Utilizing community paramedicine and streamlining operations during COVID-19
In this episode, Chris Cebollero speaks with Will Dunn, clinical manager of Eagle County Paramedics, who shares how his agency is handling operations during the COVID-19 pandemic
In this Inside EMS Podcast episode, co-host Chris Cebollero speaks with Will Dunn, clinical manager of Eagle County Paramedics, who shares how his agency is handling operations during the COVID-19 pandemic and national emergency. Dunn provides a chronological timeline of ECM's preparation methods, including training and tabletop planning. The ECM clinical manager also shares how they are using their community paramedics, what patient care is like right now and areas to watch out for.
This is a show for everyone to hear best practices, and to ensure they are not reinventing the wheel during this public health national emergency.
Read the full transcript of the interview below:
Chris Cebollero: Well, welcome once again to this special edition of Inside EMS. Kelly Grayson is on the EMS World Tour doing his continuing education and sharing that knowledge with everyone around the United States. Even in this time of coronavirus, he is being selfless in teaching his knowledge.
But I am excited today to talk to you about the, you know, things that are happening within our career field. You know, one of the things that I think is going to be very, very important is we’ve got to be able to take best practices, we’ve got to be able to take experiences, we’ve got to be able to take the knowledge of people that are doing this work because if we are not affected now, we will be affected soon. And being able to hear these best practices is something that we want to be able to utilize.
And joining me today, all the way from the great state of Colorado is Will Dunn. He is the clinical manager of Eagle County Paramedics, one of the leaders when it comes to community paramedicine in EMS. And a lot of times, you don’t hear about Eagle County and the work that they do. But they are one of the pioneers. And Will, I want to thank you for joining me on Inside EMS. And sharing your knowledge about what is going on up there in the eye of the hurricane when it comes to Coronavirus in the state of Colorado.
Will Dunn: Well, thanks, Chris, I appreciate being on. I got to tell you, I’m not sure how we would have gotten to the point of where we are without community paramedics. We got a number of patients here that are essentially sick but staying home. We’ve got patients that we sort of needed to test that really couldn’t get to any of the testing centers. And in the early days, we didn’t want to bring them in anywhere because we weren’t set up for them. So, are community paramedics actually stood up and took one for the team by really putting themselves in front of these patients to do swabs. So, community paramedic, we should call them the utility infielder paramedic because that’s really what they have turned out to be for us.
Chris Cebollero: Good. Well, let me take you through this process. I mean, your job is the clinical manager, I’m sure is to develop the processes of how this thing is kind of going to flow for your state, flow for your system, flow for your community. But there was probably a time, Will, where you were saying, “Let’s get ready for this.” Before you finally said, “Oh, my gosh, it’s here.” So, if we kind of take it in chronological order before you kind of got thrown into this mix, what were you doing to prepare to get your workforce ready to handle what was eventually coming your way?
Will Dunn: Well, you know, it’s interesting. I was at a meeting at the state level, the Colorado Department of Public Health and Environment’s got a quarterly meeting that really drives a lot of what happens with EMS. And I got an email from my boss, Chris Montara, saying that we needed to fire up an emerging infectious disease’s surveillance tool out of dispatch.
So, that was February 11th. I remember that date very well because I was like, “Oh, I guess we are starting to talk about this.” So, that was the first thing we did. We had our Medical Director change the dispatch protocols to be able to start asking that question. And at that time, it was travel from China, cough, or fever. You know, it was rather kind of broad. I’m sorry, specific. That went into effect that week, February 11th, 12th, sometime in there.
We also started the tabletop with our supervisors to say, “Okay, what are you going to do with the 20% loss of workforce? 30%? 40%? And that was sort of some of the early things. Plus, we were trying to get some ideas of what the treatment protocols would be or what protocols to avoid. For some of us who have been old enough to remember SARS from the early 2000s, you know, it was almost like, “Oh, we are dusting off the SARS protocols.” And that is sort of what we started to do.
