3.3 Fire Safety (RACE & PASS), Disaster Preparedness, and Acute Medical Emergencies

Institutional Fire Safety and the RACE Protocol

Hospital and nursing home residents represent an exceptionally vulnerable population during fire emergencies due to physical immobility, cognitive impairment, sensory deficits, and reliance on medical life-support systems. Healthcare fires generate toxic smoke, carbon monoxide, and intense heat that can overwhelm a facility wing within minutes.

All healthcare workers must memorize and instantly execute the nationally standardized RACE protocol upon discovering smoke or fire:

┌────────────────────────────────────────────────────────────────────────────┐
│                            THE RACE PROTOCOL                               │
└────────────────────────────────────────────────────────────────────────────┘
  [R] RESCUE / REMOVE  ──► Immediately move anyone in direct, immediate danger
  [A] ACTIVATE ALARM   ──► Pull alarm box, dial 911, announce emergency code
  [C] CONFINE / CONTAIN──► Close doors & windows, place towels at thresholds
  [E] EXTINGUISH/EVAC  ──► Extinguish if small/safe (PASS); otherwise Evacuate

1. R — Rescue and Remove

• Priority: Human life always takes precedence over property. Your first duty is to rescue and remove any resident, visitor, or staff member in immediate, direct danger from the room or area where fire or smoke is present.
• Technique: Guide ambulatory residents away from the hazard. For non-ambulatory or bedridden residents, transport them using their wheelchairs, roll their entire beds down the corridor if doors permit, or utilize emergency blanket-drag techniques if rapid evacuation is necessary.

2. A — Activate Alarm

• Notification: Sound the alarm immediately after removing individuals from immediate danger (or simultaneously if multiple staff members are present).
• Actions: Pull the nearest manual wall-mounted fire alarm pull station. Call the facility emergency operator or dial 911, and announce the institutional emergency code clearly over the public address system (e.g., "Code Red, Room 214, West Wing").

3. C — Confine the Fire

• Smoke Containment: In institutional fires, smoke inhalation causes far more fatalities than radiant thermal burns. Confining smoke saves lives.
• Actions: Close all resident room doors, corridor smoke-barrier fire doors, and exterior windows. Ensure doors latch securely. If smoke begins seeping under door thresholds, place damp towels or blankets along the base of the door. Shut off non-essential electrical equipment. Piped medical oxygen zone valves must be shut off only when authorized by the fire department or designated charge personnel.

4. E — Extinguish or Evacuate

• Extinguish (If Safe): If the fire is small, contained (e.g., a localized wastebasket fire), not spreading rapidly, and you have an unobstructed exit behind you, use an appropriate portable fire extinguisher.
• Evacuate: If the fire is large, spreading, producing dense choking smoke, or if an initial extinguisher discharge fails to suppress it, evacuate immediately.
  • Horizontal Evacuation First: Move residents through fire-barrier doors into an adjacent, safe smoke compartment on the same floor level.
  • Vertical Evacuation Second: If the entire floor is compromised, move residents downward through fire-rated stairwells. NEVER USE ELEVATORS DURING A FIRE, as elevator shafts act as natural chimneys for smoke and power failures can trap occupants between floors.

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Fire Extinguisher Operation: The PASS Protocol

To operate a portable pressurized fire extinguisher correctly, memorize the PASS sequence:

Fire Extinguisher Classifications

• Class A: Ordinary combustibles (wood, paper, cardboard, trash, textiles, plastics). Memory aid: Leaves Ashes.
• Class B: Flammable liquids, greases, and gases (gasoline, oils, kerosene, paints, solvents). Memory aid: Boils or Barrels.
• Class C: Electrical fires involving energized electrical equipment (appliances, wiring, circuit breaker panels, motors). Memory aid: Current.
• Class ABC: Multipurpose dry chemical extinguishers (containing monoammonium phosphate). These are the standard extinguishers mounted throughout healthcare corridors and resident wings.
• Class K: Commercial kitchen fires involving high-temperature cooking oils and deep-fat fryers.

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Hazardous Oxygen Therapy Safety Rules

Supplemental medical oxygen is a prescribed medication administered to treat hypoxemia. While oxygen gas is non-flammable and will not burn on its own, it is a powerful oxidizer and combustion catalyst. In an oxygen-enriched atmosphere, materials ignite at much lower temperatures, burn with explosive speed, and produce intense, uncontrollable flames.

