DANGER IN THE STATION: DRUG-RESISTANT INFECTIONS

DEREK WILLIAMS

As fire and emergency services workers, we are constantly reminded of the inherent dangers of our jobs. We accept these dangers as manageable risks to protect lives and property. We do this out of a sense of duty and try to eliminate as many of the risk factors as we can. As the world changes, so do the hazards of our jobs. We must recognize these new hazards and manage them with a proactive approach rather than from a reactive crisis management standpoint.

An emerging new hazard to our ranks is Methicillin-Resistant Staphylococcus Aureaus (MRSA) (photo 1).

(1) Electron micrograph of MRSA. (Photo courtesy of Wikipedia free encyclopedia.1)

MRSA is a type of staph infection that is resistant to antibiotics called “Beta-Lactams,” which include methicillin and other more common antibiotics such as oxacillin, penicillin, and amoxicillin.2 Because these bacteria are unique in that they remain unaffected by all but the highest concentrations of antibiotics, they are extremely difficult to treat, especially if allowed to remain untreated inside the body over time while gaining strength.

MRSA is commonly found on the skin and in the nose of healthy people. It is estimated that approximately 25 to 30 percent of the population is colonized with staph, approximately one percent being colonized with MRSA. The truly serious nature of MRSA arises when it finds its way from on the body to inside the body. This may occur from even the tiniest cut, scrape, or abrasion.

CLASSIFICATIONS

There are two classifications of MRSA. The first is Hospital Based MRSA. MRSA occurs most frequently among persons in hospitals and healthcare facilities (such as nursing homes and dialysis centers) who have weakened immune systems.

The second classification is Community Associated MRSA, more commonly referred to as CA-MRSA. These infections are acquired by persons who have not been recently hospitalized (within the past year) or have not had a medical procedure such as dialysis, surgery, and catheters. Staph or CA-MRSA infections in the community are usually manifested as skin infections such as pimples and boils and occur in otherwise healthy people.

TRANSMISSION AND CHARACTERISTICS

CA-MRSA most commonly can be encountered in the following places or ways:

Communal living areas [fire stations, locker rooms, jails, and social services housing (half-way houses), for example].
Shared personal items such as bedding, towels, razors, and bar soap.
Shared personal hygiene areas such as sinks, showers, and toilets.
Equipment such as cardio equipment, weight rooms, sports “pads”/protective equipment, firefighting turnouts, and EMS/CPR manikins.

MRSA is transmitted most frequently by direct skin-to-skin contact, referred to as “direct transmission.” MRSA can live on surfaces (especially warm, moist surfaces) for extended periods of time, the exact length of which has not been specifically identified. Its ability to live on surfaces such as gurneys, bedding, and bar soap can lead to “indirect transmission” of MRSA to emergency services personnel.3 Factors that have been associated with the spread of MRSA skin infections include close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene.

Staph bacteria, including MRSA, can cause skin infections that may look like a pimple, boil, or spider bite (a very common misdiagnosis) and can be red, swollen, and painful with pus or other drainage (photos 2-5). MRSA infections are usually asymptomatic in healthy individuals and may last from a few weeks to many years. More serious infections may cause pneumonia, bloodstream infections, surgical wound infections, and even death. Symptoms include fever, lesions, shortness of breath, high fever and chills, wound drainage, or increased white blood cell count. Infection warrants treatment.

(2-5) “Typical” MRSA manifestations. [Photos courtesy of Phoenix (AZ) Fire Wellness Office/MRSA Power Point®.]

COLONIZATION

As discussed, asymptomatic individuals may have MRSA but not show any signs or symptoms. This coupled with the bacteria’s ability to live on inanimate surfaces may lead to what is referred as “colonization.” With colonization, MRSA is present in or on a body site; no clinical signs or symptoms of illness or infection are present. Colonization may not warrant treatment, but a colonized patient may transmit MRSA to others.

Colonization may be found in “pods” or “clusters.” This occurs when a number of people from the same social or work group test positive for MRSA. The Centers for Disease Control and Prevention (CDC) has investigated clusters of CA-MRSA skin infections among athletes, military recruits, and prisoners.4 Clusters of MRSA in locker rooms have been a hot topic of discussion among athletic trainers and coaches for almost a decade.

