4.1.20

540 is back in the county and should be in service shortly.

Doffing guides are now taped to the stairwell doors of the ambulances. Please use them when doffing.

We are getting closer to a process to sterilize N95 masks. I think it should be out within the next 5 days.

We are going to skip doing monthly inventories this month (except for 540) so we do not have to rip down the plastic wrap.

Brian

3.31.2020

Hello, 
Not much new to report today. Things remain oddly quiet on the EMS front.

Doffing. There is a new doffing checklist that will be laminated and placed in the ambulances tomorrow. Partners should coach each other on the doffing of PPE after a call with a positive or suspected COVID patient. Numerous studies show that providers often make mistakes when doffing and it may be a source of infection.
https://www.ncbi.nlm.nih.gov/pubmed/30890193
The doffing sheet is attached. Let me know if there is a way to make it easier.

Spray Nine. We are trying out a new cleaning agent. Spray Nine is approved for Corona Virus use and has a 30 second sit time as opposed to sani-quat which is ten minutes. Spray Nine is also a cleaner, where Sani-Quat is just a disinfectant. There will be small spray bottles and a gallon jug at each end of the county starting tomorrow. Let us know what you think of it. https://www.spraynine.com/

Brian

3.30.20 blast.

Daily blast:
Not much new to report today.

15 positive cases in the county today, holding at 1 death.

Masks on ALL patients from now on. I think it is time to start putting masks on all patients. The article below certainly made me rethink who is a risk and isn’t. It is not known when someone does become able to transmit the SARS-CoV2 disease, but it certainly seems possible to have the virus for some time before becoming symptomatic. While this is a small study and observational in nature, I will be treating all patients as potentially infected for the time being and putting a procedure mask on them. I may explain it as “this is to keep you safe from all the healthcare providers who might have SARS-Cov2 and not know it yet.”

Is this overly cautious? I do not know, but I am willing to be wrong and waste a $1.10 as cheap insurance. Last week I had quite a scare when someone that we brought in as “just drunk” was discharged and brought back in 12 hours later with SPo2 in the 70%’s and complaining of coughing. While it was very unlikely to be SARS-Cov2, you don’t want to find out the patient you transported the day before without a mask just developed a fever and cough.

“When paranoid, you can be wrong 1000 times and you will survive. If non-paranoid, wrong once and you, your genes and the rest of your group are done.”– Nassim Nicholas Taleb, author The Black Swan.

My goal is to be overly safe here and to be able to say that no one got SARS-CoV2 from work after things calm down a bit. The ER may question you and I would encourage you to direct any questions to me. You can just say it is policy. Plus we want to keep our patients safe and many places are just assuming healthcare workers have it.

Hopefully, this chart will simplify things a bit for CCEMS. I made it at 20:30 after a long day so if something is not clear, let me know.

covid risk chart

The article that prompted this. https://www.medpagetoday.com/infectiousdisease/covid19/85657?xid=nl_popmed_2020-0330&eun=g759438d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CoronaBreak_033020&utm_term=NL_Daily_Breaking_News_Active

 

A potential treatment. Convalescent plasma is showing some promise in at least one small study and has FDA approval.
https://www.medscape.com/viewarticle/927716

Accident alert – Colorado state patrol has been on accident alert since 3/26. If there are no injuries and no suspected intoxication, they are not coming, and parties should just fill out a report on-line. https://www.colorado.gov/pacific/dmv/report-accident

3.29.2020

Blast for Sunday

MDI’s on the bus
UV light cleaners
Quat for cleaning
Interesting articles

Albuterol – MDI: There seems to be a significant concern in some circles about generating aerosols in SARS-CoV2 patients at this time it is hard to know what is something to be hypervigilant about and what will turn out to have been overly cautious—only when viewed in retrospect will we know for sure, but erring on the side of caution seems like a good choice. We have added albuterol MDI (metered dose inhalers) to the yellow bag. These are multi-dose but should NEVER be re-used on another patient, offer to leave it with the patient at the ER if you use it, otherwise put it in the trash.

This is 90mcg per puff. Dr. Gross stated that with the MDI 8-10 puffs is usually equivalent in terms of effects of a neb treatment. I think that sounds like a reasonable plan. As far as a protocol goes, give a few puffs and re-asses, go up to 10 puffs and see if there is an improvement, if there is not improvement work on plan B or C. IM epi could be used in an extremely unstable patient with COPD/Asthma and suspected SARS-CoV2 with severe bronchospasm.

