Emergency medical service(s) (EMS) personnel receive training in scene operations and safety during the didactic portion of their training. The training covers the events and concerns in normal EMS response, such as motor vehicle accidents, acts of violence, and electrical hazards, to name a few. Despite this training, prehospital personnel are still injured or killed in the line of duty every year. A study in the Annals of Emergency Medicine places the fatality rate of EMS workers at 12.7 fatalities per 100,000 workers, compared with 5.0 fatalities per 100,000 workers for the general population. Because of poor data collection, less is known about EMS injury rates compared with those of other public safety personnel, although a study by the Rand Corporation that examined injury rates for all public safety personnel does address the subject. Ten emergency medical technicians (EMTs) and paramedics were killed at the September 11, 2001, World Trade Center (WTC) disaster, and at least 116 were injured.
Responding to a disaster presents a unique set of circumstances usually not found in normal daily work situations. Depending on the type of disaster, this could include secondary collapse of structures, operating in unfamiliar surroundings, exposure to smoke and dust, fatigue and dehydration, lack of or disregard for safety equipment, and a host of other hazards. Disasters that result from acts of terrorism present unique challenges in that terrorists may actually want to injure first responders and medical personnel. Both volunteer in-hospital personnel who respond to a disaster because of its proximity to a work site and EMS personnel called to respond to a disaster must be cognizant of the hazards and risks associated with such a response and be prepared to take measures to mitigate those risks. Responders who get injured or incapacitated add to the burden of other public safety personnel who must treat them as well as those injured in the original incident. Medical responders who become injured reduce available resources to the original victims.
Historical perspective
Health care personnel, both prehospital and hospital-based, have routinely responded to disasters with little regard for their own safety. One only has to look at the media coverage surrounding the 2013 Boston Marathon Bombings to understand the risks the hospital personnel faced, thinking they were going to be treating running-related injuries instead of the blast injuries associated with two lethal shrapnel bombs detonated near their aid stations at the finish line of the race. If the second bomb had detonated 10 minutes later, when the area was covered with health care personnel treating victims from the first bomb, there is little doubt there would have been casualties from among their ranks. The body of literature on disaster medicine and management both in the United States and internationally is considerable, but little of this literature deals with the safety of emergency medical responders. Formal prehospital care has been evolving for four decades, with better training programs, teaching methods, and protocols; however, safety training and equipment for in-hospital medical responders have lagged behind.The formal Incident Command System (ICS), even though in use since the 1970s for some fire services, has only recently become a true component of health care operations. EMS agencies have been slowly adopting the ICS during the last 10 years, and the hospital community conducts formal training, as mandated by The Joint Commission and reinforced by the National Incident Management System codifying a hospital’s role in disaster operations. , Within the ICS and reporting directly to the incident commander is the incident safety officer (ISO), who has final authority over all operations in regard to responder safety. However, historically this organizational structure has not always been effective, especially when it comes to disasters. In large disasters, a single safety officer often does not have enough resources to control the large number of responders, including volunteers, who arrive wholly unprepared for the tasks ahead. In the WTC terrorist attack on 9/11, it was observed that “physicians dressed only in scrubs, clogs, and surgical masks attempted to negotiate the jagged metal debris to carry out their well-meaning medical interventions.” In some situations, firefighters gave up their own personal protective equipment (PPE) to protect the volunteers.
Many hospitals have had “crash boxes” of essential medical and surgical equipment for out-of-hospital response for years, but rarely has the equipment included safety gear other than a vest and hard hat. Clinical personnel from hospitals have routinely responded to disasters—and still do as witnessed during the Boston Marathon attacks—with little or no safety training and even less PPE appropriate for the type of incident. In the 1995 bombing of the Murrah Federal Building in Oklahoma City, a volunteer nurse dressed only in jeans and a sweatshirt suffered a fatal head injury from falling debris. With the vast volume of literature that has come out after the 9/11 attacks, a true understanding of the problem of keeping responders safe has now come to light.
Current practice
The current practice of scene safety for disaster response is still evolving, largely in response to review of the 9/11 disaster. The Rand Corporation, in concert with the National Institute for Occupational Safety and Health (NIOSH), has published several reports that attempt to broaden the knowledge base of this problem. Rand and NIOSH undertook more research into the problem, publishing Emergency Responder Injuries and Fatalities , which highlights the types and causes of injuries to public safety personnel while also citing the lack of adequate methods for tracking EMS personnel in injury data. They offer suggestions on how to capture better data on EMS injuries and fatalities. Three other volumes look at the problems faced with protecting public safety personnel when they respond to disasters and offer solutions to better protect those personnel.
Still, more effort needs to be expended in understanding how disaster response is different from situations normally encountered by both EMS and hospital personnel. Auf der Heide argues that the difference between the normal mission of emergency response and disaster response is not just one of magnitude managed by bringing into play larger numbers of people and equipment, but rather the interplay of a variety of factors. In normal response situations, responders might be exposed to a minimal number of hazards or risks, usually for a very short period. In contrast, in disaster operations, responders may be exposed to multiple hazards and risks for prolonged periods and often without adequate rest ( Box 39-1 ).
