Workforce Safety and Wellness (Framework For Paramedic Practice) Part 2

Specific Stressful Situations Acute Traumatic Stress

Witnessing horrific and disturbing events can generate intense fear and a sense of helplessness in Paramedics. Unchecked, these feelings can lead to acute traumatic stress. Acute traumatic stress is an unexpected and sudden stressful event which is unlike the stress of day-to-day EMS and understandably requires a different approach.

PROFESSIONAL PARAMEDIC

Like medicine, the most effective critical stress management is prevention-oriented. Planning for the ability to provide humane relief during a major incident provides the best opportunity to reduce acute stress.

When possible, a predeployment briefing that explains the situation, and potential stressors that the Paramedic is about to encounter, can go far toward decreasing the shock and subsequent acute traumatic stress. For example, search and rescue predeployment briefings should include a discussion of the possibility of the operation changing from one of rescue to a recovery operation. Tempering the hopes of concerned rescuers can help to reduce the impact of a poor outcome, thereby protecting rescuers, without diminishing the prospect of a rescue.

Clear delegation of authority and the assignment of specific tasks can help to eliminate some of the confusion and helplessness that Paramedics will experience when confronted with a horrific situation. With proper guidance, command, and control, Paramedics can persevere against incredible adversity.


Incident command also needs to consider the mental and physical limitations of the emergency service respond-ers under their command. Rotations to out-of-service in order to take a rest break, eat some food, drink fluids, and use lavatories, all part of rehabilitation, can help respond-ers handle stress more effectively. It is also useful to have trained counselors who are observing for signs of stress and can provide immediate interventions in the case of an acute stress reaction.

STREET SMART

Whenever possible, the media should be restricted from the rehabilitation area. Reporters tend to use inflammatory or untactful language in their questions in order to achieve a desired effect or to prompt a response. Unfortunately, ill-chosen or less than tactful words can have devastating effects upon emergency services responders.

Demobilization is another opportunity to mitigate the effects of the acute stressors and to decrease the incidence of acute traumatic stress reactions. Debriefings, or "after action reports," should be used to emphasize the successes on-scene. Disagreements regarding specific aspects of scene development should be reserved until later. During a debriefing, first-line responders should be monitored, possibly including an exit physical examination. These post-event physicals can reveal signs of stress including sustained tachycardia, persistent headaches, and hypertension.

After a major incident all responders should be encouraged to get rest, moderate their intake of alcohol, and reduce their caffeine intake. Responders should also be encouraged to engage in self-affirming activities such as spending time with family and friends or getting involved in a favorite sport.

Defusing

On occasion, and because of the nature of the incident or based upon an observation of emergency services respond-ers, it may necessary to order a defusing. A defusing is an immediate intervention intended to avert acute stress reactions among the responders. Usually initiated within eight hours, a critical-incident response team (CIRT) is called in to meet with the affected personnel, typically front-line responders.

The purpose of a defusing is to quickly explore the event and then educate responders about the effects of stress. The lesson includes a discussion of signs and symptoms of acute stress reaction as well as means of managing stress. If done correctly, a defusing can either eliminate the need for further critical incident stress debriefings or enhance the productivity of future critical incident stress debriefings. Crew leaders, educated in debriefing techniques, can support their fellow crew members (Figure 3-4).

Several criteria can establish the need for a critical incident stress debriefing (CISD).18-20 Perhaps the most common reason for a CISD is an extraordinary event-related occurrence. Examples of responder-related extraordinarily stressful events include a line-of-duty death, serious injury of a coworker while on-the-job, and post-event suicide of a fellow responder. Examples of event-related extraordinarily stressful events include the traumatic death of a child or children; prolonged rescues, especially those that turn into a body recovery operation; and prolonged hostage situations.

A CISD can be triggered by a request for CISD, often from either an affected responder or an enlightened incident commander. It can also be triggered by indirect personnel, such as family members, who observe behavioral changes in the responder. Concerned coworkers, who are still witnessing signals of distress, such as constant ruminating after three weeks, can also request a CISD.

A CISD is a private meeting, where only the CIRT and responders are invited. Typically, rank holds no privilege and conditions are established from the outset. This encourages open dialogue among the CISD’s participants. With all responders and the CIRT assembled in one room, the CIRT leader begins by making introductions. A typical CIRT has a mental health practitioner as well as emergency responders who are trained in critical incident stress debriefings. Once the introductions are completed, the leader starts the process of divining the facts, asking for thoughts and reactions, all in a nonconfrontational atmosphere.

