From Zombies to lethal viruses, Hollywood loves making doomsday films about something deadly spreading around the world at an alarming rate that kills everyone. Wolfgang Petersen’s 1995 movie “Outbreak” brought pandemic’s to the big screen; alerting the masses as to just how fast an invisible threat can spread across our tiny planet. One of my favorite dialogues from the movie summarizes how we should think when it comes to pandemic planning:
I hate this bug.
Colonel Sam Daniels:
Oh, come on, Casey. You have to admire its simplicity. It’s one billionth our size and it’s beating us.
So, what do you want to do, take it to dinner?
Colonel Sam Daniels:
Colonel Sam Daniels:
(Quotes: retrieved February 8, 2016, from http://www.quotes.net/movies/8532)
I need to be clear, I do not expect paramedics to ever be in a position to eradicate a pandemic bug, but we all have a role to play and a responsibility to our communities to stop the spread as much as possible. As with everything we do in public safety, planning and preparation are keys to our success when a tactical deployment is required. Paramedic Services and Emergency Medical Services (EMS) will often see patients presenting with the signs and symptoms in the field; at times before an official declaration had been conducted.
The key to the effectiveness of any response is going to be comprehensive planning. The assumptions that must be considered prior to an outbreak include:
- The ability of the virus to spread rapidly
- The fact that people may be asymptomatic while infectious
- Simultaneous or near simultaneous outbreaks in communities across the country, limiting the ability of any jurisdiction to provide support and assistance to other areas
- Enormous demands on the health care system
- Delays and shortages in the availability of vaccines and antiviral drugs
- A sudden decrease in the accessibility of equipment and enhanced PPE items
- Potential disruption of national and community infrastructures
- Rates of severe illness, hospitalizations, and deaths will depend on the disease
- Rates of absenteeism will depend on the severity of the pandemic
- Certain public safety health measures are likely to increase rates of absenteeism
- A pandemic will come in waves (6-8 weeks)
While it may seem to some people that organizations have too many plans; when we are faced with unpredictable scenarios we must have pre-plans in place for several tactical options. Pandemic planning is no different. The main goal of a preparedness program is the improvement of public safety.
Putting together a working group to develop a plan before the event strikes will greatly decrease any break downs in service delivery. Paramedics are not immune to the ailments of the world and they are often the front-line of healthcare when the populous becomes unwell. Appoint a pandemic coordinator and consider appointing a workforce coordinator who would be responsible for addressing pandemic issues and the impact on the workforce.
The planning must identify potential risks to response delays to calls for service, staffing levels, fleet services, and even supply chains. A service should complete a full HRVA on a regular basis however it is a good idea to do an assessment specific to the effects a pandemic might have. The use of vulnerability assessments and identification of shortfalls allow communities to better prepare for worst case scenarios.
N.B. Steps should be taken to ensure that EMS plans are consistent with federal, provincial, and local, health and emergency plans.
Principles of EMS Pandemic Planning
- Medical Direction – Federal and Local Public Health
- Co-ordination with local Health Authorities
- Co-ordination with receiving facilities
- Plan for succession and delegation of authority for key leadership decision making / authority positions within the organization
- Quality Improvement
- Education and Training
- Communication with partner responders
- Procurement of extra supplies
- Preparing for the pandemic surge
- Protecting the EMS workforce via enhanced PPE
- Operational considerations
- Modified Dispatching protocols
Education and PPE
One of the biggest challenges that responders face is the unknown. Every day paramedics go into uncontrolled environments with little to no factual information. They rely on the information provided to them through their dispatch center, their quick threat assessment of their surroundings, and once they make patient contact paramedic’s turn their attention to a patient’s history (past and present). Often, this close proximity and contact with the patient is the first opportunity for the paramedics to establish what concerns to health exist; both for the patient and now for the paramedics.
The more up to date and current the information is that can be shared as an epidemic or a pandemic develop the better educated paramedics are as they respond in the field. Once threats are identified addition continued medical education can assist paramedics in having the required knowledge of what exists as a threat to public health. This allows them to quickly identify certain signs and symptoms with patients and also decrease their angst of the unknown.
Part of the education component must be the training around the required enhanced personal protective equipment (PPE). Staff need to be comfortable that the PPE will in fact protect them as well as being made aware of when to don and doff the PPE appropriately. Education must consist of the physical donning and doffing of the PPE as well as the buddy system checks (a printed check list with all PPE kits ensures nothing is missed in the process) done in real time.
Post exposure training must include what staff are to do after they are done a potential infectious call for service e.g. deconning of themselves, equipment, and vehicles. Also, staff should review any possible paperwork that a specific agency requires for exposure tracking purposes.
A pre-pandemic training and exercise program will help EMS agencies ensure that all paramedics have baseline training to support and understand their role in responding to pandemic.
All Staff – Frontline as well as support services must understand:
- Implications of a pandemic
- Control measures including the use of enhanced PPE
- Current organization plans
- Current community plans
There will be an increase in the number of calls for service over and above the regular day to day EMS calls within a community. The increased volume of calls for service will be due to those presenting with actual signs and symptoms as well as those worried well. An additional strain to EMS services will be caused by Hospital overloading resulting in off load delays of paramedic crews, hospital diversions with increased transport times, and staff absenteeism.
Paramedics are not immune to illness’ that affect our communities. Managing a staff shortage because of illness in personnel or their family members will be required. To assist in the management of a staff shortage agencies should calculate the minimum number and categories of personnel necessary to sustain EMS services and day to day operations. Contingency staffing plans need to be developed in collaboration with other local EMS providers
Responding to a pandemic must begin at the initial point of contact for an agency. Proper call triaging during a pandemic is paramount for not only the safety of responders but also to ensure the best possible response to categorised calls for service. While calls will still be required to be prioritized is an enhanced requirement to ensure that all possible precautions are met and that responders have the best intelligence prior to arrival on scene.
Public Safety Access Points (PSAP), 911 and EMS Communications Centers will need to coordinate with the local medical directors in order to develop an augmented call taking process to screen in-coming calls. A full review of the temporary protocols must be conducted for all of the Call Takers and Dispatchers. The new protocols should be shared with all of the agency’s employees to ensure that they are aware that proactive steps have been set in place to best screen the calls that they will be attending to.
Preparing a pandemic response plan should include several critical points for paramedic services:
- Paramedic services must ensure that they have a pre-written pandemic response plan
- 9-1-1/paramedic service call centers is set up with triage process to distinguish callers with the current pandemic from those with other ailments
- Paramedic crews must be able to differentiate symptoms to confirm the presentation of a possible pandemic patient versus other ailments or even the worried well
- All paramedics must be fit tested and trained in the proper level of enhanced PPE
- Enhanced PPE kits must be readily available to all staff and in various sizes
- Processes should be in place for the proper deconning of the paramedics as well as the ambulances and equipment used
- Ensure that scheduling plans are developed for large amounts of absenteeism
- Established a liberal sick-leave policy and encouraged use of that sick leave for EMS responders exhibiting symptoms of, or documented illness with, the current pandemic
Planning and logistical strategies in order to operate during a pandemic outbreak is imperative for all paramedic services. Paramedic service leaders will need to plan and make adjustments in their normal operations to maintain service and provide care to the community in its time of greatest need. Failing our communities because of poor planning is inexcusable. It is incumbent for paramedic services to maintain their ability to function, even at a reduced level and with significant alterations, during a pandemic event. Pandemic plans, as with all that we do, must be a tested plan that is practiced and updated on a regular basis.