I belong to a critical care email list. For some time now we have been following the Ebola outbreak in Africa. As of today the “official” death toll stands at almost 700, including 2 doctors, and another expected to die. (with an estimate only 25% infected are receiving medical treatment)
Reports from the area state that at least one of the doctors was infected outside the containment zone and it was attributed to a breach in containment procedures.
In the latest part of the conversation, it was postulated, “how many on the list have actual experience or even training on how to operate in an environment where isolation equipment levels above what is found in surgery or ICU was required.?” “How many of you even have such equipment available?”
Needless to say, there were not many of us. You see, hazardous materials training is part of being a firefighter. It also helps to be at a place that has the county hazmat truck as well as several passionate experts on the topic. But from EMS providers, nurses, doctors, etc, we talk about this stuff in school, but never actually even touch it, much less train on it.
We know the phrase “gloves on! Scene safe!” medical providers do not enter into dangerous situations they tell us in school. We talk about cold zones, warm zones, hot zones, decon, etc, but it is nothing but talk, and it is often taught by people who are just parroting what they were taught, but never actually experienced.
By now, you might have come to the conclusion “that is just a tragedy waiting to happen!”
You are wrong…
It has happened. It is happening. It will happen again. Several years ago, when I actually did public speaking for free, I gave a presentation at a university on Chemical, biological, and radiological emergencies. I even included photos of some of my former coworkers from an event I was part of. I have informally taught many of my EMS partners about seemingly obvious hazards like “don’t park the ambulance in the puddle of flammable liquids at the car accident we just responded to.”
As a plug to my Friend Kip, he started a training class on violence against healthcare providers called DT4EMS. In talking with him on the subject, he noticed that there is a culture of talking about provider violence and safety and people who haven’t experienced his course and material are not only untrained, but in some cases are getting “informal” training from people who have no Fucking idea what they are talking about (It’s my blog I can use any language I want). Those same people often have never had any experience in what they are talking about, no education on it, and never actually did the things they profess. (probably why many of them are not in jail to their benefit).
In my fire/EMS experience I have been a part of more than a few mass casualty incidents, including one internal hospital disaster in a major facility.
The biggest lesson I learned in all of them was: Whoever did the planning obviously didn’t know shit about it nor had any experience, because if they had been present even once, they would realize just how shitty their plan was. We ended operating on basically no plan at all many times, because the plan was completely untenable. Not only that all the fancy equipment they bought, that we never even touched before, was completely useless. In some cases it even inhibited our ability.
Another lesson I learned in these experiences is the whole idea of “hot, warm, cold zones” are not static. Just like in provider safety for violence, what was safe can become unsafe for reasons beyond recognition, planning, and control. Now like many “accidents” there are often several close calls before an actual incident takes place. Since I started talking about people killed by Ebola, what that means there were likely several instances of infection control breeches before somebody actually got infected, and died…
I was no there, so I don’t have anybody to ask: In surgery, the nursing staff, and usually all providers present, immediately identify and correct any perceived sterility breech. Was that common in the Ebola treatment facility? Was anyone supervising provider fatigue? How much training was provided in these operations prior to deploying volunteer healthcare providers? In the austere environment (I have experience there too) the techniques and procedures have to be modified for the environment. Was this done? How?
Back to the presentation I gave on hazardous materials for a minute, I actually have the 911 recording of an organophosphate poisoning which involved a specialized hazmat team which took place on exactly the same day as an organophosphate poisoning in a distant municipality that didn’t have trained or experienced providers. The end result, trained experienced providers handled the situation to a positive outcome for all. The B team had 96 of their own hospitalized after exposure and the initial patient still died. Some 500 off-duty healthcare workers had to be pressed into service to care for their injured coworkers. Fortunately, nobody outside of the initial patient died.
In healthcare we have classes like “Advanced Cardiac Life Support” and all sorts of other merit badge style courses. I estimate 70+% of all providers who take these courses (whether mandated or voluntarily) will never actually be present for an actual resuscitation in their work environment in their entire careers! They are forced to take them “just in case…” Having taught these classes for more than a decade, it has been my observation most of these professional healthcare providers who are not professional resuscitation providers have one goal in mind. To do a few simple tasks that are easy to remember while praying or wishing not that the patient lives, but that an expert comes to help them resuscitate the patient.
How much training have you had in person safety? How much training have you had in hazardous materials? How many times have you actually even seen or touched the equipment? Have you ever put on an SCBA? Do you even know what that acronym means?
How about a “Gumby suit?” Think you could start an IV in one? How about when you are hot, physically exhausted, and hungry? For days? How many of you have thought about rotating your working people or even yourself through rest/rehab periods? Ever have any training on mitigating a mass casualty incident or disaster? Any experience? Do you even know anyone with such?
Would you volunteer to go into an environment not compatible with life with no training or experience? You know, like a fire, chemical leak, underwater, space, or a place where a virus that kills more than 60% on the low end and 90% on the upper end of all those it infects?
As of this writing, at least one person who was infected with Ebola in the outbreak area air-traveled and died in another country. There are people in quarantine on 2 other continents who have flu-like symptoms after returning from the area by air.
I am not trying to spread panic about Ebola. I doubt it is coming here or will affect my life in any way in the near future. But I am writing this to point out a major deficit in medical and healthcare. Because while Ebola may not affect you or I, I have been to organophosphate events, chlorine spill events, fires, floods, tornados, and a few other environments incompatible with life. If you work in healthcare or medicine, I suspect one day you will very likely experience these or similar events and patients.
How does your plan look? Who made it? Ever practice it? Do you have the equipment you will need? Do you know how to use it? Do you even know where it is? Forget helping others, are you able to keep yourself from being a secondary victim?
You may never purposefully travel to a hostile environment on purpose. You may never volunteer to respond to a disaster. You may never resuscitate a patient or family member in your life or even witness one. I’ll bet you never asked to be assaulted by a patient at work either. But any of this could happen on any given day.
Perhaps we need to stop talking about it and actually prepare for it? What do you think?