2 The Well-Being of the EMT

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Topics Well-Being Personal Protection Diseases of Concern Emotion and Stress Scene Safety Planning Your Time: Plan 100 minutes for this chapter. Well-Being (15 minutes) Personal Protection (30 minutes) Diseases of Concern (20 minutes) Emotion and Stress (15 minutes) Scene Safety (20 minutes) Note: The total teaching time recommended is only a guideline. Core Concepts: Standard Precautions, or how to protect yourself from transmitted diseases The kinds of stress caused by involvement in EMS and how they can affect you, your fellow EMTs, and your family and friends The impact that dying patients have on you and others How to identify potential hazards and maintain scene safety

Well-Being Back to Topics Teaching Time: 15 minutes Teaching Tip: Lessons on well-being will be lost if the instructor does not lead by example. Practice what you preach. Demonstrate healthy choices in the classroom. Consider healthy snacks and limit caffeine. Actively discuss other healthy choices, and make well-being the accepted norm. Back to Topics

Importance of Well-Being Keeping yourself prepared for demands and risks of EMT is very important. If you are unable to function for any reason, patients may not get needed care. Covers Objective: 2.2 Discussion Topic: How might prevention and a healthy lifestyle protect you in your career as an EMT? Knowledge Application: Have students work in groups. Assign each group a step toward improving wellness. Have each group develop a plan to implement such a step in an EMS system.   Assign a research project. Ask each student to seek out a workplace wellness plan (it does not have to be an EMS-related plan) and discuss it with the class.

Maintaining Well-Being Maintaining solid personal relationships Exercise Sleep Eating right Limiting alcohol and caffeine intake Seeing your physician regularly and keeping up to date on vaccines Covers Objective: 2.2 Discussion Topic: Describe at least five steps that you can take to promote well-being in your own life. Class Activity: After discussing healthy steps toward well-being, list changes that individuals could make toward greater well-being. Keep a running count and track progress. Include yourself as well.

Personal Protection Back to Topics Teaching Time: 30 minutes Teaching Tip: Teach realism. Try not to allow students to just say "Standard Precautions," but rather make them actually take precautions. For example, require the use of appropriate protective equipment during simulated calls. Use real examples of personal protective equipment. Provide students the classroom experience of working with the equipment. Practice good hand hygiene. Not only will it teach good habits, but it will also decrease disease transmission in class. Back to Topics

Standard Precautions Standard Precautions include steps to protect self from pathogens. Scene size-up and protocols provide information on which precautions to take. Covers Objective: 2.3 Points to Emphasize: Equipment and procedures that protect against the blood and body fluids of the patient are referred to as Standard Precautions. The EMT must assess each situation to determine the most appropriate level of personal protection. Talking Points: Precautions are needed against the four types of risks, or routes of infection: inhalation risks such as TB (protection from HEPA mask); ingestion risks such as eating or drinking in a contaminated area, or touching your mouth with contaminated fingers; absorption risks such as through mucous membranes and eyes; and injection risks such as being stuck by a dirty needle. These four routes will also be important when discussing poisonings, overdoses, hazardous materials, and bioterrorism. Discussion Topic: Define Standard Precautions. What precautions should you take for every patient? continued on next slide

Standard Precautions The Occupational Safety and Health Administration (OSHA) has issued strict guidelines about precautions against exposure to bloodborne pathogens. Refer to local protocols for wearing personal protective equipment. When in doubt, wear it. Covers Objective: 2.3 Points to Emphasize: Equipment and procedures that protect against the blood and body fluids of the patient are referred to as Standard Precautions. The EMT must assess each situation to determine the most appropriate level of personal protection. Talking Points: Precautions are needed against the four types of risks, or routes of infection: inhalation risks such as TB (protection from HEPA mask); ingestion risks such as eating or drinking in a contaminated area, or touching your mouth with contaminated fingers; absorption risks such as through mucous membranes and eyes; and injection risks such as being stuck by a dirty needle. These four routes will also be important when discussing poisonings, overdoses, hazardous materials, and bioterrorism. Discussion Topic: Define Standard Precautions. What precautions should you take for every patient?

Personal Protective Equipment Covers Objective: 2.3 Talking Points: Emphasize that the Occupational Safety and Health Administration (OSHA) has issued strict guidelines about precautions against exposure to bloodborne pathogens. Employers and employees share the responsibility for these precautions. Always wear personal protective equipment to prevent exposure to contagious diseases.

