Is EMS prepared for an epidemic or pandemic?

The global COVID-19 epidemic is challenging EMS agency and fire department capability to assess, treat and transport patients


This article, originally published 1/31/2020, has been updated with current information

The novel coronavirus, first identified in late 2019 in China, continues to spread around the globe. There is increasing urgency for EMS agencies and first responders, as well as their partners in public health and emergency medicine, to review and deliver training on respiratory infection transmission, patient assessment, first responder personnel protective equipment and patient transport. 

The surge in concern, from civilian purchasing masks and hand sanitizer faster than stores can receive shipments to hospitals reporting the theft of N-95 masks, is making it even more difficult for paramedic chiefs to ensure adequate stocks of infection control and decontamination equipment are available. 

Training on proper PPE use is a critical need for EMS personnel. (AP Photo/Elaine Thompson)
Training on proper PPE use is a critical need for EMS personnel. (AP Photo/Elaine Thompson)

Supervisors and PIOs need to repeat the core prevention message of wash your hands, catch your cough, don’t go to work or school if ill, and get your flu shot. In addition, geriatric citizens with underlying respiratory disease are being advised by the Centers for Disease Control and Prevention to avoid mass gathering locations where the virus may spread more easily. 

Departments also need to collaborate with their EMS medical director to update policies for patient assessment and isolation based on guidance from the World Health Organization and the CDC. Based on the current spread of patients with COVID-19 it's critical that policies are updated to account for: 

  • Assessment of first responders known or suspected to have been exposed to the novel coronavirus which starts with near real-time communication from hospital infection control officials. Communication from hospitals back to EMS about patients who tested positive for COVID-19 after ambulance transport is critical. Boston EMS union officials are incensed that a hospital-based EMS sub-station was used for testing suspected patients. 
  • The efficacy, as well as practicality, of a 14-day quarantine for an increasing number of exposed first responders.
  • Lack of PPE, especially respiratory protection, for all responders who might make contact with a patient with COVID-19 symptoms.  
  • Dispatching of resources. FDNY fire companies with medical first responders have been ordered to not respond to "911 calls for asthma attacks, fever, coughs and difficult breathing."
  • An expanding array of COVID-19 guidance for EMS coming from the CDC, WHO, American Ambulance Association, Paramedic Chiefs of Canada, Global Medical Response (AMR), and a multitude of state EMS officers and member organizations. 
  • Training 911 telecommunicators, medical first responders from fire and law enforcement, EMTs and paramedics on updated screening protocols and the increasing availability of telemedicine to assess patients without transport. 
  • The potential collateral impact of COVID-19 including the cancellation of blood drives, in-person events for delivering EMS mandatory training, and recruitment events.   

Is EMS prepared for an epidemic or pandemic

Almost half of 2019 EMS Trend Report respondents felt their organization is either slightly or not all prepared for an epidemic or pandemic. 

Respondents were asked, “How prepared is your organization for an epidemic/pandemic?"

Nearly half of respondents selected "Not at all prepared" or "Slightly prepared." Less than 3% of nearly 3,000 respondents felt their organization was extremely well prepared. 

Self-reported perception of preparedness was highest for respondents who are primarily affiliated with a hospital-based EMS system or a public, third-service EMS system.

Respondents from private, for-profit and fire-based EMS systems reported nearly equal levels of slightly prepared or not at all prepared.

Immediate EMS actions to improve epidemic or pandemic preparedness

There isn’t an easy button to immediately and inexpensively improve EMS preparedness for an epidemic or pandemic, whether the cause is influenza, coronavirus or an unknown pathogen. But there are a variety of just-in-time training opportunities, as well as longer-term protocol and policy changes an organization can make to better prepare its personnel for an epidemic. Here are immediate action ideas and suggestions EMS1 received from EMS leaders, physicians and public health experts in late January:

Proactively engage with public health authorities

First, EMS agencies should be communicating and engaging with their local and regional public health authorities in a proactive manner so that in a public health emergency, the lines of communication are open. Second, take guidance from trusted sources like the CDC and WHO. Third, ensure your crews are trained in both proper handwashing and appropriate PPE. Fourth, keep your crews updated with the latest information regarding signs/symptoms as well as disease spread. Finally, another important aspect of this is the development of policies that speak to PPE and handwashing.

