Evaluation of Paramedics Tasks and Equipment to Control the Risk of Musculoskeletal Injury

FINDING SOLUTIONS Research at the Workers’ Compensation Board

1150-20 B 1999 (99FS-14)

EVALUATION OF PARAMEDICS TASKS AND EQUIPMENT TO CONTROL THE RISK OF MUSCULOSKELETAL INJURY

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Phone (604) 276-3068 / Fax (604) 279-7406 Toll-free within BC – 1-800-661-2112 1150-20 A1999 (99FS-14

Evaluation of Paramedics Tasks and Equipment to Control the Risk of Musculoskeletal Injury

Issue: Reducing the risk of musculoskeletal injury for paramedics. Agency: Ambulance Paramedics of British Columbia CUPE Local 873 Representative: Donald Cragg Funding: $49,500.00

Context: A paramedic’s work environment is often unpredictable. The confined space of the patient compartment, the task requirements, and the configuration of equipment within the patient compartment contribute to the risk of MSI. Currently there is little information regarding design guidance for ambulances and related equipment that is based on prevention of MSI through the application of ergonomic principles.

Objective: To evaluate aspects of the main stretcher and patient compartment of the ambulance that contribute to the risk of musculoskeletal injury for paramedics, to priortize issues and suggest possible solutions, and to evaluate two of the suggested solutions.

Design: The study had three phases. The initial phase, an evaluation of BC Ambulance Service’s (BCAS) ambulance design specifications and work performed by paramedics within the ambulance, included a questionnaire distributed to all BC paramedics, simulations of composite task scenarios, and simulations of individual task components. During the second phase, focus groups were used to prioritize issues and brainstorm possible solutions to the findings from the initial evaluation. The third phase was an evaluation of two potential solutions, the use of a mechanical lift assist (Antboxx) on the main stretcher and redesign and configurations of the jump kits.

Setting: Ambulance stations throughout British Columbia, and the Chilliwack, BC driver-training course.

Subjects: 269 BC paramedics responded to the questionnaire. The simulations, focus groups and solution evaluations involved paramedics from various BC locations and stakeholders from the union, Paramedic Academy and BCAS.

Main Outcome Measures: The questionnaire analysis provided information on discomfort and injury patterns, and perceptions regarding causation of discomfort and injury and the design of the ambulance and stretcher systems. The simulations are summarized relative to specific awkward postures that were commonly observed and implications for injury.

The focus groups prioritized the problem areas and brainstormed solutions. The evaluation the mechanical lift assists examined the changes in load and force required by the paramedics to lift and lower the stretcher and to load and unload from the ambulance. A cost-benefit analysis was also conducted. The evaluation of jump kit features gathered paramedic opinions on the importance of different kit features.

Results: The questionnaire analysis identified lowering and lifting, pushing over rough terrain and loading into or out of the ambulance as the perceived most physically demanding aspects of using the stretcher. The most physically demanding aspects associated with transporting patients were conducting CPR, accessing patients, and accessing equipment. Paramedics identified the lower and upper back and neck as causing the greatest discomfort and the end of a typical shift, this was consistent with lost-time injury statistics. The task simulations identified ten activities that presented risk to the lower back and the concurrent risk factors and ten activities that presented risk to the upper back or shoulders and the concurrent risk factors.

The focus groups not only gathered information but also raised awareness of musculoskeletal injury prevention. Two priority activities were selected at each focus group to brainstorm solutions. The priority areas differed for focus groups but those selected were: raising and lowering main stretcher, heavy patient on stretcher, load and unload stretcher, sitting in ambulance, bracing during transport, monitoring vitals, ride suspension, accessing cupboards, jump kit too heavy, and changing main oxygen.

Evaluation of the Antboxx, a mechanical assistive device for stretchers, indicated that force levels required by paramedics to lift, lower or load the stretcher were lower that those required using an unassisted stretcher. The cost/benefit analysis showed that payback of the initial expenditure to outfit the stretchers currently used by BCAS with the Antboxx would require a 17% reduction in back injuries. Size, weight and placement of jump kits were determined to be the most important features in relation to reducing risk of MSI.

Conclusion: The project identified numerous risks and potential solutions for consideration. Several solutions have been considered or were in the process of being implemented during the study. The Antboxx appears to present a viable solution to some of the risks associated with the stretcher. However, it is suggested that a pilot project should be conducted to track its efficacy relative to reducing back injuries and to identify training and logistical issues that will need to be addressed if the system is to be successful. Design and access changes to jump kits must target reducing the weight of the kits and improving the body mechanics while lifting or carrying the kits. Novel or alternative jump kit styles should be tested across regions and stations with varying needs to ensure consensus and to allow regional consideration in the selection of a solution. FINAL REPORT: FINDING SOLUTIONS GRANT 99FS-14 EVALUATION OF PARAMEDICS TASKS AND EQUIPMENT TO CONTROL THE RISK OF MUSCULOSKELETAL INJURY

Prepared for: Grants and Awards Coordinator Workers' Compensation Board 8100 Granville Avenue Richmond, BC, V6Y 3T6

Prepared by: Ambulance Paramedics of British Columbia CUPE Local 873 Unit 2270, 21331 Gordon Way Richmond, BC, V6W 1J9 and: Ergonomics and Human Factors Group BC Research Inc. 3650 Wesbrook Mall Vancouver, BC, V6S 2L2

BCR Project No : 6-08-0793

November, 2000 Final Report: Finding Solutions Grant 99FS-14 i

Acknowledgements

The project was coordinated by Judy Letendre (BCAS paramedic and CUPE 873 member) and Dan Robinson (BC Research Inc./Robinson Ergonomics Inc.), with technical support from the Ergonomics and Human Factors Group at BC Research Inc., including Carmel Murphy, Joanna Zander, Will Jang, and Scott Davis.

The following individuals made significant contributions that assisted in the completion of this project:

BCAS paramedics and CUPE 873 members throughout the province who completed questionnaires.

Stations who generously gave their time to provide task simulation and focus group information- UBC, Surrey, Chilliwack, Langley, Abbotsford, Pentiction, Kelowna, Vernon, Williams Lake, Quesnel, Prince Rupert.

Jim Fissel, Manager Fleet Operations, BCAS.

Trevor Timpson, Region 2 Safety Representative and Stretcher Maintenance.

Tom Breiter, Manager, Safety Programs and Disaster Planning, BCAS.

Don Cragg, CUPE 873.

Roger Gibson, Unit Chief, BCAS.

Wendy Warren, OSH Coordinator, Paramedic Academy.

Wes Lowenberg, paramedic, BCAS.

Eric McCooeye, Unit Chief, Qualicum Beach, BCAS.

Doug Harstrom, Ferno-Washington.

Wayne Burdeny, Stryker Corporation.

Keith Wyss, Parr Emergency Products.

Bill Bailey, Paramedic Academy.

Brent Patriquin, Unit Chief, Prince Rupert and the Rupert crew for their continual support and input. Final Report: Finding Solutions Grant 99FS-14 ii

Executive Summary

The Ambulance Paramedics of BC (CUPE 873) with the support of BC Ambulance Service, and the technical assistance of BC Research Inc. have performed an evaluation of aspects of the main stretcher and patient compartment of the ambulance that contribute to the risk of musculoskeletal injury for paramedics. This included the administration and analysis of a questionnaire to paramedics throughout the province, which provided valuable information regarding discomfort and injury patterns, as well as perceptions regarding causation of discomfort and injury, and design of the ambulance and stretcher systems. Simulations of composite task scenarios were conducted in a moving ambulance on a driver training range, and individual task components were simulated to evaluate risk factors for musculoskeletal injury that are associated with work in the patient compartment or involving the main stretcher. Focus groups were facilitated throughout the province to present preliminary results from the questionnaire and task simulations, which provided the foundation to prioritize issues and brainstorm possible solutions. Based on the outcome of these analyses, and considering knowledge of concurrent activities at BCAS and at equipment vendors, further analysis was performed on two potential solutions. The use of a mechanical lift assist (Antboxx) on the main stretcher was found to provide a potentially viable option to significantly reduce risk of back injury associated with stretcher handling. Aspects of jump kit design and configuration were evaluated within the context of reducing risk of shoulder and back injury. Recommendations were provided to reduce the width and weight of jump kits, provide a backpack style shoulder strap, and investigate alternative placement of the jump kit within the back of the ambulance. This last aspect is also one of the recommendations in concurrent redesign of the rear of the ambulance. Final Report: Finding Solutions Grant 99FS-14 iii

Table of Contents

Acknowledgements ...... i

Executive Summary ...... ii

Background ...... 1

Injury Statistics for BC Ambulance Service ...... 2

Questionnaire...... 4

Demographics...... 4 Physical Job Demands ...... 6 Discomfort and Injury ...... 10 Patient Compartment Design ...... 12 Main Stretcher Design ...... 15

Task Simulations ...... 16

Composite Task Scenarios...... 16 Task Component Simulations ...... 17 Identified Risk Factors...... 18

Focus Groups ...... 23

Paramedics ...... 23 Stakeholders Focus Group ...... 28

Selection of Priority Issues - Synthesis of Data ...... 29

Solution Evaluation...... 30

Main Stretcher Lift Assist...... 30 Jump Kit...... 39

Concurrent Solutions ...... 46

Patient Compartment ...... 46 Stretcher handling...... 46

Benefits Gained From This Study ...... 47

Bibliography...... 48 Final Report: Finding Solutions Grant 99FS-14 1

Background

The British Columbia Ambulance Service (BCAS) employs approximately 3200 paramedics who respond to more than 380,000 calls per year. Calls classified by urgency indicate 40% emergency, 40% non-emergency, and 20% patient transfers. BCAS is responsible for providing emergency care throughout the large and diverse geographical area (947,800 square kilometres) of British Columbia, with approximately 400 ambulances travelling a combined distance of 31,000 kilometres per day. (Ministry of Health, 1997; Yolland, 1997).

The paramedic’s work environment is largely unpredictable and is well established as a source of considerable stress (e.g., Young and Cooper, 1997; Cydulka, et al., 1997; Neale, 1991). Much of the paramedic’s time is spent providing patient care while transporting one or more patients in the patient compartment of the ambulance. The confined space of the patient compartment, the task requirements, and the configuration of equipment within the patient compartment contribute to risk of MSI by requiring the paramedic to adopt and maintain awkward postures (Letendre et al., 1999). While these postures and associated activities may not require large muscle forces when performed in a controlled environment, the motion inherent in the driving environment is likely to demand increased muscle activity (force) to perform the same task. The configuration of the patient compartment in an ambulance and the stretcher systems are controllable features whose modification may be effective in reducing the risk of MSI.

As with other health care providers, the requirements for patient handling present a significant risk of injury to paramedics (Lavender et al., 2000a; Lavender et al., 2000b). While it is difficult to control the variable environment in which a paramedic is required to treat a patient, the design of the stretcher system and patient handling protocols are controllable features that may be utilized to control risk of MSI.

Although the issues of occupational stress and musculoskeletal injury among ambulance paramedics are well documented and established in the literature, the current literature does not adequately relate occupational stress or the risk of injury to the design and configuration of ambulances, stretchers and related equipment in a manner that is useful for generating solutions. Similarly, the current literature is also lacking design guidance for ambulances and related equipment that is based upon prevention of MSI through the application of ergonomic principles. Engineering solutions to ergonomic problems are the preferred route to successful intervention, but must be based on sound analysis of the problems and iterative testing of concepts intended to control risk. Based on his review of MSI among BCAS employees, Yolland (1997) recommended “complete ergonomic assessments of ground ambulances in an effort to identify ways to improve the safety of existing ambulances and to ensure the future purchase of safe and well-designed ambulances” (p. 98).

