Unsafe Situations

From your first day in EMS class, your instructors likely emphasized the mantra of “BSI/scene safety.” Even with years in the field, you may still get reminders of safe practices and the tools, procedures, and protocols to use. The intentions behind this are good, and research supports the safety practices we teach, yet some EMS providers don’t follow the rules and advice they’re given.

An EMT instructor I had many decades ago was right when she said, “You can’t help anyone if you become a patient yourself.” Following safety procedures and establishing consistent routines can help reduce that risk across EMS—here are some areas to keep in mind. 

Restraints

Every state in the country has a seat belt law that requires drivers and front-seat passengers to buckle up. For any provider who has responded to a serious motor vehicle crash where the patient was not restrained, the thought Why didn’t they just buckle up? has surely occurred. 

The most common answer EMS providers give to this is that it’s challenging to provide patient care while restrained. A 20-year study of ambulance accidents by NHTSA found 84% of EMS providers in patient compartments were not wearing a seat belt or other restraint.¹ 

Over the last several years, changes to new ambulances have aimed to improve this number. These include six-point harnesses that allow providers to deliver patient care while still restrained. Further, some ambulances, especially type II vans, are being reconfigured to put provider seats closer to the patient and in a better position if the ambulance is in a collision. 

The bottom line is this: Wear your seat belts in the front and back. As you always strap your patient securely to the stretcher, strap yourself securely to your chair as well. If your restraint system doesn’t allow active care while restrained, consider asking the driver to pull over and stop while you unbuckle to render care.

Lights and Siren

Looking at the results of various studies, the use of lights and sirens reduces EMS response times between 1.7–3.6 minutes and transport times by 0.7–3.8 minutes. Some of these studies included independent physician reviews of transported medical cases. The summary of the data suggests the reduction in prehospital time produced a clinical difference in only about 5% of cases.² That means 95% of the time, lights and sirens make no appreciable difference in patient outcome.

At the same time, the research is clear that use of lights and sirens, especially during transport to a hospital, significantly increases the risk of an ambulance crash. According to a 2019 study, during the transport phase “the crash rate was 7.0 of 100,000 without lights and sirens and 17.1 of 100,000 with lights and sirens.”³ 

So there’s a 40% greater chance of ambulance crash with lights and siren use, while only 5% of patients may have a clinical benefit from the time that use saves. Most system directors are aware of this data, and many agencies now have policies for transport without lights and siren. 

Driver Distractions

In 1981 the FAA enacted what are known as “sterile cockpit” rules. They say, “No flight crew member may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crew member from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties.” The FAA cites activities like eating, nonessential conversations, and reading material unrelated to conducting the flight.⁴ 

This concept, which allows for the undistracted operation of aircraft by pilots, should also be adopted by ambulance operators during the response and transport phases of calls. While many EMS providers pride themselves on their ability to multitask, it can’t make you a more reactive driver if you’re texting, finishing your burger, talking on your phone, or doing anything else besides safely operating the ambulance. To reduce the risk of a crash, consider a sterile cockpit rule.

Roadway Visibility

Roads and highways are among the most dangerous places for first responders to work. According to the Emergency Responder Safety Institute (ERSI), 44 emergency responders were killed while working roadway incidents in 2019.⁵ These numbers include EMS, firefighters, law enforcement, and tow truck operators. 

There are several good practices to avoid becoming one of these statistics. According to Chris Strattner, director of the Rockland County (N.Y.) Police and Public Safety Academy, the key is to be seen. “Navy blue is a terrible color to be seen at night, yet it is the predominant color worn by responders,” Strattner says. “To compensate for this, at night wear a high-visibility vest, personal blinky lights, or a lighted 360-degree helmet.” 

Keep your reflective vest in an easily accessible location, such as the pocket on the rig door or on your seat itself—that way it becomes second nature to don it when getting out on the highway. Wearing a high-visibility vest that says EMS or Fire Department reduces the chance a provider will be confused with law enforcement. Additionally, using barrier vehicles at highway scenes, like fire apparatus behind ambulances, provides added protection against civilian drivers who aren’t paying attention.

Eye Protection

Glove and mask use by EMS has certainly increased over the last year-plus, but eye protection has not advanced with the same gusto. According to the American Academy of Ophthalmology, nearly 20,000 eye injuries occur at work each year.⁶ Nearly 90% of these injuries could be avoided if appropriate eye protection were worn. (Granted, most of these injuries are industrial, not medical, but EMS can find itself in nearly any situation rendering care.) 

According to the AAO, common causes of eye injuries include particles, debris, fluids, chemicals, and flying objects. Bloodborne and other pathogens are part of this list. Additionally, much like your skin, your eyes can be harmed by repeated exposure to UV rays.

Today the relevant safety standards for eye protection are ANSI/ISEA Z87.1-2015, which articulates the design, performance specifications, and markings of eye and face safety products worn in occupational settings, and OSHA’s 1910 standard on bloodborne pathogens. According to OSHA, appropriate eyewear should have the “ability to protect against specific workplace hazards, should fit properly, and be reasonably comfortable to wear.”⁷ It should also “provide unrestricted vision and movement, should be durable and cleanable, and should allow unrestricted functioning of any other required PPE.” 