I think trying to avoid giving a patient anything like an inhaler might be a good idea, but if they need it, they need it, and this is safer for us than a neb. It is not unreasonable to think there could be patients with both SARS-CoV2 and COPD or asthma that will be encountered. The neb is in the med kit in the yellow bag and we hope to have restock available in the gray cabinet soon.

If you administer albuterol via MDI, wear an N95, gown, gloves, and goggles. If at all possible, have the patient self-administer it.

UV cleaner boxes: There is a Lumin UV-C cleaner box at the Salida station and there will be one for BV on Tuesday. These are pretty cool, but they are a little more fragile than I expected. While they are not proven (yet) to kill SARS-CoV2, it seems like a pretty reasonable bet they do as UV-C light kills almost any virus (https://www.researchgate.net/publication/8362562_Inactivation_of_the_coronavirus_that_induces_severe_acute_respiratory_syndrome_SARS-CoV and full paper here https://medtradex.com/assets/Uploads/Literature-UVD-Corona.pdf). Please note this is the SARS-CoV1 virus and not the CoV2, but we may be able to extrapolate.

 Anything that fits in there should be okay to sanitize. Radios fit if you take the antennae off.

To use it:
1. Open the door
2. Put stuff in there
3. Close the door
4. Hit the on button

5 minutes later it will beep and turn off and your stuff is done. If you want to sanitize both sides of the object you need to use the little stand in there that keeps things off the bottom so light can reflect upwards. Some things do have a slight odor after and the manufacturer recommends taking the drawer out and cleaning it with dawn and letting it dry overnight to get rid of the odor. It also seems to dissipate within a few minutes, at least it did from the N95 I tried.

I have put three phones in there and had no issues. Pens, keys, stethoscopes, laryngoscopes, anything you can think of should be okay. We are not going to be responsible if your personal property gets harmed in there, but I will be putting all my stuff in there and per the manufacturer:

One year of daily use amounts to 30 hours of actual exposure time. In accelerated aging tests, 3B has validated no damage to plastics or silicone in over 150 hours of testing, roughly equivalent to 5 years of daily use.

You can read more about them here: https://www.3blumin.com/lumin/

Cleaning the bay and exercise equipment. Please use quat to clean in either a spray bottle or in a mop bucket (2 oz per gallon) and remember to let sit for 10 minutes.

Interesting articles/podcasts:

I haven’t gotten through this all yet, but it is pretty interesting. We may consider a Doffing checklist in the near future. And the aerosols certainly seemed to travel a bit. This is one of the videos from it: https://www.youtube.com/watch?v=w3fu5kd1iYM and the full podcast can be found at: https://www.foamfrat.com/index.php/foamfratpodcast/14-foamfrat-podcast/594-podcast-95-covid19-simulation-w-troy-reihsen-7sigma

New Yorker had an interesting article by Atul Gawande: https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers

In other news FDA approval for N95 sterilization is starting to emerge and I suspect will be in many states soon: https://www.battelle.org/inb/battelle-critical-care-decontamination-system-for-covid19

This is a good article about how long after exposure people become sick.

We estimated the median incubation period of COVID-19 to be 5.1 days (CI, 4.5 to 5.8 days) (Figure 2). We estimated that fewer than 2.5% of infected persons will show symptoms within 2.2 days (CI, 1.8 to 2.9 days) of exposure, and symptom onset will occur within 11.5 days (CI, 8.2 to 15.6 days) for 97.5% of infected persons.

Keep in mind your mileage may vary and viral load probably plays a role here – the average person would not be exposed to a patient spewing viral material on a ventilator. But if you make it to day 14 after an exposure without symptoms you are 97.5% in the clear. https://annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported

The last article that is interesting (to me) is this: http://www.overcomingbias.com/2020/03/know-when-to-fold-em.html It talks about how the viral load one receives may dictate the outcome and the controversial ideas that sheltering in place can have untoward effects and why we see so many fatalities in some areas but not others.

Brian

3.28.2020

Daily temps
Boots off
Tape wars continued (Gorilla clear for the win)
7 gallon jug
Tape the pass-through/breeze way – nothing behind chair
Saving N95’s masks

Temps. Check your temps at hour 0-24-48 and once everyone has done this, text or email it to Derik.

Boots. Take your boots off before you go to restock on the south end. Please do not track cooties into the station.

Tape wars finals. We have a winner with Gorilla Clear tape. It is sticky 30 minutes after being doused and cheap for a big roll at Walmart. It will be rolled out tomorrow (Derik can you get some? There is a roll at the station).

