The Happy Medic (THM) recently posted a fantastic topic on his blog. I love diving into controversial decisions that we have to make every shift. Here’s one of those questions that we need to answer on just about every call. Should we walk the patient to the pram or carry them?
This is one of those things that we have no choice but to address in every system on just about every call. How to we get the patient to the pram? When is it OK to walk them?
It seems like this subject got rolling on Justin’s (THM) blog when EMS types from around the country started sending him feedback about his role in the documentary film, The Chronicles of EMS. He was surprised by the volume of comments about him choosing to walk patients to the ambulance.
Unfortunately, I understand the surprise of some of the Chronicles viewers. I once worked in a system where allowing a patient to walk to the pram was taboo. Allowing EMS providers to use their judgment was also taboo so the no-walking policy went hand-in-hand with the general management style.
Now I work in system much like Justin’s. Our operational guidelines give care providers much more leeway. Using good judgment, doing things that make sense and being accountable for the decisions that you make are all given a higher priority than strict adherence to thick policy manuals that outline every aspect of operational minutia. (Whoa, that was quite a mouthful.)
When I transitioned from the carry-everyone-to-the-pram mindset to the do-what-makes-sense mindset it took a bit of adjustment. Here are a few of the things I’ve learned about walking folks to the bed or even the ambulance.
1) Ask the patient about the last time they walked. Have they been sitting for a long time or have they been up and about? If they were walking around, how did it feel? Have they had any dizziness or ataxia? If so, you might want to rule out walking them.
2) Don’t even try it if the patient has potential cardiac, respiratory or hemodynamic instability issues and be cautious with altered mental states (including intoxication.) It’s important that your decision to walk the patient be guided by common sense.
If you put a c-collar on them for a potential spinal injury then you shouldn’t be walking them to the backboard. If they’re post-ictal, they shouldn’t be walking down stairs. Think about whether or not walking and exertion could make their condition worse. If you don’t feel confident, don’t road test them.
3) Stand them first, then walk them.When your ready to walk the patient, reach down and grab their pulse. Then ask the patient to stand. (Not walk.) Let them stand and get their bearings for a few seconds. Feel their hearts response to the positional change. Watch their expression and skin.
If anything doesn’t look right, ask them to sit back down immediately. Figure something else out. If everything looks OK and the patient reports feeling fine ask then to walk with you but keep that hand on their pulse until you are comfortable that they’re good to go.
4) Spot them. Just like a gymnastics instructor. Stand in a position where you can catch them if they loose their balance. If the patient needs to navigate some stairs, position someone above and below and watch them close. If the patient is heavy, you may need a couple people to help you. And if the patient does fall, remember that you your role isn’t to catch them but to help them to the ground.
Use you medical judgment and don’t get complacent. Walk the patient when it makes clinical sense to do so. If you’re walking your patient out of laziness, you’re bound to end up with some ridiculous policy forbidding you to do it anymore. Be smart and those policies won’t ever be necessary.
Now it’s your turn: Does your organization have a policy regarding waking patients to the pram? What guidelines do you use when making this decision?
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