Chapter 2

The Well-Being of the EMT-I

FGTC 2010 EMT-I

The Well-Being of the EMT-I

• Personal health, safety, and well-being are vital to an EMS operation.

• Hazards vary greatly, ranging from personal neglect to environmental and human-made threats to your health and safety.

• You must learn to effectively cope with the mental and physical stresses that are part of the job.

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Self-Control

• You must remain calm and in control in order to effectively perform as an EMT-I.

• You will see horrifying events, life-threatening illnesses, and injuries.

• Self-control is developed through:– Proper training– Ongoing experience in dealing with all types of

physical and mental distress– A dedication to serve humanity

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Emotional Aspects of Emergency Care

• Even the most experienced providers have difficulty overcoming personal reactions.

• Emotions must be kept under control at the scene.

• You will be asked to perform as an EMT-I under stressful conditions such as:– Recovering human remains– Dealing with mass casualties and the severely

wounded

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Death and Dying

• Life expectancy has increased.• Heart disease claims the most lives.• Trauma is the leading cause of death for those

1-34 years old.• There is a tendency to deny death.• Witnessing and dealing with death is part of

an EMT-I’s job.

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Physical Signs of Death

• Death is defined as the absence of circulatory and respiratory function.

• Questions sometimes arise as to whether to begin basic life support.

• If the body is still warm and intact, initiate care.– Exception: If hypothermia is present, initiate care.

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Presumptive Signs of Death

• Unresponsive to painful stimuli• Lack of pulse or heartbeat• Absence of breath sounds• No deep tendon or corneal reflexes• Absence of eye movement• No blood pressure• Profound cyanosis• Decreased body temperature

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Definitive Signs of Death

• Obvious mortal damage, such as dismemberment at the neck or waist

• Dependent lividity• Rigor mortis• Putrefaction (decomposition of body tissues)

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Medical Examiner Cases• Poisoning• Accidental death• Suspicion of criminal activity

• Death at the scene• Unknown cause of death• Suicide• Violent death

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The Grieving Process

• The stages of grieving as revealed by Dr. Elisabeth Kübler-Ross:– Denial– Anger– Bargaining– Depression– Acceptance

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What Can the EMT-I Do?

• Provide gentle, caring support.• Offer to call a relative or religious advisor.• Make helpful statements and comments.• Be yourself and be sincere.• Understand that grief is a process that must

be worked through.• Be a good listener.

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Dealing With the Patient and Family Members

• Be calm. Family members may express rage, anger, and despair.

• Respect the family’s wishes and privacy.• Do not create false hope.

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Initial Care of the Dying, Critically Ill, or Injured Patient

• People who are dying will feel threatened and may express concern about survival through: – Anxiety– Pain and fear– Anger and hostility– Depression– Dependency– Guilt– Mental health problems

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Anxiety (1 of 2)

• Response to the anticipation of danger.• Patients may ask:

– What will happen to me?– What are you doing?– Will I make it?– What will my disabilities be?

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Anxiety (2 of 2)

• Patients who are anxious may have the following signs and symptoms:– Emotionally upset– Sweaty and cool skin– Rapid breathing– Fast pulse– Restlessness/tension– Fearful or shaky

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Pain and Fear

• Some people have difficulty expressing and admitting fear.

• Some people show signs of fear through:– Bad dreams– Withdrawal– Tension and restlessness– “Butterflies” in the stomach– Nervousness or anger

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Anger and Hostility

• Anger can be expressed through complaining and demanding behavior.

• Sometimes patients may want to express anger towards you or others.

• Be tolerant; resist becoming defensive.• Make sure you are safe at all times.• Do not take their anger personally.• Retreat from hostile situations.

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Depression

• Natural response to illness, especially when prolonged or terminal.

• There is little an EMT-I can do to alleviate the pain of depression during their brief time of caring for the patient.

• Be compassionate, supportive, and nonjudgmental.

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Dependency

• When medical care is rendered, a sense of dependency may develop.

• Feelings of helplessness can be present, as well as resentfulness.

• This can lead to more feelings of inferiority, shame, or weakness.

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Guilt

• Family members can find they feel some relief when a prolonged illness is finally over, which can lead to feelings of guilt.

• Sometimes feelings of guilt can result in a delay in seeking emergency medical care.

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Mental Health Problems

• Common characteristics of mental health problems can present as:– Loss of contact with reality– Distortion of perception– Regression– Diminished control of basic impulses and desires– Abnormal mental content

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Receiving Unrelated Bad News

• Patients who are critically or terminally ill may not want to hear unrelated bad news.

