Y'all Are Nasty

I was pretty new to EMS when I was assigned to transfer a patient from one hospital to another.  The patient had something called “Mersa” and looked nasty – bumps and boils and weeping sores.  I knew that Ebola was named after a river in Africa where it was first found and Lhasa fever had a similar story.  So I thought that “Mersa” was a hemorrhagic fever named after the Mersa River.  There must be a Mersa River in the Congo or something.  Weird that this guy had it in Colorado. 

The most screwed up part of that story is that I transported him from one hospital to another without an astronaut’s space suit between him and me.  I just had a gown, gloves, and glasses.  Even that was only because the nurse insisted I wear a gown.  I was much dumber in my youth.

It was much later that I learned that the poor guy’s disease wasn’t “Mersa,” but MRSA.  Methicillin-resistant Staphylococcus aureus.  S. aureus is a pretty common bacteria, and overly aggressive prescribing of antibiotics combined with not taking all the prescription has resulted in antibiotic resistance. 

There are two kinds of MRSA.  Healthcare-acquired MRSA (HA-MRSA) infections are usually associated with hospitals and nursing homes and usually involve invasive procedures and devices like catheters.  Populations at risk for HA-MRSA include the sick, the hospitalized, and patients who reside in long-term care facilities.  Community-acquired MRSA (CA-MRSA) occurs in otherwise healthy people and is spread by skin-to-skin contact.  So contact sport athletes, childcare workers, and people in crowded conditions (jail, military, etc.) are more at risk.  Both kinds of MRSA are resistant to methicillin antibiotics.  Those are most of the more common antibiotics that are prescribed and include most of the penicillins, amoxicillin, and most cephalosporins. 

CA-MRSA infected back abscess (Courtesy Gregory Moran, MD, Public domain)

MRSA contamination can be asymptomatic, but an infection usually begins as small red bumps that look like pimples or a spider bite.  Within a few days, those pimples grow to larger, painful boils and eventually abscess.  Most MRSA infections remain confined to the skin and superficial tissues.  In some patients, though, as the bacteria burrow into the patient, joints, bloodstream, and heart valves can become infected.  Without treatment, MRSA can progress to necrotizing fasciitis, infective endocarditis, and necrotizing pneumonia. 

CA-MRSA infected shoulder (Courtesy Gregory Moran, MD, Public domain)

CA-MRSA responds better to antibiotics, including sulfa drugs, clindamycin, and tetracyclines.  HA-MRSA is resistant to most of those, however.  So the treatment of choice now has become vancomycin.  New drugs (linezolid, daptomycin, and ceftaroline) are also approved for MRSA treatment. 

MRSA abscess after drainage and packing (Courtesy Maj. K Waibel, MD, Public domain)

So how is MRSA infection prevented?  It is embarrassingly simple: handwashing, surface disinfection, and covering any wounds or scrapes you may have.  That’s about it.  So let me ask you, how often do you wear gloves throughout the patient contact?  How often do you disinfect or wash your hands?  When was the last time you disinfected your stethoscope?  Or the blood pressure cuff?  Worse, consider who had your ambulance last.  Did they do those things?

If you say always or pretty much always, I can call you a liar and be statistically correct more often than not.  Tons of studies show that we are horrible about those things.  EMS providers are bad at standard precautions.  We are in denial about it. 

A 2014 study looked at 423 EMS deliveries to an ED and watched what the 899 providers were doing.(1)  Only 57% arrived wearing disposable gloves.  Under 30% washed their hands.  Just over 30% disinfected at least one piece of equipment (washed blood off the stretcher, usually).  Y’all are nasty.

Another just-published study watched for handwashing among paramedics.(2)  It isn’t a strong study, using paramedic students to watch medics in a convenience sample and only collected about half of available employees in 258 calls over 6 months.  Only about 62% washed their hands.  About 1% sanitized their hands before patient contact.  Only about 20% washed their hands before meals. You all are nasty.

