Memos & News
EMS Needs to Mask Patients & Wear PPE for Almost All Cases
Last reviewed: 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 upfront, 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 of wearing gown, masks, gloves and eye protection.
It seems totally obvious and logical to recommend that EMS wear full PPE in any case that could reasonably be SARS-CoV-2 – if not in every case that an EMS crew transports.
CDC on EMS & Other Healthcare Worker Exposures
“… 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 & EMS: 1) NO MORE CPAP ON ARRIVAL, and 2) USE YOUR PPE PLEASE!
Last reviewed: 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.