Resident Eagle: Inside the War Room—Medical Directors Take On COVID-19

Resident Eagle is a monthly column profiling the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (the "Eagles"), who represent America’s largest and key international cities. Every month it will discuss the latest cutting-edge issues and findings in emergency care. 

Tentative dates for Gathering of Eagles 2021 are June 14–18, Hollywood, Fla. For more see useagles.org.

When the first COVID-19 cases were reported in Washington state in mid January, ears of EMS medical directors around the world perked up.  They immediately recognized the need to examine existing protocols for efficacy in a pandemic and share best practices with those who had the first cases.

Gathering these experts virtually was Paul Pepe, MD, the creator of the Eagles coalition, jurisdictional EMS physician medical directors from major U.S. municipalities and their counterparts worldwide.  Pepe convened the first COVID-19 Eagles conference call on February 20, and they continued into May. On the calls (available on the EMS World website) participants share the latest COVID-19 clinical and operational news and brainstorm new ideas. The Eagles meet twice a week, often with 40–50 calling in.

With 11 weeks of webinars to look back on, it is instructive to examine the past content of the meetings.  What were the first concerns? What are some successes and best practices identified in this boots-on-the-ground group exchange? While not a complete analysis of all content, it still provides lessons for the future.

Weeks 1–4: Feb. 20–March 17

Highlights and news: 

Jon Jui, MD, MPH, Portland, Ore.: 

• Patients asymptomatic but infectious: “This appears to be more infectious than the flu.”
• EMS has unique PPE needs due to close, extended contact with patients in ambulances, poor vehicle ventilation
• Data from China seems to show acute phase of immunity for first 30–60 days,  long-term immunity unknown
• Patients taking ACEs or ARBs may have more severe course

Michael Osterholm, PhD, MPH, Center for Infectious Disease Research and Policy: 

• Testing is serious challenge worldwide, true data on patients is unknown
• WHO recommending surgical masks for providers, CDC appropriately recommends N95s
• No scientific basis for seasonality argument 

Michael Sayre, MD, Seattle, Wash.:

• Swab of flu patients found COVID-19 virus in teenage patient, first COVID-19-related death reported Feb. 26 at Harborview Medical Center in Seattle; as of early March, 22 cases, 8 deaths
• Call volumes not increasing
• Return-to-work policies need to be established

C.J. Winckler, MD, San Antonio, Tex.: 

• Lackland Air Force Base designated to house quarantined patients flown in from Japan on Feb. 7

Peter Antevy, MD, Davie, Fla.:

• Call patients on FaceTime ahead of arrival or only send in one provider upon arrival

Sophia Dyer, MD, Boston, Mass.:

• Biogen conference in Boston hotel may be reason for case increase, state of emergency established in mid March

Craig Manifold, DO, San Antonio, Tex.:

• Associations and unions advocating for exposure to be considered workers comp 

Successes/Best Practices:  

Sayre: 

• After report of first case in the U.S. in Washington, health department cooperated with EMS to communicate risks and infectivity
• Perhaps avoid transport when appropriate
• Use filters when performing airway maneuvers, avoid aerosol-generating procedures (AGPs)
• PSAPs expanding screening questions, 9-1-1 24-hour hotline for health department in Seattle (and San Antonio) helpful for “worried well”
• Screen body temperatures of workforce, asymptomatic means not contagious. Built drive-through testing for first responders, eight-hour turnaround for test results
• Health department shares daily with EMS list of COVID-positive patients
• Scout system where one provider stands six feet away from patient, don PPE after that if necessary

Ray Fowler, MD, Dallas, Tex.:

• IM epinephrine or patient’s own MDI instead of nebulized medications to avoid AGPs

Looking forward:

• Are antivirals effective?
• EMS may play role in home testing
• Obesity correlates with higher severity of illness
• Future threat not from overseas travelers but from community spread, proximity, and duration, with patient affect “dose” of contagion 
• Reuse PPE due to likely shortages?
• PCR results may have false negatives, need two consecutive negative tests to be sure
• Increase in nursing home cases from visitors or workers carrying the virus?
• Ventilator rationing if social distancing does not work and hospitals are overwhelmed?
• Seattle adding full PPE for cardiac arrest patients 
• Some evidence virus could be aerosolized 
• Trying to stop the virus is “like trying to stop the wind,” says Osterholm

Weeks 5–8: March 24–Apr. 17

Highlights and news: 

Glenn Asaeda, MD, New York, N.Y.:

• March 24 call volume is 5,200 per day, 1,000 per day higher than average; not all patients are transported 
• If providers are exposed but asymptomatic, they work and are monitored
• City struggling with social distancing, testing not available, public health investigations eliminated: It’s “chaos” 
• FDNY purchased pulse oximeters for the two-thirds of response units that didn’t have them

Osterholm:

• U.S. seeing increase in serious illness in young adults and children
• Defense Production Act (DPA) is meaningless—manufacturers struggling to change processes overnight to ramp up PPE production
• Testing is currently “the Wild West”; we do not know if antibody-positive patients have immunity; 65%–70% of population may be infected before we see downturn and another peak

Sandy Schneider, MD, ACEP:

