GERMS THAT KILL

Health-care workers today are more likely than ever to become ill and die from infectious agents. More than 25 percent of the 8,422 people infected with SARS (Severe Acute Respiratory Syndrome) were health-care workers, including firefighters; 229 health-care providers died.1 To protect yourself and your family from known and unknown biological threats, you need to be able to recognize infected patients and avoid germs. With three simple steps, you can be ready for any germ that comes your way. With the shortage of flu vaccine this winter, you’ll need all the help you can get.

Anthrax, cholera, plague, smallpox, and botulism top the Centers for Disease Control and Prevention (CDC) list of most deadly and likely bioterrorist agents.2 While unknown terrorists may be out there, Mother Nature is surely the greatest bioterrorist of all time. Everyday bugs like colds and the flu, chickenpox, measles, pertussis, and meningitis have killed more people than all wars and terrorist acts combined. Influenza (flu viruses) alone kills at least one-quarter million people worldwide every year. Your fire station kitchen or local kindergarten classroom probably has germs that could easily make your whole department ill.

The three steps to keeping yourself and your family safe from germs we know (and new germs yet to be discovered) include increased awareness, enhanced protective measures, and active avoidance plans that prevent outbreaks from spreading.

Step 1: Look Out for Germs

Germs don’t hunt people down and attack; they are transmitted by contact, respiratory droplets, and airborne droplets.3 By far, the most common form of germ transmission is indirect contact, and hands are the leading germ carrier. Hands that touch an infected object or body site (a runny nose, for example) can spread infectious material to another hand, a door knob, a steering wheel, a dish, or a telephone. Your hands carry infection into your body when you touch your eyes, mouth, nose, or other openings. Patient care devices such as thermometers, blood pressure cuffs, oximeter probes, and glucometers carry germs from one patient to another. Children spread more germs than adults by drooling on toys and handing them to others and through their frequent, close physical contact with others.

Direct contact is a more efficient way to spread germs but is less common than indirect methods. Examples of direct-contact infection include blood that enters the body of another person through a cut in the skin, scabies or lice that transfers from a patient directly to the skin of a caregiver, and herpetic whitlow (herpes simplex virus) transferred from the mouth of a patient to the fingers of a health-care provider.

Respiratory droplets emitted with a cough or sneeze or while talking also spread infection over short distances, typically limited to a three-foot radius. These germs infect others by landing in their eyes, nose, or mouth. Pertussis (whooping cough), influenza, colds, SARS, and meningitis are some of the infections spread by respiratory droplets.

Airborne droplets are smaller and of lighter weight than respiratory droplets. They spread infection by staying suspended in the air for long periods of time until inhaled by others. Tuberculosis (TB), measles, and chickenpox are examples of airborne droplet germs.

Objects that might carry germs into a fire station include deliveries (packages), food (the cake delivered by Mrs. Smith or the open bottle of water your partner hands you), air (the HVAC system, SCBA bottles), and blood-contaminated clothing or surfaces of any kind.

To be safe, firefighters need to be able to spot an infected patient before getting too close. Learning the signs and symptoms of every infectious illness seems ridiculous, but there are three flags that can warn you not to approach without protection. The first is high fever, defined as 102°F or higher. SARS gave us a refresher on infectious disease, reminding us once again that the only consistently reliable symptom of serious disease is fever.4 The best way for prehospital providers to measure temperature is by asking the patients if they have a fever. This has been shown to be more reliable than any field temperature measurement device. An equally ominous sign of infection is a rash. Combine fever or rash with your impression of the patient or “look test,” and you should spot the infectious patient every time. Quick summary: Look for high fever or rash and a person who looks really sick.

Step 2: Gear Up

The most essential piece of germ gear is an isolation mask that you can pass to a potentially infectious patient and a family member. Have them put on the mask before you get any closer than three feet. If they need oxygen, put an isolation mask over the O2 delivery device. Don’t give your patient an N95 mask; it filters only inhaled air. Make sure that you and your fellow firefighters have ready access to gloves, hand cleanser, goggles, isolation gowns, and N95 respirator masks and have policies on when to use each of them. Disposable bag valve masks (BVMs), suction equipment, and airways also help to reduce indirect contact spread of infection.

