Bledsoe v1 ch04_lecture

Copyright © 2017, 2013, 2009 Pearson Education, Inc. All Rights Reserved.

Bryan E. BledsoeRichard A. Cherry Robert S. Porter

Paramedic Care: Principles & PracticeVolume 1, 5e

Chapter 4Workforce Safetyand Wellness



Standard• Preparatory (Workforce Safety and Wellness)



Competency• Integrates comprehensive knowledge of EMS

systems, the safety and well-being of the paramedic, and medical–legal and ethical issues, which is intended to improve the health of EMS personnel, patients, and the community.



Introduction• Safety and well-being of workforce is fundamental

aspect of performance. – Physical, mental, emotional well-being

• Death, dying, stress, injury, infection, fear all threaten your wellness.

• Most paramedic injuries: lifting and being in and around motor vehicles.



Prevention of Work-Related Injuries• Ambulance collisions major source of injury for

paramedics.– Improved structural integrity and crashworthiness of

emergency vehicles– Restraint systems– Protocols and call screening



Prevention of Work-Related Injuries• Physical acts of lifting and moving patients injure

paramedics.– Power-lift stretchers– Specialized bariatric ambulances: large stretchers,

ramp, mechanical winch.– Properly and safely lifting and moving patients is

essential provider skill.



Prevention of Work-Related Injuries• Long shifts (24 hours or more)

– Paramedics physically and mentally tired long before shift over.

• Nutrition and physical fitness play role in long-term survival in EMS.



Basic Physical Fitness• Core Elements

– Muscular strength– Cardiovascular endurance (aerobic capacity)– Flexibility

• Each equally important




– Muscular strength: regular exercise trains muscles to exert force and build endurance.

– Isometric exercise: active exercise performed against stable resistance; muscles exercised in motionless manner.




– Isotonic exercise: active exercise; muscles worked through range of their motion.

– Weight lifting: muscular strength; all-around training for body.




– Cardiovascular endurance: exercising at least three days a week vigorously to raise pulse to target heart rate.



Table 4-1 Finding Your Target Heart Rate

1. Measure your resting heart rate. (You will use this total later.)

2. Subtract your age from 220. This total is your estimated maximum heart rate.

3. Subtract your resting heart rate from your maximum heart rate, and multiply that figure by 0.7.

4. Add the figure you just calculated to your resting heart rate.




– Walking briskly; stationary bike; stairs– Make exercise a daily habit




– Flexibility: without adequate range of motion, joints and muscles cannot be used efficiently or safely.

– Stretch main muscle groups regularly; try to stretch daily.

– Never bounce when stretching.– Consider studying yoga.



Basic Physical Fitness• Nutrition

– Alter established bad habits.– Change in behavior: commitment, self-discipline,

understanding change process, patience.– Set realistic goals.– Good nutrition fundamental to well-being.



Figure 4-1 Dietary guidelines from the U.S. Department of Agriculture are summarized in the ChooseMyPlate chart that uses a dinner-plate–shaped chart to represent appropriate foodgroup portions.(U.S.Department of Agriculture, www.ChooseMyPlate.gov)



Basic Physical Fitness• 10 Tips to a Great Plate

– Balance calories.– Enjoy food; eat less.– Avoid oversized portions.– Eat certain foods more often: fruits and vegetables,

whole grains, fat-free or low-fat dairy products.




– Make half your plate fruits and vegetables.– Switch to fat-free or low-fat (1%) milk.– Make half your grains whole grains. – Eat some foods less often: solid fats, added sugars,

salt.




– Compare sodium in foods.– Drink water instead of sugary drinks.

• Nutrition Facts label: information about nutritional content.

– Check serving size.



Figure 4-2 Example of a standardized food label.



Basic Physical Fitness• Plan ahead; carry small cooler filled with whole-

grain sandwiches, cut vegetables, fruit, wholesome foods.