Chris Cebollero: So, now, I mean, when you think about it, you are just kind of going through the process. And I agree with you, we’ve gone through a lot of these. We talk about Ebola when that happened in 2014. We went through the donning and doffing on how we are going to set our ambulances up to make sure that we are not causing cross contamination. And I agree with you, I think that if you went through these pandemics or these, you know, even talk about SARS. You talk about the bird flu and the swine flu and all these other things that really should have given us kind of a polish to prepare for this. But it’s one of those things that is out of sight, out of mind, Will, that you don’t really keep up on.
So, now as you start to prepare, there was a time where you probably woke up to say, “Oh my gosh, it’s here. And it kind of snuck up on us. How did that happen?”
Will Dunn: Well, you know, we were fortunate that we knew as an international destination that there was a chance that we would start to see it internally. We stood up our county EOC early. The hospital stood up it’s incidence command system. We stood up our incidence command system. It really, sort of, virtually just to start out with this, our command calls with the hospital started off a couple of times a week. And then it was once a day during the work week. And then it was once a day seven days a week. Now we are up to three times a day with our hospital partners and the medical community just so we are all on the same page.
That probably was one of the best things that we did is we got some of those communication kinks worked out early. Like you can’t have necessarily 60 people calling into the same 800 number for conference calls. You really need to really use something like Zoom Conferencing or Google Hangouts that give the options for people to join via internet versus calling on a phone number. Because the systems are just not designed to handle the kind of demand that we have been putting on them.
We used to joke that we would have a couple of big boxes in a basement somewhere that had SARS on it. And that was crossed out. Then H1N1, and then that was crossed out. And then, you know, bird flu, then that was crossed out. And then, Ebola, and that was crossed out. But we did have those boxes.
And so, when things really started to emerge, we were able go through and inventory. To be able to come up with what we had that was available. We were able to put in orders early to supplement our PPE. We were able to calculate a burn rate or suspected burn rate on what that is. We know that at some point we are going to run out. We are very fortunate that we got connections with a major manufacturer of outerwear. And we were able to get in touch, through connections that we have, because the largest ski resort company. And be able to order some foul leather gear that we can use as reusable PPE. We came up with what the list was for that and we decided to double it. So, hopefully we’ve got some strategies for multiplying our PPE.
Chris Cebollero: Yeah, I got to tell you, there was a lot of great information in that answer. But one of the ones that I really want to kind of touch on and go over because I think it is very, very important is you said that the lines of communication were opened up early. And I think that is one of the things, Will, that we forget in the time of, you know, these types of situations that we take it for granted that we are going to be able to communicate and get with the people who are really kind of on our side or be able to help us deliver the highest quality of patient care or be the best resources to us.
And, you know, I have been in these situations a lot of times where we’ve hoped that communication was going to work. But as we know from our experiences that hope is not a strategy. But it sounds like you developed, really kind of fell into almost the perfect storm that things really kind of worked out for you.
Will Dunn: Yeah, you know, we were fortunate that we had a lot of like-minded people. Between the County Department of Health, or County Manager, the Public Safety folks in the county, the hospitals, the hospital system, the largest sort of group of family practice docs, that group was purchased by the hospital about a year ago. So, there was lots of people that had to communicate. But we were able to sort of distribute and say, “Let’s get the people that need to make decisions communicating frequently.” It’s a burden. There are some days where my first conference call, command call internally starts at 7 in the morning. We usually have a hospital meeting at 8. And then the incidence command calls at 9.
What we figured out though is that when everybody is scheduling their meetings at the top of the hour. And that is also something that is probably saturating capacity. So, now we are trying to switch some of those meetings to start at odd times, sort of irregular times, like 9:20 or 10:50. Something like that because there is less of a surge for people trying to communicate. So, that is something that I would certainly recommend that you consider.