Personal Protective Equipment Protective gloves Always have vinyl or other nonlatex gloves readily available. Gloves should be changed between patients. Covers Objective: 2.3 Critical Thinking: EMTs wear gloves on almost every call. Should you put on gloves the moment that you climb into the ambulance to respond to a call? What are the advantages and disadvantages of doing so?

Personal Protective Equipment Covers Objective: 2.3 Talking Points: Always remove gloves in a manner that does not allow the contaminated surface to come in contact with bare skin. Disposable arm covers can be used to reduce the amount of exposed skin when wearing short sleeve shirts. Pull at top of glove #1 and pull glove #1 inside out. © Edward T. Dickinson, MD

Personal Protective Equipment Hand cleaning Hand washing Alcohol-based hand cleaners Considered effective by the Centers for Disease Control (CDC) Alcohol-based hand sanitizers can be used if soap and water are not available. Covers objective: 2.4 Point to Emphasize: Because proper hand cleaning prevents the spread of disease, it is an essential component of personal protection.

Personal Protective Equipment Covers objective: 2.4 Talking Points: While washing, pay particular attention to the area between fingers, the nail beds, and under fingernails. (Remember, it is the friction that removes the material, not the soap.) The minimum time spent washing should be long enough to sing "Happy Birthday" twice. Patting hands dry reduces abrasion of the skin. If the sink is not equipped with foot controls, use a clean, dry paper towel to turn off the water. Careful, methodical hand washing is effective in reducing exposure to contagious diseases.

Personal Protective Equipment Covers Objective: 2.4 Alcohol-based hand cleaners are effective and often available when soap and water are not.

Personal Protective Equipment Eye and face protection Eye protection prevents splashing, spattering, or spraying fluids from entering the body. Should provide a guard from the front and the sides Covers Objective: 2.3

Personal Protective Equipment Covers Objective: 2.3 Wear a NIOSH-approved respirator when you suspect a patient may have tuberculosis.

Personal Protective Equipment Masks In cases where there will be blood or fluid splatter, wear a surgical-type mask. In cases where tuberculosis is suspected, wear an N-95 or high-efficiency particulate air (HEPA) respirator approved by the National Institute for Occupation Safety and Health (NIOSH). Covers Objective: 2.3 Knowledge Application: Demonstrate the donning and proper use of various examples of personal protective equipment.

Personal Protective Equipment Covers Objective: 2.3 Wear a protective mask and face shield when suctioning a patient.

Personal Protective Equipment Gowns May also wear gown to protect clothing and bare skin from spilled or splashed fluids Covers Objective: 2.3 Talking Points: You may also consider covering the patient's face with a mask to reduce the spread of droplet-borne disease. However, this will restrict your ability to observe and monitor the airway. It is also a good idea to make sure that others are complying with Standard Precautions. This is assuring the safety of others as well as reducing the risk to yourself. Discussion Topic: For each piece of personal protective equipment discussed, describe an example of a situation in which that level of protection would be necessary. Class Activity: Send students on a clinical scavenger hunt. Assign a clinical objective that requires students to locate different types of personal protective equipment while they are attending clinical situations. Consider making this activity a contest by giving a prize to the student who can find the greatest variety at one site. Knowledge Application: Present various patient scenarios. Discuss with the class the most appropriate level of personal protection.

Diseases of Concern Back to Topics Teaching Time: 20 minutes Teaching Tip: With concerns regarding emerging dangerous infectious diseases such as H1N1, communicable diseases can make for a relevant, topical discussion. Use real-world concerns to drive home points. Use scenarios to illustrate how laws pertaining to infection control help protect the rights of EMS workers. Back to Topics

Hepatitis B and C Infection that causes inflammation of the liver Can live on surfaces in dried blood for several days Hepatitis B (HBV) deadly; killed hundreds of health care workers each year before vaccine available Hepatitis C (no vaccine yet) poses same risk. Covers Objective: 2.5 Point to Emphasize: Hepatitis B, hepatitis C, tuberculosis, and HIV/AIDS are communicable diseases that EMTs may encounter while performing their duties.