EFFECTS ON EMERGENCY SERVICES WORKERS

How do MRSA and CA-MRSA affect emergency services workers? We are a particularly high-risk group. We contact patients with MRSA not only in medical settings such as nursing homes and dialysis centers but also patients with CA-MRSA in group homes, shelters, jails, and so on. We are a high-risk group for CA-MRSA just by the very nature of our jobs. We, for the most part, live a “communal” lifestyle at the fire stations, sharing close quarters and personal hygiene areas/items.

MRSA has already touched the fire service. The following are examples of MRSA infections and cases of “clusters” of MRSA found in several fire departments.

•The Phoenix (AZ) Fire Department (PFD) and the City of Los Angeles (CA) Fire Department (LAFD) were valuable resources, because they have been actively tracking MRSA infections. Because of this, the LAFD as well as the PFD were able to collect data regarding the number of MRSA and CA-MRSA exposures. Tracking of MRSA among fire department members has proven difficult because MRSA either was not identified as the initial cause of injury and reported to infection control officers or members simply treated the infection with the help of their primary care physician and the use of sick time. The Mesa (AZ) Fire Department has recognized this as a significant threat to our membership and now is actively tracking MRSA and CA-MRSA infections among our members.

The Los Angeles (CA) Fire Department

Since April 2003, the LAFD has had 136 claims for possible MRSA infection. Of these, 50 were confirmed MRSA cases, five of which required hospitalization of the members for aggressive antibiotic treatment. The LAFD also found “clusters” of MRSA at certain fire stations where several crews on several shifts contracted MRSA despite no known source patient contact.5 It was found that the MRSA in these cases was CA-MRSA (community-based MRSA) transmitted to the members by surface contact of unclean work areas such as the workout rooms, bathrooms, and kitchens.

Since then, the LAFD has issued new strict guidelines/standard operating procedures related to station cleaning procedures, personal hygiene, and personal protective equipment during patient contact as well as proper decontamination (hand washing with liquid soap) after every medical call. Since these procedures have been put into place, the LAFD has seen a dramatic reduction in MRSA-related industrial injuries.6

The Phoenix (AZ) Fire Department

During the years 2004 through 2006, the PFD had 29 cases of MRSA infections. Eleven members required some level of hospitalization for treatment. Since then, with the help of the department’s infection control physician, Dr. Sem Jou, Phoenix has instituted procedures to protect its membership.

Dr. Jou has educated the members relative to the benefits of cleanliness, hygiene, proper diet, rest, and the risks of neglecting these areas. Phoenix has also installed antibacterial hand cleaner dispensers in various areas of the stations, including the entryways, bathrooms, and kitchen. Dr Jou and the PFD have emphasized prevention and education. The result has been a marked decrease in the instance of MRSA infections among members.7

The Mesa (AZ) Fire Department

Mesa Fire has already had MRSA cases within our ranks. More members may have been infected with MRSA; most likely, some cases went unreported or were not diagnosed. Although we have an extensive Wellness Program, only until recently have we recognized the potential of MRSA and CA-MRSA to affect our members. Here are just two cases of MRSA affecting our members.

Case 1-Mesa Fire Department Engineer/EMT: In September 2001, a Mesa firefighter/engineer from Station 10 went to fourth-quarter training and participated in rescue drills crawling in full turnouts. At 11 a.m., he noticed a small red bump, similar to an ingrown hair, on his knee. By 3 p.m., the firefighter had a fever, and his knee was hot to the touch and was swollen and painful to move. He went to a local emergency room and was given his first dose of oral antibiotics at 9 p.m.; he then went home to rest.

The next day, the firefighter went to his primary care physician and was given a shot of concentrated antibiotics and instructed to increase his oral dose. Two days after noticing the bump, the firefighter went to see an orthopedic physician (associated with Mesa Fire for member injury treatment) because the pain was increasing and he believed that he had an orthopedic injury. The physician recognized it as aggressive MRSA and admitted the firefighter to a local hospital, where he was on IV antibiotics for four days.

