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PPE and Biohazard Guide for EMS Providers
Coming into contact with hazardous substances is an unavoidable part of an EMS provider's job. In the vast majority of cases, the risks to yourself, your coworkers, and your patients are minimal — as long as you consistently follow best practices.
The notion that it's important to practice proper biohazard control procedures and to wear personal protective equipment (PPE) seems too obvious to warrant stating. In a sense, it is, but the most obvious things are often the ones we start to overlook or neglect once they become frequent, time-consuming aspects of our lives.
In this guide, we'll outline both the overarching principles and specific methods of PPE usage and biohazard management.
Biohazard Management: Core Principles
Whether you work on an ambulance, in a hospital, or in patients' homes, you're bound to run into biohazards. Hazards come in many different forms, each of which requires a different approach, but there are a few universal principles to keep in mind.
Protect Yourself and Your Crew First
Health care providers know that it's important to protect their patients from biohazards, but unfortunately, many often neglect to protect themselves adequately. Simply put, you can't help anyone if you're sick or dead.
It's equally important to avoid the mindset that providing excellent patient care somehow requires compromising your own safety. Most often, this manifests in the form of behaviors such as forgoing gloves in the name of saving a few seconds and thus providing care more quickly. As is the case with driving code 3, your patient's life, limb, or eyesight almost never depends on saving five or ten seconds.
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Responsible patient care sometimes necessitates a reasonable level of risk to providers, but failing to fully protect yourself and your coworkers is never a reasonable risk.
When in Doubt, Err on the Side of Overkill
In general, pathogens are tenacious things. In many cases, a single drop of blood or other bodily fluids can be enough to infect someone else. Biohazard protocols for EMS providers already emphasize maximum caution, but these guidelines can't account for every conceivable situation.
For instance, suppose that the hospital you work in is out of the disinfectant it normally uses and you have to use a new, unfamiliar cleaning product that isn't specifically mentioned in the relevant protocol. If exact guidance isn't readily available, you may have to use your best judgement, which should err on the side of too much cleaning and disinfecting. It never hurts to spend a few extra minutes to ensure that your work area is clean and safe.
Similarly, once you've thoroughly cleaned the area and disinfected your equipment, it may be appropriate to do it all once more, especially if there was a big mess, if exceptionally dangerous pathogens were involved, or if you simply have nothing more pressing to do at the moment.
Resist the Temptation to Take Shortcuts
Yes, it can be annoying and time-consuming to put on PPE. Some providers may take shortcuts when cleaning up a biohazard, thinking that their extensive experience or increased caution can replace best practices.
Knowledge and caution are certainly helpful, but they only go so far toward protecting you and your patients against biohazards. In the grand scheme of things, an extra minute or two is insignificant, especially when shortcuts have the potential to be fatal—so be sure to always follow the most recent guidelines on biohazard management and PPE usage.
Proper Usage of PPE
PPE comes in several different forms, each of which is designed for specific situations and types of hazards. This guide will briefly introduce the most common PPE you'll use as an EMS provider. Shop protective equipment
Disposable nitrile or latex gloves are the most essential item of PPE in your toolkit, in that you'll be wearing them every time you make contact with a patient or with any form of biohazard. Nitrile is preferable because it's hypoallergenic, whereas latex can cause allergic reactions in a significant number of people.
Always ensure that your hospital or ambulance has small, medium, and large gloves, and that you choose a size that fits your hands snugly without limiting your dexterity. If you must wear ill-fitting gloves, too big is better than too small—gloves that are too small rip easily and can expose you to biohazards.
There are two distinct types of medical masks: those designed to protect others from the wearer and those designed to protect the wearer from others. Some can effectively serve both purposes, but surgical masks are not one of them—they are only effective at protecting your patients and coworkers from large particles that you exhale, cough, or sneeze.
To properly don a surgical mask, align the metal strip (if there is one) with the bridge of your nose and use your fingers to bend it into a shape that fits snugly, such that the mask will loosely stay on your face without the straps in place. Then, hook the elastic straps over your ears (if they are vertically aligned) or behind your head (if they are horizontally aligned). Surgical masks do restrict your breathing to some extent and are uncomfortable to wear for long periods of time, but you should be able to breathe well enough to speak and work for at least fifteen minutes at a time. If you can't, make small adjustments to the metal strip or the elastic straps as needed. Shop disposable masks
N95 and N99 masks—so named because they filter out 95% and 99% of harmful airborne pathogens, respectively—are designed primarily to protect the wearer, although they do provide some protection for others as well. They look similar to surgical masks but are generally more effective.
The process of donning an N95 or N99 mask is virtually the same as that for a surgical mask: Mold the metal strip snugly to the bridge of your nose and situate the straps comfortably behind your ears or head.
Rebreathers and Gas Masks
Rebreathers and gas masks serve similar, but distinct, purposes. Rebreathers are capable of extracting carbon dioxide from the air you exhale and recycling the unused oxygen such that you can continue breathing it. You'll likely use one if you respond to an active fire. More rarely, you may use one when responding to chemical spills or scenes at which airborne toxics are present.
Gas masks don't recycle air, but they do filter out toxic and poisonous substances. They require detachable filters that must be changed regularly.