Building on this taping issue—ensure nothing is behind the captain’s chair in the back of the ambulance as it rips the tape. This obviously defeats the purpose and could expose the driver to potentially infectious situations if aerosols are generated.

Big jug. There is now a 7 gallon jug of premixed quat at the station for your filling convenience—with a funnel. BV jug is coming tomorrow.

Saving N95 masks. We still have an ample supply of N95 masks, but I do not want the N95’s to become like my retirement account where I say, “I wish I had started saving a long time ago.” We are not re-using them now. It seems very likely in the next few weeks there will be one to three ways to sterilize N95’s and re-use them approved by the FDA. Again, we are still extremely well off in the PPE department, this is just to ensure that if things changed and the supply chain does not start back up again, or the pandemic has a longer timeline than we thought, we have options at a later date.

Before using the masks – maybe when you do your start of shift checklist, write your name and the date on the bag (it’s fine if you used it on day 2, it’s close enough). After using the respirator, place it in the paper bag and put it in the covered bin. While initially this sounds like a COVID-bomb waiting to explode, the ER is just throwing them in bags and putting them in their lockers and such and major metropolitan hospitals are just dumping them in bins. I’ll be blunt on this, it sounds like a royal pain in the ass to do this after a call, but if we want to ensure that we are still rocking N95’s while others are wearing air conditioning filters in a scuba mask or something the church sewing club made up this might be what it takes. Obviously soiled N95 masks should be disposed of. Remember this is a virus and spread by droplets or from a high flow spray like a neb, it is not radiation and is not going to off-gas. As long as you don’t lick the masks in the box, they don’t pose a risk to you.

Goodnight.
Brian

TGIFBLAST 3.27.2020

Blast for Fri 2.27.2020 (TGIF Edition)
tl;dr:
New AHA guidelines came out recently.
Beware of Complacency – delayed consequences
Thanks to Bob V.
PPE in the hospital
Pocket N95
Brian off the car (sort of) for the next 30 days

AHA COVID 19 Guidelines. I am not sure if anyone has heard about this but the AHA dropped some new guidelines about COVID 19 recently. I am not sure when this happened. I have only glanced through them. I’ll try to do a deeper dive tonight. Please read them. If you find something in there that we are not doing, and you think we should be doing please reply all to this email. I will miss some things for sure. Or if you see things we shouldn’t be doing—throw them out too. Finally, someone defined what “eye protection” in the setting of creating aerosol is – goggles or face shield, NOT glasses. I think unless you are in a PAPR or fully enclosed face shield respirator, an open-ended face shield is not going to do much for aerosols.

AHA COVID Guidelines for EMS and Resuscitation

The AHA medical compendium page for COVID is here: https://professional.heart.org/professional/General/UCM_505868_COVID-19-Professional-Resources.jsp?fbclid=IwAR109W4DT1T4vBbDv5vHM3UaG9bND9cg6ip52djqBBW_I9sZwo-SMRPUi2Y

There are some other things on the AHA site that are worth a look. https://cpr.heart.org/en/about-us/coronavirus-covid-19-resources

For example – what about pets?
https://www.heart.org/en/healthy-living/healthy-bond-for-life-pets/can-my-pet-spread-the-covid-19-virus

Complacency. Beware of complacency out there. I have not seen it in our agency, but I have seen it elsewhere in healthcare this week and there is a very real possibility there are consequences from this. When the feedback from slips, lapses and drift is delayed by 5 days give or take (median time from exposure to symptoms) it is easy to not see cause and effect and let the confirmation bias slip in. Don’t.

Be diligent in your PPE, hand washing, and cleaning and putting masks on patients when you can. Don’t touch your face, restock hand sanitizer. We are doing well with it so far and are getting through this. This is a marathon, not a sprint. Just because no is getting sick, don’t be fooled, keep up what you are doing.

A huge thanks goes out to Bob V. for his work in exploring alternative mask sources. He got a fantastic looking prototype made by Oveja Negra and it is an amazing alternate plan if some things fall through. If you are looking for bike packs or packs in general, consider spending your money there as they really went above and beyond and are a local business.

