Chapter 2

Workforce Safety and Wellness

I. Introduction
A. To take care of others, we must take care of ourselves.
1. If your safety is threatened, you will not be able to care for the patient.
B. EMT training includes recognition of hazards to your health, safety, and well-being:
1. Personal neglect
2. Environmental and human-made threats
3. Mental and physical stress
C. The emotional well-being of the EMT and the patient are intertwined, especially in high-
stress rescues.

II. General Health and Wellness

A. Wellness goes beyond the prevention of disease. It is a state of complete mental, physical, and
social well-being.
B. As a health care provider, you should model a life of health and wellness.
C. A state of wellness must occur at:
1. Work—through protection from communicable disease and scene hazards.
2. Home—through a healthy diet; exercise; getting enough sleep; refraining from use of tobacco,
drugs, and excessive alcohol; and taking time to relax.
D. EMTs are often called upon to work in circumstances that result in both acute and
cumulative stress. As an EMT, your role is to:
1. Be prepared
2. Anticipate needed resources
3. Control the scene
4. Care for the patient
E. The calm manner in which you approach the scene will help to calm the patient, family
members, and bystanders.
F. Wellness and stress management
1. Prolonged physical stress can drain the body of its reserves.
a. Depleted of key nutrients
b. Weakened
c. More susceptible to illness
2. Stress is any event, thought, or action perceived as a threat.
3. Even people who are completely healthy may be constantly dealing with stress.
 4. Understanding how stress affects you physiologically, physically, and psychologically can help
you:
a. Control your reactions
b. Minimize the effect of stress
G. Regardless how stressful the situation, you must focus on the following considerations, in this
order:
1. Personal safety
2. Scene safety, including safety of others
3. Patient care
H. Utilize the help of others, including your partner, police, a supervisor, other additional
personnel, or even bystanders to help manage crisis situations.
I. Stress management refers to the tactics that have been shown to alleviate or eliminate stress
reactions.
1. These steps may involve changing a few habits, changing your attitude, and perseverance.
2. Strategies to manage stress:
a. Minimize or eliminate stressors as much as possible.
b. Change partners to avoid a negative or hostile personality.
c. Change work hours.
d. Change the work environment.
e. Cut back on overtime.
f. Change your attitude about the stressor.
g. Talk about your feelings with people you trust.
h. Seek professional counseling if needed.
i. Do not obsess over frustrating situations that you are unable to change
j. Try to adopt a relaxed, philosophical outlook.
k. Expand your social support system beyond your coworkers.
l. Develop friends and interests outside emergency services.