This case illustrates not only that MRSA can be easily misdiagnosed but also that not all physicians know that MRSA should be considered in their diagnoses. For this reason, it is important for health care providers to keep abreast of changing patterns of infection in their local communities to properly diagnose and treat these cases.8

Case 2-Mesa Fire Department Captain/Paramedic: One afternoon in April 2006, a Mesa fire captain on duty at Station 6 noticed an irritation on top of his foot. By 9 p.m., the irritation had formed a small bump, similar to an ingrown hair, with redness and swelling around it. The captain went to his primary care physician two days later. The doctor examined the bump but did not identify it as MRSA. The captain was given a shot of antibiotics and a script for oral antibiotics.

After five days, the foot was painful to touch, hot, red, and swollen. On the sixth day, the captain went back to his primary care physician. When consulted, another doctor in that office, who had been involved in treating military personnel in the past (one of the other high-risk groups), recognized it as aggressive MRSA. The captain spent the next three weeks on high-dose antibiotics. Only after two weeks did the captain see any improvement to his foot. The captain told the Mesa Fire Wellness Office captain that during this process he began to wonder, “Will I be able to do my job with a prosthetic limb?” That’s how bad it got! He was sure he would lose his foot (photos 6-8).

(6) The wound after the first doctor appointment. (Stock photos of member injury. Used with permission of injured member.)

(7) The wound at its worst. The captain already had been given antibiotics by injection and mouth for several days.

(8) The wound started to heal after he had been on antibiotics for two weeks.

IAFF: “SERIOUS HAZARD FOR FIREFIGHTERS”

The International Association of Fire Fighters (IAFF) recognizes this as a serious hazard to firefighters. The following quotes are from the IAFF’s main Web site at www.iaff.org/safe/content/MRSA/MRSA.html regarding firefighters’ health and MRSA:9

“Firefighters, by nature of their contact with the public, are in constant danger of exposure to many infectious diseases. MRSA is a serious, potentially life-threatening infection.”
“The primary concern for firefighters is the switch from hospital-acquired to community-acquired infections.”
After reviewing this issue and recent events, IAFF General President Harold A. Schaitberger stated, “Following universal precautions with every patient contact, including hand washing, is very important-regardless of whether or not the patient’s disease status is known. What you can’t see may kill you.”

PROTECTING AGAINST MRSA

So how do we protect our membership from MRSA infection? There are several things we need to do to stop the spread of MRSA and protect fire and emergency workers:

Wear personal protective equipment (PPE) on all medical calls.
Use personal hygiene before and after calls/decontamination.
Clean the station and follow personal hygience protocols.
Clean workout rooms and equipment.
Clean turnout/PPE.

Placing a barrier between you and the patient greatly decreases your chances for MRSA infection. Current PPE guidelines and techniques create a very effective barrier. Continually wear gloves during patient contact; remove them whenever you must access equipment. Don a fresh pair of gloves when patient contact is resumed. But as stated before, MRSA can live on surfaces. You must use PPE during the entire call, including during decontamination procedures afterward. Before and after decontaminating equipment, wash your hands thoroughly. In addition, always consider the following when it comes to protecting yourself from MRSA:

Have you touched unprotected areas of the scene-did you kneel on the floor with shorts (if they are part of your uniform) or handle items/equipment on-scene with contaminated gloves?
Are you bringing MRSA, along with other contaminates, back to the station or your home and family on your boots or clothes?

After a call, make every effort to wash your hands and any unprotected area that may have contacted the patient or equipment. The CDC recommends using an alcohol-based hand cleaner as a first-line decontamination agent if hands are not visibly contaminated. If hands are visibly contaminated, wash hands with liquid soap (do not use bar soap-MRSA lives on bar soap) immediately after a call; then use a disinfectant hand cleaner. Hand washing alone is inferior to alcohol-based hand cleaners for the purpose of decontamination unless the hands are visibly contaminated. Antibacterial/alcohol-based hand cleaners that do not require water for use should be kept on all apparatus for this purpose. At the Mesa Fire Department, we have issued a Medical Personal Protective Equipment Pack to our entire membership. This PPE pack consists of a fanny pack holding such items as glasses, gloves, medical protective sleeves, TB-masks, and antibacterial hand cleaner. This pack can be carried on members during every medical call to provide initial PPE as well as backup PPE to replace soiled/contaminated equipment. The PPE pack has been used very successfully within our department (photo 9.)

