Is It Safe?

One of the scariest movies I’ve seen is Marathon Man, a 1976 film starring Dustin Hoffman, Roy Scheider and Laurence Olivier. Hoffman and Scheider play brothers, Babe and Doc, who become involved in a plot by Olivier’s character—Dr. Szell, a Nazi war criminal loosely based on Josef Mengele—to retrieve stolen diamonds from a New York City safe deposit box. After Doc dies trying to stop Szell, the former Auschwitz “dentist” kidnaps Babe to find out what Doc might have told him about Szell’s agenda. Szell repeatedly asks Babe, “Is it safe?” while giving new meaning to the term “invasive procedure.” Babe knows nothing of Szell’s plan and desperately offers every conceivable response to Szell’s interrogation—“I don’t know if it’s safe,” “Yes, it’s very safe,” “No, it’s not safe at all”—before realizing there’s no right answer.

I think safety is just as nebulous in EMS. It’s supposed to be our number one priority; most of our practical exercises require verbal confirmation of scene safety and personal protective equipment before we’re allowed to approach patients. When we do begin care, our prime directive, “First do no harm,” places safety ahead of therapeutics. The messages are mixed, though, in classrooms and the field. Consider the following scenario:

You’re dispatched to an adult female, sick. There’s no other information. You arrive at the scene—a small house in a quiet, suburban community—and announce yourself at the locked door. There’s no response from inside. You try again—still no reply. You notice a half-open single-hung window near the door. It would be easy to raise the window and crawl in. There are lots of reasons not to—the unseen, the unknown, the unwise—but you do it anyway, because you’re wondering if someone’s on the floor. Sure enough, you find an elderly female horizontal and barely breathing. You open the door from inside, update your partner, initiate life-sustaining measures, expedite transport and deliver a critically ill CHFer to the closest ED. Your patient lives, and you never hear about any rules you broke.

Let’s change that scenario a bit: After getting no response from inside the house, you call PD for a possible aided case, etiology unknown. The dispatcher gives it high priority, but it still takes cops 4–5 minutes to respond. They gain entry, clear the scene and escort you to the same CHFer mentioned above—except this time she’s in respiratory arrest, which becomes cardiac arrest, which becomes futile after 20 minutes on scene. You followed the rules and minimized risk to you and your partner, but there’s no positive reinforcement from the chain of command. You find yourself dwelling on what if—forever.

Protocols and textbooks preach the kind of caution exercised in the second scenario. “Don’t become a patient,” they warn. I see the logic, but I don’t think it’s compatible with all cases. Sometimes we have to raise our risk-tolerance threshold.

I’m pretty sure I had a presence of mind about risk when I started in EMS. There were lectures on dangerous chemicals, contraptions, drugs and diseases. I spent my first three years in the field carrying gloves even when I was off duty. I stopped doing that after my first needlestick. A few years later, an unexpected encounter with carbon monoxide left me envious of my fire-service colleagues with SCBA, until I realized I wouldn’t have known to wear it even if I’d had it. Finally, there were some remarkably stupid lifts—patient-laden ground-to-ambulance stair chairs, for example—that now make me wish we’d never evolved into beings of upright posture. Add bouts with viruses of the month, and I wondered why I didn’t find office work more appealing.

The greatest danger I faced turned out to be moving ambulances, when I’m inside them. Four wrecks—two with injuries—emphasized the importance of bench restraints, but left me wondering how I was supposed to treat patients I couldn’t reach. I loosened my seat belts until there was no point in wearing them.

Physical challenges can be dwarfed by mental or emotional ones. Failure to engage—even in the name of safety—can lead to second-guessing and subdued self-esteem. Most EMS providers I’ve known have been obligate rescuers. They want to help. They need to help. Sometimes safety gets in the way.

There’s no amount of prophylaxis that overrides all the dangers of EMS. Caregivers looking for assurances they’re safe would be better off seeking another occupation. The best we can do is take reasonable precautions, and accept the consequences of an inherently risky profession.

No, Dr. Szell, it’s definitely not safe.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.