Nurse aides must enforce non-negotiable oxygen safety protocols:

1. Prominent Warning Signage: Display bold "OXYGEN IN USE — NO SMOKING" warning signs prominently at the entrance of the resident's room and directly above the head of the bed.
2. Absolute Ban on Open Flames: Strictly enforce a 50-foot no-smoking and no-open-flame perimeter around oxygen equipment. Matches, lighters, candles, cigarettes, e-cigarettes, and vaping devices are strictly prohibited inside resident rooms or near oxygen delivery systems.
3. Prohibition of Petroleum-Based Products:
   • The Hazard: Petroleum jelly (such as Vaseline), mineral oil, and oil-based skin lotions are volatile hydrocarbons. When exposed to concentrated oxygen, petroleum products can undergo rapid oxidation and spontaneous combustion, resulting in severe facial and airway burns.
   • The Rule: Never apply petroleum-based ointments to a resident's lips, nostrils, or face while they are receiving oxygen. Use only water-soluble moisturizers (such as water-based surgical lubricant or designated saline-based oral gels).
4. Static Electricity Prevention: Avoid wool blankets and synthetic fabrics (nylon, polyester, rayon) that generate static electric sparks. Use only 100% cotton linens, blankets, and gowns on residents receiving oxygen.
5. Electrical Equipment Inspection: Prohibit electrical equipment that could generate sparks, including electric razors, heating pads, motorized toys, and hair dryers. Ensure all healthcare equipment is grounded with 3-prong hospital-grade electrical plugs.
6. Compressed Gas Cylinder Storage: Oxygen tanks are pressurized to upwards of 2,000 pounds per square inch (psi). If a cylinder valve shears off, the tank acts as an unguided missile capable of penetrating concrete walls. Cylinders must always be secured upright in approved rolling metal carts or chained in wall racks. Never leave oxygen cylinders standing freestanding on the floor.

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Wyoming Severe Winter Disasters & Blizzard Preparedness

Wyoming's geography and high-altitude climate present severe environmental hazards. Long-term care facilities in rural Wyoming counties (such as Fremont, Campbell, Carbon, and Sheridan) routinely face extreme winter weather events, including ground blizzards, sub-zero temperatures (wind chills reaching -30°F to -50°F), highway closures (such as extended shutdowns of I-80, I-25, and mountain passes), and severe electrical grid failures.

Critical Disaster Protocols for Wyoming CNAs

• Essential Personnel Status: Certified nursing assistants are designated as essential emergency personnel. During severe winter blizzards, shift relief staff may be physically unable to travel on closed roads for 24 to 48 hours or more. CNAs on duty must be prepared to remain at the facility, implement emergency staffing rotas, and care for residents without abandonment.
• Emergency Generators & Red Outlets: When severe winter ice or high winds sever municipal power lines, emergency diesel generators automatically engage within 10 seconds. Life-sustaining medical devices—including mechanical ventilators, continuous oxygen concentrators, suction machines, and feeding pumps—must be plugged exclusively into emergency red electrical outlets backed by the generator.
• Shelter-in-Place Stockpiling: Facilities maintain emergency winter reserves, including a minimum of a 72-to-96-hour supply of potable water (1 gallon per resident per day), shelf-stable, non-perishable foods, and emergency medication supplies (ensuring refrigeration for insulins and vaccines via emergency power).
• Thermal Protection: In the event of secondary heating system failures, nurse aides must layer residents in warm cotton clothing, thermal socks, knit caps, and multiple cotton blankets. Continuously monitor frail residents for early clinical signs of accidental hypothermia (shivering, cold pale skin, apathy, slurred speech, slow shallow breathing, and bradycardia).

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Acute Medical Emergencies & Frontline CNA Scope of Action

During acute, life-threatening medical crises, the nursing assistant must initiate immediate life support within their authorized scope of practice while simultaneously summoning emergency assistance.

1. Airway Obstruction and Choking

Foreign-body airway obstruction (choking) frequently occurs during meal times among residents with dysphagia (swallowing difficulties) or poor dentition.