Wear PPE in the hospital. Effective immediately you must wear a procedure (surgical) mask, gloves, and protective eyewear that wrap around your head—your corrective lens (aka normal glasses) are not enough. If you absolutely need prescription safety eyewear (and we are talking NEED, not want) let me know ASAP and we will see what we can do. Feel free to ask me more, but in a nutshell there are aerosol generating procedures occurring in the hospital in rooms that are not negative pressure with suspected/positive patients. I was going to put something about disciplinary action here, but if the threat of getting SARS-CoV2 isn’t enough, or the thought of infecting others isn’t enough to make you put it on, I’m not sure I can make you do it. This should also be practiced in any hospital you go to. Do not go into a room where aerosols are being generated without goggles and an N95 or better protection. I think you are safe in the hallways with a procedure mask and glasses.

Bail out Pocket Mask.

On the south end please talk to the shift supervisor – I believe there is a bag of these in BV—and get one of these masks and put in your pocket. This way if you inadvertently walk into a situation where you wish you had an N95, you will have an N95.

You do not need to fit test these.

 

 

 

Put procedure masks on every patient. With the unknowns out there about when a person can spread the virus—do they need to be symptomatic or is there a period before that when they can infect others? Consider putting a mask on almost every patient at this point and wear a procedure mask and glasses around every patient. Who is to say that you are not going to infect them as well? It is better for patients and better for us. While this may be overly paranoid, it is cheap insurance.

If there are any symptoms or doubts, escalate to an N95 mask without hesitation.

Consider the following – The CDC recommends:

Facemasks are an acceptable alternative until the supply chain is restored. Respirators should be prioritized for procedures that are likely to generate respiratory aerosols, which would pose the highest exposure risk to HCP. Eye protection, gown, and gloves continue to be recommended.

When the supply chain is restored, fit-tested EMS clinicians should return to use of respirators for patients with known or suspected COVID-19.

I read this as the CDC saying if we had enough N95’s that is what we should wear around known positive or suspected positive patients. I know many people are wearing surgical masks around this and while I think it certainly offers some protection, in the symptomatic patient, an N95 is likely to be better.

In the next few days, we will start the discussion about how to best prolong our supply of N95 masks. We have an adequate supply, but we should consider conservation strategies early, just in case the supply chain is not restored any time soon. I do not want to look back on this time and have regrets about our use.
Brian is coming off the car for the next month (sort of). I am going to work 12 hour shifts on my normal shifts. I simply am not able to keep the pace I am currently doing and run calls or transfers. In the past week I worked about, well too many hours, (sorry budgetary line item) and I can’t maintain that pace. I can do what I am doing or run calls/transfers but not both.
I will be putting out fires as they arise, dealing with clinical issues and protocols, exposures, follow-ups, some outreach, helping crews as needed and I can and trying to do whatever is needed for you guys. This is only for the next month, there are no long term plans for anything else. I can also help on transfers needing a third person when I am there and perhaps at other times. Of course if our staffing level needs dictates a different plan this can all be changed. I’ll also be in and out a fair bit and working evenings. My wife’s schedule has some flexibility, so if you need something call or ask.

As the cool guys say,

stay frosty.

Brian

Blast for 3.26.2020 (late night edition)

Daily Blast for 3.26.2020 (running a bit late)

  • We have stopped using bleach for disinfecting ambulances as of today. Sani-Quat recently got approval from the EPA to be used on the novel corona virus (SARS-CoV2). Instructions for how to mix it are on the big bottles of concentrate and are now on the sidebar of this web page as well as on the gallon jugs of concentrate.
  • We are making it in both the gallon sprayers and in the quart spray bottles. Please follow the directions on how to mix it. Do not just eyeball it. In every ambulance there is (or will be by tomorrow) a gallon or two sprayer for large scale decon, a small spray bottle and stuff to make more. In each ambulance there is a baggie with 15ml of Quat in syringes for mixing the 32 oz spray bottles and there is a 2oz bottle of concentrate to add to one gallon of water in a sprayer. There is Quat concentrate at both ends of the station. The bottles should live in the oxygen tank cabinet, so we all know where they are.