BC Research Inc. (1999) performed an evaluation of BCAS ambulance design specifications and work performed by paramedics within the ambulance, for the purpose of providing ergonomic design recommendations that would enhance the safety, comfort and efficiency of future ambulance designs. This report provided twenty-five design recommendations that were intended to reduce the risk of MSI for paramedics. Recommendations included changes to seating, storage of equipment, and rear bumper design. These recommendations are discussed in greater detail in the section Concurrent Solutions, below. Final Report: Finding Solutions Grant 99FS-14 2

Injury Statistics for BC Ambulance Service

In the course of their work, BCAS personnel are at high risk for both acute and chronic musculoskeletal injuries (MSI) to the back, neck, arm and wrist (Yolland, 1997). In fact, BCAS has spent approximately $120 million during the past 15 years on costs associated with accidents and injuries. Costs associated with injury, estimated at $3 million per year in 1996, are projected to reach $17 million by 2010 (Yolland, 1997).

MSI’s represent 67% of all injuries sustained by BCAS crew members from 1984 to 1996. Sprain and strain injuries comprised 90% of all MSI’s sustained by ambulance attendants over this time period. Injuries to the lower back and shoulder represented about 40% and 10% of all MSI’s respectively (Yolland, 1997). Data since 1996 indicate that back and shoulder injuries are still prevalent. The high incidence of back injuries and other MSI’s is not unique to the BCAS, but is consistently reported by other ambulance services worldwide (e.g., Lavender et al., 2000a; Mitterer, 1999; Gershon et al., 1995; Nordberg, 1993; Schwartz et al., 1993; Leyshon and Francis, 1975).

Recent injury statistics and associated costs for the period of January 1997 to August 2000 were provided by Peter Yolland, Ministry of Health. Incidents resulting in back and shoulder injury are summarized in Tables 1 and 2. The combined cost of injuries to the back and shoulder of BCAS personnel was 60,560 days lost and $10,683,000 (compensation, medical and rehabilitation costs) during this period. High call volume areas sustain the majority of injuries. Lumbar back injuries are the most frequent incidents for all BCAS regions.

Table 1. BCAS Incidents Resulting in Shoulder or Back Injury (January 1997 to August 2000)

Description Number Days Lost Compensation Medical Rehabilitation Total Cost of Cost Cost Cost Incidents

Shoulder(s) 17 Left 120 Right 144 Total Shoulder 281 12272 $1,507,371 $347,856 $13,961 $1,869,189 Back 221 Back & Neck 463 Lumbar 685 Thoracic 108 Cervical 42 Total Back 1477 48288 $6,860,727 $1,952,819 $768,032 $8,813,546

The purpose of the Finding Solutions project is to identify engineering solutions that reduce the risk of musculoskeletal injury associated with the main stretcher, back of the ambulance, or other relevant equipment. Therefore, injury incidents were classified by a description of the incident and whether the incident involved stretchers, drug kits (jump kits), or the back of the Final Report: Finding Solutions Grant 99FS-14 3 ambulance. Table 2 summarizes these data. The two most frequent type of incidents involved pushing or pulling the jump kit (489 incidents) and lifting the stretcher (452 incidents).

Table 2. BCAS Incidents Involving Stretchers, Rear of the Ambulance or Jump Kits (January 1997 to August 2000)

Description Stretcher Rear of Jump Kit Ambulance acts of violence 3 6 bending 7 4 9 bodily reactions 5 3 carrying 90 4 11 catching 2 8 caught in, under, between 12 94 climbing 6 1 exposure/contact with 10 30 2 slip/trip/fall 38 22 12 lifing 452 37 7 MVI 2 25 N/A (Not Applicable) 27 5 40 overexertion 14 1 60 patient induced (inactive) 1 patient transfer to/from bed/stretcher 111 2 pushing/pulling 70 9 489 repetitive physical motion 1 2 rubbed/abraded 2 stress 1 struck against/by 15 10 27 under investigation 1 thrown against stationary object 8 undetermined 2 4 32 Total Incidents 871 174 791 Days Lost 31769 3670 2109 Compensation $ 4,236,916 $ 513,431 $ 318,529 Medical $ 956,247 $ 96,679 $ 60,955 Rehabilitation $ 170,668 $ 13,961 $ 1,390 Total Cost $ 5,363,831 $ 624,072 $ 380,874 Final Report: Finding Solutions Grant 99FS-14 4

Questionnaire

A questionnaire was distributed to paramedics throughout the province by sending copies to all stations with a cover letter explaining the project and the purpose of the questionnaire. In addition, the questionnaire was posted electronically on the members area of the CUPE 873 website. Anonymity of respondents was maintained by allowing the option of returning completed questionnaires directly to BC Research Inc.

The questionnaire was designed to elicit information regarding the demographics of respondents, physical job demands, work-related discomfort, and design of the patient compartment and main stretcher.

Demographics

A total of 269 questionnaires were returned, representing slightly less than 10% of paramedics in British Columbia. Tables 3 through 6 summarize the demographics and employment characteristics of paramedics responding to the questionnaire. Figure 1 provides further detail regarding the age distribution of respondents.

Table 3. Demographics of Paramedics Responding to Questionnaire

Mean Minimum Maximum Standard Deviation

Age (years) 41 20 63 9 Weight (pounds) 182 112 280 33 Height (inches) 69 (5'9") 48 (4'0") 76 (6'4") 3.7 Gender 75% male 25% female Hand Dominance 87% right 13% left

40 35 30 25 20 15 10 5

Number of Paramedics 0 20 23 26 29 31 34 37 40 43 46 49 52 54 57 60

Age (Years) Over 60

Figure 1. Age distribution of paramedics responding to the questionnaire. Final Report: Finding Solutions Grant 99FS-14 5

Table 4. Certification Level

Paramedic Number of Certification Respondents Level

Driver only 1 OFA 9 EMA I 104 EMA II 122 EMA III 27 EMD 2

Table 5. Geographical Regions

Geographical Region Number of Respondents

1: Vancouver Island and Surrounding Islands 58 2: Lower Mainland to Lilloet, including Hope 85 3: Okanagan; Revelstoke to Ashcroft; Clinton to Osoyoos 54 4: Kootenays; Nakusp to US border; Field to Grand Forks 20 5: 100 Mile House to Mackenzie; Valemount to Bella Coola 19 6: Hazelton to Queen Charlottes; Stewart and Atlin 11 7: Vanderhoof to Smithers; Atlin and Deese Lake 7 8: Chetwynd and north 9

Table 6. Employment Characteristics Job Factor Mean Minimum Maximum Standard Deviation Years at BCAS (full time) 13.1 <1 32 8.8 Years at BCAS (part time) 7.3 <1 28 5.0 Hours per week 40 0.5 140 (on call) 17.7 Calls per shift 4.7 0 26 3.7 Usual Vehicle Type 197 Crestline 95 Van 28 Box Employment status 41% full time 30% part time 29% call-out

The distribution of call duration for each region is illustrated in Figure 2. Responses are categorized as less than 1 hour, between 1 and 2 hours, or more than 2 hours in duration. Final Report: Finding Solutions Grant 99FS-14 6

40 <1 hour 30 1-2 hours 20 2+ hours 10

0 Number of Respondents 12345678 Region

Figure 2. Distribution of call duration according to region.

When asked what they tend to do between calls, 40 % of respondents indicated that they read or review training materials; 45% indicated that they rest; and 61% indicated other activities such as cleaning, administrative duties, or home-based activities while on call. While not working on shift for BCAS, 40% of respondents report working at another job, and 71% of respondents report participating in moderately intense physical activity at least 3 times per week.

Physical Job Demands

Paramedics report transporting an average of 3.7 patients per shift using the main stretcher (range: 0 to 30; standard deviation: 2.9); and an average of 4.0 patients per shift in the ambulance (range: 0 to 16; standard deviation: 2.9). Paramedics perceive the average weight of a patient to be approximately 174 pounds (standard deviation: 28), with the typical range of patient weighing between 90 pounds and 290 pounds. The range of patients handled by paramedics were reported to include infants through unusually large adults (7 to 558 pounds).

When asked the maximum patient weight that can be safely and comfortably lifted on the main stretcher by the paramedic and their partner, the average response was 231 pounds (range: 130 to 400; standard deviation: 43). Paramedics report lifting the main stretcher from below knee height for 27% of lifts (range: 0 to 100%; standard deviation: 29). Eighty-six percent of respondents reported that they carry the main stretcher up or down stairs, with 46% of respondents indicating that they carry the main stretcher up or down more than 3 stairs and 5% indicating more than 10 stairs (maximum reported = 20 stairs).

Paramedics were asked to identify the aspects that they find most physically demanding when using the main stretcher (Ferno 35A), transporting patients inside the ambulance, and during other job related tasks. They were also asked to rate the level of effort required to perform specific tasks associated with stretcher use or performed within the ambulance. Level of effort was estimated using a scale of 1 (very easy) to 5 (very difficult). Final Report: Finding Solutions Grant 99FS-14 7

Lifting or lowering the stretcher was most frequently reported to be the most physically demanding activity related to use of the main stretcher (Table 7). Comments indicated that this was related to the weight of the patient and stretcher, but that it was also related to lifting from the lowest position of the stretcher, lifting with an inexperienced partner, or lifting to a height above waist level. These aspects of lifting the stretcher are also related to loading and unloading the ambulance. Loading the stretcher into and out of the ambulance was identified as demanding in terms of the height of lift required, raising and lowering the wheels, guiding the head end smoothly into the antlers of the floor mount, and loading into an ambulance while parked on a slope.

Table 7. Physically Demanding Aspects Associated with Use of the Main Stretcher

Physically demanding aspect Number of respondents Lifting or lowering the stretcher 128 Rough terrain (e.g., snow, gravel, sand, carpet, slopes) 117 Loading into or out of the ambulance 90 Stairs 83 Confined spaces (e.g., hallways, elevators, doorways) 44 Loading onto or unloading patients from the stretcher 22 Use of gatches, handles or straps 22 Pushing or pulling the stretcher 21 Carrying equipment on or around stretcher 18 Fitting tall or large patients on the stretcher 12 Performing CPR on the stretcher 6

Table 8 summarizes the rating of effort for performing specific tasks associated with use of the main stretcher. The greatest effort was perceived to be related to pushing the stretcher over rough terrain and raising the stretcher from the ground.

Table 8. Mean Rating of Level of Effort Required to Perform Tasks on the Main Stretcher

Task Level of Effort (1 = very easy; 5 = very difficult) Pushing stretcher over rough terrain 4.0 Raising stretcher from ground 3.1 Loading patient on stretcher 2.9 Placing stretcher in ambulance 2.4 Removing stretcher from ambulance 1.7 Raising head/back rest 1.4 Final Report: Finding Solutions Grant 99FS-14 8

Table 9. Physically Demanding Aspects Associated with Transporting Patients in Ambulance

Physically demanding aspect Number of respondents CPR 80 Accessing patient (e.g., right side, legs) 61 Accessing equipment (e.g., under bench, across patient) 57 Seating (e.g., bench high, seat belts, too deep, sideways) 51 Ride quality/bracing 39 > 1 patient/transfer of #9 stretcher to bench 32 Confined space (e.g., head room, foot space, moving in vehicle) 22 Bending over (unspecified context) 19 Monitoring vitals 19 I.V. 18 Combative patients 11 Vomiting/turning patient 9 Writing (e.g., while in motion, no writing surface) 9 Bag valve mask 8 Repositioning patient 7 Communication/noise levels 7 Intubation 6

Within the ambulance (Table 9), the most physically demanding activity reported by paramedics was performing CPR, which is inherently demanding due to the requirement for chest compressions. Paramedics also identified the effort required to access the patient and equipment within the ambulance as physically demanding. The height, depth and orientation (sideways) of the bench seat, as well as the position and lack of arm rests on the jump seat at the head of the stretcher were identified as contributing to the physical demands of providing care to the patient. The procedure for positioning the secondary stretcher (#9) on the bench seat when transporting more than one patient was identified as a physically demanding task.

