It's Always 'Safety Third' In Emergency Medicine— Covid-19 Or Not, The First Priority Is Patients


 
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By Sarah Frances McClure, DO, Seth Collings Hawkins, MD, Christopher Ashby Davis, MD & Benjamin N. Abo, DO

"A ship in harbor is safe, but that is not what a ship is for." -William Shedd, Salt from My Attic (1928)

Emergency medicine physicians have a long history of caring for large volumes of patients in challenging, resource-limited, and overburdened environments. Despite many forefathers and foremothers dedicating their work to medical care in the emergency setting, Emergency Medicine as a boarded specialty, is relatively young, having only been recognized as a specialty in 1979. However, our heritage is deep and may serve as a case study for other specialties in dealing with pandemics, disasters, and societal threats.

The term "in the trenches," frequently used to describe emergency medical work, reminds us of our common mission throughout medicine to care for the sickest and unruly of patients, as well as the wartime-like environment many of us feel we work in. We are all in this together -- multiple minds, one team, strength, power. The term "the shop" in reference to the emergency department reminds us that the work we do is methodical to us as if we were mechanics of the body, but alien to those standing on the outside.

We care for anyone who walks through our doors without question of ability to pay or even desire to follow up all of the work we pour into each individual. We see a problem as a challenge, and we accept the challenge -- time and time again. Our work is physically and emotionally exhausting at baseline but we constantly train for the surge in capacity that happens daily around the country. In the war on COVID-19, emergency medical professionals and EMS may be the shock troops, the spear point. Still, there is a vast army of professionals also engaged in the conflict, who need an equally robust explanation of the risk management plan for delivering health care in this pandemic era.

We published the "Safety Third" concept in 2018. That article, outlined an emergency services paradigm with intellectual roots in the Safety Third concepts of Burning Man and in the works of Mike Rowe from "Dirty Jobs."

The fundamental postulate of the argument is that "Safety First" can never be accomplished in emergency services. Emergencies do not occur in safe environments. Here, we suggest that risk management paradigm can be extended to pandemic management by healthcare professionals as a whole.

The article addressed the question of, "if safety is third, what comes first and second?" First there must be a mission, and accomplishing it is the first goal. Second, the player's heart must be in that mission. You, as an emergency medicine physician, must identify with that mission to justify putting yourself at risk. You must not only identify with that mission but you must accept that mission. Third, safety protocols can be implemented to lessen the risk involved, and increase the probability of success, when completing the task at hand -- bringing safety into its rightful place as a contextual modifier within the very first priority. This paradigm was developed out of Hawk Ventures and its Carolina Wilderness EMS Externship program. A 2019 extern, John Allen, himself a Special Forces combat veteran and now a fourth-year medical student, expressed these principles succinctly: "Get it done (mission first), have fun (purpose), and safety is third."

This idea of Safety Third in prehospital and emergency medicine rings truer than ever now amidst the COVID-19 pandemic. Nowhere is safe -- our jobs, our homes, our grocery store, our parks. By the time this article is posted, the number of cases may have doubled, tripled, quadrupled. The economy has plummeted as our citizens are ordered to stay at home and avoid social contact in a social distancing public health effort not seen within the last 100 years, designed to keep the caseload manageable for our current healthcare system. Safety first is not relevant anywhere right now. The hospital is the least safe of all places as COVID-19 patients sit in the hallways waiting for rooms that will likely not be available during the course of their illness.

While the entire world is mandated to be tucked snugly inside of their homes, we, emergency medicine physicians, and other critical operators on the healthcare team, venture out of our homes to the hospital where the threat is imminent.

We go every day to face our fate. We put ourselves in the line of danger because we have a mission -- for the good of our communities, we must work mechanically, diligently, and as quickly as possible in a disaster zone with no end in sight. We accept that mission. We thrive in that mission.

This is not to say we are not anxious, frustrated, or angry. We are human and we are vulnerable. We are all of these things at various points during our days. We are a special breed of physician, and we show up when others cannot. We push past these thoughts of anger and feelings of frustration and fear. We have trained for this. We show up because we identify with a mission to care for our fellow humans suffering from a disease that we, ourselves, fear.

Safety Third recognizes that we do have steps we can take to make the process of achieving our very first priority, accomplishing our mission, safer. Personal protective equipment (PPE) is critical to accomplishing those steps. One need only read the moving words from a former Ebola nurse to understand how PPE, and safety, are crucial to the first priority of "Get it done":

"Doing nothing [if you don't have PPE] may be the hardest thing you've ever had to do in your life. Many of you say, I could never do that. I wouldn't be able to stop myself from rushing in and saving my patient. Liberian nurses and doctors said the same thing, and many did run in to help, saying 'PPE be damned. My patients need me.' Then they became infected, they infected others. And they died. They didn't help anyone after that. Do not let the deaths of hundreds of healthcare workers be forgotten."

We have watched our fellow physicians, nurses, patient care technicians, EMS personnel, and law enforcement personnel contract this virus and die. We have appealed to our administrations for the right to wear PPE or for assistance in obtaining PPE. These are the same administrators that have preached "Safety First" all of our careers and the same NIOSH that has governed our safety-first PPE mandated by OSHA. We have voiced our anger with the changes of federal standards based less on science and more on availability set forth by NIOSH. We have stood up against those telling us to "calm down" and "a surgical mask will be fine." We recognize our needs, and we fight. We fight together, no matter our differences.

It is up to us to support each other through this pandemic. It is up to us to create social media groups with our peers across the world who voyaged this sea first. It is up to us to share workflow and to support each other emotionally through this tragedy. We have created our own protocols with our families and roommates to keep them as safe as possible while we fight on the frontlines. We have sat down and had difficult and unfortunately necessary discussions with our loved ones surrounding what happens if we succumb to this disease. Some of our families have determined that the mission to keep the family together, and as seemingly as normal as possible, is stronger than the mission to avoid contact with each other. Some of our families have determined that the mission to avoid transmission between family members is most important.

These are decisions that each physician and his or her family must make together -- intentional or not, these decisions are weighed against the Safety Third model. What is the family's mission? Is the family connected to this mission? What safety protocol can be put in place to support this mission?

In the end, we recognize that our best protection against this disease is proper PPE. It is PPE that can be worn every shift for the entire shift and that follows best practices and science rather than political considerations. We gather together to share resources and knowledge surrounding proper PPE to protect ourselves and our colleagues against this virus. We have seen our peers and colleagues fired while fighting for proper PPE to be provided and worn in our departments and throughout the hospital. Our professional societies have taken a strong stance to protect their emergency physicians with proper PPE and against administrations retaliating against physicians speaking out for their safety to simply be third. We need to unify behind this message. Safety may be our third consideration on its own, but during a pandemic, it is intrinsically required to complete our first priority: getting the job done and caring for our patients.

 
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