policy, the supervisor may be called in to assist with the paperwork and accident investigation. Add the cost of the insurance company's expense and establishment of a reserve (the amount of money that must be set aside to cover any future medical, indemnity or legal costs of each injury). Historically, a reserve of $5,000-$8,000 is normal for a back injury. As you can see, the cost of this injury is easily more than $6,000 of indirect costs within hours of the event.

Let's further assume that you present to the ED for evaluation and treatment. (It is a good idea to have a qualified panel of physicians for these situations, subject to individual state worker's compensation regulations.) The ED bill includes X-rays, medicine and professional fees. You are sent home with instructions to stay in bed and be rechecked in 48 hours. Now the organization has a recordable lost-time accident, and the supervisor must complete more paperwork (as if he doesn't have enough to do already). So much for your vacation!

After two days, you are rechecked. Pain continues with increased symptoms. Now you relate that the pain radiates into your thigh, which is indicative of nerve root compression. An MRI is ordered, and you are kept off the job. Since you were scheduled to return to work after vacation and you're now unable, your organization must find a replacement but continue to pay you (through sick time or another mechanism). Replacement costs continue to add to the overall costs.

All of these numbers are organizational losses. Consider your personal costs. Suppose you had paid for your trip in advance. Potentially, some, if not all, of the money is lost. Also, you are currently not working. Someone may have to assist you with daily living activities. Your spouse may have to take vacation time or apply for family medical leave benefits to care for you. Your spouse's place of employment then incurs costs for a replacement. As you can clearly see, the direct and indirect costs continue to increase.

Treatment

Many practitioners continue to evaluate patients and routinely put them off work for extended periods without considering the need to do so. Another common practice is having a primary physician refer the patient to a specialist, who immediately determines that the patient is a surgical candidate. Despite overwhelming medical literature on "failed back surgery," and evidence that repeat surgery rarely leads to improved outcomes, there are documented cases of patients who have had as many as 20 spine operations. 5,8

As practitioners continue to recommend treatment modalities that may not increase the employee's chance of returning to work, treatment costs continue to rise. The longer the patient is off work, the probability of developing psychosocial maladaptive tendencies increases.

Bed rest is not the cornerstone of therapy. Increasing evidence indicates that bed rest slows healing and contributes to debilitation. New thinking emphasizes a return to reasonable activity and encourages continued activity, including work. This philosophy must be tempered with any objective clinical findings.

Recent studies offer some insight into this paradigm shift. A Finnish study found that after 3 weeks, patients assigned to the bed rest group had spent an average of 22 hours at rest vs. 5 hours for patients assigned to the light back-exercise group and 2 hours for patients assigned to a continuous-activities group. Time lost from work was also measured. The continuous activities group had 4.1 lost time days vs. 5.7 lost time days for the exercise group and 7.5 days for the bed rest group.9

A second study conducted in Seattle suggests that a purely conservative approach produces comparable outcomes. Investigators categorized physicians as high frequency (prescribed bed rest and medications), moderate frequency (combination of bed rest and minimal exercises) and low frequency (self care and early return to activity).

After one month, patients reporting moderate or severe limitations were highest in the high-frequency group (46%) compared with 30% in the low-frequency group. After two years, the limitations of patients were comparable, but after one year, the costs of care were 79% higher in patients treated by high-prescribing physicians.10

So what should you expect? Bed rest for 2-3 days may be an option for patients with symptoms of leg pain, but is not recommended for patients with uncomplicated, nonspecific low back pain. Bed rest for more than four days may lead to debilitation. Exercising of the low stress variety can prevent deconditioning. Most patients can start aerobic exercising (walking, swimming, etc.) in the first two weeks.8,11,12 Providing sedentary modified duty should be considered if a regimen of walking and standing is included. Just sitting may aggravate the injury. The intra-discal pressure increases may prolong recovery.13 The ability to move about, sit and flex is most beneficial.14 Further information suggests that expensive imaging studies should be reserved for patients who are initially acutely symptomatic, become disabled or show no signs of improvement.

