Discussion: Disease Transmission Risks in EMS

[AnthonyM83]

I think a lot of EMT classes don't do an adequate job of going over disease and transmission risks from the job, so let's discuss this here to be better educated about it in the field.

My main concern is usually TB and Hepatitis...the ones everyone seems to freak out about in the field and ER, followed by MRSA.

TB is scarier because you never know when someone with it might start a coughing fit without warning, especially in the back of the ambulance. Hepatitis I believe is a blood-borne pathogen only? so I have a little less concern. MRSA can be passed on skin contact, but less likely to really debilitate you at a young age (what about when you grow older and still a carrier from 40-60 years ago?).

Does anyone have more info on the basics of disease transmission of the common ones we see out there?

[Medic26]

Although in EMT class they really don't cover as much as they should, when you get hired your employers are supposed to get you "trained" for all of the above. Most employers also lack the adequate level of in house training regarding bloodborne pathogens and their own policies on how to handle/prevent exposures.

TB is scary and fairly rare unless you have large prison polulations you serve. Its transmitted in the vapor droplets. Put a mask on the patient if they have a cough and/or put a mask on yourself. Even if its not TB your protected agianst SARS, avian flu or whatever else could be "infecting" them. Hell most of the time its a simple flu or virus anyway. Use that noisy exhaust fan in the back of your bus to keep some air moving.

As far as preventing disease transmission, wear gloves and wash your hands after every run. According to the CDC its the greatest one thing you can do to prevent transmission of any disease, germs, etc.

[Timmy]

I’m one to freak out about disease transmission! I always wear gloves but don’t often wear goggles. The new trend with my service is wearing your goggles on your head/hat like sunglasses, which proved extremely beneficial at a recent rave party I attended when you could pretty much call our first aid room the vomatorium. Even with gloves on your still not 100% safe because of the microscopic holes.

I agree, lack of education! I’m always weary of things like HIV after a scare with a football player (I was in the clear) TB is pretty rare but always a possibility. I keep up to date with my immunizations. I’ve caught the flu off a patient and touch wood it never gets any worse than that! I guess transmission from needle stick injury is a major one.

The thing with standby, if your out in the middle of a Motocross track you really don’t have access to hand washing facilities unless you pour a bottle of water over your hands. My service swears by anti bacterial hand gel (you pour a bit in your hands, rub it around and it dries smells like alcohol). Also isowipes. Are these products beneficial?

To be truthful, I don’t wash my hands after every call, but most of the time I don’t have access unless I go into a public toilet.

I guess you could ask if anyone working in EMS has caught anything from a patient?

[AnthonyM83]

How many of you have the TB vaccine? I didn't even know there was one...apparently it's only 80% effective and only for children, but it came out after WWII...so maybe I did get it? Don't have my childhood medical records...

TB is pretty common around here. Lost track of how many patients we've transported with it...seems like pretty much every homeless person has it...along with hepatitis...(I've gotten the Hep B series, but apparently there's a newer Hep A vaccine too)

[akflightmedic]

The TB vaccine (BCG) has been around for a while and it seems more popular in Euro countries, Canada and parts of the middle east more than the US.

As for the "new" Hep A vaccine, that has been available for any years. One of my old employers used to offer it to everyone along with the Hep B as required by law.

Over here in my current position, we administer Twinrix, which is a combination of Hep A and Hep B vaccine. I probably have given in excess of 1000 of these injections as we vaccinate all employees and the local nationals.

As for TB being transmitted state side in an ambulance, first of all it is not all that common that someone has active TB and is being transported by you. If however you are unsure and a patient is hacking away and has the other factors or symptoms indicating TB, place a mask over them and one over yourself. Turn on the exhaust fans or open the slide window if you have one.

The risk of you catching TB by being in close quarters for that short amount of time is slim, however you should still take reasonable precautions.

[firedoc5]

How many of you have the TB vaccine?

I have. We had 3-5 local patients that were positive for TB, and at least two of them were active cases. So we had a few extra in-services and were vaccinated because of them.

There had always been a history of TB patients around there. In matter of fact there is an old TB sanitarium there left over from the '60's. A hospital there converted it into class rooms and offices.

[VentMedic]

TB: very much alive and active in specific populations but can also be found in all economic types.

Tuberculosis, TB, is caused by bacteria called Mycobacterium tuberculosis.

Multi-drug resistant tuberculosis called MDR-TB is also prevalent in some areas.