• Conscious Resident with Partial Airway Obstruction: If the resident is forcefully coughing, speaking, or breathing, DO NOT INTERFERE. Stay with the resident, provide calm reassurance, and encourage forceful coughing to expel the object.
• Conscious Resident with Complete Airway Obstruction: If the resident exhibits the universal choking sign (hands clutched to throat), cannot speak, cough, or breathe, exhibits high-pitched inspiratory stridor, or turns cyanotic, perform abdominal thrusts (Heimlich Maneuver) immediately:
  1. Stand behind the resident and wrap your arms around their waist.
  2. Make a fist with one hand, placing the thumb side of your fist against the resident's abdomen, slightly above the navel and well below the tip of the xiphoid process.
  3. Grasp your fist firmly with your other hand.
  4. Deliver quick, forceful inward and upward thrusts into the abdomen.
  5. For pregnant or severely obese residents, position your hands across the center of the breastbone (sternum) and deliver firm chest thrusts.
  6. Repeat thrusts until the object is expelled or the resident loses consciousness.
• Unresponsive Choking Resident: If the resident becomes unconscious, ease them gently to the floor, call loudly for the nurse / activate 911, and begin CPR (Cardiopulmonary Resuscitation) starting with 30 chest compressions. Each time you open the airway to give ventilations, look inside the mouth. If you see the foreign object, perform a gloved finger sweep to remove it. NEVER PERFORM A BLIND FINGER SWEEP, as this wedges the obstruction deeper into the trachea.

2. Seizure Management (Tonic-Clonic)

A generalized tonic-clonic seizure involves sudden loss of consciousness accompanied by violent muscle contractions. The CNA's goal is to prevent secondary physical injury:

• Protect from Trauma: Ease the resident to the floor if they are seated or standing. Place a soft pillow, folded blanket, or jacket beneath their head. Clear away nearby tables, chairs, or sharp objects.
• Loosen Clothing: Loosen restrictive clothing around the neck (collars, ties) to facilitate breathing.
• Time the Event: Note the exact start time and track the duration of the convulsive phase.
• Strict Prohibitions:
  • NEVER restrain the resident or forcefully hold down their jerking limbs; this causes bone fractures and muscle tears.
  • NEVER insert any object into the resident's mouth (no tongue depressors, spoons, or fingers). Residents cannot swallow their tongues, and forcing objects into clenched jaws causes fractured teeth, bleeding, and airway obstruction.
• Post-Seizure Care (Recovery Position): Once convulsions cease, gently turn the resident onto their side into the lateral recovery position. This allows saliva, mucus, or vomitus to drain freely from the mouth, preventing pulmonary aspiration. Stay with the resident, provide calm orientation, and alert the charge nurse immediately.

3. Fainting (Syncope)

Syncope is a transient loss of consciousness caused by temporary insufficient cerebral blood flow.

• Impending Fainting: If a resident reports sudden dizziness, lightheadedness, pale skin, or tunnel vision while standing, immediately assist them into a chair with their head lowered between their knees, or ease them to the floor.
• Unconscious Resident: If the resident loses consciousness on the floor, place them flat on their back (supine) and elevate their lower extremities approximately 12 inches to enhance venous blood return to the heart and brain. Loosen tight collars, ensure adequate airway patency, apply a cool damp cloth to the forehead, and notify the charge nurse.

4. Circulatory Shock

Shock is a life-threatening physiological state where the cardiovascular system fails to deliver adequate oxygenated blood to vital organs (caused by severe hemorrhage, sepsis, dehydration, or myocardial infarction).

• Clinical Signs: Rapid, weak, thready pulse; rapid, shallow, irregular respirations; pale, cold, clammy, cyanotic skin; dropping blood pressure; restlessness, confusion, or decreasing level of consciousness.
• CNA Interventions: Summon the licensed nurse immediately. Keep the resident lying flat with lower extremities elevated 8 to 12 inches (unless contraindicated by head injury, dyspnea, or suspected spinal trauma). Cover the resident with blankets to prevent heat loss (do not overheat). Never administer fluids, food, or oral medication, as digestive circulation is shut down and aspiration risk is high.

5. Severe Hemorrhage (External Bleeding)

Arterial bleeding is characterized by bright red blood spurting under pressure; venous bleeding flows steadily and dark red.

• Direct Pressure: Don medical gloves immediately. Apply firm, continuous direct pressure over the bleeding wound using a sterile gauze dressing or clean linen.
• Do Not Remove Dressings: If blood soaks through the dressing, do NOT remove the initial dressing (removing it pulls away newly formed clotting factors). Apply additional gauze pads directly on top of the saturated dressing and maintain continuous firm pressure.
• Elevation: Elevate the bleeding extremity above the level of the heart if no bone fracture is suspected. Summon the charge nurse immediately and monitor for signs of circulatory shock.