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Well-Being of the EMT
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So..., your pager goes off....THERE'S A CALL!!! AND IT'S YOUR TURN TO DRIVE!!! You jump into the ambulance, heart just a-pounding, ready to go. There's a call!.....That's all you know. Sound familiar? Maybe not. Not if you're new to this. But, if you've been around for awhile.....You know what we're talking about. This is an accident looking for a place to happen. And if you, or one of your crew members, get hurt, not only will you serve no further purpose, but, you'll further tax the system. Not only will a second crew need to be mustered to handle your CALL, but a third crew will be needed to take care of you (or your partner.)
You haven't been real attentive to your health, diet, personal sanitation, etc, lately. Got a heck of a "cold." Fever, chills, sweating, coughing, sneezing. THERE'S A CALL!!! You gonna go? What kind of impression are you going to leave with the patient, when you sneeze in their face?
The Personal Health, Safety, and Well-Being of the EMT are critical to the proper functioning of any EMS System. This is a serious subject and we tend to give it the respect that it deserves on this page.
In addition to suggesting that you be more attentive to your personal health and well-being, we're going to introduce you to ways of recognizing possible hazards, and protecting yourself from them. And the whole thing starts with understanding that it is important to REMAIN CALM!!! It is our considered, collective opinion that disruptive emotional excitement is born of fear, and that fear is a product of ignorance. People (ordinary people) rarely fear what they "know." An element of discomfort (fear) is introduced when an individual is about to embark on an activity, or engage in an event, with which they are unfamiliar or, if they are uncertain of it's outcome. You have already taken the first step toward a calm, controlled response in an environment where those around you are falling apart. Your education, experience and dedication will equip you to deal with Horrifying Events, Death and Dying, the Critically Ill, and the Injury and Suffering of others, as well as protecting you from some of the "fallout" from such scenes.
It is inevitable that at some point in your career, you will encounter a scene, or deal with a patient, that will affect you beyond your ability to cope. Most of the situations, with which we deal, are full of stress. When that stress becomes greater than our ability to cope, it's called "Critical Incident Stress." Critical Incident Stress Debriefing (CISD) is a "chat session," with individuals that know the stress that caused the problem, individuals that know the job and understand the problem, trained individuals that can help the EMT deal with the problem and move on.
(PERSONAL NOTE: About 20 years ago, while responding as a BLS search and rescue diver, to a local lake for a child who had been missing for about 2 hours, I was "lucky" enough to be the diver, out of four others, to recover the little boy, who was celebrating his 5th birthday that day. He had been underwater for well over an hour, from reports of when and where he had been seen last. The team removed him from the water, we worked (in shifts) on him at lakeside for about 20 minutes, while a four-wheel drive ambulance was moved into place. Resuscitation attempts continued at the hospital for about another 30 minutes, after CPR had been administered for the 20 minute ride to the hospital. Once the little boy's core temperature had been raised to an acceptable level, further resuscitation was withheld. The little boy died. My son was 6 years old at the time, and I remember that the only face that I could see, when we removed this little boy from the water, was the face of my son. I was the closest rescuer to him at the time and started CPR, had to stop.... was relieved by another team member.....went off in the woods....and lost lunch. About three weeks later, my now ex-wife, who is also an EMT, noticed a look on my face that has come to be called, "THE THOUSAND MILE STARE." She contacted the local CISD Team and one evening they knocked on my front door, took me back to our squad building, showed me a picture of the little boy, and sat patiently, while I cried for the next half hour. One week and two sessions later, I was able to stop crying, and we started talking. Two sessions after that, they asked if I was ready to get back in the water. I was.
My purpose in relating this event is not a plea for sympathy, or a ploy for accolades. It is an attempt on my part, by relating a very personal event, to educate you, my reader. I was supposed to be a "big bad EMT, a man." I was reduced to a tear stained pathetic figure by an event. A Critical Incident event. And I was the one, during EMT class that swore "it would never happen to me." There was no shame associated with that pathetic tear stained figure, either from any member of the CISD Team or any member of my squad. I can talk about that event now, but, can you imagine the emotional damage that might have been done, had my ex-wife not been alert enough, smart enough, or caring enough to take action. If you've been affected, ask for help. If you notice someone else that has apparently been affected, offer help. If they refuse, and you're convinced that they've been affected, take action. We are a team, and we need to look out for each other.
