Memos & News
EMS: Protect Yourself; Wear All PPE at All Times
Posted November 21, 2020
Prevalence of COVID-19 has risen again in southern Massachusetts to the point that EMS personnel should now assume that every patient, symptomatic or not, could be infected with COVID-19. EMS personnel should thus wear full protective equipment on every call: Gown, gloves, eye protection, and an N95 mask or equivalent.
Please also remember:
- Wash hands and stethoscopes frequently
- Discontinue any aerosol-generating procedures (CPAP, nebulizer treatments) prior to entry to the ED. (We may or may not restart such therapies once a patient is safely roomed.)
- The decision to start CPAP or a nebulizer treatment in the ambulance must now, again, be individualized. These procedures increase risk to the EMS providers of a COVID-19 infection — exactly how much it increases the risk is not clear, especially if the providers wear N95 masks and other protective gear. (Arguably, a patient coughing is a bigger risk than a patient on CPAP, when it comes to aerosolizing respiratory droplets). Case by case, each EMS provider will have to make their own medical judgment about whether a given patient should have a nebulizer treatment or be placed on CPAP — balancing the risk to themselves and their colleagues personally, against the benefit expected for the given patient.
Identifying Patients: We Rely on EMS
Posted November 9, 2020
To provide best possible care, Southcoast hospitals is going to rely more and more on our pre-hospital partners to identify patients who may otherwise be too confused or altered to identify themselves. This is especially critical in the COVID-19 era when we have limited visitors — we can no longer rely on many family members to identify their loved one.
EMS providers, please do your best to obtain the exact name, birth date and address of patients who can’t identify themselves; bring copies or cell phone photos of driver’s licenses or other identification; bring a name and phone number for any family member who helped with identification.
St. Luke’s ED: Limited Visitors Policies Back in Effect
Posted November 3, 2020
Please note that at St. Luke’s emergency department, given rising prevalence of Covid-19, we are again moving to a no visitors / limited visitors policy.
Exceptions are rarely made for patients with critical, life-threatening illnesses, or who at baseline require a caregiver for mental or physical disability.
We ask our EMS partners to:
- Communicate this with families at scenes
- Make a special effort to fully identify patients — take a photo of a driver’s license or bring it along, get confirmation from a named family member or facility staff person of the patient’s exact identity (name, date of birth)
- Make a special effort to take down contact information for a relevant family point person we should call with updates or questions
- Make a special effort to identify Code Status or advanced directives when that might be relevant
Families can also always call the St. Luke’s ED themselves, 508-973-5390, for updates on relatives brought to us by ambulance. They should be encouraged to have one family member be the point person for such calls.
Separately but related, please also remember:
- Wear appropriate protective gear, wash hands and stethoscopes frequently, keep yourself and patients safe
- Discontinue any aerosol-generating procedures (CPAP, nebulizer treatments) prior to entry to the ED (we may restart them once a patient is safely roomed)
Weds Night from 8 p.m.: Ambulance Entry Change
EMS Return-to-Work Guidelines after Covid-19 Infection
Posted October 20, 2020
After an EMT, paramedic or other healthcare worker tests positive for Covid-19 — when and how can they go back to work? The algorithm per CDC is simple:
- Mildly symptomatic, with a positive Covid-19 test?
Out of work:
- For 10 days since symptoms first appeared, and
- For 24 hours since last fever, and
- Until symptoms “have improved”
(So 10 days after onset of symptoms, one could still have residual cough, say, but could return to work — as long as improving and no fever for at least a day. CDC does recommend people with persistent mild symptoms wear a face mask at all times at work.)
- Asymptomatic, with a positive Covid-19 test?
Out of work for 10 days. If develop mild symptoms in that time, revert to “mildly symptomatic” category above.
- Severely / critically symptomatic with Covid-19 — OR, even asymptomatic, but with an underlying compromised immune system?
CDC says out of work “for at least 10 and up to 20 days” since symptom onset. So these special cases could be discussed with medical control; or, as CDC notes, with input from an infectious disease specialist if that was felt necessary; or could simply default to a 20-day quarantine.
