Prehospital healthcare workers include many thousands of healthcare workers in many organizational settings. Some work full time as emergency medical care workers for private or public providers. Others spend most of their time conducting other tasks (e.g., fire fighting) but must occasionally provide emergency medical care. Others volunteer their services, spending a few to many hours every week with volunteer rescue squads (usually in rural areas).

These workers also differ in their medical training. Some have years of specialized training for their careers and frequent updating of their medical training. Others have only very limited emergency care training and little continued training because of their other job requirements.

The common tasks performed by these workers include the provision of emergency medical care outside the hospital (or healthcare facility) setting and the transport of these patients to healthcare facilities. The types of patient being cared for obviously vary among different prehospital care providers. Some mainly transport patients who are not critically ill, whereas others mainly respond to trauma incidents. Geographic location and many other factors obviously affect the potential exposure of these workers to people with communicable diseases.

The workplace for prehospital healthcare providers can be viewed as including four settings: (a) the accident scene or other place where initial care for the patient is provided, (b) the transport vehicle, (c) the healthcare facility receiving area (usually emergency room), and (d) the facility in which the responder is stationed (e.g., hospital,
fire house). From the perspective of infection control, the third setting is not discussed in this chapter. However, it should be noted that emergency medical providers may be at some risk for acquiring infections even after arrival at the healthcare facility.

The site of the initial care (e.g., patient’s residence, accident scene) is probably the most problematic of the four locations. In contrast to most other healthcare workers, the emergency medical responder usually has little information about the patient’s condition when initially providing medical care at the scene. Thus, the responder is usually not aware of whether the patient has a communicable disease. Collection of some diagnostic information is obviously a critical aspect of providing initial emergency care, but information about a specific infectious disease often will not be obtained. Often, a specific infectious disease will not be diagnosed until after the patient has been hospitalized.

In providing care, the responder usually must rely on verbal information from the patient or the family that may not fully reflect the patient’s medical condition. In some cases, the patient may be unconscious and otherwise unable to provide any information, and knowledgeable family members may not be present. In the absence of specific diagnostic information, the responder must depend on his or her initial physical assessment of the patient, perhaps with additional knowledge such as the likelihood of the patient having an infectious disease because of the geographic location (i.e., how common is the disease in that area).

The responder not only lacks diagnostic information but must also provide emergency medical care at the site. In many cases, this care must be provided at the patient’s residence. The responders may have a very limited work area and poor lighting, making certain procedures, such as starting intravenous lines, difficult. In addition, the patient may be combative or otherwise difficult to manage, further increasing the risk of this type of procedure. For airborne communicable diseases, there may be increased risk of exposure, because the responder must work in a residential environment in which the patient has been staying. This area may lack adequate ventilation and may have contaminated surfaces.

An accident or trauma scene may pose additional dangers. In addition to the limited space, poor lighting, and other problems, the trauma scene may have broken glass and other sharp objects that could contribute to the spread of blood-borne pathogens. In some cases, the responder may have to spend a long period stabilizing the patient until the patient can be extricated from a motor vehicle. Taking proper infection control precautions in a confined space with a seriously injured patient may be quite difficult.

Another aspect of providing emergency care at the scene that is obvious but is especially important is that all protective equipment that is needed at the scene must be carried by the responders. If they do not bring the necessary equipment with them, the equipment must either be retrieved from their transport vehicle or from their station or not used at all. Anticipating what will be needed and then providing ready access to that equipment can be quite challenging. The availability of equipment may be particularly problematic for responders who most often fulfill other duties (e.g., law enforcement or fire fighting) but are also expected to provide emergency medical care.

The situation in transport vehicles is somewhat better. The patient is usually stable enough to be transported. Better medical and monitoring equipment is also available. However, this setting also has a number of problems. First, patients often must be rapidly transported to the hospital and may often be in very critical condition. Medical care and procedures such as starting intravenous lines must be conducted very quickly. Most transport vehicles have very little room, further compounding this problem. Transport also may cause problems because of the movement of the vehicle during transport. This is obviously a problem while trying to perform procedures during transport (e.g., insertion of intravenous lines). Another potential problem is that most emergency transport vehicles are poorly ventilated. Most ventilation either comes from opening windows or from the vehicle’s heating or cooling systems, which often simply recirculate most of the air in the vehicle (2). Recent studies have also demonstrated the potential for surfaces in the transport vehicles to be contaminated with methicillin-resistant Staphylcoccus aureus and other bacterial pathogens that may be a source of risk for both the patients and the prehospital healthcare workers (3,4).

Another site where emergency medical responders work is their station. In some cases, this may be a hospital. In others, it may be a fire house or a similar structure. Some responders may even work from their homes (e.g., rural volunteer units). This location is most important in terms of infection control in that responders must often return to that site to clean their equipment. Proper equipment and practices for this setting are obviously important.

Prehospital healthcare workers share many of the risks of occupationally acquired infections with healthcare workers in other settings. Although most of their contacts with infectious patients are relatively brief, the lack of information about the patient’s conditions and difficult environmental conditions may increase their risk relative to the more controlled hospital environment.

There is relatively little documentation of the actual risk of occupationally acquired infections among emergency medical providers. Hepatitis B has probably received the most attention (5). However, other infections have occasionally been reported. For example, there is a case report of toxic shock syndrome in a firefighter from a Streptococcus pyogenes infection acquired from cardiopulmonary resuscitation of an infected child (6).

Although somewhat dated, the most complete documentation of the infectious diseases risk for prehospital healthcare workers comes from a survey of the emergency medical service in Portland, Oregon (7). Using verbal and written exposure reports and other sources, the author documented 256 reported infectious disease exposure incidents over a 2-year period (1988-1989). The incidence of reported exposures was 4.4 per 1,000 emergency medical service
calls. Of these, approximately 24% involved respiratory exposure and 47% involved exposure of intact skin. Approximately 29% involved the exposure of nonintact skin or mucous membranes to blood or other body fluids or needlesticks. Fourteen incidents involving either needlesticks or exposure of nonintact skin or mucous membranes to blood or other body fluids were reported over the 2-year period. Although difficult to generalize to other emergency medical settings, these data do provide some sense of the scope of infectious diseases exposures for prehospital healthcare workers.