How we keep first responders’ health and safety a top priority is a subject on many peoples’ minds.
EMS providers have implemented scores of treatment changes across the country to keep everyone safe — patients and first responders. Efforts put in place to effectively treat COVID-19 suspected or positive patients address EMS risk management.
Shawn Baird, LP, MA, serves as vice president of rural services for Metro West Ambulance serving Oregon, Washington, and northern California. He will become president-elect of the American Ambulance Association in November 2020.
To offer examples of treatment changes in the field when working with COVID-19 patients, Baird cites a recently developed patient care document, “Washington County EMS Protocols.”
A work group response team drafted the document to identify which treatments posed risks to EMS crews. It also includes treatment workarounds intended to keep teams safe when working with highly infectious patients.
As protocols continually change from states and counties, Baird stressed the importance of keeping a flexible mindset. EMS professionals will continue learning as we understand more about COVID-19 and necessary safety protocols.
“Modify work practice, modify medical practice or equipment changes to minimize the risk of circulating concentrated amounts of the virus,” Baird said.
EMS risk management
Sometimes it requires providers use treatment practices they learned at the start of their EMS careers, he said.
“For patients with congestive heart failure, instead of intubation, it’s been more popular to use CPAP,” he said, adding he does not advise standard intubations.
The risk with intubation is that the EMS crew might become exposed to infectious disease droplets when patients exhale, Baird said.
“The patient could be blowing aerosolized COVID-19 into the atmosphere, so we are trying to minimize that by using nitroglycerin and going back to using CPAP with a filter in the line,” Baird said.
If intubation is the only option, the goal is to keep providers at a distance from the patient’s face and prevent exposure of any respiratory excretions.
“Intubation with video laryngoscopy and bougie is strongly preferred over direct laryngoscopy,” states the document. “This is to maximize the distance from the patient and limit exposure.”
When patients go into cardiac arrest, creating a physical barrier between the EMS crew and the patient is now becoming common practice, said Evan Resnikoff, chief of operations with Newtown Ambulance, in Newtown, Penn.
“We make a shroud around their upper torso, head, neck and face to cover the area, so we are not aerosolizing around them or allowing air around them to escape,” he said.
This protocol came straight from the State of Pennsylvania in a guidance report. It suggests leaving room and space to perform CPR to isolate patients from providers for proper EMS risk management.
New-old asthma treatments
Before COVID-19, it was standard to treat asthma patients with nebulizers such as albuterol, Resnikoff said. But that’s not the case anymore.
“The state of Pennsylvania said we need to be careful with aerosolized treatments that use nebulizers with CPAP or BIPAP,” Resnikoff said. He added the state approved the use of terbutaline in its place, which is injected intramuscularly.
Terbutaline was approved in 1974 by the FDA to delay preterm labor during pregnancy.
Medics can administer IV steroids for asthma patients, said Resnikoff. But the downside is it takes nearly 20 minutes to work.
Epinephrine is another option in the case of an allergic reaction, he said. But it’s typically used in patients younger than 50. Patients can use their own inhalers only if they contain a spacer, which prevents aerosol release.
Mental health transports
Paramedics assess patients with mental health needs on a regular basis. Often this ends with a trip to the emergency department.
But assessment changes during a pandemic with the ED at capacity, said Asbel Montes, vice president of strategic initiatives and innovation for Acadian Companies. Acadian is a private ambulance provider that serves Tennessee, Mississippi, Louisiana, and Texas.
Instead, paramedics work with a psychiatrist via telemedicine to determine which facility will take the patient.
“There is a screening process we use with mental health professionals,” Montes said. “It’s a protocol-driven process and our paramedics are trained to use it for telemedicine.”
Some facilities will not take a patient with substance abuse problems, is taking methadone or has a chronic dementia diagnosis. They also factor in the degree of patient agitation, according to Montes.
Quarantine presents specific challenges for people with substance abuse history, Montes said. It became evident that people in recovery were likely to relapse. Ambulance providers such as Acadian anticipated the spike in mental health calls because of lack of access to medication refills, psychiatrists or social workers.
“Our No. 1 goal was setting up behavior health protocols because we knew the pandemic would further exacerbate mental health needs,” Montes said. “We knew with quarantine, it would increase calls for substance abuse issues.”