ACEP COVID-19 Field Guide

Author: Jeffrey M. Goodloe, MD, FACEP, Hillcrest Medical Center Emergency Center, Tulsa, Oklahoma; Professor of Emergency Medicine, EMS Section Chief/Director of the Oklahoma Center for Prehospital and Disaster Medicine, University of Oklahoma School of Community Medicine; Chief Medical Officer, Medical Control Board, EMS System, Metropolitan Oklahoma City, Tulsa, Oklahoma; Medical Director, Oklahoma Highway Patrol

ACEP provides the following general guidance relative to COVID-19 to physicians working with EMS organizations, with the understanding that policy determinations on clinical matters within applicable EMS organizations rest with the respective jurisdictional EMS medical director(s). See the ACEP Policy Statement “The Role of the Physician Medical Director in Emergency Medical Services Leadership.”

Before proper attention can be focused on maintaining the highest possible clinical standards for patient care in this unprecedented time, primary decisions must be made to attain and maintain the best possible personal protective equipment (PPE) programs for the EMS organization. PPE programs include initial and ongoing training on and confirming appropriate use of specified PPE, both donning and doffing procedures as well as instructions on how to avoid inadvertent self-contamination during on-scene care and stabilization, enroute care, and hand-off to emergency physicians and other members of the health care team.

Given widespread and prevalent shortages of PPE throughout health care systems, including EMS organizations, the constellation of available items as well as brands or types of the organization’s usual and customary PPE can change. This dynamic should be factored into both the initial and ongoing training for any EMTs or paramedics with clinical care responsibilities.

Many EMS organizations have already produced short, yet effective, in-house training videos on correct PPE practices. One such video “Donning, Doffing and Handwashing Procedures” from the Seattle Fire Department and King County, Washington, EMS is graciously promoted and shared on their continuing education website. This video incorporates the important components of both respiratory droplet and aerosolization protection for EMTs and paramedics. The CDC has also produced illustrated instructions that can be widely shared, used as a part of training, and even used as a visual reminder affixed within emergency apparatus for EMS personnel.

While not the direct responsibility of the EMS physician medical director, as the clinical leader of the EMS organization, it is important to work collaboratively with administrative leadership and, if applicable, in-house supply chain managers to best understand the present implications of available PPE and when, if needed, changes are required.

While not optimal, at the time of this field guide’s release, due to PPE shortages, many EMTs and paramedics are conserving PPE by reusing surgical style masks and N95 (or higher) respirators throughout a duty shift. In many areas, these same items are required to be reused over multiple duty shifts, as long as they remain intact, undamaged, and unsoiled. While it may seem obvious, N95 (or higher) respirators must still be properly fit-tested to individual personnel. Facial hair changes and other considerations may need to be mandatory to achieve necessary fit performance.

A commonly used mnemonic for EMS PPE needed for suspected or confirmed COVID-19 patient encounters is MEGG — Mask – Eye shield – Gown – Gloves — as detailed both within the previously mentioned training video from Seattle/King County, Washington, and the CDC illustrated instructions. One increasingly used additional strategy to conserve PPE, and to limit the number of EMS personnel to the minimum clinically necessary for the patient’s condition, is the “scout” plan. The scout plan involves sending one MEGG-attired EMT or paramedic, depending on apparatus staffing and any prearrival medical dispatch information gleaned, to make patient contact. “Contact” often may be first established at a distance of 6 feet from the awake, interactive patient. This distance is often cited as one of relative safety to minimize exposure to respiratory droplet and aerosol particles. Once the initial patient condition is confirmed, the scout EMT or paramedic can summon the number of additional personnel deemed necessary, using either visual or verbal cues at a distance to signal the awaiting personnel. It is often good practice for one of the other responding personnel to be in a MEGG configuration to avoid any delay in immediately needed care due to PPE donning.

As with personnel quantity, careful consideration should be made as to the medical equipment initially brought to the patient’s side. If the initial assessment reveals a more stable patient, leaving as much equipment as possible outside the residence, or patient location, can reduce the ambient or patient respiratory contact with that equipment, perhaps saving decontamination time later.

A thoughtful summary of many of these points can be found in a guide produced by the Washington Resuscitation Academy entitled “COVID-19: 10 Steps to Help Patients While Staying Safe.” Our thanks go out to EMS physicians Michael Sayre, Tom Rea, and Mickey Eisenberg as well as the many others involved in the generous preparation of this resource. Additional PPE-related resources can be found at the National Highway Traffic Safety Administration’s Office of EMS and the US Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR). 

Many effective strategies are currently employed throughout EMS organizations. Careful attention to the post-patient transfer time is necessary for proper ambulance and other emergency apparatus decontamination. Using virucidal solutions and physical wipedowns are important steps in the decontamination process. Personnel compartments (eg, ambulance front compartments, fire engine cab compartments) should be strictly kept clear of any PPE used during patient contact and care. Emerging technologies such as virucidal foggers, ultraviolet light devices, and other modalities are now being used, with further research pending in some cases. Thoughtful distillation of rigorous, research-based evidence should be implemented with any purchase or use of these decontamination strategies.