By Mike Hudson
It is now apparent that COVID-19 is a global pandemic that will affect street level operations of every public safety organization in our country. By all definitions, this crisis will become a mass-casualty incident—a biological MCI.
As EMS and fire department training officers scramble to find relevant fact-based training for their personnel, chiefs, supervisors, and medical directors are trying to manage risk to personnel without compromising patient care.
The clear and present threat to clinicians looming with every patient contact comes in the form of a highly contagious virus that has created a finite line between our safety and the expected standard of care.
There are several currently published recommendations from national and federal health organizations that are specific to the EMS arenapresented in this article; recommendations that are not anecdotal. Looking at the current state of Italy’s health care system, it is apparent to the seasoned prehospital care provider that the typical approach to patient care and ambulance transport will have to be modified to accommodate the surge of cases we will encounter over the coming days and weeks.
Make no mistake, this is a national MCI and with that comes the latitude to adjust response and operational procedures to keep first responders safe so they can do the most amount of good for the most amount of people.
Understanding the hazards and threats associated with COVID-19 is the key to risk mitigation. The first overseas cases of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) were identified in China in 2003. COVID-19 was identified in November 2019 once again in China. COVID-19 has two strains and both are spread by respiratory droplets, SARS-CoV-2 is the most resilient and contagious of the strains.
A recent study from the National Institutes of Health, Centers for Disease Control and Prevention (CDC), and UCLA and Princeton University scientists in The New England Journal of Medicine found that SARS-CoV-2 was detectable in aerosols for up to three hours; up to four hours on copper; up to 24 hours on cardboard; and, the worst case scenario, up to two to three days on plastic and stainless steel.1 This means that this virus can be easily spread by first responder personnel. Skin, gloves, medical equipment, discarded uniforms, and medical waste can all become vectors of transmission hours and days after droplets land.
Response to projected surge numbers associated with COVID-19 are nothing short of a national MCI. Medical control entities and state administrators are now logically allowing EMS departments to modify current street operations by waiving traditional policies and protocols. As an example, New Jersey’s DOH EMS office has aggressively moved to grant state-wide waivers modifying numerous rules for EMS providers, such as reducing restrictions on MICU crew configuration to increase the deployment of resources and easing restrictions on provider reciprocity. Both are force multipliers. Fire departments in other states like Arizona, Colorado, and Florida are also modifying prehospital operational and medical protocols to accommodate the expected surge of patients. Modifying protocols for personnel safety can be done just as easily.
Published Recommended Guidelines: The Department of Health and Human Services (DOHHS) published the EMS Infectious Disease Playbook in 2017 as a response guide for EMS services and providers who are tasked with the care of potentially infected patients related to the SARS virus.
Response and Pre-arrival Information
The CDC recommends that triage questions from public safety answering point (PSAP) dispatchers be tailored to identify those patients that have symptoms of COVID infection, then that information be passed on to the responding EMS crew.2-3
- Persistent cough or respiratory distress;
- History of recent travel and/or exposure to others with COVID-19;
- Abdominal distress or GI bleed.5
The last place you want to be for any extended period is in the patient’s own environment. A street-smart EMS provider knows that entering a dark house on any given night is fraught with possible safety threats. The accepted procedure in many EMS systems is to ask the patient to walk to the front door and outside into the light where the initial assessment can begin.
Consider COVID-19 as a threat in a pitch-black house on a moonless night. The CDC has acknowledged that the threat of COVID transmission diminishes once the patient is outside in unrestricted atmospheric air, so it would make sense that all ambulatory patients should be assessed out in the open air whenever possible. Back in the ‘90s, this was known as the “doorway diagnosis” or “doorway triage.”
Stable ambulatory patients can walk to a stair chair placed in the front yard or walk to the ambulance for more diagnostic assessment procedures and ALS care. The DOHHS recommends that EMS assesses patients at a distance of six feet to limit the spread of droplets;3 if this six-foot assessment is done outside, the risk to providers decreases exponentially. The bottom line is that providers need to limit their time in the patient’s environment as well as limit close-proximity interactions with patients who don’t require lifesaving procedures.
Personal Protective Equipment (PPE) for COVID-19
Thorough hand washing before and after patient contact is very important along with other protective measures. Federal health organizations dictate that EMS personnel in proximity of a patient wear an N-95 mask, eye protection, fluid resistant gown and of course gloves.2-4 Patient care attendants must stay in full PPE while providing care in the ambulance “box.”
Decontaminate equipment before stowing in outside compartments whenever possible. Drivers of ambulances and medical transport vehicles must remove most of their PPE before sitting in the driver’s seat and need only wear an N-95 mask while transporting a COVID patient3 but PPE must be re-donned to assist the attending EMS provider with stretcher transfer.
Post patient contact guidelines for all crew members must include the proper disposal of PPE, aggressive hand washing, and equipment decontamination4 including the ambulance’s patient compartment and outside compartment door.
