When the nation refers to frontline workers during the COVID-19 pandemic, there is nobody closer to the front than EMS workers. Not only do EMS workers enter the high viral loaded homes of people sick with COVID-19, but they also then spend up to about 30 minutes in the back of a poorly ventilated enclosed space with that person during treatment and transport. This exposure time places the EMS provider in direct danger – making the process of donning, decontaminating and doffing PPE of paramount importance. The beginning of the pandemic saw old protocols used for severe hypoxia. This led to an enormous amount of intubation and ventilator use until doctors began to understand the pathophysiology of the virus better.
Doctors then figured out that better outcomes could be achieved by utilizing oxygen, proning/positioning, high-flow nasal cannula and continuous positive airway pressure (CPAP), amongst other interventions. This put intubation as the last resort, rather than the first action. The medical community learned one of the most challenging aspects about COVID-19 in the Spring of 2020, “silent hypoxia.” In the field, EMS providers and patients presenting to the hospital were found to have oxygen saturations levels abnormally low with no symptoms of respiratory distress. Saturations were so low that it was assumed that it must have been equipment malfunction. These oxygen saturation levels were confirmed with arterial blood gas analysis, lung scans showing severe damage and a positive test for COVID-19. Compounding the already massive challenge of asymptomatic transmission presented by SARS-CoV-2 is the fact that patients can deteriorate at home without even knowing it. The problem with this is that by the time patients actually develop any respiratory symptoms, the damage done is already significant.
- Breaking the Chain of Survival? The Impact of COVID-19 on Prehospital Care
- How Empress EMS (NY) Responded to COVID-19 in the Pandemic’s Epicenter
- What Does the Future Hold for EMS after COVID-19?
For EMS providers in the field, not much changed for treatment protocols (at least in my home state of Rhode Island). There, the only protocol change was to avoid nebulizer use and administer epinephrine 1:1000 IM for respiratory distress to avoid aerosolization of the virus. Despite the amount of treatment information available just by following FOAMed, no COVID-19 protocol was created. During the first wave in the Spring of 2020, a protocol was created that allowed to leave people at home instead of transporting them to help out the already overwhelmed hospital system. The problem with leaving too many people home was that other medical issues went untreated and this led to poor outcomes.
The wave of COVID-19 that started in the Fall of 2020 led to an advisory that all COVID-19 patients that call for EMS be transported to the hospital. The lockdowns made people terrified to go to the hospital. Later in the fall, people were going back to the hospital for all types of reasons, including COVID-19, and the EMS and hospital system has been busier than ever. In Rhode Island, hospitals have been rotating being on diversion almost daily.
It is the opinion of this author that a COVID-19 protocol should be created for EMS. Even if about 80% of the known cases producing mild/moderate illness without the need for hospitalization,1 the remaining people need the best practices put forth to maximize the level of treatment that should be provided to them. The combination of proning and increasing oxygen therapy – and as a last resort, CPAP – has been extremely effective in improving oxygenation and the comfort of patients. Aerosolization of the virus is something that EMTs can protect themselves from and the truck and equipment will be decontaminated afterwards. Exposure to illness has been an occupational hazard since the dawn of EMS and there has never been a greater emphasis on personal protective equipment (PPE) than during this pandemic. Therefore, there is no reason to not provide the best interventions possible for patients.
Part of this COVID-19 protocol should be the delivery of the proper message. EMS is uniquely situated to be able to spend more time with a patient than a doctor. During this time, patients should be educated. Many patients have said they visited their primary care physician or were seen at the hospital and were not given any education on what to do once they go home to fight COVID-19 on their own. This author has asked every COVID-19 patient that said they were previously treated if they received any information on pulse oximetry or proning/positioning. Every single patient said no. This is most certainly a travesty and it can be changed by allowing EMS in the field to deliver information to people. Discharging people to their homes to recover as if this virus is no different than other viral illnesses is irresponsible when it is well known that “silent hypoxia” can develop and cough/shortness of breath can be improved with proning.
Massive amounts of stimulus money have been poured out into the country to help ease the burden of COVID-19, and in the beginning, there was a rush from all corners of industry to repurpose their operation to build ventilators and create PPE. What the country needs now more than ever is a portable pulse oximeter put into the hands of every person who tests positive for COVID-19. If the inventory does not exist, then it should be prioritized. The fact that this is not the message almost a full year into the pandemic is astounding. It reveals a failure in public health policy. Isolating the factors that could cause the worst outcomes and equipping people with the necessary tools to identify them before they develop severe illness seems like it should be shouted from the rooftops by public health officials.