Alves and Bissell randomly selected four ambulances and swabbed five locations in each to check what kind of pathogens grew.(3)  They isolated seven species of bacteria. Four of the species were “substantial pathogens” and three of those four had significant antibiotic resistance. Y’all are nasty.

In 2007, a group of researchers swabbed 21 ambulances and almost 50% tested positive for MRSA.(4)  Y’all are nasty.

Another group of authors grabbed fifty consecutive stethoscopes that walked in through the ambulance doors to an ED and swabbed them.(5)  Sixteen of the fifty had MRSA – that is almost one third of stethoscopes being positive for MRSA.  The same number of medics couldn’t remember when they cleaned their stethoscope last. Y’all are nasty.

Speaking of Staph on stethoscopes, a 1995 study surveyed nurses, doctors, and EMS providers about stethoscope cleaning and swabbed their stethoscopes.(6)  Only half of providers cleaned the piece of equipment they hang around their necks daily or weekly.  89% grew Staph and 19% grew S. aureus.  The two pieces of good news in this study is that there were no differences between provider types and a simple alcohol swab reduced the bacterial load by 94%.  Y’all are nasty.

Sorry to keep beating the dead horse, but y’all are nasty and need to hear this.  So let’s just do one more.

A 2013 study swabbed the nasal cavities of EMS personnel.(7)  Five percent tested positive for MRSA.  That’s right – if this extrapolates to the wider EMS community, 5% of your coworkers sneeze out MRSA onto the steering wheel and dash.  The 5% rate is about five times the general public rate. 

Y’all are nasty.  That statement comes from my own experience, as well as tons of studies like the ones listed here.  Start to pay attention to how often your partner washes their hands. 

So let’s do each other (and ourselves) a favor.  Clean.  Wash your hands.  Disinfect surfaces in the ambulance.  Clean your stethoscope.  Do the simple things and remind your partner to do the same.  Start to instill those habits in students.  Our coworkers, our patients, and our families deserve a little more in the way of cleanliness.  Because MRSA, while nasty, is only one kind of infection that we have to deal with.

1. Bledsoe BE, Sweeney RJ, Berkeley RP, Cole KT, et al. EMS provider compliance with infection control recommendations is suboptimal. Prehosp Emerg Care 2014;18(2):290-4.

2. Ho JD, Ansari RK, Page D. Hand sanitization rates in an urban emergency medical services system. J Emerg Med. 2014;47(2):163-8.

3. Alves DW, Bissell RA. Bacterial pathogens in ambulances: Results of unannounced sample collection. Prehosp Emerg Care 2008;12(2):218-24.

4. Roline, CE, Crumpecker, C, Dunn, TM. Can Methicillin-resistant Staphylococcus aureus be found in an ambulance fleet? Prehosp Emerg Care 2007;11(2):241–244.

5. Merlin MA, Wong ML, Pryor PW, Rynn K, et al. Prevalence of Methicillin-resistant Staphylococcus aureus on the stethoscopes of emergency medical services providers. Prehosp Emerg Care 2009;13(1):71-4.

6. Jones JS, Hoerle D, Rieske R. Stethoscopes: A potential vector of infection? Annals Emerg Med. 1995;26(3):296-9.

7. Miramonti, C, Rinkle, JA, Iden, S, Lincoln, J, et al. The prevalence of Methicillin-resistant Staphylococcus aureus among out-of-hospital care providers and emergency medical technician students. Prehosp Emerg Care 2013;17(1):73–77.

I Hate Rats

My partner and I were once sent to a cardiac arrest.  If I remember correctly, I think it may have even been a request for a pronouncement.  One way or the other, I was driving that day and we were alone.  The fire department didn’t go with us on pronouncements back then.  We arrived at a little bungalow in the southwest part of the city and were directed to the back by the 911 caller, who was waiting out front.  He told us to use the back door, waved in the appropriate direction, and then left.  Never a good sign.

The little house was kind of a dump from the front.  It wasn’t especially well cared for.  Any part of the yard that wasn’t bare dirt was growing only weeds.  The front yard had newspapers piled up on the porch for weeks.  There were two or three junked cars on the side of the house and the back yard was no better than the front. 

