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3.1 Discussion
In confined spaces such an ambulance vehicle the danger of being infected by a contagious disease
that is spread by aerosol is a real possibility 3. Therefore, if we know that a patient is infected with an
airborne disease before transportation, we can take infection control measures and carry out specific
disinfection procedures to combat the infecting agent 4. If we are properly informed, the procedures
can be performed to avoid cross infection of practitioners and other patients. But cleaning alone is
probably not enough. Shigella sonnei can remain on a glass or metal surface for up to 10 days at
temperatures of 15°C. Staphylococcus aureus sticks to hospital cleaning equip-ment such as mops for
over 56 days.5 So the strict and rigorous implementation of these procedures is very important
because if is not done correctly and thoroughly we cannot guarantee that we have eliminated the risk
of infection. And sometimes in ambulance services the cleaning is made only by alchohol or some
alchohol based solution. But we often forget that disinfection procedures with sodium hypochlorite,
70% ethanol or chlorhexidine all work very well as bactericides but not as virucides. 4 So we need to
follow the instructions given on the liquids that we are using.
Another problem identified out by the survey is the lack of information given to the EMS providers
about the patient status. Let imagine that in the next weeks another SARS epidemic occurred. That
brings up even more issues given that potential scenarios involving epidemics could affect national
and even international security. 6 And a possible lack of information can mean infection for EMS
providers and even more patients. But in that case the information about the patient status will be
probably given. Why only in the worst-case scenarios? Why is important to have the right information
in time? Only because that is the only way to ensure a safe level of procedures. So if in some diseases
as cases involving viral hemorrhagic fevers, the plague, smallpox and the flu can be enough to isolate
the patient and guarding his airway7,8 in other situations only by using Individual Protection
Equipment (IPE), medical personnel can increase their level of protection as a preventive measure
against the risk of infection.9,10 However, we must bear in mind that the correct (and necessary) level
of individual protection is completely ineffective against contagion if there is no training on how to use
it.4
When a contagious patient is to be transported by ambulance the use of medical transportation
vehicles with a dividing panel that separates the driver from the patient area11 should be compulsory,
and for greater protection vehicles should have High Efficiency Particulate Air Filtration (HEPA) to
prevent infections spreading from the vehicle to the outside. Moreover, the amount of medical
material used should be kept to a minimum and any equipment that generates aerosols as well as
humidifiers should be avoided. The inside surfaces should be protected with single use, waterproof,
plastic covers because of the risk of infectious particles that could be deposited there or that might
cling to the different horizontal and vertical wall surfaces. 4
Isolation devices and procedures for transporting patients in cases of NBC (nuclear, biological,
chemical) danger have been introduced in EMS services. The use of isolation in the medical
transportation of individuals affected by a contagious infection in a scenario involving an epidemic, or
who have been contaminated in a technological or NBC incident, would create distinct advantages for
the patients and medical staff (and the rescue team). 4 Time would be saved, the available medical
resources would be managed more effectively, and the quality of care would be improved.
In addition to the various solutions mentioned so far - information about the patient status and
diagnosis, self protection, patient isolation and proper vehicle cleaning - there are some other items
that should be included in protocols for ambulance transport of a contagious patient. One simple but
sometimes forgotten example is mandatory hand cleaning. Another is the proper use of masks for both
the patient and for the practitioner.
Some useful guidelines can be gleaned from a protocol intended for the transport of TB patient 13.
This states that the ambulance ventilation system should be operated in the nonrecirculating mode,
and the maximum amount of outdoor air should be provided to facilitate dilution. If the vehicle has a
rear exhaust fan, use this fan during transport. If the vehicle is equipped with a supplemental
recirculating ventilation unit that passes air through HEPA filters before returning it to the vehicle. If
possible, physically isolate the cab from the rest of the vehicle, and place the patient in the rear seat.14
URGENTNA MEDICINA - IZBRANA POGLAVJA 2010
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