    Remember to let Sani Quat sit on potentially infected surfaces for at least ten minutes to kill everything.
  • I wasted several hours this morning doing bleach-math and mixing up solutions for bleach resulting in a bleach protocol before I got the word about Sani Quat. I have put this bleach protocol on the website sidebar just in case there is ever a future need. A lesson learned today is that not all bleach is created equally and it important to really check which bleach has what concentration; ‘splashless’ bleach is practically worthless for disinfection.
  • Taping up the cabinets is a great idea, unfortunately, the tape is not holding up. Tomorrow we will be testing some more tapes against cleaning solutions. We have one tape that absolutely will not come off unless you want it to, but it is pricey, so we will try one more tomorrow and then decide which tape to use.
  • Goggles are in. I have distributed goggles to all the full-time personnel. They are at your respective stations. PRN employees should ask their supervisor as soon as they come on shift for a pair. I have some glasses that should fit over prescription eyewear coming in the next day or two. These goggles are yours to keep. I am working on a plan to sanitize them and will have more on that very soon.
  • Some of you may have heard that two employees were on isolation for a night at a hotel. I am relieved to say that they were released today as the patient’s test returned negative.
  • There was a death in Columbine manor recently of a suspected SARS-CoV2 patient. There results came back negative.
  • Remember to spray door handles on the outside of the ambulance after transporting SARS-CoV2 patients.
  • Shift checklist. A shift checklist has been implemented to ensure we have equipment that is vital to our safety while dealing with SARS-CoV2. Please have both partners do a two-person double check off and both sign off on this at the beginning of your shift. Turn it into the box each shift. There will be disciplinary action for not doing this – not because I want to punish people but because we absolutely must do this to be safe and not doing it puts all of us at risk. This needs to be done first thing in the morning on your first shift. The shift checklist is now at both ends of the county in all ambulances and available on the webpage sidebar.
  • PPE remains good, no shortages or changes for now.
  • Currently no employees are on isolation or awaiting test results on themselves or source patients.

If you haven’t seen the new web page, go to https://chaffeecountyems.com/sars-cov2-employee-information/ the password is ccems.

3.25.2020

Bullet Points:

  • All ambulance cabinets are covered in plastic.
  • Goggles for everyone should be here tomorrow or Friday at the latest.
  • Columbine Manor now has two positive patients.
  • New policy for low-risk dispatches.
  • Emails will be switching to a once a day news blast and will be archived here.
  • New policy on PPE for drivers.

 

New procedure for low-risk dispatches. To decrease the use of PPE on medical calls YOU deem low risk off of dispatch, such as a nosebleed, it is acceptable to send in one person wearing eye protection, gloves and a procedure mask and get a quick size up of the patient from six feet away. If things look at all suspicious for SARS-CoV2 infection, back out, put on a gown and N95 and goggles or eye protection as needed. Put a procedure mask on the patient as soon as you can.

Goggles – I will have goggles for everyone here tomorrow or the next day at the latest, with the exception of the people wanting goggles that can go over glasses – those will be here in a few days. If you need goggles talk to a supervisor when you come on shift.

Zoom meetings – we are talking about having on-line meetings using zoom. We could do this as a scheduled thing or on an as needed basis. The way it works is that you get an email invite and click on the link and can do video or just voice and join in.

Ambulances cabinets are taped up with plastic. Please try and run out of the yellow bag. If you need something out of the cabinet – cut the tape/plastic and get it and re-tape and put up new plastic. This keeps the supplies cleaner and makes cleaning easier. Thanks to Josh Copelan for pushing this out.

Please tape and seal off all compartments in the ambulances! things to leave out are listed below and can be cleaned/ sprayed with bleach after each call.

-3 IV start kits
-2 18 Gauge and 2 20 Gauge IV catheters
-Extra electrodes placed in monitor
-Thermometer
-Place Narcotics in the RSI fridge
-Make sure there is a stethoscope out for use

Work out of the yellow bag as much as possible.

Columbine manor now has two patients that are positive for SARS-CoV2.

Fatality from SARS-Cov2. The patient that was positive for SARS-CoV2 that Mara, Josh Copelan and I took on a ventilator to Memorial passed away at some point in the past 24 hours.

PPE for driving to the hospital. Consider doing the following: it is a suggestion and you can deviate as needed. After the patient is loaded in the back of the ambulance have the driver doff their PPE before getting in the front of the ambulance. If the patient seems like they are low risk and are not producing aerosols wear a surgical/procedure mask. If there are aerosol generating procedures occurring in the back the driver should wear all their PPE (N95, goggles, etc).

Always err on the side of more PPE than less PPE.

Viral Filters. Be paranoid about the viral filters for airways. Check and re-check that you have them in the ambulance.

Email blast. Josh, Derik, Jason and I are going to try to switch to a once a day email blast in the early evening to prevent information overload. Ideally there will be one email from one of us with relevant information from each of us.

lastly, to prevent having to search through a multitude of emails we have created a web page that will archive these daily email blasts and other relevant info. Check it out at https://chaffeecountyems.com/sars-cov2-employee-information/ the password is ccems (all lower case).

Stay safe out there.