Defusing session led by a Paramedic.

Figure 3-4 Defusing session led by a Paramedic.

Table 3-2 High Potential Critical Incidents

1.

Line of duty death

2.

Suicide of a colleague

3.

Serious work-related injury

4.

Multi-casualty incident

5.

High threat incident (terrorism)

6.

Severe traumatic injury to children

7.

Close relationship with victim

8.

Excessive media exposure

9.

Prolonged operations

10.

Overwhelming events (disasters)

Timing is important to a CISD. If responders are still experiencing acute stress they will have a limited number of communication channels to handle incoming information. They will not be able to tolerate the ambiguity that may occur during the discussion.

The objective of every CISD, and the next step in the process, is education. Responders are first taught about typical or "normal" reactions to stress, asked to reflect upon these symptoms, then taught about means to manage the stress that naturally accompanies any incident.

Following a CISD, a member of the CIRT may have identified a responder manifesting symptomology consistent with acute stress reaction who might benefit from professional psychiatric services. These psychiatric interventions, provided immediately after the event, can potentially prevent long-term disability such as post-traumatic stress disorder.

Post-Traumatic Stress Disorder

If symptoms of acute stress disorder do not resolve within a four-week period, then post-traumatic stress disorder (PTSD) must be considered.26,27 The essential feature in post-traumatic stress disorder, per the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual, fourth edition (DSM-IV), is the development of "characteristic symptoms following exposure to an extreme traumatic stress involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury or a threat to the physical integrity of another person."

Symptoms of PTSD include persistent intrusive recollections of the event and flashbacks. Chronic absenteeism may represent the Paramedic’s attempts to avoid anything associated with the psychological trauma. Paramedics who have experienced a violation of a key psychological assumption, such as safe return from duty, might have tendencies toward PTSD.

Personal Injury Prevention

Many individuals get involved with emergency services because of the excitement and danger of a rescue, never really thinking that they themselves might actually get hurt. To the

Paramedic, nothing may be more stressful than personal injury. Despite their best efforts to mitigate hazards, injuries do occur. In many situations, these injuries could have been lessened, or eliminated altogether, with proper preplanning and a safety-conscious attitude on the part of Paramedics.

The problem of emergency responder death and injury may have been brought to the forefront by a 1973 publication entitled America Burning. America Burning, a presidential white paper, brought to light the indifference to safety in the fire service.28 Subsequently, all emergency responders have experienced an increased emphasis on safety, primarily through increased regulations and standards (Table 3-3). Paramedics, both in and out of the fire service, must be aware of the standards and regulations that affect them.

Regulations are mandatory and carry the weight of law, whereas guidelines and standards are voluntary and only offer directions for safe practice. Other recognized sources of standards include the American National Standards Institute (ANSI) and the American Society of Testing and Materials (ASTM). However, when specific injuries increase in certain areas lawmakers frequently turn to standards and guidelines for direction.

Back Injury

The prevalence of back injury among Paramedics is high and potentially preventable.29-31 A reduction in the incidence of back injury can be realized if Paramedics adhere to a few basic back safety rules. In many cases, back injury occurs because of improper lifting and carrying.

A Paramedic should lift only those loads that can be carried safely. Many EMS agencies have guidelines regarding safe lifting, often tied to a functional job description, and mandate that additional rescuers be called for heavy lifting. When lifting any object—stretchers to jump kits—Paramedics should bend their knees, stoop down, and lift with their legs. Keeping the object close to the body and in-line helps to reduce the chance of a back injury. Part of back safety is back health. Exercise, discussed earlier, helps to maintain the strength and flexibility of the back and reduces the chance of injury.

Table 3-3 Sample of Safety Regulations and Standards Applicable to Paramedics

Safety Regulations within the Code of Federal Regulations (CFR)

Confined Space Rescue 29 CFR 1910.146

Hazardous Materials Response 29 CFR 1910.120

Bloodborne Pathogens 29 CFR 1910.1030

National Fire Protection Association Standards

Fire Department Infection Control NFPA 1581

Hazardous Materials Awareness Competencies NFPA 472

Centers for Disease Control and Prevention (CDC)

Guidelines for Exposure to Tuberculosis

Guidelines for Hepatitis B Exposure

Risk Management

Progressive EMS agencies have developed a plan for risk management, a plan that emphasizes safety and whose goal is to reduce Paramedic injury in an effort to promote a culture of safety in their organization.