• Buy fresh fruit, yogurt, sensible deli selections.

• Monitor fluid intake.

• Water: thirst quenching, cheaper, better for you.



Basic Physical Fitness• Exercising/eating well can help prevent cancer

and cardiovascular disease.

• Minimize stress through healthy stress management practices.

• Assess yourself and family history.

• Exercise: improve cardiovascular endurance; lower blood pressure.



Basic Physical Fitness• Know cholesterol and triglyceride levels; keep in

check.

• Diet minimizes chances of getting certain cancers.

• Use sunblock; wear sunglasses and hat when you can.

• Watch for warning signs of cancer.

• Risk assessment; self-examination habits.



Basic Physical Fitness• Habits and Addictions

– People who work high-stress jobs overuse and abuse substances.

– Know whether addiction is: psychological dependency, sociocultural dependency, true physical addiction.

– Get free of addictions, particularly those that threaten well-being.



Basic Physical Fitness• Back Safety

– To avoid back injury: Keep back fit for work you do. Use proper lifting techniques. Condition muscles that support spinal column. Consult exercise coach or trainer.



Basic Physical Fitness• Back Safety

– Correct posture minimizes risk of back injury.– Good nutrition maintains healthy connective tissue and

intervertebral discs. – Excess weight and smoking contributes to disk

deterioration. – Get adequate rest.



Figure 4-3 Correct standing posture. Note the straight line from the ear through the shoulder, hip, and knee to the arch of the foot.



Figure 4-4 Correct sitting posture.



Basic Physical Fitness• Proper Lifting Techniques

– Move a load only if you can safely handle it.– Ask for help when you need it—for any reason.– Position load as close to body and center of gravity as

possible.– Keep palms up whenever possible.




– Do not hurry.– Bend knees, lower buttocks, keep chin up.– "Lock in" spine with slight extension curve; tighten

abdominal muscles to support spinal positioning.– Always avoid twisting and turning.




– Let large leg muscles do work of lifting, not your back.– Exhale during lift; do not hold breath.– Given choice, push. Do not pull.– Use help when moving patients up and down stairs and

into and out of ambulance.




– Look where you are walking or crawling.– When rescuers working together as team to lift a load,

only one person in charge of verbal commands.– Be careful!



Figure 4-5 For back safety, always employ the important principles of lifting.



Personal Protection from Disease• Infectious Diseases

– Caused by pathogens (bacteria and viruses) spread from person to person. Bloodborne or airborne pathogens



Table 4-2 Common Infectious Diseases (1 of 2)

Disease Mode of Transmission Incubation Period

AIDS (acquired immune deficiency syndrome)

AIDS- or HIV-infected blood via intravenous drug use, semen and vaginal fluids, blood transfusions, or (rarely) needle sticks. Mothers also may pass HIV to their unborn children.

Several monthsor years

Hepatitis B, C Blood, stool, or other body fluids, or contaminated objects.

Weeks or months

TuberculosisRespiratory secretions, airborne, or on contaminated objects.

2 to 6 weeks

Meningitis, bacterial

Oral and nasal secretions. 2 to 10 days

Pneumonia, bacterial and viral

Oral and nasal droplets and secretions. Several days

Influenza Airborne droplets, or direct contact with body fluids.

1 to 3 days



Table 4-2 (continued) Common Infectious Diseases (2 of 2)

Disease Mode of Transmission Incubation Period

Staphylococcal skin infections

Contact with open wounds or sores or contaminated objects.

Several days

Chicken pox (varicella)

Airborne droplets, or contact with open sores. 11 to 21 days

German measles (rubella)

Airborne droplets. Mothers may pass it to unborn children.

10 to 12 days

Whooping cough (pertussis)

Respiratory secretions or airborne droplets. 6 to 20 days

SARS (severe acute respiratory syndrome)

Airborne droplets and personal contact. 4 to 6 days



Personal Protection from Disease• Infectious Diseases

– Consider blood and body fluids of every patient you treat as infectious.

