Real World BSI for the EMS Newbie

In Episode 5 of the podcast, Ron and I talked about his first clinical rotation, in which he assisted with an Incision and Drainage procedure.

In it, I chastised Ron for not wearing a face and eye shield during the procedure. Sadly, this is an area of infection control often neglected by health care providers, myself included.

Aaron the Truck Driver summed it up nicely in the comments to that post, by cribbing a few lines from a Jim Croce song:

You don’t spit into the wind
You don’t pull the mask off an ‘ole Lone Ranger
And you don’t mess around with an abscess without goggles.

In EMT class, I’m sure you’ve learned to chant the mantra reflexively before every skill station, “BSI precautions. Is my scene safe?”

And for the most part, no one really addresses what BSI really means. To practice effective Body Substance Isolation, you must protect yourself with barrier devices that protect against all the easy routes of infection.

That means wearing your gloves and eye protection, kiddies.

When it comes right down to it, your skin is a very effective infection barrier… when it’s intact. Problem is, your skin is rarely intact. Look around your nail beds and cuticles, for example. There are usually tiny little breaks in the skin there, from worn or untrimmed cuticles, hangnails, what have you. All of these little openings are potential routes of infection for health care providers.

That’s why we wear gloves during most patient encounters, to provide an extra layer of protection for our already very effective infection barrier of intact skin.

But gloves do nothing to protect you against the EASIEST route of infection into your body – your mucous membranes.

To protect against that very real threat, you must wear face and eye protection whenever you are near splashing bodily fluids. It’s not a joke. I know a number of people who contracted hepatitis C or HIV through blood spattering into their eyes. I’ve had at least one colleague die from it.

20 years ago, that colleague didn’t realize those few droplets that washed right out would one day be a death sentence, but they were.

Glasses and face masks are hot and uncomfortable, and may limit your vision while working. They’re, quite frankly, a pain in the ass to wear.

But that pain in your ass will disappear as soon as you take them off. Infectious hepatitis or HIV will not. Drug-resistant tuberculosis will not.

Wear your eye protection!

Back before we understood the germ theory of disease transmission, surgeons often went from one procedure to another, one patient to another, without washing their hands. Infection in hospitals was rampant.

One such surgeon, Baron Joseph Lister, noted that babies delivered by midwives had a lower mortality rate than those delivered by surgeons, and correctly surmised that it was because midwives washed their hands more often. He ordered the surgeons under his supervision to wash their hands thoroughly between patients with 5% carbolic acid, and to sterilize instruments with it. He made them wear clean gloves, and spray the carbolic acid solution in the operating theatre.

Infection rates plummeted.

Thus, Lister became known as the father of modern antisepsis, and changed the way we view sterility in medical care.

And yes, he’s the guy Listerine is named after. Don’t go trying to gargle 5% carbolic acid, though.

Now, what does all this hand washing business have to do with you as an EMT, you ask? “I wash my hands after every single patient!” you may say.

If that is true, then I salute you. But do you actually know how to wash your hands? Like most things, there is a right way and a wrong way to do it:

The video pretty much covers it, but I’ll add a couple of things: if you were to swab and culture any surface in a bathroom, the most bacteria-laden surfaces you will find are the door handles and faucet handles. They’re nastier, even, than the toilet seat.

When you think about it, those are the very last things anyone touches before they wash their hands. So, to avoid touching them with your newly-washed hands, turn off the faucet using the paper towels you just used to dry your hands, and use them to open the bathroom door.

Pitch them in the garbage can like a good citizen, and back-heel the door closed behind you.

If you work in a fairly busy system, you may find yourself washing your hands often enough that they become chapped and cracked. If this happens to you, invest in a personal bottle of hand sanitizer that has lotion and moisturizers in it.

If you practice in class like you play in the field, you’ll probably put on gloves hundreds of times throughout your EMT class.

But I’d be willing to bet you’ve never practiced taking them off.

I ask you, what good is an effective infection barrier if you only contaminate yourself when you remove it?

Try this little experiment the next time your EMT study group meets:

1. Have everyone don exam gloves.

2. Now, using stage blood (your instructor probably has some in their moulage kit, and if not, shaving cream will do), spread the liquid over the entire surface of your hands, top and bottom, between the fingers, etc., all the way up to the cuff of the gloves.

3. Now try to remove your gloves and place them in a biohazard waste can without getting blood on your bare skin.

Every time I’ve done this exercise in an EMT class, there are some students who not only manage to get “blood” on their hands, but also on their mouths, teeth, face, clothing, and the wall near the trash can. You name it, they get blood on it.

There is a way to remove gloves without contaminating yourself and your surroundings, but I won’t tell you what it is. It’s your job to find it.

Research, after all, is part of your EMS education, too!

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  • Steve

    Another excellent post. I will admit that I am one that neglects the face/eye protection.

