Ebola Preparations: The Greater Cincinnati Area EMS Provider Perspective

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by Mike Steuerwald, M.D.

By CDC/Cynthia Goldsmith [Public domain], via Wikimedia Commons

By CDC/Cynthia Goldsmith [Public domain], via Wikimedia Commons

 As we are all coming to realize, there is a tremendous amount of information to digest when it comes to preparations for potential Ebola cases...

I sat down with Dr. Don Locasto and Dr. Dustin Calhoun to discuss their work with the PHEMAC committee. PHEMAC stands for "Public Health EMS Medical Directors Advisory Council." They exist specifically to deal with situations like this within our region.

PHEMAC recently released an update to all regional EMS providers. The goal of the update was to distill down all of the information out there into a useable form for our local teams. The text is available below.

Our discussion summarizes these initial recommendations, as well as makes suggestions for staying up-to-date as more recommendations are released. You can listen to the podcast here, or by subscribing to us through iTunes. 

October 20, 2014 PHEMAC Ebola Update

To: All Regional Fire Departments, dispatch centers and EMS Services

From: Public Health EMS Medical Directors Advisory Council (PHEMAC)

Re: Ebola Virus Disease (EVD) - UPDATE

PHEMAC is a group of EMS/Fire officers, EMA officials and EMS and Public Health medical directors in the Cincinnati region that meet quarterly to discuss issues pertinent to both the EMS and Public Health functions. PHEMAC played a key role in providing a single source of information during the H1N1 influenza outbreak a few years ago and is now ramped up to provide the EMS/Fire Community the same service regarding the current EVD situation. All information released by PHEMAC includes input from public health and will follow CDC guidelines as closely as possible. Some CDC guidelines may need additional interpretation.

We strongly recommend that ALL EMS PROVIDERS read this 3 page update in its entirety for your own protection and officers review this document during drill sessions.

By now the concern expressed by our EMS Community regarding EVD exposure has reached a fevered pitch. To address the misinformation and the overflow of information the PHEMAC committee held a conference call on 10/17 and decided to produce a more detailed release regarding EMS/Fire questions related to EVD exposure. We also discussed that the flow of information should come from a single and consistent source to avoid misinformation and the increase fear related to this issue. PHEMAC will function as that source. PHEMAC will be hosting a weekly conference call to review if there is a need to release further updates. PHEMAC will also conduct an interim conference call should there be dramatic changes.

On October 2, the PHEMAC committee made the following recommendations based on CDC guidelines:

  1. Call screening has, or will begin at both the County and City Dispatch centers.
  2. Fire Departments have been advised to screen patients with symptoms of EVD.
  3. Education specific to EVD should be shared with all department members.

Remember: This process has been developed to PROTECT THE EMS PROVIDER!

As a reminder, the screening questions below should be asked at both the dispatch and direct contact levels. Remember, this is the LEAD STRATEGY to prevent EMS personnel exposure.

  1. Patient has symptoms of fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding.
  2. Patient that have traveled to or have had contact with a traveler to West Africa (Guinea, Liberia, Sierra Leone or other countries where EVD transmission has been reported by WHO) within 21 days (3 weeks) of symptom onset.

EVD Facts:

  1. EVD is a virus that causes a hemorrhagic fever: see symptoms above.
  2. Symptoms may appear between 2-21 days after exposure. Average: 8-10 days.
  3. Disease mortality is approximately 50-90% in the third world countries with little to no health care system. It is assumed that that mortality rate will be significantly lower in countries with a robust health care system.
  4. Transmission of EVD is through DIRECT CONTACT with bodily fluids.
  5. Viral stability on surfaces. The stability of the virus on surfaces has not been completely validated. It is probably in the 4-5 hour range. But a more cautious approach may be warranted (up to 24 hours).
  6. Exposure Definitions:
    1. High Risk:
      1. Percutaneous (e.g., needle stick) or mucous membrane exposure to blood or body fluids of EVD patient.
      2. Direct skin contact with, or exposure to blood or body fluids of, an EVD patient without appropriate personal protective equipment (PPE).
    2. Low Risk:
      1. Household contact with an EVD patient.
      2. Close contact with EVD patients defined as the following:
        1. Being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area (back of ambulance) for a prolonged period of time while not wearing recommended PPE.
        2. Having direct brief contact (e.g., shaking hands) with an EVD patient while not wearing recommended PPE.
  7. Exposure Confirmation:
    1. The local health department will handle the confirmation of EVD through the Ohio Department of Health. This should take no longer than 24 hours, and may be shorter. The CDC will then complete further confirmation.
  8. There is currently no FDA approved treatment for EVD.