The back door was ajar by about a foot.  Speaking of which, two of them were sticking out the back door from the knees down.  The lower legs of this person were blackened from dependent lividity and the rest of the body was not visible.  There was trashed furniture, yard tools, and piles of water bottles outside the door.  Inside was worse.

Peeking inside the house revealed a hoarder den.  There were newspapers and catshit stacked to the ceiling in every room.  There appeared to be tunnels, or pathways, through the detritus.  To us, it looked like the back door would only open about a foot.  There was a stepstool for the homeowner to climb into the partially opened doorway and into a trash tunnel.  That stepstool was lying on its side just outside the door.  It further looked like the homeowner fell into the house and the eight-foot newspaper piles collapsed onto them.  The only part of the person visible from the doorway was a skeletonized hand sticking out of the trash pile.  It looked like when the Terminator pulled his skin off in T2.  Except a cat was finishing off whatever meat was left on the skeletal palm. 

There wasn’t much for us to do there, so my partner contacted base for a time of death.  It may have been the first time he got a pronouncement without knowing the patient’s gender.  All we could see were rotting legs and a skeletal hand.  It is a sad way to go.  I wondered whether the patient suffocated or starved to death. 

We then went back to the front yard to wait on the cops, who were enroute to take over the death scene.  They arrived after about ten more minutes.  Two officers arrived at the same time.  We walked them around the side of the house again, with my partner explaining the scene to them. 

As we walked, with my partner in the lead, followed by the cops, furtive movement caught my eye.  A blur darted left to right across my path between the property fence and a storm cellar door in front of me.  You know the doors I’m talking about – they are mostly horizontal, barely above the ground, and seem like something Auntie Em would hide from tornados in.  I knew what it was that made the blur. 

“RAT!”  I shouted.  I can say that I shouted, because I am the author of this piece.  A witness may indeed describe the noise I made as a shriek, but I am going with a strong, manly shout of warning.

Then I jumped flat-footed from the ground into the bed of an ancient El Camino that was sitting on cinderblocks.  I cleared about 40 adrenaline-boosted inches straight up and landed inside the vehicle, pointing in the general direction of the offending rodent.  The first police officer, who was about six foot two and 250 pounds of low-fat muscle threw himself on top of the five-foot cedar fence and sat there, trying to raise his legs higher.  The other officer didn’t know where to go, so he did a little high-knee dance as he spun in a circle and squealed.  He drew his service pistol and waved it in the general direction of the ground as he spun.   I’m really glad he didn’t peel off some blind shots.

My partner, the ass, was laughing so hard that he had to put his hands on his knees to keep from falling over.  He is one of those tough guys who aren’t really flustered by anything.  He certainly wouldn’t leap flat-footed into an El Camino in a single panicked bound. 

Rats suck.  Filthy little beasts.  And their tails look like worms.  They give me the heebie-jeebies just thinking about them.  Seriously, the hair on my arms is standing up as I type this. 

Dude.  Look at this thing.  It looks like it is roaring.  Terrifying.
By Andreas Rejbrand, via Wikimedia Commons (Creative Commons Attribution-Share Alike 2.5 Generic license)

Long story short, the two officers and I pulled ourselves together enough to continue to the back yard.  The cops saw the legs, got the time of death, and beat feet with me back to the police cruisers in the front.  Our jobs can ask a lot of us, but dealing with rats goes beyond the call of duty. 

I don’t know how they got the body out of the house.  With the door that wouldn’t open, the rats, and the piles of hoarded trash, they may have had to cut the roof open and rappel in.  I don’t know because we didn’t wait around.  Damn rats.   But I miss that partner.

EMS Kevlar is Silly

I spent the first half of my career wearing a bulletproof vest while at work.  Most paramedics in my system did, so I just kind of followed along.  Plus, I was in the Big City EMS department.  Big cities are dangerous, right?  And the vest looked cool – made me feel like a cop or something.