• Urgent care centers seeing fewer patients, rural EMS suffering badly

Stefan Poloczek, MD, Berlin, Germany:

• Starting ambulatory EMS model, putting medics on cars
• Increased numbers of domestic violence and suicide patients

Ed Racht, MD, GMR:

• Call volume down 25%, significant drop in trauma calls
• As of March 27 there were 460 GMR providers nationwide under quarantine 

Ben Weston, MD, Milwaukee, Wisc.:

• African-American community hit hard, working on messaging to them

Amal Mattu, MD, Baltimore, Md.:

• Inflammation can turn stable plaques unstable, leading to MI. China and Italy report COVID-related deaths from myocarditis and acute heart failure

Ken Scheppke, MD, Florida:

• Be careful discharging patients to nursing homes, group facilities: “These are the folks who will create the tidal wave.” 

Jui:

• Data show COVID-19 viral load higher in sputum than other bodily substances, incorrect swabbing could explain false negatives. Gold standard is testing for viral antibodies, and Abbott’s ID NOW test holds promise

Scott Weingart, MD, Stonybrook, N.Y. and David Farcy, MD, Miami, Fla.: 

• Patients presenting as “happy hypoxemics” with low oxygen saturations and no distress aside from tachypnea; patients should not be treated with traditional sepsis or ARDS protocols 

Kim Pruett, MD, Albuquerque, N.M.:

• Call volumes down, large outbreak on reservations, underlying chronic illness means higher severity, rural clinics need extra training

Robert Holman, MD, Washington, D.C.

• As of April 7 54 members of DCFEMS infected, D.C. hotels are quarantining homeless 

Jim Augustine, MD, Canton, Ohio

• Majority of Eagles’ agencies (60+) surveyed are changing CPR protocols

Jon Krohmer, MD, NHTSA:

• Customs and Border Patrol (CBP) are inspecting PPE in case of counterfeit products 

Peter Hackett, MD, Telluride, Colo.: 

• COVID-19 pneumonia not the same as high-altitude pulmonary edema (HAPE)—while both have hypoxemia, inflammation causes COVID-19 pneumonia, treatment approaches differ

David Ratcliffe, MD, Manchester, U.K.: 

• Hospitals about 50% empty—what about non-COVID disease patients?

Emily Nichols, MD, and Meg Marino, MD, New Orleans, La.:

• 30% increase in cardiac arrest calls 
• Increases in call volume and acuity, widespread provider absences forced switch to tiered responses 

Erica Carney, MD, Kansas City, Mo.:

• Firefighters concerned, demanding to know locations of positive crew members, department intranet can send questions to union and administration

Successes/Best Practices:  

Sayre:

• iGel instead of ETI showed secretion and aerosolization, reconsidering protocol
• Return-to-work policy includes 14-day quarantine after exposure; if asymptomatic, back to work
• Cancer research center doing serological testing on COVID-19-positive patients and those who haven’t been tested or had symptoms, will follow them with pre-infection immunological markers

Augustine:

• Many have moved to supraglottic airways, anticipate new products in development

Jui:

• Portland using video laryngoscopy only, now full PPE on every call
• Critical care physicians using heparin or TPA to anticoagulate COVID-19 patients

Pepe:

• Use pulse oximeters as screening tool, some facilities giving to patients for home use

Lekshmi Kumar, MD, Atlanta, Ga.:

• MIH responding to lower-acuity calls to help patients stay home

Paul Bailey, MD, Perth, Australia:

• As of April 17, 157 cases among 2.5 million population, 6 deaths 

Randy Katz, MD, Hollywood, Fla.:

• Proactively testing nursing home staff to anticipate outbreaks that overwhelm EMS and hospitals

Stein Bronsky, MD, Colorado Springs, Colo.:

• Apps allow EMS video consultations with low-acuity patients, reducing PPE use and exposure risk

Weingart and Farcy: 

• Proning awake patients and using HFNC instead of ETI and ventilators in hospital, best to use low PEEP settings

Holly Stewart, MD, Lubbock, Tex.:

• Prefer mechanical filters then electrostatic on airway circuits; production of filters is ramping up, but there may be shortages

Antevy and Winckler:

• Literature review of convalescent plasma transfusion shows promise for COVID-19
• South Texas Blood and Tissue Center collecting plasma from previously infected patients

Asaeda: 

• April 17: FDNY back to normal or lower call volume, successful support from FEMA with additional units, 3–4 times increase in daily cardiac arrest calls

Looking forward:

• Clinical course of disease varies but symptomatic may experience mild symptoms (fever, shortness of breath) with severe escalation around the eighth day after infection 
• Early termination for patients unlikely to be resuscitated? 
• How to avoid intubation? 
• Treat STEMIs with lytics and avoid cath lab? 
• Benefits of hydroxychloroquine?
• Be wary of all COVID-19 tests and their inaccuracy, use PCR testing in conjunction with antibody testing 
• IAFF/IAFC leadership pushing for antibody testing for members, reports of recovered patients testing positive multiple times
• Long-term disease or effects in providers who have recovered?
• May need thromboelastography (TEG) testing for coagulability, microemboli found in autopsies of COVID-19 patients
• What are the ethics of ramping up for nothing? Downstream effects of no elective surgeries, medical appointments, etc.