Tuberculosis (TB) Infects lungs Highly contagious Airborne Covers Objective: 2.5

AIDS HIV Attacks immune system, leaving patient unable to fight off infection AIDS Set of conditions that results when the immune system has been attacked by HIV Covers Objective: 2.5 continued on next slide

AIDS Lower risk for health care workers than hepatitis or TB Contact with blood usual route of infection Covers Objective: 2.5

AIDS: Etiology and Pathophysiology Video Covers Objective: 2.5 Video Clip AIDS: Etiology and Pathophysiology What is AIDS? How can AIDS be transmitted? Which populations have the greatest risk of contracting AIDS? Explain how the treatments available for AIDS work. Click on the screenshot to view a video on the subject of AIDS. Back to Directory

Emerging Conditions and Diseases Ebola People in the U.S. infected in 2014 Hemorrhagic fever High rate of deaths and lack of definitive treatment Covers Objective: 2.6 Discussion Topic: Compare and contrast the infectious diseases that concern health care workers. Discuss routes of transmission, protective measures, and consequences of infection. Knowledge Application: Have students work in small groups. Assign each group a particular disease. Have the group research the disease and present its findings to the class. continued on next slide

Emerging Conditions and Diseases Severe Acute Respiratory Syndrome (SARS) Spread through respiratory droplets Middle Eastern Respiratory Syndrome (MERS) Found primarily on the Arabian Peninsula Covers Objective: 2.6 Discussion Topic: Compare and contrast the infectious diseases that concern health care workers. Discuss routes of transmission, protective measures, and consequences of infection. Knowledge Application: Have students work in small groups. Assign each group a particular disease. Have the group research the disease and present its findings to the class. continued on next slide

Emerging Conditions and Diseases Avian flu Found in poultry; can affect humans Not easily transmissible from human to human Influenza Around for hundreds of years 1918 pandemic killed between 30 and 50 million people around the world Covers Objective: 2.6 Class Activity: Consider having the class volunteer at an immunization clinic. Flu shot season traditionally presents many opportunities. Use this as an opportunity to discuss the role of the EMT in public health. Critical Thinking: Pandemic flu is a major concern to EMS workers. Discuss how the role of an EMT might change if the United States ever had to face a true pandemic emergency.

Infection Control and the Law EMS personnel, other health care workers are at high risk of coming in contact with infectious diseases. Guidelines for workplace safety developed by OSHA and other federal, state, and local agencies Covers Objective: 2.7 Knowledge Application: Have students work in small groups. Assign each group a particular law that pertains to infectious disease. Have the group research and discuss how that particular law is relevant to EMS workers.

Occupational Exposure to Bloodborne Pathogens The OSHA standard on bloodborne pathogens requires infection control be joint responsibility of employer and employee. EMS agencies provide training, protective equipment, and vaccinations to employees. Employees participate in infection exposure control plan. Covers Objective: 2.7 Discussion Topic: Discuss the 1998 OSHA bloodborne pathogen standard. How does it pertain to EMS workers? Class Activity: Review the exposure control/infection control guidelines of an actual EMS service. Discuss how that service has engineered personal protection and standard precautions. continued on next slide

Occupational Exposure to Bloodborne Pathogens Infection exposure control plan Adequate education and training Hepatitis B vaccination Personal protective equipment Methods of control Housekeeping Labeling Postexposure evaluation and follow-up Covers Objective: 2.7

Ryan White CARE Act Allows EMS providers to find out if they have been exposed to potentially life-threatening diseases while providing patient care Designated officer gathers facts about potential exposures. Covers Objective: 2.7 continued on next slide

Ryan White CARE Act Two notification systems Airborne disease exposure Bloodborne or other infectious disease exposure Once notified of an exposure, employer will refer you to a health care professional for evaluation and follow-up. Covers Objective: 2.7

Tuberculosis Compliance Mandate OSHA's respiratory standard Selection and use of respirators Caring for or transporting a patient with suspected TB Wear a NIOSH-approved N-95 or HEPA mask when you are: Caring for patients suspected of having TB Covers objective: 2.8 Point to Emphasize: Immunization is a key component of disease prevention. continued on next slide

Tuberculosis Compliance Mandate Caring for or transporting a patient with suspected TB Wear a NIOSH-approved N-95 or HEPA mask when you are: Transporting an individual from such a setting in a closed vehicle Performing high-risk procedures such as endotracheal suctioning and intubation Covers objective: 2.8 Point to Emphasize: Immunization is a key component of disease prevention.

Immunizations Immunizations for hepatitis B, other infectious diseases should be available through EMS agency. Regular TB testing may also be required. Local system protocols vary. Covers objective: 2.9 Point to Emphasize: Immunization is a key component of disease prevention.