III. Infectious and Communicable Diseases

A. An infectious disease is caused by organisms within the body.
B. A communicable disease can be spread:
1. From person to person
2. From one species to another
C. Infection risk can be minimized by:
1. Immunizations
2. Protective techniques
3. Handwashing
D. When these protective measures are used, the risk of the health care provider contracting a
serious disease is negligible.
E. Familiarize yourself with the following terminology related to infectious diseases.
1. Pathogen: a microorganism that is capable of causing disease
2. Contamination: the presence of infectious organisms or foreign bodies on or within objects such
 as dressings, water, food, needles, wounds, or a patient’s body
3. Exposure: a situation in which a person has had contact with blood, body fluids, tissues, or
airborne particles in a manner that may allow disease transmission to occur
4. Personal protective equipment (PPE): protective equipment that an individual wears to prevent
exposure to a pathogen or a hazardous material
F. Routes of transmission
1. Transmission is the way an infectious disease is spread.
a. Direct contact (eg, blood-borne pathogens)
b. Indirect contact (eg, needlesticks)
c. Airborne transmission (eg, sneezing)
d. Foodborne transmission (eg, contaminated food)
e. Vector-borne transmission (eg, fleas)
G. Risk reduction and prevention for infectious and communicable diseases
1. All EMTs are trained in handling blood-borne pathogens.
2. The CDC has developed standard precautions concerning:
a. Hand hygiene
b. Personal protective equipment: gloves, gown, mask, eye protection, face shield
c. Patient care environment: soiled patient care equipment, environmental controls, textiles
and laundry, needles and other sharp objects
d. Special circumstances: patient resuscitation, respiratory hygiene/cough etiquette
3. Proper hand hygiene
a. Handwashing is the simplest, yet most effective way to control disease transmission.
b. Wash hands before and after patient contact, even if you wear gloves.
c. If there is no running water, use a waterless handwashing substitute.
4. Gloves
a. Wear gloves if there is any possibility for exposure to blood or body fluids.
b. Vinyl, nitrile, and latex gloves are effective protection. Wear heavy-duty gloves when
cleaning the ambulance.
c. Change gloves between patients.
d. Removing gloves requires a special technique to avoid contaminating yourself with the
materials on the outside of the gloves
5. Eye protection and face shields
a. Eye protection protects from blood splatters.
b. Prescription glasses are not adequate.
c. Goggles or face shields are best.
6. Gowns
 a. A gown provides protection from extensive blood splatter.
b. A gown may not be practical in many situations.
i. May even pose a risk for injury
7. Masks, respirators, and barrier devices
a. Wear a standard surgical mask for fluid spatter.
b. Place a surgical mask on any patient with a communicable disease.
i. Use a mask with a particulate air respirator on yourself if the disease is tuberculosis.
c. Mouth-to-mouth resuscitation may transmit disease.
d. With an infected patient, use:
i. Pocket mask
ii. Bag-valve mask
e. Dispose of these devices according to local guidelines.
8. Proper disposal of sharps
a. Proper disposal helps to avoid exposure to HIV and hepatitis.
b. Do not recap, break, or bend needles.
c. Dispose of used sharp items in an approved, closed, rigid container.
9. Employer responsibilities
a. There is no guarantee of a 100% risk-free environment. The risk of being exposed to a
communicable disease is a hazard of your job.
b. Follow OSHA guidelines and other national guidelines and standards to reduce your risk of
exposure to blood-borne pathogens and airborne diseases.
c. Know your department’s infection control plan and follow it.
H. Establishing an infection control routine
1. Infection control should be an important part of your daily routine.
2. Components of an infection control plan:
a. Determination of exposure risk
b. Education and training
c. Hepatitis B vaccine program
d. Personal protective equipment
e. Cleaning and disinfection practices
f. Tuberculin skin testing/fit testing
g. Postexposure management
h. Compliance monitoring
i. Record keeping
3. Cleaning is an essential part of the prevention and control of communicable diseases, as it
ensures the removal of surface organisms that may remain in the unit.
 a. Clean the ambulance after each run and on a daily basis.
b. Use appropriate PPE while cleaning.
c. Remove contaminated linens, and put them in an appropriate bag for handling.
4. Whenever possible, cleaning should be done at the hospital. There is more information about
cleaning the ambulance in Chapter 37, “Transport Operations.”
I. Immunity
1. Even if germs reach you, you are not necessarily at risk for infection.
a. Immunity is a major factor in determining which hosts become ill from which germs.
b. Host: the organism or individual that is attacked by the infecting agent
c. You may be immune, or resistant, to particular germs.
d. Immunity:
i. Having been immunized or vaccinated
ii. Able to recover from an infection from that germ
2. Preventive measures
a. Maintain your personal health. Annual health examinations should be required for all EMS
personnel.
b. Immunizations.
i. You are required to get the hepatitis B vaccine or sign a waiver.
ii. Other recommended immunizations include tetanus, diphtheria, and pertussis boosters every 10
years; measles, mumps, and rubella (MMR) vaccine; influenza vaccine (yearly); and varicella
(chickenpox) vaccine or having chickenpox.
J. General postexposure management
1. If you are exposed to a patient’s blood or bodily fluids:
a. Turn over patient care to another EMS provider.
b. Clean the exposed area with soap and water.
c. If your eyes were exposed, rinse your eyes for 20 minutes.
d. Activate your department’s infection control plan.
2. You will have to complete an exposure report.
3. Time is important! Some diseases will act quickly, whereas others will remain dormant.
4. Early activation of a plan is critical.

