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 COVID-19 (and other potential pandemic) guidance 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 physician medical director(s). See the ACEP Policy Statement “The Role of the Physician Medical Director in Emergency Medical Services Leadership.”

Before the highest clinical standards can be applied to treating potentially infectious diseases, primary decisions must be made to attain and maintain the best possible personal protective equipment (PPE) programs for EMS organizations. PPE programs include initial and ongoing training on and confirmation of the appropriate use of PPE. As part of training, EMS staff should be instructed on donning and doffing procedures and how to avoid inadvertent self-contamination during on-scene care and stabilization, en route care, and handoff to emergency physicians and other members of the health care team.

Given periodic shortages of PPE that notably occurred throughout health care systems during the COVID-19 pandemic — including EMS organizations — the available PPE items, their brands, and types can change. This reality should be factored into both the initial and ongoing training for any EMS personnel.

Many EMS organizations have already produced short, effective, in-house training videos on correct PPE practices. The CDC has also produced illustrated instructions that can be shared, used as part of training, and affixed in emergency apparatuses as a visual reminder for EMS personnel.

Although it is not their direct responsibility, as clinical leaders of jurisdictional EMS organizations, EMS physician medical directors should work collaboratively with administrative leadership and, if applicable, in-house supply chain managers to understand present implications of available PPE and to understand when changes are required.

PPE manufacturer instructions should be followed for the best protection. For instance, N95 (or higher) respirators must be properly fit tested to individual personnel. Facial hair changes and other considerations may need to be mandated to achieve the necessary fit performance.

Since its emergence in late 2019, SARS-CoV-2 is widely recognized to transmit through both droplets and aerosol particles. Early in the COVID-19 pandemic, a commonly used mnemonic for the EMS PPE needed for suspected or confirmed COVID-19 patient encounters was MEGG: mask, eye shield, gown, gloves. Although use of gowns for these encounters has decreased over time, both in and out of hospitals, other PPE components are still warranted to better protect EMS personnel.

Vaccinations against prevalent types of SARS-CoV-2 have become widely available. Few EMS organizations have mandated employees receive these vaccinations, and vaccine acceptance varies among EMS personnel, like with the general population. However, EMS personnel who are optimally vaccinated against COVID-19, as defined by the CDC, have additional protection to that provided by PPE alone.

One strategy used to conserve PPE during the pandemic and limit the number of EMS personnel exposed to the virus during patient encounters was the scout plan. The scout plan involved sending one PPE-attired EMT or paramedic (ie, a scout) — depending on apparatus staffing and any prearrival medical dispatch information gleaned — to make patient contact. Often, contact was first established at a distance of 6 feet from the awake, interactive patient. This distance was often cited as a relatively safe way to minimize exposure to respiratory droplets and aerosol particles. Once the patient’s initial condition was confirmed, the scout EMT or paramedic summoned the number of additional personnel deemed necessary, using either a visual or verbal signal at a distance.

As with personnel quantity, consideration should be given to the medical equipment brought to the patient’s side. If the initial assessment reveals a stable patient, leaving as much equipment as possible outside the residence or patient’s location can reduce the equipment’s exposure to respiratory droplets. Contact isolation is now considered less essential for COVID-19 than originally thought but continues to be needed for other infectious diseases.

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. Thoughtful distillation of rigorous, research-based evidence should be implemented with any purchase or use of PPE and with any use of decontamination strategies.