    Now, I don’t know if Ron’s class or any of the reader’s class includes any supplemental OB time (I know some instructors will add the requirement of witnessing a birth) but let me throw this nugget of information:

    Birth’s are messy and a few are best decribed as “explosive”. Having witnessed the birth of both of my children prior to my start in EMS, I was cocky going into my OB clinicals during Medic school. “I got this” I would say. Gowned up and face shield on, I was shoulder to shoulder with the OB/GYN. It was nothing like the birth of my children and to this day, I still have no idea how in the world I ended up covered in every form of human excrement imaginable. A fine layer of mist on the face shield and that yellow gown looked like I was in a fight with spray paint. And my God the smell! Getting sprayed by a skunk would be about the best way of masking that odor.

    Guess what you’ll find taped to the OB kit in my ambulance now?

  • Steve

    Another excellent post. I will admit that I am one that neglects the face/eye protection.

    Now, I don’t know if Ron’s class or any of the reader’s class includes any supplemental OB time (I know some instructors will add the requirement of witnessing a birth) but let me throw this nugget of information:

    Birth’s are messy and a few are best decribed as “explosive”. Having witnessed the birth of both of my children prior to my start in EMS, I was cocky going into my OB clinicals during Medic school. “I got this” I would say. Gowned up and face shield on, I was shoulder to shoulder with the OB/GYN. It was nothing like the birth of my children and to this day, I still have no idea how in the world I ended up covered in every form of human excrement imaginable. A fine layer of mist on the face shield and that yellow gown looked like I was in a fight with spray paint. And my God the smell! Getting sprayed by a skunk would be about the best way of masking that odor.

    Guess what you’ll find taped to the OB kit in my ambulance now?

  • http://happymedic.com the Happy Medic

    I hear “BSI DCAPBTLS” out here and not a single person can tell me what it means other than “autofail.”
    I prefer using the phrase, “I’ll don gloves gown and goggles as necessary…” Seems to cover the bases and keep the appropriate items fresh in my mind.

  • http://happymedic.com the Happy Medic

    I hear “BSI DCAPBTLS” out here and not a single person can tell me what it means other than “autofail.”
    I prefer using the phrase, “I’ll don gloves gown and goggles as necessary…” Seems to cover the bases and keep the appropriate items fresh in my mind.

  • http://oregonemtstudent.blogspot.com Brad

    @HappyMedic
    I am a Basic student and I can tell ya what BSI and DCAP-BTLS means :D

    BSI: Body Substance Isolation (gloves,mask,goggles,gown)
    DCAP-BTLS: Deformities Contusions Abrasions Punctures Burns Tenderness Lacerations Swelling

    My instructor drummed that into our heads “If you’re going to be using acronyms and abbreviations, you damned well better know what you are saying!”

    @AmboDriver
    The proper way to take off gloves is to remove one completely inside out, ball it up with your other gloved hand, and remove that one inside out as well. Self contained and non contaminating :)

    Regards
    ~Brad
    @EMTGoose

  • http://oregonemtstudent.blogspot.com Brad

    @HappyMedic
    I am a Basic student and I can tell ya what BSI and DCAP-BTLS means :D

    BSI: Body Substance Isolation (gloves,mask,goggles,gown)
    DCAP-BTLS: Deformities Contusions Abrasions Punctures Burns Tenderness Lacerations Swelling

    My instructor drummed that into our heads “If you’re going to be using acronyms and abbreviations, you damned well better know what you are saying!”

    @AmboDriver
    The proper way to take off gloves is to remove one completely inside out, ball it up with your other gloved hand, and remove that one inside out as well. Self contained and non contaminating :)

    Regards
    ~Brad
    @EMTGoose

  • http://tooldtowork.blogspot.com totwtytr

    In addition to faucet handles and door knobs, don’t forget the handle on the paper towel dispenser. That’s assuming it doesn’t have one of the 747 jet engine warm air driers or an automatic paper towel dispenser.

    Remember EMS Rule #5. Wash your hands before you use the bathroom.I don’t know about you, but I put my hands in plenty of places where I wouldn’t put my wedding tackle, but I never, ever, put my wedding tackle somewhere that I wouldn’t put my hands.

  • http://tooldtowork.blogspot.com totwtytr

    In addition to faucet handles and door knobs, don’t forget the handle on the paper towel dispenser. That’s assuming it doesn’t have one of the 747 jet engine warm air driers or an automatic paper towel dispenser.

    Remember EMS Rule #5. Wash your hands before you use the bathroom.I don’t know about you, but I put my hands in plenty of places where I wouldn’t put my wedding tackle, but I never, ever, put my wedding tackle somewhere that I wouldn’t put my hands.

  • OrdoPM

    on a side note… DCAP-BTLS used to be summed up as simply crepitus and deformities.

  • OrdoPM

    on a side note… DCAP-BTLS used to be summed up as simply crepitus and deformities.

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