Fire Department EMS: Thinking Outside the Box for COVID-19

与冠状病毒的救护车

By Mike Hudson

现在很明显188.博金宝 is a global pandemic that will affect street level operations of every public safety organization in our country. By all definitions, this crisis will become a mass-casualty incident—a biological MCI.

As EMS and fire department training officers scramble to find relevant fact-based training for their personnel, chiefs, supervisors, and medical directors are trying to manage risk to personnel without compromising patient care.

The clear and present threat to clinicians looming with every patient contact comes in the form of a highly contagious virus that has created a finite line between our safety and the expected standard of care.

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目前有一些国家和联邦卫生组织的建议，这些建议专门针对本文中的EMS。不是轶事的建议。Looking at the current state of Italy’s health care system, it is apparent to the seasoned prehospital care provider that the typical approach to patient care and ambulance transport will have to be modified to accommodate the surge of cases we will encounter over the coming days and weeks.

毫无疑问，这是一个国家的MCI，这是调整响应和操作程序以确保急救人员安全的纬度，以便他们可以为最多的人做最多的利益。

背景

了解与COVID-19相关的危害和威胁是减轻风险的关键。新型冠状病毒病毒（严重的急性呼吸综合症2 [SARS-COV-2]）的首次海外病例在2003年在中国发现。2019年11月，Covid-19再次在中国发现。Covid-19有两种菌株，两者都通过呼吸液滴传播，SARS-COV-2是菌株中最有弹性和传染性的。

A recent study from the National Institutes of Health, Centers for Disease Control and Prevention (CDC), and UCLA and Princeton University scientists inThe New England Journal of Medicinefound that SARS-CoV-2 was detectable in aerosols for up to three hours; up to four hours on copper; up to 24 hours on cardboard; and, the worst case scenario, up to two to three days on plastic and stainless steel.1This means that this virus can be easily spread by first responder personnel. Skin, gloves, medical equipment, discarded uniforms, and medical waste can all become vectors of transmission hours and days after droplets land.

对与Covid-19相关的预计电涌数量的响应无非是国家MCI。医疗控制实体和国家管理员现在允许EMS部门通过放弃传统政策和协议来修改当前的街道运营。例如，新泽西州的DOH EMS办公室已积极地授予全州范围的豁免，以修改EMS提供商的众多规则，例如减少对MICU Crew配置的限制，以增加资源的部署并减轻对提供商互惠性的限制。两者都是力乘数。亚利桑那州，科罗拉多州和佛罗里达州等其他州的消防部门也正在修改院前运营和医疗方案，以适应预期的患者激增。修改人员安全协议可以同样轻松地完成。

Published Recommended Guidelines:The Department of Health and Human Services (DOHHS) published theEMS传染病剧本在2017年，作为EMS服务和提供者的响应指南，他们负责照顾与SARS病毒有关的潜在感染患者。

同时，CDC和U.S. Public Health Service Commissioned兵团(PHSCC) have also released several guidelines for prehospital care providers, which are referenced at the end of this article.

响应和出行前信息

疾病预防控制中心建议对公共安全应答点（PSAP）调度员的分类问题进行量身定制，以识别那些患有COVID感染症状的患者，然后将信息传递给反应的EMS船员。2-3

  1. 持续的咳嗽或呼吸窘迫；
  2. Fever;
  3. 不适；
  4. History of recent travel and/or exposure to others with COVID-19;
  5. 腹部困扰或胃肠道出血。5

场景安全

您想在任何长时间内想成为的最后一个地方是在患者自己的环境中。街头聪明的EMS提供商知道，在任何给定的夜晚，进入黑屋都充满了安全威胁。许多EMS系统中公认的程序是要求患者步行到前门，然后进入可以开始初步评估的光线。

Consider COVID-19 as a threat in a pitch-black house on a moonless night. The CDC has acknowledged that the threat of COVID transmission diminishes once the patient is outside in unrestricted atmospheric air, so it would make sense that all ambulatory patients should be assessed out in the open air whenever possible. Back in the ‘90s, this was known as the “doorway diagnosis” or “doorway triage.”

Stable ambulatory patients can walk to a stair chair placed in the front yard or walk to the ambulance for more diagnostic assessment procedures and ALS care. The DOHHS recommends that EMS assesses patients at a distance of six feet to limit the spread of droplets;3if this six-foot assessment is done outside, the risk to providers decreases exponentially. The bottom line is that providers need to limit their time in the patient’s environment as well as limit close-proximity interactions with patients who don’t require lifesaving procedures.