– Safeguards against infection mandatory for all medical personnel.



Personal Protection from Disease• Standard Safety Precautions

– EMS straddles disciplines of health care and public safety, and risks of both.

– Considerations about minimizing risk for you, your patient, your partners, other responders, community.



Personal Protection from Disease• Infection Control Measures

– Standard Precautions Blood and body fluid precautions designed to reduce risk of

transmission of bloodborne pathogens. Body substance isolation (BSI)—precautions designed to

reduce risk of transmission of pathogens from moist body substances.




– Standard Precautions apply to: Blood All body fluids, secretions, and excretions except sweat,

regardless of whether or not they contain visible blood Nonintact skin Mucous membranes




– Standard Precautions All EMS personnel take same precautions with every patient. Personal protective equipment (PPE):

– Protective gloves– Masks and protective eyewear– HEPA and N-95 respirators



Figure 4-7a Proper gloves, mask, and eyewear prevent a patient's blood and body fluids from contacting a break in your skin or spraying into your eyes, nose, or mouth. Combined mask and eye shield.



Figure 4-8a A high-efficiency particulate air (HEPA) respirator. .




– Standard Precautions Personal protective equipment (PPE) Gowns Resuscitation equipment Hand-washing supplies




– Handwashing: most important infection control practice. Lather with soap and water. Scrub for at least 15 seconds. Rinse under running water. Dry on clean towel. Plain soap, antimicrobial handwashing solution, alcohol-based

foam/towelette




– Ebola Virus Disease (EVD) Contracted through broken skin or mucous membranes, blood

or body fluids, needles and syringes, infected fruit bats or primates, semen.

Standard PPE alone not sufficient to ensure protection from EVD.




– Ebola Virus Disease (EVD) PAPR (powered air purifying respirator) N95 respirator Single-use (disposable) fluid-resistant or impermeable gown

that extends to mid-calf or coverall without integrated hood




– Ebola Virus Disease (EVD) Single-use (disposable) nitrile examination gloves with

extended cuffs Single-use (disposable), fluid-resistant or impermeable boot

covers that extend to mid-calf or single-use (disposable) shoe covers




– Ebola Virus Disease (EVD) Single-use (disposable), fluid-resistant or impermeable apron

that covers torso to level of mid-calf; used if patients with EVD have vomiting or diarrhea



Table 4-3 Ebola PPE Protection

Patient's Ebola Exposure Level Definition

Known or suspectedexposure

Known disease, known contact with Ebola patient or travel within 21 days to an area with current Ebola cases

Possible exposure Environmental or interpersonal exposure in an area with suspect or recent cases, except as outlined in previous box

No known exposure No known exposure to EVD patients or travel to areas with a known outbreak of the disease

Signs/Symptoms Definition

Asymptomatic No symptoms relevant to an infectious disease.Fever Measured temperature ≥ 100.4°F.Body fluids Patient has fever with vomiting, diarrhea, blood in vomitus

and/or feces, is incontinent of urine or stool, or is sweating, salivating, or otherwise producing blood and body fluids to which emergency responders could be exposed.



Personal Protection from Disease• Vaccinations and Screening Tests

– Get immunizations: Rubella (German measles); measles Mumps; chicken pox Childhood diseases Tetanus/diphtheria Polio; influenza Hepatitis A and B Lyme disease



Personal Protection from Disease• Vaccinations and Screening Tests

– Tuberculosis (TB) screenings.– EMS personnel and emergency responders often first

to receive vaccines when virus becomes threat.



Personal Protection from Disease• Decontamination of Equipment

– Properly dispose of PPE or contaminated medical devices. Red bag marked with biohazard seal Needles and sharp objects discarded in labeled, puncture-

proof containers



Figure 4-10a Dispose of biohazardous wastes in a bag that is properly marked.



