In deaths and dollars, the final toll of the 2019–2020 novel coronavirus outbreak has yet to be tallied. But for EMS providers across America and around the world, it’s already become the most consequential event since 9/11. Unprecedented protective measures taken within EMS systems, across the galaxy of healthcare, and in virtually all other industries seem destined to outlive the outbreak and yield benefits against future occurrences. But over the winter/spring of 2019–20, it’s been anxious, harried, and turbulent.
With this special issue we look across the spectrum at several important aspects of the pandemic and its response, including how systems at and around America’s ground zero in Washington reacted; scenes from the hard-hit nation of Italy; some basic pharmacological questions; and how agencies are leveraging their MIH capabilities against the disease.
There’s lots more to read, hear, view, and learn on our special dedicated COVID-19 site. Please bookmark that and refer back for the latest news, recommendations, opinions, and analysis.
Stay abreast also of the latest recommendations from the CDC, WHO, and your relevant state and local authorities. Practice those precautions and stay safe—when crises like this occur, you’re an essential part of getting America through them.
Coronavirus Lessons From Ground Zero
When EMS personnel from the Kirkland (Wash.) Fire Department (KFD) responded to the Life Care Center nursing home in late February 2020, they weren’t expecting anything out of the ordinary.
“Based on the calls for patients suffering from fever and respiratory problems, we believed the highest likelihood was a flu outbreak,” says KFD EMS Capt. Joel Bodenman. “Although the medical situation was taken seriously, there didn’t appear to be a crisis unfolding.”
That was then. As we know now, Life Care Center turned out to be the epicenter of Washington State’s COVID-19 outbreak. At least 40 people connected to the facility died of the disease. And because they didn’t know COVID-19 was at this facility, a number of Kirkland first responders were exposed to the virus and left out of commission.
“We ended up with approximately a third of our workforce in quarantine or isolation,” says Bodenman. “This seriously affected our remaining firefighters/EMTs, leading to many Kirkland employees working extraordinary hours since this outbreak began.”
Since the Life Care Center outbreak, the Kirkland Fire Department has learned some important lessons about dealing with COVID-19.
Take it seriously—Yes, COVID-19 is not Ebola or the plague. But it is still extremely serious; particularly because the U.S. healthcare system is not geared to deal with a pandemic.
Wear the right PPE—According to the CDC, the right PPE for dealing with COVID-19 patients consists of gloves; goggles, face shield, or glasses approved for splash protection; full-length gown; and N95 or higher-level respirator.
Keep your distance when possible—It is obviously not reasonable to expect EMTs to keep their distance when moving COVID-19 patients. But they can reduce their risks by minimizing contact when possible. King County EMS began sending single responders in full PPE into homes to screen patients not identified by dispatch; Eastside Fire and Rescue looked at handing tablets to family members to take in to patients.
Transport patients safely—When an ambulance transports a COVID-19 patient to a hospital (be sure to alert the receiving site ASAP about their status), there is always a risk of infection. To reduce the danger:
Put a mask on the patient and ensure the pass-through between the driver and patient compartment is closed if possible;
Family members and friends should not ride along. If they must, they should wear face masks;
Turn on the ventilation fan;
Leave all doors open upon exiting the vehicle to ensure it has a clean air exchange as you bring the patient into the hospital.
“When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area,” says Vince Robbins, past president of the National EMS Management Association. “During transport, vehicle ventilation in both compartments should be on nonrecirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle. If the vehicle has a rear exhaust fan, use it to draw air away from the cab toward the patient-care area and out the back end of the vehicle.”
If the ambulance doesn’t have an isolated driving compartment and uses unfiltered air during transport, “Open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting,” Robbins says. “This will create a negative pressure gradient in the patient area.”
Disinfect after transport—Once the COVID-19 patient has been delivered, disinfect the ambulance as soon as possible. Wear full PPE during the process and thoroughly clean and disinfect all areas surfaces that may have come in contact with the patient or been contaminated during care using EPA-registered hospital-grade disinfectants. Leave the vehicle’s doors open to ensure safe ventilation of fumes.
James Careless is a freelance writer and frequent contributor to EMS World.
First-Person Perspective: The Scene in Italy
As you may know, Italy was among the earliest nations hit hard by the COVID-19 pandemic. My EMS station and hometown are located about 10 miles from Codogno, the first Italian city put under quarantine.
