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Lifting injuries in ambulance crews
Publ. Hlth, Lond. (1975) 89, 71-75
Lifting Injuries in Ambulance Crews G. E. Leyshon ,9- H. W. S. Francis
West Riding County Hea/th Department, Wood Street, Wakefie/d
Lifting injuries continue to be an important, but surprisingly, decreasing cause of disability in West Riding ambulancemen. One in every 15 men at risk was off sick each year between 1968-70 with a lifting injury, but this had fallen to one in 36 in 1974. Possible reasons for this improvement are suggested. Ambulance driver/attendants probably meet more members of the public in need or in difficulty than any other group employed by the local health authority. They have to lift patients in many different ways and circumstances and cannot always use ideal methods since it is part of their job to help the sick and injured in the circumstances in which they are found. Patients may be too ill to help themselves in any way and stairs in houses may be precipitous and narrow. Extrication of the injured from smashed vehicles is a special hazard and although ambulancemen are taught the correct way to lift patients, it may not always be possible to put this training into practice. It would not be surprising to find that lifting injuries were common in this group of health workers. Ambulancemen are not the only group prone to lifting injuries; it is a hazard common to all manual workers engaged in heavy lifting. A report by the Industrial Survey Unit (1966) stated: " . . . Rheumatic complaints result in some 30 million lost work days every year in Britain . . . . Back pain, technically 'lumbar disc disease', was the biggest cause of sickness absence attributable to rheumatic complaints". Robertson (1970) in a survey of workers in an oil refinery in 1967 found that injuries and diseases of the musculo-skeletal system was by far the commonest cause of sickness absence, being more than twice as frequent as the next most common cause--gastro-intestinal disease. Back injury in dock workers is also a major problem (Blow & Jackson, 1971); probably most industries would report similar findings. It is not easy to identify exactly how much disability there is caused by lifting injuries," but an estimate can be obtained from certification of diseases which could be caused by injury. Thus in the Digest of Statistics Analysing Certificates of Incapacity (1973) the total from all causes of certified incapacity in males in 1969-70 was over 8 million spells; that due to diseases of the musculo-skeletal system and connective tissue (C61, C62 and C65) was nearly 683 000 spells and if we include some certified as injuries (CN70)--sprains and strains of joints, injuries unspecified to face, neck, trunk, upper and lower limbs--the total becomes 1.3 million spells. Expressed as a rate/thousand persons, it is third only to acute respiratory infections and all other injuries; this latter category could include some injuries due to lifting. Other health workers also suffer injury from lifting--it is a special hazard among nurses, (Cyriax, 1969; Davis, 1967; C u s t e t al., 1972) but relatively less attention has been paid to the problem in ambulancemen. A Survey on Morbidity and Mortality of Ambulancemen (1972) showed that of 430
G. E. Leyshon and H. IV. S. Francis
72
ambulancemen who had to retire prematurely, the main reason was ischaemic heart disease (410-414) in 99 cases, but displacement ofintervertebral disc (725) and injuries to back and limbs (N996) accounted for 63 early retirements; but if we also include a group certified as suffering from diseases of the musculo-skeletal system, excluding P.I.D. (710-738)--there were a further 31 cases--then those combined groups which must have a bearing on lifting injuries was the major cause. An analysis was carried out of injuries sustained by West Riding ambulancemen whilst lifting patients for the 41 months from March 1964 to July 1967 (Francis, 1968). During this period one in five ambulancemen suffered injuries whilst carrying patients--a total of 102 men suffering 109 lifting injuries out of an average work force of 499 driver/attendants-this is an average of 30 men injured per year. All but one injury occurred when lifting patients, the other by lifting an oxygen cylinder. A further survey of lifting injuries a m o n g ambulancemen for the years 1968-72 has been carried out and the results are reported here, together with those reported in the earlier survey for comparison. The survey deals with all ambulancemen engaged in active duty and, as the West Riding Ambulance Service deals with both accident and emergency cases as well as routine out-patient transportation, each ambulanceman does both aspects of ambulance work. Results