What if the healthcare worker is ready to return — but obtains a second Covid-19 test, and is still testing positive? This suggests they are still shedding virus, and until recently it was felt they needed to remain out until they were no longer testing positive. In our region, we have had a handful of cases of EMS personnel who feel well and are ready to work, but who have been sidelined for weeks, with serial tests persistently coming back positive. The good news is: Those people are almost certainly testing positive but no longer contagious, and can return to work.
Research summarized by CDC now shows that many people will shed Covid-19 coronavirus particles for 3 months or more after an infection — but the viral particles at that point have been chewed up by the patient’s immune system and are no longer contagious.
For those who had mild infections and a strong immune system, no “replication-competent” viral particles have been isolated after 10 days from symptom onset; for some who had a critical Covid-19 illness or an underlying immunocompromised state, contagious viral particles were identified for a longer period — but even then, 95% of the time, by 15 days from symptom onset the virus particles shed were degraded to the point of being non-contagious. These conclusions are based on study of viral particles isolated themselves, but also on contract tracing studies that have followed patients shedding Covid-19 viral particles for weeks and months, and have confirmed that their close contacts are not being infected. Given this, it is not necessary to obtain a repeat Covid-19 test to return to work; and if one is still obtained and is positive, it can be ignored.
Finally, note that there is a near-zero incidence of Covid-19 reinfection so far. In fact, in the United States, there has only been one convincingly reported case, in a healthy 25-year-old man in Nevada, and worldwide only 4 other cases. Early reports of Covid-19 reinfections were most likely situations where a person recovered from Covid-19, then contracted a different viral illness but was still testing positive for Covid-19. So for anyone who tests positive for Covid-19, for at least the next 3 months, they do not need to take repeat Covid-19 tests if they develop a fever and / or viral syndromes, but can instead simply stay out of work until no fever for 24 hours and symptoms are improved.
BLS protocols: Bronchodilators, Epi, CPAP & Glucagon
Posted August 13, 2020
The Statewide Pre-Hospital Treatment Protocols for 2020 allow BLS providers — if properly trained — to provide select medical interventions that were once reserved for paramedics. These sections of protocol must be explicitly activated by the EMS medical director. For EMS services that receive medical direction from Southcoast physicians, this memo confirms the following select optional protocols (and only the following) are active and can be accessed — again, with the provision that BLS providers must have received appropriate training, and the service they work for must have approved local use. (Please note that once the medical director activates these options, this only clears the way for EMS leaders to further implement — all actors should be sure to review these protocols before “going live,” as the state has included significant commitments for training and for post-call quality improvement reviews).
Once trained and approved by their local EMS leadership, BLS providers working under Southcoast medical direction may:
- Section 6.1: initiate bronchodilators in patients who already take them and have an established diagnosis of reactive airway disease
- Section 6.3: use the Selective Spinal Assessment protocol to determine whether or not a patient requires a hard cervical collar immobilization.
- Section 6.6: administer intramuscular epinephrine injections for anaphylaxis via “Check and Inject” kits (as an alternative to epinephrine auto-injectors or “Epi Pens.”)
- Section 6.9: initiate Continuous Positive Airway Pressure (CPAP) in appropriate patients suffering respiratory distress in setting of bronchospasm or congestive heart failure.
- Section 6.10: administer intramuscular glucagon injections for patients with documented hypoglycemia and who are too altered to take by-mouth glucose / sugars.
Covid-19: Please stay vigilant!
Posted July 22, 2020
Please note that Covid-19, while it has waned in southern Massachusetts and Rhode Island, does still remain prevalent in the region. We are seeing Covid-19 cases in our emergency departments still almost every day. So it is important to continue, as EMS providers, to use appropriate protective gear (N95 masks with patients; surgical masks at least when not engaged in patient care), wash hands, and practice appropriate physical distancing. The experience of EMS and emergency departments in our area confirms: You will be at low risk of contracting Covid-19 even if you care for multiple contagious Covid-19 patients — provided you do these 3 simple things.
