Cold Calculations and the Search for Inner Warmth

With arctic air masses moving across the country this week, the issue of cold has moved to the forefront of many people’s minds. For EMS (Emergency Medical Services) agencies and organizations there are particular concerns about two groups of people – patients, and EMS crews.

Extreme cold puts added stress on patients who are already ill or injured, in ways not necessarily connected to the cold. Cold stress makes shock states worse, and for that reason extra steps must be taken to ensure patient warmth. Finally, in addition to these problems, which make the handling of the normal patient load that much more difficult, there are a number of additional patients whose principal or only medical problems are caused by the cold itself.

Isolated areas of skin exposed to extreme cold over a period of time can freeze, creating a condition, popularly known as frostbite, that is extremely damaging to the tissue involved. A greater danger is the lowering of body temperatures. The delicate chemical reactions that make up the human body can operate within only a limited range of temperatures. Exposure to the cold – or exposure to any conditions that rob the body of its own natural warmth – lowers the patient’s body temperature; this condition is known as hypothermia, and is also extremely dangerous. As the body loses heat it eventually reaches the point where it shuts down completely.

Shivering in a Stand-by Status The members of ambulance crews are of course just as susceptible to the cold as anyone else. But there is an aggravating factor involved: During the course of their duties, EMS staff are often required to spend extended periods of time either in their vehicles or outside, waiting at an incident scene where they are exposed to the weather.

In many cities, ambulance crews are required to remain in their vehicles, usually   parked on the street, when not on a specific assignment. These long periods of time sitting in the ambulance can create major health problems if the heating in the cab is not sufficient to help the EMS staff maintain their own body temperatures. This problem is exacerbated by the fact that EMS crews are often called on to “stand by” at the scene of incidents (fires, for example) or mass gatherings – e.g., the recent New Year’s Eve celebrations, and last week’s Inaugural Parade in Washington, D.C. – even when EMS is not the initial or principal focus of the gathering.

At a minimum, ambulance heating systems should be tested – and, if necessary, repaired – well in advance of winter weather. The same maintenance check-off list recommended for the family car should be used for emergency vehicles, paying particular attention to ensure that the coolant is checked and that the entire cooling system is flushed if needed. The check-up also should include a close examination of the exhaust systems; carbon monoxide buildup within the cab of a vehicle with tightly closed windows could be a significant hazard. Vehicles lacking a fully operational heating system should be taken out of service until they are repaired.

Blanket Protection, IVs, and Flexible Garments During the winter months, additional blankets should be added to the equipment usually carried in each vehicle.eally, provisions also should be made to ensure that the recommended temperatures for intravenous (IV) fluids and oxygen can be maintained; warming a patient “from the inside” is the most medically effective process to follow, because the human body starts to shut down one part at a time, starting with the skin and extremities. In contrast, warming from the outside causes the cold blood that has been trapped in the extremities to return to the inner core of the body, thereby lowering the temperature of the inner core.

Special care is required to ensure that EMS crews also are provided with outer garments that not only provide the warmth needed but also allow the flexibility to perform their work without significantly shedding those garments. A sometimes more important need – on the scene of an incident where an EMS crew may be kept waiting for a long period of time – is to ensure that there is adequate shelter from the elements.

With the radio communications now available in almost all political jurisdictions throughout the country it is unconscionable to force EMS staff (and/or other first responders) to simply “stand by” in the cold – or, during the summer months, in extreme heat – until they are actually needed. Stationing the EMS staff in the lobby of a nearby building, or in their own vehicles, until they are actually needed decreases the risks to their own health without decreasing their operational effectiveness.

The first responsibility of any emergency agency is to ensure the safety both of its own staff and of other responders directly involved in EMS operations. Preparation for the cold is vital not only for the safety of the crews themselves, but also for the survival rate of the patients they serve.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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