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Large geographic scale
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Unfamiliar environments and surroundings
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Falling debris
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Secondary collapse of damaged buildings
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Exposure to hazardous materials
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Excessive noise from machinery and equipment
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Adverse weather
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Inadequate PPE
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Debris fields, causing fall or trip hazards
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Convergent volunteers
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Secondary explosive devices planted by terrorists
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Secondary events following natural disasters (tsunami or firestorm following earthquake; levee break following hurricane)
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Prolonged duration, causing excessive fatigue, lack of sleep, and inadequate food and hydration
Large Geographic Scale and Unfamiliar Surroundings
In most emergency medical responses, activities are confined to a small area. Responders can readily identify hazards, see who else is responding, quickly estimate the extent of the emergency, and get a sense of how many victims there are. In disasters, especially natural disasters, the geographic scale of the disaster may be overwhelming. The destruction from Hurricane Andrew in Florida and Louisiana in 1992 covered more than 1000 square miles. In late 2004, a tsunami in southeast Asia spanned a vast area over three continents. The disaster area from Hurricane Katrina in the southeastern United States in 2005 covered an area of 90,000 square miles over three states. Because of the possible large geographic scale and the loss of familiar surroundings that can occur during a disaster response, it may be difficult to request assistance if responders are not certain of their surroundings. They may be unable to see hazards that could affect them but are not in their immediate field of vision. The large geographic scale may also mean that responders are on-scene for many hours, days, or even weeks as they work to ameliorate the effects.
It is reported that after the 9/11 terrorist attacks in the United States at least “six federal and municipal fire and EMS departments, three private ambulance services and a number of volunteer fire departments and ambulance squads responded to the Pentagon” and that an ambulance as far away as Texas responded to the WTC disaster. , Even though these efforts can be commended, responders unfamiliar with the local surroundings can present safety problems. Finding the way to a staging area or to the scene of a disaster will take more effort for personnel responding from long distances than it will for local units. Responders unfamiliar with the area can inadvertently end up in locations that might contain hazardous materials, as happened during the Hurricane Andrew response. Even local responders can have difficulty navigating unfamiliar surroundings if local landmarks and signs have been destroyed and traffic signals are not functioning because of power outages, which also occurred during the Hurricane Andrew response. Complicate this with the fact that during the initial stages of a disaster, the public may be evacuating the area, causing highway congestion that can contribute to motor vehicle accidents. Responders unfamiliar with the area may not be aware of alternative routes to arrive at their assigned destination if roads are blocked or cannot be navigated because of damage or debris. Hospital personnel who respond to disaster sites are generally not familiar with operating in situations with little light, limited resources, and multiple hazards. Escape routes and safe areas may be difficult to find for those not accustomed to operating in a particular area. Electrical hazards, a problem even when responders are familiar with the area, become more of a problem in unfamiliar surroundings when responders who are trying to orient themselves might not be as vigilant as they normally would be and could walk or drive into hazards, such as live electrical wires. It is essential for responders to ensure that they know where they are going, how to find alternative routes if original routes are blocked, and how to contact coordinating agencies if they become lost. Global positioning systems offer hope in allowing response units to navigate unfamiliar territory. It may be difficult to obtain maps in the early phases of a disaster, but having a map of the area is advisable, even if it is hand-drawn.
Falling or Flying Debris
Debris from buildings damaged during the initial disaster impact or debris that is dislodged by rescue operations can be a problem. Medical personnel on-scene who are focused on treating patients may not be aware of hazards overhead, and noise from equipment operating at the site can mask the sound of the debris as it falls. Appropriate head and eye protection is critical for all personnel at the scene. The typical eye protection provided to health care workers for body fluid splashes offers little protection in a dusty or smoky environment, as was found during the 9/11 response actions; more than 1000 eye injuries were reported during the first 10 weeks of response operations.
Secondary Collapse of Damaged Buildings
Buildings that survive the initial shock in earthquakes can collapse because of aftershocks or from rescue efforts. WTC Building 7 did not collapse until after 5 pm on 9/11, almost 8 hours after the first plane struck one of the towers. Responders who plan to set up triage or treatment stations in buildings should first ensure that the buildings have been deemed safe by building engineers or ISOs and are at a safe enough distance from other damaged buildings in the event of collapse. Escape routes and safe zones should be determined when operating in the vicinity of damaged buildings.
Exposure to Hazardous Materials
There is always a risk of unintentional hazardous materials exposure at every disaster site. Intentional hazardous substance exposure through terrorism is covered in other chapters of this text, but hazardous materials are ubiquitous and can be found in hospitals, laboratories, railways, universities, and transportation centers, to name a few. During earthquakes, underground pipelines or aboveground storage tanks may be damaged, leaking hazardous, often flammable materials into the environment. Buildings damaged during explosions or earthquakes may have leaking fuel tanks, or chemicals used in manufacturing processes may leak or mix together to form new, more toxic compounds.