Lifting injuries continue to be an occupational hazard of ambulancemen. Table 1 shows that there were an average of 31 lifting injuries in 30 men in the 5 years between 1968-72, i.e. one injury for every 20 men at risk; but the number of injuries decreased quite appreciably in 1971 and 1972. Thus, from 1968-1970, there was one m a n injured for every 15 at risk. In 1971 this had fallen to one in 27 men, and in 1972 to one in 36 men. T~LE 1. Lifting injuries per year and number of men at risk. Numbers of men injured are shown in parentheses Year
1964-67 1968 1969 1970 1971 1972 Average per year 1968-72
Total lifting injuries
Back
Limbs
Others
109 64 35 10 Average/Year Average/Year Average/Year Average/Year 32 19 10 3
No. of men at risk
499
41 (36) 36 (35) 41 (39) 24 (23) 18 (17)
32 28 37 21 17
8 4 3 3 0
1 4 1 0 1
549 582 603 616 620
31 (30)
27
3.6
1-4
594
The average time lost per injury (Table 2) is about a week. Although this was about two weeks in 1970 and over three weeks in 1972, if we exclude the two extensively long absences of 154 days in 1970 and 270 in 1972, the average days lost in these two years become 9.8 and 8-7 days. A clearer indication of sickness absence is given in Table 3 - - " a v e r a g e " and "range" are unsatisfactory ways of describing the situation. Although more than half the men did not lose any days, 11 were off for more than one month, some for considerable periods; the m a n who had been off for 270 days was later considered as permanently
Lifting injuries in ambulance crews
73
i n c a p a b l e o f r e s u m i n g his j o b . N o m a n was i n j u r e d m o r e t h a n twice in a n y one year, t h o u g h 16 were i n j u r e d one or m o r e times in different years to a m a x i m u m o f three injuries. T o t a l absences and t o t a l days lost for all causes tire shown in T a b l e 4. Thus the 1568 days lost because o f lifting injuries a c c o u n t e d f o r only 3.3 ~ o f t h e t o t a l o f days lost for all absences. TABLE2. Days lost from work because of lifting injuries Year
Total/Days
Average/Days
1964-67
569
5.6
1968 1969 1970 1971 1972
189 230 558 173 418
4.6 6-4 13i6 7-2 23.2
Range/Days 0-73 0-87 0-63 0-154 049 0-270
TABLE3. Frequency distribution of days lost 1968-72 Days lost
1968
1969
1970
1971
1972
Total
0 days 1-6 7-13 14-20 21-27 28+
28 4 7 1 0 1
22 3 6 1 3 1
23 2 3 5 3 5
14 3 2 1 2 2
6 3 3 4 0 2
93 15 21 12 8 11
Total
41
36
41
24
18
160
TABLE4. Sickness absences (all causes) by year
Year
No. of absences for sick leave during the year
Total days lost
Average days lost per absence
1968 1969 1970 1971 1972
712 751 817 776 846
8303 9093 10 846 8646 10 207
11-6 12.1 13.2 11.0 12.0
Total
3902
47 095
12.0
A n analysis o f injuries b y age (Table 5) shows t h a t the highest rate, in general, is in the 36-45 y e a r age g r o u p a n d least in the 56-65 years. This a p p a r e n t p a r a d o x o f the y o u n g e r m e n suffering f r o m the highest rate c o u l d be explained b y this g r o u p accepting the m o s t difficult "lifts", o r p o s s i b l y because o f their l a c k o f t r a i n i n g a n d experience. T h e r e is no definite p o l i c y t h a t the o l d e r m e n deal with sitting cases. I t is also clear f r o m T a b l e 5 t h a t the age structure o f e m p l o y e e s has c h a n g e d in the five years, 1968-1972. T h e largest age g r o u p e m p l o y e d has always been the 35-44 y e a r olds, b u t in the years u n d e r review there has been a 30 ~ increase in t h e n u m b e r s in the y o u n g e s t group. This increase has been caused b y the e x p a n s i o n o f the service.
