But Can They Lift?

     Anybody who screens EMS field candidates will tell you, not just anybody can do EMS. You need a good brain to pass your tests, earn your certs and think your way through calls. You need the manual dexterity and multitasking capabilities of an ED nurse. You need the maturity and psychomotor skills of a professional driver. You need a warm and willing heart. And, no matter how talented you are in all of those areas, you need to be able to lift - often, a lot.

     It's a fact that sick people are heavy, and plenty of them are very heavy. According to figures from the Centers for Disease Control and Prevention, the percentage of overweight Americans has doubled since 1980.¹ The list of disorders they face as consequences of their obesity could be used to describe our most common daily 9-1-1 calls.

     Twenty years ago, EMS crews would encounter 300-lb. patients only occasionally. In today's systems it has become fairly routine. And although modern self-lifting ambulance cots address the challenges of loading and unloading those folks at the ambulance, the cots themselves weigh more than 140 lbs. That's not an issue if all you do is transfers on flat, stable surfaces, but it's too heavy for a field cot.

     EMS crews do a lot of lifting, moving and carrying while they're not close to an ambulance. They are routinely required to help people in places a cot won't go, and eventually get those people into an ambulance - often traversing surfaces that are neither level nor stable, like hillsides, construction sites and soggy cornfields. Sooner or later, that necessitates the ingenuity (and plain physical strength) of a limited number of people (very often, only two).

     Not strong enough to do that? You're guaranteed to hurt someone. It may be a patient. It may be a colleague, and it may be you. Strong enough? Sooner or later you stand a good chance of getting hurt anyway. One of the scary things about this business is that we're all just one injury away from the ends of our careers and a complete restructuring of our lives. Our mandatory skill set is at least as preclusive as a professional athlete's.

     Unfortunately, when an EMT gets hurt, our industry's commitment is pretty much limited to standard workers' compensation. There are no tradeoffs for the risks you face in the field. And it's not enough to just keep yourself fit. In fact, the surest way to hurt yourself is to get halfway into a lifting maneuver and have your partner do something stupid - or simply fail at his or her end of the cot. Considering most of us aren't taught about body mechanics as EMTs, that's a very likely scenario.

     We've heard from more than one human resources director that lift tests can't be done. But often, can't is just a bureaucratic term for won't. Lift tests can be fair, practical and relevant to the demands of an EMT's job, and therefore legal. EMTs are valuable, and their safety more than warrants the effort.

     We work for a small community-owned hospital that operates a nonprofit 9-1-1 ALS ambulance service in an area that's home to some 30,000 people. Three years ago, we grappled with the daily consequences of EMTs who simply couldn't lift. We solicited the help of our hospital's human resources, legal and physical medicine specialists to develop a lift-testing process for new applicants.

     That resulted in a post-selection, pre-hire evaluation that takes about an hour, including a brief private health screen described below. This test is the last step in our selection process for new EMTs and paramedics. We've broken it down into five simple parts, described as follows.

I. PHYSICAL ASSESSMENT
     Each applicant must pass a basic health screen and a musculoskeletal assessment prior to performing the lift test. These two steps are designed to identify risk factors that might injure the applicant. A Physical Activity Readiness Questionnaire (PAR-Q) and the musculoskeletal screen are administered by a licensed physical therapist. Any positive findings on the PAR-Q, a blood pressure over 160/100, or significant abnormal findings on the musculoskeletal screen triggers a request for a medical evaluation and clearance prior to proceeding with the lift test. The musculoskeletal screen includes basic assessments of range of motion, strength and balance. During this part of the screening process, the applicant also reviews a lift test description handout and is given the opportunity to express any concerns about the test and discuss its requirements. Lift testing commences only if the applicant chooses to proceed and there are no abnormal findings to preclude it.

II. EDUCATION
     The physical therapist witnesses and documents the test, which is administered by a supervisor and an experienced crew. The supervisor explains that the reason for the test is the safety of our own crews as well as the applicant, and warns the applicant that they could get hurt during the test, but that the supervisor will interrupt the test immediately if that appears likely. We explain that if the supervisor interrupts the test, his/her judgment will be considered final. The supervisor then discusses the principles of proper lifting in terms of the lifter's anatomy and the mechanics of the cot.

