WHAT IS THE RISK?
February 7, 2012
Emergency Medical Dispatchers (EMDs) often handle seemingly commonplace emergencies. Lift assists, fender benders, interfacility transports, and other calls have a tendency to lull the calltaker into a comfortable rhythm. Add accidental dials, hang ups, wrong numbers, and the occasional preemptive citizen programming 9-1-1 into a phone call, and a calltaker may feel almost robotic in the work routine.
Still, there seems to be that occasional call that snaps the EMD out of the comfort zone. Usually, it’s that unspoken sense of true urgency or unique tone of focused panic in the caller’s voice that pulls the EMD to the edge of the chair. Something intuitively cues the calltaker that this is a chance to make an indelible difference in someone’s life. For most dispatchers, it’s a part of what draws us to this profession. However, sometimes it’s an unpredictable curveball that catches us off guard and sends us to the breakroom with more questions than answers.
Last April, I took a call for a 19-year-old HIV-positive patient who was unconscious with agonal breathing. While attempting to open the airway, I instructed the caller to clear the mouth and nose of vomit. The caller stalled and said, “Don’t I need gloves on? He’s HIV positive.” Although I had provided CPR instructions many times before, this was the first time I had to consider protecting the caller from infectious disease while still helping a dying patient. I felt the seconds slipping by and answered, “Take whatever precautions you think are necessary.” With divine timing, paramedics walked in the door seconds after. I knew I’d caught a break.
Truthfully, that curveball left me feeling about as confused as a cow on Astroturf. A myriad of questions bombarded me: What was the actual risk to the caller? What personal protective equipment (PPE), if any, does a caller have available? Is it reasonable to expect the caller to do CPR without PPE? Vomit wasn’t a risk. . .or was it? What was the right verbiage? Does my protocol address this? If so, where? There must be a better way to handle such situations. Hopefully, this article will serve as a guide should you find yourself handling a similar situation someday.
Disease and responder risk
Hepatitis and HIV top the list when most think of infectious diseases. However, other common infectious diseases include tuberculosis (TB), clostridium difficile (C-diff), and particularly-resistant staph infections (namely MRSA, VRSA, VISA).1 These diseases may be transmitted when an individual makes intimate contact with certain bodily fluids of the host. Blood is the obvious concern, but other potentially infectious bodily fluids include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, and amniotic fluid.2 An infection can occur when these fluids are absorbed through mucus membranes, sexual intercourse, or a break in the skin. Nasal secretions or sputum, when inhaled, often transmit respiratory diseases. Hepatitis A can be transmitted through the ingestion of food or water contaminated by fecal matter. Less infectious fluids include sweat, tears, urine, or vomit, unless contaminated by visible blood. Saliva is typically not assumed to be infectious except under certain circumstances like dental procedures that create pathway to the bloodstream. While modes of infection are varied, an easy guideline to follow is that all bodily fluids, especially those contaminated with blood, should be considered potentially infectious.3
The threat of infection is mitigated through universal precautions. The Centers for Disease Control and Prevention (CDC) recommended universal precautions in 1987 in reaction to the AIDS crisis.4 The intent was to protect healthcare workers from infection.Universal precautions are simply steps first responders take to protect themselves from infectious diseases. Universal precautions include hand sanitation, use of PPE, and safe disposal of needles or other sharps. Risk assessment plays an important role in determining what PPE is necessary.5 Think of the type of fluids present in terms of their potential splash risk. Gloves should always be worn when in direct contact with fluids, i.e. clearing the mouth and nose. A gown, goggles, face shield, or CPR mask may be appropriate as the situation warrants. Be sure to cover any open cuts, abrasions, or open skin of the responder with a waterproof bandage if an infectious disease is present.6
Accidental needle sticks, lacerations, or splashes (no matter how minor) should be brought to the attention of the responding paramedics. Alternatively, the PEPline (National Clinicians’ Post-Exposure Prophylaxis Hotline) (1.888.448.4911) is a great resource. They’re staffed 24/7 with clinicians who can provide expert instructions for accidental needles sticks, splashes, or other exposures to common blood-borne pathogens.7
Risk to the caller
False assumptions and lack of understanding on proper treatment can lead to tragic results. However, the patient, not the caller, most often encounters the risk. Take the tragic case of Claude Green, for example:
Claude Green was driving through Welch, West Virginia, with his friend, Bill Snead. Green suffered a heart attack while driving, but Snead grabbed the wheel as Green became unconscious. Once the vehicle was safely stopped, Snead started CPR. Shortly thereafter, Police Chief Robert Bowman was the first to arrive on scene. Welch is a small town of approximately 2,400 residents and the chief apparently knew Green.
Specifically, Bowman knew Green was gay. Chief Bowman ordered Snead to stop CPR because he believed Green was HIV positive. When Snead continued chest compressions, Bowman reportedly pulled Snead away and told him to sit on the curb. Snead remembered Green had started to breathe before he was forced to stop CPR.8 Green reportedly went without potentially life-saving CPR for around 8–10 minutes.9
Once EMS arrived on scene, they picked up where Snead had left off. Again, Bowman warned them to be careful since Green was HIV positive. EMS relayed the need for universal precautions to the hospital upon transfer because of the presence of HIV. The problem: There was no risk.