Personal Protective Equipment (PPE): What is appropriate?

  1. If the patient has been screened positive by the two questions above (either at dispatch or by direct contact), the following should occur:
    1. Limit the number of personnel in contact with the patient. Personnel that have initial contact should remain with the patient throughout care and transport, without adding any extra personnel unless absolutely necessary.
    2. PPE should include: facemask, gloves, impermeable gown, eye protection
    3. If tolerable, the patient should be requested to wear a facemask.
  2. PPE level should be increased if there is an excessive amount of bodily fluids present, the additional protection should include:
    1. N95 mask for respiratory protection.
    2. Doubling gloves, disposable shoe covers and leg coverings or Level C hazardous materials suit.
  3. Note: The CDC may be updating the PPE recommendations this week. We will update at that time.
  4. Videos and links providing a good source for the proper donning and doffing of PPE are:
    1. See link below.
    2. PHEMAC in conjunction with local Fire Departments will release a training video on how to doff PPE. This will be released in a separate communication.
    3. Practicing the PPE procedures during drill sessions is strongly advised.

Patient Care:

  1. The use of a thermometer by EMS to confirm/rule out fever is recommended.
  2. The patient should be cared for like any other ill/injured patient with the following exceptions:
    1. The risk/benefit of procedures that require increased contact with patient body fluids should be considered. Any procedure that aerosolizes body fluid should be avoided.
    2. The procedures involved in a cardiac arrest that could lead to increased body substance exposure should be performed in a controlled environment (i.e.: at the scene). Patients in cardiac arrest should be treated according to the department’s medical protocol, including the termination of resuscitation without transportation.

Notifications:

  1. The following notifications are required, and should be performed as early as possible:
    1. Administrative personnel as designated by the Fire Department.
    2. Destination hospital for the patient.

Transportation, Hospital Selection and Arrival:

  1. The EVD patient can be transported to any regional hospital.
  2. The use of a helicopter for transportation of a field EVD patient is not appropriate for multiple reasons. If you feel you need a helicopter for this type of patient call your typical contact numbers for further direction. http://www.cdc.gov/vhf/ebola/hcp/guidance-air-medical-transport-patients.html
  3. The EMS unit will receive instructions from the receiving hospital as to what to do. This is why it is critical to notify as early as possible.
  4. The hospital may request that you keep the patient in the EMS unit until the hospital can set up to receive the patient.
  5. The transfer of the patient will be directed by the hospital staff with the primary effort to not contaminate the receiving hospital unit.

Post Patient Transfer:

  1. The following issues will need to be addressed:
    1. Appropriate and careful doffing of PPE - see above.
    2. Discarding of contaminated waste:
      1. All disposable equipment should be placed in double red biohazard bags for disposal.
  2. EMS provider exposure risk assessment:
    1. The Department of Health should be available to guide the EMS crew as to level of contamination.
    2. Recommendations will be made at that point as to the crew’s availability to return to service.
    3. This decision will be made by the Fire Department Administrator/Supervisor based on Health Department recommendations.
  3. Emergency vehicle decontamination:
    1. After patient transfer do not move the vehicle pending discussion with the Fire Department Administrator/Supervisor.
    2. The Department of Health will be available to provide guidance regarding EMS Vehicle decontamination.
    3. Discussion regarding the return of EMS vehicles to service will be conducted between the Health Department and Fire Department Administrator/Supervisor.
    4. This decision will be made by the Fire Department Administrator/Supervisor based on Health Department recommendations.
    5. Guidelines have been issued by OSHA: https://www.osha.gov/Publications/OSHA_FS-3756.pdf

Additional References:

General Information: http://www.cdc.gov/vhf/ebola/index.html

Information for Health Care Providers: http://www.cdc.gov/vhf/ebola/hcp/index.html

PPE: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety-answering-points-management-patients-known-suspected-united-states.html#ppe

Questions/recommendations:

Donald Locasto, MD

Donald.Locasto@uc.edu