Straps

I may have mentioned recently that I started a new part-time job. I’m an EMS coordinator at a local hospital. I’m still keeping my full-time medic job, only I won’t be working so much overtime. I haven’t written yet about the new job — I need to think more about the proper way to write about it. I obviously will have to keep the same confidentiality and fair play standards I have tried to keep when writing about EMS calls. In the meantime, the job affects this blog in that it I have less calls to chose from by only working the street 40 hours instead of 60-70, and I have less time to write. I hope to still post at least twice a week with at least one post being street material.

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Today, I’m going to resort to an old trick that served me well as far as material in the past. Instead of posting a comment on another blogger’s site, I’m going to use his post to riff on my own.

Again I turn to one of my favorite bloggers, Baby Medic, who recently posted Points of View, a thoughtful account of doing a great job medically, getting a STEMI patient to the cath lab, only to return to his ambulance to receive a “ticket” from a supervisor for not using all five straps (leg, waist, chest with connection to right and left shoulder) to secure the patient on his stretcher.

In general, I sympathize with Baby Medic on this. He did an awesome job, helping save a patient’s life only to be met with demerits for not using all the straps. On the other hand, (maybe it is my new position talking), if you have policies, and you are going to enforce those policies, you have to be even-handed about it. You can’t ticket only medics you dislike or only medics who provide inferior care if you are going to let medics you like and medics who provide great care get away with violating the policy. And far as policies go, if 5-straps are the safety standard, then you have to encourage the application of that standard.

Again on one hand, I understand the need for patient safety. Heaven forbid, you have a rollover and your patient is not properly secured. On the other hand, had that supervisor witnessed nearly every patient I have brought in for however long back, he wouldn’t have enough ticket books to write me up with. I am, you see, a chronic violator of the 5-strap rule.

In fact, in the middle of writing this post, in which I will finally come down on the side of needing to properly secure patients, I did a call (an OD), in which I only used two of the 5 straps. I try not to be a do as I say, not as I do guy, but sometimes, it is what it is.

When I started in EMS in 1989, we only had two straps. Sometime in the early 90’s we got three. We went to five sometime back — I don’t know maybe five or six years ago. I had a hard time with that new third strap. I have a really hard time with the 5-straps. By hard, I mean hard time complying, not hard time understanding the need. (I do love the five straps on boarded patients — keeps them from coming off the board on decelerations).

Here’s why it is hard. I work in high volume systems where care is largely provided during transport. Not just rare lights and sirens transports, but routine no L&S emergency transports. I get the patient, I get them in the ambulance, we get on the way to the hospital and I do what I have to do. It is hard for me to properly assess a patient with the five straps on, sitting them up to listen to lung sounds, getting an accurate 12-lead, or keeping them in a comfortable position when they are having a hard time breathing or are nauseous. This isn’t to say, it can’t be done, it is just often difficult. The same goes with the seat belt around my waist, which I confess I don’t wear much either.

Maybe I need to change my ways. Maybe I need to do as much care as possible in the driveway or at curbside, and then when all is done, strap everyone up and say to my partner. We’re all set. I do this only on occasion when I have certain unnamed drivers who I deem to be lead-foot, herky-jerky, take-my-life-in-their-hands drivers.

If I do use all five straps, I’ll get one of those few movie, or coffee and doughnut coupons I have heard they at times pass out to people who bring in their patients in with the proper straps as a reward incentive. While at the same time, I’ll be arriving at the hospital five or ten minutes later than I might have otherwise. In most patients, that won’t make a difference, but in a STEMI like Baby Medic’s, it may in fact make a big difference.

Years ago I use to work in a hardware factory on an assembly line. They run assembly lines at a speed a little faster than comfortable, which is the most efficient speed. Just enough to keep you working at your peak. Too slow and it is unproductive, too fast and it falls completely apart. We had three bosses — each of which had different agenda. The time keepers wanted things done the fastest, the quality control person wanted them done the best. And the line supervisor wanted the best done product in the shortest amount of time.