Tragically, Chief Bowman had assumed Green was HIV positive because of his sexual orientation; he was wrong. Green was pronounced dead at the hospital after CPR was attempted for roughly 30 minutes. The ACLU sued Chief Bowman and the City of Welch for wrongful death on behalf of Green’s family although Bowman disputes that he refused Green CPR.10
Even if Green had been HIV positive, the odds of contracting an infectious disease through simple CPR are extremely low. It is well documented that the fear of contracting a disease has caused significant reluctance on the part of lay rescuers to perform mouth-to-mouth resuscitation (a Refused Mouth-to-Mouth pathway is available in the MPDS). Documented cases of actual infection are rare. When they have occurred, the infections have been the result of more invasive procedures by professional rescuers, not laypersons performing simple CPR. In fact, there are no documented cases of a person contracting HIV while providing simple CPR.
The Green case illustrates how a lack of action (omission) is often more litigious than a well-meaning attempt to provide care. This phenomenon was well documented in the early years of pre-arrival instructions when public safety agencies refused to provide remote care out of fear of liability and were conversely sued for not providing care. An often overlooked fact, considered seriously in civil law, is that a call to 9-1-1 is an implied call for help. The EMD is obligated to provide that help in the form of response and instruction and is not liable for damages associated with medically-approved instruction, provided no negligence is involved. A bystander, family member, neighbor, or any other citizen caller is under no legal obligation to provide help as instructed by an EMD, and the individual may refuse to do so. However, the call must be considered a call for help and, therefore, a duty to act by the EMD becomes compulsory.
A final consideration involves the notification of responders or other healthcare providers regarding a known infectious disease diagnosis. While the transmission of information to another healthcare provider regarding a patient’s medical history is considered part of a patient care report, and is not generally considered a breach of patient confidentiality, singling out a particular disease for such a transmission of information may be considered a violation of a patient’s civil rights. Therefore, a policy or practice involving a responder notification such as, “Use universal precautions,” for patients with a particular disease can actually be litigious in and of itself, and the measures taken for potential benefits could be more harmful than the risk it is meant to prevent.
Case in point: An EMD takes a “sick person” call from a residence and learns that the patient is HIV positive. The information is relayed to a first-responding police officer who, in turn, informs the arriving paramedics. Unfortunately, the patient’s landlord is within earshot. While the patient is en route to the hospital, an eviction notice is being prepared. The police department is then accused of breaching patient confidentiality, resulting in a violation of civil rights.
Field responders are taught that universal precautions are to be applied universally. The Centers for Disease Control and Prevention recommends: “Wherever patient care is provided, adherence to infection prevention guidelines is needed to ensure that all care is safe care.” Notice that this advice is not limited to a particular disease(s) and certainly should not be, since the presence of an infectious disease is not always known.
Infectious diseases pose a very minimal risk to laypersons attempting patient resuscitation. Callers should be instructed to help because it is assumed they have asked for help, and any delay in offering that help reduces the odds of patient survival. Callers can and do refuse to help; this is their prerogative. If a caller refuses to perform mouth-to-mouth, a provision is provided in the MPDS.
Responder notification regarding a particular disease can be litigious, no matter how discrete, and can result in direct or indirect discrimination. Unless the patient’s disease history is legitimately needed in the patient’s pre-arrival report, and is not limited to a particular disease(s), responders should be trusted with applying universal precautions as they were trained, universally.
1 "Healthcare-associated Infections." Diseases And Organisms In Healthcare Settings. Centers For Disease Control And Prevention, CDC. 2011; Mar 25. http://www.cdc.gov/HAI/organisms/organisms.html#s (accessed May 22, 2011).
2 "Universal Precautions." Healthcare Wide Hazards. Occupational Safety & Health Administration, OSHA. http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html#OPIM (accessed Web. 22 May 2011).
3 See note 2.
4 "Universal Infection Control Precautions." Infection Control Policies. Leeds Teaching Hospitals. NHS. 2003. 1–5.
5 See note 4.
6 See note 4.
7 "What to Do If You've Had a Needle Stick Injury." Safety Resources. Inviro Medical. 2009. http://www.inviromedical.com/SAFETYRESOURCES/WhattoDoifYouGetaNeedleStic... (accessed June 3, 2011).
8 Brouhard, R. "Deadly Ignorance." About.com Guide. 2007; Jan 15. http://firstaid.about.com/od/cpr/a/07_hivcpr.htm (accessed May 27, 2011).
9 "Estate of Claude Green V. Robert Bowman." Case Background. American Civil Liberties Union, ACLU. 2006; Mar 2. http://www.aclu.org/lgbt-rights_hiv-aids/estate-claude-green-v-robert-bo... (accessed June 3, 2011).
10 Gentner, J. "Police Chief Sued for Denying Gay Man CPR." USA Today. 2006; Mar 2. http://www.usatoday.com/news/nation/2006-03-02-cpr-suit_x.htm (accessed June 3, 2011).