But it’s also, I’ve never been a part of any sort of large exercise or mass causality or anything where one of the things that constantly comes afterwards was, “Well, this is where we broke down on communication.” That seems to be the red thread in everything. I think that we are fortunate that we have all the players, all the decision makers on the same calls. So, we can make those decisions without having to- We can move very quickly which allows us to be agile with that. And also, we sort of stressed the system before the system got stressed as we were ramping up and figuring out which changes we needed to make.
Chris Cebollero: Very cool. So, now that you are into this process, you know, and you are starting to see patient’s kind of pop in. You talked about the community paramedics and them kind of being on the front lines. As you now start to see these patients, what’s the one thing you weren’t prepared for? It sounds like you tried to think of everything. But you know as well as I do, in these situations, we don’t know what we don’t know. And we only hope that we have the right processes in place. What is the one thing so far that has given you some, “Aha moments? I didn’t even think of that?”
Will Dunn: So, I think the biggest one is I underestimated the crew fatigue and the crew stress on having to, you know, PPE up for all these calls. We do critical care interfacility, paramedics only. The first vent transfer that we did with the COVID, I think she was COVID positive at that point. We learned that it was really hard to do in your standard PPE. We went to PAPers for interfacility, which was a big thing. But part of that is for crew comfort and for crew mental fatigue. It’s just, I feel badly that we did not anticipate how significantly having the mental toll of putting yourself basically in the line of the COVID-19 fire on so many calls. And hoping that you are donning and dopping your PPE in a correct way.
As the clinical manager, I took a lot of the stress of making sure from a safety standpoint that our protocols that we were doing everything as safely as possible. But I think that as a management group we under-estimated just the emotional toll. We think that it is absolutely critical that we are getting home at the end of their shift. We do 48, 96s here. Although we have done things that we have never done before. Like canceled vacations and let people know that we may have to mandatory them to stay later. And again, we are sort of fortunate as an EMS agency that we have very little turnover and we have some scalability because of the seasonality of our work. But we are trying to avoid at any cost having to hold people over. Just letting them go home on their four day. And let them take their entire four day off.
I don’t know, because I think we are a bit in the eye of the hurricane. I don’t know necessarily how or if we are going to be with the longevity of that is. We may have to do some different scheduling. But I think it’s critical that people are getting down time and time to take off. You know, we are also seeing that we need to make sure that their families are being taken care of, dog walking, that type of thing. We are trying to make sure that people who are off are available to sort of support the people that are on. And that has helped a lot.
Chris Cebollero: You know, it does sound like you have kind of thought of the things that need to be worked out. And it’s good to see that you are paying attention to that. You know, one of the things that is very interesting is that our EMS providers have a lot of things that they have stresses about. We talk about schedules. We talk about money. We talk about all those things. But one of the things that is amazing, and I made this comment earlier today, Will, is that when we get into the fight of things, whether it is pandemics, you know civil disobedience, whether it’s natural disasters. The people that we work with in our career field are some of the most dedicated and professional people that I have ever encountered in my career because they will go that extra mile. It’s good that you are getting them off. And it’s good that you are, you know, kind of balancing that work life balance while we can. Because if this thing scales the way we think it’s going to scale, that maybe few and far between. But truly these professionals probably take a little Umbridge too to the fact of, “I don’t want to go home. I want to be able to stay and help out.”
Will Dunn: Well, so, that is also an excellent point. And that is true. And I think if we asked our crews to step up, they certainly would. But we are looking to doing some other forced multipliers. Interestingly in this ski community, because the mountains are closed, the busiest EMS agency in Eagle County is Vail Ski Patrol. And they are shut down. We were able to tap into their command staff. And we requested that they pull all their medical gear. We did this with a number of the mountains.
