EMT-Basic/Preparatory/Well-being

Lesson 1.2: Well-being of the EMT-Basic

Every day, Emergency Medical Technicians face some of the most stressful situations that anyone could possibly imagine. Sickness and injury can place a tremendous amount of stress on a patient, a family, and ultimately even on a medical provider. EMTs are often dispatched to the scene of cardiac arrests both witnessed and unwitnessed, and the ability to recognize and deal with the stress experienced by family members faced with the loss of a loved one is an important skill for the EMT-Basic. Stressful situations for the EMT can arise when patients succumb to their injury or illness while under the EMT's care, or from scenes which are particularly bloody or otherwise graphic.

As if the emotional stress wasn't enough, EMTs are also placed at physical risk on many calls. Since the patients you will respond to are sick and/or injured, the potential for transmission of diseases from your patient to you is particularly high. In order to perform well as an EMT, you will need to learn ways to reduce your exposure to bloodborne and airborne pathogens on emergency scenes, as well as to protect yourself from the many other hazards which may exist on the incident scene.

Objectives
By the end of this lesson, the EMT-Basic should be able to:
 * 1) List possible emotional reactions that the EMT-Basic may experience when faced with trauma, illness, death and dying.
 * 2) Discuss the possible reactions that a family member may exhibit when confronted with death and dying.
 * 3) State the steps in the EMT-Basic's approach to the family confronted with death and dying.
 * 4) State the possible reactions that the family of the EMT-Basic may experience due to their outside involvement in EMS.
 * 5) Recognize the signs and symptoms of critical incident stress.
 * 6) State possible steps that the EMT-Basic may take to help reduce/alleviate stress.
 * 7) Explain the need to determine scene safety.
 * 8) Discuss the importance of body substance isolation.
 * 9) Describe the steps that the EMT-Basic should take for personal protection from airborne and bloodborne pathogens.
 * 10) List the personal protective equipment necessary for each of the following situations: hazardous materials, rescue operations, violent scenes, crime scenes, exposure to bloodborne pathogens, exposure to airborne pathogens.
 * 11) Explain the rationale for serving as an advocate for the use of appropriate protective equipment.
 * 12) Identify and practice the use and proper disposal of personal protective equipment appropriate for the situation.
 * 13) Practice effective decontamination and cleaning procedures as well as completing appropriate post-incident reporting documentation.

Emotional Aspects of Emergency Care
Emergency medical care is often focused primarily on the patient's physical ailments, but being a patient advocate and treating the whole patient involves attending to the patient's emotional needs as well as their physical needs. You will need to recognize the emotional responses of patients to their physical conditions in order to provide the highest quality of care to your patients.

The Stages of Death and Dying
One of the most serious emotional responses that an EMT will need to recognize is the patient’s emotional response to the process of dying. When confronted with a terminal diagnosis, most patients will undergo a progression of emotional "stages" which are a part of the process of dealing with the reality of their own mortality. Keep in mind that every patient's emotional response will be different, but the vast majority of patients will experience emotions in one of these categories at any given time when confronted with their own death.
 * Denial: At first, most patients will tend to try to deny the fact that they are going to die. They try to convince themselves that "this couldn't happen to me."
 * Anger: During this stage the patient begins to question why this is happening to them. They blame others for their own condition.  EMTs may become the target of the anger, and they should never take the patients anger or insults personally.  The EMT should be tolerant of the patient's emotional state and should not become defensive so as to avoid escalating the situation.  The EMT should listen carefully and attentively to the patient and employ good communication skills to convey a sense of empathy to the patient.
 * Bargaining: The patient begins to accept the ultimate conclusion to the dying process, but tries to postpone the death for a short time. During this stage, the patient will want to accomplish tasks that they hadn't accomplished before, thinking that maybe this will help their body last until their tasks are complete.
 * Depression: At this point, the patient is accepting of their inability to change their own fate, but they are exhibit sadness and despair over their failure to do certain things that they wish they could have done with their lives. These patients may avoid communicating with others and retreat into their own private emotional world.
 * Acceptance: By this stage, the patient has fully accepted their fate. Their acceptance of death does not mean that they will be happy about dying; they have only realized that there is nothing they can do about it.  During this stage, the family will typically require more emotional support than the patient.

Dealing with dying patients and their family members
When dealing with dying patients and their family members, there are several key points that you should consider.
 * Recognize the patient's needs: Every patient wants to be respected, and you should do everything you can to maintain the dying patient's sense of dignity and control, and including the patient in the conversation when you are speaking to the patient's family in the patient's presence. You should not stop the patient from sharing their feelings with you, but you should also respect their privacy if they choose not to.
 * Understand that family members may express rage, anger, or despair: Family members may feel hopeless and may blame responders for not doing enough to save their dead or dying family member. Realize that these emotions are not personal and would be directed at anyone in your position.
 * Listen empathetically: to both patients and family members. There is nothing you can do to keep a patient from dying or to bring back a dead patient beyond your normal standard of care, but sometimes listening patiently and conveying a sense of understanding can help patients and their families deal with their emotions.
 * Do not falsely reassure: It is important never to lie to a patient or family member, especially when the patient is in critical condition. Saying things like "You're going to be fine" can be irritating to patients and families when they know it isn't true.
 * Do whatever you can to comfort the patient and their family: you should let the patient know that you are going to do everything you can to help them. Use a gentle tone of voice, and a reassuring touch, if appropriate.

