Peter Canning over at Street Watch has started a new series of posts called Street Lessons. His first post is about hypotensive patients and how to move. Or, more accurately, how NOT to move them. As in don’t sit them up and put them in a stair chair.

I’m a little late to this as he posted this back in May, but I thought I’d comment. I’d have done that on his blog, but it appears that comments are closed on that post. Oh well, it makes for easy blog fodder.

After over 30 years in EMS it just amazes me that this is still controversial. One of the first things I learned as a new EMT was how and when to use a scoop stretcher.

I’ve been in love with the scoop ever since.

Putting a hypotensive patient in a scoop to move them down (or up) stairs should be the natural thing to do. Properly strapped in, you can literally stand them on their head if you have to. Or you can keep them more or less flat with a little effort.

One of Peter’s readers posted the following comment,

Kristi says,

having someone lift over their heads and another bending over to carry doesn’t sound like very good mechanics to me!! That is a great way to hurt yourself and your partner, drop your pt and have them code any way!!!

Lifting mechanics are important, but unfortunately the patients, the people who designed and built houses over the years, and the houses themselves don’t care about mechanics. As with golf, we often have to play the patient as they lay. EMS is hard on our bodies, as I know all too well. I’d say that Kristi knows lifting mechanics, but probably doesn’t know lifting. Patients fall where they fall and it’s our job to treat them as we have to. Moving patients is part of the treatment and like any other treatment, we have a responsibility to do it properly even if it’s harder for us. If you can’t lift a patient, then you need to swallow your pride and call for help. Everyone has limits to their strength and it’s important to know and work within them.

If the patient is properly secured to the scope and there is a right and wrong way to doing that, they are going to be very secure on the device.  If your system doesn’t have scoop stretchers, shame on them. If you can’t convince them to buy them you can use a long board, but it’s definitely sub optimal for the purpose.

Another alternative, and again it’s not the best, is to turn the chair around. Yes Kristi, the lifting mechanics are not that good, but the patient will benefit from doing it. Start by putting the chair on the floor with the back resting on the floor and the seat portion pointing up. Lift the patient into the chair that way and secure the straps. The LIFT the chair in that position so that the patient’s head is at the same level as their knees. Or as close to that as possible.

Then carry the chair (and patient) down “backwards” with the head at the bottom and the legs at the top. Once you at street level, move the patient to the stretcher as quickly as possible. They’ll go better that way.

While I’m in rant mode a couple of other things.

If the patient is hypotensive in the supine position DO NOT SIT THEM UP “To See  if they are postural”. By definition they are postural and sitting them up will only make them more ill. Got that. leave them supine or even raise their head a little bit.

Do not use Trendelenburg position. It does no good and probably does harm to the patients.

“But TOTWTYTR, we’ve always used Trendelenburg. We were taught to use it on about day five of EMT school. It has to work, it’s in our text books.” Wah, wah, fucking wah.

Like much, if not MOST of what we’ve been taught over the years, this is wrong. It’s just that no one has thought to unteach EMS providers something that “real” medicine has known for a long time.

Ahh, you don’t believe me, do you? Would you believe Bryan Bledsoe, DO?

In 1967, Los Angeles researchers evaluated the Trendelenburg position and found that it did not provide any benefit in improving circulation during clinical shock. British researchers evaluated the effectiveness of the Trendelenburg position on both hypotensive and normotensive patients. The study included 76 patients—15 of whom were in shock (systolic BP < 70 mmHg). A Swan-Ganz catheter and a radial artery catheter were inserted. The patients were then tilted in a 10-20 degree head-down position for 3-5 minutes and physiologic parameters were measured. They concluded, “Our study failed to document any consistent beneficial or detrimental effect of Trendelenburg positioning in acutely ill normo- or hypotensive patients.

Not that some of these studies go back to 1967. That was even before Johnny and Roy showed us hot to EMS (mostly wrong as it turns out) and before just about all of us were in EMS.

I’ll add that putting a patient in a head down position with his legs raised up higher than his head can put pressure on the diaphragm and thus increase the Work of Breathing. Which is the last thing that a sick person needs when they are ill and hypotensive. I’ll go one step further and suggest that patients do better if they are in “low physiologic” position. Or if you prefer, you can call it low semi Fowlers position. Think of the mechanics of breathing and how putting a patient in a head down position makes that harder.

Which might seem contradictory to you for me to sing the praises of scoops and tell you not to use Trendelenburg, the two aren’t really contradictory. In both cases you want to avoid making the patient’s cardiovascular system from having to do more work than absolutely necessary. Sitting a hypotensive patient upright is bad, maybe even fatal. Lying them flat with their head lower than their feet doesn’t seem such a hot idea either. Avoid both when ever possible.

Most of the time, the patient and their condition will dictate what position in which they are most comfortable. If you sit them out and they lose consciousness, that’s a rather strong hint that they can’t tolerate that position. It’s also a rather strong hint that you’ve just harmed your patient, either temporarily or permanently.

Not. The. Intended. Effect.

Act accordingly.