In those agencies, either a risk manager or a safety committee identifies known hazards and then tries to mitigate those hazards. These activities are consistent with requirements under the general duty clause contained within the Occupational Safety and Health Administration’s (OSHA) regulations.

Through a study of the frequency of injury, the severity of injuries, and the economic impact of those injuries (including workers’ compensation claims), the risk management team identifies trends and implements change (e.g., new regulations, procedures, or protocols). The risk management team would then perform an audit and reassess the success of the change. This plan-do-check-act approach, the PDCA cycle, is a form of continuous quality improvement and is the same model used in business.

Safety

The saying goes "safety starts at home." Every Paramedic has a responsibility to help maintain the safety of both the station and the emergency response vehicle (ERV).

Of immediate concern in the station is the problem of fire and life safety. EMS stations should serve as models of a safe building for the community. Sprinklers should be placed in all living areas and fire extinguishers, as well as fire alarms, should be readily available. In addition, fire escape routes should be posted and clearly visible and fire drills should be routinely practiced.

Another concern is falls that occur while on the premises. Wet floors and snow-covered walkways present a clear and present danger. Precautions should be taken to eliminate or mitigate the danger if possible.

Vehicle Safety

Paramedics depend on their emergency response vehicle (ERV) for protection during an emergency response. A combination of lights, reflective surfaces, and sirens help to increase the visibility of EMS while on-scene. Therefore, these safety devices should be regularly checked to be sure they are in working order. However, a greater danger may exist from mechanical failure. High speed driving, sudden stopping, and multiple drivers driving in all kinds of conditions combine to put an extraordinary stress on ERVs.

To prevent mechanical failure, and ensure a timely response, EMS agencies should have a program of preventative maintenance (PM) for their ERV As opposed to a traditional "wait until it breaks then fix it" approach, a pre-ventative maintenance program forestalls the incidence of failure, thereby decreasing the incidence of injury and potential litigation.

Emergency Response

Paramedics are at greatest risk of personal injury during the initial response to the scene of an emergency. Despite safe vehicle operation, collisions with other vehicles on the road do occur. Every emergency vehicle operator (EVO) should practice caution when advancing upon intersections. Many EMS agencies require all ERV to come to a complete stop, when opposed by the red light, before proceeding.

When passing other vehicles, while running lights and sirens, the EVO should expect the unexpected and be prepared to drive evasively in order to avoid collision. Most states require emergency vehicles to pass on the left. Passing on the right runs the risk of having confused drivers suddenly turn into the path of the ERV

Paramedics should be on a heightened state of alert when multiple emergency vehicles are on the road. Unsuspecting motor vehicle operators, seeing one emergency vehicle pass, may pull out into the path of the next emergency vehicle. Police escorts are discouraged in many EMS systems for this reason.

If more than one emergency vehicle is traveling the same route it may be prudent to change siren modes. There is a better chance that the motorists will hear two distinctly different sounds and recognize that there is a second emergency vehicle. While a safe following distance increases the safety of the chase vehicle, the wisdom of having two ERV responding lights and sirens must be questioned. If it is plausible, the chase vehicle should turn off its lights and siren, allowing the first ERV to be the first responder to arrive on-scene.

A defensive driving attitude, or due regard for others on the road, can help to limit the number of motor vehicle collisions. A number of emergency vehicle operator courses and accident reduction programs are available to Paramedics. Some insurance companies offer a reduction in premiums (personal and corporate) for participation in these programs.

Scene Hazards

Personal safety is the primary concern of Paramedics upon arrival on the scene of an emergency. The responsibility for scene safety is both an individual responsibility as well as a collective responsibility of the team. At larger incidents a safety officer may be assigned to maintain safety. However, at a small incident (e.g., a typical call for an emergency), overall responsibility falls to the officer-in-charge.

When approaching the scene of a motor vehicle collision, the driver and the Paramedic should slow the vehicle and take a moment to get a "windshield survey" of the scene. Obvious hazards, such as a patient lying in the roadway or smoke and fire, should be reportedly immediately as part of the "first due" report. It is safe practice to call out, by radio, or note somewhere in the cab of the ERV the license plate numbers of the vehicle being approached. Some EMS agencies are not allowed to approach vehicles that are reported stolen until law enforcement officers arrive.

