In EMS, our world is filled with unknowns. We typically enter an incident with a very basic idea of what the call might be, and we perform our craft from there, working with the signs and symptoms we can identify. But working within an industrial facility can create situations that go beyond our standard practices.
The best way to be prepared is for EMS providers to work with industrial facilities before an incident occurs. The situation could be along the lines of a typical medical or a trauma incident. However, it’s also possible that you’ll need to respond to a serious incident or an incident that might require the use of specialized rescue teams and resources. Regardless of the exact circumstances, it is imperative that municipal responders work with industrial facilities to prepare a general plan for responses within their facilities. The time to begin to plan for the unique incidents that can occur at an industrial facility is now.
On-Site Providers and Their Level of Care
Some larger facilities have on-site medical services. These medical services may be offered by providers such as paramedics or nurses, who have full-time medical responsibilities within the facility. In many cases, a nurse will be on site for employee wellness and to treat minor injuries in order to reduce employee visits to emergency rooms and urgent cares.
An on-site nurse may also be responsible for respiratory fit testing and drug test administration. The nurse can respond directly to the field to treat injuries or illnesses. In some cases, full-time on-site providers may also provide emergency response services to other facilities. In these cases, employee training will vary from first responder, to EMT, to paramedic. Sometimes these employees will belong to an EMS organization outside the industrial facility in a part-time or volunteer capacity. These employees bring their experience and skills to their full-time job. Membership on a medical emergency response team (MERT) could be voluntary or it could be a requirement of their position at the facility.
Outside EMS providers should be aware of the level of training of emergency responders on site. They should also know the answers to the following questions:
- Is there an on-site infirmary?
- What level of service will the on-site responders provide first responder, BLS, or ALS?
- What type of equipment do they have?
- Is that equipment compatible with the equipment we have?
- Do they have transport capabilities? (Some facilities will have ambulances on site to transport a patient to the facility gate to meet the outside EMS provider. Other facilities will transport patients directly to the hospital.)
- Who is their medical control and what are their protocols?
Depending on how remote an industrial facility is and the severity of the incident, you may need an air ambulance. Here are questions to explore before an emergency is in front of you:
- Does the facility have a helipad for helicopters to land? Large facilities often have a landing zone for helicopters. If they have a helipad, be sure to find out if the coordinates for the landing zone are on file with the air ambulance service(s).
- Has the air ambulance service looked at the helipad? Recently I was part of a team who conducted emergency response drills at three coal-fire power plants. In all three cases, we had one of the local air ambulance services fly into the facility as part of the drill. This exercise created a twofold opportunity: 1) The service was able to fly in and observe the helipad. In each case, the flight crews identified debris near the pads that could become dangerous projectiles. They also identified that one of the windsocks needed to be moved for a more appropriate placement. 2) Plant responders had the chance to work with the air ambulance team. In fact, one facility’s team brought the patient to the area of the helipad prior to the arrival of the air ambulance. This was a valuable lesson to the responders on the hazards of the rotor wash kicking up debris, dust, and general cool air exposure toward the patient. (Responders should stay well away from the landing zone as aircraft is taking off or landing.)
- Who is going to request the air ambulance? Industrial facilities will often establish a relationship with an air ambulance service and request the air ambulance outside the municipal emergency response system. In the event the facility requests the air ambulance it is vital the ground ambulance is aware of the request. Such awareness and communication will prevent a situation where two air ambulances are dispatched to the scene.
Injury Potential
Is it possible that you’ll be challenged by incidents beyond typical injuries and illnesses? Of course. Crews should meet with officials at the facility to learn about their processes and potential hazards. These hazards could be chemical, mechanical, or environmental, and injuries can result from a range of causes:
Confined spaces: As confined spaces require special training and equipment for entry, it’s important to know where the nearest confined-space team is. Atmospheric issues are the top cause of confined-space fatalities. Crews must not enter a space without the proper precautions. Fifty percent of confined-space fatalities are would-be rescuers, which begs the question: are workers doing their jobs from heights and using fall protection? An employee hanging from fall protection will be saved from a fall, but the effects of suspension trauma will begin to set in if the harness is not properly sized and the employee is not familiar with the deployment of stirrups to take the pressure off their body.