     The supervisor instructs the lifter to keep his/her pelvis as close to the cot as possible, and describes the test in advance. The supervisor then removes the mattress from a Stryker MX-PRO ambulance cot (so its mechanics are visible), and the crew demonstrates its operation during lifting and lowering and loading and unloading.

III. PRACTICE
     A crew member and the candidate practice lifting and lowering the unladen cot (from its ends, still without a mattress) and then loading and unloading it into and out of an ambulance from a hard, level surface, until the supervisor is satisfied the applicant understands the procedure. The supervisor carefully demonstrates how the safety catch on the tailboard interfaces with the drag bar on the head end of the cot, and makes sure the candidate experiences its effect. Even if the applicant has extensive experience with the same type of cot, the supervisor presumes nothing, but describes and practices every aspect of its operation with them prior to testing.

IV. TEST
     Prior to testing, the crew reinstalls the mattress, places a 165-lb. Rescue Randy weighted dummy on it, and lowers the cot to the floor. The supervisor observes while the candidate and a crew member raise the cot to its loading position, then switch ends and lower it to the floor, and finally raise it to loading position again. Finally, they load it into and unload it from the ambulance. The supervisor and physical therapist confer briefly and announce a pass/fail determination in the applicant's presence. Additionally, they may confer with the crew, but the supervisor always takes responsibility for the decision. If the applicant does not pass, the supervisor explains why.

V. POST-TEST COUNSELING
     If the applicant fails the test, the physical therapist explains to them privately how they could effect a different outcome should they decide to reattempt the selection process later. In two years' experience with this process, neither of our unsuccessful candidates has chosen to reattempt. We believe we would be favorably impressed in the future if one did.

     Our small agency experiences less than 10% turnover, but this process has identified two people out of 14 otherwise successful applicants who simply did not possess sufficient physical strength to lift the weighted cot. (Prior to the lift test, applicants go through pre-hire screening, a written test, a skills test and two interview stages.)

Making Sure They're Able to Do the Job
     This process is intended to preclude the placement of people in a job they are physically incapable of performing. The ability to lift and load a cot bearing a 165-lb. manikin is a reasonable expectation, and probably represents a low threshold for the actual physical demands of the job. If an applicant cannot successfully perform this lift test, it's reasonable to assume they would not be able to conduct their responsibilities in the field. In fact, when presented in the field with a lift they are incapable of performing, they would be prone to injury themselves and place others at risk. Our controlled test environment allows applicants to demonstrate their ability to perform the task while minimizing risk to themselves and others.

     Physical therapists, with their training in musculoskeletal disorders, biomechanics and medical risk factors, are well suited for designing and administering these tests. The musculoskeletal screening done prior to testing is vital to performing a safe test, and should only be performed by trained professionals.

     For example, if an applicant is expected to lift a cot from the lowest position, they will need to have adequate range of knee and hip motion to squat, and enough strength to rise from the squat position. Any applicant who lacks adequate range of motion or strength when screened should not be allowed to attempt the test until they have been evaluated and cleared by a physician to do so.

     While it is well known that EMS work is a high-risk pursuit, we believe we are making this job at least a little safer by screening, testing and placing only personnel who have demonstrated their physical capability to perform the duties of an EMT.

     -Darrell Messersmith

Resources

• Applicants receive an advance copy of a handout that describes the test verbally and visually. For a PDF of the handout, e-mail Thom Dick at boxcar_414@yahoo.com.
• A physical therapist uses a one-page document to record the test. The document is then forwarded to human resources staff and filed. For a PDF or MS Word version of the document, e-mail Thom Dick at boxcar_414@yahoo.com.

ACKNOWLEDGMENTS
     This process would not have been adopted without the support of Human Resources Director Jackie Dunkin and attorney Mark Sabey. The authors would also like to acknowledge the help of their colleagues Geoff Watson, Steve Rollert, Mitch Cox and Scott Byars, who helped them illustrate this article.

References
     1. www.cdc.gov/nccdphp/dnpa/obesity/index.htm.

Thom Dick has been involved in EMS for 38 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.

 Darrell Messersmith, MSPT, is director of physical medicine at Platte Valley Medical Center in Brighton, CO. He has worked extensively in the area of outpatient orthopedics, work-related injuries, preplacement screening and worksite ergonomics since 1995.