As America passes into the season of flu, colds and winter illnesses, some EMS providers are still utilizing protocols that have the dispatch center and the first arriving providers ask questions about the potential the patient could have Ebola virus disease. Others are asking about measles, and Middle East respiratory syndrome (MERS). But, aren’t we past those dangers, and isn’t it time to stop screening for these diseases?
Although enhanced entry screening was discontinued for travelers coming to the United States from Liberia on Sept. 21,1 enhanced screening is ongoing for those returning from Sierra Leone or Guinea. These travelers are being tracked by local public health authorities, and are told to advise emergency providers in the field or in the hospital if they’re having key symptoms or an elevated body temperature.
The Centers for Disease Control and Prevention (CDC) and many local public health authorities request that Ebola screenings continue to be done in the emergency system—at least until the threat in the involved countries is down to zero. A single Ebola infection in the United States would be another difficult and expensive event, and prevention is much less costly.
The use of screening language in 9-1-1 centers and by EMS providers was a recent topic for the EMS medical directors who make up the U.S. Metropolitan Municipalities EMS Medical Directors Consortium—the well-known “Eagles” coalition—and the group compared notes and discussed measures to help stem the spread of several timely diseases that are low frequency but very high priority.
Regarding Ebola, 25 cities represented by the Eagles continue to screen for Ebola. Ten cities reported that screening had stopped, although some were screening for measles or MERS, based on local risk circumstances. There were three characteristics of cities that continued the Ebola screening: those that were affected by the Ebola outbreak in 2014; those with busy international airports; and those located in the eastern areas of the U.S.
Some medical directors are taking a conservative approach. “I’m asking our dispatch agencies to continue screening for patients with appropriate symptoms,” one medical director said, “not just for Ebola, but the newer global threats as well.”
Others have modified screening, especially those where travel to the affected regions is rare. “In our city we are continuing to ask travel questions. But they’re generic and we’re more focused on MERS at this time.”
In another U.S. city, there’s hardly any screening at all—only when the patient’s address is in the dispatch system as a person being monitored due to recent travel to an at risk area.
And still others have removed the Ebola screening process entirely: “We stopped screening. Each time [screening] occurs, it starts an enormous cascade of events for EMS/fire/police and the hospital. The one true symptomatic traveler was handled outside of 9-1-1 response and transport, all through public health coordination.”
SCREENING IS STILL GOOD PRACTICE
In a recent article published in Disaster Medicine and Public Health Preparedness, Kristi Koenig proposed a consistent approach to all persons who are a potential threat for infectious diseases or other hazards, based on “vital sign zero.”2 This concept encourages EMS providers or the 9-1-1 call-taker to ask a few quick, critical questions about key symptoms or exposures before attempting to obtain standard vital signs. Answers to vital sign zero questions would identify a risk for spreading disease or a contaminant to the EMS crew or others.
Sometimes a patient will offer critical information before being asked:
>> “I just returned from work in a developing country, and I’m short of breath and coughing up blood. I called my public health provider, who advised me to call 9-1-1, but to ask that you protect yourselves from tuberculosis.”
>> “I was at Disneyland, and now have a rash and fever, and the Internet says I’m at risk for having measles.”
Typically, however, patients won’t be so helpful, and EMS providers must continue to take the lead in calls that may involve an infectious disease. Screening a patient suspected of carrying infectious disease should ideally occur at an appropriate distance—usually six feet—away from the patient. The provider asks about symptoms and recent travel, and where the answers indicate a risk of infectious disease, appropriate precautions should be taken to protect the patient, the EMS crew and bystanders. Precautions might include applying a mask to the patient, donning appropriate personal protective equipment, and utilizing the protocol developed for these vital sign zero patients. With precautions in place, the crew can proceed to obtain a full medical history, obtain vital signs, perform patient assessment and examination, and begin treatment.
In the case of Ebola, the CDC continues to advise that emergency providers take note of persons who describe “Residence in, or travel to, a country or area with widespread Ebola virus transmission or uncertain control measures or having had contact with an individual with confirmed Ebola virus disease within the previous 21 days.” The current two countries are Sierra Leone and Guinea. A positive answer to these questions would dramatically increase the potential risk of the patient.
The second set of questions looks for symptoms that provide the best indication of Ebola, including: fever, severe headache, muscle pain, weakness, fatigue, vomiting, abdominal pain, diarrhea and unexplained hemorrhage.
Positive responses to both questions merits high levels of precaution, and the receiving hospital should be notified.
Ongoing guidance from the CDC is to screen for travel to any region where concerning diseases are present, including Ebola, measles and MERS. This includes the responsibility of 9-1-1 centers to identify situations where a patient may have a risk for an important infectious disease, and to initiate communication protocols that allow safe operation by first responders and the first receivers at hospitals.
1. Centers for Disease Control and Prevention. (Oct. 9, 2015.) Interim U.S. guidance for monitoring and movement of persons with potential Ebola virus exposure. Retrieved Oct. 20, 2015, from www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html.
2. Koenig KL. Ebola triage screening and public health: The new “vital sign zero.” Disaster Med Public Health Prep. 2015;9(1):57–58.