Robert Vroman, M.Ed., BS NREMT-P

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How to get the most out of blood borne pathogen training

OSHA standards can be confusing, but here’s what EMS agencies need to know to maintain training requirements and compliance

How to prevent contamination and stay safe during large-scale incidents

Planning, personal protective equipment and routine vaccinations helps maintain infection control

Pa. paramedic chief retires after 38 years

Colleagues say Sean Chandler served as a role model to the younger paramedics, and because of him “several residents of this city are no doubt alive and well today"

Study: New heart failure drug shows big promise

Former AHA president: "It's been at least a decade since we've had a breakthrough of this magnitude"

Dispatcher mistakes with new 911 system rock Fla. county

Transition has resulted in units to the wrong address, calls wrongly classified and a delay because "the headset was not properly plugged into the jack"

Girl, 9, dies in sand hole collapse at Ore. beach

People tried to dig her out but the sand kept collapsing; police and then medics performed CPR once she was pulled free

Rescuer describes feat to save Maine rock climber

Bob Baribeau and his team of six technical rescuers took nearly two hours of climbing through a crack in a jumble of boulders to reach a woman who fell

Responders free 22 trapped Nicaraguan gold miners

They're working to free at least four more using groups of five or 10 miners entering the mine on wooden ladders, tying themselves off and searching for those trapped

Ill. responders train for water rescues

They spent a week in August taking the department's boats to a river in Illinois to go over water rescue procedures

Commuting firefighters free injured passengers in Chicago airport shuttle crash

They were driving behind the bus when it crashed near O'Hare Airport; they freed the driver and passengers from the wreckage with a hammer
Top

EMS1 Topic Articles

How to get the most out of blood borne pathogen training

OSHA standards can be confusing, but here’s what EMS agencies need to know to maintain training requirements and compliance

How to prevent contamination and stay safe during large-scale incidents

Planning, personal protective equipment and routine vaccinations helps maintain infection control

Pa. paramedic chief retires after 38 years

Colleagues say Sean Chandler served as a role model to the younger paramedics, and because of him “several residents of this city are no doubt alive and well today"

Study: New heart failure drug shows big promise

Former AHA president: "It's been at least a decade since we've had a breakthrough of this magnitude"

Dispatcher mistakes with new 911 system rock Fla. county

Transition has resulted in units to the wrong address, calls wrongly classified and a delay because "the headset was not properly plugged into the jack"

Girl, 9, dies in sand hole collapse at Ore. beach

People tried to dig her out but the sand kept collapsing; police and then medics performed CPR once she was pulled free

Rescuer describes feat to save Maine rock climber

Bob Baribeau and his team of six technical rescuers took nearly two hours of climbing through a crack in a jumble of boulders to reach a woman who fell

Responders free 22 trapped Nicaraguan gold miners

They're working to free at least four more using groups of five or 10 miners entering the mine on wooden ladders, tying themselves off and searching for those trapped

Ill. responders train for water rescues

They spent a week in August taking the department's boats to a river in Illinois to go over water rescue procedures

Commuting firefighters free injured passengers in Chicago airport shuttle crash

They were driving behind the bus when it crashed near O'Hare Airport; they freed the driver and passengers from the wreckage with a hammer
Top

EMS1 Columnist Articles

How to get the most out of blood borne pathogen training

The federal Occupational Health and Safety Administration, or ‘OSHA’ was created by Congress under the Department of Labor in 1970 to better protect workers by assuring safe and healthy working conditions.

The Blood borne Pathogens (BBP) standard, found in the Code of Federal Regulations (29 CFR1910.1030), took effect in March 1992 to reduce what then amounted to more than 200 deaths and 9,000 blood borne infections each year. The standard was amended by the Needlestick Safety and Prevention Act of 2000 (Pub. L. 106-430) to address a rising incidence of accidental sharps injuries. The Blood borne Pathogens standard remains the most frequently accessed standard on the OSHA web site[1] which, in allb likelihood, suggests significant need for information and clarification about the standard.

BBP training requirement’s

The BBP standard covers any work-related (including volunteer labor) exposures to blood or other potentially infectious materials as defined in the standard.

Generally, the standard requires employers to develop an exposure control plan and update it annually, implement the use of standard precautions as well as engineering controls and practices to protect workers, supply personal protective equipment, make hepatitis B vaccinations available, provide post-exposure evaluation and follow-up, use labels and signs to indicate hazards, provide information and training to workers, and maintain medical and training records. This article focuses specifically on the training requirements.

Digging through the standard, you will find training mentioned in several places: Blood borne Pathogens 1910.1030(g)(2)(i); (ii)(A) through (C); (iii) through (vii)(A) through (N); (viii) and (ix)(A) through (C).

BBP training must be provided at no cost and during the employees’ working hours. Training also needs to be in the worker’s own language and at a level appropriate to the worker’s educational and literacy level.

There are three types of training: initial, additional and annual.

  • Initial training is done on hire or when a volunteer starts with an organization, and must be completed before the worker begins work in any role where they have a risk of exposure.
  • Additional training is provided when assigned tasks or risks of exposure change, or when new safety procedures or equipment are put in place.
  • Annual training is done within one year of the previous training.

