Improving EMS Safety on Scene FeaturedWednesday, 24 May 2017 00:00 Written by Super User
Guest blog written for ATS by Robert Avsec
In August 1979, I was a new EMT working my first job in EMS as an employee of the private sector ambulance service that had the contract to provide EMS to the city of Richmond, Virginia. On one of my first tours of duty, my partner and I responded to a reported shooting in the Fairfield Court projects in the east end of the city.
Like many urban areas in the late 1970s, Richmond was seeing the fallacy in project housing for low income families; the people were still poor, the buildings were deteriorating by the day, and the sale of street drugs was quickly becoming the #1 job in the neighborhood.
Back to the call. It was a hot and humid night and when we arrived and there were probably 40-50 people, mostly young black men and women, outside the address apartment. When we pulled up at the curb and got out of the ambulance with our equipment, several people started yelling loudly, "Make way for the ambulance doctors!" And with a little assistance from two very big men, the crowd quickly parted opening our way to the front door of the apartment.
But that was 1979, not 2017. It's an increasingly dangerous world providing EMS in communities across the U.S. Physical encounters with violent patients, exposure to lethal drugs like fentanyl, and the presence of firearms in too many potentially volatile situations have changed the approach used by EMS providers for scene management. Or at least by now it should have.
Fire departments that provide EMS to their communities respond to more EMS calls than fire calls. Everyone knows that, right? But how many of those fire departments provide the same level of resources to those EMS calls that they provide to fire calls? You know, enough resources to handle the necessary tasks?
A two-person ambulance crew responding to an emergency is not a safe, effective, or efficient staffing configuration given the potential risks to personnel and the organization for most fire departments. Let's look at what tasks need to be done on a typical EMS call to keep everyone safe and get the job done.
1. Assess the outside of the residence or business for potential hazards or threats to EMS personnel. Are you walking into a domestic violence situation? Perhaps a meth lab? Start planning how you'll remove the patient from the structure via stretcher, especially in a hurry.
2. Continue the assessment once in the residence or business. Find out how many people are present in the home, account for their whereabouts, and continue to account for their location until the call is over. You don't want to be that medic who suddenly has a gun pointed at the back of your head by the patient's son who says, "My momma ain't gonna die today, right?"
3. Assess the personal protective equipment needs for personnel working around the patient. Are there respiratory or bodily fluid hazards present? Everybody is pretty comfortable these days about gloving up before providing patient care, but do they recognized when they need eye and face protection? Or gowns to protect you from bodily fluid contact? (It's very easy to develop tunnel vision while providing patient care, especially to a very sick or badly injured patient).
Structural firefighting PPE is very expensive, and that makes it a poor choice for EMS protective clothing (Your department can buy cases of latex gloves, face-masks and eye shields and disposable gowns for the cost of one set of structural PPE that becomes contaminated and can't be cleaned).
4. Patient care duties. Obviously, the most critical task responsibilities are those needed to provide patient care. That requires that there be an attendant-in-charge for determining a patient care plan and implementing that patient care plan. Ensure that only the people necessary to provide patient care are in the "hot zone", i.e., close proximity to the patient where they can be exposed to bodily fluids or an accidental needle-stick from a contaminated needle.
5. Patient movement to the ambulance. Assess what's necessary to get the patient to the ambulance, procure the necessary equipment while patient care is being delivered. (Going back to point #1 above, this process should begin upon arrival).
6. Demobilization tasks. Ensure that all contaminated EMS equipment and supplies are properly bagged for removal from the scene. Clean up any blood or other bodily fluids left behind by the patient. Ensure that an adult takes responsibility for the home or business. If no adult is available, ensure that the home or business is locked and secured.
The above are by no means an all-encompassing list, but I think they provide a pretty good list of tasks that must be accomplished on an EMS call for service involving a single-patient. Now ask yourself: how safely, effectively, and efficiently could all of them get done by two EMS providers?
At a minimum, there needs to be a third crew member to handle the incident management functions (Points 1, 2, 3, 5, and 6 above). Managing the incident and providing patient care are two distinctly different functions; doing both well is beyond the capabilities of a two-person ambulance crew, in my opinion.
The way I see it, fire departments have a couple of options. Option #1, staff your ambulances with three EMS providers instead of two. Option #2, respond a fire unit with each ambulance response to provide the additional staffing needed on scene to complete the necessary incident management functions while the two-person ambulance crew focuses on providing patient care.
Why should the busiest type of unit in your department—and one responds to calls for service that always have the need for both incident management functions and patient care functions—get the smallest amount of resources, and no officer in charge? Especially when those ambulances and their crews respond to so many potentially dangerous encounters? Something to think about, no?
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Battalion Chief Robert Avsec (Ret.) served with the Chesterfield (Va.) Fire & EMS Department for 26 years. He was an active instructor for fire, EMS, and hazardous materials courses at the local, state, and federal levels, which included more than 10 years with the National Fire Academy. Chief Avsec earned his bachelor of science degree from the University of Cincinnati and his master of science degree in executive fire service leadership from Grand Canyon University. He is a 2001 graduate of the National Fire Academy's Executive Fire Officer Program. Since his retirement in 2007, he has continued to be a life-long learner working in both the private and public sectors to further develop his "management sciences mechanic" credentials. He makes his home near Charleston, W.Va.