If the emergency responder is the first emergency vehicle on-scene then the vehicle should be placed in such a manner so as to protect the patient and the responders. Typically, the ERV is staggered, out-of-line, from the vehicle ahead so that a safety zone is created.

The ERV is now acting as a warning device, with its lights flashing, and as a physical barrier. To improve its functionality as a barrier, the tires should be turned sharply, away from the pathway to the vehicle ahead.

If the scene is already protected by another emergency responder, then most EMS agencies have a policy of parking beyond the scene, parking in the direction of the most likely destination hospital, and toward the route of intended exodus. Parking in front of the scene helps reduce the exposure of the second emergency vehicle to collision.

Before approaching an unknown vehicle, headlights should be turned on high and any available takedown lights or spotlights aimed toward the vehicle ahead. This lighting helps to illuminate the interior of the vehicle as well as create a safe working zone.

Some EMS systems require that the Paramedic radio the license plate of the vehicle before it is approached. If the plate comes back on a stolen vehicle the Paramedic is to wait for the arrival of law enforcement.

After selecting only the minimal equipment required for an initial response, the Paramedic would approach the rear of the vehicle. Carrying additional equipment, such as ECG monitors and so forth, is unnecessary and presents an additional burden if the Paramedic has to flee suddenly. The Paramedic should choose to either approach the vehicle from the passenger side or to go around the back of the ERV and approach the vehicle from the driver’s side. The Paramedic should avoid walking in front of the ERV headlights, backlighting his position and announcing his presence to the driver. Surprise is an important safety technique.

With flashlight in hand, and carried away from the body, the Paramedic would examine the inside of the vehicle for weapons as well as for the number of patients and then position him- or herself behind the B-post of the vehicle. From this venue the Paramedic can continue to inspect the interior of the vehicle’s occupant compartment for evidence of damage as well as weapons before proceeding with patient care.

A Paramedic approaches a house call much differently than a road call for a motor vehicle collision. While houses vary, from the apartment in a high-rise development to the bungalow on a beach, the basic safety principles remain the same for all and need only be modified to the conditions on-scene. A current controversy in EMS concerns the style of uniforms. Some EMS agencies advocate the button-down style of uniform that presents a clean image and portrays a military bearing to the wearer. Other Paramedics argue that these uniforms make Paramedics look like law enforcement officers, especially to the distorted eyesight of a confused or intoxicated patient (Figure 3-5). Patients could respond inappropriately, even violently, to this misperception.

Similarities between law enforcement officer uniforms and EMS uniforms.

Figure 3-5 Similarities between law enforcement officer uniforms and EMS uniforms.

An alternative EMS appearance, dubbed the soft look, consists of polo-style shirts. These shirts, without the badges of authority, are argued to be safer.

The use of personal body armor while performing EMS is another controversy in EMS. Some argue that body armor is necessary to protect Paramedics. Citing gun ownership statistics, body armor advocates believe that body armor is part of personal protective equipment (PPE). In opposition, other Paramedics believe that wearing body armor will encourage Paramedics to enter scenes that they would otherwise not have entered, under the false assumption that the body armor will protect them. Opponents of body armor argue that Paramedics do not have a duty to enter into unsafe scenes.

Like their approach to a motor vehicle collision, Paramedics should slow their approach to a house call until both the driver and the Paramedic can get a windshield survey. Emergency lights should be extinguished well before arrival, so as to not alert the occupants of the impending approach of emergency responders. The ERV should be slowed to a near stop at a 45-degree angle from the scene. From this vantage, the Paramedic can take a moment to look and listen for evidence of scene violence.

Properly carrying equipment can ensure the Paramedic's safety.

Figure 3-6 Properly carrying equipment can ensure the Paramedic’s safety.

If there is no evidence of scene violence, the Paramedic should park the ERV either diagonal across the end of a driveway, or backed into the scene. This position permits a hasty retreat if need be.

Carrying only the minimum equipment needed, the Paramedic should approach the house from an oblique angle if possible, cutting across the lawn if necessary. Potential attackers assume the Paramedic will approach the house from the sidewalk or other walkways. If a flashlight is needed to illuminate the pathway, then it should be carried away from the body and care should be taken to not backlight the Paramedic.