Initial training is specifically detailed in the BBP standard to include:

  • Access to a copy of the 1910.1030 standard and an explanation of its contents
  • A general explanation of blood borne diseases and their symptoms
  • Information on modes of transmission of blood borne pathogens
  • Review of the employer’s exposure control plan and information about where the worker can obtain a copy of the written plan
  • Description of methods for recognizing tasks that involve potential for exposure to BBP and OPIM
  • Explanation of methods to prevent or reduce exposures (engineering controls, work practices, PPE) including limitation of these methods
  • Information on PPE types, proper use, location, removal, handling, decon and disposal
  • Explanation on how to properly select PPE
  • Hepatitis B vaccine information including effectiveness, safety, benefits, method of administration and administration free of charge
  • Appropriate actions to take in an emergency involving blood or OPIM and who to contact to determine if an exposure has occurred
  • Information on procedures to follow after an actual BBP exposure, including how to report the incident and what medical follow-up will be made available
  • Details on post exposure evaluation and follow-up
  • Explanation of any signs and labels or color coding used by the employer to comply with the BBP standard
  • An opportunity for interactive questions and answers with the person conducting the training session

The four most common questions about the initial training are:

  1. What diseases need to be covered"
  2. Who is qualified to conduct the training"
  3. What exactly does OSHA mean by interactive Q&A"
  4. Are there specific time requirements"

When in doubt, ask OSHA

None of these are explicitly described in the standard itself, and this results in considerable confusion among EMS services and other employers. Fueling this confusion are self-proclaimed authorities who offer interpretations that may not be consistent with OHSA’s intentions.

Questions about any standard should be directed to the author of the standard itself. OSHA accepts questions, makes careful interpretations of their standards, and posts these interpretations online for anyone to read. Called “Standard Interpretations,” these answers to queries cover the most common and sometimes inane sort of questions others have asked.[2]

Under the blood borne pathogens standard 1910.1030, there are currently 278 Standard Interpretations. Perusing these can be somewhat overwhelming but using key words in your web browser will usually lead to the answers you need.

For example, the four most common questions above all involve training requirements. Using the “find on this page” feature to look for the word, ‘train’ would readily highlight applicable correspondence.

OSHA also enforces their standards; failure to comply can result in fines. To assure consistency among inspectors and assist employers in understanding what is expected, OSHA issues Compliance Directives.

These are also available online; for the blood borne pathogens standard, there are currently two.[3] The first is OSHA’s own exposure control plan for its employees (who OSHA expects are not reasonably anticipated to have exposures to BBP). The second is specific instructions for OSHA staff on how inspections are to be done. Included are examples of engineering controls evaluation forms and a model exposure control plan.[4].

OSHA’s definition

OSHA defines blood borne pathogens in their standard as any “pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).”

The fact that a worker can be reasonably anticipated to have exposure to BBP means that all of the potential diseases associated with blood and body fluids need to be covered in the initial training.

Conveniently, the Ryan White Law of 2009 required the Secretary of Health and Human Services (HHS) to publish a list of potentially life-threatening infectious diseases.[5] This requires health care facility notification to emergency response employees (EREs) when they diagnose a patient. The HHS list happens to be broken down into categories of disease transmission, one of which is “contact or body fluid exposures.” These are the diseases, at minimum that need to be covered in initial BBP training.

BBP training resources

There are many resources for training materials, particularly materials suitable for initial training. EMS textbook publishers and OSHA compliance publishers, as well as publishers of first aid and CPR textbooks, provide a variety of resources useful for delivering BBP training.

A new organization, the National Association for Public Safety Infection Control Officers will offer resources to trainers in the future.

Additional training, conducted when assigned tasks or risks of exposure change, or more likely when new safety procedures or equipment are rolled out, is often less difficult to obtain training materials for. Annual training, however, can be a challenge.

OSHA has repeatedly indicated that the primary purpose of annual training is to provide workers with an update of changes.[2] Unfortunately, many employers are under the impression that annual training is designed to review the initial training. While OSHA agrees that this is worthy of consideration, it is not the intended objective.

That means that annual BBP training should be new and different every year. Training aids that reflect these updates in science, with opportunity to customize with employer policies and procedures, are not widely available. One source is Infection Control Emerging Concepts operated by Katherine West, an infection control consultant well known in the EMS and fire service communities.

Who is qualified to conduct BBP training"

This leads to the age-old question of who is qualified to conduct BBP training. In their guidance for inspectors, OSHA defines the qualifications needed for a trainer to include any person who is, “knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace.”

The trainer also needs to be familiar with how the elements of the training program relate to the particular workplace. There is no requirement that the trainer be a licensed or certified health care provider. Unless OSHA believes the training program is deficient, they typically would not investigate the qualifications of the trainer.

When needed, OSHA would consider the trainer’s completion of specialized courses, degree programs, or work experience. They would also consider whether the trainer has received specialized training. There is no magical “certification” that would qualify anyone to be a qualified BBP trainer.

Training is largely performance based, that is, predicated on whether the trainer and the training materials accomplish the goal of educating workers about the required training elements of the BBP standard.

Increasingly, online and distributive learning programs are being used to deliver education and training to workers. While programs delivered by video, computer, or other means assure consistency, they can present challenges meeting the OSHA requirement that they provide the opportunity for interactive questions and answers with the person conducting the training session. This has been the source of numerous inquiries,[2] and will probably generate more questions and answers as learning technologies continue to evolve.

To date, OSHA has made it clear that the trainer does not need to be physically present in the classroom during the training. However, workers must have direct access to the trainer to ask questions at the time of the training. OSHA has clarified that a “telephone hotline” and direct video conferencing link is acceptable. They have also clarified that leaving a voice mail message or sending an email with questions is not acceptable.

Clearly, training must include ability for attendees to have real-time access to a trainer. OSHA has also indicated that a potential weakness of computer-based and video training may be that it lacks an opportunity for workers to practice use of safety equipment, including PPE. Employers should integrate opportunity for hands-on practice with each BBP training session.