G. E. Leyshon and H. W. S. Francis
74
TABLE5. Number of men injured in age groups by year Year
Age group
1968
1969 1970 1971 1972 Rate Rate Rate Rate Rate per per per per per At 1000 At 1000 At 1000 At 1000 At 1000 Inj. Nsk men lnj. risk men Inj. risk men Inj. risk men Inj. risk men
--35 --45 --55 --65
10 143 70 17 170 100 11 147 75 3 89 34
9 158 57 12 177 68 6 159 38 9 88 102
15 178 15 176 8 150 3 99
84 85 53 30
10 192 8 187 5 139 1 98
52 43 36 10
5 192 7 173 4 161 2 94
26 40 25 21
Total
41 549
36 582
41 603
68
24 616
39
18 620
29
75
62
Discussion There has been a considerable decrease in the number of lifting injuries sustained between 1968 and 1972. The numbers prior to 1970 were similar to those reported in the earlier survey between 1964 and 1968. As injury accounts for only 3-3 % of all time lost t h r o u g h sickness it could now be regarded as relatively unimportant except that the occasional person is severely disabled and may become permanently incapable of carrying out his duties. Lifting injuries are not only a source of considerable discomfort to the sufferer but an inconvenience for the employing authority and to work-mates who have to cover f o r the absence. Unlike absences from some other causes the man cannot resume his duties until this injury is completely healed; this can lead to prolonged absences. Injuries continue to affect the back mainly and this is to be expected in view of the nature of the work. What is surprising is that in a relatively vulnerable group of workers the injury rate is low compared to that found in the surveys previously mentioned. Cust et al. estimated the annual incidence of occupational low back pain, of which 46 %" was attributed to injury, to be around 2 % for trained nurses and of the order of 5 % in some age groups for nursing auxiliaries. As in this survey, the highest rates were found in the younger age groups. There are several possible explanations for this low rate and the improvement. More young men are now employed by the service (Table 5). Although the young men, theoretically fitter, should suffer less injury than their older colleagues, the rates show that it is the younger groups who suffer the highest rate of injury, for the reasons previously postulated. It is clear from Table 5 that the decline in injuries has occurred throughout all age groups, so that the employment of younger fitter men is unlikely to be the reason for theimprovement. Better selection of men at the pre-employment medical examination has eliminated those with a history of significant backache. A firmer attitude was taken after the results of the earlier survey were known and applicants who might previously have been accepted before 1968 were now considered unsuitable for employment. I f this was the total explanation it should have produced a greater fall in rates in the younger age groups, for by and large the new recruits are younger men. Greater attention is paid to lifting in the training courses for ambulancemen which became widely accepted in 1969, in the Miller courses (the six week course for the ambulanceman's proficiency certificate), in the introductory courses for new recruits, and in the refresher courses for the experienced ambulancemen. Particular attention was paid in the West Riding Ambulance Training School because of the results of the earlier survey. Finally there have been changes in equipment. Cots with wheels were introduced into
Lifting injuries in ambulance crews
75
the West Riding Service in 1968 as the older vehicles were replaced. By 1969, these were extensively used throughout the service and eliminated the "long carries". It is not possible to say which of these factors contributed most to the improvement, probably a combination of all; the most important lesson would appear to be, that having carried out the earlier survey and found a significant amount of disability due to lifting injuries, the introduction of relatively simple measures has produced a substantial improvement. Lifting injuries, certainly in ambulancemen, appear to be amenable to prevention. There is no reason to suppose that other industries with a similar problem would not benefit if more stringent preventive and educational measures were applied.
Acknowledgements We are grateful for the help received from Dr R. W. Elliott, County Medical Officer, Mr L. Lord, the County Ambulance Officer, Mr R. F. Lee, the Ambulance Training Officer and Mr G. Brabant, the Finance Officer for proving the statistics.
References Blow, R. J., Jackson, J. M. (1971). Rehabilitation of registered dock workers. Proceedings of Royal Society of Medicine 64, 753-757. Cust, G. et al. (1972). The prevalence of low back pain in nurses. International Nursing Review 19, 169-178. Cyriax, J. (1969). Posture and pain. District Nursing .12, 154, 155, 158. Davis, P. R. (1967). The nurse and her back. Nursing Times. 1,403-1,404. Digest of Statistics Analysing Certificates of Incapacity, June 1969-May 1970. D.H.S.S. 1973. Francis, H. W. S. (1968). Lifting injuries in ambulance crew. West Riding Health Notes 2, 22. Rheumatism in Industry. (1969). Industrial Survey Unit of the Arthritis and Rheumatism Council for Research in Great Britain and the Commonwealth. Robertson, A. M. (1970). The challenge of the painful back--an industrial and medical problem. Transactions of Society of Occupational Medicine 20, 42-49. Survey on Morbidity and Mortality of Ambulaneemen. (1972). Health Department, Durham County Council.
