Lessons Learned From Ebola Scare

Winter 2015
A quarterly publication of the National Association of Emergency Medical Technicians
Lessons From the Ebola Scare
Some scoff at calling it a crisis, but experts agree EMS needs more
infection control training and improved preparedness
By now, the outlines of the event that kicked off the nation’s Ebola mania
are familiar. On Sept 20, Thomas Eric Duncan, a 42-year-old Liberian man
infected with the Ebola virus, boarded an airplane bound for Dallas. He
became ill shortly after arriving, but was sent home from the Texas Health
Presbyterian Medical Center’s emergency department five hours later with
antibiotics. He returned to the hospital two days later – this time in a Dallas
Fire-Rescue ambulance.
Duncan’s diagnosis and death in early October rocketed Ebola to the top
of every news show and headline in America. The U.S. Centers for Disease
Control and Prevention (CDC) raced to prevent both the disease – and
misinformation about it – from spreading, while hospitals and EMS agencies
tried to figure out how to prepare. They conducted drills, listened to CDC
webinars, beefed up their personal protective equipment (PPE) kits and
stockpiles, and learned how to ready patient compartments for Ebola patients
using duct tape and plastic.
And then, as quickly as it exploded, the Ebola crisis in the U.S. petered out. Two
months after Duncan’s death, the only other death on U.S. soil was a surgeon who had
caught the disease in Sierra Leone. The infected Texas Presbyterian nurses survived – one
even had her picture taken with President Obama. And no other infected West Africans
had managed to slip undetected onto U.S. airliners.
Among U.S. first responders, Ebola fatigue set in. At EMS World Expo in Nashville
last November, Ebola had become a running joke. “More Americans have married Kim
Kardashian than have died of Ebola,” said Dr. Bob Winter, National Clinical Director
for Emergency Preparedness, Resilience and Response (EPRR) and Critical Care in
England, speaking during the World Trauma Symposium.
Wisecracks aside, EMS leadership and other medical professionals continue to regard
Ebola as a potent reminder of the vulnerability of our nation’s population to emerging
infections, and the importance of remaining vigilant and prepared to respond to
dangerous pathogens that can threaten at any time.
“This is a bump in the road compared to other future threats we are going to face,”
says Dr. Paul Pepe, director of emergency medical services, speaking during a special
session at EMS World Expo. “It was a good drill for the big one that is going to come,
the pandemic or the SARS du jour.” (Severe Acute Respiratory Syndrome, or SARS, is a
viral illness that emerged in China in 2002 and quickly spread across nations, killing an
estimated 775 people, including 44 in Canada. The outbreak dissipated in the summer
of 2003.)
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Lessons From the Ebola Scare
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Preparing First Responders
In late August 2014, with the Ebola outbreak spreading in
Africa, the CDC issued guidance for hospitals dealing with
known or suspected Ebola patients, and shortly thereafter,
for EMS, Public Safety Access Points (PSAPs) and other first
responders. The guidelines recommended that PSAPs and
first responders inquire about recent travel for patients with
fever and other symptoms. (The International Academies
of Emergency Medical Dispatch quickly released a new
Emerging Infectious Disease Surveillance tool.)
When dealing with a potentially infected patient, EMS
practitioners should don gloves, a gown, mask and goggles
to protect from contact and droplet contamination. “Unlike
patient care in the controlled environment of a hospital
or other fixed medical facility,
EMS patient care before getting
to a hospital is provided in an
uncontrolled environment,” noted
the CDC. “This setting is often
confined to a very small space and
frequently requires rapid medical
decision-making and interventions
with limited information.”
The initial PPE recommendations
are similar to the precautions EMS
is urged to take to protect from
other diseases, such as flu, noroviris, and MRSA (Methicillinresistant Staphylococcus aureus), says Dr. Paul Hinchey,
NAEMT’s medical director and medical director for AustinTravis County EMS in Texas. Many EMS agencies, including
his own, responded to the CDC recommendations by
reviewing basic PPE usage for all responders.
And for a little while, that seemed like enough. But then
the two nurses who cared for Duncan fell ill – and the Ebola
frenzy reached a fever pitch.