The level of effort required to perform tasks within the ambulance was perceived to be greatest for CPR, loading the #9 stretcher, writing while the vehicle is in motion, and working from the jump seat (Table 10). Final Report: Finding Solutions Grant 99FS-14 9

Table 10. Mean Rating of Level of Effort Required to Perform Tasks within the Ambulance

Task Level of Effort (1 = very easy; 5 = very difficult) CPR* 4.0 Loading #9 stretcher 3.8 Writing* 3.1 Working from the jump seat* 2.9 Intubating or initiating IV 2.8 Working from the bench seat* 2.7 Monitoring patient status* 2.6 Accessing cupboards* 2.2 Removing portable oxygen 2.1 Removing monitors 1.9 Raising head/back rest* 1.8 Removing the jump kit 1.7 Note: * indicates tasks performed while vehicle is in motion

Table 11. Physically Demanding Aspects Associated with Other Job Related Tasks

Physically demanding aspect Number of respondents Lifting patients from the ground 52 Changing main oxygen tank 43 Extrication (from car, boat, plane) 38 Stairs 34

Carrying equipment (e.g., jump kit, O2, monitors, clamshell) 32 Removing equipment from the ambulance 18 Cleaning or restocking the ambulance 17 Unfit or inexperienced partners 12 Chair cot 12 Handling heavy patients 10 Performing protocol on the ground (e.g., CPR) 9 Prolonged sitting 5 Final Report: Finding Solutions Grant 99FS-14 10

Of the other job related tasks (Table 11), there were several issues identified that are due largely to uncontrollable variables in the work environment. This included the need to lift patients onto the main stretcher, extricate patients from an accident site, and navigate stairs. However, several issues that are directly influenced by the design and selection of equipment were also identified. This included changing the main oxygen tank, removing equipment from the ambulance and carrying equipment to or from the accident location. Equipment most frequently identified in comments were the jump kits, oxygen tanks, and monitors. These are used routinely for a high percentage of calls.

Paramedics reported using the main stretcher to assist in carrying some equipment, with 96% of respondents placing oxygen tanks on the stretcher, 50% placing patient's personal effects and clipboard on the stretcher, and 32% using the stretcher to carry monitors or defibrillator. Approximately 25% of respondents report using the main stretcher to carry the jump kit.

Paramedics were asked to rate how tired they feel at the end of a typical shift, using a rating scale from 1 (very alert) to 5 (exhausted). The median response was 3 (standard deviation: 1.1).

Discomfort and Injury

To gain insight into the regions of the body that are at greatest risk for injury, paramedics were asked to rate the level of physical discomfort that they experience at the end of a typical shift. Discomfort was rated on a scale of 1 (no discomfort) to 5 (severe pain). Figure 3 provides a summary of the number of respondents rating discomfort as 3 or greater for specific body parts.

Discomfort or pain in the lower back was reported by 50% of respondents. Discomfort or pain in the upper back and neck were reported by more than 20% of respondents, and in the right or left shoulder by more than 10% of respondents.

Paramedics reported that low back discomfort was related to prolonged sitting within the ambulance (front or back seats), unsupported sitting in the bench seat, lifting (patients, stretchers, equipment), and maintaining awkward postures while treating patients, particularly during long transfers. Upper back and neck discomfort were also related to these contributing factors, but were also perceived as related to stress (increased muscle tension) and driving posture (upper back).

Discomfort in the shoulders was perceived as related to removing equipment from the ambulance (jump kits, monitors, oxygen), carrying equipment, and carrying patients long distances on the #9 stretcher or spine board when access with the main stretcher isn't possible.

The level of discomfort reported in the back, neck and shoulders, as well as the factors that respondents perceive as contributing to this discomfort are consistent with the lost-time injury statistics provided in Tables 1 and 2, and with self reported injuries in Table 12. This may be due in part to high levels of discomfort among respondents who have experienced an injury, but is also likely to represent respondents who experience discomfort but have not yet experienced a lost-time injury. Final Report: Finding Solutions Grant 99FS-14 11

140 120 100 80 60 40 20 0

Frequency of Discomfort Rating 3 to 5 3 Rating of Discomfort Frequency r r t t d e e k d d k k s g g e e m m m m o o c c c a y y r r r r n n k e e d l l o o e d a a c e e e l l a a a a a a f f

o u u h h b b L N r r r r t R H L L R r r t R o o e e e e L R e e u h h p p w w s s p p p w B o o l l p L u u o R L U L L R R

Figure 3. The number of discomfort ratings of 3 to 5 for each body part.

Work-related lost-time injuries (WCB claim while employed as a paramedic) were reported by 50% of respondents, with 50% of those with a lost-time claim indicating that they have reported more than one claim, and 54% reporting that they continue to experience pain or discomfort related to their injury. The body parts injured and resulting in lost-time claims that were reported in the questionnaire are summarized in Table 12.

Table 12. The Most Frequently Injured Body Parts Resulting in Lost-time Claims

Body Part Number of Lost-Time Injuries Reported Lower back 112 Shoulder 34 Leg 23 Upper back 15 Neck 14 Lower arm and wrist 11 Foot and Ankle 11 Upper arm and elbow 5 Hand and fingers 9 Final Report: Finding Solutions Grant 99FS-14 12

Patient Compartment Design

Paramedics were asked to rate the adequacy of features within the patient compartment, within the context of performing their job safely. Table 13 provides a summary of the number of respondents indicating each rating category for the design features of the patient compartment. Figures 4 - 7 provide an illustration of these data.

Table 13. Rating of Features within the Patient Compartment

Frequency of Rating: Very Poor Good Very Excellent Poor Good Environment Lighting 1 19 139 76 37 Noise 37 130 91 11 3 Vibration 81 105 74 9 2 Layout Overall space 10 44 151 46 21 Overhead clearance 17 60 127 50 19 Access to patient 13 60 157 31 9 Line of sight to patient 7 26 153 61 20 Access to equipment while seated 54 129 62 21 5 Access to equipment while standing 11 57 149 45 9 Access to jump kit 24 80 120 39 9 Arrangement of storage/equipment 11 53 162 35 11 Seating Location 19 58 154 32 8 Comfort 49 116 81 20 4 Back support 95 105 53 13 4 Seat padding 26 67 146 26 7 Seat belts 49 63 126 28 8 Handles, Latches, Knobs Ease of opening 16 65 147 32 10 Comfort 14 47 164 32 8 Within reach 15 49 167 27 11 Adequate number of handholds 20 49 150 38 11 Placement 15 54 155 34 11 Final Report: Finding Solutions Grant 99FS-14 13

180 160 140 120 100 80 60 40

Frequency of Rating 20 0 Lighting Noise Vibration

very poor poor good very good excellent

Figure 4. Rating of features related to the environment within the patient compartment.

180

160

140 g 120

100

60 Frequency of Ratin of Frequency 40

0 Overall space Overhead Access to Line of site to Access to Access to Access to Logical clearance patient patient equip seated equip jumpkit storage standing

very poor poor good very good excellent

Figure 5. Rating of features related to the layout of the patient compartment. Final Report: Finding Solutions Grant 99FS-14 14

180 160 140 120 100 80 60 40 Frequency of Rating Frequency 20 0 Location Comfort Back support Padding Seat belts

very poor poor good very good excellent

Figure 6. Rating of features related to seating in the patient compartment.

180 160 140 120 100 80 60 40

Frequency of Rating Frequency 20 0 Ease of Comfort Within Adequate # Placement opening Reach handholds

very poor poor good very good excellent

Figure 7. Rating of features related to handles, latches and knobs in the patient compartment.

These data indicate that paramedics rate the noise and vibration levels in patient compartment to be high. Paramedics rated the ability to access equipment while seated as poor, and a large number of paramedics had concerns regarding access to the jump kit, access to the patient and overhead clearance. The comfort and back support provided by seats in the back of the ambulance were rated as poor or very poor by a large number of paramedics. Respondents appear to be generally satisfied with the handles, latches and knobs provided. Final Report: Finding Solutions Grant 99FS-14 15

Main Stretcher Design

Paramedics were asked to rate the adequacy of several features on the main stretcher (Ferno 35A), within the context of performing their job. Table 14 and Figure 8 summarize the responses. With the exception of the head raising mechanism and removal from the ambulance, all other aspects were rated slightly lower than "good". The pull handle, manoeuvring, and weight were rated poor or very poor by more than 35% of respondents. Raising and lower the stretcher, loading into the ambulance, pinch points, and patient straps were rated poor or very poor by more than 25% of respondents.

Table 14. Rating of Features on the Main Stretcher (Ferno 35A) Frequency of Very Poor Good Very Excellent Rating: Poor Good Handles 11 52 171 25 1 Pull handle 42 80 121 21 1 Raising mechanism 9 63 165 24 3 Lowering mechanism 10 63 164 24 4 Head raising mechanism 2 43 161 54 7 Weight 11 88 143 19 1 Pinch points 14 65 154 22 0 Manoeuvring on wheels 22 79 132 29 1 Removing from ambulance 4 39 164 49 7 Transferring into ambulance 11 68 149 31 6 Patient straps 20 66 143 28 2

180 160 140 120 100 80 60 40 20

Frequency of Rating 0

s t g e e le m m m h ts c d is ig n in n n n e vr la a anis a W poi u u H l handle ch h e b e ech o m nt straps inc n a e Pul m m a g mechanis g P M o n t Pati in in ng from ambulancng Raisi i rri Lower fe mov s Head raising e n R ra T very poor poor good very good excellent

Figure 8. Rating of features related to the main stretcher (Ferno 35A) Final Report: Finding Solutions Grant 99FS-14 16

Task Simulations

A series of task simulations were conducted to allow an analysis of risk factors for musculoskeletal injury during a variety of tasks that are typical for paramedics in British Columbia. The use of task simulations allowed for repeatable, controlled conditions that are not easily observed during typical work.

Task simulations were conducted in two environments. The Chilliwack Driver Training Range was utilized for simulation of composite task scenarios while the vehicle was in motion. Performance of tasks with vehicle motion was important to ensure that working postures represented the level of bracing that was typical of actual work in the ambulance. In addition, individual task components were simulated in a stationary environment (no vehicle motion) using personnel at stations in Chilliwack, Langley and Abbotsford. Collectively, the composite task scenarios and individual task components that were simulated included most of the activities related to the patient compartment, main stretcher or equipment that had been identified as problematic in the preliminary analysis of questionnaire feedback.

Composite Task Scenarios

Composite task simulations were conducted at the Chilliwack Driver Training Range using a new Crestline ambulance, a Ferno 35A stretcher, and a training dummy as the patient. The driving route on the test track required both left and right turns typical of city driving, sharp turns, stop sign and rapid braking (simulated emergency stop). Typical driving time ranged from 10 to 15 minutes per scenario.