No minimum time requirements

The last of the commonly asked questions about BBP training is whether OSHA has defined a required number of hours or minimum time needed for initial, additional or annual BBP training.

The answer to this, after searching all of the OSHA references,[1-3] is an unequivocal “no.” Training under the BBP standard is entirely performance based.

This means that the number of hours needed for any training equals the time necessary to accomplish the objectives of that training. It will vary depending on the experience and educational background of the workers, and the details of the employer’s exposure control plan.

An EMS agency, for example, would likely find that the number of hours needed for initial training varies between EMTs paramedics, and physicians based on the knowledge and experience of each. Annual training will vary from year to year, depending on changes in infectious organisms, medical science, and safety equipment. Some years, annual training might be incredibly brief. There is no possible way that OSHA or anyone else could define specific hour requirements to meet a performance based standard.

The bottom line to blood borne pathogen training is that OSHA has readily accessible and specific objectives for initial, additional and annual training. Every emergency response organization needs a trainer who is familiar with infection control science, able to stay up to date on changes, and aware of how those changes affect the organization.

Canned or commercial training programs can be helpful, but cannot replace a qualified trainer. BBP training is performance-based and will look different in every organization, depending on the needs, experience, education and background of the workers.

References:

1. U.S. Department of Labor, Occupational Safety & Health Administration. Regulations (Standards – 29 CFR). On-line, available at: www.osha.gov/pls/oshaweb/owasrch.search_form"p_doc_type=STANDARDS&p_toc_level=1&p_keyvalue=1910.

2. U.S. Department of Labor, Occupational Safety & Health Administration. Standard Interpretations 1910.1030. On-line, available at: https://www.osha.gov/pls/oshaweb/owasrch.search_form"p_doc_type=INTERPRETATIONS&p_toc_level=3&p_keyvalue=1910.1030&p_status=CURRENT.

3. U.S. Department of Labor, Occupational Safety & Health Administration. Documents referencing regulations (Standards – 29 CFR) – 1910.1030. On-line, available at: https://www.osha.gov/pls/oshaweb/owalink.query_links"src_doc_type=STANDARDS&src_unique_file=1910_1030&src_anchor_name=1910.1030.

4. U.S. Department of Labor, Occupational Safety & Health Administration. Enforcement procedures for the occupational exposure to blood borne pathogens standard. On-line, available at: https://www.osha.gov/pls/oshaweb/owadisp.show_document"p_table=directives&p_id=2570

5. Centers for Disease Control and Prevention. Ryan White Act of 2009 – Workplace safety and health topics. On-line, available at: www.cdc.gov/niosh/topics/ryanwhite.

6. Kerr D, Dietze P, Kelly A. Intranasal naloxone for the treatment of suspected heroin overdose. Addiction. 2008; 103:379-386.

How to prevent contamination and stay safe during large-scale incidents

Maintaining standard precautions during multi-patient incidents presents unique challenges

The use of personal protective equipment (PPE) during routine patient contact has been the standard of care for nearly two decades. With access to gloves, safety glasses, face shields, HEPA filter masks and gowns, EMS providers have many tools at their disposal to prevent cross infection, mainly of blood borne pathogens.

Yet, incidents that result in more than a couple of patients also create special challenges for maintaining infection control standard operating procedures (SOPs). Many agency protocols state the maintenance of standard precautions during mass casualty events, but do not provide specifics of how to do so.

Challenges to PPE use

Maintaining standard precautions during multi-patient incidents presents unique challenges. For example, at a multi-vehicle crash where there are several traumatized, bloody patients to be managed, it is not unusual for one EMS team to manage all of them for the first phase of the rescue. How does one prevent patients from being cross contaminated by the rescuers"

Motor vehicle crashes result in a wide variety of sharp hazards that can easily slice open patient care gloves. Meanwhile, heavy duty work gloves are bulky and nearly impossible to use when performing fine motor skills.

Incidents involving hazardous materials are even more challenging. Removing patients from the hot zone and decontaminating them requires specialized training and equipment, which is time-consuming and difficult to set up within a few minutes. EMS crews have to protect themselves from the same agent, and minimize the potential to carry the hazard off site and spread the contaminant to the emergency department.

The same issues go for biological events, which was highlighted by the recent transport of two Ebola patients into the U.S. EMS crews may not be trained or equipped to handle a large influx of patients infected with a serious disease.

Planning improves response

EMS providers use a series of approved, preplanned protocols when managing their patients in everyday situations. That mindset is applied to large scale events as well. Agencies should have plans in place that are evaluated on an ongoing basis. Table top exercises should be conducted at least annually. Agencies should also conduct full scale simulations on an ongoing basis; plans that look great on paper often fall apart under realistic situational and time constraints.

Use PPE that works

PPE must fit well in order to function effectively. Routine fit-testing of HEPA masks is essential. Wearing the right-sized glove will minimize the chance of tearing while optimizing tactile sensation. Gowns should be available in a variety of sizes to accommodate different body types.

It also helps to evaluate PPE fully by having a committee of field providers, supervisors and administrators weigh the pros and cons of each product and vendor before purchasing. Sometimes the most expensive version isn't the most effective; neither is the cheapest.

Maintain vaccinations and routine testing

EMS providers must maintain the full array of vaccinations and routine testing. Childhood diseases such as mumps, measles and rubella can be devastating to an adult. Maintaining immunity against serious illnesses such as hepatitis B and tetanus will greatly reduce the likelihood of contracting the disease. Establishing baseline knowledge about tuberculosis can reduce transmissibility of the disease with annual or biannual TB testing.

