Martin Pelletier, EMT-Paramedic from Canton (NY) Fire & Rescue, offers this rebuttal to a March 30, 2020, article from New Jersey Paramedic Mike Hudson entitled, “Fire Department EMS: Thinking Outside the Box for COVID-19“
I am writing to rebut Mr. Hudson’s article from March 30, 2020. The onset of the SARS-COVID-19 pandemic set many EMS agencies into a headspin in the face of this infectious threat. Yet, there are certain facets to this piece that may not reflect best practices when it comes to emergency medical services (EMS) operations. The objective of our response not only applies to the current pandemic but also the future of EMS as a profession since it requires both an efficient and a quality approach to prehospital care while also ensuring provider safety.
I emphasize caution regarding the author’s message to, “Skip the million-dollar ALS [advanced life support] work-up.” This is a precarious stance for two reasons. First, ALS assessments and interventions should have been rendered only to those patients who genuinely needed them and not as a point-of-care approach before the pandemic. I agree with Mr. Hudson’s comment on avoiding the search for “zebras,” but COVID-19 should not be the sole reason stop doing this. When we hear about the financial strains and reciprocal underfunding by the Centers for Medicare & Medicaid Services or the enormous ambulance bills many patients receive, it shows the need to be efficient in our practice. Unless there are exceptional circumstances, those patients with low-grade musculoskeletal pain, falls without risk factors, general sickness symptoms that do not fit under sepsis or cardiac criteria, low-grade pain, and low-acuity behavioral health are good examples of who we need to avoid over-triaging.
The second reason to be wary is that the author’s sentiment is due to the EMS providers’ misconstruing it and, therefore, shortchanging patients who genuinely have acute complaints. I especially stress this in cardiac, respiratory, and sepsis patients. Many readers may be misled by your article that it is acceptable to delay or withhold these treatments due to the pandemic, and that is nothing short of a travesty. For instance, there have been several reports of missed STEMIs in the field due to EMS providers shortchanging patients on the basis that they were a COVID-19 risk and, hence, should not receive close-contact interventions like a 12-lead ECG.
Assuming there are no obvious scene obstacles, we must continue to render ALS assessments and initial interventions at the patient side for those patients who meet the indications for such. Obtaining a 12-lead ECG at the cardiac patient bedside can activate the cath lab faster rather than deferring such assessment to the ambulance. Beginning interventions on the respiratory distress patient in the home vs. waiting several minutes to do it in the ambulance can be the difference between relieving their symptoms and watching them arrest. Even for basic life support providers, being able to do an initial assessment at the patient side will allow them to request ALS backup sooner should they determine the need for such rather than deferring it to the ambulance. I realize that there is increased risk of infection to the provider by doing so; this is where EMS must be compliant with and trust their personal protective equipment while reaffirming their commitment to rendering the best quality of care despite the dangers they face daily.
Although my response may have an anticlimatic tone to Mr. Hudson’s article on COVID-19, there are elements to his piece that are valuable. Emergency medical technicians (EMTs) and paramedics must have the ability to triage and judge whether or not a patient meets the indications for an ambulance ride to the emergency room. The ability to triage to other resources or refer patients to other modes of help on their own accord needs to become a part of the prehospital provider’s toolbox. For patients who are not in significant distress, we must remove the stigma of allowing them to self-ambulate to the stretcher and ambulance.
Finally, systems must be transformed so that they have multitiered responses with alternative point-of-entry options. Whether it means investing in our EMT-Bs and AEMTs, utilizing detox units (like the city of Denver), community paramedicine, or bringing advanced practitioners into the field, leaders need to find new and creative ways to operate EMS systems rather than sending six paramedics on the ambulance and a fire engine to every EMS call. I personally have not been a fan of using the COVID-19 pandemic as a catalyst for forwarding one’s agenda, but considering our profession was already at a breaking point before 2020, this may be the only opportunity to change how we function for the better.