Exposure to smoke, dust, and other airborne contaminants represents a major problem in disasters where there are large fires or when buildings collapse. NIOSH continues to study the effects of smoke and dust on rescue workers from the 9/11 attacks. Shortly after the attack, NIOSH found that 60% of a subset (1138) of study participants who were evaluated on July 16 and December 31, 2002, suffered from new-onset lower respiratory symptoms, while 74% reported new-onset upper respiratory symptoms. New York City reported that twice as many EMS workers who were at the scene of the 9/11 attacks have below-normal pulmonary function tests for their ages 6 to 7 years after the exposure, even among those who never smoked. Among smokers, the decline in pulmonary function is even more pronounced. Proper PPE must be available and its use mandated on-scene by the ISO, and all disaster responders should have at least hazardous materials awareness training before venturing into disaster scenes. When in doubt about a situation, wait for special operations teams who have testing devices that can determine whether the scene is safe for operations.
Excessive Noise from Machinery and Equipment
Depending on the nature of the disaster, heavy equipment may be needed to facilitate the response. This equipment may create excessive noise either through the exhaust or from moving debris. This noise makes communication with other medical team members difficult and may make it difficult to hear warning signals indicating aftershocks, secondary explosions, etc. Although wearing hearing protection is advisable, it creates similar limitations. Hearing protection is also usually designed for blocking high-frequency noises and not the low-frequency noises associated with heavy equipment. In addition, it is difficult to hear radios and other communications devices while wearing the protectors.
Adverse Weather
Because health care workers generally dress for their immediate shift, they may be unprepared to deal with the prolonged nature of disasters. EMS workers accustomed to short-sleeve uniform shirts for daytime wear in the summer might find themselves getting chilled by evening, and hospital personnel who respond in hospital garb might be unprepared for sudden rainstorms. Responders to the Oklahoma City bombing had to deal with temperatures that fluctuated from 80 to 40 °F, strong winds, rain, and lightning. Health care workers both in and out of the hospital who might be called on to respond to disasters should have clothing appropriate for a wide range of weather conditions, including cold-weather gear and raingear.
Inadequate Personal Protective Equipment
EMS and hospital workers are commonly not well prepared and inadequately trained for disaster response when it comes to using PPE. Administrators’ budgets are often thought to be too lean to spend money on something that happens infrequently and requires a large outlay of funds and training time. It is also suggested that because there is no central federal authority responsible for monitoring PPE for medical response personnel, unlike firefighters and the National Fire Protection Agency (NFPA), funding from government sources for PPE is lower. Even NFPA’s Standard on Protective Clothing for Emergency Medical Operations only deals with exposures from body fluids and not the types of hazards likely to be encountered in disaster operations. Experiences from recent disasters indicate that even with good PPE, the multihazard nature of disasters makes it difficult to have the right equipment all of the time. In a disaster environment, PPE must not only protect the wearer from blood-borne pathogens but also offer protection from other disaster-specific hazards. In addition, because of the extended nature of disaster response, agencies must be able to replenish PPE as it wears out, becomes wet, or breaks down from exposure to chemicals. The duration of effectiveness of filtration canisters on respirators is related to the particulate load, and thus canister replacements may be necessary more frequently than posted during heavy use periods.
The multiagency response aspect of disasters can also make the sharing of equipment difficult. With multiple standards for PPE across public safety entities, the chance of cross-agency compatibility of PPE is small. PPE that might be adequate for firefighting is generally not acceptable for the treatment phase of patient care, although it might be appropriate for the patient access phase. Having access to bunker gear is not the answer either, as experiences have indicated that too often bunker gear is too heavy and cumbersome for the prolonged response required to deal with disasters.
Eyewear designed to prevent exposure to body fluids is not adequate when removing patients from rubble piles in high-dust environments. Face shields or glasses designed to offer splash protection may not be appropriate in situations in which dust or smoke can penetrate the sides of the glasses or shields. Safety goggles of the kind used in construction may be more appropriate, although they may be uncomfortable for prolonged periods, may fog, and can hinder peripheral vision. Resources should be available for rinsing off glasses because dust and dirt particles can lead to scratched lenses, hindering visibility. Many medical responders are not issued hand protection that complies with Occupational Safety and Health Administration (OSHA) standards for protection from “absorption of harmful substances; severe cuts or lacerations; severe abrasions; punctures, chemical burns; and harmful temperature extremes.” Gloves designed to protect against bloodborne pathogens, even though appropriate for general patient care, should be worn underneath a more durable glove when operating in the multihazard environment often encountered in disaster situations; leather is not advised because it absorbs water and cannot be decontaminated. A glove that resists wear, cuts, and punctures but is pliable enough to provide treatment is necessary.
Relying on other agencies or resources to provide adequate equipment is not advised. The different agencies responding to disasters use a variety of brands and models of equipment, making compatibility with respirators, face masks, and cartridge filters not guaranteed. Responders should not use equipment offered by others without at least some training in its use ( Box 39-2 ).
Related posts:
Role of Emergency Medical Services in Disaster Management and Preparedness
Psychological Impact of Disaster on Displaced Populations and Refugees of Multiple Traumas
Nongovernmental Organizations in Disaster Medicine
Worker Health and Safety in Disaster Response
Community Hazard Vulnerability Assessment
Operations and Logistics
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