Emotion and Stress Back to Topics Teaching Time: 15 minutes Teaching Tip: Everyone has experienced stress. Relate class-related stress (tests, quizzes, and the like) to your discussion. Utilize stress-mitigation strategies during the class (and not just during this lesson). Imprint important habits now that will relate to various job-related stressors later. Have students play different parts in various stress-related scenarios. Topics should include death and dying and recognizing the signs of stress. Back to Topics

Physiologic Aspects of Stress Stress inevitable in the EMS profession. Recognizing signs of stress and developing strategies to deal with stress are very important to the EMS career. Covers Objective: 2.10

Physiologic Aspects of Stress First stage Alarm reaction (fight-or-flight) Second stage Stage of resistance (coping) Third stage Exhaustion (loss of ability to resist or adapt to the stressor) Covers Objective: 2.11 Point to Emphasize: Stress has a distinct and significant physiologic effect.

Types of Stress Reactions May occur as the result of a critical incident Any situation that triggers a strong emotional response

Acute Stress Reaction Often linked to catastrophe Occurs in EMTs and patients Signs and symptoms develop soon after incident. Physical, cognitive, emotional, and behavioral symptoms Normal reactions to extraordinary situation May require professional intervention Covers Objective: 2.12 Point to Emphasize: Stress can elicit acute, delayed, and cumulative reactions. Each of these can harm the well-being of an EMT.

Delayed Stress Reaction Posttraumatic stress disorder (PTSD) Signs and symptoms not evident until long after incident. Delay makes dealing with reaction much harder. Patient may not recognize what is causing problem. Requires intervention by mental health professional Covers Objective: 2.12

Cumulative Stress Reaction Results from years of sustained low-level stressors Early signs Vague anxiety Emotional exhaustion Covers Objective: 2.12 continued on next slide

Cumulative Stress Reaction Progresses to physical complaints, loss of emotional control, irritability, depression May present as severe withdrawal or suicidal thoughts requiring long-term psychological intervention Covers Objective: 2.12

Causes of Stress Multiple-casualty incidents (MCI) Calls involving infants or children Severe injuries Abuse and neglect Death of a coworker Covers Objective: 2.10 Point to Emphasize: There are many causes of stress, and these causes may vary from individual to individual. EMTs must learn to recognize their own stressors and to detect the signs of stress in their lives. Discussion Topic: Define stress. What kinds of situations might cause stress in your career as an EMT? Critical Thinking: How does stress relate to the previous discussion about well-being? What are the roles of wellness strategies in stress reduction? Knowledge Application: Conduct a stress inventory. Have students anonymously submit causes of stress with which they are familiar. Discuss how these stressors vary from person to person.

Signs and Symptoms of Stress Eustress Positive form of stress that helps people work under pressure and respond effectively Distress Negative stress causing immediate and long-term problems with health and well-being Covers Objective: 2.11 Talking Points: Explain the difference between eustress and distress. Discussion Topic: What are the signs of stress? continued on next slide

Signs and Symptoms of Stress Irritability Inability to concentrate Changes in daily activities Anxiety Indecisiveness Guilt Isolation Loss of interest in work Covers Objective: 2.11 Talking Points: Explain the difference between eustress and distress. Discussion Topic: What are the signs of stress?

Think About It If your partner is beginning to show signs of stress, what should you do? What possible risk could there be to your partner, you, or a patient if stress is left unresolved? Do you have an obligation to act to help your partner? Covers Objective: 2.11 Talking Points: If the actions of a partner are beginning to be unsafe, there is an obligation to act. Action may begin with a simple one-on-one conversation, but may require action by administration or management. Most departments have resources available for employees who are having difficulty dealing with job stress. Some people feel that admitting to being stressed out is a sign of weakness. This is not a healthy attitude; stress that is not dealt with does not get better on its own. This may lead to serious consequences for all involved.

Dealing with Stress Lifestyle changes Develop more healthful and positive dietary habits Exercise Devote time to relaxing Change shift or location for lighter call volume, different call types, more family time Covers Objective: 2.13 Point to Emphasize: Lifestyle changes and critical incident stress management can help EMTs overcome work-related stress. Discussion Topic: Discuss lifestyle changes that help many people deal with stress. How would you build these changes into a daily routine? continued on next slide

Dealing with Stress Critical incident stress management Comprehensive system Includes education and resources to prevent stress Ways to deal with stress appropriately when it occurs Covers Objective: 2.14 continued on next slide

