It’s a routine call for a person with a minor injury. When you arrive, you find a patient with a tiny laceration on one arm. The patient is holding a towel over the wound; very little blood is visible. This is a “Band-aid job.” But wait a minute. Did you put on your gloves? For a Band-aid call? Are you kidding?
Despite Occupational Safety & Health Administration (OSHA) and Centers for Disease Control (CDC) rules and many local protocols, we continue to put ourselves at risk on the street by failing to follow the basic universal precautions against bloodborne pathogens. In most cases, these failures happen on the “simple” calls or because of lack of awareness of the risks of some “routine” EMS activities.
Let’s look at what’s involved in the risk. In many of her reports for EMS audiences, noted infection control expert Katherine West, BS.N., MS.Ed., C.I.C., explains: “Don’t confuse contamination (blood on the skin) with exposure (blood entry into the body) and exposure with infection … Even with adequate dose, virulence and entry into the body, infection may not occur because of resistance.”
If you look at this in the same light as our fire training, the process of infection is like the fire triangle of heat, oxygen and fuel. Removing one element of the triangle causes the fire to go out. If you remove one element of the process of contact with bloodborne pathogens, you can virtually eliminate the risk of infection. That’s why the basic universal precaution of eye protection, coverage of the mouth and nose, and the wearing of gloves is so important. Taking basic precautions eliminates the most common routes of exposure: through eye membranes, airways or broken skin on hands.
In most cases, common sense should dictate how you protect yourself on a call. “The protection should be proportional to the realistic danger,” said Robert Bass, M.D., executive director of the Maryland Institute of Emergency Medical Services Systems, the governing agency for the state’s EMS system.
In the case of our Band-aid call, gloves may be all you need. However, on a messy trauma or with a violently ill person, full protection — including a disposable gown — may be necessary. It’s also important to remember that most universal precautions equipment is designed for one-time-only use and must be disposed of as infected waste when the call is over.
“It’s really important to clean up your scene after a call,” Bass said. “It’s not appropriate to toss bloody dressings, used gloves and other waste into the nearest streetcorner trash can. We’ve all done it but it poses a significant risk to the public, and as EMS providers, we should know better.”
Bass also suggested that EMS providers warn non-rescue personnel who may be at risk while working the call. For example, the police officer doing the accident investigation or even the tow-truck driver who picks up the wreck may risk coming in contact with blood and other body fluids left on the vehicle at the scene.
“Blood and body fluids can still be infectious more that 24 hours after an incident,” Bass noted. “Don’t think that the need to take precautions and be aware of risk stops with you.”
Another consideration when protecting yourself against bloodborne pathogens is the need for sensitivity to the reaction of your patients to your precautions. It’s very important to make sure that your patient fully understands the reasons why you are donning protective equipment before rendering EMS care. This writer was involved in an incident in which a minority patient who was bleeding profusely became violently angry when the rescue crew put on gloves and face masks before starting treatment. The patient accused the crew of not wanting to touch or smell a person of another race. It took a good bit of explaining to convince the patient that no racism was involved or implied in this routine procedure.
Also consider the fact that gloves, gowns and masks can be terrifying to small children. It may be easier to approach the child unprotected and gradually don your protective equipment while explaining to the child that you want to get “all dressed up” to help make things better.
Another issue that often arises concerning universal precautions is the fact that there are times when you may need to protect the patient from yourself as much as you need to be protected from the risk of catching anything from the patient.
“Certain patients with suppressed immune systems are highly susceptible to the slightest infection,” Bass said. This group includes some transplant patients, AIDS patients and patients receiving chemotherapy.
“Even organisms that would not affect the normal, healthy EMS provider could cause serious illness in these fragile patients,” Bass said.
All EMS workers face the risk of infectious disease. Hepatitis B and C are the most common risks. Despite hysterical media coverage, HIV is a relatively low risk. Only one EMS worker in the United States has been documented to have become HIV positive because of on-the-job exposure.
As this is written, there is a major debate among EMS experts about a proposed new National Fire Protec-tion Association (NFPA) Standard 1999 on Protective Clothing for Emergency Medical Operations, requiring something equivalent to a total-body enclosure garment for use as protection against body fluids and other potentially infectious materials. Firehouse® will review this debate in a forthcoming column.
Rich Adams, a Firehouse® contributing editor, is a volunteer EMT with the Bethesda-Chevy Chase Rescue Squad in Montgomery County, MD. He operates RDA Associates Inc., a public safety video production and consulting firm in Silver Spring, MD.