Rapid Response: When demand outstrips supply: Decompressing the system by doing the best for the most
3 takeaways from the FDNY order to not transport cardiac arrest patients if they cannot be resuscitated in the field
As the COVID-19 situation widens and deepens, the phrase we are about to hear a lot will be, “the needs of the community will have to be considered over the needs of the individual.” As demand outstrips supply – in our case front line staff and lifesaving PPE – a change in the way we do business is arriving.
For the last few weeks, many have discussed the implementation of Crisis Standards of Care, the process by which rules, regulations and standards are relaxed to just get the job done. This has essentially covered the certification, qualification and methodology by which we deliver EMS in this new and emerging world order. The next phase in the evolution of our response is one of capacity and ability. When the going gets tough to the point where a “reverse triage” is needed to salvage those that have a chance, it is a decision that is not taken lightly and those deciding on it, delivering it or being affected by it will likely live with these decisions far beyond the pandemic.
We have seen the numbers of infections and death escalate each day as COVID-19 heads to a peak that has yet to be reached. In particular, through our EMS lens, we have watched with a feeling of sadness, frustration and admiration, the plight of the EMS workers in New York. We are witnessing the attrition rate on all key workers on the front line, whether its EMS, firefighters, police officers or hospital staff, and sadly, we don’t know when it will peak and we don’t know when it will end.
What happened. All of these factors in New York have culminated in one clinical decision that may be hard to stomach but perhaps is a necessary stage as they seek to do the best for the most. This week, FDNY’s EMS personnel have been ordered, with immediate effect, not to transport cardiac arrest patients if they cannot be resuscitated in the field. EMS instructions require that CPR be initiated and if ROSC is achieved, then transport as usual, but when the patient is determined not to have a pulse and cannot be revived, then to cease, declare the patient dead and pass them over to NYPD.
Why it’s significant. The decision was taken to preserve hospital and ambulance resources, which as we know, are all being overrun with demand.
We are all aware that intubation and inevitably pushing hard and fast creates aerosolization and potential infection to those running the arrest. Taking that patient to the hospital adds many more healthcare professionals to the code in the ED, hence the decision to safeguard resources. We also understand about CPR discussion of “scoop and run” versus “stay and treat” until we have an outcome.
The decision to change taken in New York follows guidance and practice that already exists elsewhere in the country in clinical cardiac arrest protocol. This may be a tough one, for those for whom this is a new clinical change, but the war of attrition on the clinicians and capacity of New York calls for measures such as this. It may well also be the case in this particular subset of patients that the eventual outcome, ROSC and survival to discharge changes little.
FDNY EMS Chief, Lillian Bonsignore, recently reported that the “sheer number of medical calls was shocking.” That volume, combined with the COVID-19 infection rate in responders, causing exposure, diagnosis and quarantine, have depleted the workforce to critical levels. A small respite has arrived in the shape of a FEMA ambulance package, bringing providers in from all corners of the nation, but in the war, COVID-19 has been described as, the enemy is unrelenting, and all reinforcements are moving straight into the front line to attack head-on.
The experience of New York is providing a live playbook for the delivery of mass population EMS and as Dr. Anthony Fauci has briefed us, “this will get worse before it gets better.” It seems that change is the only constant right now and because of the need to save the masses, more adjustments should be expected.
3 Takeaways on the FDNY COVID-19 Crisis Standards of Care
Here are my takeaways from the actions taken in New York to respond to the COVID-19 public health emergency.
1. Crisis standards of care
The actions taken in NY during these challenging conditions reflect the needs of the many and are a necessary approach to healthcare service delivery during these unique and challenging times. To understand how the practice will change in your locality, refer to your local or state Crisis Standards of Care plans. The recent webinar delivered by NHTSA, “What EMS needs to know about Crisis Standards of Care and COVID-19” provides insight to CSC that apply to our current state.
2. Fire and EMS personnel health and wellbeing
On the last check, the FDNY alone reported that out of a staff of 17,000 personnel, 2,800 were out sick – 23% EMS workers and 16% firefighters. Being able to identify and report out on the level of attrition taking place on the front line, what IAFC President, Gary Ludwig, calls the “warriors at the tip of the spear,” is an essential activity right now. The IAFC is maintaining a Fire & EMS COVID-19 Personnel Impact Survey that is tracking national stats including staff that are exposed, diagnosed and quarantined. This GIS system is additionally supported by NAEMT and the American Ambulance Association, who fully encourage their members to contribute to it.
3. Impactful headlines
While my focus here has been the preservation of staff and function as we ride the surge, I need to close on a media note. The impactful headlines that draw attention to the story leave the vision that anyone succumbing to an out of hospital cardiac arrest is going to be left, ignored and written off. This could not be further from the truth, as all efforts are going to be made, on the scene, to resuscitate and revive. This should be reinforced. The takeaway is that we must go to great lengths to educate our press contacts and assist them in understanding what we do and how we do it.
Additionally, In stories involving cardiac conditions, the terms cardiac arrest and heart attack are almost interchangeable in the eye of the journalist. We all understand the difference, and it frustrates us when they mix up the plumbing with the electrics, but for the sake of public understanding and clarity, we must do a better job.
That’s my view, I would like to hear yours in the comments below.
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Additional resources for Crisis Standards of Care and COVID-19
Learn more about Crisis Standards of Care and COVID-19 with these resources:
- Lexipol Coronavirus (COVID-19) Learning & Policy Center
- COVID-19 breaking news and action items for EMS
- CDC updates EMS, 911 guidance for COVID-19
- Temporary CMS changes provide needed flexibility
- NHTSA Webinar Quick Take: What EMS needs to know about Crisis Standards of Care and COVID-19
- FDNY EMS ordered not to transport cardiac arrest patients that can’t be resuscitated in field
- NREMT approves provisional certifications during national emergency
- Minn. EMS agencies asked to maintain normal operations during emergency