People in olden days were insane!  Polish inventor Jan Szczepaik invented the bulletproof vest in 1901.  Here is the first (successful) test of the invention with a shot at his (egregiously underpaid) servant done with a 7mm revolver at three paces.  (Author unknown. Public domain via Wikimedia Commons)

I never had need of it.  Wait – once I didn’t have it on when my right nipple almost got bit off while wrestling a dude on PCP.  I wish I had the vest on at that moment, but that wasn’t a vest thing.  The nipple-biting incident was the culmination of a string of bad choices on my part.  Improving my choices that night could have resulted in me not needing a vest, and not getting my nipple almost bit off.

For those of you smart enough to forego bulletproof vests, they are hot.  They cost a few hundred dollars.  They are uncomfortable in that they ride up in front and cause your shirt to come untucked.  They make you look 40 pounds fatter.  They don’t breathe at all.  The torso sweat throughout your shift goes right into the vest and never leaves – after a week a vest smells like my 8^th grade gym locker did (the year I never took my gym clothes home).  Of course, you can expend a lot of effort and expense getting defunkifying sprays and cleaners. 

I’ve been at my agency for 15 years.  In that time we’ve gone from about 70,000 calls per year to close to 100,000 calls per year.  So some back-of-the-envelope math says that I’ve been employed while my agency ran more than one million EMS calls.  Do you know how many times I’ve heard of a medic being saved by their bulletproof vest?

None.

What troubles me about the vests is that they are outward signs of inappropriate risk estimation.  When one researches EMS injuries, such as these 2011 data, one finds that EMS providers dodging gunfire at work is an exceedingly rare event.  Which is consistent with what I have seen in the last 15 years.  The 2001 data show that the most common event that results in injury is “Bodily reaction and exertion.”  That classification includes lifting heavy stuff and performing repetitive microtasks.  Second is “Harmful exposures” (not necessarily hazmat spills – this includes noisy environments and emotionally stressful events) and third is “Contact with objects and equipment” (needlesticks, rough surfaces, etc).  “Falls” comes fourth and “Transportation incidents” comes fifth.  You have to go to the sixth most common event to find “Assaults and violent acts.”  Most of the 2,100 assaults in 2011 are unchanged by wearing a vest or not.  Violent acts include animal and insect attacks, face punching, finger biting, shoves, cutting/stabbing, and other non-ballistic torso injuries.  You knew a bulletproof vest isn't knife proof, right?

So if we alter our behavior and equipment to match the risks inherent in our jobs, we should focus on lifting mechanics and moving in the back of an ambulance.  I don’t know about you, but standing in a hunched position in the back of the bus ends up hurting my low back.  I do much better if I just sit on the bench or captain’s chair.  Consider hearing protection when you have the siren on.  Watch out when you are handling needles.  Watch your step on icy or uneven ground.  Wear safety goggles.  Consider some kind of grip-enhancing overshoes on icy days.

Traffic accidents are pretty common for EMS providers.  When was the last time you put a seatbelt on yourself in the back of an ambulance?  Maybe not when you are moving around and getting equipment, but there are calls when your work is mostly done and you are typing a PCR and chatting with the patient.  Is your seatbelt on then?  Do you wear a high visibility vest or uniform when working in roadways?  Honestly, you are more likely to be run over working on the side of the road than you are to be shot in the torso.

Those are the things we would do if we were concerned about safety.  Until you are doing those simple things to improve your safety, I don’t believe you when you say you just want to be safe.  Deep down, you know the Kevlar vest is mostly a fashion statement.

I have been injured many times in my career.  I have three or four needlesticks under my belt.  I have a few falls where I had enough hang time to realize that having my feet over my head in midair was not a good position.  Those hurt.  I may have missed a few days of work here and there due to back pain after ill-advised lifts.  Once I wedged myself between the floor and ceiling of the ambulance in order to use both hands to treat a patient.  My partner hit a speedbump, my neck crunched, and my arms went numb for three days (I was embarrassed, so didn’t even report that one).  There was the nipple biting incident (again, poor choices on my part) and I once got punched in the mouth by a girl wearing a big-assed diamond ring.  I donate a chunk of scalp on the infernal oxygen christmas tree almost every day.  I’ve been in a bunch of wrecks but have gotten off lucky and never been hurt in one.

