Taylor Ratcliff, MD speaking on TEMSA’s medical director panel at EMS EVOLUTION 2019.

The Texas EMS Alliance recently sat down with Dudley Wait of the Southwest Texas RAC and Taylor Ratcliff, MD of Baylor Scott & White Healthcare to discuss EMS preparation related to the coronavirus and the COVID-19 patient.

Taylor Ratcliff, MD works for Baylor Scott & White Healthcare as the Central Texas division director for prehospital medicine and is the system emergency management medical director.  He is an emergency physician and EMS medical director for many agencies in Central Texas, in addition to being one of the Texas EMTF medical directors and IDRU physicians.

Dudley Wait serves as the Southwest Texas RAC’s Director of MEDCOM.

TEMSA: What should EMS agencies be doing to prepare for the virus in their community?  Does this differ from normal operations and protocols? 

Dudley Wait: EMS agencies should be reviewing their PPE and assessment and treatment protocols that could be involved with a response to a potential COVID-19 patient.  Many of these things are “best practices” for assessing any patient with an acute respiratory infection (starting the assessment six to eight feet away, putting the surgical mask on patient if coughing and/or sneezing, etc.).  The level of PPE for this including a gown is also a change for a standard respiratory response but potentially it shouldn’t be.

Taylor Ratcliff: I’m not sure how many agencies actually have a “novel virus” protocol, but after the Texas Ebola case I think we all hopefully have a process for a potential HCID patient.  The big thing is dusting off the PPE.  In many cases when we check our trucks each day, we look into the cabinet with our package of PPE, but I doubt we get it out, inspect it and make sure our N95 masks look good, our gowns don’t have rips and tears, or frankly that our PPE isn’t disintegrating!

The big change to me is in the screening.  We need to be sure we are looking for symptoms of illness and asking the appropriate travel or exposure questions.  That really even needs to be happening with the 911 call.  Also (and I hope it doesn’t happen) if things get really hot and heavy, we will likely need to change our transport options where some patients who aren’t significantly ill stay home.  We should be working with our public health partners, healthcare coalitions and hospitals to have a plan in place on when to activate those pandemic transport plans.

TEMSA: How are you and your colleagues in the EMS and medical arenas keeping up to date?

Taylor Ratcliff: There are several agencies that are providing helpful information right now.  I think most people are following CDC websites for information and updates.  More for entertainment, but Johns Hopkins has an interactive map right now showing cases across the globe.  The CDC is hosting calls with providers that are currently caring for COVID-19 patients to gather information on what clinical challenges they are facing in addition to providing information about emerging treatments and clinical trials.  The bulk of treatment remains supportive but every day there is more preliminary information about anti-viral medications and progress on vaccines. 

Dudley Wait: There are a variety of sources for updated information.  Starting at the broadest to the local World Health Organization, CDC, NHTSA, DSHS, local public health, and your RAC.  STRAC has a page that is being kept up to date with the latest information (www.strac.org/coronavirus). Also, the American College of Emergency Physicians has rolled out their new electronic journal (JACEP) and they have been pushing out a lot of strong work on COVID-19.

Dudley Wait speaking at EMS EVOLUTION 2019.

TEMSA: What recommendations do you have for EMS agencies to prepare for the coronavirus and other novel viruses?  

Dudley Wait: Agencies MUST re-educate or refresh their crews on PPE for patients with communicable diseases.  Likely most agencies have not done fit testing with N-95 masks since Ebola or H1N1.  Now, PPE is in such short supply that it is not recommended to do fit testing due to the amount of masks it would burn through.  Additionally, medics must be educated on the recommendations for treatment and transport.  PPE donning and doffing, transport recommendations of putting a respiratory infection patient in your ambulance, deconning the ambulance after the call and exposure reporting and personnel monitoring all need to be established and covered with every medic.  Although COVID-19 appears to be similar to the flu, but even the flu can be fatal so proper precautions must be taken … and to do that everyone must know and understand those recommendations.

Taylor Ratcliff: ​As mentioned in question one above, there is good information coming out from the CDC, NHTSA and other pre-hospital professional societies.  The big thing is to make sure and cross-check your information sources and make sure they agree and are from a reputable source.

TEMSA: How are you coordinating with other health officials in your area? 

Taylor Ratcliff: This one is huge; if you aren’t already you need to be meeting with your local, county or state regional health colleagues, as well as their emergency management counterparts.  They likely have information for you regarding persons under investigation or monitoring and can help you formulate a plan for altered transport strategies and when to enact those plans.

Dudley Wait: I work for our Regional Advisory Council now and we are closely tied in and working hand in hand with our Public Health Authorities.  Everyone should know who their health department is and be having regular conversations with them during this heightened period.  Also, we have established a COVID-ALERT process for our EMS agencies and for hospitals that may need it.  This ALERT brings local leaders together with the EMS crew, their medical director and their bosses to discuss these patients before the patient is loaded or transported.  Our region’s plan is to leave those at home that can stay at home and only transport those that are critically ill and then have Public Health go to their residence to assess them and track them per their protocols.  With medical direction, operations and public health all on the phone at the time of the encounter can make the best decision.  It also allows for early notification and preparation of the receiving facility.  In the STRAC region, we are doing 3-5 of these a day.

TEMSA: How do you think the coronavirus will play out?

Taylor Ratcliff: My crystal ball is broken … I’m not putting a bet on anything!

Dudley Wait: I believe we will see an escalation of cases in the US. But as better testing options present themselves, we will see that the largest majority that acquires COVID-19 have minor, if any symptoms, and thus the fatality rate and transmission capability is closer to that of influenza.  I believe we will see a resurgence of COVID-19 next winter, and hopefully, it will be shorter-lived and not any more virulent than this version.

I also hope that this will serve as a long-term wake-up call to healthcare about the need to practice proper infection hygiene and utilize better control mechanisms at all levels of care from EMS through living facilities to hospitals.