But Vail Ski Patrol is the one that is the biggest and closest to us. They were able to pull all their medical gear down off the mountain, inventory it, and cash it. So, that gave us a surge capacity of 50 oxygen cylinders for instance. So, we are trying to think ahead of forced multiplying. We’ve got people that work for both Beaver Creek and Vail Ski Patrols and Beaver Creek Public Safety that know our systems, know how to load are perams, know generally where things are.
We are looking at onboarding those just so that we have some bench strength if we do start losing people so that we can essentially add to our street capacity if we have people that can’t come into work. I think that we are trying to do things to make, and again, we don’t know where this is going. It might be the largest, unplanned, training exercise of all time. Which I will be fine with if it is.
Chris Cebollero: That’s right.
Will Dunn: But if we are going to see the category 5 hurricane, medical hurricane come in, I want to make sure we are staffed as well as we can. So, people know that at the end of that watch, they can go home. I think that is what is going to get us through this. They can recharge, do whatever they need to do, come back in 48 hours later, 96 hours later, 24 hours later, whatever that is. But I think it’s huge that people know that they can go home, that they are going to get a break.
And I think that is what I’m seeing in some of these other places where it looks really, really brutal. That the crew fatigue, emotional toll on our staff, we need to minimize any way that we can.
Chris Cebollero: Yeah. And I want to be respectful of your time. I know that you have so much going on. But just a couple more questions for you. When it comes to some of the patients that you are seeing, what are you learning from that?
Will Dunn: So, it is interesting. These patients sometimes start of relatively well. They are sick. They might be a little bit hypoxic. But their oxygen demand continues to grow. Their hypoxic burden gets worse. So, this is a patient that might do okay with a couple liters of oxygen for a couple of days. But then they get worse. Now they need to be on lots of oxygen or intubated.
The other thing that we have noticed, we RSI’ed somebody that I thought was ridiculously early in his clinical course. And even though he was properly pre-oxygenated, his stats just dropped like a rock. It was impressive. Our crews noticed that. So, we think that we see something where there is increased oxygen demand and early hypoxic with RSI. So, that is something that I would be on the lookout for as you are potentially encountering these patients. The patients that need oxygen, need a lot of it. And if you are in a situation where you need to RSI a patient, anticipate rapid desaturation.
We got some telemedicine protocols in place. So, that there is the ability for our regular street crews and our community paramedics to access these patients. And advise them that they are healthy enough to stay in their home for at least the time being. The problem is they can continue to get worse as their hypoxic burden increases and their demand for oxygen increase. They might be okay with a couple of liters of oxygen. But pretty soon they need a lot more oxygen.
Chris Cebollero: You know, we talked earlier on about community paramedics. How are you using community paramedics in this pandemic?
Will Dunn: They are the utility infield of paramedics. I think I might have mentioned before. They are doing tests. They are swabbing for COVID-19 patients, so people don’t have to come out of their homes. There is no primary care going on in our county right now. There is no follow up. There is no infant well-child checkups. So, they are taking on the burden of doing primary care for these patients that no longer have access to our medical facilities because they are closed. At least for the time being.
So, there are patients, potentially wound care patients that need some sort of follow up. But they are not allowed in the medical facilities. So, are community paramedics are going out and seeing those. So, they are doing the community paramedic thing that they have always been sort of trained and practiced to-do. But the burden they have is increasing because they are seeing a lot of these patient’s in their homes who would typically still would have gone in and seen their doctor.
We actually onboarded some nurses that were on reserve from the hospital. And we were trying to force multiple our community paramedic staff as well.
Chris Cebollero: I think one of the things that happens when we are in the middle of a disaster preparation such as this. And I love how you said this, “Is this the largest training exercise, unplanned training exercise.” Because I think that is really what it comes down too. We have to be able to prepare for something that may not even happen. And I keep my fingers crossed for everybody out there that, that is the way it is.
But from a provider standpoint, one of the things that I realized in my career as an EMS leader is that sometimes the workforce doesn’t know the challenges that the leadership teams have to go through in preparations for things like this.