Weeks 9–11: April 21–May 5

Highlights and news: 

Mattu:

• American College of Cardiology recommends COVID-19 patients with STEMI on EKG should go to cath lab, EMS should stop in ED for rapid testing to establish status

Sayre: 

• Performing post-mortem nasal swabs on DOA patients in the field
• Two-thirds of area’s deaths are from long-term care facilities

Bill Seifarth, NREMT, Columbus, Ohio:

• Provisional testing for new certifications and extended deadlines for recertifications of providers

Michael Levy, MD, Anchorage, Alaska:

• AHA recommends some protocol changes for CPR, 50% of Eagles surveyed said ALS services would change termination of resuscitation protocols, 60%+ reported increase in scene terminations

Roberto Fumagalli, MD, Milan, Italy:

• EMS calls surged to 5,000 from 2,000 in one day in April, managed many in dispatch
• Speculation is that virus was in country in December 2019; increase in pneumonia patients, overcrowded hospitals and non-invasive ventilation may have spread virus

Jui:

• Saliva testing is potentially accurate and more comfortable than nasal swab

Holman:    

• D.C.: 500-bed surge center will open May 8, may peak late May/early June
• April 24: 84 DC EMS providers tested positive

Schneider:

• FEMA allotted $100 million for EMS PPE

Joelle D’Onofrio, DO, San Diego, Calif. and Marino:

• COVID-19-positive pregnant patients: increased risk of premature labor, symptoms may appear post-partum; less than 1% infants born to COVID-19-positive moms tested positive; Chinese study shows 0.6% of pediatric patients have severe symptoms

Pepe:

• Moment of silence to honor the lives of Chief Don DePetrillo of Seminole Tribe in Davie, Fla. and Lorna Breen, MD, of New York Presbyterian-Columbia Hospital

Krohmer: 

• Concerned about rural areas and disparities in care, educational messaging needs to go out to non-English speakers, form interstate and intrastate compacts to assist others

Fionna Moore, MD, United Kingdom: 

• Cancer screening, vaccinations on hold, 12–18 months to get back on track. What are the downstream effects of this?

Racht: 

• Using physicians on telehealth to encourage people to come to hospital when they are sick

Crawford Mechem, MD, Philadelphia, Penn.: 

• 250-bed surge facility closed at Temple University due to lack of patients
• Crime may be up, baseline opioid issue not decreasing

Kumar: 

• Georgia reopening but many businesses are choosing not to
• Higher EMS volume over past weekend, more penetrating trauma, more people willing to go to the hospital now that reopening might mean it’s “safe”

Augustine: 

• Effects on EMS education and ride-alongs means no patient contacts, will have downstream effects
• Building up vaccination programs, should allow EMS to administer vaccines to public 

Successes/Best Practices:  

Marcus Ong, MD, Singapore: 

• Less than 1% fatality rate in Singapore, no healthcare providers have been infected, perhaps due to early ramping up of PPE supplies

Bailey:

• April 24: disease elimination in Australia is a possibility, fewer than 100 known cases 

Massimo Antonelli, MD, Rome, Italy:

• Consider noninvasive airway maneuvers like CPAP helmets (not yet popular in the U.S.), helps increase hospital capacity
• Hypercoagulability in COVID-19 patients, best seen in TEG testing, randomized trial underway in Italy of heparin treatments

Fumagalli:

• Number of patients admitted to ICU is decreasing, Italy may “reopen” May 4 

Holman: 

• Remdesivir trial results show that early intervention, maybe prophylactically, is better: “This is a proof of concept and a game-changer.”

Brent Myers, MD, ESO: 

• 1,800 agencies shared data regarding COVID-19 patients, shows EMS has good success identifying patients who are likely infected

Scheppke: 

• Proning patients in EMS is quite simple, there may be a concern for safety during transport, unconventional position could risk other interventions, but lateral works, easily reversible and increases O₂ saturation in minutes

Keith Lurie, MD, St. Cloud, Minn.: 

• Re: proning: Need sufficient mean arterial pressure, avoid CPR in this position

David Miramontes, MD, San Antonio, Tex.: 

• Cardiac arrests in San Antonio down from 2019, DOAs same as 2019

Looking forward:

• Multiple testing of patients reveals positive then negative antibodies, still don’t know if these patients are immune to future infection
• 25% of patients testing positive are reporting loss of taste and smell
• FEMA inspecting all PPE entering U.S., reports of counterfeit N95s
• EMS in Florida asked not to enter nursing homes if possible but to perform patient handoff outside of facility
• One remdesivir trial showed no benefit, ended early, was only posted briefly before being taken down from WHO site; second trial shows “remdesivir can interrupt the disease process.  Creating a pill version is an area of opportunity,” says Jui. 
• Conduct rapid testing of family members on scene so the patient might be more willing to go to ED?
• Be aware of providers feeling guilty that they may feel their hands are tied, this isn’t what they are used to.  

Hilary Gates, MAEd, NRP, is the senior editorial and program director for EMS World.