The use of physical therapy in the acute stages--Days 1-4--was not helpful; however, our study found that physical therapy after the acute episode was helpful. Thirty-eight percent of the patients (113) were referred to PT. Of this number, 45 patients were initially diagnosed as acute, which warranted "no work." Of these patients, 67% were returned to modified duty within five PT visits, approximately 10 days after injury onset. Of patients who were not referred to PT, only 50% were returned to modified duty after approximately 10 days.

Review of the literature suggests that a gradual increase in reconditioning of the lumbar muscles is helpful in returning the patient to activity. Additional benefits of a formalized exercise program are favorable psychological effects and potential weight loss.

Prevention

The healthy back has a natural internal curve, which is maintained by the abdominal muscles anteriorly and the paraspinal muscles posterior-laterally.

The simplest solution in dealing with the most common work injury is achieved by eliminating the factors that contribute to the injury. Most injuries stem from poor flexibility or poor muscle tone. The musculature is simply too weak to handle the activity attempted. By developing an action plan designed to assess the capabilities of the healthcare provider, initiating a strengthening regimen and providing education to healthcare workers will decrease not only the occurrences, but also the severity.

Developing a job description that delineates employee duties (this helps with hiring the right people), you can isolate and determine the physical requirements of essential job functions. Understandably, healthcare providers become involved with many unique situations; however, most general functions can be documented.

Next, work with a local hospital or an occupational medicine facility that does not just concentrate on making money on injured workers, but can help establish a preplacement functional capacity exam (FCE). This exam should mimic, as closely as possible, the job functions of a prospective employee. If lifting a litter occurs 30 times per day, the new employee should demonstrate this function. The purpose of the FCE is to determine whether the applicant can physically handle the demands of the job.

The FCE does not replace the physical agility test. The FCE provides concrete information about an applicant's abilities to perform essential tasks. By screening out potential problems, you reduce your liability risk.

Seek to provide the engineering or personnel components that eliminate the need for providers to expose themselves to lifting situations. How can you do this when your job requires lifting patients? It is incumbent on EMS management to reduce the risk of injury, but not necessarily to reduce the need to lift. For example: How many organizations stuff more and more equipment into fewer bags? This activity increases the possibility of a back injury. How many organizations have reduced ambulance staff to cut costs? It is likely that one provider must now attempt to carry or maneuver equipment or a litter single- handedly. If both providers are getting the litter, who is with the patient? Do you call for help when a patient needs to be removed from a third-floor apartment? Or do the providers bundle the patient and attempt a two-person carry down three flights of steps? The amount of strain on the neck, shoulders and back is unbelievable. Too often, management or employees protect their back by wearing a back support rather than looking at methods to reduce the risk. This shortsighted action does not eliminate the causes of injury. Numerous studies address the use of back belts, so I won't rehash available information. The point is, don't rush into providing "protection" when you should be looking at improvements to eliminate the cause.

Next, educate your associates about the value of a strong back. Let's face it: Most EMS providers carry around excess weight, smoke and only sporadically engage in any type of sustained physical activity. A high percentage of prehospital providers are not at the peak of health when we do our jobs. By promoting exercise, particularly low impact flexibility exercises, the probability of employees injuring themselves decreases.

A study conducted at a heavy metal foundry supports the fact that stretching prior to beginning work reduces reported back injuries. Workers in this plant are subject to many of the same physical requirements as prehospital providers. In a 6-week period, 33 employees complained of some degree of back pain. Three employees were referred to a physician for treatment. A group of workers helped develop a flexibility program. One part of the program focused on education; a second portion centered on body mobility and flexibility. Before work, employees gathered and performed a series of flexibility exercises, which lasted approximately 10 minutes. After 3 months, the results were notable. The number of back pain complaints decreased substantially. Seven people complained of some degree of back pain, with no physician referrals needed. By promoting warmup exercises and periodic stretching throughout the day, significant reduction in injury exposure is possible.

Conducting educational in-services for employees that review how injuries occur, methods of prevention and proper care of the back will go further in reducing the potential for injury than trying to rebound from an injury.