Charlie Corby, Advisor, Emergency Medical Ed
Death and dying are events with which, you will at sometime, have to cope. For the most part, the patient will probable be elderly and you will console yourself with the understanding that "he lived a long life." Keep in mind, though, that there may, very possibly, be a "better half" to this patient. A "better half" that must now go on living, without his/her best friend. It's been suggested that when a spouse loses his/her mate, that the first words spoken to the surviving spouse by a member of the resuscitation team, after resuscitation has been withheld, are words that the survivor will remember forever. But the team can't just pack up their gear, walk out of the house, and ignore the poor survivor. Something has to be said. Just understand the impact that your words will have. You might want to start by suggesting that "We have to talk. It's not good." Go on to explain, in simple terms, exactly what condition the patient was in when you arrived. Continue, by explaining what was done, and maybe what wasn't done (and why, if you can.) Make sure that the survivor knows that everything that could be done for the patient was done. And, even if the survivor did something that may have added to the failure of the effort, assure him/her that they (him/her) took the appropriate action under the circumstances. To lead them on any other path will only create a life of guilt for them. At some point, you will have to tell them that their loved one has died. You need to be specific, and use the word "died" or "dead." Euphemisms like "passed on," "no longer with us" will only serve to confuse the survivor. You may want to offer to accompany the survivor to the bedside of the patient, for the purpose of saying "good-bye." Watch the survivor very carefully during this entire event. If the information is turning into a critical event for the survivor, stop, give them some time to digest the information that has been offered to that point, and ask if they are ready to hear more. Do not rush the process. Do not force any information or action on the survivor, that they feel they are not ready for. Also, do not discount the effectiveness of non-verbal communication. A caring hand on the shoulder or a caring hand offered for holding, can say more than words are capable. Keep in mind that you may have a second patient on this scene, the surviving spouse. If you "push" them, they might become a patient a lot sooner than they would had you given them the time that they needed. Finally offer information about what's going to happen next. For this reason, it's best if, before hand, you are aware of what local protocol is, regarding unattended deaths in your area. Offer to call a family member, church pastor, close neighbor, someone, who can spend some time with this individual. They are probably going to need an adjustment period into the concept of living alone. It a "new trick" for an old dog. Be prepared to deal with a whole room full of different emotions. From grief, to rage, anger, denial, despair. Don't be surprised if some, or all, of it is directed at you. Do not let your guard down. Do not allow yourself to be hurt or injured by this individual. It's common practice throughout the States that a police officer be present at such an event (unattended death.) If you feel threatened, "invite" the officer to move closer to you.
If your patient isn't dead, but dying. Don't lie to them. Answer direct questions with direct answers. Half-hearted denials are easily detected by patients, and the patient's imagination, left to create "the worst" will do just that. Explain, in simple, detailed language, exactly what can and will be done for them. Impress them with your professionalism. They will draw comfort from it, knowing that if they are unable to care for themselves, that you (and the rest of the team) will do it for them. Find obvious "positives" to bring to their attention, but don't make stuff up. During a class at the squad building, a man burst through the door, and SCREAMED, "I've just been stung by a bee." His obvious concern was that he was highly allergic to bee stings, and he was afraid that soon, he wouldn't be able to breath. We walked him to the back of an ambulance, and "hooked him up" with some oxygen, called the dispatcher and a squad was summoned. We returned to the patient to assure him that he would be at the hospital in a very short time. While talking to him, we noticed that he was talking in long stringy sentences through the oxygen mask. He was told that the emergency was going to be treated like a full-fledged emergency, but we wanted him to "know" something. "What's that!" was his response. "Right now...., you're breathing," was our reply. The patient cocked his head, took a few easy breaths, looked us in the eye and said, "You're right." He immediately relaxed, and that relaxation served to protect him. You see his heart rate decreased. The flow rate of blood through his body slowed. If there was venom in his blood, and he was allergic to it, it (the venom) was moving through his system more slowly, giving us more time to get him to the definitive care that he needed. All because the "obvious" was brought to his conscious awareness. He thought he was dying.
If your patient is confused or disoriented, do not play into any delusions, and make every effort to orient the patient. If your patient is a substance abuse patient, you'll need to become educated in "body language." Look for small signals of irritation. Restlessness, staring, clenched fists. More on that later.