• Such news can depress the patient or cause them to give up hope entirely.

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Caring for Critically Ill and Injured Patients

• Avoid sad and grim comments.• Orient the patient.• Be honest.• Acknowledge the seriousness of the condition.• Allow for hope.• Locate and notify family members.

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Injured and Critically Ill Children

• Basic treatments remain the same.• Consider variations between children and

adults.• Being accompanied by a relative may relieve

the child’s anxiety.

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Dealing With the Death of a Child

• Society expects death of the elderly, not of children.

• Answering the difficult questions of your own mortality will be of help.

• The EMT-I is responsible for helping the family.

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Helping the Family

• Acknowledge the fact of the child’s death in a private place.

• Tell the parents that they may see their child.• Do not overload the parents with information.• Parents should be encouraged to talk about

their feelings.

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Stressful Situations (1 of 2)

• Examples of stressful situations for EMS personnel– Mass-casualty situations– Infant and child trauma– Amputations– Abuse

• Present a professional demeanor in your words and actions.

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Stressful Situations (2 of 2)

• Professional judgment takes priority over compassion.

• Give patients the opportunity to express emotions.

• Some patients feel terrified when separated from family members.

• Be respectful of religious customs.• Handle the deceased with respect and dignity.

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Factors Related to the Patient’s Reaction to Stress

• Socioeconomic background• Fear of health care personnel• Alcohol or substance abuse• History of chronic disease• Psychological disorders• Reaction to medication• Nutritional status• Feelings of guilt

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Uncertain Situations

• When uncertain if the patient’s condition is an emergency, contact medical control.

• Minor symptoms may be early signs of severe illness or injury.

• When in doubt, err on the side of caution.

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Stress Warning Signs and the Work Environment

• EMS is a high-stress job.– Understanding the causes and effects of stress is

critical to your job performance and health.• Stress is the impact of stressors on your

physical and mental well-being.• Stressors include emotional, physical, and

environmental situations.

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Physiological Responses to Stress

• Increased respirations and heart rate• Increased blood pressure• Cool, clammy skin• Dilated pupils• Muscle tension• Increased blood glucose levels• Decreased blood flow to the GI tract

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Physical and Psychological Symptoms of Stress

• Fear• Nonresponsive behavior• Depression• Oversensitivity• Anger• Irritability • Frustration

• Fatigue• Changes in appetite• Headaches• Insomnia/hypersomnia

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Signs and Symptoms of Posttraumatic Stress Disorder

• Depression• Startle reactions• Flashback phenomena• Amnesia of event

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Critical Incident Stress Management

• Confronts responses to critical incidents and defuses them.

• Process designed to help EMS personnel deal with responses to critical incidents.

• Composed of trained peers and mental health professionals.

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Stress and Nutrition (1 of 2)

• Prolonged stress drains the body’s reserves.• Under stress, the body’s fuel sources are

consumed in large quantities.• Glucose

– Quickest source of energy. – Taken from glycogen stored in liver.

• Proteins– Drawn from muscles.– Long-term source of glucose.

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Stress and Nutrition (2 of 2)

• Fats– Used by tissues for energy.

• Water – Conserved by retaining sodium.

• Vitamins and minerals– Depletes vitamins B and C and most minerals that

are not stored in large amounts by the body.

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Benefits of Good Nutrition

• Muscles will grow and retain protein.• Bones store calcium and become stronger.• Well-balanced meals provide necessary

nutrients to body.

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Stress Management

• There are positive and negative ways of handling stress.

• Stress management refers to the methods of alleviating stress reactions.– May involve changing habits, changing your

attitude, and perseverance.

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Strategies to Manage Stress

• Eat nutritious food and maintain adequate fluid intake.

• Maintain a regular exercise program.

• Use relaxation and breathing techniques.

• Find balance between work and family.

• Rotate your schedule when possible.

• Seek help when the stress becomes overwhelming.

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Critical Incident Stress Debriefing

• Program in which severely stressful job-related incidents are discussed.

• All information is confidential.• Held within 24 to 72 hours of a major incident.• CISD leaders and mental health personnel

offer suggestions for overcoming the stress.

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Components of a CISD System

• Preincident stress education• On-scene peer support • Disaster support services• Defusings• CISD• Follow-up services• Spouse and family support• Community outreach programs• Other wellness programs

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Workplace Issues

• Cultural diversity• Your effectiveness as an EMT-I• Avoiding sexual harassment• Substance abuse

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Scene Safety and Personal Protection

• The steps you use to protect yourself must be automatic.

• You should begin protecting yourself as soon as you’re dispatched.

• Take appropriate safety measures to control and make the accident scene visible.