It’s not known how the nurses became infected, Pepe says,
though it’s thought that it may have occurred when they
removed contaminated PPE. Under fire from nurses unions
and politicians, on Oct. 20 the CDC issued more stringent
Ebola guidelines for healthcare workers that stressed the
importance of more infection control training and supervision,
recommending that no skin be exposed when workers are
wearing PPE, that health workers wear a disposable full-face
shield instead of goggles, and that each step of PPE “donning
and doffing” be supervised by a trained observer.
Winter 2015
Ebola patients at the end stages of the disease can emit a
startling amount of fluids – vomit, diarrhea and blood, Pepe
explained. As the disease progresses, their viral load increases,
making these fluids highly contagious.
As the spotlight turned to the correct usage of PPE, it
became increasingly clear that “putting on PPE and taking it
off is not that easy to do safely,” noted Dr. Richard Carmona,
a former paramedic, nurse and U.S. surgeon general,
speaking during the World Trauma Symposium.
Following the Lead of Hospitals
When the CDC issued more stringent guidelines for
hospitals, there was one group of healthcare workers missing
from the recommendations – EMS. Without specific
guidance for pre-hospital care
practitioners, Hinchey says, EMS
agencies struggled to interpret the
extent to which the new guidelines
for hospitals should be applied to the
EMS workforce.
Some discussions centered around
whether EMS needed to suit up in
full PPE when taking care of patients
in the so-called “dry” phase of the
disease, which is characterized by
fever and muscle aches, or only
during the significantly more contagious “wet” phase. The
thinking was that EMS was most likely to encounter patients
in the “dry” phase, whereas by the time patients reached the
“wet” phase, they would already be known to have Ebola and
special response units could be called in.
Following the lead of hospitals, many EMS agencies
determined that attempting to train every staff member
to respond to Ebola was neither feasible nor necessary.
Instead, they established Ebola response teams. In AustinTravis County, for example, all responders received refresher
training in basic PPE, but a select group of about 40 to 50
received specialized Ebola training. This included the daily
practice of putting on and taking off full PPE using a buddy
system and spot checks, Hinchey says.
“I couldn’t train every single person in the system
to get in and out of every level of PPE and keep them
proficient,” Hinchey says. “We started to use the hospital
model, picked a small cadre of people and trained them to
a very high level.”
Resources Strained by Hoaxes
As Ebola worries spiked among the public, so did the
number of scares and hoaxes, making identifying who was
actually a suspected Ebola patient increasingly difficult.
At University of Toledo Medical Center in Ohio, a
frequent EMS user with a fever claimed she had contact with
a man from West Africa, leading to four EMS practitioners
and the patient being placed into isolation, and hospital staff
treating her wearing full protective gear, for what turned out
to be a common viral illness, according to the Toledo Blade.
At EMS World in Nashville, many practitioners swapped
stories about Ebola scares. In Delaware, a woman known to
be an EMS frequent user claimed she had close relations with
a man from West Africa who had Ebola symptoms, which led
to activation of the receiving hospital’s Ebola response plan
and the responding ambulance being put out of service and
decontaminated, says Mike McMichael, a longtime volunteer
EMT. The woman was eventually charged with making a
false report to emergency services.
Whether real or imagined, none of those responses
were free. In the weeks after they treated Duncan, Texas
Presbyterian lost 50 percent of their business, with patients
cancelling scores of elective surgeries and other procedures,
Pepe noted. University of Nebraska’s Medical Center, which
treated two Ebola patients, put its cost at $1 million. Harder
to measure are the costs to other hospitals that have yet to
see a single Ebola patient, but readied biocontainment or
isolation chambers nonetheless.
Resource challenges for EMS were outlined in NAEMT’s
testimony submitted to Congress for the Nov. 12 Senate
Appropriations Committee Hearing on the U.S. Government
Response to the Ebola Outbreak.
“Paramedics and EMTs transported the first case of Ebola
in Dallas and EMS practitioners have played a role in the care
and safe transport of every Ebola patient in the country …
We are dedicating scarce resources toward creating dedicated
ambulances retrofitted to make them capable of treating and
transporting patients with Ebola.”