Figure 4-10b Discard needles and other sharp objects in a properly labeled, puncture-proof container.



Personal Protection from Disease• Decontamination of Equipment

– Contaminated nondisposable equipment must be cleaned, disinfected, or sterilized. Cleaning: wash object with soap and water. Disinfection: clean with disinfecting agent. Sterilization: chemical or physical method to kill all

microorganisms.



Personal Protection from Disease• Post-exposure Procedures

– Exposure: occurrence of blood or body fluids coming in contact with nonintact skin, eyes, mucous membranes or by parenteral contact.



Personal Protection from Disease• Post-exposure Procedures

– Immediately wash affected area with soap and water.– Get medical evaluation.– Take proper immunization boosters.– Notify agency's infection control liaison.– Document circumstances surrounding exposure.



Death and Dying• Loss, Grief, and Mourning

– Kübler-Ross Stages of Grief Denial, or "not me." Anger, or "why me?" Bargaining, or "okay, but first let me. . ." Depression, or "okay, but I haven't . . ." Acceptance, or "okay, I'm not afraid."



Death and Dying • Because paramedics encounter death and dying

often, there is mistaken belief they handle it better.– Let yourself deal with death and dying when it occurs.– Grief is a feeling. – Mourning is a process.



Death and Dying • On initially hearing the news of a death, a person

experiences a paralyzing, totally incapacitating surge of grief.

• Wait until it is past and the survivor is ready and able to receive information and make decisions.



Death and Dying • Intense feelings for four to six weeks

– Loss, anger, resentment, sadness, guilt, loneliness

• Key to process of mourning is passage of dates and anniversaries.

• Children's perceptions different from adults'.



Table 4-4 Needs and Expectations of Children Regarding Death (1 of 3)

Age Range Characteristics Suggestions

Newborn to age 3 Senses that something has happened in the family, and notices that there is much activity in the household. Realizes that people are crying and sad.Watch for irritability and changes in eating, sleeping, or other behavioral patterns.

Be sensitive to the child's needs.Try to maintain consistency in routines.Maintain consistency with significant people in child's life.

Ages 3 to 6 Believes death is a temporary state, and may ask continually when the person will return. Believes in magical thinking, and may feel responsible for the death or that it is punishment for own behavior. May be fearful of catching the same illness and die, or may believe that everyone else he loves will die also.Watch for changes in behavior patterns with friends and at school, difficulty sleeping, and changes in eating habits.

Emphasize that the child was not responsible for the death.Reinforce that when people are sad, they cry, and that crying is normal and natural.Encourage the child to talk about and/or draw pictures of his feelings, or to cry.



Table 4-4 (continued) Needs and Expectations of Children Regarding Death (2 of 3)


Ages 6 to 9 May prefer to hide or disguise feelings to avoid looking babyish. Is afraid significant others will die. Seeks out detailed explanations for death, and differences between fatal illness and "just being sick." Has an understanding that death is real, but may believe that those who die are too slow, weak, or stupid. Fantasizes in an effort to make everything the way it was. Denial is the most helpful coping skill.

Talk about the normal feelings of anger, sadness, and guilt.Share your own feelings about death.Do not be afraid to cry in front of the child. This and other expressions of loss help to ive the child permission to xpresshis feelings.

Ages 9 to 12 Begins to understand the irreversibility of death. May seek details and specifics of the situation, and may need repeated, explicit explanations. Hard-won sense of independence becomes fragile, and may show concern about the practical matters of his lifestyle. May try to act "adult," but then regress to earlier stage of emotional response. When threatened, expresses anger toward the ill/deceased, himself, or other survivors.

Set aside time to talk about feelings.Encourage sharing of memories to facilitate grief response.



Table 4-4 (continued) Needs and Expectations of Children Regarding Death (3 of 3)


Ages 12 to 18 Demanding developmental processes are an awkward fit with the need to take on different family roles. Retreats to safety of childhood. Feels pressure to act as an adult, while still coping with skills of a child. Suppresses feelings in order to "fit in," leaving teen isolated and vulnerable.