If there is a foreseeable blood or bloodborne pathogen contact with the mucous membranes of the eye, wear appropriate eye protection. Regular glasses do not provide this. Goggles, safety glasses, and face shields are the easiest and most common eye protection EMS can wear. Sunglasses typically only protect against UV rays. 

Carbon Monoxide

A trend in recent years has been for EMS providers to have portable carbon monoxide (CO) detectors attached to their first-in bags or radio straps. Carbon monoxide is a colorless, odorless, toxic, flammable gas formed by the incomplete combustion of carbon. CO is produced from sources such as vehicles, gasoline engines, portable generators, gas-powered tools, camp stoves, burning charcoal and wood, gas ranges, heating systems, and poorly vented chimneys. Structural fires are a common source of CO exposure for both victims and firefighters. CO poisoning is the most common poisoning in the United States and many countries around the world.

Since CO calls are often incidental, an initial dispatch might be for a “sick person” or “flulike symptoms.” Carbon monoxide poisoning often mimics flu symptoms, with nasal stuffiness, fatigue, headaches, nausea, and lightheadedness. Cardiac patients are more susceptible to CO symptoms, so a cardiac dispatch could be telling as well. Your index of suspicion should increase if several people develop symptoms of headache, nausea, and fatigue or drowsiness at the same time. Children and pets are often affected before adults.

Early symptoms of exposure to CO include headache, general body weakness, dizziness, and lethargy. Extended exposure may result in blurry vision, nausea, vomiting, shortness of breath, and altered mental status. CO affects several areas within the body but is most significant in systems and organs with the highest oxygen requirements, such as the brain, lungs, and heart.

The first priority if either your CO meter alerts or the patient presents with the above symptoms is to promptly evacuate the structure and call for a fire department and utility company response. Know that if you’ve been exposed too long, you and your crew might be patients as well. Consider calling for additional ambulances, including ALS if you are a BLS unit.

Conclusion

While classes, rules, and regulations may inform providers of recommended methods of safety, it is the provider’s willingness to follow through with these procedures and use the proper equipment that will keep them and their crews intact. While nothing can make this job 100% safe, doing the proper thing for the right reasons will reduce any EMS provider’s chance of becoming a patient, rather than caring for one.  

Sidebar: Additional Safety Concerns

No article can fully list all the safety issues EMS providers need to be aware of, and no program or tool can completely mitigate risk. But some other safety concerns that agencies, supervisors, and individuals should think about and be proactive with include:

• Tactical scenes—Crews operating in warm zones might want to have rescue task force training, as well as ballistic protection.
• Situational awareness—Keep your head on a swivel. Don’t get lulled by normalcy and be aware of your surroundings.
• Weather—Are your crews kept hydrated in hot and humid weather, and do their rigs have working air conditioning? Is there reflective rainwear available?  Are hats and warm jackets available during cold weather?
• Water—If your service area has water hazards, are your personnel trained at a minimum at the water rescue awareness level, and is there a throw bag or other flotation device on the apparatus?
• Sleep—If your crews work 12- or 24-hour shifts, are there break times? Do providers make sure they are getting a good night’s sleep when off duty, especially if their schedule has varied shift work?
• Ergonomics—With larger patients becoming more the norm than the exception, powered cots, loader systems, and powered stair chairs are great tools for preventing injuries, especially back injuries.
• Mental health—It’s up to each provider to monitor his or her own stress and mental health. In EMS we see things that take a toll. There’s no weakness in asking for help, and it is incumbent upon your agency to provide it. You know the old adage from airline safety: You have to put on your own oxygen mask before assisting another. You can’t help others if you are not OK.

References

1. National Highway Traffic Safety Administration. The National Highway Traffic Safety Administration and Ground Ambulance Crashes, www.ems.gov/pdf/GroundAmbulanceCrashesPresentation.pdf.

2. Neulander MJ, Siddiqui DI, Mountfort S. EMS Lights And Sirens. [Updated 2020 Sep 18]. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing, 2021.

3. Watanabe BL, Patterson GS, Kempema JM, et al. Is use of warning lights and sirens associated with increased risk of ambulance crashes? A contemporary analysis using National EMS Information System (NEMSIS) data. Ann Emerg Med, 2019 Jul; 74(1): 101–9.

4. 14 CFR §121.542/135.100—Flight Crewmember Duties.

5. Emergency Responder Safety Institute. 2019 ERSI Struck-by-Vehicle Fatality Report, www.respondersafety.com/Struck-By-Incidents/2019-ERSI-StruckByVehicle-Fatality-Report.aspx.

6. American Academy of Ophthalmology. Eye Injuries at Work, www.aao.org/eye-health/tips-prevention/injuries-work.

7. Occupational Safety and Health Administration. Personal Protective Equipment, www.osha.gov/Publications/osha3151.pdf.

Barry Bachenheimer, EdD, NREMT/FF, has more than 35 years in EMS and fire as a provider and instructor. He is a frequent contributor to EMS World.