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During mass casualty situations with multiple patients in different triage categories, or during routine one-on-one patient care, patient positioning is often the first treatment provided by EMS personnel. Several types of patient positioning exist and each has a different intention.
Position of Comfort
POSITION OF COMFORT: where a provider allows the patient to give his/her opinion as to what position they are most comfortable in, and the provider assists the patient to that position.
The position of comfort is indicated for patients with isolated injuries (i.e., broken arm or leg, muscle cramps, strains, sprains, etc.) and when the patient is alert, most often during one-on-one routine care.
Allowing the patient to choose what angle to sit at or whether or not to lay all the way back (supine position), letting the patient hold an injured extremity (in essence, self-splinting it), or agreeing to let a patient sit on his or her left or right side per request are all techniques for the position of comfort.
Pregnant patients in the 2nd or 3rd trimester should be placed in the left lateral recumbent position to take the weight of the pregnancy off of her vena cava. This prevents a decreased preload and hypotension.
RECOVERY POSITION: indicated when a patient is found by an EMS professional to be unresponsive, unconscious, or in a state of shock and is primarily used a temporary position during the interim between initial contact and definitive care, usually in mass casualty incidents where large-group triage is necessary.
To place a patient in the recovery position,
- the rescuer will place the patient on his/her left side with the patient's right arm stretched out, palm down, on the ground.
- The patient’s left arm should be positioned palm up and under the head, forming a makeshift resting place for the patient’s head.
- The legs should be positioned in the same fashion, with the right leg stretched straight or with only a slight bend, and the left leg tucked underneath, bent at an angle toward the area behind the patient.
The position of the arms and legs serve to act as a sturdy base that keeps the patient on their left side, also known as the left lateral recumbent position or recovery position.
Patients are positioned in this fashion to allow for normal, unimpeded respirations and to prevent aspiration into the lungs of foreign material due to the possibility of vomiting while unconscious or altered. In the back of the ambulance or on-scene while undergoing aggressive care, many patients are placed in the supine position (i.e., lying flat on the back). This position allows for the best access of the EMS professionals to initially assess the patient in full and to apply complex and life-saving treatments and procedures.
The semi-fowler position is the default patient position for patients without spinal precautions. Lying flat on the back with the head of the bed elevated slightly, usually 35 to 35 degrees.
This position can assist with oxygenation in patients with fluid in the lungs, congestive heart failure, pulmonary edema, pneumonia, and foreign body airway obstruction can all benefit from this position.
The elevation of the head can also assist with elevated intracranial pressure, making this an excellent position for stroke patients, or those with new-onset neurological signs and no evidence of head trauma.
Semi-fowler is limited in that it places the airway in an excellent position for aspiration. iIf nausea or vomiting develops during transport it is appropriate to place the patient into the left lateral position (recovery position) or be prepared to provide aggressive suctioning.
Depending on your jurisdiction the "shock position" may be used to transport patients that are hypotensive or at high risk of becoming hypotensive when no suspected spinal injury is present.
The shock position is flat on a stretcher with the legs elevated to 45 degrees or above, this decreases the pooling of blood in the large veins of the legs, maximizing blood flow to the heart and brain.
Consider this position in the event of acute blood loss (internal or external).
Patient positioning is extremely important to providing the highest level of care for each and every situation. This is whether the patient is conscious and is asking for the stretcher or cot to be adjusted just a little bit for comfort, or an unconscious patient involved in a terrorist attack or natural disaster has been field-triaged and needs to be placed in the best position possible ("parked") until further care can continue (so that more patients can receive care), or the patient is undergoing advanced procedures and monitoring by one or multiple EMS professionals.