Although education is important in prevention, back schools should not be relied on solely to eliminate the complaint. One study found that workers who are educated about how to avoid back injuries cannot apply the lessons in the real world. They found that although workers retained a significant portion of the safety information provided in the back schools, it was not enough to overcome the needs of the job. Changing physical work situations is more likely to reduce the risk of injury than just training workers how to lift.

This reinforces the first premise of safety: Engineer the hazard out of the job. We need to look at the things we ask of our prehospital providers. No one is saying we should eliminate lifting, but maybe we can reduce the number of things we lift.15

Finally, if an employee reports an injury, seek prompt evaluation and treatment. When a physician evaluates and treats the patient promptly, the employee returns to work more quickly. When back injuries occur, many factors contribute to overall costs. Delays in proper treatment will guarantee many administrative headaches, as well as increased costs. Developing a relationship with providers who are familiar with your business will help control your costs. By establishing a qualified panel of physicians who can demonstrate their commitment to rapidly evaluating and initiating current treatment protocols, direct medical costs are lowered. Additionally, the provider should be aggressive and progressive and try to return the injured worker to a modified duty program when medically indicated.

Conclusion

After 2 weeks of rehabilitation, you return to work. You will require at least 6 more weeks of modified or alternative duty. Throwing you right back into the same work environment will only reaggravate your injury. Chances are, the second injury will be more complicated and cost 2-4 times more than the first. Can you afford it? Is prevention cheaper than not knowing what costs will be incurred for an injury? Prevention is controllable. At the split second an injury occurs, neither you nor your employer can necessarily control the damage to the back. From that point on, you and your employer are at the mercy of the multiple factors that dictate the outcome. Are you prepared?

| |

|Principles of Lifting |

|Prepare for the lift mentally. Visualize how the lift will occur and what the end result will be. |

|Plant your feet firmly with a wide base of support. |

|Bend your knees. |

|Grasp the load firmly, keeping it close to the center of your body. |

|Keep the spine upright. |

|Lift with your legs. |

|Don't twist with your body. While lifting, shift your feet. |

| |

References

1. Anderson GBJ. The epidemiology of spinal disorders. In Frymoyer JW, Ed. The Adult Spine: Principles and Practice, pp 107-146. New York, NY: Raven Press Ltd., 1991.

2. Vallfors B. Acute, subacute and chronic low back pain: Clinical symptoms, absenteeism and working environment. Scand J Rehab Med Suppl 11:1-98, 1985.

3. Sternbach RA. Survey of pain in the United States: Nuprin pain report. Clin J Pain 2(1):49-53, 1986.

4. Fisher R. Professional Safety, p. 28, Sept. 1996.

5. Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: Low back pain and the health of the public. Ann Rev Pub Health 12: 141-156, 1991.

6. Mooney V, Saal J. Evaluation and treatment of low back pain. Clinical Symposia 48:(4) p. 5, 1996.

7. Internet: Goldberg, Ken, MD. How to Avoid Back Pain.

8. Bigos S, Deyo RA, Romanowski S, Whitten R The new thinking on low back pain. Patient Care, July 15, 1995.

9. Malmivaara A, Hakkinen U, Aro T, et al. Treatment of acute low back pain--bed rest, exercise, or ordinary activity? N Engl J Med 332: 351-355, 1995.

10. Von Korff, Barlow W, Cherkin D, Deyo RA. Effects of practice style in managing back pain. Ann Intern Med 121:187-195, 1994.

11. Deyo RA, Diehl AK, Rosenthal M. How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med 315 (17): 1064-1070, Oct. 23, 1986.

12. Bortz WM. The disuse syndrome. West J Med 141 (5): 691-694, Nov. 1984.

13. Kuhlengel K. Workers Compensation Symposium, Jan. 6, 1997, York, PA.

14. Kornecki L. Targeted medical care reduces lost-time injuries. Occup Health & Safety, pp. 57-58, Sept. 1995.

15. Occupational Health Management, 7: 9, pp. 101-104.

|Dennis Mitterer, MS, ASP, ARM, NREMT-P, is an occupational health and saefty consultant. Dennis also teaches in the paramedic |

|program at Harrisburg Area Community College in Harrisburg, PA, and is a paramedic for the Lancaster (PA) EMS Association and Lancaster |

|General Hospital. |

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