Because these devices are not commonly used by EMS providers, and because they're a bit more complicated to use than gloves and masks, you should ask your chief or training officer for guidance on their availability and proper use.
These simple, disposable covers slip over your boots to protect them from hazardous fluids. It's a good idea to wear them anytime you expect that you might have to step in blood, urine, or some other hazard. They may not completely eliminate the need to clean your footwear afterward, but they should make it much easier.
Aprons, Face Shields, and Full Body Suits
When you encounter biohazards that are especially extensive and/or dangerous, gloves and masks alone may not cut it. Full-body protection such as aprons and face shields are fairly straightforward; simply put them on over your clothing and replace them as needed.
True full-body hazard gear, such as CBRN (chemical, biological, radiological, and nuclear defense) suits, is highly specialized and requires substantial training to use properly. As an EMS provider, you will likely never be required to use such equipment, except in the event of a large-scale catastrophe. Shop Isolation Gowns
Best Practices for Managing Specific Biohazards
The proper response to a biohazard depends on its exact nature. This guide will briefly introduce you to different kinds of biohazards and to the best practices for dealing with them, but it is not intended to be—nor can it be—a replacement for official guidelines published or endorsed by your local medical director.
A "sharp" is a needle, scalpel, or any other medical device designed to cut or pierce the skin. Less commonly, the term is also used to refer to non-medical hazards such as rusty nails or broken glass at the scene of an accident.
Needles should never be uncapped any longer than necessary. When you're finished with one, reattach the safety cap by laying it on a flat surface and guiding the needle slowly into it with one hand. Use the same method for scalpels and other medical devices. Never hold the cap in your hands while putting it back on the needle, as this significantly increases the chances of sticking yourself. Dispose of the needle and cap in an authorized container, and do the same with catheters, IV tubing, or anything else that came into contact with bodily fluids.
Potentially contagious bodily fluids include blood, saliva, semen, vaginal fluids, mucous, urine, feces, and even moisture exhaled in the course of normal respiration. Not all diseases and infections are transmissible via all types of bodily fluids, but fortunately, you don't have to remember anything beyond this: Treat all of them as potentially infectious. Always wear gloves, at bare minimum, when interacting with patients and when cleaning up hazardous waste. More extensive or dangerous hazards may warrant more extensive PPE.
To clean contaminated surfaces or equipment, use towels, paper towels, or disinfectant wipes to wipe up the bulk of the material, and immediately dispose of them in biohazard bags. Then conduct at least two rounds of detail cleaning with disinfectant wipes, or antimicrobial spray and clean towels, paying special attention to cracks and crevices. Again, always dispose of used cleaning materials in designated biohazard bags or cans.
Decontaminating Personnel and Equipment
When you respond to a call that results in your ambulance or work area becoming contaminated by a biohazard, it's important to remember that you'll be out of service until the hazard is cleaned up. Under (almost) no circumstances should you respond to another call until you, your partner, and your equipment have been thoroughly cleaned. As soon as you transfer care, getting back in service should be your top priority. Be sure to read up on our guide on cleaning and disinfecting ambulances.
Post-Exposure Testing and Management
In the event of an accidental needle stick or other direct exposure to a biohazard, it's critical that you notify your partner and supervisor immediately and follow established testing and treatment procedures. Failure to do so needlessly endangers your health and your credentials—and your patients and coworkers, should you pass an infection or disease on to them. Furthermore, your company or agency will pay for any testing or treatment you might require, but only if you follow established procedure. If you don't, you may be financially responsible for your own treatment.
It's rare but not unheard of for EMS providers to encounter biologically dangerous substances other than sharps and bodily fluids. For instance, anthrax occurs naturally in soil; it's uncommon in the United States for anthrax to infect humans, but it does happen from time to time. Addressing all possible biohazards is beyond the scope of this article, but you should be aware that they come in many varieties, many of which aren't obviously dangerous. If you work in an area where such hazards are present, your company or agency should provide training and resources for dealing with them.
CBRN (Chemical, Biological, Radiological, Nuclear) Considerations
EMS providers don't generally train for large-scale CBRN scenarios, although there are exceptions. Short of a few niche cases, such as chemical spills on the highway, you will likely never be asked to respond to a situation that necessitates CBRN gear.
However, you may be asked to volunteer in the event of a mass-casualty scenario that overwhelms the emergency response system. If your department has sufficient resources, consider requesting annual or biannual CBRN training.
Resources and Further Reading
There are many private companies, non-profit organizations, and government agencies that publish guidelines on PPE and biohazard management. Your local hospital or medical director may adopt a particular set of guidelines wholesale, or they may modify them or publish their own. In any case, it's a good idea to regularly review them, and to review other guidelines published by prominent experts.
Here are some good resources that are updated at least every few years:
EMS Infectious Disease Playbook, published by ASPR (the Assistant Secretary for Preparedness and Response) and TRACIE (Technical Resources, Assistance Center, and Information Exchange)
Guide for Developing an EMS Agency Safety Program, published by the National EMS Safety Council
Bloodborne Pathogens and Needlestick Prevention, published by OSHA
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