Canton (NY) Fire & Rescue
Mike Hudson replies to Martin Pelletier’s comments:
I am humbled and appreciative that you would take time out of your life to read something I wrote, and then take more of your time to communicate feedback. I want to thank you for your points and concerns. Your rebuttal brings a few important points to light that others may also be struggling to accept.
First, the article was written during a period of time when government health experts and emergency medical services (EMS) managers didn’t know what they didn’t know about an emerging ultra-contagious coronavirus. The pandemic could only be described as a nationwide bio-hazard mass casualty incident (MCI), with initial governmental death predictions originally to be 2.2 million fatalities in the first six months.1
My article was published at a time when first responders were becoming infected and falling acutely ill following exposures to patients with a new hybrid strain of SARS. We were all told by the Centers for Disease Control and Prevention that exposures could occur just by entering buildings known to hold multiple infected persons.2 I wrote that article at a time when my colleagues were being admitted to the hospital sick with SARSCoV2 and paramedics in my state dying from infection. More than seven weeks into the pandemic, I frequently saw flashes of EMS crews on the news transporting supposed COVID cardiac arrest victims with CPR in progress.3. EMS systems in major cities were still transporting clinically dead patients (during a bio-MCI) to hospitals that were already inundated with COVID infections.
In some cases, we were transporting patients that were so wrought with the virus that it had killed them already. By the time victims going through cardiac arrest got to the hospital, their chances of survival were about 1% (according to the data coming out of the U.S.4 at that time), and first responders continued to get sick in greater numbers.5,6 At the time, my article was in peer review. Some fire departments were starting to come to their senses.
By late April 2019 they were establishing alternate transport protocols and TOR directives based on MCI theory. Some of the nation’s biggest fire departments are now just coming to grips with the science and the data and have adopted more aggressive TOR policies—policies aimed at managing infectious risk to their personnel and decreasing risk to hospitals and the public8—in the shadow of what they now call a biological disaster.
My article was written when proper personal protective equipment (PPE) was sparse and hospital ICU beds were full. I felt the need to invoke a conversation about triage transport policy alignment within the rules of a high-fatality MCI. The article was not meant to give definitive solutions for the entire U.S., nor speak for our profession. I may have forgotten that not all systems are like the ones in which I have practiced, where paramedics have the choice to treat patients while on the move rather than in a dark, dingy, two-family studio apartment. The “M” in MICU stands for “mobile.” Obtaining a 12-lead ECG or POC lactate test can wait until we are outside of a possibly contaminated home; it’s the safest approach for all levels of first responders. However, I never implied not to assess and transport those patients that are mildly sick or those who may have complicated underlying benign medical complaints. Instead, I encouraged using the appropriate level of transport. Here in New Jersey, most paramedics are still not entering private homes with probable COVID cases no matter what the initial complaint, including chest pain. The MICU team will stand fast on scene while the emergency medical technicians serving as pseudo-triage officers assess and bring higher acuity patients out to the MICU for assessment. Either way, the patient goes to the hospital, sometimes with advanced life support care.
You really do have valid points, but points that are more applicable to those systems that have unlimited EMS and paramedic resources with legit proper PPE and minimal COVID infection rates. (Are there truly any systems with unlimited resources?) The ideas in my article were relevant for an evolving, highly contagious zoonotic disease that no one (besides China) had any idea of the effects or definitive vectors of transmission, a disease where asymptomatic people were still contagious. I would ask that first responders not be myopic when faced with an unknown, not-so-clear and present danger that has both crippled and killed many of our colleagues during the course of their duties.5,6 Regardless of pandemic status, our safety on duty is paramount to the overall continued integrity of the EMS systems we work within. I agree with you that this pandemic may stimulate a much-needed change, but we cannot deprioritize our safety in lieu of administering patient care in high-risk environments or when caring for high-risk patients. How can we be expected to do the most amount of good for the most amount of people if public safety personnel are constantly becoming sick, injured, or quarantined? We essentially become combat ineffective if we don’t take radical steps to protect our personnel.