“NIPPV was found to have the farthest dispersion of virus at 3 feet.”
The COVID-19 pandemic is placing immense and unimaginable pressure on Emergency Medical Systems (EMS) everywhere. As the virus rages around the country, first responders are increasingly vulnerable to contracting the virus, personal protective equipment stocks are shrinking and as was feared, the global death toll now tragically includes a growing number of EMS personnel. In some cases, it is unknown whether these first responders contracted the virus through community contacts or through contact with infected individuals while performing their duties.
“… uncertainty results in increased risk to the EMS provider, uncertain stresses on the supplies of personal protective equipment (PPE) and requires rapid adjustments in EMS practice, in order to keep clinicians safe.”
What Makes a Pandemic
COVID-19 is a member of the coronavirus family, which are common throughout the world, and typically cause mild to moderate illness (WHO, 2020). Other members of the coronavirus family include, but are not limited to, SARS-CoV (“severe acute respiratory syndrome”), which in November 2002 to July 2003 outbreak spread around the world and resulted in over 8000 cases and 774 deaths, with a case fatality rate of around 9-11%. In 2012, a novel coronavirus, MERS CoV (“Middle East respiratory syndrome”), causing severe respiratory symptoms was identified and resulted in fatalities comparable to SARS.
Pandemics have occurred intermittently for centuries, and three specific conditions must be met for a pandemic to be declared (DoT, 2020):
- A new virus must emerge for which there is little or no human immunity
- It must infect humans and cause illness; and
- It must spread easily and sustainability (continue without interruption) among humans.
As such, on March 11, 2020, the World Health Organization (WHO) Director-General, Doctor Tedros Adhanom Ghebreyesus, declared the novel coronavirus (COVID-19) outbreak a global pandemic. He said that the WHO is “deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction”.
The last three pandemics were in 1918, 1957, and 1968. While history offers useful benchmarks, the characteristics and influence of new pandemic influenza viral strain on EMS models of care, are not known before they begin. This uncertainty results in increased risk to the EMS provider, uncertain stresses on the supplies of personal protective equipment (PPE) and requires rapid adjustments in EMS practice, in order to keep clinicians safe.
This report identifies and explains the common changes to EMS practice that have transpired in response to the COVID-19 pandemic.
Current evidence (and this may change with ongoing research) suggests that the mode of transmission of COVID-19 is through direct contact with saliva or discharge from the nose when an infected person coughs or sneezes, and from respiratory droplets that have the potential to be propelled for up to two meters (WHO, 2020) The majority of positive COVID cases have been linked to the person-to-person transmission through close direct contact to someone with respiratory symptoms or transmission through an index case who was subsequently tested positive for COVID-19 and/or has developed mild symptoms.
People with COVID-19 have presented with a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms tend to appear 2-14 days after exposure. The most common symptoms at the onset of COVID-19 include (CDC, 2020) (Michelen, 2020):
- Fever (most common 82-87% of cases)
- Cough (second most common 36.5-44% of cases)
- Shortness of breath or difficulty breathing
- Muscle pain
- Sore throat
- New loss of taste or smell
Available treatment is currently limited to supportive care. At this time there is no cure, no vaccines, and no specific treatments for COVID-19.
COVID-19 Impacting EMS:
COVID-19 presents daunting challenges for EMS clinicians and complicates the provision of EMS care for a number of reasons: 1) the unknown prevalence of COVID-19 in the general population 2) the ability of asymptomatic patients to shed the virus 3) the ease of transmission of the virus 4) the variability and non-specific nature of symptoms in affected people.
In order to protect EMS personnel from exposure to COVID and to provide a safe response to patient needs, EMS agencies have been forced to reassess and collectively adjust practice in order to provide safe patient care. This includes dispatch modification, the appropriate use of PPE, and changes to the treatment and management of all patients, especially for patients with cough, fever and difficulty breathing, prior to knowing their infectious status.
Dispatch Modification to 911 Calls
Safe and intelligent response by EMS requires an integrated approach and ideally, this begins with the 911 Dispatch centers.
The Centers for Disease Control recently called for the “close coordination and effective communications” between all emergency response stakeholders- 911 call centers, the EMS system, healthcare facilities, and the public health system (CDC, 2020). This direction includes:
- Creation of modified caller queries
- Dispatchers should question callers to determine the risk of infection
- All persons transported who meet criteria should be transported as a person under investigation (PUI) (PUI is defined as a patient who has been tested for COVID-19 but has not received their result)
Emergency Medical Dispatch Centers and 911 Public Safety Answering Points (PSAPs) in many cases have coordinated with their local EMS agencies and medical direction, to develop and utilize modified caller queries that question callers and determine the possibility that this call involves a person who may have signs or symptoms and risk factors for COVID-19. If the caller answers YES to ANY of the queries, this information is then relayed to response agencies.
If information about the potential for COVID-19 has not been provided by the PSAP or Dispatch Center, EMS clinicians should nonetheless exercise a high index of suspicion in all patients and particularly those presenting with fever and respiratory symptoms.
CHANGES TO PRACTICE
Point of Care Risk Assessment & Personal Protective Equipment:
Point of care risk assessment is used to determine appropriate personal protective equipment (PPE) for the care of confirmed or suspected COVID-19 patients. Many EMS agencies are now employing this approach to care.
Initial assessment begins with a single EMS clinician donning appropriate PPE (N95 Respirator, eye protection-goggles or disposable face shield that fully covers the front and side of the face, single pair of disposable patient examination gloves and a disposable gown), and assessing the patient separately from all responding personnel not wearing PPE (CDC, 2020). Responders without appropriate PPE are kept at a minimum of 6 feet from the patient, if possible. Patient contact should be minimized until a facemask is on the patient, and EMS have donned the appropriate PPE (CDC, 2020).