(9) Mesa Fire Department PPE Pack. [Photo courtesy of Mesa (AZ) FD.]

CLEANING PROTOCOL

Decontaminating all equipment, including the med boxes, after each call is essential. If equipment is thoroughly and properly decontaminated after each call, it eliminates the potential of contacting MRSA and other contaminants on equipment surfaces. Many times, medical equipment is given detailed decontamination attention after a call. However, the boxes/bags in which the equipment is carried are often neglected. Often, boxes/bags containing medical supplies are placed on unclean surfaces during the course of medical treatment. If not properly decontaminated, they could potentially expose members to MRSA and other biohazards during normal equipment handling at a later time. A disinfectant or bleach concentration can be very effective in decontaminating such equipment. Spray the box/bag with a disinfectant, and do not wipe off. Allow the disinfectant to sit on the equipment and air dry. This is the only way to kill MRSA effectively.

Even if you do not run medical calls or are exposed to patients on a regular basis, the danger of CA-MRSA still exists at fire stations. Proper hygiene and cleanliness are the only ways to combat CA-MRSA clusters at fire stations. We need to take a “back to basics” approach to cleaning the stations and equipment. This must be done each day with particular attention to detail on our Saturday station detailing/cleaning routines (if that is part of your department’s culture). Disinfect surfaces, paying close attention to common areas. Saturate the area to be cleaned, and let the surface air-dry. Wash bed covers, blankets, and other linens commonly used routinely. Pay particular attention to the kitchens, bathrooms, workout areas, and equipment each day; give them a thorough disinfecting at least once a week.

A cleaning schedule for EMS and community training equipment, such as CPR manikins, should be devised to ensure that all pieces are cleaned on a regular basis following manufacturer guidelines. This is especially important for equipment used by multiple providers and students. Don’t forget the areas of the apparatus that should be disinfected, such as door handles, headsets, and the steering wheel.

MRSA stays on warm/moist surfaces for unknown/extended periods of time. Each time you use exercise equipment, disinfect it for the next person. Not only is this common courtesy, but cleaning equipment after each use has been proven to help halt the spread of CA-MRSA. (4)

Keeping firefighting PPE/turnouts clean is another essential step to limiting MRSA and CA-MRSA infections. Departments should institute a turnout cleaning procedure following guidelines set forth in NFPA 1500, Standard on Fire Department Occupational Safety and Health Program, Jan 31, 2002; NFPA 1971, Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting, Feb. 7, 2005; and NFPA 1581, Standard on Fire Department Infection Control Program, Nov. 12, 2003, for protective clothing and equipment; Occupational Safety and Health Administration (OSHA) standards regarding infection-control programs; and manufacturer guidelines.10

Mesa Fire’s system for turnout washing combines an in-house cleaning program with dedicated washers and specialty dryers for turnouts and a private contractor certified by the manufacturer for turnout repair and cleaning (photo (10). We have had great success with this system, scheduling regular turnout cleaning through our battalions as well as having an emergency cleaning repair system in place. This system is supported by Saturday PPE inspections by the company officers. The department is also considering issuing two sets of turnouts to all members. This would allow a member to have a clean set of turnouts on hand at all times should one be contaminated. This also allows members to schedule routine cleaning of their turnouts and still be available for shifts and overtime. A system that ensures PPE cleanliness and repair not only greatly decreases the chance for exposure to MRSA and other biohazards but also ensures that the turnouts are in good operational condition at all times.

(10) Mesa Fire Department turnout washing area. (Photo courtesy of Mesa (AZ) Fire Department.)

EDUCATION: THE FIVE Cs

The best way to prevent MRSA and CA-MRSA is education. The CDC has distilled the educational components down to “The five Cs”: close contact, contaminated items, crowding, cleanliness, and compromised skin.11

