All posts by kellyg

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!

Essential Gear

Welcome, Newbie. Throw your gear in the rig, sign out a portable radio for yourself, climb in the back with me and we’ll get our supplies inventoried.

I’ll point to the cabinet, call out what we’re supposed to have, and you count. Why? Because I have to do it every shift, and doing it this way helps you figure out where to grab stuff when we ask for it. Don’t ask silly questions, Rookie.

How do I know you’re a rookie? Well, partly it’s that endearingly eager-to-please look on your face, or the fact that you are disgustingly chipper at 0530 in the morning, but mainly it’s that Batman utility belt you’re wearing. The more stuff you have on your belt and in your pockets, the less experienced you are.

Write that down, kid. It’s an EMS axiom.

What’s that? Hey, don’t apologize. The whole eager-to-please and chipper thing is rather endearing, actually, kinda like puppies and baby ducks and Lolcat posters. We expect you to act like a newbie. What you don’t want is to look like a newbie.

So ditch the window punch and the EMS holster and the glove pouch and the oxygen cylinder wrench and the CPR collar pin and the trauma shears and the seat belt cutter and the penlight and the pocket EMS notebook with write-on/wipe-off waterproof pages, and… holy crap, kid, you’re carrying a lot of stuff! What’s in the backpack, a midget doctor for consultations? Just shed all that crap for now. Some of it I’ll let you have back later.

For now, all you really need is a watch, a pen and a stethoscope.

Hold on there, Hero. Not so fast. Not just any watch, pen or stethoscope. Let your friendly Uncle Ambulance Driver offer some guidance on which ones to purchase. Let’s start with the easy one first:

Pens

Yes, I said pens. What’s that? You’ve got one of those fancy tri-color medical pens for more efficient charting? Good for you. Now ditch it. You need one pen color – black. No red, no green, just black. Blue will do in a pinch, but black is better.

And you need more than one, because invariably you will lose one, or break it, or you’ll hand it to a patient to sign something when his hands are covered with their own civilization of yet-to-be-discovered harmful bacteria or cooties, or your partner will need to borrow one…

… which reminds me, can I borrow your fancy tri-color pen? Thanks, I forgot mine this morning.

Avoid felt tip pens, no matter how fine the tip, because the ink tends to bleed through the paper and smudge. Roller balls are okay, but gel tip pens work best. You want something that can easily write on the back of a glove without snagging or tearing through that protective cootie barrier you’re wearing.  You’re going to jot lots of little notes on the back of your hand, and gel point pens tend to work best for that.

Buy a pack of those retractable gel-tip black pens, and keep the spares in your backpack.

The only thing you need to remember is transcribe those notes onto paper before you step out of the rig, because you’re going to strip off those gloves and wash your hands as soon as you end the call, which brings us to the next item…

Watch

Never come to work without a watch. Without a watch, you can’t count a pulse, or respirations, or even tell what freakin’ time it is, and don’t tell me you’ll use the clock on the cardiac monitor. That’s a cop out.

Your watch needs either a back light or luminous hands, because you’re going to be reading it in crappy lighting conditions. It needs to have a second hand, or be a digital watch that displays seconds.

And since you’re going to wash your hands many, many times a day, it needs to be a waterproof watch. Avoid watches with fabric or leather bands, because those materials tend to catch and grow all sorts of nasty bacteria.

Your watchband needs to be metal or plastic, and ideally, you need to take your watch off and wash it just as thoroughly as your hands. After every shift, take it off and scrub it thoroughly with antibacterial soap. Use a toothbrush to get into every nook and cranny.

Um, don’t use your regular toothbrush for that, okay? I know it should go without saying, but you never know with newbies.

If washing your watch all that often seems like too much of a hassle, you might try a fob watch or one that attaches to your stethoscope tubing.