The smaller community hospitals may only have one or two inpatients with active TB. Some large county hospitals in the major cities may have easily 5 - 10 active cases as inpatient. The hospital Pulmonary Labs may do 2 - 4 sputum testings per day for AFB, Acid-fast bacilli indicating the presence of Mycobacteria. The clinics may do many more in some regions of the city. Many people can be treated outpatient if they have a home and can be restricted for a few days to that home. The family members are also tested but do not always test positive provided they are healthy and the person infected isn't coughing in the usual "Consumption" manner.

In the hospital, if someone is coughing and I am going to have to be in the potential line of droplet fire, I will be wearing a mask and goggles since there are also many other things that can be in the sputum besides TB that I don't want in my eyes or sinuses. This is especially true when giving a nebulizer and I can not get at least 5 foot between us even with kids. Pertussis is still out there along with a wide variety of viruses. A mask is still advised when in the same room with patients who are coughing forcefully, in a risk group or will be tested for AFB.

Florida still has a state hospital, "sanitarium", for TB for the patients that need confinement during treatment. The links on its website can give you more information about TB.

http://www.doh.state.fl.us/AGHolley/index.html

BCG, or bacille Calmette-Guérin, is used in many countries with a high prevalence of TB to prevent childhood tuberculous meningitis. However, BCG is not generally recommended for use in the United States because of the low risk of infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine’s potential interference with tuberculin skin test reactivity.

Since HIV is again in a resurgence in the U.S. there are still many populations at risk for TB. HIV is now found again in the 20somethings of all economic groups that were born in the 80s and missed the massive public eduation done in the late 80s and early 90s.

I do recommend that you keep the usual vaccinations up to date such as MMR, Tetnas, Hep B and Varicella if your titer is low or not existent. I also recommend following the guidelines for Hep B titer testing.

Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) are viruses.

HCV can live outside the body on surfaces for several days.

HIV is a very fragile virus and does not survive long outside the body.

Now for the very common bacteria; MRSA and VRE. However there are many others including MSSA and MSSE that are not resistant yet but can still be deadly to some patients and is still difficult to treat.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

Mode of Transmission - MRSA is transmitted primarily by contact with a person who either has a purulent site of infection, a clinical infection of the respiratory tract or urinary tract, or is colonized with the organism. Hands of personnel appear to be the most likely mode of transmission of MRSA from patient-to-patient. MRSA can be present on the hands of personnel after performing such activities as wound debridement, dressing changes, tracheal suctioning, and catheter care.

Infection refers to invasion of bacteria into tissue with replication of the organism. Infection is characterized by isolation of the organism accompanied by clinical signs of illness such as either fever, elevated white blood count, purulence (pus), pneumonia, inflammation (warmth, redness, swelling), etc.

Colonization is the presence, growth, and multiplication of the organism without observable clinical symptoms or immune reaction.

MRSA - Colonization may occur in the nares, axillae, chronic wounds or decubitus ulcer surface, perineum, around gastrostomy and tracheostomy sites, in the sputum or urine. One of the most common sites of colonization in both patients and employees is the nose (anterior nares). While personnel may become colonized with MRSA (as they may with susceptible S. aureus), they rarely develop infections.

Reservoirs for MRSA - Colonized and infected patients are the major reservoir of MRSA. MRSA has been isolated from environmental surfaces including floors, sinks, and work areas, tourniquets used for blood drawing, and blood pressure cuffs. Evironmental surfaces should be routinely disfected to reduce the bacterial load.

Healthcare workers can have skin lesions infected with MRSA and should be treated. Decolonization should be considered for those employees with persistent MRSA nasal carriage (ex. chronic sinusitis), especially if the healthcare worker had contact with patients who were subsequently found to be positive for the same strains.

Vancomycin-Resistant Enterococci (VRE)

Enterococci are normally found in the bowel and the female genital tract. When exposed to antibiotics for any reason, the drug-resistant bacteria may survive and multiply, resulting in an overgrowth of drug-resistant enterococci in the bowel, referred to as colonization.

Reservoirs of VRE - Enterococci are part of the normal flora of the gastrointestinal tract and female genitourinary tracts. Most infections with these microorganisms have been attributed to the patient's endogenous flora. However, a recent study found VRE is capable of prolonged survival on hands, gloves, and environmental surfaces. E. faecalis was recovered from countertops for 5 days; the E. faecium persisted for 7 days. Thus environmental surfaces may serve as potential reservoirs for nosocomial transmission of VRE and need to be considered when cleaning equipment.

