Five Lessons of the Pandemic

In recent years, emergency medicine physicians and our partners in emergency management have participated in bird flu and pandemic flu preparations with local governmental officials. Yet we never allowed ourselves to entertain the reality of a true pandemic resulting in tens of thousands of American deaths, nor did we imagine the unpleasant task of deciding which patients required EMS transport and hospitalization. We did not consider the reality of our children being unable to attend school; empty grocery shelves and closed gas stations; or the possibility of us or our families becoming ill. These potential realities struck home on April 24, 2009, when the city of San Antonio's emergency manager called and said, "We need to talk. Have you ever heard of H1N1?"

The discovery of H1N1 infection in five people in California and two teenage boys in Schertz, TX (a city bordering San Antonio), led to weeks of meetings and behind-the-scenes discussions. There were unending conference calls, school closure decisions, suggestions of social distancing, and hospital employee and visitor surveillance for flulike symptoms, all topped with media frenzy and general fear and uncertainty throughout the public. We scrambled to find our pandemic flu plans and dust them off--only to realize we were not thoroughly ready.

Our challenge: Apply the plans, smooth any wrinkles and get fully ready--fast.

Uneasy Issues

In San Antonio and the region served by the Southwest Texas Regional Advisory Council (STRAC), public health officials faced tough decisions daily as they led the response to this new threat. Difficult choices included decisions about closing schools and banning public gatherings; when and how to distribute antivirals to uninsured and low-income patients; identification of those needing H1N1 testing; what to do when the region ran out of viral testing medium; and so on, with countless new decisions daily. City and regional hospitals wrestled with concerns of overloading already-stressed emergency departments. EDs grappled with the worried well and patients sent by private physicians for testing. They anticipated the challenge of unfunded patients who needed antiviral medication. Hospitals dealt with their own employee populations: when to begin employee and visitor screening, identifying employees needing prophylaxis, and more issues compounding daily.

We in the EMS community encountered the same and other issues. We had unique problems caused by the novel flu strain--a strain with uncertain morbidity and mortality. As medical directors responsible for the prehospital care of the citizens of San Antonio and well-being of more than 1,600 emergency providers in San Antonio and Bexar County, our list of questions grew hourly. How do we keep medics and firefighters safe and healthy? What standard precautions should they use? Should precautions include personal protective equipment for every patient encounter? What is considered exposed and at-risk? When should EMS personnel be placed on antivirals for prophylaxis, and how will it be funded? Will we treat their families too? How do we educate medics and firefighters and instill the gravity of the situation’s potential and the importance of wearing PPE, without causing panic?

We knew we may face difficult ethical choices too: choices like, who will and won't be given transport to the hospital if the system becomes overwhelmed? Who will be given respiratory treatments, such as nebulized albuterol or intubation, if the risk of exposure to medics becomes too great with these procedures? Who may not receive an ambulance when they call 9-1-1? These potential decisions were enough to make most medical directors uneasy. In the end, we did what we do best: We planned and developed protocols for such foreseeable issues. Mitigation plays a central role in preparing for the next event. The following are a few of the lessons we learned.

1. Stay in the know: Fortunately, our city has an experienced Office of Emergency Management to regularly (weekly) bring all stakeholders together in planning. This helps keep communication lines open among public health, fire/EMS, police, city government, hospitals, public-service agencies and other related groups. These interfaces function during planning and preparation for a disaster and during disaster operations. Our public health department (the San Antonio Metropolitan Health District) was the lead agency and worked well with the STRAC. They kept us current through daily conference calls and face-to-face interactions. We regularly monitored updates from the CDC, the Texas Department of State Health Services (DSHS) and our regional public health office. Keeping track of hour-to-hour changes in recommendations allowed us to make decisions effectively and confidently. Disseminating accurate information to EMS crews was essential for patient care, standard precautions, crew safety, hospital notifications, prophylaxis and treatment of potentially exposed crews, and directives for screening employees for ILI (influenza-like illness).

2. Collaborate, collaborate, collaborate! We realized the importance of remaining current with guidelines from local, regional, state and federal partners. We discovered the benefits of close collaboration with public health, emergency management, hospitals and other EMS services in our area. Early on, we spoke frequently with the Schertz EMS director to remain abreast of their decisions and guidelines in a location with confirmed swine flu.