If pepper spray / tear gas: Call Ahead; Need to Decon
Posted June 3, 2020
Please note that patients exposed to pepper spray, tear gas or other riot-control gasses / agents can expose EMS and other healthcare providers via off-gassing from their skin and clothes. They need decontamination prior to entering a hospital. EMS providers should call ahead to warn the emergency department if bringing such a case, and will likely be directed to a decon area prior to proceeding to any ED room. (At St. Luke’s, for just an isolated case or two this would mean either entering the ambulance bay and proceeding to the next-door decon room and its showers, or possibly being directed to enter via the decon room’s external door; in event of multiple cases there may be outside tent decon facility operations.)
Decon — which people with minor exposures who don’t feel they need medical care can also perform on their own — basically involves removing and bagging exposed clothes, washing with soap and water, and for eye irritation, irrigating with water for several minutes. For more information see this excellent CDC info sheet on riot-control agents.
Rounds Postponed for June.
We are postponing the planned educational rounds for June 2020. (Rounds requirements for paramedics for 2020 will also be adjusted, in light of COVID-19 disruptions.)
Advisory: COVID-19 Associated with STEMIs
Posted May 13, 2020
Please note that viral respiratory infections, including influenza A and B, RSV, and now COVID-19, are all associated with a large increase in risk for myocardial infarction / STEMI. A study two years ago found that having had a viral illness in the past seven days dramatically increased risk for an MI. Influenza B increased risk of MI in the next seven days by 10-fold, influenza A by 5-fold, RSV by 3-fold. It is also noteworthy that historically, more people die after influenza from a cardiac cause than a pneumonia.
COVID-19 has also been implicated in cardiovascular pathology. It has been associated with STEMIs, as well as NSTEMIs and STEMI-mimic myocarditis. (Why? Unclear, but overall, it like influenza is associated with all-body inflammatory processes, which in turn increase risk for pathological clotting.) Paramedics should please remember to consider STEMI in the differential for a patient with a viral syndrome picture.
For Non-911 EMS: Use St. Luke’s Main Lobby Entrance
Posted May 12, 2020.
All emergent / 911 EMS arriving to St. Luke’s should continue to use the regular ambulance bay doors as always. But non-emergent ambulance teams should enter through the main hospital lobby. (Although in past non-emergent EMS has arrived via the MRI access area, that door is now closed). The hospital is screening all staff and visitors on arrival, and EMS staff can also expect to be screened for temperature readings.
Rounds Postponed for May.
We are postponing the planned educational rounds for May 2020. (Rounds requirements for paramedics for 2020 will also be adjusted, in light of COVID-19 disruptions.)
Advisory: COVID-19 May Present as Cardiac Arrest
Last reviewed: April 30, 2020
A recent letter in the New England Journal of Medicine reports that out-of-hospital cardiac arrest (OHCA) rose rapidly during the first 40 days of the COVID-19 pandemic in Italy, in tandem with rising cases of the coronavirus infection. The implication is that many COVID-19 cases presented for the first time to healthcare as cardiac arrests.
EMS providers should assume any OHCA could be COVID-19 related; and should review the latest American Heart Association guidelines on managing cardiac arrest in cases of confirmed or suspected COVID-19. Some of these AHA recommendations are counter-intuitive to past practice. They include:
- Wear all appropriate PPE and minimize personnel involved
- Consider use of mechanical chest compression devices (to help limit staff involved / exposed)
- Use viral filters if intubating / ventilating patients
- HOLD compressions if intubating, to ensure first-pass success and minimize airway manipulation / exposure
- Whatever airway strategy is used, if possible consider early attachment to ventilator’s closed circuit (with viral filters) as opposed to bag-mask ventilation
- Finally, consider the appropriateness of even starting or continuing resuscitation in cases strongly likely to be COVID-19, given the possible poor prognosis; this can be discussed with medical control if needed.
Update on Expedited COVID Testing for First Responders
Last reviewed: April 7, 2020
Effective immediately, first responders who are SYMPTOMATIC and need a COVID-19 test can self-present to the St. Luke’s ED triage area. If they identify as a first responder in need of a test, then they will be directed to a tent for rapid COVID-19 testing that is open now from 9am to 6pm. This replaces the prior protocol of calling ahead to the ED.
