To Walk or Not To Walk?

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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Comments

  1. Great stuff, I love it! Indeed the blanket no walking policies are for billing and billing alone which makes me sick, but what can you do other than follow the protocols, policies and rules, in that order.
    It was inspiring when I heard from one viewer of the Chronicles who told me he knew I had no fear when I walked people to the cot or rig. When in fact i was simply doing what I always do.
    And as we all saw, the first man in the film was not having a cardiac event after all, so he does not fit into your list, but a good many others do.
    For example, the language barrier with the gentleman with the laceration to his forearm. If i can’t get a for sure rule out to walk, the cot comes to him.

    I like that your post touches often on common sense.

    THM (Sounds like a movie channel)

    HM

  2. My service does not exactly have a “No walking policy” but it is frowned upon. There have been some major cases and issues in surrounding services as well as mine that has resulted in our Medical Control as well as my employer to crack down on patients being walked.

    Are these cases where I feel a patient could been walked? Absolutely not. One was in another city, and got a great deal of publicity: a paramedic walked a potential MI patient down 3 flights of steps to his ambulance. The patient coded and died, and the paramedic falsified his chart stating that the patient was stair chaired. His defense was “Well, we usually stair chair everybody so I just wrote that out of habit. That service now has a “carry EVERYONE policy.”

    Another was in my service. A crew had an elderly epistaxis patient who they walked out the door in 30 degree weather with no jacket/robe and in socks. The patient also had a CHF History, and she was so anxious and worked up that she actually flashed as a result.

    From reading everything that both of you have written, it appears that your providers in both of your services have earned a lot of leeway and have shown that they have the ability and knowledge to make the “lets take a stroll” judgement. I think some people take it too far though, and walk too many people. One poor decision whether it be a well informed one or not could jeopardize the integrity and reputation of an entire department.

    Do I walk people? Absolutely. Do I walk as many as I could? Absolutely not.

    Just my 2 cents!

  3. Thankfully I work in a system that allows for common sense. I’m sure every once in a while someone screws up but for the most part things go well.

  4. Interestingly a study of c-spine motion during extrication found that the test subjects had the least amount of c-spine motion when allowed to exit the vehicle with a c-collar applied and no additional assistance. Link http://www.jems.com/news_and_articles/columns/Wesley/are_c_spine_precautions_for_everyone.html

    A policy like everyone must be carried inevitably leads to three things:
    1) impossibility of enforcement
    2) falsification of documentation
    3) decline in respect for authority

  5. If you put a c-collar on them for a potential spinal injury then you shouldn’t be walking them to the backboard.

    You’ve never collared someone for protocol and not for actual need?

    I suppose I could’ve TRIED to backboard the sitting, ambulatory prior to arrival head injury patient from his position 25 steps up the stairs with just myself and my partner. But I decided it was safer for everyone involved to walk him, with hands-on, to the stretcher and board.

    I’m not saying I got a kick out of it. I just felt like the three of us going down the stairs in the name of the textbook would feel like a pretty silly decision laying on the sidewalk.

  6. I try to walk patients whenever possible. Dropping a patient while moving them on a litter is the second highest reason EMS crews get sued. (failure to care for the airway is first) If a 300-pound patient can walk out their front door and down the porch steps to the litter, they are much safer then if we tried to carry them.

  7. Steve Whitehead says:

    @ HM, Thanks for the inspiration. Really good topic. I think our medicine is very similar.

    @ Scott, I agree that we get a lot of leeway and, to a degree, we’ve earned it by using good judgment and putting pressure on medics who don’t. But it always pains me when administrators make blanket policies instead of dealing directly with the medic who used poor clinical judgment in the first place. It’s easier to make a blanket rule than to properly build your people.

    @Greg I’m all for the c-collar stand and turn move, but I’m not for the c-collar and walk to the ambulance move. I think one is often practical and one is often lazy.

  8. Steve Whitehead says:

    CBEMT I didn’t say I’ve never collared someone for protocol CB, you said that. but I did say I’ve worked in many different systems over the past two decades with many different policy manuals and protocols. I’ve c-spined people for a lot of unnecessary reasons in my career.

    But now I c-spine people for only one reason, because, based on mechanism or presentation, it’s clinically indicated. And I take responsibility for the decision to do it, or not do it. When it’s indicated, I do it right. When it’s not, I don’t do it at all.

    If the guy at the top of the stairs has a clinical indication for c-spine then he’ll get it right there and I’ll gladly carry him down on a backboard. If my partner and I aren’t up to the task then I’ll call for assistance. And if he’s not indicated then I’ll walk him down to the pram sans immobilization and transport him.

  9. Steve Whitehead says:

    @Julian I hear what you’re saying Julian, but personal liability should never trump clinical judgment. Walk them because it’s safe and reasonable to do so.

    Would you mind if I asked your source on the #1 and #2 liability statement? I was in a podcast last week with Chief Skip Kirkwood who is also a lawyer and he felt that our greatest liability was “High Risk” AMA refusals. Sick people who need to go to the hospital but refuse our care. http://emsgarage.com/archives/494

    I’m interested to read your source. It could make for a good future post.

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  1. [...] started off the month with a bunch of questions. What does it mean to be safe at home, to walk or not to walk and five hard questions about EMS 2.0. Then I told you all about L.C.E.S. for EMT’s, trust as [...]

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