environments normally include domestic residences, care homes, shops, place of entertainment or even a doctor’s surgery waiting room. But in reality they will locate their patient lying in a field, a farmers cattle shed, on a factory floor, inside a barn, amongst metal workings or overhead gantry’s, on a houseboat, below decks in a gin palace, in a rancid roadside dyke or inside a motor vehicle which has been involved in a traffic incident.

The ambulance clinicians are easily identifiable, as their bright green and yellow ambulance approaches, in most cases with blue lights flashing; and after stopping, they alight wearing their green uniform. Unless there are specific reasons to the contrary, the clinician will be wearing a short sleeved shirt, not because they wish to appear macho on a cold afternoon, but because there is a requirement that they are “bare from the elbows down”; a policy decision made in an attempt to reduce the risk of the clinician contaminating or cross-infecting a patient with dirt or bacteria carried on their long sleeve, behind their wristwatch strap… without regard to the pig pen, riverside mud, cow pats…. The wearing of wedding rings is permissible and until recently, it was acceptable to wear a wristwatch that had a steel strap that could be easily washed every time the wearer washed their hands. Bearing in mind that the ambulances do not have a supply of water and soap to accommodate this, the only means to clean ones hands in a football field, farmer’s field, or road-side dyke is with cloth clinical wipes or gels, despite the preaching’s that remind us hot water and soap” is the best method of cleaning dirty hands (and elbows).

Pre-hospital healthcare workers do not work in spotlessly clean environments which is one reason why after a Paramedic has inserted a cannula into a patients vein, they are required to apply a yellow label at the body site which states it is an emergency action and the cannula should be removed within 48 hours (to reduce the risk of infection), having been performed in an out of hospital environment… boat yard, factory floor, supermarket car park… Hopefully the picture is developing that there is a vast difference between what goes on in a clinically spotless hospital and what is attempted by clinicians “in the field”.

Ambulance clinicians will endeavour to maintain the hands (and the rest of their person) as clean as possible during their shift, but one still must accept that there are surfaces within their working area where the clinicians hands, body or uniform is at risk of becoming dirty and or contaminated. These include, but are not limited to: within the patient’s household, inside and outside of crashed motor vehicles, surfaces within the ambulance or on the ambulance tail lift area, and also surfaces within the factory, sports hall, supermarket, pig sty, kennel, stable, pavement or holiday park. Don’t forget that every time the clinician shakes your hand, puts a hand in a pocket, reaches inside their jacket, takes your pulse or makes you a cup of tea, there is the potential for the “beasties” to transfer to each and every surface that hand makes contact with… unless they wash their hands after every single action or function that their being with a patient requires them to undertake.

The aim here is to identify contact areas by which the clinician or their clothing may become infected or contaminated. Sitting down on a dirty seat, kneeling in the grass verge, walking on a riverside tow path, happenevery day; as is transferring the dirt from one scene to another via the soles of one’s boots, the wheels of the carry chair or the stretcher trolley, the underside of the grab bag or defibrillator, suction unit, drugs bag, orthopaedic scoop stretcher or rescue board. As the picture develops, we gain the awareness of the many and various routes that unhealthy and unwanted beasties can be picked up, conveyed and transferred throughout the day; but the current focus is solely on the clinicians hands, with the emphasis being on keeping the body “bare from the elbows downwards”. There are no apparent concerns about any other area… yet.

However; the pre-hospital healthcare provider does not just look after the patient, they also drive the ambulance and so there is the added risk that whatever undesirable filth is picked up by the soles of the boots or uniform, there is the risk of it being transferred into the separated crew cab, with the potential for it to be redistributed even further afield. This is why all ambulances need to be regularly withdrawn from service and subjected to a thorough and meticulous deep clean, including the crew cab up front.

There is a requirement for clinicians to clean the interior of their ambulance and remove all unwanted matter, in between every patient; but clock-stopping time constraints imposed by the government on hospitals and ambulance services, bring hefty financial penalties (fines) if the ambulances spend too long at hospitals, a fact which is much reported in the media. However, those pressures are increased by high volume 999 calls being received by ambulance control centres, and the pressures within the call centres are equally as stressful for those control room staff as they are for the clinicians out on the road.