Exposure to high heat or electrical exposure: It’s important to keep in mind that responders are very familiar with orange high-voltage cables in electric vehicles. These cables are typically 480 volts, in an industrial facility 480 volts is considered low voltage. This terminology is important for responders to understand as respond to an electrical injury at a facility and the industrial electrician states the patient was exposed to “low voltage.”
Sheer mass: The sheer mass and storge-energy potential of industrial equipment could lead to crush injuries or trauma. EMS providers must work with facility rescue teams or local municipal rescue teams to establish lines of communications and expectations when it involves confined space rescues, man versus machine incidents, or other incidents where rescues are required. These lines of communications must be completed long before an incident occurs. Rescue can be a very difficult balance of tending to the patient’s needs and patient extrication. Commonly space is very limited and simultaneous medical care and rescue is difficult or impossible. This challenge can be further complicated when the team responsible for providing rescue and the team responsible for providing patient care do not have an established working relationship.
Hazardous materials: While hazardous materials are common at facilities, sometimes the chemicals go beyond what we typically associate with a particular manufacturing process. For example, some industrial processes require ultra-clean water. In such cases, a facility might have a water treatment facility on site. Or perhaps a coal-fired power plant uses demineralized water in its boilers. The hazards associated with coal are known, but as emergency responders are we thinking about the various caustic chemicals that go into water treatment? When it comes to dealing with hazardous materials is there an onsite hazmat team that can respond and evacuate the patient from the Hot Zone and perform decontamination prior to handing the patient off to EMS?
Decontamination: Before you hand a patient off to the EMS, they must be decontaminated. This reduces the exposure effect on the patient, and it reduces the secondary exposure of cross contamination of the EMS crew or the ambulance. EMS must communicate the expectation that the facility will have a Safety Data Sheet (SDS) available to EMS prior to their arrival. The SDS offers guidance on the strength and concentration of the chemical and first-aid requirements. What is the hazard level and the appropriate treatment of the chemical exposure? For example, it’s important to know if a facility pickles titanium with hydrofluoric acid so strong that it requires a medication to be immediately applied to the affected area.
Here’s why: This action will start to combat the devastating damage this highly corrosive material will do on the human body. Failure to apply the antidote cream as soon as possible can result in devastating injury; in the case of a limb exposure the loss of the affected limb is highly likely. Many facilities have the necessary medication on site so they can apply it prior to the arrival of first responders. Ask yourself: As EMS providers, are we familiar with this chemical and with this treatment? How does this treatment fall within our protocols? From an economic standard it is better for the site to purchase and maintain this specialized agent and to leave the agent on site for rapid treatment.
General Facility Conditions
When you’re considering the overall facility, keep questions like the following in mind:
- What are the facility’s general personal protective equipment (PPE) requirements?
- Is our personnel familiar with these requirements?
- Do we have the equipment required or can the facility provide the equipment upon arrival?
Basic PPE on most industrial sites includes:
- Hard hat
- Eye protection
- Long-sleeved shirts
- Safety shoes.
In addition, crews might need to wear personal air monitors while working on site. For example, in refineries personnel within the operational area are required to wear a hydrogen sulfide (H2S) monitor. Or there may be restrictions on the use of electrical equipment due to a potential flammable atmosphere. Does our EMS equipment meet those requirements? If not, we’ll need to move our patient to a safe area to begin our assessment. Our cell phones do not meet the intrinsically safe requirements of many potentially explosive atmospheres within an industrial facility.
Some general industry stressors will expose us to extreme conditions and will challenge us on providing patient care. Here’s an overview:
- Noise level: The noise level will make communication with the patient and fellow team members extremely difficult. Ambient noise conditions may require responders to wear hearing protection and, in some cases, double hearing protection.
- Temperature: The general temperature of many facilities is typically greater than emergency responders are used to. Responders must take precautions to avoid touching the equipment. And more importantly they may need to take heat precautions for extended operations, even for incidents in the winter. Industrial workers are typically conditioned to work in this extreme heat but fellow responders may quickly fall ill to heat exposure creating additional patients.