Close Contact (skin-to-skin): We must continue to encourage the use of PPE on medical calls and whenever there is close contact with customers in the field. We must continue to evaluate the adequacy of current PPE and challenge paradigms regarding equipment and procedures. We must continue to change as the world does, to allow our procedures to reflect current threats to our membership.
Contaminated Items: We must continue to emphasize proper decontamination of equipment (including turnouts) and provide procedures, develop guidelines, and provide properly equipped areas/facilities to support contamination.
Crowding: The CDC regarded this as a high priority primarily for areas such as jails, social service housing, and the like. However, we must understand that the very concepts of camaraderie and family that we instill in our membership and take pride in also predispose us to CA-MRSA clusters. By this, I mean that we enjoy one another’s company (for the most part) and do not mind living in close quarters with one another. We, as a population, must respect one another by maintaining our personal hygiene, engaging in the common courtesy of cleaning equipment and areas after use, and understanding that the closeness we enjoy at our fire stations must not be taken for granted.
Cleanliness: We must continue the tradition of keeping our equipment and stations clean. We must instill this trait as a source of pride among our younger members and take a back-to-basics approach with established members, reminding them of the importance of cleanliness in station life.
Compromised Skin: Any time you or a member of your crew has a compromised skin area, you must protect that area from exposure. Proper bandaging and the use of suitable duty uniform when needed (long pants or long-sleeve shirts) provide protection from exposure during medical calls and protect the area from possible infiltration of MRSA. Remember, MRSA on skin is common and not a problem. It is when it finds a route inside the body that its truly dangerous potential is unleashed.

• • •

MRSA and CA-MRSA infections are on the rise. I hope that this article helps you to recognize these new and serious hazards for firefighters and emergency services workers. I encourage you to use the Internet as a resource to continue your education and awareness regarding this subject. Many Web sites have valuable information on MRSA and CA-MRSA. The CDC has a wealth of information on this and many other subjects affecting our members.

Endnotes

1. Photos 1-5. “Methicillin-resistant Staphylococcus aureus,” Wikipedia, The Free Encyclopedia,http://en.wikipedia.org/w/index.php?title=Methicillin-resistant_Staphylococcus_aureus&oldid=62042460 (accessed July 5, 2006).

2. Centers for Disease Control and Prevention, “Methicillin-resistant Staphylococcus aureus, information bulletin,” www.cdc.gov/ncidod/aip/research/mrsa.html (accessed July 5, 2006).

3. Jeffery R. Lejeune and David M. Berkowitz, “Bad Bugs. What You Need To Know About VRE/MRSA,” Journal of Emergency Medical Systems (JEMS), Dec. 2000.

4. The New England Journal of Medicine, “A Clone of Methicillin-Resistant Staphylococcus Aureus Among Professional Football Players,” http://content.nejm.org/cgi/content/short/352/5/468 (accessed July 5, 2006).

5. Phone conversations regarding MRSA among LAFD members with City of Los Angeles Fire Department Captain Chadwick Spargo and Captain Vance Boos, LAFD Medical Liaison Unit/Wellness Office, July 2006.

6. Safety Bulletin 04-14 (Addendum) “CA-MRSA,” Safety Bulletin (Addendum) 05-05 “MRSA Prevention and Treatment Guidelines,” and Department Memorandum “MRSA, Addendum to Bulletin 04-14, Captain Randy Yslas, Medical Liaison Unit, City of Los Angeles Fire Department (internal), Feb. 22, 2006.

7. MRSA Power Point® educational piece. Capt. Clarence “T-Baby” Tucker, Phoenix (AZ) Fire Department Health Center, 2006.

8. Mike McEvoy, Ph.D, REMT-P, RN, CCRN, editor fireEMS and consultant Fire Engineering, clinical associate professor pulmonary and critical care medicine at Albany Medical College in Albany, N.Y.: Proofreading and MRSA technical advice on first draft.

9. “Educational Project: MRSA,” International Association of Fire Fighters, http://www.iaff.org/safe/content/MRSA/MRSA.html (accessed July 10, 2006)

10. National Fire Protection Association, Quincy, Mass.

11. Lisa Schnirring, “MRSA Infection, Physicians Expect to See More Cases in Athletes,” The Physician and Sports Medicine, 3:10, Oct. 2004.

DEREK WILLIAMS has been a firefighter in the state of Arizona for 15 years. For the past 11 years he has served as a firefighter/paramedic in the Mesa (AZ) Fire Department, where he is assigned to a ladder company and is a member of the hazardous materials team. He has an AAS degree in fire science and paramedicine from Mesa Community College, where he has also been an instructor. He also serves part time in the Firefighter Wellness Office, assisting in the area of firefighter injury management.