Reconnaissance and Triage
Limiting the number of persons and amount of equipment entering a potentially contaminated area decreases risk of contamination. Before a major military operation, intelligence is gathered by smaller reconnaissance units that are deployed ahead of troops to identify threats and help coordinate logistics of the operation. This same type of approach can prove beneficial for the responding fire department and EMS agencies and aligns with CDC recommendations for COVID response. As the president says, we are “at war” with this virus.
To decrease the probability of exposure to COVID-19, an arriving engine company or ambulance should, whenever possible, request that the patient come to the front door where the assessment will occur. If the patient cannot ambulate, one EMT in full PPE should enter the scene (building, residence, home) to triage the patient and figure out what resources are needed.
This triage responder should be minimally equipped with a portable radio, bleeding control kit, and a surgical mask for the patient. Once inside, the patient can either be moved outside with the help of bystanders or a proper amount of resources can be requested into the scene.
If the patient is found in cardiac arrest or peri-arrest, the triage provider will call in resources and initiate compression-only CPR as per AHA guidelines. The objective of this procedure is to decrease risk and limit exposure to non-essential personnel until patient viability or signs of obvious death can be confirmed.
Additional initial equipment brought into the scene by the triage responder should focus on life threat intervention and need only consist of a bag-valve mask (preferably with a Bacterial/Viral HEPA filter device that fits in-line for nebulizers, CPAP, extraglottic and endotracheal tubes), SpO2 device, and a thermometer.
A provider using an SpO2 device on a walking/talking patient can quickly assess acuity without having to make any physical contact. The SpO2 device can be slipped onto the finger and requires only a simple decontamination procedure.
The SpO2 device, if pulsatile, can let a provider know that distal peripheral circulation is present, which means that the BP is at least 90 mmHg systolic. The device will also indicate whether the O2 saturation is adequate at > 94% and can alert clinicians to heart rate and regularity—all in just 10 seconds with one piece of equipment and without touching the patient.
When a resuscitation case is confirmed by the triage provider, additional equipment and personnel in full PPE can be brought into the scene. The minimum resuscitation equipment brought to point of care should include an AED (if a BLS service), an oxygen source, suction unit, and a portable patient transfer device such as a scoop or CombiCarrier or Reeve’s stretcher. If the victim is viable, they should be removed immediately so that ALS personnel can provide care in the relatively clean and well-lit environment of the ambulance.
Transporting non-viable contagious patients to the ER can jeopardize the safety of other health care providers and holds no benefit for the patient or his or her family.
Several studies and peer reviewed papers6-7 already recommend the consideration of paramedic termination of resuscitation (TOR) in cases of cardiac arrest for more than 30 minutes because in-hospital resuscitation is likely to be futile.7 Even resuscitation cases that have no ROSC, termination orders after a projected downtime of > 30 minutes are being obtained by medics in systems that have current TOR protocols.6-8
Walking (Infected) Wounded
Number one on the CDC and DOHHS list of coronavirus risk management strategies is to maintain a distance of six feet when assessing the patient.3 It has been long understood that, during triage at an MCI, the walking wounded are considered low priority because patients able to talk and ambulate while presenting awake and oriented are probably perfusing with adequate oxygenation. Assessing the patient from six feet away keeps patient contamination threats at a safe distance even if they cough or sneeze.
Number two on the CDC and DOHHS list of coronavirus risk management strategies is to have the patient put on a surgical face mask before the assessment begins, decreasing the respiratory droplet threat.2-3
Transport of low-acuity, potentially contaminated patients will require modified COVID-19-inspired guidelines for non-EMS transport, but that does not negate our duty to get the patient to testing and definitive care. One of the primary guidelines for the walking wounded category under normal disaster MCI triage criteria is that if you can walk and talk and have no immediate life threat, you may not need an ambulance, so get green tagged and assigned to a non-medically attended ride to the hospital. This can be applied to suspected COVID-19 patients. Unnecessary use of ambulances by infected, stable ambulatory patients quickly depletes valuable, limited resources and increases the risk of personnel contamination. This phenomenon was brought to light in a 2010 documentary Firestorm following Los Angeles County Fire Department’s Station 65 during the flu epidemic on Skid Row.
Skip the Million-Dollar ALS Work-up
Limiting the amount of time you spend with a patient in close proximity is important. Less exposure time means less risk. In addition, limiting the amount of equipment that enters the scene is imperative. Policies regarding response bag contents and minimum equipment standards need to be modified, especially for ALS personnel during this pandemic. There is no reason to bring the stretcher, two complete jump bags, oxygen, and expensive cardiac monitor into a contaminated area for a stable, conscious patient.
The cookbook days of obtaining four sets of vitals, an ECG, a FSBGL, a lactate level, and a prehospital IV on every stable patient receiving should be modified or shelved during this pandemic.