Composite task scenarios included: • code 2 simulation; • code 3 simulation; • CPR while in motion; and • code 3 simulation with ALS. The code 2 scenario was transfer of a patient with a splinted leg fracture, initiated with the patient on the stretcher. This scenario included manoeuvring the stretcher to the ambulance, transfer of the stretcher into the ambulance, patient care while in transit, and transfer out of the ambulance. Driving patterns were non-urgent. Patient care while in transit included the following activities: • raising the head of the stretcher; • placing blankets under one leg; • monitoring vital signs; • administering onboard oxygen; • administering entonox for pain; • dealing with a vomiting patient; and • paper work. Final Report: Finding Solutions Grant 99FS-14 17

Code 3 scenarios involved transfer and care of a critically injured motor vehicle accident victim, initiated with the patient on a spine board placed on the main stretcher. Paramedics were required to transfer the patient on the stretcher into the ambulance, care for the patient while in transit, and transfer out of the ambulance and into a nearby building. The majority of patient care was performed from the bench seat. Intubation, use of the bag valve mask and suctioning were performed from the jump seat. Driving patterns simulated urgency and included rapid acceleration, deceleration, and cornering. Patient care while in transit included the following activities: • cutting off a pair of pants to inspect a leg; • monitoring vital signs; • use of suction to clear vomit; • changing a dressing on the lower leg (rebleed); • completing paperwork; and • initiating an IV (if qualified). The Advanced Life Support scenario was identical to the Code 3 scenario, except that there was a requirement for intubation.

The CPR scenario involved transfer of the patient into the vehicle and transportation of the patient to hospital while performing CPR and using a bag valve mask. For this scenario, a first responder was recruited to assist during transit.

Video was recorded during all simulations to allow later analysis. Two miniature cameras were mounted inside the ambulance, and a hand-held video camera was used to record activities outside the vehicle. Participating paramedics were interviewed to identify both perceived issues and potential solutions.

Task Component Simulations

Specific task components were simulated with personnel from stations in Chilliwack, Langley and Abbotsford. Personnel volunteering for the task simulations included both male and female paramedics, with stature ranging from 5' 0" to 6' 7".

Task components included: • loading and unloading the main stretcher from the ambulance; • raising and lowering the main stretcher; • raising and lowering the head of the main stretcher while in the ambulance; • accessing cupboards from the bench seat; • accessing, removing and replacing jump kits; • accessing, removing and replacing oxygen (small tank); • accessing monitors; and • paperwork. Final Report: Finding Solutions Grant 99FS-14 18

Participating paramedics were video recorded while simulating each of the task components, and interviewed to identify both perceived issues and potential solutions.

Identified Risk Factors

Risk of musculoskeletal injury is generally believed to be related to the occurrence of awkward postures, forceful exertion, static postures, repetition and vibration. The greatest risk of injury exists when there is extreme exposure to any single risk factor, or when more than one risk factor occurs simultaneously (Bernard and Fine, 1997). The primary risk factors for musculoskeletal injury that were identified during task simulations are summarized relative to specific awkward postures that were commonly observed. Each of the awkward postures of concern are detailed below in terms of when they are likely to occur, what other risk factors concurrently occur, and the implications for injury.

The motion environment in a moving ambulance presents an unstable and sometimes unpredictable base for working postures. Paramedics have developed a variety of bracing techniques to counteract the motion while seated and while moving within the patient compartment. Several hand-holds are used to maintain three points of contact while standing (feet plus one hand). Feet and legs are often wedged against the stretcher rails or between the stretcher and the bench seat to provided added stability while sitting on the bench seat. Considerable physical effort is required to maintain balance in a moving vehicle while performing tasks such as writing or patient care that require controlled accuracy. Bumps in the road, driving over curbs, executing turns and lane changes at speed, and rapid deceleration or acceleration can all result in transient requirements for high exertion to maintain or restore balance. Communication between driver and attendant, as well as driving style may significantly influence the predictability and occurrence of events that require high forces for balance. Unpredicted changes in motion require high forces to restore posture and present the added risk of impacting against the interior of the vehicle or its contents.

Forward flexion of the trunk occurs in combination with rotation (twisting) and high forces during many activities that are common for paramedics. Flexion in excess of 90 degrees is often sustained for long periods in load-bearing positions. These factors present risk of injury to the lower back. Sitting postures within the patient compartment are generally unsupported due to the requirement to maintain proximity to the patient or equipment, and due to the height and depth of the bench seat. Flexion of the trunk is often accompanied by extension and rotation of the neck to maintain a forward visual field, which presents a risk of injury to the neck. Static extension of the neck in excess of 45 degrees accompanied by rotation in excess of 30 degrees was observed. Activities observed during task simulations that are associated with risk factors for low back injury are listed in Table 15.

Shoulder flexion and abduction occurs in combination with high forces and could be considered repetitive due to the range in activities that result in flexion greater than 45 degrees. Extreme postures of the shoulder (flexion and abduction greater than 90 degrees) that are often maintained for more than 30 seconds are utilized while using hand-holds to brace against motion inside the vehicle or when accessing equipment in the cupboards. Removal of jump kits, monitors and portable oxygen from the ambulance require extreme postures, often combined with ballistic forces to jerk equipment into position. Loading the main stretcher into Final Report: Finding Solutions Grant 99FS-14 19 the ambulance requires that the bottom of the stretcher is lifted clear of the floor. This was observed to require a forceful shoulder elevation (shrug) for paramedics of shorter stature or when the ambulance was parked on an incline. These factors present a risk of injury to the shoulder and upper back. Activities observed during task simulations that are associated with risk factors for injury to the shoulder or upper back are listed in Table 16.

Table 15. Activities presenting risk to the lower back and concurrent risk factors.

Activity Concurrent Risk Factors Sitting (e.g., at station, waiting, in transit) Prolonged, static flexion; rotation, vibration Raising and lowering stretcher High force, flexion Raising stretcher wheels Moderate forces; rotation, flexion, lateral flexion Loading/unloading stretcher High force Entonox access from below bench High force; flexion, lateral flexion, rotation CPR High force; flexion; repetition; static posture Monitoring vital signs Static flexion, rotation while seated Reaching equipment in cupboards High force (bracing); flexion, rotation Reaching far side of patient (e.g., patient High force (bracing); flexion, rotation straps, dressing wounds, cutting clothes) Bag valve mask Static posture; flexion Accessing jump kit/ALS kit on bench seat Rotation; lateral flexion; high forces (bracing) beside paramedic

Table 16. Activities presenting risk to the shoulders or upper back, and concurrent risk factors.

Activity Concurrent Risk Factors Loading stretcher into ambulance High forces, shoulder elevation Releasing stretcher mount High impact forces, flexion, Reaching equipment in cupboards High forces; extreme flexion and abduction Bracing against motion (holding rails) High unpredictable forces; static flexion and abduction Removing jump kits High ballistic forces; flexion or extension and abduction Removing monitors High ballistic forces, flexion Removing portable oxygen High ballistic forces, shoulder elevation and abduction Entonox access and mixing High forces; flexion CPR High forces; repetitive; static flexion Raising head of stretcher from bench seat High forces; flexion of right shoulder Final Report: Finding Solutions Grant 99FS-14 20

Tending to patient (vitals, inspection, etc.) Static posture; flexion; occasional high forces Bag valve mask Static flexion (may be supported by knees)

Typical postures required when removing jump kits, raising the stretcher from floor level, loading the stretcher into the ambulance, tending to a patient from the bench seat, reaching the cupboards from the bench seat, and performing CPR within the ambulance are demonstrated in Figures 9 through 14.

Figure 9. Forward flexion of the back that is typical of raising the stretcher from the lowest level while using good lifting technique. Final Report: Finding Solutions Grant 99FS-14 21

Figure 10. Typical postures required to support the foot end of the stretcher and to raise the wheel carriage when loading a stretcher into the ambulance.

Figure 11. Rotation of lower back and flexion and abduction of the shoulder typical of a one- handed lift of an ALS jump kit from the rear of the ambulance. Final Report: Finding Solutions Grant 99FS-14 22

Figure 12. Forward back flexion while sitting on the edge of the bench seat to tend to a patient.

Figure 13. Forward flexion of the back and shoulder required to reach across a patient to the equipment cupboard. Final Report: Finding Solutions Grant 99FS-14 23

Figure 14. Forward flexion required to perform CPR while the stretcher is in the lowest position within the ambulance.

Focus Groups

Focus groups were primarily designed to obtain feedback and input in identifying priority issues and potential solutions by facilitating brainstorming and discussion sessions with relevant individuals. As a secondary outcome, focus groups provided the opportunity to present preliminary results from the current study, and to increase the overall awareness of factors contributing to the risk of musculoskeletal injury and possible strategies for controlling that risk.

Two sets of focus groups were conducted. The first set of groups focussed on obtaining the participation and input of paramedics throughout the province. In addition, a focus group was facilitated to obtain input from other stakeholders within CUPE Local 873, the Paramedic Academy and BCAS.

Paramedics

Two paramedic focus groups were initially scheduled to occur at the Justice Institute of British Columbia. Recruitment of participants was attempted using a combination of notices in the CUPE 873 newsletter, on the Paramedics of BC (CUPE 873) website, and faxes to local stations. This proved to be ineffective and resulted in the attendance of only two people for the first focus group, and cancellation of the second focus group. Feedback from these individuals, as well as other paramedics, indicated that participation would be more likely if the focus group was held at the ambulance station and within the working schedule of the paramedics. Final Report: Finding Solutions Grant 99FS-14 24

Focus groups were scheduled and conducted at three ambulance stations in the Lower Mainland, and in Penticton, Kelowna, Vernon, Williams Lake, Quesnel, and Prince Rupert. At each station, the paramedics that were working and available at the time participated in the focus group. Groups ranged in size from 1 to 16 participants, and on occasion were interrupted by calls for service that required paramedics to attend.

Process

Focus groups were organized in a three part process that involved: • background presentation; • prioritization of issues; and • brainstorming for solutions to priority issues. The background presentation provided an overview of the project and purpose, statistics regarding the incidence of musculoskeletal injury within BCAS, and an overview of generalized risk factors for musculoskeletal injury. This served to set the tone for the discussion, focus on appropriate types of injuries, and clarify terminology used to refer to risk factors. As a secondary outcome, the background presentation encouraged questions and discussion regarding the project, and assisted in raising awareness of musculoskeletal injury prevention.

Prioritization of issues was guided by a list of activities that had been identified through the questionnaire and task simulations as presenting multiple risk factors for musculoskeletal injury. The initial list of activities that present multiple risk factors for musculoskeletal injury include the following:

• CPR (in ambulance) • Raising/lowering stretcher • Bracing against motion • Raising head of the stretcher • Sitting • Loading/unloading stretcher • Intubation • Raising/lowering stretcher wheels • Setting up intravenous (IV) • Lifting/carrying jump kit • Monitoring vital signs • Lifting/carrying oxygen tanks • Using bag valve mask (BVM) • Entonox tank handling • Access supplies in cupboard • Loading #9 stretcher Paramedics were first asked if there were any activities that were not on the list that they felt should be added to the list. Added to this list by focus group participants were: stretcher too high; ride suspension too rough ; steps into rear compartment too high; poor lighting in cupboards; moving in the back of the ambulance; spine board strapping when in the ambulance; bench seat lids too heavy; items caught in cabinet doors preventing opening and closing; lack of appropriate seat belting method; and handling heavy patients on stretcher. Paramedics were then asked to use a silent ballot approach to vote for the activities that presented their top two priorities for finding solutions.

Brainstorming and discussion were facilitated for the top two priorities at each station that participated. Brainstorming was conducted according to the following guidelines, which were presented and explained to participants: Final Report: Finding Solutions Grant 99FS-14 25

• List every idea (there are no bad ideas) • Do not discuss • Do not judge • Repetition is okay • Everyone contributes A list of possible solutions was generated from the brainstorming session for each of the priority issues. Solutions for Priority Issues

Brainstorming solution lists that were generated for each priority issue are provided below. These represent aggregate lists that include solutions from more than one group of paramedics for a given issue. Suggestions presented include the complete, unedited lists. Some suggestions indicate specific issues that could be dealt with as part of a solution to the priority issue.

