Emergency Action Plans: Are You Ready? (Part 6 - Medical Emergencies)

Workplace Medical Emergencies

Medical emergencies (whether work-related or not) can happen to anyone at any time in any location. Now, re-read that and let that sink in for a minute.

During my years in EMS, I had cardiac arrest patients that were 9 years old and I had cardiac arrest patients that were 90 years old. There were situations where someone was injured or became ill from a "freak accident", whereas others were simply due to carelessness. Regardless of how it happened, however, we need to be able to get the patient(s) the needed medical attention in an appropriate time frame.

If you refer to OSHA's Medical Services and First Aid standard (29 CFR 1910.151), it states the following:

• The employer shall ensure the ready availability of medical personnel for advice and consultation on matters of plant health.
• In the absence of an infirmary, clinic, or hospital in near proximity to the workplace which is used for the treatment of all injured employees, a person or persons shall be adequately trained to render first aid. Adequate first aid supplies shall be readily available.

Now the question is: What does OSHA defined as "in near proximity"? Well, it's funny you should ask that because I have the answer! According to a 2007 letter of interpretation, OSHA states that "While the standards do not prescribe a number of minutes, OSHA has long interpreted the term "near proximity" to mean that emergency care must be available within no more than 3-4 minutes from the workplace, an interpretation that has been upheld by the Occupational Safety and Health Review Commission and by federal courts." With that being said, OSHA exercises discretion in enforcing the first aid requirements in particular cases. OSHA recognizes that a somewhat longer response time of up to 15 minutes may be reasonable in workplaces, such as offices, where the possibility of such serious work-related injuries is more remote.

Why is this so critical? Let's take the cardiac arrest patients mentioned above. Based on numerous scientific studies, it's stated that for every minute a person is in cardiac arrest without CPR being performed, they lose a 7%-10% chance of survival.

After around 10 minutes of cardiac arrest, the mortality rate in adults is near 95%.

But what about other workplace medical emergencies, such as falls from heights, corrosive chemical burns, carbon monoxide poisoning, or struck-by injuries? All of these situations have a varying rate of severity, but all of these situations still need medical treatment. Are you prepared for all the medical emergencies that may come your way? You don't necessarily have to know how to treat every type of injury or illness, but you DO need to be able to get the patients to someone who can in a time frame appropriate for the incident.

Key Questions to Ask Yourself:

• Do you have a distinct notification system for this type of emergency so that employees know what it is? Will you make a facility-wide notification? Or will you only notify key personnel?
• Are your employees aware of their responsibilities during this type of event?
• How far away is the closest medical facility, hospital, or clinic? Is it "in near proximity"?
• Do you have employees trained in CPR, AED use, and basic first aid?
• Do you have first aid supplies readily available for use? Are they continuously checked and re-stocked, as needed?
• Do your employees know when to treat something "in-house" versus calling 9-1-1 right away? (For my EMS folks, is it a "stay and play" situation? Or is it a "load and go"?)
• How many ambulances/EMS agencies are in your immediate area? How large is their coverage area?
• What is the average response time for Fire/EMS in your area? Is the local fire department a volunteer station or is it staffed 24/7?

Medical Terminology

Before we get too deep in the discussion, it's important that we understand some basic medical terminology. For example, "first aid" according to OSHA may be different than what you consider "first aid". What requires outside medical treatment to me may be different than what you consider needing medical treatment. However, I'll keep the definitions fairly generic to so that we can all get a general understanding.

• ALS - Advanced life support.
• BLS - Basic life support.
• Injury - This is something that occurs instantly, such as hitting your thumb with a hammer, falling down the steps, or getting hit with a forklift.
• Illness - This is something that occurs over a period of time. While most of us hear the word "illness" and think of the common cold, it can also include ergonomic-related illnesses (e.g., carpal tunnel), back strains, and carbon monoxide poisoning from chronic exposure to hazardous fumes.
• First Aid - For OSHA recordkeeping purposes, OSHA has a specific list of what they consider to be "first aid" (click here for the list). If it's not on the list, then it's not first aid and is therefore considered "medical treatment". Period.
• Medical Treatment - This refers to any form of treatment given that is NOT included in OSHA's first aid list referenced above, regardless of who provides the treatment (e.g., supervisor, EMT, physician, etc.).