IV. Scene Safety

A. The personal safety of all those involved in an emergency situation is very important.
1. Begin protecting yourself as soon as you are dispatched.
a. Wear seat belts.
b. Don appropriate PPE.
2. Continue to protect yourself once on scene.
a. Make sure the scene is well marked.
 b. Place warning devices to alert other motorists of the scene.
c. Park at a safe distance from the scene.
d. Make sure there is plenty of light if it is dark.
e. Wear reflective clothing if it is dark.
B. Scene hazards
1. Hazardous materials
a. Upon arrival, look at the scene and try to read any labels, placards, and identification
numbers from a distance, perhaps using binoculars.
b. A specially trained and equipped hazardous materials team will be called to the scene to
handle disposal of materials and removal of patients.
c. The DOT’s Emergency Response Guidebook is an important resource to help identify
hazards.
d. Do not begin caring for patients until they have been moved away from the scene and are
decontaminated or the scene is safe for you to enter.
e. Do not enter the scene unless it is safe to do so.
2. Electricity
a. Dealing with downed power lines is beyond the scope of EMT training.
b. Mark off a danger zone around the downed lines using utility poles as landmarks. The
safety zone is one span of the power pole’s distance.
c. Energized lines behave in unpredictable ways.
d. If you must enter the scene, wear the proper protective equipment according to the type of
incident.
e. Lightning is a threat in two ways:
i. A direct hit
ii. Ground current
f. A repeat lightning strike in the same area can occur.
g. Avoid high ground to minimize risk of a direct lightning strike.
h. To avoid being injured by ground current, stay away from drainage ditches, moist areas,
small depressions, and wet ropes.
i. When lightning is nearby, make yourself the smallest target possible and drop all
equipment.
3. Fire
a. Common hazards:
i. Smoke
ii. Oxygen deficiency
iii. High ambient temperatures
iv. Toxic gases
v. Building collapse
vi. Equipment
 vii. Explosions
b. Make sure you are properly protected.
c. Be trained in the use of appropriate airway protection.
d. A number of toxic gases may be produced in a fire, including carbon monoxide, cyanide,
and carbon dioxide.
i. Carbon monoxide, cyanide, and carbon dioxide are colorless, odorless gases.
ii. Carbon monoxide is responsible for most fire deaths.
iii. Inhaling cyanide prevents cells from using oxygen.
e. There is always a possibility that a burning structure will collapse.
4. Vehicle crashes
a. Vehicle crashes are common events for EMS providers.
b. They provide some of the most unstable and potentially lethal situations an EMS provider
will face.
c. Vehicle collision hazards include traffic, an unstable vehicle that may fall on you, downed
power lines, risk of violence, airbags, glass, and sharp metal objects.
d. Use sufficient protective gear to reduce the risk of injury.

V. Protective Clothing: Preventing Injury

A. Wearing protective clothing and other appropriate gear is critical to your personal safety.
B. Become familiar with the protective equipment available to you.
C. Inspect your clothing and gear regularly—ideally before you reach the scene.
D. Types
1. Cold-weather clothing consists of three layers:
a. A thin inner layer that pulls moisture away from the skin
b. A thermal middle layer that serves as insulation
c. An outer layer that resists wind, rain, sleet, and snow
2. Turnout gear
a. Protects from heat, fire, sparks, and flashover
b. Also called bunker gear
3. Gloves
a. Protect from heat, cold, and cuts
b. May reduce dexterity in a rescue situation
4. Helmets
a. Helmets should be worn to protect the EMT from falling objects.
b. Helmets should provide top and side impact protection.
c. Secure chin straps are needed.
d. In electrical hazard situations, wear a chin strap and face shield.
 5. Boots
a. Should be water resistant, fit well, and be flexible
b. Steel-toed boots are preferred.
c. Traction is important for rescue situations.
d. Two pairs of socks are better than one thick pair of socks.
6. Eye protection
a. Wear protective glasses with side shields during routine patient care.
b. When tools are in use, use a face shield and goggles.
7. Ear protection
a. Soft foam industrial-type earplugs
8. Skin protection
a. Protect against sunburn during outside work.
b. Use a sunscreen with a minimum rating of SPF 15.
9. Body armor
a. Bulletproof vests
b. Range from lightweight and flexible to heavy and bulky
c. Vests may not be practical for daily use; they are costly and do not protect against rifle
ammunition or stabling attacks.
10. Long/loose hair, rings, and jewelry
a. Many EMS services have restricted policies regarding hair, rings, and jewelry.
b. You should tie hair up neatly, limit the number of rings worn, and wear only a watch on the
wrist.