Personal Protective Equipment (PPE) for COVID-19

与其他保护措施一起，患者接触之前和之后进行彻底洗手非常重要。联邦卫生组织指出，EMS的人员处于患者的距离，戴上N-95面膜，眼部保护，耐液体礼服，当然还有手套。2-4患者护理人员必须在救护车“盒子”中提供护理时保持完整的PPE。

Decontaminate equipment before stowing in outside compartments whenever possible. Drivers of ambulances and medical transport vehicles must remove most of their PPE before sitting in the driver’s seat and need only wear an N-95 mask while transporting a COVID patient3but PPE must be re-donned to assist the attending EMS provider with stretcher transfer.

所有机组人员的患者联系指南必须包括适当处理PPE，激进的洗手和设备净化4包括救护车的病人车厢和室外门。

Reconnaissance and Triage

Limiting the number of persons and amount of equipment entering a potentially contaminated area decreases risk of contamination. Before a major military operation, intelligence is gathered by smaller reconnaissance units that are deployed ahead of troops to identify threats and help coordinate logistics of the operation. This same type of approach can prove beneficial for the responding fire department and EMS agencies and aligns with CDC recommendations for COVID response. As the president says, we are “at war” with this virus.

To decrease the probability of exposure to COVID-19, an arriving engine company or ambulance should, whenever possible, request that the patient come to the front door where the assessment will occur. If the patient cannot ambulate, one EMT in full PPE should enter the scene (building, residence, home) to triage the patient and figure out what resources are needed.

该分类响应者应最低限度地配备便携式无线电，出血控制套件和患者的手术面罩。进入室内后，可以在旁观者的帮助下将患者移到外面，或者可以将适当数量的资源送入现场。

如果患者在心脏骤停或降落周围发现，则分类人员将根据AHA指南呼吁资源并启动仅压缩性心肺复苏术。该程序的目的是降低风险并限制对非必需人员的暴露，直到可以确认患者可行性或明显死亡的迹象为止。

通用设备

Additional initial equipment brought into the scene by the triage responder should focus on life threat intervention and need only consist of a bag-valve mask (preferably with a Bacterial/Viral HEPA filter device that fits in-line for nebulizers, CPAP, extraglottic and endotracheal tubes), SpO2 device, and a thermometer.

A provider using an SpO2 device on a walking/talking patient can quickly assess acuity without having to make any physical contact. The SpO2 device can be slipped onto the finger and requires only a simple decontamination procedure.

The SpO2 device, if pulsatile, can let a provider know that distal peripheral circulation is present, which means that the BP is at least 90 mmHg systolic. The device will also indicate whether the O2饱和度足够> 94％，可以提醒临床医生的心率和规律性 - 仅需10秒即可提供一件设备，而无需触摸患者。

复苏设备

当三角人提供者确认复苏案例时，可以将全部PPE的其他设备和人员带入现场。到达护理点的最低复苏设备应包括AED（如果是BLS服务），氧气来源，吸力单元和便携式患者转移设备，例如SCOP或COMBICARRIRE或REEVE的担架。如果受害者是可行的，则应立即将其删除，以便ALS人员可以在救护车的相对清洁且光线充足的环境中提供护理。

Transporting non-viable contagious patients to the ER can jeopardize the safety of other health care providers and holds no benefit for the patient or his or her family.

Several studies and peer reviewed papers6-7already recommend the consideration of paramedic termination of resuscitation (TOR) in cases of cardiac arrest for more than 30 minutes because in-hospital resuscitation is likely to be futile.7Even resuscitation cases that have no ROSC, termination orders after a projected downtime of > 30 minutes are being obtained by medics in systems that have current TOR protocols.6-8

步行（感染）受伤

一号在CDC和DOHHS coronaviru列表s risk management strategies is to maintain a distance of six feet when assessing the patient.3It has been long understood that, during triage at an MCI, the walking wounded are considered low priority because patients able to talk and ambulate while presenting awake and oriented are probably perfusing with adequate oxygenation. Assessing the patient from six feet away keeps patient contamination threats at a safe distance even if they cough or sneeze.

Number two on the CDC and DOHHS list of coronavirus risk management strategies is to have the patient put on a surgical face mask before the assessment begins, decreasing the respiratory droplet threat.2-3

Transport of low-acuity, potentially contaminated patients will require modified COVID-19-inspired guidelines for non-EMS transport, but that does not negate our duty to get the patient to testing and definitive care. One of the primary guidelines for the walking wounded category under normal disaster MCI triage criteria is that if you can walk and talk and have no immediate life threat, you may not need an ambulance, so get green tagged and assigned to a non-medically attended ride to the hospital. This can be applied to suspected COVID-19 patients. Unnecessary use of ambulances by infected, stable ambulatory patients quickly depletes valuable, limited resources and increases the risk of personnel contamination. This phenomenon was brought to light in a 2010 documentary大火在流感流行期间，洛杉矶县消防局的65滑行。

Skip the Million-Dollar ALS Work-up

限制您与患者紧邻的患者度过的时间很重要。更少的暴露时间意味着较小的风险。此外，限制进入现场的设备的数量是必须的。需要修改有关响应袋内容和最低设备标准的政策，尤其是对于此大流行期间ALS人员的政策。没有理由将担架，两个完整的跳袋，氧气和昂贵的心脏显示器带入受污染的区域，以供稳定，有意识的患者使用。

The cookbook days of obtaining four sets of vitals, an ECG, a FSBGL, a lactate level, and a prehospital IV on every stable patient receiving should be modified or shelved during this pandemic.