Rough estimates put providing training and a set of singleuse PPE, such as masks, gloves, gowns and goggles, for each
of the nation’s more than 850,000 EMS practitioners at more
than $34 million, according to this testimony. The higher
levels of PPE needed to manage Ebola patients in later stages
of the disease will cost more than $255 million to equip and
train as little as 20 percent of the EMS workforce.
The testimony called attention to the need for Congress
to pass the Field EMS Bill (H.R. 809/S. 2400 in the
113th Congress). The legislation would provide additional
preparedness funding for EMS, and would establish an
Office of EMS and Trauma in the U.S. Department of
Health and Human Services (HHS) – placing EMS squarely
among its partners in public health and healthcare as they
coordinate responses to emerging infectious diseases.
“What this event has done is highlight the fact that EMS
is an integral part of the health system, and we may be a
key piece of the first contact with emerging diseases, a key
piece of identifying them and navigating them through the
healthcare system,” Hinchey says. “The Field EMS Bill helps
better align EMS with the healthcare side of the universe,
which will help with funding and the functionality of our
response to these types of events.”
Lessons Learned
As the immediate threat recedes, EMS leaders say it’s crucial
to make sure that lessons learned from the Ebola response
aren’t quickly forgotten.
A big one was that putting on and taking off
PPE isn’t as simple as it sounds, and that
ongoing training is needed to keep skills
fresh. “What did Ebola teach us? That skills
are perishable,” Carmona says.
In Austin-Travis County, EMS practitioners moving
forward will be expected to demonstrate competency in
correctly donning and doffing PPE annually, Hinchey says.
“Before Ebola, folks very seldom spent a lot of time thinking
about PPE – never mind training,” he says. “We have a much
greater awareness of the importance of wearing PPE and
getting in and out of it safely.”
Those infection control lessons also apply to other, more
routine bacterial or viral illnesses, even the upcoming flu
season, he adds. It’s been well documented that even basic
infection control guidelines are not always followed. “Pretty
routinely, both in the hospital or the pre-hospital settings,
healthcare workers will do some of the parts – wear the gloves
and goggles but don’t wear a mask, or take off the PPE and
don’t wash their hands after,” Hinchey says.
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Grady EMS Supports CDC Clinicians
When word spread that Dr. Kent Brantly, an American
aid worker who contracted Ebola while treating patients
in Liberia, was coming for treatment to Emory University
Hospital in Atlanta, the nation let out a collective shudder.
His arrival marked the first time the scary disease from a far
off place had reached American shores.
At Grady EMS,
Brantly’s Aug. 2 arrival
was a day they had
spent years preparing
for. They reviewed
protocols, draped the
walls and floor of an
ambulance in sheets of
plastic and went over
plans with multiple
local, state and federal
agencies, including the
U.S. State Department
and the Federal Bureau
Photo courtesy Grady EMS
of Investigations (FBI).
Then, Grady EMS’s Biosafety Transport Team headed out to
transport the ill doctor from the airfield where his medical jet
landed to Emory’s isolation unit, about a 40-minute drive.
“There were people on social media saying, ‘Don’t bring
him here,’” says Wade Miles, interim director of Grady EMS
and Biosafety Transport Team supervisor. “But that’s not the
right thing to do. To be a part of a team that was willing to
be there for him when he needed it means something to us.”
Faith in the Training, Protocols
Think about it for a moment. You’re called to respond to a
patient who has a highly contagious, often lethal disease. Your
job is to climb into the back of the ambulance, seal the doors,
and provide the best care you can. Would you be willing?
For the Biosafety Transport Team, the answer is yes. “You
train for all these years, expecting the worst and hoping for
the best,” Miles says. “It takes a lot of faith in our training,
our processes and procedures, and our leadership to not put
us in harms way.”
Grady EMS’s Biosafety Transport Team got its start 12 years
ago, after the U.S. Centers for Disease Control and Prevention
(CDC), headquartered in Atlanta, approached nearby Emory
University Hospital about building a special isolation unit that
Winter 2015
could care for CDC clinicians who, either working in the lab
or in the field, became ill with an unusual or highly infectious
pathogen. The Emory team realized that they needed a ground
ambulance component, so they asked the Grady Memorial
Hospital-based ambulance service to participate.
Today, the team includes four paramedics and Dr. Alexander
Isakov, the team’s medical director.