If the patient meets PUI criteria, all clinicians wear appropriate PPE. If the patient does not meet PUI criteria, at a minimum, clinicians should follow their organizations’ standard precautions and an N95 face-mask (CDC, 2020).
EMS Treatment of Patients with COVID-19
Care of patients with COVID-19 presents many challenges, and especially for those patients who are exhibiting respiratory distress, as they may require supplemental oxygen or airway management, which increases the risk to the clinician. COVID-19 is primarily transmitted via airborne droplets and fomites during close contact. As with any disease disseminated by airborne droplets, the EMS clinician needs to create a safe and focused treatment plan prior to beginning treatment.
As such, it is important for the EMS clinician to appreciate the variation in the disbursement of infected droplet particles, during the delivery of respiratory support for patients with COVID-19 infection.
Recent research has focused on the common EMS oxygen delivery devices and the relative disbursement distance of aerosolized particles generated by each. Researchers conclude that the device that produces the least amount of spread at less than 10cm (4 inches), is the non-rebreathing mask (NRBM) using an oxygen flow rate of 10 LPM. This is followed by nasal cannulas with particle dispersion that can reach as far as 40 cm (1.3 feet) at a 5 LPM flow rate. Nebulized medication treatments, a cornerstone of EMS management for patients with bronchospasm, show the dispersion of particles up to 80 cm (2.6 feet). The use of non-invasive positive pressure ventilation (NIPPV), which includes CPAP and BiPAP, demonstrates the highest dispersion of particles at up to 95cm (3 feet) (Whittle, 2020).
With the uncertainty around the COVID virus and the associated transmission-risk to medical personnel for those patients who require treatment, the goal is to create an oxygen saturation greater than 90% (Whittle, 2020). This can be accomplished by following a staged approach to care, and progressing to more advanced interventions as necessary, with their associated increased risk, to maintain oxygen saturation above 90%.
“the device that produces the least amount of spread at less than 10cm (4 inches), is the non-rebreathing mask (NRBM) using an oxygen flow rate of 10 LPM.”
Aerosol Generating Procedures:
Although the coronavirus is primarily transmitted via patient droplets, where the treatment plan involves aerosol-generating medical procedures (AGMP), the risk of viral transmission increases. As such, full droplet and contact PPE precautions, including and especially, the N95 respirators are required. AGMPs expose EMS providers to a greater risk of disease transmission. Clinicians should exercise extreme caution, and follow local guidelines and protocols for consulting medical control before performing AGMPs (AHA, 2020).
AGMPs include the following situations (SafeAirwaySociety, 2020):
- Non-invasive ventilation or positive pressure ventilation with inadequate seal
- Utilizing a BVM
- High flow nasal oxygen therapy (>6L/min)
- Nebulization of medications
- Tracheal suction (without a closed system)
- Tracheal extubation
- Cardiopulmonary resuscitation prior to and during airway management
- Non-invasive ventilation for acute respiratory failure (CPAP)
Additionally, there are procedures that are vulnerable to aerosol generation and they include:
- Tracheal intubation
- Front-of-neck airway (FONA) procedures (including tracheostomy, cricothyroidotomy)
Where EMS providers have alternative treatment options, and where the risk vs benefit consideration is appropriate, alternative therapies should be considered, choosing those options with a lower risk profile. An alternative therapy for example, that should be considered in the coronavirus patient, is the use of metered-dose inhalers (MDI), rather than nebulization. Other practical considerations that can reduce the risk to the EMS clinician include the following:
- Using HEPA filtration with all BVMs and other ventilator equipment
- Limiting the number of providers present during the AGMP procedure
- Opening the rear doors of the transport vehicle
- Activating the HVAC system during AGMP
- Where nasal cannulas must be used, placing a facemask will help to minimize droplet spread.
The COVID-19 era has presented a new world for everyone, but especially for EMS providers. There exists a clear and present danger from a highly contagious virus, negatively affecting both EMS clinician safety and the management of patient clinical needs. EMS agencies have the opportunity to educate themselves and their clinicians, and to take specific precautions and serious actions to keep their much-valued clinicians safe and healthy.
EMS professionals are strong, dedicated, and compassionate health care providers and as such, deserve to know and understand how their jobs can put their health at risk, and the measures they can take to mitigate this risk.
Be safe, stay strong, and let’s continue to take great care of each other and our patients.
AHA. (2020). CPR & Emergency Cardiovascular Care Interim Guidance for Healthcare Providers during COVID-19 Outbreak.
CDC. (2020). Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.
DoT, U. (2020). National Strategy for Pandemic Influenza: Implementation Plan.
FEMA. (2020). 911 guidance for pandemic response. Retrieved from https://www.usfa.fema.gov/operations/infograms/041620.html.
GoC. (2020). COVID-19 Pandemic Guidance for the Health Care Sector. Retrieved from https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/covid-19-pandemic-guidance-health-care-sector.html#a325.
Michelen. (2020). In patients of COVID-What are the symptoms and clinical features of mild and moderate cases. Centre for Evidence-Based Medicine.
SafeAirwaySociety. (2020). Consensus Statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Medical Journal of Australia.
Whittle. (2020, April). Respiratory Support for Adult Patients with COVID-19. J Amer Coll Emerg Phys Open.
WHO. (2020). https://www.who.int/health-topics/coronavirus#tab=tab_1. Retrieved from WHO: Coronavirus.
Written by Jennie Helmer, ACP, M.Ed. Jennie is a Paramedic Practice Leader and the Research Lead with the British Columbia Emergency Health Service. She is a licensed ACP and Paramedic Specialist. She holds a Master’s in Education from the University of British Columbia (Masters in Adult Learning and Global Change) and has a Bachelor of Commerce from Royal Roads University.