Protocol 6.11 on Calling Select Codes in Field Activated
Last reviewed: April 2, 2020
Effective immediately, paramedics who receive medical control from Southcoast Hospitals medical directors (at Charlton Memorial, Tobey or St. Luke’s) can make use of Statewide Treatment Protocols Medical Control Option 6.11, “Withholding and Cessation of Resuscitation.”
Medics must present the case to the Online Medical Control physician via CMED. Medics should continue resuscitation during this med control call. Do not stop before or during the radio call — assume the code is still active! If the emergency physician reviewing the case is not comfortable in any way, the physician may well decline this. In that case, paramedics must continue resuscitative efforts and transport to nearest hospital.
In addition to receiving Online Medical Control approval to stop the resuscitation, the case itself must meet the following minimum requirements to be considered for this:
- Adults only (18 and over)
- Patient not visibly pregnant
- No relevant hypothermia suspicion
- All standard ALS has been provided — includes medications, defibrillation if relevant, respiratory support, but does not necessarily require advanced airway
- Patient has been PERSISTENTLY in either asystole or PEA for > 20 minutes (so, can’t be in and out of ventricular dysrhythmias, or having intermittent return of spontaneous circulation)
- No relevant hypothermia suspicion
- If patient has advanced airway, it must have been confirmed by End-Tidal CO2 with waveform
Many codes are called already in the field without Online Medical Control involvement. These are cases with DNR orders, with trauma inconsistent with life, or signs of prolonged arrest such as dependent lividity or rigor mortis. When paramedics have those findings, they can call the code on their own authority and do not need Online Medical Control. This is true even if a resuscitation has been initiated prior to recognizing a valid DNR, or signs of lividity.
EMS May Defer Transport of Certain COVID-19 Cases
Last reviewed: March 31, 2020
Effective immediately, EMS has been given permission by the state to not transport well-appearing, viral syndrome-only cases that meet strict criteria. The medics must call for On-Line Medical Control every time to share the decision-making in real time with an emergency department physician. Medics can provide treatment at the scene per their discretion, but such treatments must be consistent only with supportive care for a viral syndrome (i.e., antipyretics, anti-emetics, etc.)
Patients eligible for this protocol of deferred transport must:
- Only appear to have COVID-19 / viral syndrome, no other complaints
- Be alert and oriented
- Be between ages 18 and 55
- Have at least 2 viral syndrome symptoms (cough, sore throat, nasal congestion, fever, chills, myalgias)
- Have a heart rate, blood pressure and respiratory rate in normal limits for their age
- Have an oxygen saturation of more than 94%
- Have no signs or symptoms of recent syncope, chest pain (other than mild, cough-associated pain), cyanosis, respiratory distress
- Have no past history of COPD, asthma, heart disease, diabetes or immunosuppression
- Have access to a primary care provider or other outpatient healthcare provider
- Agree, or have a caregiver who consents, to not going to an emergency department
CPAP, Nebulizer Therapies During COVID-19 Pandemic
Last reviewed: March 31, 2020
CPAP and nebulizer treatments have potential to aerosolize viral particles. For this reason, Southcoast asks that EMS discontinue all such therapies upon arrival to our emergency departments. This is not because such therapies are inappropriate — as we all know, they can be excellent for dyspneic patients — but because we prefer not to continue them while the patient is being wheeled down the hallway. This is to protect other patients in the department, in the event the patient being treated turns out to have an infectious process such as COVID-19. Once in the patient room, the emergency department may well re-initiate the same therapy, per the physician’s discretion.
The state OEMS recently released an emergency protocol update regarding care of possible COVID-19 patients. This protocol notes that CPAP and nebulizer treatments have potential to aerosolize viral particles, and says paramedics “may defer” those treatments to the receiving hospital.
To be clear: Paramedics can still start CPAP or nebulizer treatments for dyspneic patients. But they are also empowered not to do that, for example if the patient seems to be in only mild distress. This is at paramedic discretion, and will have to be a balancing act every time between the safety needs of the EMS crew — aerosolizing procedures like nebs do create a small increased risk — and the medical care needs of the patient.