Raising and lower main stretcher • More staff to decrease the number of lifts by one person in the shift. • Decrease unit hour utilization. • Increase Ambulances. • Better use of trained assistance. • Lift assist devices. • Decrease weight of ancillary equipment (e.g., O2 bottles). • Collapsible stretcher (head end must raise and fold down). • Trade in adjustable foot end for some other feature because it does not get used enough. • May not need all 7 levels (top one too high, bottom one too low). • Hydraulic lift to raise stretcher up (but gives extra weight when handling stretcher). • Gatches do not always work right - improve mechanism. • Get closer with arms more at side to lift because when squat/straddle stretcher to lift, the arms are in front of body - maybe different handles. • May not be able to use legs to lift because of stretcher shape. • Lifting from the bottom bar results in contact stress on the forearm from the pull handle. • Lighter stretcher but maintain strength. • “Click” or feedback at up position to prevent drop by accident. • Better lateral stability.

Heavy patient on stretcher (general aspects of stretcher handling) • Walk some patients. • Call for help - have marked designated lifting spots on stretcher (good hand positions so bystanders who are assisting can see where to put hands- like on all 4 corners). • Auxiliary mechanical help because cannot always call for extra help. • Stretcher frame of bed and base longer and wider- but must compress into elevator. • Central pivot point on ambulance so can pivot head or foot down/up or level. Final Report: Finding Solutions Grant 99FS-14 26

• End of stretcher can drop down so can turn into a chair (reduce amount of patient handling because if used a chair cot to extricate then do not have to transfer to another stretcher). • Top of stretcher able to move laterally so could move patient closer to attendant. • Top of stretcher could double as a stretcher if removable from legs (i.e. clamshell). • Bigger 4x4 wheels like on strollers. • Better grips on stretchers (more hand conforming). • Safer methods of raising/lowering stretcher. • Fully automatic self loading stretcher (Ferno has a 77A self loading stretcher). • Locking floor guides/tracks on floor for stretcher wheels.

Load/Unload stretcher • Self collapsing stretcher. • Have wheels to release stretcher. • Make a lighter weight, same strength stretcher. • Make stretcher easier to manoeuvre around corners. • Have ability to redistribute weight when have a heavy patient. • Have a leg/ramp drop down as in aircraft to load. • Have a strap/something to pull stretcher in car (hydraulic or air). • Lock out system so can’t lower stretcher below knee height. • Add another hook as a safety device for getting stretcher out of car or strap so can’t come all the way out without a release. • Track for stretcher wheel on floor of ambulance. • More people. • Use slide boards to get people on/off stretchers. • Prevent catching on the antlers when loading/unloading.

Sitting • Increase staff / ambulances to decrease cross coverage. • Increase and better locate Station to minimize cross coverage. • Cross Coverage locations that facilitate the paramedic being able to get out and stretch (particularly when inclement weather). • More focus on station duties and movement; not sitting around because you've been away so long you need to take a break. (We sit in the ambulance with or without the patient and we sit in the station after we've been gone a long time and return). • Need better seat belts on bench. Can’t use existing ones because they pull too far back—lap belt? • Can’t use jump seat for some patients because at head.

Bracing • An ambulance large enough to accommodate multiple staff in the back so they don't have to move around to get equipment. Final Report: Finding Solutions Grant 99FS-14 27

• 3 person ambulances. • A track system that holds the single seat in it and you slide the seat around to where you need to be and lock it in. • Improved ambulance design. • Lower bench seat so feet can reach floor.

Monitoring vitals • Automatic monitors. • Centre mount stretchers so shorter distance to move. • Back rest that comes up when sitting on edge of seat and can fold down.

Ride suspension • Air ride system. • Egg shell/double mattress on bench seat (may make it too high). • Stretcher shocks. • More seat cushioning on seat and better support for back (lateral motion). • Carry spare tire to make sure suspension is loaded - weight helps.

Accessing cupboards • No sliding doors (air or spring operated) but they cannot open on their own. • Wider shelves- easier to access. • Relocate cupboards to same side as patient. • Overhead shelves. • More outside cupboards (rear corners like spine boards). • Have inside/outside access (jump kit, O2, entonox) to reduce reach. • Lights in cupboards. • Rear shelves- cargo netting is difficult to get into, compartments too small for blankets so make to fit, shelves too high and to the side so must twist.

Jump kit too heavy • Empty kit (make it smaller) to contain only what is needed. • Make local, regional, provincial policy for jump kit contents so its not arbitrary to crews – makes it easier for part time staff so know what to expect. • Have in 2 smaller kits. • Have tackle box because is solid and has trays so expands (this used to be the old style). • External/internal door for accessing from ambulance (lower level of access). • Step up plates? • Different cases – pelican, backpacks, kit vests or jump suits. • Install a carrying tray on cot for jump kit. • Slide tray bases in cupboards or on floor for jump kits to reduce pulling forces. Final Report: Finding Solutions Grant 99FS-14 28

Changing Main Oxygen • Relocate. • Liquid or Aluminum tanks (size and weight reduction). • Rechargeable tanks. • Hydraulic lift. • Dolly (skid plate). • Large oxygen tanks are better laying down. • External doors.

Miscellaneous suggestions not related to top two issues • Stretcher handles- make so they do not stretch (see Vernon picture). • Have 2 Entonox tanks- one portable and one quick connect like oxygen. • Access to oxygen, jump kit and ALS kit by inside/outside doors at rear corner. • Suction- use a breakaway cord to make grab and run easier.

Stakeholders Focus Group

A focus group involving representation of key stakeholders from CUPE 873, the Paramedic Academy, and BCAS was facilitated at BC Research Inc. on July 18th, 2000. Participants included Tom Breiter (Manager, Safety Programs, BCAS), Jim Fissel (Manager, Fleet Operations, BCAS), Roger Gibson (Unit Chief, BCAS), Wendy Warren (OSH Coordinator, Paramedic Academy), Trevor Timpson (Stretcher Maintenance, BCAS), and Don Cragg (CUPE 873).

A presentation was provided that outlined the purpose of the project; background knowledge; and preliminary results from the questionnaire, paramedic focus groups, and task simulations. Participants then participated in a round-table brainstorming session to list possible solutions that were seen to be of high priority. This brainstorming session relied partially on the list of solutions generated from the paramedic focus groups, and partially on novel solutions that were generated by the stakeholders. From this list, each participant was asked to record a response to the following question: "what potential solutions should be evaluated for this project… if we can only look at 2 solutions?" Discussion of the results of this vote ensued, with general consensus that the final list represented solutions that were of high priority for evaluation or consideration within this project.

Solutions for Priority Issues

Based on voting and a discussion of the outcome, a set of potential solutions were identified as the highest priority for this project. The basis for selection as a priority for this project included relevance to the identified issues for musculoskeletal injury risk, current considerations of possible solutions, and belief in the likelihood of success. The priority solutions that the stakeholders' focus group selected include:

• jump kit modifications; • slider on the squad bench for transfer of the #9 stretcher; • back support on the squad bench; Final Report: Finding Solutions Grant 99FS-14 29

• methods and equipment that enhance the ability to monitor vital signs in the patient compartment; and • use of the Ant Boxx assistive device to raise and lower the stretcher. The complete list of possible solutions that were identified by the stakeholders' focus group as having strong potential for further investigation is provided below.

• Release bar to close door. • Re-hinge bumper so it can tilt out of the way. • Investigate new materials for stretcher (e.g. carbon fibre). • Wheels on main cot – bigger, easier to push. • Procedures – routine stretcher maintenance. • #9 Stretcher slide on squad bench. • #9 stretcher loading - pulley system. • Monitoring vitals – investigate existing systems (Lifepack 12). • Equipment cabinet at head of bench. • IV - redesign pole to work beside you. • Back support for squad bench (removable) with lateral support – need ability to move away from violent patient. Semi-rigid foam. Made to measure seats. • Passenger seat - foot and leg room. • Investigate existing technologies for raising and lowering stretcher (e.g., ant box). • Raise main stretcher in car (Ant Boxx?) – G-forces on stretcher a concern, battery life an issue. • Jump kit – existing models – standardize equipment and split. • Jump kit – small functional (education an issue, raise awareness of MSI risk). • Jump kit - modular – soft sided with box inserts – shoulder straps in zipper compartment in bottom.

Selection of Priority Issues - Synthesis of Data

Selection of priority issues for the development of solutions required consideration of several factors, including: injury incidence; questionnaire feedback (reported discomfort, design ratings, comments); risk factors observed during task simulations; focus group feedback; knowledge of existing practical options for solutions; and constraints related to completion of this project on time and within budget.

In addition, BCAS was in the process of tendering bids for delivery of new ambulances with several design modifications that were based on a previous ergonomic study (BC Research Inc., 1999). Although these design modifications are outside the scope of the Finding Solutions project, a summary of some of the modifications that have been implemented in the prototype Final Report: Finding Solutions Grant 99FS-14 30 vehicle, and their anticipated effect on risk for musculoskeletal injury is included in the section Development of Solutions, below.

Injury and discomfort data indicated that the shoulder, neck and back are at greater risk of injury than other body regions. Injury statistics, questionnaire comments and analysis of physical risk factors indicate that lifting the stretcher and patient, and handling the jump kit present high levels of risk to the back and shoulders. Task simulations identified numerous activities that require awkward postures of the back and shoulders in combination with either high forces or prolonged static posture.

Focus groups at the ambulance stations identified priority issues that include: raising and lowering the main stretcher; handling large patients; loading and unloading the stretcher from the vehicle; sitting; bracing; ride quality; monitoring vital signs; handling jump kits; accessing cupboards; and changing the main oxygen tank. These issues and corresponding possibilities for solutions were ranked differently at some stations; however, the issue of raising, lifting and loading the stretcher was consistently ranked as a high priority.

The stakeholders' focus group identified 5 priority solutions for investigation, including: jump kit modifications; a mechanism for transfer of the # 9 stretcher; back support on the bench seat; and use of the Antboxx as an assistive device. At the time of the stakeholders' focus group, participants were aware of intended changes to the design of the ambulance that address many of the issues raised during earlier focus groups. This included modification of the mounting system for the main oxygen tank; reducing the height of the bench seat; installation of a side door for access to monitors and the jump kit; and a flip-up rear bumper that allows better access when lifting into the rear of the ambulance.

Considering the above factors, efforts for the Finding Solutions project were focussed on evaluating the effectiveness and feasibility of the Antboxx assistive device and possibilities for modification of the jump kit. Concurrently, a sliding mechanism to assist with transfer of the #9 stretcher from the main stretcher to the bench seat was designed and prototyped by participants of the stakeholders' focus group.

Solution Evaluation

Main Stretcher Lift Assist

The Antboxx (PowerLift Systems Inc., MN) is a battery powered mechanical lift assist designed as an added feature for the Ferno 35A (Ferno-Washington, Inc.) or the Stryker MX and LX (Stryker Corporation) stretchers. BCAS currently use Ferno stretchers. The Antboxx device had been previously identified by BCAS as a possible solution, but had not been seriously evaluated to establish the benefits or operational implications.

Parr Emergency Product Sales Inc. provided an Antboxx unit installed on a new Ferno 35A stretcher, and a knowledgeable sales representative for the purposes of evaluating the Antboxx. Final Report: Finding Solutions Grant 99FS-14 31

Training on the proper use of the device was provided and the sales representative remained available throughout the testing period to ensure that questions were answered.

Evaluation of the Antboxx consisted of an objective measurement of the degree of lift assist provided by the device, an analysis of practical issues for implementation of the Antboxx within the BCAS fleet, and an informal focus group evaluation of the device by key stakeholders. Participants of the focus group were individuals with experience in the selection, design and maintenance of systems for BCAS, as well as practical knowledge of the day to day work requirements of paramedics. Participants included: Jim Fissel (Manager of Fleet Operations, BCAS), Roger Gibson (Unit Chief, BCAS), Eric McCooey (Unit Chief, BCAS), Trevor Timpson (Stretcher Maintenance, BCAS), Don Cragg (CUPE 873), Judy Letendre (CUPE 873 paramedic, project ergonomist), and Dan Robinson (ergonomist, BC Research Inc./Robinson Ergonomics Inc.).