Equipment bags should be slung over the shoulder, or carried by hand, where they can be slipped off and dropped in front of pursuers. If the equipment bag is slung over the neck, attackers can grab the strap and drag the Paramedic to the ground. Paramedics must be sure to properly carry their equipment bag (Figure 3-6).

If possible, the EVO should remain in the vehicle, with the ERV running and the mobile radio on, while the Paramedic approaches the house. This permits the EVO to contact LEO if assistance is needed and to more quickly depart the scene.

If the residence is an apartment complex or similar structure with an elevator, then the Paramedic should consider using the fire service functions. Upon arrival at the intended floor, the elevator alarm should be silenced and the elevator locked. One Paramedic should approach the apartment door while another Paramedic surveys the scene for stairwells, fire escapes, and other emergency exits. Once safe entry is made into the apartment, the elevator can be released for regular service.

The Paramedic should verify the address, then approach the door from the door handle side; this cuts down on the Paramedic’s angle of exposure. Using the door’s jam as a barrier, the Paramedic would position himself perpendicular to the wall and loudly announce his presence, using the butt of a flashlight or similar object to knock on the door while shouting out, "Ambulance!" or "Fire department!" These terms are generally understood by most citizens and cannot be confused with "police" or other terms.

Entering the residence, many Paramedics suspend the EMS equipment bag and carry it in front of them, providing a barrier to attacking dogs and/or an obstacle to pursuers. Paramedics should request that all dogs be locked in another room, regardless of pleas from the family or innocent appearances. Even small, apparently harmless dogs can attack if they sense that the Paramedic is hurting their master.

Whenever possible, two responders should enter the scene together. One responder acts as the contact medic. The contact medic makes contact with the patient and begins patient care. This second responder acts in the role of the "cover medic." The cover medic watches the scene for hazards. The cover medic always keeps the "big picture" in mind, watching both the patient and the other people on scene. The cover medic should ensure that the doorway to the exit is never blocked. If possible, the cover medic should be stationed in the path to the doorway, to ensure that it remains open. Often the cover medic carries the radio in case additional aid is needed.

The cover medic should also do a quick scan of the scene to identify deadly weapons and dangerous instruments. Deadly, or lethal, weapons are those objects that are, by design, intended to inflict death or disability (e.g., a pistol or a knife; Figure 3-7a). The definition of a dangerous instrument is more amorphous. A dangerous instrument is any object that could be used, under the right circumstances, to produce serious injury or even death. An example of a dangerous instrument would be a box cutter or broken beer bottle (Figure 3-7b), both of which could produce serious lacerations.

If a cover medic is not available then the Paramedic must perform a scene survey alone. The Paramedic should avoid tunnel-vision and, borrowing a term from the fire service, perform a scene size-up before proceeding. Some Paramedics, once they are inside the door, immediately step to the side, with their back to the wall, and start asking family members simple questions. Taking advantage of the moment, these Paramedics perform a quick sweep of the room for deadly weapons and dangerous instruments.32-35

Domestic violence calls are some of the most dangerous calls for LEO and Paramedics alike. When arriving on the scene with a potential for domestic violence, the Paramedic is well advised to wait for the arrival of LEO before entering. If Paramedics have inadvertently entered into the scene of probable domestic violence, they should consider the severity of the patient’s injuries versus their personal safety, keeping their safety foremost in their minds. If the scene is unsafe, and the Paramedic can get the patient into the relative safety of the ERV they should attempt to do so. Ifthe scene is unsafe, the Paramedic should immediately withdraw and call for assistance.

If Paramedics are attacked or feel they are about to be attacked they should immediately withdraw from the scene. Some Paramedics will throw the clipboard into the hands of a potential attacker, to confuse the attacker and to allow them more time to escape.

The first goal for Paramedics during a hasty retreat is to get two or more objects called cover between themselves and their would-be attackers. Cover is any object that cannot be penetrated by a projectile, from bullets to frying pans. Examples of cover include telephone poles and even fire hydrants. The tires and engine block of the ERV also make good cover; however, Paramedics are reminded that a bullet tends to follow the plane of the ground after it ricochets and can travel under an ERV

If cover is not immediately available then the Paramedic will have to settle for concealment. Concealment is created by any object that blocks the pursuer’s vision of the Paramedic. However, concealment does not offer protection and should be abandoned in favor of cover and retreat as soon as possible.

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