• Ensure you can adequately light the area.

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Communicable Diseases

• A disease transmitted from one person to another.

• You will be called upon to treat patients with a variety of communicable diseases.

• Minimize risk of contracting disease with proper protection and immunizations.

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Routes of Transmission

• Transmission is the way an infectious agent is spread.

• Four mechanisms:– Direct– Vehicle-borne– Vector-borne– Airborne

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Risk Reduction and Prevention

• OSHA– Develops/publishes/enforces guidelines

concerning reducing risk in the workplace.– EMTs are required to be trained in the handling of

bloodborne pathogens.• CDC

– Developed a set of universal precautions.– Designed to prevent workers from coming into

direct contact with germs.

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Transmission Terminology

• Exposure– Contact with blood, body fluids, tissues, or airborne

droplets by direct/indirect contact.• Indirect contact

– Exposure or transmission of a disease from person to person through a contaminated object.

• BSI– Approaches all body fluids as potentially infectious.– EMS follows BSI rather than universal precautions.

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Preventing Transmission (1 of 3)

• Proper hand washing– Use soap and water and work into a lather.– Rinse and dry; use the towel to turn off faucet.

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Preventing Transmission (2 of 3)

• Gloves and eye protection– Minimum standard for all

EMS personnel.– Wear double gloves

when appropriate.– Eye protection prevents

blood from splattering into eyes.

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Preventing Transmission (3 of 3)

• Gowns and masks– Useful when dealing with large

amounts of blood or body fluids.• Masks, respirators, and barrier devices

– Use mask/gown appropriate for the infectious agent.

– Place mask on a patient as appropriate.

• Proper disposal of sharps– Never recap needles. – Use appropriate container.

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Employer Responsibilities

• Although not 100% risk free, your employer must provide a workplace environment that “reduces” risk for exposure.

• Standards set by OSHA, CDC, and NFPA provide a standard of care for all fire and EMS personnel whether full-time employee or volunteer.

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Personal Protective Equipment

• Vinyl and latex gloves• Heavy-duty gloves for cleaning• Protective eyewear• Masks (including HEPA

respirator)• Cover gowns• Devices for respiratory assistance

– BVM/pocket mask with one-way valve

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Exposure Control Plan

• A comprehensive exposure control plan incorporates CDC guidelines, OSHA regulations, NFPA Infection Control Standard 1581, and other applicable state and local regulations.

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Immunity and Immunizations

• Immunizations/vaccinations• Recovery from an illness builds partial immunity• “Optional” vaccinations–hepatitis A• Maintaining your personal health• Recommended immunizations:

– Tetanus-diphtheria boosters– MMR– Influenza– Hepatitis B

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Duty to Act/Components of Negligence

• Negligence includes the following:– Duty to act: Having a duty to respond.– Breach of duty: Failure to respond.– Injury: An injury has occurred. – Proximate cause: Injury was the result of your

actions/inactions.

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Some Diseases of Concern• Syphilis• Whooping cough• Newly recognized diseases such

as E. coli and SARS

• HIV• Hepatitis• Meningitis• Tuberculosis

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General Postexposure Management

• Ryan White law– Notification of the designated officer by the

hospital within 48 hours.• If an exposure occurred:

– Notify your designed officer immediately and complete an exposure incident report.

– Patient testing according to state law, followed by baseline testing on you.

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Establishing an Infection Control Routine

• Take the following steps:– Ready equipment en route.– Determine scene safety prior to entering.– Select proper PPE.– Change gloves and wash hands between patients.– Limit the number of responders involved in

patient care.– If exposed, seek care ASAP.

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Illness and Injury Prevention

• Injury is the third leading cause of death in the U.S.

• Prevention strategies– Recognizing signs and symptoms of illness/injury– Personal safety, scene safety, BSI– Public education to reduce:

• Child/spousal/elder abuse

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Scene Hazards

• Hazardous materials• Electricity

– Power lines– Lightning

• Fire (including smoke, O2 deficiency, high ambient temperatures, toxic gases, and structure collapse)

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Protective Clothing: Preventing Injury

• Eye protection• Ear protection• Skin protection• Body armor

• Cold weather clothing– Thin inner layer– Thermal middle layer– Outer layer

• Turnout gear– Gloves– Helmets and boots

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Violent Situations/Behavioral Emergencies

• Safety is your primary concern.• Call law enforcement as needed.• Interference of bystanders/family members.• Evaluate the scene for safety; don’t put yourself at

risk.• If the area is a crime scene, attempt to maintain the

chain of evidence.• Evaluate the potential of a patient to become

violent.

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