Click the image to take you to a purchase link.
Clicky for the purchase link

Click for the purchase link

If you’d rather have a stethoscope watch, let’s talk about what you’re going to attach it to. It is the most important and most expensive purchase you’ll make:

Stethoscope

When it comes to stethoscopes, cheaper is not better. If you’d rather have a cheap stethoscope that you can’t hear anything with, just use the one on the truck. Most EMS agencies use cheap, poor quality stethoscopes because a) equipment like that tends to disappear and cheaper is easier to replace, and b) they know you’re going to use your own anyway.

If you want a quality stethoscope, be prepared to pay good money for it – upwards of $100 dollars. You may find a bargain here and there in the $50-$75 range, but it’s not likely. My stethoscope was a gift, and it cost over $250 new. I guard it with my life.

Relax, you don’t necessarily need a $250 scope. I have to have one, because my ears suck, and acoustical clarity in stethoscopes does not come cheap. If you have no issues with hearing deficits, a mid-range stethoscope purchase will suit your needs nicely.

The EMS supply catalogs are full of choices, and they all claim to enable you to hear a gnat fart through a down comforter and a foot of cellulite. Caveat emptor, Rookie.

You’re not going to be able to give every stethoscope a test run, so you’ll have to rely on word of mouth and testimonials from other users. For most health care professionals, Littmann scopes set the standard for acoustical quality. You may find cheaper, off-brand scopes, but if you go that route, go for a Littmann clone. Avoid the cheap stethoscopes with hard plastic eartips and thin-walled tubing, and avoid Sprague-Rappaport style, twin-tubed scopes.

A good choice is the Littmann Cardiology III scope:

I purposely didn’t include a purchase link. Shop around for the best price. Sure, at $150 it’s a bit pricey, but it’s a scope you’ll use for your entire career.

My personal preference for stethoscopes are the Puretone scopes made by Doctor’s Research Group (DRG). The acoustical quality seems to be a notch above (in my opinion) of the comparable Littmann models, but you’ll pay a bit more for it. In my opinion, it’s money well-spent.

This is the stethoscope I carry every day:

Ain't she purty?

That’s a DRG Puretone Ti Lite Cardiology stethoscope. It has a titanium head and DRG’s patented External Noise Reduction (ENR) tubing, which really helps filter out the road noise you hear when using a stethoscope in the back of a moving ambulance.

For a comparison, stick a Littmann scope in your ears, and rub the tubing with your fingertips. You hear all sorts of noise. When you do the same thing with a Puretone, you hear next to nothing, because instead of thick-walled tubing, Puretone uses neoprene coated stainless steel springs. It makes a big difference in reducing ambient noise.

Regardless of which brand stethoscope you choose, there are two modifications you can make to any stethoscope that will drastically improve its acoustical clarity.

First, replace your old stethoscopes ear tips with a pair of Gelseal tips by DRG Puretone. They’ll seal better, and you’ll hear better.

Second, replace your stock diaphragm with a disposable, antimicrobial diaphragm. Puretone makes them, but so do many other companies. Heck, they give ’em away as freebies at EMS conferences. Buy yourself a dozen or so (they cost only a few bucks each) and replace them every month.

Remove the chill ring from your stethoscope (that’s the retaining ring that holds your diaphragm in place). It may be a threaded collar, or it may snap into place like an O ring. In any case, remove it, and your stock diaphragm. Put your old diaphragm someplace safe.

Replace the chill ring, and stretch the new, disposable diaphragm over the bell of your stethoscope. You’ll find that the sounds are much louder, but you may have to alter your technique a bit to notice it. Soft diaphragms are more sensitive to pressure, so you’ll have to use a lighter touch to notice the improvement in acoustics.

Be sure to change that antimicrobial diaphragm every month, because there are few things in an ambulance that come into more frequent contact with harmful bacteria than the head of your stethoscope.

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What’s that? You feel naked without all your extra gear? Relax, kid, you’ll get used to it, and you’ll never miss half that stuff. If it helps your confidence, I’ll let you keep your trauma shears. Or even better, try a pair of these:

EMI Rescue Shears, the Swiss army knife of trauma shears.

That’s enough advice for now, Newbie. We’ve got calls to run.

But before we do, be a pal and fetch me a cup of coffee. Black, three sugars. I’d appreciate it.