Most of the bacteria and viruses mentioned may not affect a healthy individual but can be deadly to the next patient you transport if you do not take a few simple precautions. Patients trust you and it is up to you to see that you do them no harm. That means learning about and diligently practicing good infection control. Hand washing and cleaning your equipment between patients should be always be done. Too often I see ambulance crews toss the gloves after patient care and go back to their truck or to the caferteria touching many surfaces along the way.

There's plenty of information in the EMS journals and on some of the EMS websites. The community colleges and various agencies that do healthcare continuing education for nurses and allied health professionals should at least have the mandatory infection control classes which they may be required to show proof of for some employers that do not offer the education such as agencies for contract workers. Some healthcare licenses also require some of the classes.

This question has been asked many times on several EMS forums. It does make one wonder what type of continuing education is being done for people working in EMS. The same goes for HIPAA education. Are any of these things being mentioned in the refresher courses which would be a perfect opportunity instead of reviewing basic anatomy or procedures that the services' training officers should be testing competencies?

[firedoc5]

I have a 12yr. old niece with cystic fibrosis. She has had Methicillin-Resistant Staphylococcus Aureus (MRSA). Luckily in the last year she has tested negative for it. But any time she had a cut, abrasion, moderate to severe bruising, etc., she had to use a special sanitizing gel to keep it from getting a severe infection. One of her older sisters passed away from CF when she was 9. But I don't remember her ever having MRSA.

[Eydawn]

Ventmedic, thank you for that detailed overview! It was really a great read and very informative. Could you address pertussis to a greater extent? From what I saw in Michigan, it was a lot of overreaction, a few isolated cases, and a couple of seniors who really got screwed up time-wise at my college there. Is this typic of its spread? What comorbid factors go along with it?

Wendy

CO EMT-B

[WANTYNU]

TB: very much alive and active in specific populations but can also be found in all economic types. ……..

Most of the bacteria and viruses mentioned may not affect a healthy individual but can be deadly to the next patient you transport if you do not take a few simple precautions. Patients trust you and it is up to you to see that you do them no harm. That means learning about and diligently practicing good infection control. Hand washing and cleaning your equipment between patients should be always be done. Too often I see ambulance crews toss the gloves after patient care and go back to their truck or to the caferteria touching many surfaces along the way.

There's plenty of information in the EMS journals and on some of the EMS websites. The community colleges and various agencies that do healthcare continuing education for nurses and allied health professionals should at least have the mandatory infection control classes which they may be required to show proof of for some employers that do not offer the education such as agencies for contract workers. Some healthcare licenses also require some of the classes.

This question has been asked many times on several EMS forums. It does make one wonder what type of continuing education is being done for people working in EMS. The same goes for HIPAA education. Are any of these things being mentioned in the refresher courses which would be a perfect opportunity instead of reviewing basic anatomy or procedures that the services' training officers should be testing competencies?

Vent,

Excellent post, I was going to add a little bit on possible exposure and incubation times, as just because you were in the same space with an infected patient does not mean you had a likely hood of transmission. I remember reading (somewhere) that you needed to be in close proximity for over 8 hours before you were in danger of contamination with a TB Pos patient. Remember the guy who traveled by plane recently? Many scared people none infected….

But here’s the rub, it’s a little like the lottery, the vast majority of the time, your numbers are not even close, but all you need is that one in a million, and bang, your life is changed forever, so why not reduce the risk whenever you can.

Paranoid? Sure, but better safe than sorry. As was said, we can greatly reduce our risk of exposure, and as importantly, for our trusting patients by following some straight forward practices.

Keep your bus clean (including the FRONT {Steering wheel, knobs, radio mike, etc}), after a transport use fresh sheets AFTER wiping all exposed surfaces down with an approved antimicrobial agent.

Hospital floors are DIRTY, there is no “three second rule” ANYTIME, if you drop anything on the floor, throw it out or clean it before use, never, never, never, I repeat never use (reuse) anything that has touched another patient.

Our patients trust us to do the best we can for them, let’s not betray that trust by infecting them when they have no control to protect themselves.

Wash your hands frequently.

And from a previous post, YES the hand sanitizers really do work, and are mandatory in all NYC hospitals.

Be Safe,

WANTYNU