What PPE Required for EMS?
Last reviewed: March 31, 2020
SARS-CoV-2, the virus behind COVID-19, is felt to be droplet and contact transmitted, and so surgical mask, eye protection, gown and gloves are all appropriate PPE. But remember that once nebs or CPAP are involved, it could be aerosolized, or air borne, at which point an N95 quality respirator mask is appropriate.
Southcoast, EMS & COVID-19: Other Policy Updates
Last reviewed: March 31, 2020
All staff in Southcoast EDs are wearing a surgical mask at work at all times; in many situations, staff are wearing N95s. We ask that all EMS providers wear at least a surgical mask upon arrival to the ED at all times.
Expedited COVID-19 Testing for First Responders
Last reviewed: April 7, 2020
First posted: March 31, 2020
[ UPDATE THIS PROTOCOL IS NOW OUTDATED, SEE ABOVE APRIL 7. ]
For EMS providers and other first responders who are SYMPTOMATIC with fever, cough, shortness of breath or other possible infectious symptoms, St. Luke’s ED will arrange expedited testing.
For these cases:
1) Call ahead to inform resource RN you are coming, 508-973-5390
2) Arrive if at all possible in surgical face mask
3) Come to usual ambulance entrance and ring the doorbell
4) You will be met, quickly roomed, registered, a test swab taken and you will be immediately discharged home for further self-quarantine
This is ONLY FOR SYMPTOMATIC first-responders. We CANNOT TEST providers with no symptoms just because of a COVID-19 exposure history.
EMS Needs to Mask Patients & Wear PPE for All Cases
Last reviewed: March 31, 2020
First posted: March 19, 2020
The following is policy for all EMS companies affiliated with Southcoast Hospitals for their medical direction:
Medics who do wear full PPE (gown, mask, gloves and eye protection) while caring for even a high-risk COVID-19 / a.k.a. SARS-CoV-2 case (febrile, actively coughing) do not need any special monitoring and are not considered exposed. (If a facility asks an EMS provider, “Have you been exposed to a SARS-CoV-2 patient?” the answer, provided they were wearing full PPE, is “No.”)
Medics who fail to wear PPE with a case that is subsequently confirmed as SARS-CoV-2 need, per CDC, quarantined for 2 weeks.
Medics who fail to wear PPE with a case that is subsequently shunted into a SARS-CoV-2 ruleout pathway need quarantined until the ruleout comes back negative.
Note that 48.5% of SARS-CoV-2 patients in one study in China had diarrhea (!) as their presenting complaint. Also note that patients can be asymptomatic but contagious for 2-3 days prior to developing symptoms themselves.
Taken together, this will translate as: either we will save some masks and gowns up front (but lose staff to unexpected 2-week quarantines and likely spread infection further); or we will use masks and gowns liberally upfront, decrease exposure risk not just to EMS workers but to many others, and run the risk of running out of masks and gowns later (and then improvising).
Southcoast thus formally recommends that EMS use appropriate PPE for a SARS-CoV-2 patient on all undifferentiated patients. The only exceptions should be cases that are clearly not SARS-CoV-2 in nature – that have no respiratory, GI, nonspecific symptoms (“weak and dizzy,” “don’t feel good”), or classically infectious symptoms (body aches, sore throat, etc.)
In other words, patients who present with STEMIs, strokes, psychiatric complaints, isolated GI bleeding, substance abuse, genitourinary issues, major or minor trauma, etc. — who also do not screen positive for these other respiratory, infectious or GI symptoms when asked – could reasonably be considered “asymptomatic for SARS-CoV-2.”
Given the enormous commitment on the part of the entire nation to try to limit spread of SARS-CoV-2 in other settings, many ordinary citizens — who are out of work, their kids out of school, their grocery store shelves empty — would be shocked if they were to learn that EMS providers – who have the highest level of potential exposures, stuck in the back of an enclosed ambulance for prolonged periods with patients, often while initiating emergency aerosol-generating procedures like bag-mask ventilation, neb therapies or CPAP – and who also have the broadest travel across our network of hospitals and care facilities – weren’t in every case taking the most basic of precautions. It seems logical to recommend EMS wear full PPE in any case that could reasonably be SARS-CoV-2 – if not in every case that an EMS crew transports.