Dealing with Stress Critical incident stress management Critical incident stress debriefing (CISD) Designed to help responders "defuse" after incident Team of trained peer counselors and mental health professionals meet with rescuers and health care providers involved in major incident twenty-four to seventy-two hours after incident Helps responders deal with stress Covers Objective: 2.14 continued on next slide

Dealing with Stress Understanding reactions to death and dying Do not usually see dead people except at funeral Do not normally see person die Often most difficult part of job Dealing with family may be more difficult Covers Objective: 2.15 Talking Points: These are inevitable hurdles in an EMS career. Members of the dead person's family will respond in many different ways, including directing their grief, anger, and frustration at the EMT. continued on next slide

Dealing with Stress Understanding reactions to death and dying Emotional stages Denial or "Not me.” Anger or "Why me?” Bargaining or "OK, but first let me…” Depression or "OK, but I haven't…” Acceptance or "OK, I'm not afraid.” Covers Objective: 2.15 continued on next slide

Dealing with Stress Understanding reactions to death and dying Recognize the patient's needs. Be tolerant of angry reactions from the patient or family members. Listen empathetically. Do not falsely reassure. Offer as much comfort as you realistically can. Covers Objective: 2.16

Scene Safety Back to Topics Teaching Time: 20 minutes Teaching Tips: Make scene safety real. Discuss real-world examples of injuries related to EMS work. There are many good video graphics of terrorist and hazardous materials incidents. Consider using news footage to add a real-world flavor. Have students play the parts of patients and bystanders. Simulate real-life safety hazards and play out reaction strategies. Back to Topics

Scene Safety EMS not usually a dangerous profession Being aware of potential dangers is always a priority. Determining scene safety will be the most important decision on any call. Covers Objectives 2.17 and 2.21 Point to Emphasize: Go home at the end of your shift! All EMTs must recognize that this is one of the most valuable lessons that they can learn. Teach the true importance of scene safety. Talking Points: TV shows give false information on the dangers of EMS. Even so, determining scene safety is the first step in the assessment process. Knowledge Application: Oklahoma City, 9/11, and the Eric Rudolph bombings are a few major events in which rescue workers faced terrorist violence. Use these historical examples to discuss scene safety hazards and strategies of safe response.

Hazardous Material Incidents Primary rule is to maintain a safe distance from the source of the hazardous material. Placards Ensure that your emergency vehicle is equipped with binoculars. Correspond with coded colors and identification numbers that are listed in the Emergency Response Guidebook Covers Objectives 2.17, 2.19, and 2.21 Point to Emphasize: Emergency medical scenes can threaten the lives of EMTs. Hazardous materials, terrorism, and potentially dangerous rescue operations all pose risks to emergency responders. Discussion Topic: Describe the scene safety concerns of the EMT. Use specific examples. continued on next slide

Hazardous Material Incidents Roles Recognize potential problems. Take actions for personal safety and the safety of others. Notify a trained hazardous material response team. Do not treat patients until after they have undergone decontamination. Covers Objectives 2.17, 2.19, and 2.21 Point to Emphasize: Emergency medical scenes can threaten the lives of EMTs. Hazardous materials, terrorism, and potentially dangerous rescue operations all pose risks to emergency responders. Discussion Topic: Describe the scene safety concerns of the EMT. Use specific examples.

Terrorist Incidents May be small or large in scale May include chemical agents, biochemical agents, radiation, and/or explosive devices Covers Objectives 2.17, 2.19, and 2.21 Point to Emphasize: Emergency medical scenes can threaten the lives of EMTs. Hazardous materials, terrorism, and potentially dangerous rescue operations all pose risks to emergency responders. Discussion Topic: Describe the scene safety concerns of the EMT. Use specific examples.

Rescue Operations Rescuing or disentangling victims from fires, auto collisions, explosions, electrocutions, and more Evaluate each situation and ensure that appropriate assistance is requested early in the call. Never perform acts that you are not properly trained to do. Covers Objectives 2.17, 2.19, and 2.21 Point to Emphasize: Emergency medical scenes can threaten the lives of EMTs. Hazardous materials, terrorism, and potentially dangerous rescue operations all pose risks to emergency responders. Discussion Topic: Describe the scene safety concerns of the EMT. Use specific examples.

Potential Safety Threats at Scene Covers Objectives 2.17, 2.19, and 2.21 Point to Emphasize: Emergency medical scenes can threaten the lives of EMTs. Hazardous materials, terrorism, and potentially dangerous rescue operations all pose risks to emergency responders. Discussion Topic: Describe the scene safety concerns of the EMT. Use specific examples. Placards with coded colors and identification numbers must be used on vehicles and containers to identify hazardous materials.