Transporting contaminated patients requires complete post-run decontamination of equipment and all interior surfaces in the patient care area4, which delays availability of the ambulance for up to 30 minutes. Less equipment exposed to potential droplets equates to less equipment that the providers must clean. The use of advanced diagnostic equipment should be the standard only if the patient’s condition indicates the need and should not be used to hunt for “zebras” or anomalous life threats during these unprecedented times.
The CDC and DOHHS suggest that non-invasive nebulization of medications should be used cautiously by ALS providers because these treatments can create aerosolized droplets.3 CPAP should have HEPA bio filters in-line.
The CDC and DOHHS also recommend that high-acuity suspected COVID patients have RSI and intubation considered early3 if airway failure is a high-probability or there is a projected need for more advanced gas management techniques (i.e. mechanical ventilation with pressure control). However extreme care must be taken by providers to avoid exposure while advanced airway management procedures are underway—a proper face mask and eye protection must be worn. Some EMS medical directors are advising their providers use blind-insertion rescue airways like the iGel or King Tube instead of the traditional orotracheal intubation.
Alternate Transport Dispositions
In the early days of EMS, it was society’s unwritten rule that ambulances should only be used for life threats, not for all threats. That has changed and many EMS systems transport nearly all persons requesting service. This must be modified by EMS medical command and protocols prepared for EMS providers to determine the need for ambulance transport instead of the patient or family deciding the need.
EMS is in the direct path of the COVID-19 pandemic, requiring leaders to think outside the box. Adequately trained EMS personnel with proper medical control protocols should be able to defer stable patients to alternate transport modes and facilities. An EMT or firefighter driving a modified police transport van or squad car with plastic seats can safely deliver stable ambulatory patients to the ER without an attending EMT. Police vehicles typically provide a robust barrier to the driver and their plastic or metal seating is much easier to decontaminate than an ambulance patient compartment. Cities like Denver have been using similar alternative transport guidelines for decades to transport inebriated patients to detox units via specialty vans. This same practice could be applied to COVID response.
If the suspected COVID patient is transported in the ambulance, the CDC recommends that its ventilation system be equipped with a HEPA filters and its fans set on “high” while transport is underway. 2-3 Ambient atmospheric air under pressure via an open window can also increase the filtration of aerosolized droplets.
The logical approach to managing a major portion of risk associated with COVID-19 is to use EMS personnel and resources appropriately. The days of sending a fully staffed engine company, paramedic squad, and a BLS ambulance to every 911 call that drops must be avoided. Managing medical risk starts with incident information obtained by EMD personnel at the PSAP which leads to scene safety considerations prior to arrival. Once on scene, the contamination threats can be mitigated by proper management and command of the patient encounter. Establishing a safe place to assess the patient, limiting the number of personnel contacting the patient, limiting the time spent with the patient, and limiting the amount of medical equipment at the point of care all play a major role in diminishing the overall risk to the EMS provider.
It is imperative that responders manage personal risk and leaders give them the professional latitude, protocols, and equipment to do the most amount of good for the most amount of people.
References, Sources, and Studies
- Van Doremalen, et al. Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. The New England Journal of Medicine. DOI: 10.1056/NEJMc2004973 (2020)
- Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for- ems.html
- EMS Infectious Disease Playbook, Department of Health and Human Services https://www.ems.gov/pdf/ASPR- EMS-Infectious-Disease-Playbook-June-2017.pdf
- Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
- Digestive Symptoms Tied to Worse COVID outcomes, Rick Lewis PhD, March 19 2020 https://www.medscape.com/viewarticle/927112
- EMS Termination of Resuscitation, Christopher Libby; Robert B. Skinner; Amit R. Rawal. February, 2020 https://www.ncbi.nlm.nih.gov/books/NBK541113/
- New Rule for Terminating Resuscitation of Out-of-Hospital Cardiac Arrest Patients in Japan: A Prospective Study SOS–KANTO 2012 Study Group. 2020 https://www.sciencedirect.com/science/article/pii/S073646791730471
- AHA Journals, Durations of cardiac arrest, deciding when to call the code. Mutter and Abela 2016 https://doi.org/10.1161/CIRCULATIONAHA.116.021798 Circulation. 2016;133:1338–1340 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.116.021798
Mike Hudson is a former U.S. Navy Corpsman and current nationally registered paramedic with over 25 years on the streets. In the winter, Mike works for the Discovery Channel and also works as a street level MICP in central New Jersey. In the summer, he commands a municipal USLA-certified lifesaving agency that provides river lifeguard and ocean lifeguard services for two coastal towns and serves as the lead ocean rescue specialist for a combined fire-department/lifeguard aquatic rescue response team, surf rescue team 43-88 (SRT 43-88), headquartered along the north shore of Monmouth County, New Jersey. For more information about SRT 43-88 go to seabrightoceanrescue.com.