VI. Caring for Critically Ill and Injured Patients

A. The patient needs to know who you are and what you are doing.
1. Let the patient know that you are attending to his or her immediate needs.
2. Avoid making unprofessional comments during resuscitation.
3. Treat all patients with dignity and respect.
B. Responses of the critical patient
1. Anxiety
a. Emotional upset
b. Sweaty and cool
c. Rapid breathing
d. Fast pulse
e. Restlessness
 f. Tension
g. Fear
h. Shakiness
2. Pain and fear
a. Pain is often associated with illness or trauma.
b. Fear usually relates to the oncoming pain and outcome of the illness or trauma.
c. Encourage patients to express their pains and fears.
3. Anger and hostility
a. Reactions may be expressed with demanding or complaining behavior.
b. Personal safety is important.
c. Be tolerant.
d. Back out of the situation if the patient becomes hostile.
4. Depression
a. Response to illness, especially if prolonged, debilitating, or terminal, can be physiologic and
psychological.
b. Be compassionate, supportive, and nonjudgmental.
5. Dependency
a. Patients may become dependent due to their helplessness.
b. Remain supportive and compassionate.
6. Guilt
a. When patients are dying, long-term caregivers, family members, or even the patient may
experience feelings of guilt over what has happened.
b. The guilty feelings may result in a delay seeking medical care.
7. Mental health problems
a. Disorientation, confusion, and delusions may develop in the dying patient. Common
characteristics include:
i. Loss of contact with reality
ii. Distortion of perception
iii. Regression
iv. Diminished control of impulses and desires
v. Abnormal mental content
8. Receiving unrelated bad news
a. May be the death of someone close to the patient
b. May cause the patient to give up hope
C. Techniques for communicating with the critical patient
1. Avoid sad and grim comments.
a. Remarks about a patient’s condition may increase the patient’s anxiety or compromise
 recovery.
2. Orient the patient.
a. Use brief statements.
b. Orient the patient to his or her surroundings.
3. Be honest.
a. Decide how much information your patient can understand and accept.
b. Allow the patient to be part of the care being given.
4. Initial refusal of care
a. Impress on the patient the seriousness of his or her condition without causing undue
alarm.
b. If you say, “Everything will be okay,” when it is obvious that it is not okay, you are not
being truthful.
5. Allow for hope.
a. If there is the slightest chance of hope remaining, transmit that message to the patient.
b. It is not your role to tell a patient that he or she is going to die.
c. Let the patient know you are doing everything possible.
D. Locate and notify family members.
1. Assure the patient that you will take care of notifying the appropriate people.
2. This may be a significant part of patient care because it will calm the patient.
E. Injured and critically ill children
1. Children should be cared for as any adult would be.
2. Consider variations in height, weight, and size when caring for pediatric patients.
3. It is important that a relative or responsible adult accompany the child to relieve anxiety and
assist in care as appropriate.
F. Dealing with the death of a child
1. The death of a child is a tragic and dreaded event.
2. Help the family through the initial period after the death.
3. Provide information about follow-up counseling and support services.
G. Helping the family
1. Acknowledge the death in a private place.
2. Shock, denial, and disbelief are common emotions and reactions to a child’s death.
3. If circumstances allow, let the parents hold the child. Use your best judgment to determine if
this is appropriate.
4. Let the family’s actions be your guide.
5. The family may want to see the child, and you should allow them to do so.
6. Prepare the parents for what they will see.
7. Nonverbal communication may be valuable, such as holding a hand or grasping a shoulder.
Silence may be more comforting.
VII. Death and Dying
A. Death is likely to be either:
1. Quite sudden
2. After a prolonged, terminal illness
B. The EMT will sometimes face death.
C. The grieving process:
1. Denial
2. Anger, hostility
3. Bargaining
4. Depression
5. Acceptance
D. What can the EMT do?
1. Ask the patient and family if there is anything you can do to help.
2. Reinforce the reality of the situation.
3. Be honest and sincere.
4. Do not say you know how the patient or family feels.
5. Let the patient or family members grieve in their own way.
E. Dealing with the patient and family members
1. Use special care with dying patients and their families,
2. It is best to be honest; do not give them false hope.