Sometimes the most common illnesses are the most harmful to prehospital operations. For example, during the height of flu season, a large number of EMS personnel may become ill and be unable to work, limiting operational readiness and stretching overtime budgets. Seasonal flu vaccinations are becoming increasingly mandatory for providers.

As a reminder, maintaining good health is critical. Immune systems that are compromised due to chronic illness or fatigue will allow opportunistic infections to take hold. Getting plenty of sleep, eating a balanced diet, staying hydrated and maintaining physical conditioning can go a long way in maintaining good health.

Prevent patient-to-patient contamination

Hand washing is the single most effective way to break disease transmission from one patient to another. Nearly all ambulances carry some form of waterless gel or foam that reduces infectious load on the hands; EMS providers should "goop in, goop out" each time they enter or leave the patient compartment. Follow this habit even after wearing gloves; don't forget to leave soiled PPE in the ambulance's waste disposal area, and not on the ground.

In events with a large number of patients, easy access to a large quantity of PPE is essential. Doff and don gloves each time you manage a new patient. If you are in the position of supervising an MCI, try to minimize your physical contact with patients overall.

Maximize provider safety during high-risk events

In the heat of the battle, it can be easy to forget or minimize the importance of using PPE effectively. The simple fact is, you can be affected by the illnesses of a patient by allowing an opening in the defensive systems designed to protect you.

Pay attention to the scene, and note structures and locations that can cause a glove to tear or be punctured. Some EMS providers prefer to "double glove" when taking care of patients after a motor vehicle crash; while there is little science to support the practice, it may be more ergonomic than heavy work gloves.

Be sure you have easy and rapid access to PPE. Having extra gloves in your pants pocket, and HEPA masks and gowns in your jump kit, makes it simple to retrieve basic equipment when you need it. Having a larger cache within the ambulance allows you to manage multiple patients. Safety glasses should be on your person at all times; some providers prefer to wear them the entire time while on duty, as a matter of routine.

Paying attention to the world's events can also help you prepare. During the SARS outbreak in 2002 – 2003, the Toronto, Canada EMS system struggled initially to manage the rapidly rising number of patients within the community. Many EMS providers became ill from the disease, or were exposed during routine patient care.

An earlier recognition of the illness pattern could have hastened a heightened awareness of the problem among EMS workers. As a front line defense against disease outbreak, EMS agencies must coordinate closely with public health officials to detect early signs of a possible epidemic.

Most importantly, be conscious and deliberate with standard precautions. By its very nature, a large scale incident may be a distraction to effective PPE use. By taking the time to make sure that a HEPA mask is properly fitted, or a glove is not torn, EMS providers can help keep themselves safe while helping others cope with their emergency.

Inside EMS Podcast: Can community paramedicine save major EMS agencies?

Download this podcast on iTunes, SoundCloud or via RSS feed

In this week’s Inside EMS podcast, hosts Chris Cebollero and Kelly Grayson discuss Rural/Metro’s decision to close most operations and lay off 361 EMS employees across Indiana, and what it means for the rest of the industry.

Big companies like Rural/Metro , which have been a staple of the career field for years, are now facing financial problems as reimbursement dries up and they’re not able to make the profits they once could, Cebollero said.

“When you see something like this … it really becomes kind of a challenge to say, ‘what’s going to happen to our career field in the future"’” Cebeollero said.

Grayson agreed, saying that as funding sources dwindle, and more people get added to the health care system under the Affordable Care Act, it’s natural that more people will start using EMS services and put a strain on the system.

“It’s unrealistic to assume you’re going to add that many people to the services and have demand be less,” Grayson said.

“I’ve got the answer,” Cebollero said. “Community paramedics. That’s exactly what we’re banking on.”

They also talked ambulance billing finances, focusing on Va. county fund of $75,000 to cover copays for resident s.

“The local county actually put money in place to play their copays, so their citizens don’t have to pay out-of-pocket for EMS services,” Grayson said.

And they mention a Mo. petition to halt outsourcing for ambulance billing, with residents putting pressure on the city’s fire-based EMS service to make it work.

“I think this just goes to show, more and more, as fire thinks that they can do a better at EMS, I think Kansas City has proven that they can’t,” Cebollero said.

In The Clinical Issue, they tackle the pros and cons of 24-hour shifts, and whether they should be eliminated.

“I don’t really know if they have a place in our career field,” Cebollero said.

Grayson agreed, saying the issue goes beyond concerns related to driving.

“There’s a definite link,” he said, “between fatigue, lack of sleep, and increased medical errors.”

Here are links to some of the articles and other items mentioned on the show:

5 ways EMTs can be more caring to patients

Imagine that you’re in the market for a classic sports car. You notice an online advertisement saying that an individual is giving away a mint-condition Shelby Mustang. You race over to his house, eager to get in on this unbelievable deal.

When you arrive, you’re greeted with a smile and told what you were hoping to hear.

“Sure I’ll give you a Mustang.” The man tells you. “It’s a beautiful car. ”

After patiently listening to his description of the vehicle, you anxiously ask, “Where is it" Can I see it"”

“Oh no, you can’t actually see it here, because I don’t have it,” he pleasantly explains.

Now your frustration begins to rise. Your suspicion that the deal was too good to be true comes bubbling to the surface. “Where is it"” you ask.

“I’m sorry, I don’t actually have the Shelby Mustang I was describing,” he explains. “But I am more than willing to give you one.” Smiling he adds, “After all, it’s the right thing to do. Doesn’t that make you feel good" Isn’t that enough"”

“I don’t care if you’d like to give me a car!” you exclaim, angry about the time you’ve wasted. “You can’t give me a car if you don’t have one.”