From the first day sirens broke the silence of our rural provinces almost every day of the week. We received clear instruction about how to treat COVID-19 cases (the correct use of PPE, how to properly sanitize our ambulances, and the initial instructions for BLS units to act) following the outbreak in China, but I never thought we would have the highest death toll in the world (at press time more than 17,000 and counting).
With most workplaces closed, my colleagues and I dedicated all our time to this emergency. (Italy does not have paramedics, and in many places EMT volunteers only cover eight-hour shifts each day.) Living in a rural town, we never experienced such a number of calls, 30–50 per week. Almost immediately hospitals created two types of ER that we colloquially called “the dirty one” for confirmed or suspected cases and “the clean one” for patients who had no fever.
We had Army physicians and nurses helping us triage, and anyone who entered the ER had their temperature checked first in a military tent. The Italian Army played a crucial role and built field hospitals in Crema and Piacenza.
The outbreak led to another big problem: increased response times for other types of calls. In the city of Lodi, a 53-year-old woman had a heart attack, and EMS showed up 40 minutes after the call. The system was saturated—that’s why we stopped transporting patients with minor illnesses. After we’d report to dispatch, they consulted a physician who decided if the patient could be treated at home or not. If we didn’t transport the patient, we would leave as soon as possible to respond to other calls. Over several weeks in March, all our response times were at least 20 minutes.
Sometimes it looked like we were in the middle of a battlefield: Empty streets everywhere, Army trucks transporting coffins to other regions because here we had no more room in cemeteries and crematories. You saw lots of your fellow citizens dying. The days went on and on, but it felt like everything happened in some distant memory.
After a while I wasn’t scared anymore. You had to cohabit with fear if you wanted to find some kind of equilibrium. Before this experience my dream was to become an emergency nurse, and after all this madness I’m more motivated than ever.
People started to give us free coffee and free meals, and dentists gave us surgical masks. Some people even applauded us. I wondered if those were the same people who before this pandemic were the ones spitting on us, yelling and cussing at us. And I wondered if they will do the same when this ends.
Angelo Bonfanti is an EMT in Italy.
Islands in the Storm: The San Juan County Response
The COVID-19 pandemic caused EMS agencies across the county to drastically rethink how they respond to patients with respiratory distress. Nowhere was that truer than in the Puget Sound region of Washington, an area considered ground zero for the pandemic in this country.
The first COVID-19-positive patient in the U.S. was identified in Snohomish County on January 20, 2020. San Juan County is a neighboring archipelago of 172 islands located along the Canadian border in extreme Northwest Washington. Its three ALS ground agencies, one BLS ground agency, and one ALS air ambulance serve 17,000 residents and tens of thousands of tourists across dozens of islands.
These agencies are staffed by a mix of paid and volunteer EMTs and paramedics, with one full-time staffed ALS ambulance on each of the three largest islands. One 10-bed hospital serves the largest island and county seat, San Juan Island, and two other islands have primary care clinics with limited services. The nearest tertiary care hospital is 30 minutes away by air. Almost 60% of the county’s population is 50 or older, and more than 20% is older than 70.
On January 22 the San Juan County Health Department activated its incident command system and the San Juan County medical program director published initial guidelines for EMS response. Those guidelines evolved thereafter to keep pace with the latest science and directives from the CDC and state DOH. Initial EMS guidance focused on three key areas: preparation, treatment, and transportation.
The first time leaders from partner agencies meet each other should not be during a disaster. It is critically important to build relationships with public health, hospitals, law enforcement, and local medical clinics prior to a mass-casualty event. Leaders should freely share phone numbers, identify barriers, and seek opportunities for collaboration.
Rural systems should also develop nontraditional resources to help care for their citizens. Schools, community centers, and private gyms may provide space for surge capacity, triage/testing centers, and staging areas for transportation to larger hospitals.
Given the older population of San Juan County, we emphasized reaching out to vulnerable populations, such as the elderly, to identify challenges in accessing care, food, water, and transport. The local senior centers and senior groups were used as conduits for information from EMS to citizens and to funnel questions and suggestions back.