One of our many projects was assembling door knobs and screws on a large paper sheet (30 or so door knobs to a sheet) that was then heat-wrapped and chopped into 30 individual door knob units all ready for sale.

The conflict came when the time keeper was on me or my co-workers to be more efficient in our movements, which to satisfy him, invariably led to poorer quality (the knobs would be laid down slightly off-centered), which caused the line supervisor to get angry because we’d have to rerun the sheet.

Me, I’d just shrug when they yelled at me and say, “I’m doing the best I can.” If pressed, I would freely admit I preferred to err on the side of quality. (F- the time keeper.)

We do — in this job of taking care of people — the best we can. We need to do our best to do what is best for their safety. In almost all cases that will involve using those troublesome straps. But if I have a STEMI right now and I need a good 12-lead or set of lung sounds or whatever, I can tell you I will likely unsnap those top straps and may not get around to resnapping them. But I will try. I make that resolution today.

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A question has been raised in the comments about how do we know the five point straps are actually safe. I admit I was taking that on faith alone. I have just looked up the web site of the noted ambulance safety expert Nadine Levick and found the following from one of her handouts:

“Firmly secure patients with over the shoulder harnesses. If medically feasible, have them sit as upright as possible for safety.”

Here are two links:

Best Practices Interview

Objective Safety Home Page

Check Nadine Levick out, and if you ever get a chance to hear one of her lectures and watch some of her videos on ambulances classes, they will chill you to the bone.

Here’s some comments of mine after attending her lecture in Baltimore last year:

Funk

15 Comments

  • TOTWTYTR says:

    I have two thoughts on the five point straps. First, has anyone ever proven scientifically that they more safe for patients in the semi Fowlers position? I can see their use when the patient is (probably unnecessarily) supine and immobilized. Is a shoulder strap really more secure than a cross chest strap? Not from what I’ve seen, which brings me to the second point. About 90% of the time, the shoulder straps are applied incorrectly. They don’t go over the shoulders and the buckle is NOT centered. In an accident chances are they are going to do nothing for the patient. It’s obvious to anyone who works in EMS that the shoulder harnesses were poorly designed afterthoughts to appease some risk manager who read something about straps, stretchers, and terrible things happening to patients. Really, we need to look at this issue objectively and if straps are needed, design a more secure system that is easier to us. I probably should have made a blog post out of this, but I think it’s better off in your comments section.

  • PC says:

    Thanks for the comments. I do agree that straps when they are put on are probably not fastened right. Also, I have had many patients end up nearly srangling themselves as they squirm aound. Stroke patients are particuarly hard to strap in.I have also seen several varieties of straps. The ones we use to have were made out of a cheap material that had very sharp edges. Many of us refused to use them for that reason. Now we have the seat belt material type that are less likely to cut.I added a section to the origional post to address the research angle. Basically the nation’s foremost expert says they are a good idea. I don’t know if this is based on her safety research, which is extensive or just her sense of what makes sense.

  • brendan says:

    Any shoulder strap doubters simply need to contact Alert Ambulance in Fall River, MA, and ask them what happened back in the early 90’s that made lack of all straps a terminable offense at their company.

  • TOTWTYTR says:

    Expert or not, I’d still want to see what the science is on how well shoulder straps work. Brendan, anecdote isn’t evidence, nor is anyone suggesting that no straps be used. What we’re questioning is how well shoulder straps do at achieving the goal of increasing patient safety. If there is a better way to secure patients, then we’re all in favor of it. Notice that Stryker changed the design of their shoulder straps so that they are more firmly anchored to the stretcher. That’s a move in the right direction, but so would be determining and marking on the stretcher where the straps should go. As it is, I see about 100 variations on strap mounting in just my service alone.

