By Dr. Ken Lavelle, MD, NREMT-P
It is a lazy Sunday morning and you are on the scene of a small house fire. It has been knocked down and crews are doing overhaul. Suddenly you are called to the rear of one of the ladder trucks, where you are directed to a firefighter that is leaning against the apparatus in obvious pain, grabbing his back. There is an extension ladder on the ground nearby.
The firefighter reports he was lifting the ladder back on the truck when he suddenly had severe pain in the lower back. He has had this before, but never this bad. He reports the pain is a 10 on a scale of one to 10. There was no trauma — nothing stuck his back and he did not fall. A rapid physical assessment reveals that his airway, breathing and circulation is intact. He has no neck pain. He has some tenderness in the lower back, worse to the right of the spine. He is able to stand but does not want to move.
At this point some questions come to mind:
• What happened to him and what is causing his pain?
• Does he need C-spine immobilization?
• How do you transport him?
• Is there anything you can do to make him more comfortable?
Low back pain (LBP) is a very common ailment. Two thirds of all people will develop LBP at some point in their lives. It is usually temporary, as in 75 to 90 percent of the pain is resolved in two to four weeks. However in about five percent of patients, the pain becomes chronic.
Acute LBP is usually a result of increased tension in the paraspinal muscles — the muscles next to and near the spine. Often it is a result of lifting or overuse. Specifically there can be avulsion of the attachments of the muscle, rupture of muscle fibers or tearing of muscle sheaths. Most of the time a definitive diagnosis is never made, because the pain resolves, and most LBP patients do not get an MRI or other advanced testing before it does.
There are certain "red flags" that we consider in the emergency department, to decide if we should do imaging (Radiographs or Xrays, CT Scans, MRIs) or blood work. These include:
• Age over 55
• History of HIV, cancer
• IV drug abuse
• Unexplained fever or weight loss
• Traumatic injury
• Symptoms such as numbness in the groin area or loss of bowel/bladder function
In the absence of these "red flags," and normal vital signs and physical exam, we usually will treat patients with medication such as an NSAID (Non-steroidal Anti Inflammatory Drug) — ibuprofen, naproxen, etc. If the pain is very severe they may receive a narcotic pain reliever in the emergency department. A muscle relaxant can be added, such as valium or flexeril if there is significant spasm found on the examination. Patients should actually avoid bed rest, as it can worsen the symptoms.
OK, so now that we understand what is most likely going on, what do we do about it in the field?
Does he have to go to the hospital? In this case he can hardly move so he really should. I doubt a patient like this will refuse transport. In some cases the patient will experience a sharp exacerbation of pain briefly, but then it will improve to the point where they want to try and manage the pain on their own, especially if they have a history of LBP. Review vital signs and the red flags as listed above. If the vitals are normal and they have none of the red flags, then not transporting may be reasonable. Obtain a refusal as normal. If they have abnormal vitals, or they have some of the red flags, strongly encourage transport.
Follow local protocol, but in the absence of any trauma or neck pain, cervical immobilization with a collar and longboard is really not indicated. Making this decision does require you to be sure about the history you have gathered, and if you want to be extra cautious and place a collar and use a long spine board you certainly can do so, but don’t be surprised if we take everything off soon after you arrive at the hospital. The hard board can exacerbate the pain as well.
There is a consideration as to how to move the patient. If you have a patient lying on the ground, using a longboard or, even better, a "scoop" stretcher to lift them up and place them on the stretcher may be easier for everyone. A "scoop" stretcher that comes apart is good because the patient does not have to stay on the hard surface during transport. At the hospital we can use a sheet to transfer them from your bed to the other.
In many areas this would be a basic life support (BLS) transport. However if you have the ability to, and your medical director and medical command permit, it is not unreasonable to give the patient some analgesia during transport. If we at the hospital determine that the patient does not have any imaging or labs, then we are only waiting for the patient to feel better before we discharge them. Treating them faster not only helps them feel better, but also clears the bed for another patient, which could decrease divert time.
Some medical command physicians may be reluctant to give the order for narcotic pain relief in this case. They are sometimes concerned about the actual diagnosis, or about masking any symptoms for their own exam at the hospital. Studies have proven this is not the case, but it is hard to change old habits. Knowing the physician personally, and also giving a good report while showing that you have considered some of the more serious possibilities may help you get the medication order you desire. Some options include morphine sulfate (0.1mg/kg IV), Fentanyl (0.5-1 mcg/kg IV) or, as a muscle relaxant, Valium (5-10mg IV).
If you have never had severe Low back pain, it can be very difficult to understand how limiting and debilitating it can be. Allow the patient to move as slowly as they need to, and then transport safely to the emergency department for evaluation and treatment.
Prevention of these types of injuries is important as well for all of us. Proper stretching and muscle conditioning is key, but is often not possible in the type of job we do. Ask for help when moving heavy objects, or even objects of lesser weight but require us to be in awkward positions. Low back pain can affect the strongest and most muscular firefighter — in some ways it just means that they have more muscle to tear! If you develop mild Low back pain, try to avoid bed rest — keep as active as you can. Short term NSAIDS such as ibuprofen and possibly muscle relaxants are indicated. See your primary care or occupational medicine physician if necessary.