Facing Ebola: The EMS Response to America’s Newest Infectious Disease Threat

It was October 15, but the Tyvek suits were still brutally hot in the Texas sun. Despite the air purifying respirators, American Medical Response (AMR) Dallas paramedics Brian Wall and Jesse Brown were sweating as they made their final preparations to care for the first of two, now famous Ebola-infected nurses. They would transport each from a Dallas, Texas, hospital to an air ambulance waiting at Love Field, also in Dallas, where they would be flown for more definitive care at the National Institute of Health, in Bethesda, Maryland and Emory University Hospital, located in Atlanta, Georgia.

Ebola Virus Disease (EVD) had entered the national consciousness just two week prior to the nationally televised transports when the U.S. Centers for Disease Control and Prevention confirmed the first known case in this country. A traveler from West Africa named Thomas Duncan had been admitted to a Dallas hospital with the virus. Ebola was now a U.S. problem.

AMR, the nation’s largest ambulance service provider, found itself at the center of the storm when it transported the nurses, both of whom had provided care to Duncan at Texas Health Presbyterian Hospital. The two transports forced multiple federal, state and local agencies involved to think outside of the typical hospital walls and apply those same care and precautions to providers in the field. Mobilizing a critical, highly-publicized transport of this scale took leadership, coordination, communication and skill.

At the same time, the Greenwood Village, Colorado-based emergency medical services (EMS) provider had to quickly prepare 18,000 EMS personnel for the possibility of transporting suspected and confirmed EVD patients.

The EVD Transports

The two transports were handled by AMR’s Dallas operation, but out of the Arlington, Texas station. Since it wasn’t a typical transport, AMR asked for volunteers, and the two paramedics were joined by Arlington-based EMT Larry Waldon.

Less than 12 hours after AMR agreed to transport the two nurses, Wall, Brown and Waldon were being prepped. Equipment and experts also began arriving. Brown remembers thinking, “This is some heavy-duty stuff here.” A compassionate paramedic, Brown had always been interested in humanitarian medicine. “I never thought I would do it in my own hometown,” he said.

“In the EMS world, we pride ourselves on being ready all the time—this ratcheted it up,” said AMR Arlington General Manager Shane Smith. The advantage for AMR was the trust, communication and support that was already in place before EVD arrived in the U.S. “Our executives were right on the ground with us every step of the way. That went a long way to establishing and continuing that trust,” he said.

While the AMR leadership team coordinated with the U.S. State Department, CDC, Health and Human Services and the Texas Department of State Health Services, final preparations were made for the crew. Atlanta-based Grady EMS Interim Director Wade Miles flew to Arlington to provide on-scene expertise for the crew, particularly in donning and doffing decontaminated gear. “We felt comfortable that we knew the procedures, and that we would be walked through it when it was time to be [decontaminated],” Wall said. Even so, Ed Racht, MD, AMR chief medical officer, who was on scene with the crew for the entire operation, told them that, if at any time they felt uncomfortable, they had the authority to stop the whole thing.

The first transport went, more or less, according to plan. “The equipment is very hot,” Brown said of the suits. Some changes were made for the second transport. “It was much more relaxed,” he said. “The second day went just as it was supposed to.”

Since no breaches had been observed during the transport, the EMS crew was monitored for 21 days for fevers and symptoms by the medical team at the Williams Medical Command Center, a critical nexus for Mobile Integrated Healthcare services provided by AMR sister company Evolution Health.

Only the crew members who had direct patient care responsibilities required monitoring. They were placed on administrative duty and not allowed to treat patients until cleared—the same procedure as exposure to a tuberculosis patient. As long as the providers had no symptoms, there was no reason to isolate them from their families.

Although the crew received the typical banter from their peers when they returned to duty, it was Waldon’s wife who experienced the most significant repercussions. Because of her contact with him, she was suspended from her job for three weeks “out of an abundance of caution.”

Preparing for EVD

Soon after the CDC confirmed the first case of EVD in this country, AMR created a national leadership team of experts from across the various companies owned by AMR’s parent, Envision Healthcare. They developed plans for patient and provider safety, purchased equipment, implemented training and coordinated a clinical response.

AMR coordinated with the CDC as its primary resource for EVD information. However, the media and uninformed “experts” were playing into the public’s fear of the virus. Much of what needed to be managed were perceptions, not reality. It was vital that AMR employees trusted and listened to their leadership. To that end, the communications team maintained a steady stream of up-to-the-minute specifics about the virus, providing clarifications, where necessary, regarding AMR’s procedures. A special page was created on the company’s public website for information about EVD (www.AMR.net/Ebola), and educational programs were implemented for AMR employees nationwide. Special training in enhanced PPE and decontamination were emphasized. EVD screening questions were integrated into AMR’s protocols and electronic patient care reports.

To handle an anticipated flood of questions from caregivers in the field, AMR established a Clinician Hotline that was available 24/7 through the Williams Medical Command Center. The hotline provided immediate access to experts who could assist with clinical decisions and collaboration with hospitals.

Externally, AMR general managers were encouraged to support their communities by providing up-to-date information to local government officials, other EMS agencies and fire departments.

Since October 8, 2014, AMR paramedics and EMTs have had more than 850,000 patient contacts nationwide. Of those, 190 patients were identified as having risk factors and symptoms consistent with EVD, requiring the providers to don protective equipment. To date, there have been no confirmed cases.

Conclusion

Despite their initial uncertainty, Wall, Brown and Waldon say that they are glad they participated. “[AMR] took all the precautions,” Waldon said. “The odds of me catching anything were very slim.” Brown agrees. “Whenever I had a question, they were there. We were well protected,” he said.

Although they don’t like to be called heroes, AMR Senior Vice President of Professional Services and Integration Ron Thackery commends all those who worked on the transports for their courage. “We had a bunch of brave people. People who have the distinct honor for EMS who said, in a time of need, I will do what it takes to help people,” he said.

At the end of the day, Racht said that it is the emphasis on good personal protection precautions that eliminates the risk of EVD or any other infectious disease. The same lessons AMR learned will be invaluable for the next threat. “Ebola happened to be the particular bug, but the reality is that we must all plan for the next rapidly-emerging infectious disease, whatever it may be,” he said.