Lifting Injuries in Ambulance Crews G. E. Leyshon ,9- H. W. S. Francis
West Riding County Hea/th Department, Wood Street, Wakefie/d
Lifting injuries continue to be an important, but surprisingly, decreasing cause of disability in West Riding ambulancemen. One in every 15 men at risk was off sick each year between 1968-70 with a lifting injury, but this had fallen to one in 36 in 1974. Possible reasons for this improvement are suggested. Ambulance driver/attendants probably meet more members of the public in need or in difficulty than any other group employed by the local health authority. They have to lift patients in many different ways and circumstances and cannot always use ideal methods since it is part of their job to help the sick and injured in the circumstances in which they are found. Patients may be too ill to help themselves in any way and stairs in houses may be precipitous and narrow. Extrication of the injured from smashed vehicles is a special hazard and although ambulancemen are taught the correct way to lift patients, it may not always be possible to put this training into practice. It would not be surprising to find that lifting injuries were common in this group of health workers. Ambulancemen are not the only group prone to lifting injuries; it is a hazard common to all manual workers engaged in heavy lifting. A report by the Industrial Survey Unit (1966) stated: " . . . Rheumatic complaints result in some 30 million lost work days every year in Britain . . . . Back pain, technically 'lumbar disc disease', was the biggest cause of sickness absence attributable to rheumatic complaints". Robertson (1970) in a survey of workers in an oil refinery in 1967 found that injuries and diseases of the musculo-skeletal system was by far the commonest cause of sickness absence, being more than twice as frequent as the next most common cause--gastro-intestinal disease. Back injury in dock workers is also a major problem (Blow & Jackson, 1971); probably most industries would report similar findings. It is not easy to identify exactly how much disability there is caused by lifting injuries," but an estimate can be obtained from certification of diseases which could be caused by injury. Thus in the Digest of Statistics Analysing Certificates of Incapacity (1973) the total from all causes of certified incapacity in males in 1969-70 was over 8 million spells; that due to diseases of the musculo-skeletal system and connective tissue (C61, C62 and C65) was nearly 683 000 spells and if we include some certified as injuries (CN70)--sprains and strains of joints, injuries unspecified to face, neck, trunk, upper and lower limbs--the total becomes 1.3 million spells. Expressed as a rate/thousand persons, it is third only to acute respiratory infections and all other injuries; this latter category could include some injuries due to lifting. Other health workers also suffer injury from lifting--it is a special hazard among nurses, (Cyriax, 1969; Davis, 1967; C u s t e t al., 1972) but relatively less attention has been paid to the problem in ambulancemen. A Survey on Morbidity and Mortality of Ambulancemen (1972) showed that of 430
G. E. Leyshon and H. IV. S. Francis
72
ambulancemen who had to retire prematurely, the main reason was ischaemic heart disease (410-414) in 99 cases, but displacement ofintervertebral disc (725) and injuries to back and limbs (N996) accounted for 63 early retirements; but if we also include a group certified as suffering from diseases of the musculo-skeletal system, excluding P.I.D. (710-738)--there were a further 31 cases--then those combined groups which must have a bearing on lifting injuries was the major cause. An analysis was carried out of injuries sustained by West Riding ambulancemen whilst lifting patients for the 41 months from March 1964 to July 1967 (Francis, 1968). During this period one in five ambulancemen suffered injuries whilst carrying patients--a total of 102 men suffering 109 lifting injuries out of an average work force of 499 driver/attendants-this is an average of 30 men injured per year. All but one injury occurred when lifting patients, the other by lifting an oxygen cylinder. A further survey of lifting injuries a m o n g ambulancemen for the years 1968-72 has been carried out and the results are reported here, together with those reported in the earlier survey for comparison. The survey deals with all ambulancemen engaged in active duty and, as the West Riding Ambulance Service deals with both accident and emergency cases as well as routine out-patient transportation, each ambulanceman does both aspects of ambulance work. Results