The Antboxx device is powered by a commercially available 12 volt rechargeable battery (Dewalt). An electric motor drives a screw attached to the stretcher's scissor mechanism to provide the mechanical lift. The device is mounted to the underside of the foot end of the stretcher, allowing control of the device by the paramedic loading or unloading the stretcher from the ambulance. The Antboxx is intended to assist with raising and lowering the stretcher and patient, as well as raising and lowering the wheel carriage while loading the stretcher into or out of the ambulance. Because the device acts as a passive brake when lowering the stretcher, it eliminates the possibility of suddenly dropping a patient to the bottom level.

The Antboxx has three functional settings. The "extend legs" setting is used to raise the stretcher and patient, or to drop the wheel carriage when unloading from the ambulance. The "lower patient" setting is used to provide a gradual descent when lowering the stretcher and patient. The "fold legs" setting is used to rapidly raise the wheel carriage when loading the stretcher into the ambulance. While this setting can be also be used to rapidly lower the stretcher, the speed of descent is typically too fast for patient comfort. Operation of the Antboxx requires setting a toggle switch to the appropriate setting and pulling the gatch handle at the foot end to initiate movement of the stretcher or wheel carriage. Use of this gatch handle is required for manual raising and lowering of the stretcher. Paramedics are required to provide stabilization at both head and foot ends while raising or lowering the stretcher, and must provide some of the lifting force when raising the stretcher with a patient on it. When loading the stretcher into the ambulance, the Antboxx is capable of raising or lowering the wheel carriage unassisted.

In the event of battery or mechanism failure, the Antboxx has a manual override system that disengages the motor from the stretcher. This requires the paramedic to remove the battery, cut a thin wire safety seal, move a toggle switch, and manually pull on an "override" handle to disengage the power unit. This procedure can be completed in less than 5 seconds, but requires training to ensure proper execution.

The Antboxx is purported to provide an 80% assist for raising the stretcher with a patient who weighs up to the rated capacity of the stretcher. However, the Parr representative indicated that this was only true for raising the stretcher from the first level above the bottom, since there Final Report: Finding Solutions Grant 99FS-14 32 is minimal mechanical advantage at the bottom level. It was also indicated that the amount of assist provided by the Antboxx was dependent on the charge level of the battery, with adequate power provided for approximately 12 lifts before requiring a battery recharge. It was recommended that each unit be accompanied by three rechargeable batteries: one installed, one charged spare, and one recharging.

Evaluation of Efficacy

Analysis of the effectiveness of the Antboxx focussed on addressing whether there was a significant reduction in the force that paramedics are required to generate throughout stretcher handling, and an analysis of other changes in the task requirements. This evaluation was performed for specific stretcher handling task components, including: raising the stretcher; lowering the stretcher; loading the stretcher into the ambulance; unloading the stretcher from the ambulance; and pushing or pulling the stretcher.

Raising the Stretcher

Without the Antboxx, raising the stretcher with a patient on it requires a paramedic at both the head and foot end of the stretcher. The paramedic at the foot end squeezes a gatch handle with their left hand to release the mechanism that holds the stretcher at the current level. Both paramedics then lift the stretcher to the desired level, supporting the full weight of the patient, bed section of the stretcher and any equipment placed on the stretcher. The gatch handle is released at the top of the lift. Paramedics allow the stretcher to settle downwards into the next postion, and must ensure that the mechanism has engaged before they remove lifting force. Failure to do so can result in dropping the patient to the lowest level of the stretcher. This presents a risk of injury or discomfort for the patient, and risk of injury to a paramedic who may attempt to catch the dropping stretcher.

With the Antboxx, raising the stretcher follows essentially the same sequence, with the following changes. Prior to raising the stretcher, the paramedic at the foot end must use visual inspection or a check with the left hand to ensure that the Antboxx toggle switch is in the "extend legs" position. If the switch is in the "fold legs" position, the stretcher will drop rapidly rather than raise. This unanticipated load may pose an added risk of injury to paramedics expecting the stretcher to be partially supported. The gatch handle is squeezed to initiate power from the Antboxx and to release the mechanism supporting the stretcher. Both paramedics lift the stretcher to the desired level, supporting a portion of the weight of the patient, stretcher and equipment on the stretcher. The Antboxx assists the lift by providing a portion of the lifting force. At the top of the lift, the gatch handle is released to stop the Antboxx motor. Paramedics allow the stretcher to settle downwards and lock into the next lowest position. The weight of the patient and stretcher are supported by the Antboxx, eliminating the potential for an accidental rapid drop.

An evaluation of the lifting force required of the paramedics was conducted to establish how much assistance is provided by the Antboxx. A force transducer (Maywood Instruments, Basingstoke UK) was attached between the stretcher frame and a handle to measure force at the head end of the stretcher while raising the stretcher with a patient weighing 106 kg (234 lbs). Final Report: Finding Solutions Grant 99FS-14 33

This weight is near the 250 lb. rated load of the stretcher and represents the worst case scenario for assisted lifting. Data was acquired to a laptop computer for later analysis.

To raise the stretcher and patient from fully lowered to fully raised position in the absence of an assistive device requires approximately 80 kg force at the head end of the stretcher for a duration of 1 to 3 seconds. Figure 15 illustrates the force required of the paramedic at the head end when assisted by the Antboxx to raise the stretcher and patient from the fully lowered position to the fully raised position.

Load (kg) 20

0 0 2 4 6 8 10

Time (s)

Figure 15. Force profile (kilograms) versus time (seconds) for raising a patient (234 lbs; 106 kg) from the bottom stretcher level to full up position with the assistance of the Antboxx.

A peak force of 58 kg is required at the bottom of the lift where the Antboxx has minimal mechanical advantage. This represents an effort of approximately 73% of that necessary without the Antboxx. Once the stretcher has been raised to approximately 20" (sitting height), the mechanical advantage of the Antboxx increases and the force required by the paramedics decreases to less than 25 kg for the upper portion of the lift. This represents an effort of less than 30% of that necessary without the Antboxx. The time typically required to complete this lift was approximately 4 to 5 seconds. Correct use of the assistive device requires a gradual increase in force applied to exceed the threshold of the Antboxx and to initiate upward movement of the stretcher at the speed of the Antboxx motor.

Correct use of this type of assistive device requires some learning to establish a feel for how much force is required to obtain the optimal benefit of the assist. While learning to utilize the assist, there is a tendency to provide either not enough or more force than is required. Auditory cues from the sound of the Antboxx motor assist in the application of optimal force while lifting, and can be learned in a relatively short period of time. Lifting by a skilled paramedic who has established a feel for the force required is anticipated to reduce the duration of the lift to approximately 3 seconds.

Figure 16 illustrates three types of errors observed while learning to raise the stretcher with the Antboxx. The first error is the application of inadequate supporting force during the initial 2 Final Report: Finding Solutions Grant 99FS-14 34 seconds, which stalls the Antboxx motor. An adequate level of force (58 kg) was then applied to initiate movement from the lowest position. However, beyond the 4 second time mark, an applied load in excess of 40 kg is maintained when a load of 25 kg would have been adequate to assist the lift (second error). Application of the load was applied beyond the time required to have achieved the highest position (third error). To avoid these types of errors, installation of the Antboxx on stretchers should be accompanied by training that specifically addresses the skill of knowing how much force is required by the paramedic for optimal benefit.

load (kg) load 30

0 0 2 4 6 8 10 time (sec)

Figure 16. Force profile for poor technique while raising a stretcher and patient (106 kg) from the fully lowered position to the fully up position using the Antboxx.

It was noted that positioning the stretcher at a higher initial level when loading the patient onto the stretcher would eliminate the high peak force required during the first 8 inches above the fully down position. This practice would also reduce the severity of forward flexion required while performing the lift.

The potential benefits of the Antboxx while raising the stretcher include: reducing the lifting force required of paramedics; guiding the speed of the lift to avoid ballistic lifting; and eliminating the possibility of accidentally dropping the patient. The novel hazards presented by the Antboxx include the possibility of an unanticipated downward motion of the stretcher (unpredicted lifting force) if the toggle switch is incorrectly set. The potential exists for a paramedic to apply more force than is required and for a longer duration than is required. However, the force levels are lower than those required for unassisted lifting. Final Report: Finding Solutions Grant 99FS-14 35

Lowering the Stretcher

Lowering the stretcher may be performed with or without a patient on the stretcher. Without the Antboxx, both situations require the same procedure from the paramedics. With the Antboxx, the procedures vary slightly.

Without the Antboxx, the stretcher (and patient) weight are supported at head and foot ends, and the gatch handle is squeezed to release the mechanism. Paramedics support the weight of the stretcher, patient and equipment while lowering the stretcher to the desired level. The gatch handle is released and the stretcher is supported until the supporting mechanism locks into place. Failure to ensure that the mechanism is fully engaged can result in dropping the patient.

With the Antboxx, the setting on the toggle switch is different with a patient than without. Without a patient, the toggle switch is set to "fold legs". The stretcher is then powered downwards rapidly by squeezing the gatch handle. The paramedic is not required to support any weight. Releasing the gatch handle above the level desired allows the supporting mechanism to engage. The rate of descent of the stretcher is rapid and poses the hazard of pinch or crush injuries if powered to the lowest level with body parts in the stretcher mechanism.

With a patient on the stretcher, the toggle switch is set to "lower patient". Paramedics are required to provide stability at both the head and foot end of the stretcher. Paramedics lift the stretcher and patient slightly to remove pressure on the supporting mechanism, and the gatch handle at the foot end is squeezed to initiate downward motion. The weight of the patient propels the stretcher downwards with the Antboxx serving a braking function to allow a gradual descent. Paramedics are required to support minimal weight (< 5 kg) during the descent and to provide stability. The gatch handle is released immediately above the desired level and the stretcher is allowed to come to rest at the next setting of the supporting mechanism. The Antboxx eliminates the potential for accidentally dropping the patient if the supporting mechanism is not fully engaged. Incorrect setting of the toggle switch to "fold legs" can provide the hazard of an unexpected load on the paramedics and a rapid drop for the patient. In this situation, the rapid drop is controlled by releasing the gatch handle.

The potential benefits of the Antboxx when lowering the stretcher include: minimizing the duration that the full weight of the patient and stretcher must be supported by the paramedic (only to release the support mechanism); improving postural stress while under load by requiring force only at the highest level of the stretcher movement; minimizing the force required while lowering; and eliminating the risk of accidentally dropping the patient. Novel hazards imposed by the Antboxx include: the potential for an unexpected increase in load due to the possible error of setting the toggle switch to "fold legs" when lowering a patient. The potential for crush injuries as the stretcher is dropped to the lowest level exists with or without the Antboxx. However, in the case of rapidly lowering the stretcher with the Antboxx, the crushing force is increased by the power of the motor. Final Report: Finding Solutions Grant 99FS-14 36

Loading the Stretcher into the Ambulance

Without the Antboxx, loading the stretcher into the ambulance requires placement of the head end into the rear of the ambulance by wheeling the stretcher into position. The paramedic at the head end reaches to ground level and manually lifts the wheel carriage to the full up position (Figure 10). The paramedic at the foot end must squeeze the gatch handle to release the support mechanism and allow the wheels to raise. While squeezing the gatch handle, the paramedic at the foot end assumes the full weight required to support the stretcher, patient and equipment on the stretcher. Once the wheels are up, the paramedic at the head end pushes the stretcher into position and locks it in place.