Medical experts have proven the vaccine is safe and effective and are trying to convince disbelievers. This is important because herd immunity will never be reached without battling vaccine skepticism. However, as most of the general public will not receive their first dose for several months from now, people need to be educated to combat the virus and decrease the amount of damage caused by severe illness and mortality. Public health should be delivering the message of pulse oximetry at home, what to do with the information it provides and also how well proning can help their symptoms. EMS providers in the field can educate their patients on the importance of obtaining a pulse oximeter, what to do with it and how to utilize proning/positioning to ease their symptoms in conjunction with monitoring their oxygen saturation.
For healthy adults that have received a positive test for COVID-19, they should obtain a portable pulse oximeter and monitor themselves often during the day to make sure they are staying above 94%. Not only does this number reflect the normal threshold per EMS protocol for the use of supplemental oxygen administration, staying above this number is associated with better outcomes because being at 92-94% during the day corresponds with much lower SPO2 during sleep.2 This is more challenging for people with respiratory diseases, such as COPD, that would normally have low-oxygen saturation. With 88-92% SPO2 being normal for a person with COPD, below 88% would be a threshold for concern. For the otherwise healthy adults, ensuring that SPO2 stays above 94% is the best way for that person to stay far ahead of the development of “silent hypoxia.”
Proning is utilized to help with cough and shortness of breath by recruiting more lung tissue for breathing and has been seen to increase SPO2 without supplemental oxygen.3 It is recommended that people with cough and shortness of breath spend the day monitoring their SPO2 and changing their position, spending minimal time performing activities or laying supine. A flyer was posted at Elmhurst Hospital Center in Queens (NY) for its COVID-19 patients and it instructed them to spend 30 minutes to two hours proning; 30 minutes to two hours on the right side; 30 minutes to two hours on sitting up (semi-Fowlers); 30 minutes to 2 hours on the left side; and then back to the prone position.
People battling COVID-19 at home could use this information to feel better and while monitoring their oxygen saturation, they can get ahead of developing severe illness. If COVID-positive patients were able to see that their oxygen saturation has lowered to 94% and is not changing no matter what they do, then it is time to get to the hospital for a lung scan. If this was the message that was aggressively pushed, then perhaps lives could be saved. And perhaps people will not end up with irreversible tissue damage from this virus.
The best way to achieve this (if it does not show up on widespread media) is for EMS to do it in the field. All COVID-positive patients should obtain a pulse oximeter, because aside from older populations and people with comorbidities, it is unknown who may also develop severe illness. Even though EMS will not likely encounter a significant percentage of the 80% of people who only develop mild/moderate illness and recover without complication, it is very likely that EMS providers will encounter the remaining 20% that need life-saving education and that information can easily be provided during the encounter. If the message got out there to obtain a pulse oximeter, there is no doubt that the damage of this disease could be reduced. This has been the message of Dr. Richard Levitan of Prone2Help.org who helped pioneer proning and his website helps people with getting pillows to make proning more comfortable. He has also been aggressively pushing for widespread availability of pulse oximeters and the importance of early detection of hypoxia to produce better outcomes.
EMS has the power to do much more than just treat the situation they are currently seeing. People respect and trust the information provided to them by EMTs and paramedics. EMS providers are the only medical professionals that enter a person’s home during emergency situations. EMS must use this fact as well as utilize social media and news platforms to get pulse oximetry and proning/positioning out there to the people and be the face of life saving public health policy.
- Farkas, J. 2 March 2020. The Internet Book of Critical Care: COVID-19. COVID-19 – EMCrit Project.
- Shenoy N, Luchtel R, Gulani P. Considerations for target oxygen saturation in COVID-19 patients: are we under-shooting? BMC Medicine. 2020 Aug 19;18(1):260. doi: 10.1186/s12916-020-01735-2
- Sun Q, Haibo Q, Huang M, Yang Y. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Annals of Intensive Care. PMID: 32189136 PMCID: PMC7080931 DOI: 10.1186/s13613-020-00650-2