And with that you storm off, embarrassed that you were fooled by such a silly game.

You can’t give away what you don’t have

You can’t give away something that you don’t have. On the surface it seems as if nothing could be more obvious. Until you possess something, you are unable to choose to give it away. In fact, who would try to do such a ridiculous thing"

But we all do from time to time. We all make the same promise as my fictitious online advertiser on one occasion or another. In fact many of us play this ridiculous game every day that we come to work.

For instance, have you ever had a partner who was convinced that she could be compassionate toward her patient’s event though she had no sense of compassion" Or perhaps you know someone who is convinced that he can be a caregiver even though he doesn't truly care about the individuals who typically dial 911 in the district.

Have you experienced individuals who believed that when they were dispatched on a call they could magically convey kindness, even though they were unkind to everyone else (including their coworkers)" Or perhaps you’ve met individuals who thought they could be calm and collected in the face of an emergency, even though they spent most of their waking hours stressed out and rushing from task to task.

Maybe you’ve worked alongside these individuals, or perhaps you know them more personally. They are every bit as earnest and well-meaning as our sports car advertiser, and they are every bit as misguided. They want to give away something without possessing it and, for some reason, they believe it will work.

How to possess what you want to give

If you don’t have kindness, compassion and caring within you, you can’t give it away to others. If you don’t practice empathy, calmness, peacefulness or confidence in your daily life, you’ll never be able to convey these things to another.

We may try to convince ourselves, our partners or our employers that we can give away all of these things to the people whom we serve, but too often we skip the first critical step. Until we possess it, we can’t give it away.

So what’s a caregiver to do" How do we make the transition from paying lip service to things like compassion and empathy and actually start practicing them" Here are a few ideas.

1. Refuse to engage in depreciating or hurtful humor at the patient’s expense

How many times have you heard someone say, “Of course, I’d never say this stuff in front of the patient or the family but, [Insert depreciating remark here].” Often, ridiculing the patient becomes such a habitual after-call ritual that we don’t even bother with the disclaimer.

I don’t want to sound like the fun police. Humor, even the sometimes dark gallows-humor that comes with EMS work, has its place. In fact, I believe it can be a necessary protective mechanism for the stress of our job.

But also recognize that there is a line. Humor that disrespects or ridicules the patient can erode our ability to empathize with and feel compassion for our patients.

2. Handle patients with care

Feelings follow actions. It’s natural to handle something valuable carefully. Practice handling your patient with compassion.

Lift with good technique. When your patients arrive at the pram (or stretcher) cover them appropriately, pad and package them with care and ask them what you can do to make them more comfortable.

This small gesture is appreciated by the patient and family members, and it’s also an unconscious signal that we are not simply clinicians, we are caregivers.

3. Care for yourself

The popular series Mad Men depicts the changing cultural mores of 1960s' New York City. In the first season, a character goes to see her doctor who lights a cigarette and smokes it while he chastises her about her health.

Today, the behavior seems appalling, but we are every bit as foolish as the chain smoking doctor with our poor EMS diet and startling lack of physical fitness.

We can’t be expected to genuinely care for another’s health if we don’t genuinely care for our own. Put down the Twinkie and respect your own health, and caring for the health of others will follow.

4. Verbalize your intentions

Practice telling your patient and her family that you’re going to take good care of her. Simply verbalizing your intention to be caring leads you naturally into a more caring posture. Make it a habit to say things like, “We’ll take good care of you Mrs. Smith.”

When you’re leaving with a patient, take a moment to look at a family member and say, “Drive safe, we’ll take good care of your husband.”

Making the verbal commitment out loud to care for another person not only reinforces the idea in your own mind, it reminds everyone on scene of the goal to provide good care.

5. Recognize the value of the humans whom you serve

This is one of the big revelations that changed the way I think about my job. The value of the caregiver is intrinsically tied to the value of the patient.

If our patients have no value, then our care for them also has no value. If our patients have tremendous value, then our service to them also has tremendous value. You can’t pick up one side of the stick without picking up the other.

The value that you place on your patients, their health, their well-being and their comfort is also the value you place on your job. If you want to feel that what you do is significant and meaningful, begin by recognizing the significance and mean inherent to your patient’s life.

Life, all life, is significant and meaningful. Our patients have great value. Therefore our work has great value.

Giving begins with having. Caring for another isn’t a thoughtless action. It comes from a place inside. It begins with an intention.

It’s noble to want to be caring, compassionate, kind, thoughtful, calm and reassuring, but wanting isn’t enough. You’ll also need to cultivate within yourself everything that you want to give away, because you can’t give away what you don’t have.

3 bariatric lifts that reduce back injuries

A U.S. Department of Labor article “ Musculoskeletal Disorders in EMS” points out that EMTs and paramedics have the highest injury rate of any line of work. Almost half of all lost work time in EMS is transportation related, and often stems from the challenges that come with moving and lifting heavy patients

Getting a patient out of tight spaces, down stairs, and on and off the stretcher makes this a physical job. But specialized tools for moving patients can often help avoid injuries, reduce lost work hours and even save careers.

Binder Lift

Binder Lift recently introduced a new fluid-resistant version of their product called the Ultra-V. The Binder Lift fits around the torso and under the arms, and is padded around the top edge to allow you to easily move people, especially out of tight spaces.

It’s ideal for a simple lift-assist call, tricky bathroom extrications or getting somebody out of the back bedroom of a singlewide trailer. Once you get them on the cot you can leave it in place to make it easier to do the bed transfer at the hospital. Available in two sizes, with one up to 84 inches, it’s also perfect for your oversized patients. It uses coated fabrics and super-strong webbing to make it easy to clean.