Lifting injuries continue to be an occupational hazard of ambulancemen. Table 1 shows that there were an average of 31 lifting injuries in 30 men in the 5 years between 1968-72, i.e. one injury for every 20 men at risk; but the number of injuries decreased quite appreciably in 1971 and 1972. Thus, from 1968-1970, there was one m a n injured for every 15 at risk. In 1971 this had fallen to one in 27 men, and in 1972 to one in 36 men. T~LE 1. Lifting injuries per year and number of men at risk. Numbers of men injured are shown in parentheses Year
1964-67 1968 1969 1970 1971 1972 Average per year 1968-72
Total lifting injuries
Back
Limbs
Others
109 64 35 10 Average/Year Average/Year Average/Year Average/Year 32 19 10 3
No. of men at risk
499
41 (36) 36 (35) 41 (39) 24 (23) 18 (17)
32 28 37 21 17
8 4 3 3 0
1 4 1 0 1
549 582 603 616 620
31 (30)
27
3.6
1-4
594
The average time lost per injury (Table 2) is about a week. Although this was about two weeks in 1970 and over three weeks in 1972, if we exclude the two extensively long absences of 154 days in 1970 and 270 in 1972, the average days lost in these two years become 9.8 and 8-7 days. A clearer indication of sickness absence is given in Table 3 - - " a v e r a g e " and "range" are unsatisfactory ways of describing the situation. Although more than half the men did not lose any days, 11 were off for more than one month, some for considerable periods; the m a n who had been off for 270 days was later considered as permanently
Lifting injuries in ambulance crews
73
i n c a p a b l e o f r e s u m i n g his j o b . N o m a n was i n j u r e d m o r e t h a n twice in a n y one year, t h o u g h 16 were i n j u r e d one or m o r e times in different years to a m a x i m u m o f three injuries. T o t a l absences and t o t a l days lost for all causes tire shown in T a b l e 4. Thus the 1568 days lost because o f lifting injuries a c c o u n t e d f o r only 3.3 ~ o f t h e t o t a l o f days lost for all absences. TABLE2. Days lost from work because of lifting injuries Year
Total/Days
Average/Days
1964-67
569
5.6
1968 1969 1970 1971 1972
189 230 558 173 418
4.6 6-4 13i6 7-2 23.2
Range/Days 0-73 0-87 0-63 0-154 049 0-270
TABLE3. Frequency distribution of days lost 1968-72 Days lost
1968
1969
1970
1971
1972
Total
0 days 1-6 7-13 14-20 21-27 28+
28 4 7 1 0 1
22 3 6 1 3 1
23 2 3 5 3 5
14 3 2 1 2 2
6 3 3 4 0 2
93 15 21 12 8 11
Total
41
36
41
24
18
160
TABLE4. Sickness absences (all causes) by year
Year
No. of absences for sick leave during the year
Total days lost
Average days lost per absence
1968 1969 1970 1971 1972
712 751 817 776 846
8303 9093 10 846 8646 10 207
11-6 12.1 13.2 11.0 12.0
Total
3902
47 095
12.0
A n analysis o f injuries b y age (Table 5) shows t h a t the highest rate, in general, is in the 36-45 y e a r age g r o u p a n d least in the 56-65 years. This a p p a r e n t p a r a d o x o f the y o u n g e r m e n suffering f r o m the highest rate c o u l d be explained b y this g r o u p accepting the m o s t difficult "lifts", o r p o s s i b l y because o f their l a c k o f t r a i n i n g a n d experience. T h e r e is no definite p o l i c y t h a t the o l d e r m e n deal with sitting cases. I t is also clear f r o m T a b l e 5 t h a t the age structure o f e m p l o y e e s has c h a n g e d in the five years, 1968-1972. T h e largest age g r o u p e m p l o y e d has always been the 35-44 y e a r olds, b u t in the years u n d e r review there has been a 30 ~ increase in t h e n u m b e r s in the y o u n g e s t group. This increase has been caused b y the e x p a n s i o n o f the service.