This is not an article on OSHA recordability, but if you have a question about this, you can reference 29 CFR 1904 Subpart C, or reach out to my fellow safety colleague Nathan Brayman, who is the co-owner of and operates a great website called "isitrecordable.com". Simply post a question on the website and they will answer it for you and provide an explanation.

Who Is Going to Respond?

When you call 911, you will get one of four options in most cases:

1. Emergency Medical Services (EMS)
2. Fire Department
3. Law Enforcement (Police Department or Sheriff's Office)
4. The whole cavalry (all of the above)

Who you will get to respond will be based largely on what you tell the call taker(s) when you call 911. If you tell them some type of criminal activity was involved (such as a shooting), then LEOs are going to show up. If you tell them it's a medical emergency (such as trouble breathing, allergic reaction, etc.), then the fire department and EMS will show up. If you call 911, tell them the location of your emergency, then hang up (not advised), that's when you get the whole cavalry.

There are a few differences within these options, as well.

The fire department can be either 100% volunteer, career/paid, or a combination of the two. This may play for you or against you. If it's a paid/career department, they will probably beat EMS there and most of them are EMTs or Paramedics, so they can stabilize the scene until EMS gets there. If it's a 100% volunteer department, the firefighters will be responding from home and/or work, so they may take 2 minutes to get there, or they may take 20 minutes. You never really know. Statistically speaking, most volunteer firefighters are not EMTs or Paramedics either, so keep that in mind.

When EMS is dispatched, they will either send a BLS unit consisting of two EMTs (lower level of medical training), or an ALS unit consisting of at least one Paramedic (higher level of medical training). The reason I'm telling you this is because you don't want to make the call to 911 sound not so bad and have a BLS unit arrive, only to find out the EMTs need to call the ALS unit so that they can give certain medications. That's just going to delay the necessary treatment even longer for the patient(s).

Types of Medical Emergencies

The types of medical emergencies that you may experience in your workplace can depend on a number of different factors, such as the type of work you are involved in, the age and physical condition of your workers, and the location of your facility. In order to determine how to prepare, you need to determine what you're preparing for. The term "medical emergencies" is a fairly broad term and can be interpreted in two completely different ways based on who you're talking to. As an EMT, I'm going to have a different interpretation of what a "medical emergency" is versus the lay person with little to no medical training. It's all a matter of perspective, so you need to get your employees and local EMS service(s) involved in the planning stages.

First Aid (Injuries/Illnesses Treatable On-Site)

Examples of minor injuries/illnesses that can typically be treated by someone trained in basic first aid include, but are not limited to:

• Bruises/contusions (unless it shows signs of internal bleeding);
• Minor cuts, scrapes, and lacerations;
• Injuries/illnesses treated with hot or cold packs;
• Minor pain/discomfort treated with OTC medication at regular strength;
• Foreign bodies in the eye(s) that are removable using irrigation methods or a cotton swab;
• Splinters
• Heat stress that can be properly treated by drinking fluids

Serious Injuries/Illnesses Requiring Medical Treatment Beyond First Aid

Examples of serious injuries/illnesses that result in the person(s) being transported to an outside medical provider include, but are not limited to,

• Severe blood loss;
• Possible permanent disfigurement;
• Head trauma;
• Spinal injuries;
• Internal injuries;
• Loss of consciousness; or
• Any situation in which the condition of the patient is unknown or unable to be determined.

Keep in mind that the needs and well-being of the injured/ill person(s) are the first priority, not moving them out of the way to get the machine back up and running.  