VIII. Stress Management on the Job

A. EMS is a high-stress job.
B. It is important to know the causes of stress and ways to deal with stress.
C. General adaptation syndrome:
1. Alarm response to stress
2. Reaction and resistance to stress
3. Recovery—or exhaustion from stress
D. Physiologic manifestations of stress:
1. Increased respirations and heart rate
2. Increased blood pressure
3. Dilated venous vessels near the skin surface (cause cool, clammy skin)
4. Dilated pupils
5. Tensed muscles
6. Increased blood glucose levels
 7. Perspiration
8. Decreased blood flow to the gastrointestinal tract
E. Situations that are stressful for EMS providers include the following:
1. Dangerous situations
2. Physical and psychological demands
3. Critically ill or injured patients
4. Dead and dying patients
5. Overpowering sights, smells, and sounds
6. Multiple-patient situations
7. Angry or upset patients, family, or bystanders
8. Unpredictability and demands of EMS
9. Noncritical/non–911 patients
10. Hospital wait times
F. Stress reactions
1. Acute stress reactions
a. Occur during a stressful situation
2. Delayed stress reactions
a. Manifest after stressful event
3. Cumulative stress reactions
a. Prolonged or excessive stress
4. PTSD can develop.
a. Characterized by reexperiencing the event and overresponding to the stimuli that recall
the event
b. Critical incident stress management was developed to decrease the likelihood of PTSD.
G. CISM is used to help providers relieve stress.
1. CISM can occur formally.
a. Trained CISM professionals facilitate.
2. CISM can also occur at an ongoing scene.
a. Defusing sessions are held during or immediately after the event.
b. Debriefing sessions are held 24 to 72 hours after the incident.
3. CISM defuses responses to critical incidents.
a. If CISM is not an option, private counseling by a mental health professional may be
preferable.
H. Warning signs of cumulative stress:
1. Irritability toward coworkers, family, and friends
2. Inability to concentrate
3. Difficulty sleeping, increased sleeping, or nightmares
 4. Feelings of sadness, anxiety, or guilt
5. Indecisiveness
6. Loss of appetite (gastrointestinal disturbances)
7. Loss of interest in sexual activities
8. Isolation
9. Loss of interest in work
10. Increased use of alcohol
11. Recreational drug use
12. Physical symptoms such as chronic pain (headache, backache)
13. Feelings of hopelessness
I. Emotional aspects of emergency care
1. Even the most experienced health care providers have difficulty overcoming personal reactions
and proceeding without hesitation.
2. These are normal feelings.
3. Every EMT must deal with these feelings.
4. The struggle to remain calm in the face of horrible circumstances contributes to the emotional
stress of the job.
J. Stressful situations
1. Many situations are stressful for everyone involved.
2. Exercise extreme care in your words and actions.
3. Bring a sense of order and stability to the terrifying chaos that the patient is experiencing.
4. A patient’s reaction may be influenced by personality traits.
6. Give patients the opportunity to express their fears and concerns.
7. Quickly and calmly assess the actions of the patient, family members, and bystanders.
8. It is usually best to transport parents with their children.
9. Uncertain situations
a. Sometimes it is unclear whether a true medical emergency exists.
i. Contact medical control about the need to transport.
ii. If in doubt, transport.
10. Violent situations
a. Violent situations can be created by:
i. Civil disturbances
ii. Large gatherings of potentially hostile people
iii. Domestic disputes
iv. Crime scenes
b. When multiple agencies respond, it is important to know who is in command and will be
 issuing orders.
c. You and your partner must be protected from dangers at the scene to provide care.
i. Law enforcement secures the scene before your entry, or uses the cover and concealment
technique. This involves the tactical use of an impenetrable barrier for protection.
d. Call for additional help if needed.
e. Do not disturb crime scene evidence unless it is necessary to care for the patient.
11. Behavioral emergencies
a. Emergencies that do not have a clear physical cause
i. The cause may turn out to be physical (eg, hypoglycemia, head trauma, hypoxia, toxic
ingestion).
b. These emergencies result in aberrant behavior.
c. Most behavioral emergencies do not pose a threat, but some do, and you must use caution
in such circumstances.
d. Evaluate the patient for behavioral or psychiatric emergency, considering these questions:
i. How does this patient respond to you? Are your questions answered appropriately? Are the
patient’s vocabulary and expressions what you would expect under the circumstances?
ii. Is the patient withdrawn or detached? Is the patient hostile or friendly? Overly friendly?
iii. Does the patient understand why you are there?
iv. How is the patient dressed? Is the dress appropriate for the time of the year and occasion? Are
the clothes clean? Dirty?
v. Does the patient appear relaxed, stiff, or guarded? Are the patient’s movements coordinated or
jerky and awkward? Is there hyperactivity? Are the patient’s movements purposeful—for
example, in putting his or her clothes on? Are the actions aimless—for example, sitting and
rocking back and forth in a chair?
vi. Has the patient harmed herself or himself? Is there damage to the surroundings?
vii. What are the patient’s facial expressions? Are they bland or flat, or are they expressive? Does
the patient show joy, fear, or anger to appropriate stimuli? If so, to what degree?
e. If the patient does not respond, the patient’s facial expressions, pulse, and respirations, tears,
sweating, and blushing may be significant indicators of his or her emotional state.