Encourage talking, but respect need for privacy.See if a trusted, reliable friend or adult can provide ppropriatesupport.Locate support group for teens.



Death and Dying • What to Say

– Assess scene and people in each situation to determine safest and most compassionate way to deliver sad news.

– You never know how people will respond, even if you know them.

– Position yourself between them and door or other escape route.




– Do not deliver the news to large group.– Find out who is who among survivors. – Do not make assumptions.– Address closest survivor.– If survivor is alone, call for friend, neighbor, clergy

member, relative.




– Introduce yourself.– Careful choice of words helpful. – Use words "dead" and "died."– Use gentle eye contact.– Do not include statements about God's will or relief

from pain or any subjective assumption.




– Basic elements of your message: A loved one has died. Nothing more anyone could have done. You and your EMS service available to assist survivors if

needed. Give information about local procedures for out-of-hospital

death.



Death and Dying • When It Is Someone You Know

– Being involved when the life of someone you know is threatened, or lost, can have powerful impact on your emotions.

– Find a way to manage the stress and grief for your well-being.



Stress and Stress Management• Stress: nonspecific response of body to any

demand.– Interaction of events and capabilities of individual to

adjust to those events.

• Stressor: stimulus that causes stress.

• Stress both beneficial and detrimental.– Distress: negative effect– Eustress: good stress



Stress and Stress Management• Adapting to Stress

– Defensive strategies– Coping– Problem-solving skills



Stress and Stress Management• EMS Practice Stressors

– Administrative– Scene related– Emotional and physical– Environmental– Family relationships



Stress and Stress Management• To Manage Stress

– Know your personal stressors. – Know amount of stress you can take before it becomes

a problem.– Use stress management strategies that work for you.

• Adapting to stressors: receiving, processing, dissipating stressors and their effects.



Stress and Stress Management• Phases of Stress Response

– Stage I: Alarm "Fight-or-flight" phenomenon Body physically and rapidly prepares to defend itself against

perceived threat.

– Stage II: Resistance Individual begins to cope with stress.



Stress and Stress Management• Phases of Stress Response

– Stage III: Exhaustion Prolonged exposure to same stressors leads to exhaustion of

individual's ability to resist and adapt. Resistance to all stressors declines. Period of rest and recovery necessary.

– Stress also helps us function optimally.



Stress and Stress Management• Shift Work

– There will always be shift work in EMS.– Working odd hours stressful due to disruptions in

biorhythms.– Circadian rhythms: biological cycles that occur in 24-

hour intervals.– Sleep deprivation common among people who work at

night.



Stress and Stress Management• Shift Work

– Sleep in cool, dark place that mimics nighttime environment.

– Stick to sleeping at your anchor time. – Unwind after shift in order to rest well.– Do not eat heavy meal or exercise before bedtime.– Post "day sleeper" sign.– Turn off phone's ringer.



Stress and Stress Management• Signs of Stress

– Each individual susceptible to different stressors; different signs and symptoms. Physical, emotional, cognitive, behavioral.

– Burnout: extreme endpoint of stress.



Table 4-5 Warning Signs of Excessive Stress

Physical Cognitive Emotional Behavioral

Nausea/vomitingUpset stomachTremors (lips, hands)Feeling uncoordinatedDiaphoresis (profuse sweating), flushed skinChillsDiarrheaAching muscles and jointsSleep disturbancesFatigueDry mouthShakesHeadacheVision problemsDifficult, rapid breathingChest tightness or pain, heart palpitations, cardiac rhythm disturbances

ConfusionLowered attention spanCalculation difficultiesMemory problemsPoor concentrationDifficulty making decisionsDisruption in logical thinkingDisorientation, decreased level of awarenessSeeing an event over and overDistressing dreamsBlaming someone