General Guidelines

If possible, all minor first aid should be self-rendered. Due to the prevalence of bloodborne pathogens, you want to avoid contact with bodily fluids as much as possible. We don't always carry a pair of nitrile medical gloves in our pockets (unless you're working for EMS), so you may have to improvise when you arrive at the site. Did someone forget to re-stock the medical gloves? No problem! Go to the kitchen and grab a large freezer bag and stick your hand in it. The whole purpose is to create a barrier between the patient's bodily fluids and you. This is where the term "universal precautions" comes in, which means that regardless of who it is or what the situation is, you treat everyone as if their infectious.

In the case of a medical emergency, all personnel should remain calm and do only what is necessary to protect life.

• The first person on scene of a serious medical emergency should summon medical help immediately by calling company employees trained in first aid and/or 911. The first person can designate someone to call 911 (if needed) so that they may remain with the injured/ill person. If you’re by yourself, call 911 and place it on speakerphone so that you can still assist the patient.
• Do not move the injured or ill person unless he/she is in danger of further harm or it is appropriate to provide the appropriate medical care. Simply moving a worker who has fallen off a ladder and has a potential spinal injury may cause further damage and paralyze the person. Unless the building is on fire or there is another life-threatening emergency on the horizon, treat the patient(s) where they are unless advised otherwise by trained medical personnel (e.g., EMS).
• Keep the injured person warm in all cases to help prevent shock (except during heat-related illnesses). The medical term "shock", in layman's terms, is simply low blood flow throughout the body. If you can, lie the person flat on the ground to prevent the blood from pooling in their legs. The idea is to keep blood flowing to the critical, core organs of the body.
• If the person has been contaminated with a hazardous material, immediately remove all contaminated clothing and flood exposed areas with copious amounts of water from the safety shower (unless directed otherwise by a chemical’s SDS). The key word here is "copious". Flood them with as much water as possible!
• If chemicals have entered the eye(s), immediately flush the eyes with water from eyewash/facewash station for at least 15 minutes. Hold the eyes open to wash thoroughly behind the eyelids. This is probably one of the most difficult things to get someone to do, but it's extremely critical that you do this for 15 minutes, not 15 seconds.

Triage

Hopefully, if you're dealing with a medical emergency, it only involves one (maybe two) people. However, if you're dealing with a MCI (mass casualty incident), you're going to need to help with prioritizing the patients before EMS gets there. Unless you're a trained and licensed medical professional (e.g., EMT, Paramedic, Nurse, etc.), I'm going to keep it simple for you.

In the picture here, you can see what are referred to as "triage tags". They come in many shapes and sizes, but all serve the same purpose: easy identification of medical priorities. Green and yellow are somewhat minor incidents, red tags need immediate attention, and black tags are for deceased patients. I'm not asking you to purchase and/or use these tags (but if you do, then more power to ya!). I'm simply wanting you to understand the concept of it.

When dealing with a MCI, one of the easiest ways you can identify the green- and yellow tagged-patients is to yell.

Simply yell something along the lines of "If you can hear me and are able to move, proceed to ________". These patients are referred to as the "walking wounded". Once the smoke clears and all of the green- and yellow-tagged patients are grouped together, you are now left with two groups: red tags (immediate/life threatening) and black tags (deceased). Now you know where to focus your attention and where to direct first responders to once they arrive on scene. This doesn't require a lot of skill (unless you're suffering from laryngitis that day), but can ensure that the severely injured/ill patients get medical attention first.

Supplies and Equipment

First aid supplies should be easily accessible at all times, regardless of your location. If you're at a fixed facility, then there should be fully-stocked first aid kits that are compliant with the Class A First Aid Kit requirements set forth in ANSI Z308.1-2015. If you're in high-risk environments, then you will need to have a Class B First Aid Kit.

All first aid kits should contain appropriate items determined to be adequate for the environment in which they are used. If you're on a construction site or otherwise outdoors, first aid kits should be stored in a weatherproof container with individual contents sealed from the manufacturer for each type of item. 