G. E. Leyshon and H. W. S. Francis
74
TABLE5. Number of men injured in age groups by year Year
Age group
1968
1969 1970 1971 1972 Rate Rate Rate Rate Rate per per per per per At 1000 At 1000 At 1000 At 1000 At 1000 Inj. Nsk men lnj. risk men Inj. risk men Inj. risk men Inj. risk men
--35 --45 --55 --65
10 143 70 17 170 100 11 147 75 3 89 34
9 158 57 12 177 68 6 159 38 9 88 102
15 178 15 176 8 150 3 99
84 85 53 30
10 192 8 187 5 139 1 98
52 43 36 10
5 192 7 173 4 161 2 94
26 40 25 21
Total
41 549
36 582
41 603
68
24 616
39
18 620
29
75
62
Discussion There has been a considerable decrease in the number of lifting injuries sustained between 1968 and 1972. The numbers prior to 1970 were similar to those reported in the earlier survey between 1964 and 1968. As injury accounts for only 3-3 % of all time lost t h r o u g h sickness it could now be regarded as relatively unimportant except that the occasional person is severely disabled and may become permanently incapable of carrying out his duties. Lifting injuries are not only a source of considerable discomfort to the sufferer but an inconvenience for the employing authority and to work-mates who have to cover f o r the absence. Unlike absences from some other causes the man cannot resume his duties until this injury is completely healed; this can lead to prolonged absences. Injuries continue to affect the back mainly and this is to be expected in view of the nature of the work. What is surprising is that in a relatively vulnerable group of workers the injury rate is low compared to that found in the surveys previously mentioned. Cust et al. estimated the annual incidence of occupational low back pain, of which 46 %" was attributed to injury, to be around 2 % for trained nurses and of the order of 5 % in some age groups for nursing auxiliaries. As in this survey, the highest rates were found in the younger age groups. There are several possible explanations for this low rate and the improvement. More young men are now employed by the service (Table 5). Although the young men, theoretically fitter, should suffer less injury than their older colleagues, the rates show that it is the younger groups who suffer the highest rate of injury, for the reasons previously postulated. It is clear from Table 5 that the decline in injuries has occurred throughout all age groups, so that the employment of younger fitter men is unlikely to be the reason for theimprovement. Better selection of men at the pre-employment medical examination has eliminated those with a history of significant backache. A firmer attitude was taken after the results of the earlier survey were known and applicants who might previously have been accepted before 1968 were now considered unsuitable for employment. I f this was the total explanation it should have produced a greater fall in rates in the younger age groups, for by and large the new recruits are younger men. Greater attention is paid to lifting in the training courses for ambulancemen which became widely accepted in 1969, in the Miller courses (the six week course for the ambulanceman's proficiency certificate), in the introductory courses for new recruits, and in the refresher courses for the experienced ambulancemen. Particular attention was paid in the West Riding Ambulance Training School because of the results of the earlier survey. Finally there have been changes in equipment. Cots with wheels were introduced into
Lifting injuries in ambulance crews
75
the West Riding Service in 1968 as the older vehicles were replaced. By 1969, these were extensively used throughout the service and eliminated the "long carries". It is not possible to say which of these factors contributed most to the improvement, probably a combination of all; the most important lesson would appear to be, that having carried out the earlier survey and found a significant amount of disability due to lifting injuries, the introduction of relatively simple measures has produced a substantial improvement. Lifting injuries, certainly in ambulancemen, appear to be amenable to prevention. There is no reason to suppose that other industries with a similar problem would not benefit if more stringent preventive and educational measures were applied.
Acknowledgements We are grateful for the help received from Dr R. W. Elliott, County Medical Officer, Mr L. Lord, the County Ambulance Officer, Mr R. F. Lee, the Ambulance Training Officer and Mr G. Brabant, the Finance Officer for proving the statistics.
References Blow, R. J., Jackson, J. M. (1971). Rehabilitation of registered dock workers. Proceedings of Royal Society of Medicine 64, 753-757. Cust, G. et al. (1972). The prevalence of low back pain in nurses. International Nursing Review 19, 169-178. Cyriax, J. (1969). Posture and pain. District Nursing .12, 154, 155, 158. Davis, P. R. (1967). The nurse and her back. Nursing Times. 1,403-1,404. Digest of Statistics Analysing Certificates of Incapacity, June 1969-May 1970. D.H.S.S. 1973. Francis, H. W. S. (1968). Lifting injuries in ambulance crew. West Riding Health Notes 2, 22. Rheumatism in Industry. (1969). Industrial Survey Unit of the Arthritis and Rheumatism Council for Research in Great Britain and the Commonwealth. Robertson, A. M. (1970). The challenge of the painful back--an industrial and medical problem. Transactions of Society of Occupational Medicine 20, 42-49. Survey on Morbidity and Mortality of Ambulaneemen. (1972). Health Department, Durham County Council.