Anticipatory anxietyDenialFearfulnessPanicSurvivor guiltUncertainty of feelingsDepressionGriefHopelessnessFeeling overwhelmedFeeling lostFeeling abandonedFeeling worriedWishing to hideWishing to dieAngerFeeling numbIdentifying with victim

Change in activityHyperactivity, hypoactivityWithdrawalSuspiciousnessChange in communicationsChange in interactions with othersChange in eating habitsIncreased or decreasedfood intakeIncreased smokingIncreased alcohol intakeIncreased intake of other drugsBeing overly vigilant to environmentExcessive humorExcessive silenceUnusual behaviorCrying spells



Stress and Stress Management• Techniques for Managing Stress

– Detrimental techniques: temporary sense of relief; will not cure problem. Substance abuse Overeating or compulsive behaviors Chronic complaining Freezing out or cutting off others Avoidance behaviors Dishonesty about state of well-being




– Beneficial (healthy) techniques: dissipate accumulation of stress; promote actual recovery. Use controlled breathing Reframe thoughts Attend to medical needs of patient




– Long-term well-being: take care of yourself physically, emotionally, mentally.

– Regular exercise and healthy diet.– Do something you enjoy and find relaxing.– Create non-EMS circle of friends.– Create positive options for yourself.



Stress and Stress Management• Specific EMS Stresses

– Daily stress– Small incidents– Large incidents and disasters



Stress and Stress Management• Post-Traumatic Stress Disorder (PTSD)

– Anxiety disorder that develops following exposure to traumatic events. Recurrent, unwanted distressing memories of the traumatic

event(s) Reliving traumatic event as if it were happening again

(flashbacks)




– Anxiety disorder that develops following exposure to traumatic events. Recurring and unsettling dreams about traumatic event(s) Severe emotional distress or physical reactions to something

that reminds the person of the event




– Changes in how individual reacts emotionally– Can adversely affect person's mood and thinking– Can result in suicide or suicidal ideation– 2014: Code Green Campaign: awareness of mental

health issues in first responders.



Stress and Stress Management• Psychological First Aid

– Contact and engagement– Safety and comfort– Stabilization– Information gathering– Practical assistance– Connection with social supports– Information on coping– Link to collaborative services



Stress and Stress Management• Disaster Mental Health Services

– Resiliency-based care: techniques and activities that promote emotional strength; decreasing vulnerability to stress, adversity, challenges.

– Multiple-casualty incident: mental health personnel available on scene and after to provide psychological first aid.



General Safety Considerations• Interpersonal Relations

– Effective communications; building rapport.– Put personal prejudices aside.– Learn about different cultural backgrounds of people in

your area.



General Safety Considerations• Roadway Safety

– Motor vehicle collisions greatest hazard for EMS personnel.

– Incidence of ambulance and emergency response vehicle collisions increasing. Ambulances larger; more difficult to operate. Person designated to drive often person with least training and

the least experience.



Figure 4-13 Ambulance collisions pose the greatest risk of injury or death for EMS providers.(© Canandaigua Emergency Squad)




– Safely following emergency escort vehicle.– Intersection management; traffic moving in several

directions.– Note hazardous conditions; adverse environmental

conditions.– Evaluate safest parking place when arriving at roadway

incident.




– Safely approaching vehicle in which someone slumped over wheel

– Patient compartment safety– Safely using emergency lights and siren



Summary• Paramedic has training and responsibility to

manage complicated health problems out-of-hospital.

• Paramedic leader within prehospital care community.

• Paramedics who attend to their own well-being are helping themselves and providing positive role model for other EMS providers.



Summary• Paramedics need to continuously assess their

personal lifestyle practices. – Wearing personal protective equipment (PPE)– Parking safely at crash site– Managing stress daily– Eating right– Exercising



Summary• Be a lifelong student of well-being; more likely to

have healthy, long life.

• Be well, so you can help others be well too.