Stress and Stress Management
Many situations that an EMT-Basic might find themselves in may produce a stress response. Mass casualty incidents, infant and child trauma or death, amputations, situations involving domestic abuse, and the death or injury of co-workers and other public safety personnel can all cause stress in the EMT-Basic and in patients and bystanders that the EMT-Basic will come in contact with.

Other stressful situations for the EMT can arise out of family and friends' responses to the EMT's work. They may not understand why the EMT needs to work on weekends and holidays, and they may get aggravated by situations when the EMT is required to be on call. Likewise, being on call may be stressful to the EMT since they cannot plan activities around unpredictable emergencies. After a major or stressful call the EMT may want to share their feelings with friends or family, but if the person does not understand the EMT's emotions, this may cause feelings of separation or rejection, which can be highly stressful to the EMT.

Recognizing Stress
A good EMT will recognize the warning signs of stress. These signs include:
 * Irritability towards co-workers, family, and friends
 * Inability to concentrate
 * Difficulty sleeping and/or nightmares
 * Anxiety
 * Indecisiveness
 * Guilt
 * Loss of appetite
 * Loss of interest in sexual and other pleasurable activities
 * Isolation
 * Loss of interest in work

You should always be aware of these warning signs both in yourself and in those around you. If you or someone you know is showing signs of stress, encourage them to deal with their feelings of stress appropriately.

Dealing with Stress
Certain lifestyle changes can be helpful in dealing with stress. Changing diet to reduce sugar, caffeine, and alcohol intake and to avoid fatty foods while increasing carbohydrates can be helpful, as can exercise and relaxation techniques such as meditation and visual imagery. Finding time to balance work with recreation and time with family can also help prevent or reduce stress. It may be helpful to request shifts which allow more time to relax with family and friends, or to request transfer to a less busy area if possible.

Critical Incident Stress Debriefing
After a major incident or an incident which is likely to cause high amounts of stress in a large number of responders, agencies may choose to hold a Critical Incident Stress Debriefing or CISD. A CISD is conducted by a team of peer counselors and mental health professionals who help emergency responders deal with critical incident stress. A CISD will typically take place within 24 to 72 hours after a major incident, and allows for the open discussion of feelings, fears, and reactions. A CISD is not an investigation or interrogation, and all information shared at a CISD is completely confidential. CISD leaders and mental health personnel at a CISD evaluate the information shared by responders and offer suggestions on overcoming the stress.

CISDs are designed to accelerate the normal recovery process after experiencing a critical incident. They work because they allow an appropriate outlet for responders to vent their feelings within a short time frame after the incident, and because the debriefing environment is kept non-threatening. You should be familiar with how to access the CISD system in your area.

In addition to the CISD, a comprehensive plan for the management of critical incident stress includes:
 * Pre-incident stress education
 * On-scene peer support
 * One-on-one support
 * Disaster Support Services
 * Defusings
 * CISD
 * Follow up services
 * Spouse/family support
 * Community outreach programs
 * Other health and welfare programs such as wellness programs.

Safety on the Emergency Scene
Safety on the Emergency Scene involves awareness of scene hazards and the use of appropriate procedures to mitigate or lessen the impact of those hazards on responders. It includes using appropriate personal protective equipment for all calls, as well as recognizing the potential dangers of certain specialty incidents such as hazardous materials, rescues, or incidents involving violence.

Body Substance Isolation
Body Substance Isolation (BSI) is the EMT-Basic's primary line of defense against biological contaminants. Since patients are often sick and EMTs are often exposed to blood, EMTs should always take precautions to prevent contact between their own skin and the patient's bodily fluids. The EMT should always wear Personal Protective Equipment appropriate for the situation they are entering, which might include gloves, goggles, masks, and/or gowns.

Gloves should be worn on every call. The EMT can never be sure that anything they touch won't be contaminated with bodily fluids, or that anything wet that they touch doesn't contain bodily fluids, so it's a good rule of thumb to assume that anything you touch on or around the patient IS contaminated with bodily fluids. Remember: "If it's wet and it's not mine, I don't want it on me." In the interest of protecting patients, gloves should also be changed whenever the EMT comes into contact with a different patient (for example, at a mass-casualty incident). Because of potential allergies, it's best to avoid the use of latex gloves. In patient care situations, vinyl or nitrile exam gloves are best. Heavy duty utility gloves are also needed for cleaning vehicles and equipment.

Goggles or other forms of eye protection should be worn whenever there is a potential for splashing or spraying of bodily fluids. These protect the mucous membranes surrounding the eyes which will readily absorb fluids. Whatever form of eye protection is used, it should provide full protection of the eyes from both the front and sides.

Masks such as surgical masks should be used in conjunction with eye protection whenever there is potential for splashing or spraying of bodily fluids. They may also be placed on patients with certain respiratory ailments which may be spread via inhalation of respiratory droplets such as those created by sneezing or coughing, or in low amounts, even breathing. In suspected or confirmed cases of Tuberculosis (TB), an N-95 or High Efficiency Particulate Air type respirator approved by the National Institute for Occupational Safety and Health (NIOSH) should be worn.

Gowns are typically only used when there are large amounts of blood such as an arterial bleed or major trauma. Gowns are also commonly used for field delivery since childbirth involves large amounts of bodily fluids. Any situation which requires a gown will also require gloves, masks, and eye protection. It is also preferable to change your uniform after any such call if possible.

Keep in mind that any time you wear personal protective garments they must be properly removed and disposed of after use.