The Doty Belt

The Doty Belt essentially puts handles on the patient. It looks like a lifting belt, but it is for the patient, not the responder. Once it’s quickly and conveniently attached, it provides four comfortable grip handles around your patient's waist.

The quality of construction is excellent. It looks like all load-bearing hardware made more like a rescue harness than a typical lifting belt. The Doty Belt could make some difficult situations much more manageable.

The HILT

The HILT is for seated or prone patients. It looks like a soft stretcher made of rugged seat-belt grade webbing. You fold or unfold to fit your patient and their position, and it offers a range of secure grip locations at different heights.

At first I found it a little confusing, but the more you work with it the easier it gets. It is incredibly versatile; you can do six different types of lifts with it. You can lift and carry a supine patient, seated patient, or even a patient on a backboard.

Having the right tool for the job can reduce injuries and promote a healthy workplace. These simple solutions are also affordable and we should soon see much broader adoption.

Clinical solution: Chest pain while mowing the lawn

Last week we presented the scenario of a 57-year-old overweight male who experienced an onset of chest pain while mowing his lawn. His pain did not subside when he stopped his activity and did not respond to taking his own nitroglycerin. The 911 call taker had advised him to take aspirin prior to your arrival, which he did.

Assessment

There are generally considered to be two types of angina (chest pain): stable and unstable. Stable angina usually occurs with an increased level of physical activity when the heart has to work harder than usual.

Often, stable angina is anticipated and patients are able to see a pattern in their symptoms. Stable angina often resolves with rest or after taking medications (like nitroglycerine). Stable angina can be caused by a narrowing of the coronary arteries that worsens over time.

Unstable angina is abnormal for the patient. While it often begins when at rest, it may be characterized by pain, which does not improve when an increased level of activity is stopped.

Additionally, unstable angina often does not respond to medication. As indicated by its rapid onset and unusual quality, unstable angina is often caused by a new blood clot that suddenly blocks a coronary artery. This decreases the flow of oxygenated blood in the heart and eventually results in the death of cardiac tissue.

Treatment

Because Frank’s pain is different than normal, came on suddenly and did not respond to rest or medication, it seems likely that he is experiencing unstable angina. Because the suspected underlying cause of his pain is a blood clot in a coronary artery, taking aspirin early is extremely important.

Aspirin decreases platelet aggregation and can keep a clot in the heart from getting bigger. Because of its importance in treating heart attack many EMS systems are advising patients to take an aspirin when they call 911.

The acronym that many EMS providers learn when treating chest pain is MONA, which stands for morphine, oxygen, nitroglycerin and aspirin. Obviously, with a BLS ambulance, morphine is not an option in this case. And, the patient has already taken aspirin.

What about nitroglycerin"

Nitro is light sensitive and is usually packaged in dark-colored containers to protect it. Additionally, patients may not check the expiration date before taking a nitro tablet when they have an onset of chest pain.

Taking an expired tablet may not cause any harm to the patient but it may not treat his symptoms either. Some EMS systems allow EMTs to assist a patient in taking his or her own medication (like nitro), but before doing so, the EMS provider should check to ensure that the medication has not expired.

In the case of Frank, that his pain did not respond to medication may be a result of his underlying heart disease, or it may be as simple as the fact that his nitro is expired.

Oxygen has been a go-to medication for EMS providers for many years. The first two steps in our assessment and care of patients are airway and breathing after all.

Not so long ago, EMS providers put many patients on supplemental oxygen under the mistaken impression that it couldn’t hurt.

Recently however, the wisdom of that assumption is being questioned. Researchers are finding that for many groups of patients, outcomes are actually worse when oxygen is given in excess.

The mechanism of harm is thought to be linked to oxidative stress, which is a result of the reactivity of oxygen and the ability of free radicals to damage cells in the body.

In the last release of guidelines, the American Heart Association modified its recommendations for application of oxygen to patients suffering from acute coronary syndrome (ACS).

Rather than place all chest-pain patients on oxygen, the AHA now states that there is not evidence to support the “…routine use (of oxygen) in uncomplicated ACS.”[1] The guideline goes on to state that in patients who are short of breath as well, oxygen may be administered until pulse oximetry is 94 percent or above.

Ultimately, patients with chest pain need to have a 12 lead ECG performed and, if they are having an acute myocardial infarction, need to be transported to a hospital with the ability to perform a cardiac catheterization.

Outcome

After checking Frank’s nitroglycerine you find that it expired over one year ago. Since the medication is too old, you elect to withhold additional nitro.

Additionally, since Frank’s pulse-ox is above 94 percent, you do not administer oxygen. While waiting for ALS to arrive, you continue to monitor Frank’s vital signs and find no changes.

The ALS unit arrives and the paramedic immediately performs a 12 lead ECG which shows an acute MI. The patient is loaded into the ambulance and the paramedic joins your unit while you transport to the hospital.

En route, the medic places an IV and gives nitroglycerine, which provides some relief to Frank’s pain. After approximately 10 minutes, you arrive in the ED. The staff from the cath lab have been advised of your arrival and meet Frank in the code room.

Frank was taken to the cardiac cath lab immediately out of the ER. He was found to have a total occlusion of two branches of his coronary arteries. After the arteries were opened two stents were placed.

Frank made a quick recovery and was discharged home which an appointment to undergo cardiac rehabilitation.