- Surroundings: Responders must be aware of their surroundings within an industrial facility. Moving equipment and self-starting equipment can find an emergency responder in a bad place. Crews need to be very aware of their surrounding and the hazards that exist.
General Facility Layout and Access
When you arrive at a facility, take the following factors into consideration:
- Is there a standard location for EMS to arrive at or are there multiple locations?
- In the case of multiple locations how first responders learn about the location?
- Will someone meet EMS at the gate to escort them to the patient? When arriving at a facility, it is always beneficial to have someone there to escort emergency services to the emergency area. Industrial facilities are complex and personnel can quickly find themselves lost or in a place where they should not be.
- Are nonemergency crews aware of any on-site speed limits? Nonemergency crews must be aware of speed limits, and speed limits should be heavily enforced.
- Are there streets within the facility? If so, do the streets have names? In many cases, numbered streets run in one direction and lettered streets indicate the streets running perpendicular. For example, numbered streets may run east-west and lettered streets may run north-south. Columns inside the structure can be labeled the same way. A row of columns is labeled with letters going one way across the structure and a row of numbers going the opposite way. So, each column will have a letter and number designation.
- Are the building and process units laid out in floors, grades, or grades above sea level? Many industrial facilities are laid out in tiers based on equipment needs. Sometimes there may be a half floor located between two levels. Other times one may travel 20 feet or more vertically before the next elevation. To confusion, some facilities employ a grades-above-sea-level approach. For example, if the ground floor of a facility is 411 feet above sea level, the ground floor would be known as Grade 411. If you traveled 10 feet up to the next floor, that would be Grade 421.
- Do you need to have familiarity with compass directions? This can be challenging for anyone who struggles with directions. This can be further challenging because facilities will use an orientation known as Plant North, which may be slightly off from the actual North. Plant North is helpful for orientation in the day-to-day operations of the plant, but it does little for incoming responders when it’s off by a couple of degrees.
Communication and Time
Once they arrive at the facility, crews may take several minutes to arrive at the patient. Crews should give some consideration to notifying dispatch when they arrive at the patient. This notification will give a more appropriate documentation on when patient care began.
Elevators: In the case of removing personnel from upper levels of a facility it may be beneficial to use a freight elevator vs. a standard passenger elevator. Freight elevators are typically larger and have a higher weight capacity. It may make more sense to use this method to transport a patient on a stretcher with a care team.
When it comes to utilizing elevators, is it possible for the facility to place the elevator into Phase II operations, so they have total control of the elevator during a high-rise fire? The use of Phase II during an EMS response ensures EMS has complete control of the elevator. It also ensures the elevator will ignore any other calls for service. This control allows emergency responders to expedite their access to the level the patient is at and insure the car is at the level waiting when it comes time to remove the patient.
Responders might find themselves walking on catwalks or elevated grating to access the patient. Rolling a stretcher on grated walkways can create a lot of vibration on the patient. And in many cases, these walkways are narrow. They can present some psychological hazards to responders who are not used to working from height, particularly if they look through the grating and see how high they are.
With all of this in mind, EMS must identify the most appropriate route to remove the patient.
The Critical Need for Building an Early Relationship
Building a relationship and a response plan with emergency responders long before a call for service comes is a critical piece of preparation. This relationship will pay off when you arrive on scene and are faced with a potentially very complex incident. Serious industrial accidents are rare but when they occur, they can be complicated and life threatening. As emergency providers we always want to do our best to improve a patient’s outcome.
Brian S. Gettemeier has been in the fire service for 31 years with the last 28 years as a career firefighter with the Cottleville Fire Protection District of St. Charles County (MO), where he serves as an engine company captain. Gettemeier is a second-generation firefighter. He has a bachelor’s degree in fire service management from Southern Illinois University at Carbondale and holds numerous state certifications. He teaches hazard classes for numerous municipal and industrial organizations throughout Missouri and Illinois.
Brian Gettemeier will present “A Municipal Firefighter’s Guide to Industrial Accidents” at FDIC International in Indianapolis, Indiana, on Friday, April 19, 2024, 10:30 a.m.-12:15 p.m.
More: https://www.fdic.com/