With the Antboxx, the stretcher is first wheeled into position. The paramedic at the foot end sets the toggle switch to "fold legs" and squeezes the gatch handle while lifting to support the weight of the stretcher, patient, equipment and Antboxx. The wheel carriage is raised by the Antboxx within a period of 2 to 3 seconds. The paramedic at the foot end guides the stretcher into position and locks it in place. The paramedic at the head end is not required to raise the wheels and is therefore available to assist in supporting the stretcher as the wheels are raised.

Potential benefits of using the Antboxx include: eliminating the need to lift the wheel carriage; and providing additional available hands to support the stretcher while the wheels are raised. Use of the Antboxx for raising the stretcher may also increase the likelihood that the stretcher is in the highest position to allow the roll-in wheels to make contact with the floor of the ambulance. Novel hazards include the addition of 14.75 lb to the weight of the foot end of the stretcher, which must be supported once the wheels are raised. However, this represents a small proportional increase in weight and may be offset by the ability of the second paramedic to assist in the support of the stretcher.

Unloading the Stretcher from the Ambulance

Without the Antboxx, the process for unloading the stretcher from the ambulance is the reverse of loading. The paramedic at the foot end releases the locking mechanism to free the stretcher, and then pulls it out until the head end catches on the floor block. The paramedic at the foot end squeezes the gatch handle to release the wheels, while the head end paramedic supports the wheels while they drop. The rate of descent of the wheels is uncontrolled and relies on the head end paramedic to prevent a free-fall drop. The gatch is released to lock the wheels in place and the head end paramedic releases the stretcher from the floor block. The stretcher is then wheeled away from the ambulance.

With the Antboxx, the paramedic at the foot end sets the toggle switch to "extend legs" and squeezes the gatch handle to drop the wheels once they are clear of the vehicle. The Antboxx supports the wheels during a controlled descent. The gatch handle is released to lock the wheels in place, and the head end paramedic releases the stretcher from the floor block. The stretcher is wheeled away from the ambulance. The potential exists for the paramedic to forget to set the toggle switch to "extend legs" until after the stretcher has been pulled out of the ambulance. In this case, the paramedic may choose to walk the stretcher back into the Final Report: Finding Solutions Grant 99FS-14 37 ambulance so that the switch can be set properly, or the paramedic may attempt to set the switch while supporting the stretcher. Due to the distance between the gatch handle and the toggle switch, this cannot be performed while maintaining the preferred grip on the stretcher.

The potential benefits include: eliminating requirements for handling the wheel carriage; reducing wear and potential damage to the stretcher caused by free-fall dropping of the wheels. Novel hazards include: increased weight (14.75 lb.) at the foot end due to the Antboxx; and the possibility that a paramedic may attempt to change toggle settings while supporting the foot end of the stretcher.

Pushing and Pulling the Stretcher

The Antboxx serves no purpose while pushing or pulling the stretcher, but adds 14.75 lb. to the total weight of the system. Push/pull forces for a fully loaded stretcher on hard ground were measured using a force meter (Chatillon CSD200) as 5.5 to 17.5 lb. to initiate movement and a sustained force of 3 to 4 lb. to maintain movement. The range of 6 to 17 lb. force required for initiation of movement was dependent more on the initial position of the wheels than on the total weight of the stretcher system. An increase in weight of 14.75 lb. is less than 10% of total system weight (fully loaded) and is not anticipated to significantly influence push/pull forces.

The questionnaire indicated that paramedics use the Ferno 35A stretcher to ascend or descend stairs. The Antboxx adds 14.75 lb. to the weight of the stretcher and is felt more at the foot end of the stretcher. This may affect use of the main stretcher to ascend or descend stairs.

Cost-Benefit Analysis

The Antboxx is capable of significantly reducing, and in some cases eliminating, the forces required when lifting, lowering and loading the stretcher. The current force requirements often exceed the strength capacity of either one partner, or of the combined strength of the paramedic team (Yolland, 1997). In the case of the patient used during testing of the Antboxx, the 80 kg lifting requirement exceeds the strength capacity of more than half of the typical North America population. Reducing this lift to 25 kg brings it within the strength capacity of the majority of paramedics. This reduction in lifting requirements that are beyond strength capacity is anticipated to reduce the number and severity of injuries.

Training in the correct use of the Antboxx and establishment of "best practices" that consider the functional characteristics of the Antboxx are required to ensure that the full potential of the device is realized, and to minimize errors that may result in injury (e.g., incorrect toggle switch setting). Correct use of the Antboxx requires adherence to a protocol for setting the toggle switch. Errors in protocol can present new hazards. However, with training, the potential for injury due to error may be less than that which exists without the Antboxx. With any two person lift, communication and timing between partners is critical. Errors in timing or communication can result in unexpected loads or accidentally dropping the stretcher. The Antboxx mechanism reduces the amount of force being generated by the paramedics, and acts as a failsafe mechanism that prevents uncontrolled descent in the event of an error. Final Report: Finding Solutions Grant 99FS-14 38

Injury statistics for BCAS (Table 2) indicate that more than half of the incidents relating to the stretcher are categorized as "lifting". It appears that the Antboxx has the potential to significantly reduce the physical effort required for lifting aspects of stretcher handling. Testimonial letters provided by Parr indicate that several paramedic services who currently use the Antboxx have experienced a reduction in back injuries. The only letter providing injury statistics was the Waukesha Fire Department (WI, USA), who report reducing back injuries from an average of 9.33 per year to 2 injuries within the first year of implementing use of the Antboxx. While the Waukesha Fire Department appears to have achieved almost an 80% reduction in back injury, this agency is considerably smaller than BCAS, serving 3600 calls per year.

The cost per Antboxx is approximately $1600, uninstalled. Installation requires 2 hours per unit, and weekly maintenance of less than 10 minutes is required for lubrication. Battery charging stations and spare batteries will be required at all stations utilizing the stretchers. Assuming a net cost of $2000 per unit, installed, with spare batteries and a charging station, the cost for BCAS to retrofit 200 stretchers is approximately $400,000.

Based on injury and cost data in Tables 1 and 2, the average cost per back injury is approximately $6,000 and there are in excess of 400 back injuries per year, for an estimated total cost of $2,400,000 per year. Payback of the initial expenditure within the first year would require a 17% reduction in back injuries (68 fewer injuries).

In addition to these considerations, the Parr representative noted that the life of the stretcher that is anticipated to be extended with the Antboxx installed. This is attributed to reduced wear on the supporting mechanisms and scissor joints that result from controlling the descent and lifting rates. Therefore, reduced turnover of stretchers is also anticipated as a benefit of Antboxx installation.

Recommendation

The Antboxx appears to present a viable control measure with the potential to significantly reduce the number of back injuries and associated costs within BCAS. However, implementing the Antboxx fleet-wide would require considerable planning and expense. In order to evaluate the efficacy of the Antboxx within the operational environment of BCAS, a pilot project should be undertaken. This will also serve to identify training and logistical issues that will need to be addressed if the system is to be successful.

In order to track the efficacy relative to reducing back injuries, the Antboxx should be installed on a significant number of stretchers within a defined geographical or hospital region that corresponds to existing means of tracking injury statistics. The number of stretchers required Final Report: Finding Solutions Grant 99FS-14 39 will depend on the region(s) selected, but should allow paramedics within the region(s) to perform their work while predominantly using the Antboxx. Furthermore, the region(s) selected should currently experience a sufficient number of back injuries to allow an effect of 10 to 20% to be identified.

Jump Kit

Risk Factors for Musculoskeletal Injury Associated with Jump Kits

Paramedic, management and union concerns were identified regarding the jump kit contents, features and operational requirements. These aspects of the jump kit were believed to contribute to discomfort and injuries in the shoulder and low back.

BCAS paramedics use 10-20 different jump kit styles, and have the freedom to stock their kits with equipment that is perceived as useful or important. This variability makes an evaluation of risk difficult. In addition, the needs of the Advanced Life Support (ALS) and Infant Transport Teams (ITT) were viewed as different than the rest of the paramedic population. The wide variation in jump kits may indicate a lack of satisfaction with any particular model, or may be related to differing needs.

Risk factors for injury to the shoulder and back that are related to use of the jump kit can be simplified to a few key issues: weight, size, handles or carrying straps, and storage within the ambulance. Repetition adds to postural risk factors when call volumes range towards 26 calls per shift.

The weight of jump kits varies considerably, depending on the contents and style of case. Jump kit weights were measured during station visits for focus groups. Pelican case ALS kits (Figure 11) divided into A and B kits ranged from 10.5 kg to 12.5 kg each, with the lowest combined weight of both cases measured at 21.3 kg. Soft jump kits (A500 and custom kits) were measured at 6.1 kg to 18 kg, with the greatest factor determining weight being the contents selected by the paramedic to include in the kit. The 6.1 kg jump kit was configured with only those items that were perceived as useful on a routine basis.

Most paramedics were observed using the handles rather than shoulder straps to carry their jump kits. A few personalized jump kits that had shoulder straps or back pack straps were observed. The use of hand holds rather than straps increases risk of injury to the shoulder because of the muscular effort required and because of the abducted posture of the shoulder required to allow clearance of kit beside the legs. The thickness of the A500 jump kit and the location of the handle in the centre of the kit places the shoulder at approximately 30° abduction while carrying the jump kit. The narrower Pelican case allows the paramedic to carry with the shoulder at less than 10° abduction.

Jump kits are typically stored at the rear right hand side of the Crestline ambulances, on the floor and oriented perpendicular to the central axis of the vehicle. Therefore, removal of the jump kit from the ambulance requires a reach across the bumper, flexion and abduction of the shoulder, and rotation of the back. When in a hurry, paramedics will commonly jerk the bag from its storage location and drag it from the floor surface, resulting in ballistic impact forces at Final Report: Finding Solutions Grant 99FS-14 40 the shoulder. When practical, many paramedics will place the jump kit on the main stretcher rather than carry it.

Jump Kit Questionnaire

A questionnaire regarding jump kit requirements was distributed to a small group of paramedics, posted on the CUPE office bulletin board and individual interviews were conducted. Information regarding the relative importance and requirements for use of various jump kit features and contents was gathered from the questionnaire and interview responses, and used to identify critical features.

Thirteen paramedic responses were obtained from five different stations. Stations were staffed by paramedics with differing classifications, including stations with all Infant Transport paramedics; a mix of ALS and CMA/EMA I/EMA II paramedics; or all CMA/EMA I/EMA II paramedics. Responding stations ranged in size from 18-29 paramedics , with annual call volumes from 1200 to more than 9000 calls per year. The majority of calls were reported to be medical. The Crestline ambulance was the primary vehicle for 62% of respondents and the van style for the remainder. All except one respondent indicated that they place the jump kit on the stretcher rather than carry it when entering the call.

Jump kit features identified as important by respondents included: size, weight, outer covering and handles, as well as placement of the jump kit within the ambulance. The majority of respondents use the A500 style jump kit (Pacific Emergency Products, Kelowna) with a variety of net weights ranging between 13 and 30 pounds. The A500 jump kit is a rectangular, compartmentalized kit, with a soft shelled, water resistant case, a carrying handle and a shoulder strap. ALS and ITT kits are more varied, including hard cases (e.g., Pelican cases) and non-standard sizes.

Jump Kit Features

Jump kit features were rated on a scale of 1 (low importance) to 5 (high importance). Size, weight and placement in the ambulance were rated highest, indicating that these were the most important features to paramedics (Figure 17). Final Report: Finding Solutions Grant 99FS-14 41

2 (1= Low; 5= High) 5= Low; (1= Importance Rating Importance 1

f ht nt g e rap rap Size t em k st Wei c c handle Soft case g Pla Waterproo Hard case pa k ryin Shoulder s ar Bac C

Figure 17. Importance ratings of jump kit features

Comments provided by respondents regarding each feature evaluated are summarized below. Some comments are contradictory, indicating the differing opinions of paramedics.