References

1. O'Connor, Robert E., William Brady, Steven C. Brooks, Deborah Diercks, Jonathon Egan, Chris Ghaemmaghami, Venu Menon, Brian J. O'Neil, Andrew H. Travers, and Demtris Yannopoulos. "Part 10: Acute Coronary Syndromes: 2010 American Heart Association Care Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular." Circulation 122(2010): S787-S817.

The need to avoid EMS staffing reductions during budget cuts

By Allison G. S. Knox
InPublicSafety.com

As local governments make budget cuts in an effort to maintain their finances and prevent layoffs, it is critical for lawmakers and emergency medical service (EMS) leaders to remain mindful of appropriate staffing levels. Inadequate staffing for EMS could have more dire consequences than lawmakers anticipate.

For emergency medical services (EMS), when budgets are cut and staff are reduced, the result can include problematic responses to emergency calls, inadequate training of personnel, and, sometimes, lawsuits. But, there are steps that EMS leaders can take to avoid these negative outcomes.

Clearly Identify the Needs of EMS

While budget cuts are often inevitable, advocates for EMS agencies must identify the needs of their departments and push to ensure that those needs are met. Such an effort can be quite difficult during times of economic strife, but it is especially crucial when it comes to adequate staffing levels. The quality of patient care cannot be compromised and, ultimately, advocates need to stress this to local government officials.

Read full story: The Need to Avoid EMS Staffing Reductions During Budget Cuts

Fire, EMS responders share lessons from Ferguson

To say the situation in Ferguson, Mo. is a mess is to put it mildly.

At last week's Fire-Rescue International conference, I spent time with two people who've been on the ground during the Ferguson protests and riots. Both, though in different capacities, were concerned with EMS units in the hot zone. During dinner one night, they relayed some unnerving stories.

It is understandable that mainstream media outlets overlook the risks this situation presents medics and firefighters on the ground. But it is probably one of the first things everyone reading this thought about.

The stories I heard over that dinner ranged from unprovoked one-on-one aggressive confrontations to objects being hurled seemingly at random targets.

If you've not yet seen it, watch this video featured in Tuesday's newsletter and our new Paramedic Cheif newsletter for industry leaders. In it, EMS Chief Chris Cebollero walks you through the initial EMS response and how they reacted to a very fluid situation.

Chief Cebollero talks about "feeling" the situation get more dangerous and instructing his crews to keep an eye out for those who may be reaching for weapons and repositioning his ambulances for a fast and safe getaway.

During his presentation at FRI, Chief Rob Wylie talked about keeping safe in tactical EMS situations. He likened it to geese; while the flock eats, there's always one with its head up looking out for danger.

One of the interesting observations from Chief Cebollero was that if anything positive has come of this situation was that it taught those paramedics how to manage an EMS scene in a dynamic crisis.

And that is a lesson we can all take from this incident and the observations of those on the ground.

As Chief Wylie pointed out in his session, when a violent situation catches us off guard, we have a one-in-three chance of making the right decision. And those odds are dramatically increased if we've thought through the scenarios and the best reactions well before it hits the fan.

Take the situation in Ferguson, overlay it on your jurisdiction and work through how you'd handle it.

How to define leadership in EMS

Last month I wrote about a smart and talented young EMS supervisor named Jason who has little interest in leadership. He sees little he wants to emulate in the bosses running his agency and the so-called leaders at the forefront of the industry. I concluded that we need to do a better job of guiding a new generation of young people into leadership. Getting clear about what leadership is — and is not —and reflecting on our own leadership may illuminate some needed changes.

The term leadership gets thrown around a lot these days. From NEMSMA to NAEMT, IAFC, NASEMSO and the AAA, there is much talk about the need for leadership development in EMS. But here is where the confusion starts: If you listen closely, there is wide variation in what’s being talked about.

8 questions to help define leadership

Some are talking about the knowledge and skills needed to manage an EMS operation such as budgeting, deployment strategies and human resource management. Some are talking about mastering a set of officer competencies. Others are talking about creating a ladder where field providers can move from the field to supervision to management and so on. But there is little clarity about what leadership is — and, consequently, little clarity about how to develop leadership in others.

To stir the pot around this topic, consider the following questions:

  • Does calling someone a leader make them a leader"
  • Can someone manage an EMS agency without providing leadership"
  • Does the title of director, administrator, manager, supervisor, executive or chief guarantee leadership"
  • Are most EMS agencies truly led or simply managed"
  • Is your state EMS director providing leadership of EMS in your state"
  • Are the people tasked with leading EMS in the federal government exercising leadership"
  • Is the head of your association actually leading the members somewhere"
  • Is that charismatic speaker at the national conference a model of leadership"

Many are called leaders, but there is often a wide gap between the title and the actual practice of leadership.

Leadership at its core

The need for leadership shows up when there is a need for a group of people to collectively move toward a goal or destination. The acute need for leadership is often most visible in crisis.

But the need for leadership shows up daily when something impacting a group needs group action to change, be different, be improved, be created or be stopped. Leadership then is a process of identifying a goal or destination coupled with a process of influencing others to action toward the achievement of the goal or destination. At its most basic level, leadership is about seeing ahead; it’s also about social influence.

Most of us would agree that EMS would benefit from having more people who actually see ahead, describe a compelling vision of the future and inspire others to put their best efforts toward achieving that vision.

We especially need leadership that is not self-serving and has more than a personal career at its center. We need leadership that serves the basic missions of the organizations and groups being led and leadership that is benevolent and fully engaging to followers.

The development of leadership requires learning, but it also requires modeling and mentoring — which means those of us who would develop leaders need to reflect on how we personally show up as leaders.