  • brendan says:

    As for variations in mounting, I wouldn’t recommend anything other than what’s in the owner’s manual for your stretchers. They should identify exactly where the mounting points should be. At that point it’s just a matter of placing them correctly and then enforcing it. In terms of science, I suppose it’s simply a matter of finding out how many patients have been killed in crashes while wearing a full harness or some other lesser amount of straps, if that’s possible.

  • Brick City Medic says:

    In the Brick, we are required to use the shoulder straps. I’m one of the few who actually do.Peter, one thing I can suggest is to get the 12-Lead and lung sounds before you start moving. Once that’s done, you really shouldn’t have to unbuckle them again, sans re-assessing lung sounds. Even then, you can just loosen them so you can get your stethoscope to the patient’s back. Hope this helps.

  • KQUARTERS says:

    Hi I really enjoy reading your blogs and the various links to other EMS related articles/figures. Keep up the great work, your writing is interesting to read and I learn quite a lot from them as well. I’m currently x months into my job as a EMT-B. I do mostly transports (interfacility~dialysis) to code 2’s and flight calls. Keep up the great work.

  • Tom Reynolds says:

    Here in London, UK we only have two straps, both horizontal, one across the chest, the other around the knee area.We don’t have 5-ways, or even restraints – those two straps are *it*.While I suspect I wouldn’t always fully strap with 5-ways, it’d be nice to have the option.(And it used to be that the straps were fabric and hard to clean, so you can imagine what an infection risk *that* was. The strap on our carry chair is still fabric mind).

  • TOTWTYTR says:

    Brendan, if anyone would publish any statistics on this, I’d be happy. They haven’t, and I have a sneaky suspicion it’s because they don’t have any.

  • brendan says:

    I think they’re going to be impossible to get- I can’t imagine many people would volunteer information that could be used against them. Unless the police collect that kind of info in the course of the accident reconstruction investigation, I doubt you’d get it after the fact- assuming what they do get is is accurate.

  • kquarters says:

    In the area I work in, Kaiser patients are the only ones that REQUIRE the usuage of the shoulder straps which I believe was due to an accident in which a pt. who was not shoulder strapped flew out of the gurney in a crash.

  • TOTWTYTR says:

    Which is why, Brendan, that this is “non evidence based medicine” of the worst kind. We think it might help, but we really don’t have any clue if it does. A lot of money and aggravation because this sort of resembles something in the front of the ambulance that works, even though the circumstances are different. That’s why EMS will continue to remain a trade and not a profession.

  • PC says:

    Thanks for all the comments and excellent debate on this issue.The research that Levick does that I am familiar with is is she does the crash test dummy routine with ambulances and films it.They are absolutely chilling to watch. She shows the dangers of unstrapped patients and you can watch how the patients fly out of the improperly secured straps. One of the films she did showed how the new fangled side harness straps that were suppossed to let medics move around and yet still stay secured, would basically strangle the EMT in an accident.If anyone gets a change to hear one of her lectures — she is a well traveled speaker — ought to.Thanks again,PC

  • Anonymous says:

    I am just a civilian but have unfortunately been a passenger in a ambulance and the only thing that was strapped down was my head and the stretcher in the wheel mounts. At the time I didn’t think a whole lot about it ( more important things to worry about) but after reading this post- scares me- a lot could have happened but thankfully didn’t and at the time I wasn’t exactly still either due to the pain I was in at the time. A lot to ponder.

  • Rogue Medic says:

    I have yet to see these shoulder straps in person. I looked at the site and it looks like it was designed by someone who is infatuated with powerpoint. It doesn’t give a good feel for the information at all.The Best Practices link recommends coming to a full stop at red lights and stop signs. We need to discourage this. There is no reason to believe this is any safer than slowly rolling the stop sign or red light at walking speed. This is the kind of thing that appeals to the there ought to be a law types, that actually decreases safety.We do need to improve safety. Teaching better driving safety, instead of the EVOC misinformation that produces truly scary drivers. Why does it seem that somebody stumbling out of a bar at 4 AM would be a safer driver than the EVOC graduates I work with?

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