The outbreak left personal protective equipment in high demand worldwide. As a result, thoughtful use of on-hand supplies was a priority to conserve our limited supply. We reused N95s for up to five patient contacts and expired masks when our in-date stock expired. We staged equipment at two stations to provide backup in case of primary station contamination. We used dedicated ambulances for response to suspect cases and streamlined equipment and storage to allow easier decontamination. We stripped ambulances of nonessential gear, erected barriers between drivers and patient compartments, and assembled dedicated in-home assessment kits to minimize equipment contamination.
Deciding what treatments to render, and how to render them safely, was a challenge and changed frequently as the science advanced. Early and aggressive respiratory care is key to mitigating the ARDS-like picture that has become the hallmark of the disease.
Due to the infectious risk of the disease, however, we made two decisions to minimize responder exposure. First we eliminated procedures in COVID-19 patients that offered minimal benefit but markedly increased the risk of responder exposure. Nebulized medications such as albuterol were replaced with metered-dose inhalers. Similarly, in patients with confirmed or strongly suspected infection, we withheld CPR. This decision was made in light of the extremely poor survival rate of cardiac arrest as well as exposure to responders. Withholding CPR was not done lightly, and we aligned the decision with research and guidance from numerous resources, including the University of Washington.
Screening questions were developed for dispatch that allowed possible COVID-19 patients to be identified prior to EMS arrival. If a 9-1-1 caller answered the questions positively, it was announced over the radio, allowing EMS team members to don appropriate PPE prior to entry. If a caller’s illness did not meet criteria for a 9-1-1 response (i.e., no obvious respiratory or hemodynamic distress), it was forwarded to a team of on-call physicians for patient instruction and guidance about further testing.
San Juan County elected to deploy two team members into the scene of any suspicious patient. We used rapid “doorway triage,” asking patients about fever and/or respiratory symptoms to identify any symptoms not caught on initial screening. After donning PPE and performing buddy checks, both members then entered the scene. One team member provided hands-on care while the second, if not needed for care, observed the process from six feet away, watching for accidental breaches in isolation precautions.
Because of the scarcity of medical resources in San Juan County, EMS collaborated with local medical clinics and public health districts to enable on-scene testing during the initial 9-1-1 response. Viral and bacterial swab sets were stocked on each ambulance. If a patient was identified as requiring testing but was unable to find transport to the clinic, trained EMTs or paramedics obtained the nasal and oral swabs on scene and transported them to the clinic for labeling and testing. They passed patient information to the county EOC’s surveillance branch for tracking.
After use PPE was placed in two bags and left either a) at the patient’s home if the patient was transported or b) labelled and stored at the station if the patient was taken off-island. If the patient’s COVID-19 test was negative, the PPE was disposed of via normal channels. If the patient tested positive, the PPE was retrieved by the health department for disposal.
Patients transported to the hospital included those with respiratory rates greater than 30, SpO2 less than 90% (if new and not corrected by supplemental oxygen via nasal cannula), systolic BPs less than 90 mmHg, pulse greater than 125/min., fevers greater than 40ºC, and altered mental status. At-risk patients with comorbid conditions such as cardiovascular disease, diabetes, chronic respiratory diseases (CHF and COPD), smoking, hypertension, and active cancer) were also transported on a case-by-case basis.
Because of the geography of the county, all patients meeting the above criteria were transported out of the county by rotary or fixed-wing air ambulances. San Juan County’s three air ambulance partners developed transport strategies that included removing nonessential equipment and designating certain aircraft for COVID-19 patients.
The county medical program director and ground paramedics determined which hospitals were able to accept patients and routed them to the appropriate facility in concert with the air providers. Initially patients were routed to the two tertiary care centers in northern Washington; however, as the pandemic progressed and more hospitals’ isolation wards came online, patients were transported to whichever regional hospital could accept new patients.
The COVID-19 pandemic is an unprecedented event for agencies throughout Washington and has taxed every portion of the EMS response. Creative thinking and extensive contingency planning will continue to be key to anticipating challenges and opportunities as the event progresses.
Joshua Corsa, MD, is the medical director for San Juan County EMS in Washington.
The Pandemic Role of Community Paramedics and MIH
As the coronavirus pandemic continues to strain the entire healthcare system, one unique EMS specialty is being called upon to help: mobile integrated healthcare and community paramedicine (MIH-CP).