So I end this with some personal questions. If a young EMS millennial came to you wanting to learn more about leadership, could you adequately define leadership for him or her" Could you help them clearly distinguish leadership from management" Is your own practice of leadership a model worthy of followership" If you were to mentor someone in leadership, could you point to your own successes in influencing others toward a destination"

In answering these questions we will discover how we might better lead a new generation into a positive and compelling view of leadership.

Ebola: What does EMS need to know?

The largest outbreak of Ebola in history is occurring in Western Africa, with more than 1,700 infected and 1,000 deaths from the virus so far. The World Health Organization declared it a public health emergency, and Doctors Without Borders is calling it a disaster.

So how exactly did this outbreak happen" Should we in the U.S. be concerned" And what information does EMS need to know"

Although Ebola is a very concerning virus, the risk to the U.S. is still quite small. However, EMS providers should be educated about what to look for in an Ebola patient and have access to and training in use of isolation equipment.

Remember these eight points.

  • Early detection can be difficult due to the non-specific symptoms.
  • Patients with an unexplained fever and recent travel to a country known to have had Ebola — specifically Guinea, Liberia, Sierra Leone and Nigeria — or had direct contact with someone known to have Ebola, should be treated as infected until proven otherwise.
  • Exercise immediate contact isolation in patients with suspected Ebola to include gloves, goggles or face shield, full-body gown and respiratory mask.
  • Immediately notify the receiving hospital that EMS is transporting a suspected Ebola patient, since this patient will need to be isolated upon arrival.
  • Thoroughly decontaminate all equipment and surfaces potentially contaminated from treating a suspected Ebola patient.
  • Be extremely careful with blood exposure and limit the number of interventions such as starting IVs and using nebulizers unless clinically indicated.
  • Have a plan for contacting the local or state health department if a case is confirmed to be an Ebola patient.
  • Have a plan for workforce issues such as quarantine of EMS providers.

What is Ebola"

Ebola is the virus that causes Ebola Hemorrhagic Fever. The virus was discovered in 1976 when there were two simultaneous outbreaks in the Sudan and the Democratic Republic of Congo (called Zaire at the time). Some of the patients came from a village situated near the Ebola River, hence the name Ebola.

Outbreaks usually occur when a human comes into contact with body fluids from an infected animal such as a chimpanzee or gorilla, particularly when the animals are used as a source of meat. The African fruit bat is also thought to be a reservoir that can pass the virus through contact with its droppings.

Signs and symptoms

Once a human has contracted the Ebola virus there is an incubation period where the patient is not yet symptomatic. This period can last from two to 21 days.

It makes this infection particularly troubling, since someone could leave one of the countries with Ebola and not become ill until they have reached their destination weeks later. This is why people exposed to Ebola are quarantined for 21 days with daily fever checks to make sure they do not have an active infection.

Once a patient becomes symptomatic, he will display signs typical for any viral infection such as fever, nausea, joint pain and headaches. Other symptoms include conjunctival hemorrhages (burst blood vessels in the eyes), rash and sore throat, although these are less typical.

Once the patient develops a fever, he is considered infectious and has the potential to spread the virus to others through bodily fluids. Health care workers are particularly susceptible to the virus if strict contact isolation precautions are not taken.

Once symptomatic, patients can become deathly ill within days, with nausea and vomiting, bloody diarrhea as well as bleeding from other sites. Left untreated, this eventually leads to shock and death.

There is no vaccine for Ebola and with the exception of some experimental drugs, there is no approved therapy other than aggressive supportive care. Ebola is extremely lethal with a fatality rate of up to 90 percent. The current outbreak has a fatality rate of around 60 percent.

Why is this outbreak so bad"

There are a number of issues that have made this outbreak the perfect storm for an Ebola outbreak. Location and culture are two of the prominent issues.

This is the first time that Ebola has appeared in Western African countries. All of the previous outbreaks of Ebola have been in either Eastern or Central Africa.

Because of this, it is likely that the illnesses were not recognized quickly and strict isolation and quarantine practices were not instituted until the virus had already begun to spread. This is coupled with the fact that the countries of Western Africa are some of the poorest in the world with limited medical and public health infrastructure.

There are cultural issues as well that are challenging. It is African tradition to directly handle the dead bodies of family members. At the time of death, the body is at its most infectious period and it is therefore easy to spread the virus to unsuspecting family members.

Likewise, since this virus has not been seen in this region of Africa, the population has been slow to accept that a virus is causing such illness in the communities, with some people blaming western non-governmental organizations such as Doctors Without Borders for bringing an illness into their communities.

In addition there is still a reliance on traditional faith healing by a village medicine man. This practice causes the virus to spread to those in the community.

What protections are in place in the U.S."

Customs and Border Protection agents are trained to passively screen all patients coming into the U.S. from foreign countries for signs of illness. In addition, 20 airports around the country are equipped with quarantine officers from the Centers for Disease Control and Prevention.

Should the officers encounter someone with symptoms or appearing ill, they will be referred to the quarantine officer for evaluation.

In addition, CDC has recently sent some 50 experts to Western Africa to combat the virus. CDC performs testing on suspected cases and offers expert advice to clinicians around the globe.

They work in direct contact with local and state health departments and issue case definitions and guidance on handling cases of Ebola.

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Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active shooter incident is going to require repetitive bursts of significant physical activity.

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U-turn for the OB patient

If you have an OB patient about to deliver, do a U-Turn and put the patient backwards on the gurney. By placing their head at the "foot" of the gurney, this allows you to work out of the captain's chair and gives you more room. The hardest part of doing this is getting your partner to place the patient in this position. Old habits are hard to break and it may feel odd, but once in the truck ...
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