运输受污染的患者需要对设备和患者护理区的所有内部表面进行完整的运行后净化4，，，，which delays availability of the ambulance for up to 30 minutes. Less equipment exposed to potential droplets equates to less equipment that the providers must clean. The use of advanced diagnostic equipment should be the standard only if the patient’s condition indicates the need and should not be used to hunt for “zebras” or anomalous life threats during these unprecedented times.

The CDC and DOHHS suggest that non-invasive nebulization of medications should be used cautiously by ALS providers because these treatments can create aerosolized droplets.3CPAP should have HEPA bio filters in-line.

CDC和DOHHS还建议高敏感的可疑患者具有RSI和插管早期。3if airway failure is a high-probability or there is a projected need for more advanced gas management techniques (i.e. mechanical ventilation with pressure control). However extreme care must be taken by providers to avoid exposure while advanced airway management procedures are underway—a proper face mask and eye protection must be worn. Some EMS medical directors are advising their providers use blind-insertion rescue airways like the iGel or King Tube instead of the traditional orotracheal intubation.

替代运输处置

In the early days of EMS, it was society’s unwritten rule that ambulances should only be used for life threats, not for all threats. That has changed and many EMS systems transport nearly all persons requesting service. This must be modified by EMS medical command and protocols prepared for EMS providers to determine the need for ambulance transport instead of the patient or family deciding the need.

EMS正处于共同-19大流行的直接道路上，要求领导者在框框外面思考。具有适当医疗控制方案的经过足够培训的EMS人员应该能够将稳定的患者推迟到替代运输模式和设施。EMT或消防员驾驶带有塑料座椅的改装警察局或小队的汽车可以安全地将稳定的门诊病人运送到急诊室，而无需参加EMT。与救护车患者隔间相比，警车通常为驾驶员提供强大的障碍，其塑料或金属座椅更容易进行净化。数十年来，像丹佛这样的城市一直在使用类似的替代运输指南来通过专业货车运输吸收性患者到排毒单位。同样的做法可以应用于共证响应。

If the suspected COVID patient is transported in the ambulance, the CDC recommends that its ventilation system be equipped with a HEPA filters and its fans set on “high” while transport is underway.2-3Ambient atmospheric air under pressure via an open window can also increase the filtration of aerosolized droplets.

***

The logical approach to managing a major portion of risk associated with COVID-19 is to use EMS personnel and resources appropriately. The days of sending a fully staffed engine company, paramedic squad, and a BLS ambulance to every 911 call that drops must be avoided. Managing medical risk starts with incident information obtained by EMD personnel at the PSAP which leads to scene safety considerations prior to arrival. Once on scene, the contamination threats can be mitigated by proper management and command of the patient encounter. Establishing a safe place to assess the patient, limiting the number of personnel contacting the patient, limiting the time spent with the patient, and limiting the amount of medical equipment at the point of care all play a major role in diminishing the overall risk to the EMS provider.

It is imperative that responders manage personal risk and leaders give them the professional latitude, protocols, and equipment to do the most amount of good for the most amount of people.

参考，资料和研究

  • Van Doremalen,等。与SARS-COV-1相比，HCOV-19（SARS-COV-2）的气溶胶和表面稳定性。The New England Journal of Medicine。DOI: 10.1056/NEJMc2004973 (2020)
  • 医疗保健环境中怀疑或确认冠状病毒疾病（COVID-19）患者的临时感染预防和控制建议

迈克·哈德森（Mike Hudson）是前美国海军军官，现任全国注册护理人员，在街上超过25年。在冬季，迈克（Mike）为探索频道（Discovery Channel）工作，并在新泽西州中部担任街道级麦克风。在夏天，他指挥了一个市政USLA认证的救生部机构，为两个沿海城镇提供河流救生员和海洋救生员服务，并担任联合消防部门/救生员救生员救援团队的首席海洋救援专家，Surf Rescue Team，Surf Rescue Team 43-88（SRT 43-88），总部位于新泽西州蒙茅斯县的北岸。有关SRT 43-88的更多信息seabrightoceanrescue.com。

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