The 999 calls need answering; the dispatchers need ambulances available and managers want the ambulances moving… but the clinicians need to clean their ambulances, and sadly they do not come equipped with a car wash. So it’s a case of make and do… until the vehicle and crew are inspected. Despite all this, the clinicians will do their utmost to remain as clean as they possibly can, but where ever their patient is located in whatever environment, contact with the patient, their clothing, bedding, furniture or fixtures, will increase the potential for the clinician to transfer dirt or other such particles onto their hands, uniform or footwear. 

When the weather takes a down turn, forcing the clinician to don their jacket to keep warm, those undesirable particles may be transferred to the inside of the clean jacket, or onto the inside of the foul weather jacket or the hi-viz jacket which is worn roadside or where maximum visibility of the wearer is needed for safety reasons.But is it cleaned before next being worn? I think not. Ambulance clinicians are not provided with the equipment or the time to clean their uniform in between every patient… after all, they work outdoors. It is not as if they work in a hospital

Much has been said over the years about wearing a fob watch on the clinicians shirt, but given the information above; it would appear to increase the risk of contaminating the uniform shirt or inside of the jacket with every patient attended to in the pre-hospital environment. At least when wearing a wristwatch which has a metal bracelet (that can be cleaned when you wash your hands) the dial is readily available and easy to see at all times.

It does appear that the vast majority of locations where ambulance clinicians go and the environments in which they workare not fully understood by a large proportion of the public and the same could be said about the people who try to enforce in-hospital practices on clinicians who work outside of hospitals. If ambulance clinicians were to apply the stringent requirements of in-hospital cleanliness to their daily practise out on the road, they would be forced to change their uniforms several times during the shift and return their vehicle to base so that it and its equipment can be deep cleaned before accepting it back onto the road in a hospital-clean status. 

But is it a case of pot – kettle – black? Within many hospital environments over the past months, I have observed in-hospital employees wearing wristwatches, stainless steel fob watches on chests, and long sleeved tops, all within the a&e departments. It goes without saying that I cannot prove this because we are not allowed to take photographs inside the hospital. But surely the word of a trusted healthcare professional should be taken as fact? And when the hospital staff are in need a ”fresh air break” they don their civilian jacket over their uniform (passing beasties to the jacket interior and vice versa) pop outside to the pre-hospital environment before popping back inside

A major concern of mine relates to the toilet facilities. Thankfully they are not yet subjected to a “pay to use” embargo, but they do need revamping and bring up to 21st century standard. With all the other concerns within hospitals, it is concerning that having made use of the facilities and washed ones hands, we then have to place our clean hands on the dirty toilet door handles to escape. The outer door handle is in my humble opinion just as dirty as the interior handle, because nobody washes their hands before they grasp the door handle on the way in… but at least they might not be wearing a wristwatch.

We must not forget the solo clinicians who spend their shift working from a rapid response vehicle, the RRV. There is very little “personal” storage area within the RRV because the entire vehicle interior is taken up with medical equipment, and nowhere totally separate for their personal protective equipment (PPE) or, most importantly, their food and drink. The RRV clinicians, unless tethered to a specific location, must, the same as ambulance crews, carry their refreshments inside the RRV at all times, thereby ensuring that when they are eventually stood down for their break, they have their food with them. But RRV crews have no separate patient assessment area. The majority of RRV clinicians that I have spoken with inform me that they often sit the patient in the offside seat so that they can be assessed, unless the patient is inside a building. So all their equipment and refreshments are potentially exposed to any of those beasties I mentioned earlier. They also have no proper hand washing facilities.

There are no objections raised when ambulance crews pre-alert and take a patient straight into the resuscitation bay, or when they wheel a patient from one end of the hospital to the other in order to reach a specific ward; but much is vocalised about wearing wristwatches. To prevent ambulance crews from taking dirt particles into hospitals, ambulance crews should remain outside of hospital (much as they currently do at present), but instead of taking patients into the hospital, the clinical handover could be done at the entrance. Any bacteria that aresubsequently discovered inside hospital could not then be attributed to ambulance crews, as they will have remained outside in their pre-hospital environment.

I would like to leave you with this thought: nobody checks the patient, their relatives or friends, who accompany them into the hospital a&e department, to make sure they are spotlessly clean and devoid of a wristwatch…

I wish you all a very Merry Christmas and a Happy New Year. 

Jeff Pittman

Branch Health & Safety Officer.