IX. Workplace Issues

A. Cultural diversity on the job
1. Each individual is different.
2. Communicate in a respectful way.
3. Cultural diversity is an asset.
4. Diversity is an effective way to strengthen a public safety workforce.
5. Understand how to communicate effectively with coworkers from various backgrounds.
B. Avoiding sexual harassment
1. There are two types of sexual harassment:
 a. Quid pro quo
i. Harasser requests sexual favors in exchange for something else, such as a promotion
b. Hostile work environment
i. Jokes, touching, leering, requests for a date, talking about body parts
2. The intent of the harasser does not matter; rather, the perception of the act and the impact the
behavior has on someone else are the key questions.
3. Because EMTs and other public safety professionals depend on one another for their safety, it
is especially important for you to develop nonadversarial relationships with coworkers.
4. Report harassment to your supervisor immediately.
5. Keep notes of what happened and what was said.
6. Confront the harasser if you feel comfortable doing so.
C. Substance abuse
1. Increases risks of accidents and tension
2. Causes poor treatment decisions
3. EMS systems now require their personnel to undergo periodic random tests for illegal drug use.
4. Addicts and alcoholics develop great skills at covering for their behavior.
5. Seek help, or find a way to confront an addicted coworker.
6. Allowing substance abuse to go on presents a tremendous hazard to the public.
7. Employee assistance programs (EAPs) are often available.
a. EAPs provide an array of mental health, substance abuse, crisis management, and
counseling services.
D. Suicide prevention
1. A combination of cumulative stress and acute, intense stress can weigh heavily on EMS
providers.
2. If you or a colleague expresses suicidal ideations, you should seek professional help.
E. Injury and illness prevention
1. Many EMS departments have established injury and illness prevention programs.
2. Each program should include six interrelated and interdependent elements:
a. Management leadership
b. Worker participation
c. Hazard identification and assessment
d. Hazard prevention and control
e. Education and training
f. Program evaluation and improvement