Will Dunn: Isn’t that true.
Chris Cebollero: But from your side, I think this is the time that I want to educate them a little bit. Because, you know, I learned a lot of lessons in my career. Whether it was communication, whether it was not having the things necessary. But from the leadership standpoint, talk to the providers that are out there and maybe give them some sense of what the leaders of organizations are going through right now to ensure that they have the best resources necessary to be on the front lines?
Will Dunn: You know, I think that we are trying to make sure that we have all the equipment on the PPE that we are going to need for those on the front line to do their job. I think that we need to have back up plans. And we are assuring that we have back up plans. So, there is something in place to keep them safe if our primary plan of PPE runs out. I think that, you know, we have gone through and we have had arguments with our work comp provider to make sure that they will be covered if this winds up being a work-related problem. We have gone to our Board of Directors. We have had extra funds released and allocated for equipment purchases. You know, we are trying to meet with the line level supervisors to try and make sure that everyone is aware of everything going on.
But there is so much of it that is behind the scenes that I don’t know if we can every really properly communicate essentially what we do. I sort of started sending out a screen cap of my calendar for the day which shows the 13 conference calls that I do. I don’t recommend that every manager does that. But, you know, sometimes that might give some perspective if you have a mechanism for sort of putting that stuff out.
Chris Cebollero: You sound like you have gotten to a point where you are prepared. So, I think that there are people out there that are in stages of where you have gotten to at this point. If you are going to kind of talk to those people that are out there, what is the best advice that you have for them to get them ready to handle what is going on? Or what is going to be going on in their communities?
Will Dunn: If you think you are overreacting, that is probably means that you are getting close to understanding what the potential of this is. And, I agonized when I had the conversation with our Ski Patrol Director about having him put people up on the mountain and bring all their medical gear down. And then, I asked him if he was willing to do it. And he said, “Yeah, I think that is good idea. We can do that.” And then, you know, I thought about it for five minutes later and I texted him, “Yeah, maybe hold off. Maybe it’s not time for that yet.” He’s like, “Too late. The email is out. We’ve already got it arranged. Stop overthinking it.”
And that was really good advice, I think. It’s just like, “Look, we need to make sure.” I don’t think there is such a thing of being overprepared for this. If I’m wrong, and again, I hope that I am. Fine. It was the largest unplanned training exercise we have ever undergone.
The other thing is this is the hardest thing that I have dealt with in my career in the 30 years that I have been doing this. Here is what I am happy about, I don’t think anything like this is going to come along again that is going to be as hard as this has been. And if it does, we are even more prepared. It’s not going to be as hard next time because of all the lessons that we are learning with this one.
Chris Cebollero: I agree with you 100%. You know, the after direction of this is going to be really important that we are in the position that we understand this as we go forward in the future. So, Will, I want to thank you so much for taking the time out of your day. You know, we have tried to communicate for a couple days here. And you are really kind of squeezing this in for us. And I appreciate you being a solid resource for the Inside EMS listeners. And please promise us, if things pop up, that you think is going to beneficial to our career field, just get back in touch. Come back on the show that we can share your knowledge. Share your expertise. Eagle County Paramedics continues to be a leader in our career field. And I appreciate you taking the opportunity to come and visit with us and share your expertise in this matter.
Will Dunn: Hey, thanks a lot, Chris. I’d come back anytime.
Chris Cebollero: And for everybody out there, a Special Edition here of Inside EMS. We are going to go ahead and start to bring you more and more shows and not just on our weekly basis. Because there are people like Will out there, and his agency, that are really on the front lines who are developing best practices that we may not have to develop. I want to thank Will. I want to talk the people up at Eagle County for continuing their lead by example.
If you have any best practice, go ahead and send them to us at the show at EMS1.com. Please don’t hesitate to answer on the Facebook page or below this link and tell us what is going on. Until next time, we will talk to everyone again real soon.