As the pandemic began to unfold, EMS World talked with five leaders in the MIH-CP space about the issues facing their communities, what roles are best served by community paramedics, and what recommendations they have for how MIH-CP can serve during this pandemic. Contributors are Daniel Gerard, MS, RN, NRP, EMS coordinator for the Alameda (Calif.) Fire Department; Anne Montera, MHL, BSN, RN, public health consultant, Gypsum, Colo.; Jonah Thompson, BA, NRP, CP-C, MIH operations manager, Allegheny Health Network, Pa.; Michael Wright, NRP, MIH manager, Milwaukee Fire Department; and Matt Zavadsky, MS-HSA, NREMT, chief strategic integration officer, MedStar Mobile Healthcare, Fort Worth, Tex.
EMS World: What role does MIH-CP have in the pandemic that is different than traditional EMS?
Gerard: For the CP the ability to spend more time with the patient is crucial. CPs have the opportunity to assist with screening, vaccination, treatment, and follow-up. This is a boon, especially for people who are on home quarantine or home isolation. We should have an increased footprint in the community to perform public health screenings/fever checks and, when allowable, collect samples for screening services to diagnose COVID-19.
Zavadsky: MedStar’s medical director developed a process to effectively use the Medical Priority Dispatch System (MPDS) to help manage low-acuity calls that may be COVID-related. MPDS has “Card 36,” which is its pandemic/epidemic/outbreak protocol. We have developed a process by which low-acuity Protocol 36 callers with the ability to access online resources are directed to a few web-based screening resources in our community. For low-acuity callers without the ability to access the internet, we send a single-person resource (CP or other) to assess the patient and provide recommendations for further screening if necessary.
Thompson: Many frontline leaders may be tempted to see community paramedics as a pool of personnel available for surge capacity or to help cover gaps in the schedule. Not only would this be a disservice to these subspecialists, but it would also actively impede effective community response. The prototypical MIH-CP patient is likely to fall into one or more of the high-risk categories for infection with COVID-19 and development of COVID-19 illness.
How can MIH-CP be immediately utilized and/or how is MIH-CP already being utilized for the pandemic?
Gerard: CPs should be helping with screening/assessment of patients in long-term care facilities, skilled nursing facilities, daycare centers, and shelters. CPs should be reaching out to the homeless to provide screening services where they happen to be. Another opportunity for CPs is as a force multiplier for your occupational medicine staff. They are in the field every day; they can hold a “sick call” every shift change and screen staff for fever, cough, etc. and follow up with staff who are sent home ill or self-quarantine.
Montera: All the CPs in Eagle County, Colo., are on call to go perform COVID-19 testing. They are also following up on telemedicine patients so we give these patients a second set of eyes.
Wright: CPs should be helping with in-home or fixed-location testing. They should be conducting welfare checks on the elderly and assisting those with chronic disease who need medication refills.
How are you using telehealth during the COVID-19 pandemic?
Gerard: We weren’t going to use telehealth yet because of HIPAA issues and the expense of the technology. Since the Department of Health and Human Services has suspended HIPAA compliance issues relevant to telehealth, this will allow us to now look at it in a different light.
Montera: This spring we developed a way for three counties’ paramedics to use telehealth. When paramedics arrive to a patient who has symptoms of a respiratory illness, the providers stay in the ambulance and connect to the patient via text messaging and then on an app. They explain to the patient why they need to stay outside and then use the video telemedicine from the cab of the ambulance without needing to don any PPE or enter the patient’s home.
Paramedics monitor them through video and ask questions about their activities of daily living. At a cost of about $200 per call for PPE, this saves money and resources. And if the patient needs immediate medical attention, they don PPE and enter the home.
What skills, training, and attitudes can MIH-CP providers bring to support the health of the public right now?
Wright: CPs have a unique ability to communicate complex issues to the people in terms they will understand. The greatest enemy to thwarting any widespread problems is accurate, verifiable, and timely information. There is a huge need for these skills.
Gerard: A CP’s ability to perform advanced assessments is paramount. The assessment and reassessment are important tools on a longer trajectory to successfully manage a patient over days, weeks, even years. CPs can spend the time determining patient needs and capabilities to manage their health at home, without the pressure of having 9-1-1 calls stacked up.
Hilary Gates, MAEd, NRP, is the senior editorial and program director for EMS World.