If you find yourself overwhelmed by the number of patients that you suddenly have, you are probably in the middle of a mass casualty incident. Get help. Lots of it. If you are aware that a mass casualty incident exists, and you are alone, because the rest of the team hasn't yet arrived, do not enter the scene. You cannot accomplish anything by yourself, and until you have adequate resources this scene must be considered unsafe for you to enter. Wait. We'll get into more of that later, too.
As treatment modalities unfold for different types of patients, we will alert you to the specific dangers (if any) associated with the patient or the environment in which you are working, Hopefully, that will help solidify the information about the danger by associating it with either a certain type of patient or a certain environment.
Your text, most likely, goes into quite a bit of detail on communicable diseases. The information is important and a well informed EMT has a better chance of protecting himself. Remember we are trying to eliminate "ignorance" (as mentioned above, on this page.) As you familiarize yourself with the different diseases, notice how many of them are "fluid borne" (carried by fluid.) Especially those diseases that seems to be of more "recent" concern, like AIDS and Hepatitis. Following the guidelines of Body Substance Isolation (BSI) will help protect you from, and "isolate" you from body fluids, secretions, and other substances that might be carrying infection. There is no way that you can know if a body substance is a "carrier." For that reason, is it smart to assume that all body substances are infected and do everything possible to avoid them. The use of appropriate "personal protective equipment" (PPE) starts by evaluating the scene into which you are about to enter. If the scene is a relative "quiet" one, gloves may be the only equipment needed to protect yourself. If the scene is likely to become more "violent," as it might with "impending child birth" where fluids a likely to be projected into the air, it might be necessary to add eye protection, gowns, and masks. There are two other concepts that we have included in this discussion, that we consider to be part of "PPE" and they are "hand washing" and "immunity." Neither is classically considered to be a "piece" of personal protective equipment, but both are very important to the health, well-being, and ultimately, the usefulness of any healthcare provider, and both, properly practiced will be very effective in "protecting" the provider from personal infection and the transmission of that infection to others. Proper hand washing has been identified as the simplest and most effective way to control personal infection and disease transmission. Familiarize yourself with the proper technique for hand washing, and utilize it before and after every patient, before and after any event that might expose you to infection, before and after meals, before and after seÖ......OOPS!...We got carried away. Appropriate proactive immunization has become the "standard of care" for all healthcare providers and its usefulness needs no further explanation here.
Your own body, when healthy, has an intricate system of protection, but you need to be attentive to your personal health habits, and do everything possible to protect your health. As mentioned above, it is not only embarrassing to "sneeze" in face of patient, it indicates that your health is in a state of compromise and that you are at greater risk of infection.
Proper use of personal protective equipment, including but not limited to, donning and removing gloves, donning and removing gowns, donning and removing masks, and being fitted for a HEPA respirator, is something that is better left to actual classroom discussion and demonstration. The proper disposal of these items is something that common sense dictates. All healthcare facilities have very strict controls over the disposal of infectious waste, and strict adherence to those controls is expected from everyone.
Hazardous scenes are around every corner. From the "hazards" mentioned above, to fires, electricity, weather conditions, terrain, violent patients, and hazardous materials, the EMT is constantly bombarded with situations that threaten his/her well-being. In addition to the protective equipment mentioned above, some other pieces of equipment are offered. In some areas medical providers are wearing body armor. Although it is not common practice for medical providers to involve themselves in scenes involving firearms, some providers have felt better "protected" in the urban setting using this new technology. Firefighting turnout gear not only provides some protection from the hazards of fire, but will provide limited protection from environmental elements. Today's turnout gear provides a barrier to fluids (including water, rain, body fluids, chemicals, and some hazardous materials,) and is very useful in cold weather environments. Helmets and goggles provide head and face protection in environments where falling objects or projectiles might pierce the skin. Heavy turnout gloves provide a very limited degree of protection from accidental brushes with charge wires, and a somewhat better level of protection from hot/cold surfaces. If the scene is one which includes loud noises, consider some type of ear protection. Even if the noise is not painful, sound levels well above the level that destroys the small "hair-like" structures in the inner ear, can occur. Electricity is a hazard that must be anticipated without being seen. The likelihood that a provider, who is inattentive, at a scene where wires (any kind of wires) are involved, will ultimately be electrocuted, is very high. The likelihood that a provider, who is inattentive, will ultimately be struck by lightning at a scene where weather conditions are an issue, is equally as high. Attention to the environment in which you are working is vital to your well-being. Issues regarding violent patients, and hazardous materials will be discuss at length in later sections of this site.