Table 17. Summary of comments regarding jump kit features.

Feature Comments Size fits with other equipment; if too wide, shoulder abduction presents injury risk; size makes it awkward; thin out the jump kit and make longer should be a backpack Weight reduce lifting injuries if reduce weight; reduce stress on joint because we carry so often; should be a maximum weight; should be a backpack or longer kit for better weight distribution. Placement floor/waist level is great; suspend as a backpack on the door; reduce twisting and reaching; store on the stretcher; must be readily available. Covering protect inside contents with waterproof base. Hard case hard case hurts the body and will crack. Soft case more pliable for equipment; more adaptable easier on body when carrying; softer when bump legs; easier to store/handle. Shoulder straps unnecessary because put jump kit on stretcher; rarely to sometimes used; Back pack straps would help; better for off road; easiest way to carry; Final Report: Finding Solutions Grant 99FS-14 42

no need for; never used; suggest put on back/bottom of kit.

Jump Kit Contents

Jump kit contents were divided into four categories: life support, intravenous, soft tissue and miscellaneous. These categories were based on the most common arrangement within currently used kits. Paramedics were asked to rate importance and use of the contents, as well as add other contents not listed. Some items were given low importance as jump kit items because they were being used within other kits (e.g., oxygen is part of the oxygen bottle kit; intravenous is part of a separate kit). The following charts indicate the paramedic’s preferences for individual items in each category.

IMPORTANCE USE

5 4 3 2 Rating 1 1= Low 5= High Low 5= 1= 0

S VM K B S AIRWAY UBATION SUCTION GOGGLES RT MA A NEBULIZERS INT P N- NO

Figure 18. Importance and use ratings for life support contents of the jump kit

IMPORTANCE USE

5 4 3 2 Rating 1

1= Low 5= High 0

N R R IO INE NS E T L T INE A ITEMS E TIO M S O CONTA 0W SOLU RMAL MEDICA GLUC RP D1 NO IV START HA S Final Report: Finding Solutions Grant 99FS-14 43

Figure 19. Importance and use ratings for intravenous contents of jump kits.

Figure 18 indicates that all life support contents are considered of high importance even if they are not used often. Suction may have received a lower rating because it would be considered part of another kit. Goggles and masks may be carried on the individual paramedic.

Comparing Figures 18 and 19 illustrate that intravenous supplies and medications rate equally for importance and more for use than life support items. Normal saline is an intravenous solution whose use is indicated while transporting the patient to the hospital. Therefore, normal saline may not be considered by some paramedics to be a part of the jump kit.

IMPORTANCE USE

5 4 3 2 Rating 1 1= Low 5= High 1= Low 5= High 0

S SG RS ER ID NG CH D SOR PLINT PACK AN KLI S 0DR D ULA ANDA EN BULKGZ B SMAR T BD PA CLE E 0X3 ANG STERILEGZ A SAM 1 COL ZAP STRAPS TRI

Figure 20. Importance and use ratings for soft tissue contents of jump kits.

IMPORTANCE USE

5 4 3 2 Rating 1

1= Low 5= High Low 5= 1= 0

F F R S F FF RS UF U TE O NT C CU E P SS RAI BP B CI T D MOM S L LG BP C R ULT D WRIS A CHI THE Final Report: Finding Solutions Grant 99FS-14 44

Figure 21. Importance and use ratings for miscellaneous contents of jump kits.

Comparing Figure 20 to Figures 18 and 19, soft tissue contents generally rated lower than life support or intravenous contents. Interestingly, zap straps were seen as highly important to have in the jump kit.

Figure 21 illustrates that blood pressure cuffs and wrist restraints are perceived as highly important contents of the jump kit, although only the adult blood pressure cuff is indicated as high use.

Jump Kit Organization and Standardization

The concepts of compartmentalization, modularization, and standardization of jump kits surfaced many times during interviews and within responses to the jump kit questionnaire. Grouping items by category within compartments in the working kit was identified as the most important aspect for creating smooth workflow during a call and for easy restocking of the kit.

Paramedics expressed favour for the concept of standardizing the weight, type, and arrangement of the kits. It was felt that standardization could reduce musculoskeletal risk factors by selection of the most appropriate kits. In addition, consistent kit organization would lead to less fumbling and anxiety during calls, particularly when working in unfamiliar stations or in multiple stations.

Some paramedic crews have created customized jump kits that meet their individual requirements. This results in a jump kit that the specific crew prefer and can count on, and is a good solution for stations with a stable and regular crew. However, it presents additional challenges for transient or new paramedics who must learn the placement and contents of these specialized kits.

Concerns regarding standardization was expressed by some paramedics who felt that this would not address the differing requirements of each region. It was strongly voiced that what may be appropriate and effective in Vancouver would not work in areas such as Williams Lake or Prince Rupert. It was suggested that standards could be defined for each region, based on the typical environment and call type.

The concept of a modular jump kit that could be modified on a call by call basis was met with mixed reactions. Those endorsing the concept felt that this could reduce the standard jump kit to the size of a fanny pack, with add-ons for specific call types. Others felt that this would hinder pre-shift or call equipment checks, causing a loss of familiarity with location and type of supplies in each module. They also felt this may affect replacing, maintenance and repair considerations.

Jump Kit Recommendations

Paramedics are strong individuals often defining their individual preferences within their work environment by their work practises. However, their priorities on jump kit features and on Final Report: Finding Solutions Grant 99FS-14 45 some of the contents are consistent. These consistencies could be used to establish a standard or standards for jump kit design and recommended contents.

Floor or waist level jump kit access eases retrieval of the kit from the ambulance if one is going to carry the kit to the call or when the jump kit cannot be placed on the stretcher (i.e., transporting a patient).

Solutions intended to reduce the risk of musculoskeletal injury must address the main risk factors that contribute to injury. Therefore, solutions should target reducing the weight of the jump kits and improving body mechanics while lifting or carrying the jump kit. Possible solutions based on paramedic input and observation of trends in jump kit configuration and use, include the following.

• A backpack style with backpack straps in a sealable pocket on the bottom of the kit is preferable to a hand case. Handles and shoulder straps provide the option of using either. Possible option for leaving only one strap exposed for those who would prefer to slide only one shoulder into the strap. • Modularize specific items into smaller individual packs that can be rapidly attached to the base jump kit when needed. This may include intravenous, suction, or pediatric sized equipment. This would reduce the weight carried to only that which is necessary. • Reduce the size of the base jump kit to force paramedics to carry only those items that are important and used. • Soft shelled, waterproof cases tend to be lighter and are more easily handled than hard shelled cases, provided similar dimensions. • Select a narrower soft shelled kit than the current A500 style to reduce shoulder abduction while carrying the jump kit. • Compartmentalize jump kits, with compartment categories standardized throughout the province or regions. Improving the organization within the kit will reduce the likelihood of carrying spurious or redundant materials, in addition to enhancing ease of use. • Establish a weight restriction based on jump kit style (back pack or hand case) to provide guidance to paramedics who stock their own jump kit. • Provide a place to mount the jump kit on the stretcher or back door to minimize postural stress while accessing the jump kit. • ALS and ITT kit requirements should be reviewed and specified separately. All kits should be evaluated with task and operational requirements in mind, along with musculoskeletal risk factors. Paramedic compliance and satisfaction will be higher if their priorities are maintained and some latitude is provided for individual preferences. Novel or alternative jump kit styles should be tested across regions and stations with varying needs to ensure consensus and to allow regional consideration in selection of a solution. Final Report: Finding Solutions Grant 99FS-14 46

Concurrent Solutions

Throughout the period that the Finding Solutions project has taken place, several solutions that relate to the design of the ambulance and stretcher handling have been considered or are in the process of being implemented. These include modified design specifications for the Crestline ambulance, which have evolved from the recommendations of BC Research Inc. (1999) as well as continuing improvements initiated by the BCAS vehicle design team and Fleet Operations.

Patient Compartment

Solutions that are in the process of being implemented within the patient compartment of the new Crestline ambulances include the following improvements.

• Lowering the bench seat to improve seated posture, leg support and back support. • Adding a padded side wall at the head end of the bench seat to improve lateral bracing and to allow paramedics to sit facing the rear of the vehicle during long transfers. • Improving the adjustability of the jump seat and adding arm rests to improve the seated posture while treating patients from this position. • Installation of a new side door and cabinet to improve access to the jump kit, monitors and portable oxygen when at the scene. • Installation of a rear door mount for portable oxygen to improve access from the rear of the vehicle when at the hospital. • Design of a slide device to assist with transfer of the #9 stretcher from the main stretcher to the bench seat. • Improved positioning and mounting of the main oxygen tank to facilitate changing tanks with better body mechanics and minimal lifting. In addition, portable lumbar supports are available to paramedics in an attempt to improve lumbar support while sitting for long periods in the ambulance.

Stretcher handling

It was recognized that the design of the main stretcher and the associated controls can significantly influence postural loading and can require considerable physical effort. A preliminary analysis was conducted of push-pull forces required to manoeuvre the Ferno and Stryker stretchers on a variety of surfaces. This demonstrated a small advantage for the Stryker stretcher, which was believed to be due to the larger wheel on this stretcher. An analysis of the effect of wheel size on stretcher handling was identified as a logical next step; however, this was not performed during the current project. Personal communication with Doug Harstrom, Ferno-Washington, indicated that Ferno had recently performed a similar analysis as part of their product engineering activities. This analysis has not yet been obtained, but should be consulted prior to initiating an independent review of wheel selection. It was also noted by Mr. Harstrom that there are limitations regarding the wheel diameter and thickness that can be accommodated as a retrofit on the 35A stretchers, and that the relatively small increase in wheel size that was possible was not likely to have a significant effect on performance. This Final Report: Finding Solutions Grant 99FS-14 47 assumption should be tested. It was also indicated that new versions of the 35A stretcher were likely to have a larger diameter wheel.

Although not analysed in the present study, it was indicated in the questionnaire responses that many paramedics will use the main stretcher to carry patients up or down stairs, with the chair cot being the preferred method for longer stairways. An alternate method was demonstrated that can be of particular use in situations with confined space turns or small landings. This method involved the use of a standard issue wool blanket folded around the foot end of a portable stretcher, with the stretcher tilted head up and feet down during tight manoeuvres. The blanket acts as a low friction slide on a hard floor, as well as a handle to allow stabilization and lifting of the foot end of the stretcher while the paramedic maintains a stable, upright posture. Without this technique, the paramedic would be required to support the patients weight while bent forward almost to ground level.

Benefits Gained From This Study

This project has generated several benefits of relevance to CUPE 873, BCAS, and paramedics in general.

The questionnaire and focus group process has generated discussion and elevated the level of awareness of participants regarding the risk of musculoskeletal injury that paramedics are routinely exposed to, and some of the potential solutions that can help mitigate risk factors.

The solutions that were evaluated address some of the key issues identified by paramedics and by injury statistics as contributing to the likelihood of injury. The funding and focus provided by the Finding Solutions project allowed these solutions to be evaluated and considered within a much shorter time frame than would have been possible otherwise.

Interest and awareness of ergonomic design initiatives related to the new series of ambulances has been increased. This is likely to increase the acceptance and success of design changes that are being implemented by increasing the understanding of underlying reasons for these changes.

The most noteworthy contribution of this project is towards the continued development of a culture that strives for continuous improvement in the design of work and the equipment required to perform that work. Final Report: Finding Solutions Grant 99FS-14 48

Bibliography

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