Well-Being of the EMT

Well-being / healthy habits

Taking care of yourself is the foundation of a long career, and it rests on a few habits. The first is a support system of solid personal relationships with family, EMS colleagues and friends. Exercise builds strength, flexibility and cardiovascular fitness and helps with weight management. Sleep is just as important, because a lack of it leads to medical errors, poor decisions, more motor vehicle collisions (MVCs) and a weaker immune system. Eating right provides the fuel for long shifts and strenuous work.

Alcohol and caffeine should both be limited. Each impairs performance, decision making and reaction time, even when you feel more awake for having had them. Finally, see a physician regularly and stay current on your vaccines.

Standard precautions

Pathogens spread in two main ways: through blood and body fluids (bloodborne) or through droplets (airborne). Because you cannot tell by looking whether a patient is infected, standard precautions require you to assume that all body fluids are infectious. The decision about which precautions to take is made during scene size-up and is reassessed throughout the call as the patient's condition changes.

The law divides the responsibility. Under the Occupational Safety and Health Administration (OSHA), the employer must provide training, vaccines, personal protective equipment (PPE) and a written exposure control plan; the employee must follow that plan and report exposures. Federal law also provides that emergency workers can be notified if a patient they were exposed to is later found to be infected with tuberculosis (TB), hepatitis B or HIV.

PPE types

The table below sets out the types of PPE an EMT uses and when each is called for.

Table 2.1PPE types

Gloves are not a substitute for handwashing. Wash your hands after every patient contact, even if you wore gloves. An alcohol-based cleaner is acceptable unless your hands are visibly soiled or anthrax is suspected.

A few common-sense rules apply: keep PPE on your person or in your kits at all times, carry 2 sets of gloves, and if in doubt, take precautions.

Diseases of concern

Several infectious diseases are of particular concern to EMS providers because of how they spread and how serious they are. The table below summarizes them.

Table 2.2Diseases of concern

The incubation period is the time between contact with a pathogen and the first symptoms; it varies by disease.

Infection control & the law

Infection control in EMS is shaped by two pieces of federal law. The OSHA Bloodborne Pathogen Standard requires the employer to have an exposure control plan; to provide training, a free hepatitis B vaccine and PPE; to label hazards properly with the biohazard symbol; and to maintain housekeeping and decontamination procedures. The Ryan White CARE Act of 1990 gives emergency responders the right to find out whether they have been exposed to a life-threatening disease.

Notification works differently depending on the route of exposure. After an airborne exposure, such as to TB, the hospital notifies your agency's designated officer, who notifies you. After a bloodborne exposure, such as to HIV, you must request a determination yourself, through the designated officer. When caring for or transporting a suspected TB patient, or when performing a high-risk procedure such as suctioning or intubation, an N-95/HEPA respirator is required.

If you are exposed, whether by needlestick or splash, seek medical care immediately, because delay reduces the effectiveness of any preventive treatment. EMTs are also tested regularly for TB exposure, usually yearly, with the tuberculin skin test (TST).

Stress — Selye's General Adaptation Syndrome (3 stages)

Resilience is toughness, the ability to recover from difficult situations, and understanding how the body responds to stress is part of building it. Selye described that response as the general adaptation syndrome, which unfolds in three stages. In the alarm stage the body mounts the fight-or-flight response: the heart rate (HR) rises, the pupils dilate, blood pressure (BP) climbs and cortisol is released. In the resistance stage the body adapts and returns to normal as it copes with the stressor. If the stress is prolonged or severe, the body reaches the exhaustion stage, when the body's resources are depleted and fatigue and stress-related illness set in.

3 types of stress reactions

Stress reactions differ in when they appear. The table below sets out the three types.

Table 2.33 types of stress reactions

Not all stress is harmful. Eustress is positive, helpful stress; distress is negative stress that impairs performance. Certain calls are recognized as especially stressful: multiple-casualty incidents (MCIs), calls involving infants or children, severe injuries, abuse or neglect, and the death of a coworker. The signs that stress is taking a toll include irritability, poor concentration, changes in sleep or appetite, anxiety, guilt and isolation.

Dealing with stress

Managing stress begins with lifestyle. A better diet, less alcohol and caffeine, exercise and relaxation techniques all help, and so, when needed, does a change of shift or work location.

For patients and for EMTs alike, the mnemonic eSCAPe describes what to offer after a traumatic event, to every patient, every time:

• S – Social support: the person is not alone.
• C – Choice and control: offer small choices.
• A – Anticipate: explain what happens next.
• P – Plan and organize: reduce confusion.

Critical Incident Stress Management (CISM) is a comprehensive system of education, peer support and counseling. One of its components is critical incident stress debriefing (CISD), in which a team of peers and mental health professionals meets with responders 24–72 hours after an incident; a "defusing" is an earlier, smaller session of the same kind. Debriefing is now used less often and is not always recommended. Whatever form it takes, seeking help is a sign of strength, not weakness.

Death & dying — 5 stages

Patients who are dying, and their families, commonly pass through five emotional stages:

1. Denial ("Not me")
2. Anger ("Why me?")
3. Bargaining ("Let me first...")
4. Depression ("I haven't...")
5. Acceptance ("I'm not afraid")

Not everyone goes through all five stages, or in this order, and the family may need more support than the patient does. You can help by treating the patient with respect and dignity and talking directly to him or her, by tolerating anger without taking it personally, by listening empathetically, and by offering realistic comfort. Never give false reassurance.

Scene safety

Whether a scene is safe is the most important decision you make on every call. It helps to know what actually kills EMS providers. The biggest killers are heart attacks, MVCs and air-medical crashes, not violence, and back injury ends more careers than violence does.

Hazardous materials & rescue

At a hazardous materials incident, your first task is to keep your distance. Stay well back and use binoculars to identify placards. The DOT Emergency Response Guidebook gives information on safe distances and procedures. Your job is to recognize the hazard, protect yourself and others, and notify the hazmat team; you do not act beyond that. Contaminated patients are not treated until they have been decontaminated, because treating them earlier contaminates the ambulance and the ER. Terrorism may involve chemical, biological, radiological or explosive agents, and you should know your local protocols for it.

Rescue operations follow the same principle. Call for police, fire or specialist teams as needed, and never act outside your training. The PPE for rescue work is turnout gear, eyewear, a helmet and puncture-proof gloves.

Violence — Plan / Observe / React

Protection from violence follows three steps: plan, observe and react. Planning starts before the call. Wear safe clothing, meaning nonslip shoes, reflective gear and, in high-risk settings, body armor. Carry equipment you can manage, keep a portable radio with you, and assign safety roles; one EMT can act as the observer.

Observation begins on approach and continues throughout the call. Look for signs of violence such as broken glass or arguing, for a crime scene, for drug or alcohol use, for weapons, for agitated family members or bystanders, for possible perpetrators still on scene, and for pets. Turn off your lights and siren as you near the scene so that you do not draw a crowd, and do not stand directly in front of doors.

If violence develops, react with the 3 Rs:

• Respond: put distance between yourself and the threat and use cover, which protects you from projectiles, or concealment, which hides you but does not protect you.
• Radio: call for police and give clear information about the location, the number of people involved and any weapons.
• Reevaluate: do not re-enter until the police have secured the scene, and stay alert even after they have.

When you have to retreat, flee with 2 obstacles between you and the danger, ditch cumbersome gear, and take cover or concealment.