“… emergency first responders … may be permitted to continue work following potential exposure to SARS-CoV-2 (either travel-associated or close contact to a confirmed case), provided they remain asymptomatic.
“Personnel who are permitted to work following an exposure should self-monitor under the supervision of their employer’s occupational health program including taking their temperature before each work shift to ensure they remain afebrile. On days these individuals are scheduled to work, the employer’s occupational health program could consider measuring temperature and assessing symptoms prior to their starting work.
“… CDC does not recommend testing, symptom monitoring or special management for people exposed to asymptomatic people with potential exposures to SARS-CoV-2 (such as in a household), i.e., “contacts of contacts;” these people are not considered exposed to SARS-CoV-2.”
Rounds Postponed for April.
We are postponing the planned educational rounds for April 2020.
EMS and PPE Use at the ED
Last reviewed: March 19, 2020
Paramedics should at minimum use appropriate personal protective equipment on all respiratory cases and all febrile cases. They can wear PPE into the EDs while bringing patients back. Once care has been transferred, EMS providers should doff all PPE before leaving the room and wash their hands after. They can then don a fresh pair of gloves to wheel the stretcher and any other equipment back to the ambulance bay, where any further necessary decon of monitors, stretchers or other equipment can occur.
EMS And Pharmacy Restocking
Last reviewed: March 19, 2020
Effective immediately, EMS providers do not need a physician signature on their patient care report (PCR) to restock ambulance medications at our pharmacy. Simply present the (unsigned) PCR.
COVID-19: No CPAP On Arrival; Use Your PPE
Last reviewed: March 31, 2020
First posted: March 17, 2020
1) Effective immediately, please discontinue not just nebulizer therapy, but any CPAP / BiPAP therapy, prior to entering a Southcoast Hospital ED with a patient. Any patient who required that level of respiratory support should also have a surgical face mask placed on them — not an N95 — this can be placed over top of any O2 delivery device needed. Once the patient is settled in a room or other treatment area, the physician will decide whether to resume nebs or non-invasive positive pressure. Therapies such as bag-mask ventilation or CPR can and should be continued.
2) Please review with your frontline EMS providers that for any patient with fever or any patient with any respiratory complaint, they should be wearing PPE. We are seeing multiple EMS crews delivering coughing, dyspneic and / or febrile patients with zero PPE donned. This is not safe for the crews. Please remind crews that not using PPE when appropriate could have implications for them if they are placed on 2-week quarantines that otherwise could have been avoided.
Stroke care & EMS conference
Rhode Island Hospital is hosting a stroke symposium on Saturday, May 9, in Providence, and regional EMS are among those invited. Read More.
EMS And Pharmacy Restocking: Update From DPH
The state EMS offices recently clarified that when a paramedic gives a medication under state treatment protocols, there is no requirement for the paramedic to obtain a physician signature on the PCR in order to restock the medication. Southcoast Hospitals Group had actually advocated for this change so we are pleased to see it! For the moment, the practice will continue, only because we are in process of updating the contracts ambulance companies have signed with our pharmacy — the current contracts still say paramedics need this signature. Read More.
Given the current shortage of Diltiazem: In cases of rapid atrial fibrillation that require rate control per protocol, please consider there is a standing order to use Metoprolol instead. Dosing is 2.5-5 mg per protocol, often the 5 mg is the most appropriate dose. Read more.
NOVEL CORONAVIRUS: UPDATE FROM OEMS
This posting is to ensure that the EMS community is aware of recently issued guidance on the outbreak of a novel coronavirus causing respiratory disease in Wuhan, China, and to provide additional information for EMS personnel. Read more.
Given the current shortage of Dextrose 50%, cases of hypoglycemia can be treated as per a standing order with Dextrose 10%. Read more.
Patients with left ventricular assist devices (LVADs) are becoming more common in our area and are uniquely challenging. Read more.