Violence Plan Wear safe clothing Prepare your equipment so it is not cumbersome Carry a portable radio whenever possible Decide on safety roles Covers Objectives 2.18 and 2.21 Point to Emphasize: Scene safety requires pre-planning, teamwork, communication, and appropriate levels of personal protection. continued on next slide

Violence Covers Objectives 2.18 and 2.21 Point to Emphasize: Scene safety requires pre-planning, teamwork, communication, and appropriate levels of personal protection. As a safety precaution, do not stand directly in front of a door when knocking or ringing the bell.

Violence Observe Survey scene on approach. Do not announce arrival. Turn off lights and siren. Drive few feet past residence so you can see front and sides. Covers Objectives 2.18 and 2.21 Point to Emphasize: All EMTs should prepare themselves to recognize, attempt to prevent, and react to violence. continued on next slide

Violence Observe Violence Crime scenes Alcohol or drug use Weapons Family members Bystanders Perpetrators Pets Covers Objectives 2.18 and 2.21 Knowledge Application: To help students recognize and respond to violence, role-play potentially violent scenarios. Discuss planning, observation, and reaction in each case.

React to Danger Three Rs Retreat Radio Reevaluate Do not reenter a scene until it has been secured by police. Covers Objectives 2.18 and 2.21 Discussion Topic: Describe the role of planning, observation, and reaction with regard to a potentially violent situation. Critical Thinking: Compare wellness strategies to scene safety strategies. Which are more important? Which have a greater impact on keeping EMTs healthy and "on the job"? Discuss.

Response to Danger: Observe Covers Objectives 2.18 and 2.21 Knowledge Application: To help students recognize and respond to violence, role-play potentially violent scenarios. Discuss planning, observation, and reaction in each case. Never enter a scene that is potentially violent until the police have secured it and told you it is safe. AP Photo/The Sacramento Bee, Randy Pench

React to Danger Flee. Get rid of any cumbersome equipment. Take cover and conceal yourself. Covers Objectives 2.18 and 2.21 Discussion Topic: Describe the role of planning, observation, and reaction with regard to a potentially violent situation. Critical Thinking: Compare wellness strategies to scene safety strategies. Which are more important? Which have a greater impact on keeping EMTs healthy and "on the job"? Discuss.

React to Danger Covers Objectives 2.18 and 2.21 Discussion Topic: Describe the role of planning, observation, and reaction with regard to a potentially violent situation. Critical Thinking: Compare wellness strategies to scene safety strategies. Which are more important? Which have a greater impact on keeping EMTs healthy and "on the job"? Discuss. Concealing yourself is placing your body behind an object that can hide you from view.

Chapter Review

Chapter Review Your well-being is an important concept. This chapter has provided several ways to protect and maintain it. You should never take safety or Standard Precautions lightly. Each is an important decision you will make at least once at each scene you respond to—always. continued on next slide

Chapter Review Protect yourself from violence and scene hazards at all costs. Protect yourself from disease. Do not be paranoid about catching a disease, but take appropriate precautions. continued on next slide

Chapter Review Stress may be an immediate reaction from a particular call or cumulative from a combination of life and EMS. Both are bad for you. Seek help if you need to. continued on next slide

Chapter Review You will see death and reaction to death. Each is very personal to those involved. The stages of death are denial, anger, bargaining, depression, and acceptance. Treat people who are under stress fairly and compassionately, even if it is difficult to do so.

Remember Scenes are dynamic and can change in an instant. Assessment of scene safety is an ongoing process. Don't be so focused on the patient that you lose perception of what is happening around you.

Questions to Consider What precautions must I take if I am dealing with a patient who has an open wound? What can I do to help deal with stress? A patient who refuses to believe she has a terminal disease is in what stage of dealing with it? Talking Points: Gloves should be the minimum precaution for a patient with an open wound. Exercise, diet, and relaxation techniques will help deal with stress. This stage is denial.

Critical Thinking You are called to an unknown emergency at a tavern. As you approach the scene, you see a man lying supine in the parking lot, apparently bleeding profusely. Two other men are scuffling, and one seems to have a gun. What actions must you take? Talking Points: Keep a safe distance from the danger and radio for police. Keep an escape route in mind if you need to retreat. Once police have secured the scene, take standard precautions to care for a patient who is bleeding. Maintain a level of alertness in case violence starts again.