Most of those were due to my own decisions.  Most of those were avoidable.  And every single one of them didn’t require a hot, sweaty, smelly, expensive Kevlar vest to save me.  What I needed to do is slow down, watch my step, duck lower in the back of the ambulance, wait for more help when dealing with angry people wearing big-assed rings, and wear my seatbelt. 

I don’t wear the vest anymore.  But I do wear goggles, the reflective vest, and put on my seatbelt in back when I can.

Seriously, old people are nuts!  Check the look on dude's face!  And what's with the friggin' bicycle? Who rode that to the scene of the experiment?  (National Photo Company (1923), Public domain, via Wikimedia Commons)

First in on an MCI

MCIs are among the most common of unusual calls.  I mean unusual in that a single ambulance can run the vast majority of EMS calls.  It is kind of unusual to need additional busses.  But not all that unusual, right?  It is something you can expect to do in your first month on the job, and continue to run for the rest of your career.

Most places define an MCI as an incident that requires more resources than can be provided at once.  In a vernacular sense, though, a paramedic referring to “an MCI” is probably talking about a multiple patient scene.  In my jurisdiction, we begin referring to incidents as MCIs when it requires a three-ambulance response to deal with the sick and injured.  So in this post, when I am talking about an MCI, I’m talking about a scene like that.  I know that a five-victim grinder with three ambulances isn’t overwhelming to an EMS system and doesn’t represent mass casualties, but the principles are the same.

Think of how easy it is to get to a three-unit response.  It is a really common situation.  Car crashes do it all the time.  A decent fight can do it.  Shootings.  Carbon monoxide.  Weddings.  Structure fires.  Hell, most special events like NFL games are really just preplanned MCIs that develop slowly.  I’ve even run MCIs caused by spilled cleaning supplies.  Every crazy situation you can think of has been run by some poor sucker paramedic somewhere.  

Let me let you in on a secret: How well you run an MCI will make or break your reputation.

Whether the MCI is run well or poorly, it will affect how your coworkers perceive you from then on.  Even your first one.  Even if it falls on your first day.  An MCI must be run well.  And the secret to a smooth MCI lies on the shoulders of the first arriving crew.

The first crew has five actions to perform.  Taking care of these actions means the call is likely to go well, from an EMS point of view.  The five actions constitute 90% of the success of the whole scene.  Not performing the five critical actions usually means that the call becomes irrecoverable – any supervisor or later crew will have a very hard time getting the call back on the tracks.

The actions are simple: 1. Identify the call as a big deal, 2. Request more help, 3. Get onto an MCI channel, 4. Start getting bed counts, and 5. Set up the scene. 

That's it.  If you do this, the call is much more likely to run smoothly.  Like 90% likely.  And these are tasks you can do on your first day on the street. 

Identify the call as a big deal: You arrive on scene to find a three-vehicle highway accident.  One of the vehicles is a fully occupied school bus that rolled.  You have a high likelihood of ending up with more patients than you can transport by yourself, right?  If there is someone who is critically injured, you can’t just ignore them until you check out everyone on the bus, right?  You need more help.  Let people know that you are on a big-deal call: “Dispatch, this is a three-vehicle accident that involves a rolled over school bus.  Show me as ‘Highway Operations.’” 

Don’t forget your Chuck Yeager voice.

One of the biggest problems can arise when you are slow to identify your call as a big deal.  Listen, I get it.  We all want to be badasses who can handle anything the EMS Gods throw our way.  Or patients trickle in one at a time until you notice that there are too many for you to handle.  Whatever.  The earlier you identify your call as a big deal with more patients than you can comfortably transport, kick into MCI mode and identify the call as a big deal.