Acquire up-to-date information from reliable sources

Information sharing and collaboration is a must when preparing for a possible epidemic or pandemic. Every effort should be made to acquire the most up-to-date information from credible sources such as the CDC, WHO, and local healthcare authorities. EMS leaders can gather information specific to their region/state to assess risk levels that may impact the provider, suspected patients, and medical facilities.

Communities with a low risk may resume normal operations while remaining vigilant to any suspected new cases. Communities with known cases are at a higher risk of increased exposure. Additional prehospital patient screening, PPE measures (gloves, eye protection, and N95 mask) for the provider, and a surgical mask for the patient may be necessary. The prehospital provider can notify the receiving emergency department as soon as possible to initiate isolation measures upon arrival. Further consideration may be needed should a crew become exposed as well. 

Begin preparedness with community resource sharing

Preparedness is not "just" an EMS thing, it is the progressive underfunding and collapse of the entire emergency care system. I regret the main reason for this observation on the prehospital side is that EMS is not funded to prepare; in most cases it is only barely reimbursed (and in our state, not even reimbursed at cost) for a transport, if that transport even happens. 

So, what can EMS do? Most agencies are reactive and it's extremely difficult to get agency leaders to commit time, resources or funding to anything other than staffing a truck to get on the road as the financial realities are why we see so many EMS agencies closing. And our volunteers, what is left of them, may not have the knowledge, time, or resources to even develop and maintain a preparedness program.  

We have to start with community resource sharing – expertise and leadership in infection control practices, decontamination, and even simple things like policy and procedure creation that are relevant to our practice environment that are commonly missing at the agency level. 

We have to start with a culture of vulnerability – recognizing that we are susceptible every day to a new bug, and amid all the other demands, take just as seriously infection control plans and preparation as we (hopefully) take intubation success rates or CPR compression fraction. 

Finally, we have to advocate for preparedness funding to all that provide EMS, as more than once, I have found grants that will only help some agencies, and by their very nature, are non-sustainable means of maintaining the response-ability our community expects. There is a lot of work to do.

  • Jeremy T. Cushman, MD, MS, EMT-P, FACEP, FAEMS, Associate Professor and Chief, Division of Prehospital Medicine; Departments of Emergency Medicine and Public Health Sciences, University of Rochester; Monroe County, City of Rochester; and Monroe-Livingston Regional EMS Medical Director

Epidemic preparedness starts with education

As an educator, I believe the best level of preparedness for most situations starts with solid education. This education should be multi-faceted as well as operationally directed toward frontline providers, frontline supervisors, support personnel and department administrators. The education should delineate the specific roles each of these groups will fulfill if an epidemic ever occurred. Education will facilitate an organized and deliberate response, while ensuring each group stays within their lanes of responsibility during the chaos associated with an epidemic and/or pandemic event.

Prepare to provide Leadership and Perspective

It is important to recognize that during an epidemic or a pandemic there are two crises before the global community. One is managing the disease and the other is managing public opinion, i.e. fear.  As healthcare providers on the frontlines, EMS providers have the responsibility to contribute to managing both of these crises. Not only does this recognition call for the provision of compassionate care, but it can also contribute to enhancing healthcare outcomes and assist in controlling the outbreak. Educating patients and the public on actual risks and putting these risks in perspective can decrease anxiety, reduce the purchasing of N95 masks by those who don’t need them thus decrease N95 shortages, assist in decision making by patients as far as when and how to seek medical care, to name a few.

How might providing perspective look like for the current outbreak?  The WHO’s designation of 2019-nCoV  a “Public Health Emergency of International Concern” acknowledges that the disease is serious and poses a risk outside of China. Despite this designation, the national Centers for Disease Control and Prevention states that the risk to people in the United States is low - as of January 31 there are just seven confirmed 2019-nCoV cases in the US. 

We in the medical profession understand that Americans are currently at far greater risk of exposure to seasonal influenza, measles and tuberculosis than the 2019 novel coronavirus. Consider the impact of this year’s seasonal influenza alone: the CDC estimates that, from October 1, 2019, through January 18, 2020, the flu has already caused 15,000,000 to 21,000,000 illnesses and 8,200 to 20,000 deaths. Encourage your patients to get flu shots. These numbers are also comparable to the number of people who die in motor vehicle accidents in the US during a similar time period. 

