After September 11, 2001, many things in the United States changed, particularly in the transportation and security industries. Flying on a plane would never be the same again, and folks had to take off their shoes and put liquids in 3-oz. containers. Chemical, biological, radiological, nuclear, and explosive (CBRNE) training became a staple for many fire and EMS departments. The Department of Homeland Security was formed and continues to thrive nearly 19 years later. How might emergency medical services change after the current COVID-19 pandemic has subsided?
Some states require two paramedics to man a unit. Others mandate the dispatch of two paramedics to calls but don’t require those paramedics to be on the same unit. Many states require two EMTs to be on a BLS ambulance. In response to staffing shortages, some states have put waivers in place to allow for more crew flexibility. For example, in New Jersey ALS units now only require one paramedic and one EMT, and BLS units can be staffed with an EMT and an EMR. While these current waivers are in response to the COVID-19 crisis, perhaps we will see permanent flexibility in crew configurations to increase the number and abilities of units in the field.
Scopes of Practice
Different states have broadened their scopes of practice for EMS providers in response to COVID. In Indiana starting March 1, EMTs were allowed to do end-tidal waveform monitoring, use bronchodilators, and administer over-the-counter pain relivers. In Ohio paramedics are now allowed to administer a rapid COVID-19 blood test. In Texas the governor granted medical directors the authority to expand the scope of practice of qualified individuals, such as allowing an EMT in paramedic school to function as a paramedic. In New Jersey a waiver allowed paramedics to work and perform ALS skills in hospitals. The phrase “desperate times call for desperate measures” might be considered here, but who knows whether some of these exceptions might become permanent.
Cardiac Arrest Protocols
Many areas, most notably in New York and New Jersey, which are the epicenters of the COVID-19 outbreak, are seeing a significant spike in cardiac arrest calls, most likely as a result of exacerbated COVID-19 symptoms. FDNY EMS reported a 400% increase in cardiac arrest calls in March and the first week of April. According to an NBC report on April 10, nearly 70% of those calls resulted in at-home pronouncements. The Regional Emergency Medical Services Council of New York City, which provides protocols for New York City’s EMS units, established protocols that after 20 minutes of CPR on an adult patient, if the defibrillator or heart monitor shows no shock indicated or a nonshockable rhythm and there is no blood circulation, CPR is to be terminated. At that point the NYPD or medical examiner can be called to remove the body; the patient is not to be brought to the hospital.
Cardiac arrest protocols have been under scrutiny for years, and many agencies were trying progressive tactics prior to COVID, such as “heads up” CPR, use of AutoPulse and LUCAS machines, and different pharmacology combinations. Perhaps the increase in cardiac arrest calls may generate data and a new look at field treatments and timelines.
Personal Protective Equipment
The CDC advises high levels of personal protective equipment for EMS providers. Depending on the types of procedures, this could consist of any combination of N95 masks, respirators, eye protection, face shields, gowns, Tyvek suits, and gloves. In March and April, nearly all EMS agencies were reporting shortages of PPE and in drastic measures were requiring personnel to reuse masks or equipment between patients or even for entire shifts.
Many U.S. companies are now changing their manufacturing cycles, and the coming months should see a surge in the availability of masks and other PPE. There will likely be a surplus of this gear by the summer.
New EMTs are taught the first things they should consider are scene safety and body substance isolation. With COVID-19 these concepts have taken on a higher level of seriousness, and distinct infection control and decontamination procedures will become the norm for EMS crews, along with enhanced PPE.
Several years ago almost everyone who called 9-1-1 for EMS got a ride to a hospital. Over the last several years, a growing number of agencies implemented community paramedics who could engage in wellness visits rather than emergent calls. With many patients having COVID-19 symptoms and an increase in the “worried well,” EMS has seen a growing number of patients who are recommended to manage their symptoms at home in consultation with their physician. This practice shields patients who do not necessarily require treatment in an emergency department from exposing others and frees units to respond to higher-priority calls. We may see a growing use of both community medicine programs and physician screening via telemedicine to reduce transports to emergency departments.
Most face-to-face EMS training ground to a halt in March and April due to social distancing requirements. With millions of Americans working and learning from home, the use of products like Zoom and Google Meet has spiked. Most colleges and K–12 schools have shifted to remote learning. Perhaps EMS will follow suit with an increase in distance opportunities for continuing education and initial training. While nothing can take the place of hands-on experience, perhaps more content-based training will take place remotely.
Increase in Stature
EMS has always suffered from an identity crisis and often been a second thought after law enforcement and the fire service. With a growing appreciation that healthcare workers can face life threats with every patient, perhaps a sea change is underway. EMS workers deserve their own moment in the sun. EMS crews face risk of quarantine, illness, and death during this time of COVID-19. While EMS has always faced that risk, the hopeful silver lining is an increased awareness and appreciation of emergency medical providers by the American public.
Barry A. Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor, as well as a firefighter and member of the technical-rescue team with the Roseland (N.J.) Fire Department and an EMT with the South Orange (N.J.) Rescue Squad. He is also an instructor for the National Center for Homeland Security and Preparedness in New York.