As a best practice, first aid kits should be inspected:

• On the first working day of each week to verify that they are fully stocked and that no expiration dates have been exceeded. Replace any items that have exceeded their expiration dates or that have been depleted.; and
• Before being sent out to each job.

Where the eyes or body of any person may be exposed to injurious corrosive materials, a safety shower, eye wash station, or other suitable facilities is required to be provided within 10 seconds of the hazard area. For strong acids or strong caustics, ANSI states that the eyewash should be located immediately adjacent to the hazard. Ensure expiration dates are checked and the water used in storage devices is sanitized.  

The OSHA standard does not provide a great deal of detail on the types of eyewashes for employers. However, where the regulation is silent, OSHA refers employers to ANSI Z358.1-2015, “Emergency Eyewash and Shower Equipment”. The ANSI standard states that an eyewash must deliver 0.4 gallons of flushing fluid per minute for at least 15 minutes. As such, ANSI says that an eyewash bottle (such as those found on wall stations) does not meet this criteria; therefore, can only be used to support eyewashes that do (i.e., plumbed and self-contained units), but cannot replace them.

An assessment of the material or materials used shall be performed to determine the type of flushing/drenching equipment required. If you are at customer job site, portable or temporary stations must be established prior to the use of corrosive materials.  

Automatic External Defibrillators (AEDs)

If you choose to purchase an AED, be sure to check with your state guidelines and requirements. Many states require you to notify your local EMS agency of the location and number of AEDs on-site at your facility. In addition, many states also have laws requiring physician oversight of the program. Regardless of which AED you decide to purchase, they all operate the exact same way and look for the same two shockable rhythms (V-Tach and V-Fib). It's simply a matter of how user-friendly and fancy you want your's to be.

To find out which laws are applicable to your state(s), click here.

Transportation

Based on the first responder’s assessment of the patient(s), decide whether the injured/ill person(s) requires to be taken directly to a hospital’s emergency room, occupational medicine provider, or administer first aid on-site.  

Proper equipment for prompt transportation of the injured person(s) to a physician or hospital or a communication system for contacting necessary ambulance service shall be provided. Choices to consider include, but are not limited to: private automobile, company vehicle, helicopter, crew boat, EMS vehicles (including medi-vac helicopters), or any other transportation that can provide safe transportation to the hospital or doctor’s office in order to provide medical attention to the injured/ill in the quickest manner without any additional complications to the injured/ill employee.  

If you are calling 911 to have first responders come to your facility, stay on the phone with dispatch until directed to hang up. Give them specifics on the location within the facility, but help them out a little bit - send someone outside to meet them. Simply tell the 911 call taker that "We will have someone waiting for you outside the shipping and receiving entrance at gate 2 to lead you back to the patient." This saves precious time by preventing them from going to the wrong side of the building, then EMS having to find their way through a building they've probably never been in before.

Transportation needs must be pre-planned and coordinated with the transportation provider prior to an incident requiring such service. Whenever sending an employee to an outside medical facility, a member of the company should always accompany them. Sometimes EMS will have an extra seat available in the front seat of the ambulance (just don't push any shiny, red buttons!), but if not, just drive yourself over there in a company or personal vehicle.

Summary

It would be nearly impossible to be able to cover every type of medical emergency that an organization could face, but hopefully some of these guidelines will help point you in the right direction. Reach out to your local EMS agency and fire department to determine their capabilities and average response times so that you can incorporate that into your pre-planning. Establishing a good relationship with them can help ensure your employees get the treatment they need and that they know they are the top priority.

If you would like more information about OSHA's emergency action plan standard, visit the OSHA website (or click here). It will provide the minimum requirements for EAPs. However, the most important thing is to continuously evaluate your program's effectiveness and look for ways to improve it. People's lives are depending on it!

Coming up in the next article: Part 7 - Terrorism