Thus, EMS has an opportunity and responsibility to provide leadership in managing two interrelated outbreaks: one of disease and one of fear. 

  • Milana Boukhman Trounce, MD, FACEP, MBA, Clinical Professor of Emergency Medicine. Director, BioSecurity, Department of Emergency Medicine, Stanford Medical School. Chair, BioSecurity, American College of Emergency Physicians

Improve epidemic preparedness with vaccination education and screening

One of the biggest concerns I have pertaining to public health is the unfortunate influx of misconceptions and even falsehoods regarding vaccines being perpetuated on the internet. I feel that caregivers are often doubted as an authoritative source of information and patients may have a questioning attitude towards vaccines. While there is currently no vaccine against the Wuhan coronavirus, I fear that if/when it is developed, there will be individuals who undermine is use, to the detriment of public health.

I feel that EMS caregivers can be educators and spread awareness of the utility and appropriateness of vaccines in preventing illnesses. We need the public to be informed. Vaccines can prevent illnesses. By providing education and screening for vaccinations, EMS caregivers can contribute to the prevention of epidemics and pandemics.

  • Daniel Hu, PharmD, Critical care and emergency medicine pharmacist

Prepare to assess patients who are positive and negative

EMS had a dress rehearsal in its preparation for the Ebola threat a few years ago, particularly in terms of PPE and the reinforcement of universal precautions. Dusting off those plans would be a good start. EMS will be at the forefront of this event as with Ebola, influenza and even opioids, and a considerable amount of guidance and advice will be and is emerging from both the CDC and local health districts. As always, it is common sense to operate and cooperate closely with your local public health director and if necessary, Emergency Support Functions (ESF8). 

Because of the spread of fear as well as the virus, in the coming months, there will no doubt be citizens who believe they may have contracted coronavirus and will gain medical intervention via the 911 system. Call centers and triage systems must be prepared to deal with this influx, and use available systems and clinicians to provide good identification of both positives and negatives. As always, we must be prepared to respond with sympathy and empathy while we ourselves may be tiring from the increasing demand.

Immediate, simple actions for EMS

Improve epidemic or pandemic preparedness by practicing the fundamentals of infection control on everyday “routine” calls:

  • Change gloves frequently and avoid contaminating your patient compartment, computer tablets, and other fomites within the ambulance patient care compartment,
  • Between calls, use disinfectant appropriately on fomites and use antiseptic on yourself
  • Use soap and water when access to running water is available
  • Use your PPE! (And remember that the N95 goes on you and the surgical mask goes on the patient)

Review the six links in the Chain of Infection Transmission and remember that you can intervene upon any one of those six to help stop the spread of infection. Finally, minimize your risk of infection by: 

Be prepared in case this epidemic gets worse 

The most important concern for a possible pandemic from the Coronavirus or most any other pathogen in the future is personal protection and preparedness. It is not possible to mount an effective response if those responding are sick or unprepared. Follow CDC guidelines; wash your hands often and use soap and water when you can, stop touching your face, and if you are sick, stay home. Surgical masks are not helpful unless you are sick and are trying to avoid passing your illness to others. N95 masks, properly fitted and worn are a great idea, but only if you are in close contact with someone who is sick. Remember, more people come down with the seasonal flu – get the flu vaccine.

So what happens if the world goes to hell and we have a major disruption of services? Start planning now. EMS, Fire Service, hospitals, and Law Enforcement need to have adequate supplies of personal protective equipment – gloves and N95 masks. There needs to be a strong chain of command involving all of the services and local hospitals. Surge capacity needs to be examined and protocols established for mutual aid and for who goes to the hospital and how they are treated. Isolation protocols for victims both in the hospital and possible isolation at home should be established. Run tabletop exercises to find holes in your plans.

Lastly, if the world does go to hell, there will be a significant disruption of normal day-to-day life. Be prepared for food and water shortages. If enough folks get sick, utilities can be affected. Chances are this will not happen, but I remember well the Boy Scout Motto from when I was a kid: “Be prepared”

Michael Beach DNP, ACNP-BC, PNP, FAAN, Assistant Professor, University of Pittsburgh School of Nursing 

Additional resources on EMS pandemic preparedness

Learn more about how EMS can prepare for an epidemic or pandemic with these resources from EMS1:

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