Initial training is 24 hours of classroom discussions
about the symptoms, transmissibility, characteristics and
treatment of illnesses ranging from small pox to cholera, and
then hands-on practice methodically donning, doffing and
disposing of personal protective equipment (PPE).
Since its inception, the team has been called on to
transport about a dozen people, with diseases such as SARS,
extensively drug-resistant tuberculosis, and in recent months,
four Ebola patients.
Despite the recent flurry of activity, the team may go
months between calls, Miles says. To stay ready, they conduct
rigorous and ongoing training that includes twice-annual drills
with Emory simulating a full response to a high-risk patient.
“As many times we we’ve done this, every time we train,
we pull out our notebook and go line by line. We don’t do
anything by memory,” he says. “When we’re suiting up, the
whole team is watching, making sure they do exactly what
they’re supposed to do. We do the same when taking PPE off.”
Ebola Call Comes In
Because of that ongoing preparation, the Biosafety Transport
Team can be ready to activate in moments. For Dr. Brantly,
they were given 48 hours, much of that time spent coordinating
with other agencies, including those that would provide security,
given the highly publicized arrival of the physician.
A few hours before, they readied the patient compartment
of an ordinary ambulance by removing all extraneous
equipment and draping the walls and floor with impermeable
sheets of plastic secured with gorilla tape, which can
withstand the Georgia humidity. The plastic covering makes
it easier to decontaminate the ambulance from blood or
vomit after the transport, he says.
They also turned off the air-conditioner and heater and
closed the vents, helping to prevent airborne germs from
circulating around the patient compartment in the breeze.
A second ambulance was prepared identically, just in case
something unexpected happened en route.
Depending on the condition of the patient, either one
or two paramedics ride in the back, wearing full-body PPE
and a powered air-purifying respirator (PAPR), which
decontaminates air by forcing it through multiple filters. The
driver wears full PPE, with a PAPR at the ready, in case he or
she is called on to assist with patient care.
For Brantly, who could walk on his own, John Arevalo rode
in the back, while Gail Stallings drove. (Grady EMS’s second
Ebola patient transport came a few days later, when Nancy
Writebol arrived in the United States. Because she needed to
be carried on a gurney, both medics rode in the back with
her, while a third drove.)
Safely Delivered to the Destination
Inside the ambulance, Brantly also wore protective gear, and the
transport went smoothly. After safely delivering him, medics
began a key part of the mission: thoroughly decontaminating
the ambulance and carefully removing and disposing of their
Lessons From the Ebola Scare
PPE, both done at a secure location at Emory.
The driver, who has not made patient contact, stays in the
same PPE while they clean the ambulance. The other medic
or medics change into clean PPE. It’s a painstaking process,
with the entire team watching their every move.
After the entire patient compartment is wiped down twice
with a solution recommended by CDC, the PPE “doffing”
steps begin again.
One of the easiest mistakes to make, Miles says, is to rush.
“After you’ve been in the suit for awhile, you just want to get
that stuff off and get in the shower. It gets hot and stuffy. Your
boots are full of sweat. It’s like wrapping yourself in a plastic
bag and there’s no air movement,” he says. “We don’t rush
anything. Everything we do is very deliberate. They don’t make
a move until their team leader tells them to make a move.”
Visit the Ebola Response Resources section of the
NAEMT website (www.naemt.org/emshealthsafety) for latest
information in Ebola response.
continued from page 21
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Another take-away is that preparedness is an ongoing
endeavor. Austin-Travis County already stockpiles tens of
thousands of extra sets of PPE for pandemic flu, Hinchey
says. But when they tried to order the additional PPE for
responding to Ebola patients, supplies were sold out. “What
Ebola taught us is that some portion of our strategic reserves
should be dedicated to an all-hazards response that can get to
a much higher level of PPE,” he says.
And finally, the Ebola crisis should serve as a reminder that
EMS is a critical part of the nation’s healthcare system.
“In any epidemic, the key pieces to responding to it
are identifying people with the disease, isolating them
and safely transitioning them into the healthcare system,”
Hinchey says. “EMS plays a big role in that. We can
identify them, either on the phone or at the home by
asking key travel questions. We can also isolate them. Then,
we can send a special unit to transport them – all without
exposing any EMS practitioners.”
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