An integral part of our collaborative efforts was the frequent conference calls with our regional partners through STRAC. STRAC is an organization bringing together healthcare entities in 22 counties in southwest Texas (including Bexar, which encompasses San Antonio) to facilitate planning, implementation and operation of organized and unified trauma, cardiac and stroke care and disaster management in the region. STRAC manages the regional medical operations center (RMOC) located in the combined San Antonio/Bexar County EOC. The RMOC is a place where stakeholders in the hospital and prehospital arenas work side by side with their public health colleagues during a disaster. This 24/7 face-to-face interaction allows for quicker collaborative decisions and faster results during time-constraining and time-dependent events. Several days into the swine flu event, many area hospitals asked for the RMOC to activate and facilitate collaborative and unified decisions among hospitals and to improve the speed of communication with respect to public health guidance, which was often changing several times a day. The San Antonio Metro Health director, along with the executive director of STRAC and the San Antonio emergency manager, activated the RMOC. We then conducted medical direction for the San Antonio Fire Department from the RMOC, and found we made quicker decisions in accordance with Metro Health directives, the CDC, hospitals and surrounding EMS agencies.

We assumed a critical new role as RMOC medical directors, and initiated a regional EMS medical directors working group to facilitate policy guidance not only for San Antonio EMS, but for all other EMS agencies in the STRAC region. Our recently formed Regional EMS Medical Directors Committee met at the EOC during the event. It voiced resounding support for a collaborative development process for these EMS policy documents.

3. Control rumors! Stop them early and decisively. Several days into the event, an e-mail from a dispatch lieutenant spoke of a dispatcher's wife who, on a visit to her child's dentist, learned the dentist was feeling ill. The dentist allegedly told the dispatcher's wife that the dental hygienist had a confirmed case of the swine flu. Understandably, the dispatcher and his wife were worried, and asked if we would provide prophylaxis treatment for their family. We were current and knew details of the few regional patients confirmed to have H1N1 infection; these patients did not include the dentist or the hygienist. We squelched this rumor and gave our personnel peace of mind. Witnessing our calm, quick and accurate response, employees were slower to panic with the next rumor. Their knowing we kept up with accurate information helped control concerns.

4. Make information accessible: The best way to disseminate information to our medics and firefighters was through written memos. We compiled advisories for fire department personnel that were adopted by STRAC and distributed through the region. Reflecting the most current information, these advisories reflected decisions made collaboratively with STRAC, other EMS services and hospitals. They included such information as H1N1 background; actual morbidity and mortality; which patients were considered potential flu patients; how crews should approach these patients; standard precautions to utilize; other necessary protective measures; how to notify receiving hospitals of potential incoming flu patients and report them to public health; and what to do if they suspected possible crew exposure.

We distributed essential real-time information about possible flu patients to EMS crews as they responded to runs. We developed a list of questions for our dispatchers to ask 9-1-1 callers. If a caller confirmed signs or symptoms consistent with influenza-like illness, it was reported to the responding crew. This reminded crews to don PPE and maintain appropriate distance until initial assessment was completed. Our electronic medical record was modified to include a menu for ILI. This allowed near-real-time tracking of patients transported with ILI. Any crew with potential exposure was queried regarding utilization of standard precautions. San Antonio Metro Health was consulted on each case to confirm exposure and order laboratory testing. This process was enhanced by a sentinel event notification to EMS medical directors and infection-control personnel. We accomplished this electronically for 28 EMS agencies on more than 90% of EMS transports in the region.

5. Anticipate all scenarios: Fortunately, we never made any ethically challenging and difficult life-and-death decisions regarding altered standards of care. However, such decisions were contemplated, discussed and planned for. We began the daunting task of developing guidelines for our medics regarding no-load criteria and which patients should receive respiratory treatments. We now realize the possibility of facing such decisions in our future, and will have guidelines before another such event.

In Conclusion

While the H1N1 outbreak has been declared a global pandemic, our experience in the San Antonio region in the spring of 2009 was relatively mild. So far, we've dodged the bullet. But we've come closer than ever. We faced realities we'd never faced before. We not only identified difficult questions, we tentatively answered them, and in doing so established a reliable, substantive and working structure coordinating various resources on multiple levels. If there is a next time, we harbor no doubt: We will easily fall into step and quickly collaborate to implement the appropriate protocols and decisions. Our ability to do so will stem largely from our experiences that began with a simple call to talk on April 24, 2009.

Emily Kidd, MD, is an assistant professor at the UT Health Science Center at San Antonio and assistant medical director for the San Antonio Fire Department.

Craig Manifold, DO, is an assistant professor at the UT Health Science Center at San Antonio and medical director for the San Antonio Fire Department.

Eric Epley, NREMT-P, is executive director of the Southwest Texas Regional Advisory Council for Trauma and director of the Regional Medical Operations Center.

W. Nim Kidd is a district chief for the San Antonio Fire Department and emergency manager for the city of San Antonio.

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