Probably a big deal.  I'm no expert, but it looks like more than two people may have been hurt. BA38 crash, Heathrow, London, UK.  (By Marc-Antony Payne [CC-BY-3.0], via Wikimedia Commons)

Request more help: Do this early.  I find that paramedics are more likely to try to handle the call too long by themselves.  Request what you need and do it early.  Be specific in describing what you want.  If you end up cancelling some units, that is fine.  Start getting help to your scene: “I will need five ambulances to this scene to start, and you will want to start preparing to send me more…”

Get on an MCI channel:  My jurisdiction has radio channels set up to facilitate mutual aid communication between different jurisdictions.  The police have four channels, fire departments have four channels, and there are even command channels for people to talk to one another.  If I am on an MCI, I know that the more ambulances I use, the higher chance of another agency responding to my scene.  They deserve to be communicated with, as well.  In addition, an MCI can clog up a radio channel and there are other calls going on in the system.  So switch everyone involved to a tactical channel that most agencies possess: “Switch all units assigned to this call to Green1…”

Request a bed count: This step is needed more as transport numbers increase.  Three patients being transported in three ambulances probably don’t actually need a bed count.  But as the number of transports increases, hospital systems will become more stressed.  Requesting a bed count early is important for a few reasons.  First, it tells hospitals that you have a big deal call going on.  They should get ready.  Second, it tells you that Hospital A just got slammed from a different big deal call and has no trauma ORs readily available.  Good to know.  Finally, it gives receiving facilities the chance to make whatever adjustments they need to make.  Bed counts in my system can be a simple call to medical control asking where to take five patients, or it can involve dispatchers getting onto web-based MCI resources that contact hospitals region-wide.  This is a system-dependent task, so make sure you know what needs done in your system.

Set up your scene and tell people your plan: There are a few sub-tasks with this one.  We’ve all had the MCI management lecture in school with ICS jobs like staging, triage, communications, and transport.  Each call is different in how you will set it up.  A compact scene with straightforward patients is easier to handle, for example, so you may handle all of the ICS roles yourself.  Alternatively, you may decide that you will be best served by backing off and setting up the whole enchilada.  I say it depends on your call.  But every MCI needs to have this decision be an actual conscious decision.  Make the choice of how you want to run this call.

The tasks are dependent on what kind of scene you have going on, what resources you need, and that kind of thing.  You need to tell people where to go.  This is when you set up a staging area, decide on triage and treatment areas, and that kind of thing.  On any MCI, though, it is important to set up ingress and egress routes.  Be specific as to how you want people to approach your scene – it will cut down on freelancers.  For example: “Have the first two units come to me at mile marker 123.  Have units after that stage on the northbound highway at mile marker 122.  I will want cars to enter from the south and exit northbound…”

So how does this all sound?  “Dispatch, I have multiple victims at this fire with minor burns and smoke inhalation.  I’m going to need two more units, nonemergent.  Have them approach from the Main Street side and stop at First to avoid fire trucks.  Let’s move this scene to the Green1 channel, and call Burn Center Hospital to make sure they can handle six patients with minor burns, please.  I will be Southern Operations for the duration.” 

How about a bigger deal?  “Dispatch, Ambulance Six on scene.  This looks like a gas explosion and building collapse with more than fifty casualties.  Show me as Downtown Operations.  Send me three ambulances to my location at the south parking lot to set up triage.  Stage all other ambulances at First Avenue until we call them in.  I’m going to need at least twenty ambulances before this is all done.  Switch to Green1 for this scene and start getting bed counts for me.” 

One final point – this has to be practiced all the time.   The way to get good practice is to implement a plan like this on every call where you need two more ambulances.  I despise disaster drills.  I hate tabletop MCIs.  Whatever the emergency managers, chiefs, and administrators have in mind doesn't matter because it is the first medic on scene who sets these calls up for success or failure.  Don’t wait for a school shooting to try to remember all of this.  Your whole system should have this as second nature, based on running dozens of car crashes and fights that result in multiple responses.  That way, when the big one does drop, it is run using your normal practice.