Step 3: Take Aim

A well-thought-out, comprehensive infection control plan can make your fire station a more healthful place to live and work and protect you from falling ill from the next new germ that comes along in your community. I’ll mention a few items to include in your plan.

The first rule of infection control is “wash your hands.” Because your hands are the biggest offenders in spreading germs to you and others, hand washing dramatically decreases illness in community living environments and EMS settings. Alcohol-based hand cleaners are superior to soap and water, unless your hands are dirty.5 Friction is the key to cleaning hands; rub alcohol-based cleaners until your hands are dry, and use at least 15 seconds of friction when washing with soap and water.

The second rule of infection control is “stay away.” When providing EMS, consider every patient a potential source of infection. Limit the number of providers and equipment at every scene to the minimum needed to do the job. If you suspect your patient actually is infectious, limit the number of providers on transport, and by all means don’t create additional exposure potentials unless absolutely necessary. Invasive procedures like IVs, intubations, suctioning, and using nebulizers all increase potential spread of germs to firefighters.

If another outbreak of SARS were to occur this winter, would your department be able to notify responders of disease outbreaks, high-exposure areas, and weekly or daily changes in response precautions? Such an alerting system would be invaluable in a bioterrorist event to confidentially alert members about precautions, treatments, and special operations.

Gloves are helpful to protect responders from potentially infectious material. When misused, gloves merely replace hands as the most common form of indirect germ transmission. How many times have you seen an EMS provider holding a radio, pen, phone, or clipboard with a gloved hand? Gloves are for patients, not equipment.

Give some thought to how and how often you decontaminate vehicles and EMS equipment. It would not be a good news day for the department if your ambulance interior infected several patients. Worse yet, imagine spreading chickenpox from a morning nursery school tour to every patient you picked up later in the day. The same holds true for your station. A dishwasher installed in the fire station can reduce illness by up to 60 percent. Vaccines reduce illness in a similar fashion, both to those vaccinated and their family members and close contacts, including patients they care for. Oddly, despite 36,000 flu deaths each year in the United States, health-care workers have the poorest compliance with flu vaccination.

Keep your guard up for the unusual. Secure all areas of your station not in use. Have a healthy suspicion for strange odors, powders, liquids, packages, and people you don’t know. Secure unattended food and drinks-poisonings are not unheard of in emergency services and health-care facilities. The best advice against poisoning: If it doesn’t taste right, spit it out!

Lastly, educate yourself. Visit Web sites such as the Centers for Disease Control and Prevention and your local or state health department. It never hurts to keep up on current happenings in the world of infectious diseases. What you learn will keep you ready to protect yourself and your family.

References

1. World Health Organization. Communicable Disease Surveillance and Response. Severe Acute Respiratory Syndrome Web site: www.who.int/csr/sars/en/.

2. Centers for Disease Control and Prevention (CDC). Emergency Preparedness and Response Web site: www.bt.cdc.gov/.

3. CDC Draft CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004.

4. Booth, C.M., L.M. Matukas, G.A. Tomlinson, A.R. Rachlis, D.B Rose, et al, “Clinical Features and Short-Term Outcomes of 144 Patients With SARS in the Greater Toronto Area,” JAMA; June 4, 2003 (289) 21.

5. CDC “Guideline for Hand Hygiene in Health-Care Settings,” MMWR; Oct. 25, 2002 (51) RR 16.

MIKE McEVOY, Ph.D., REMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, New York; chief medical officer for the West Crescent Fire Department; and EMS director for the New York State Association of Fire Chiefs. He is a clinical coordinator and an instructor in cardiothoracic surgery at Albany Medical College in New York and a member of the editorial advisory boards of Fire Engineering and fireEMS.

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