EMS and Ebola: Field Experience with Transporting Patients

Coordinator:
Welcome and thank you for standing by. At this time all participants are in a listen only mode. During the question and answer session, please press Star 1. Today’s conference is being recorded. If you have any objections, you may disconnect at this time. Now I would like to turn the meeting over to Loretta Jackson-Brown. Thank you. You may begin.

Loretta Jackson Brown:
Thank you Diane. Good afternoon. I’m Loretta Jackson-Brown, and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Communications System at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call, EMS and Ebola: Field Experience with Transporting Patients.

PowerPoint slides are available to download for today’s call. The PowerPoint slide set can be found on our COCA Web site at emergency.cdc.gov/COCA. Click on COCA Calls. The slide set is located on the December 15th call webpage under Call Materials.

At the conclusion of today’s session, the participant will be able to discuss the unique field experiences of EMS personnel in two jurisdictions who transported patients with Ebola, describe training, equipment, policy and procedural considerations related to Ebola for EMS personnel, and identify partners to include in planning for the transport of patients suspected or confirmed to have Ebola.

In compliance with continuing education requirements, CDC, our planners, presenters and their spouses, partners wish to disclose they have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. Planners have reviewed content to ensure there is no bias. The presentation will not include any discussion of the unlabeled use of a product or product under investigational use. CDC does not accept commercial support.

At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone dialing Star 1 will put you in the queue for questions. If you have joined via audio streaming, you are in listenonly mode and will not be able to ask questions.

Questions will be limited to clinicians who would like information on EMS transportation for suspected or confirmed patients with Ebola. For those who have media questions, please contact CDC Media Relations at (404) 639-3286 or send an email to media@cdc.gov. Again, you can find those PowerPoint slide sets on our COCA Web page at emergency.cdc.gov/coca under the December 15th COCA call.

So, our first presenter today is Dr. Alex Isakov, and he is the Director of the Section of Prehospital and Disaster Medicine at Emory University School of Medicine.

The second presenter is Dr. John Lowe. Dr. Lowe is the Associate Director of Research of the Nebraska Biocontainment Patient Care Unit at the University of Nebraska Medical Center.

And the last presenter is Dr. P.J. Schenarts, Professor and Vice Chairman of Surgery as well as Chief of Trauma, Surgical Critical Care, and Emergency General Surgery at the University of Nebraska College of Medicine. In addition, Dr. Schenarts serves as the Medical Director of the Omaha Fire and EMS.

Prior to hearing the presentations from today’s speakers, Mr. Drew Dawson, the Director of the Office of Emergency Medical Services, National Highway Traffic Safety Administration at the U.S. Department of Transportation, will provide opening remarks. At this time, please welcome Mr. Drew Dawson.

Drew Dawson:
Thanks very much, Loretta, and thanks to all of you for participating today. I am pleased to be here today and to send greetings on behalf of my Federal colleagues on the Federal Interagency Committee on Emergency Medical Services, or FICEMS.

For those of you who may not be familiar with FICEMS, it is the Federal interagency body that is charged by law with coordinating the EMS related activities of a variety of Federal agencies, helping to make sure that we’re all moving in the same direction.

FICEMS has representatives of 10 different Federal agencies and one appointed state EMS director who is Joe Schmider from Texas. My colleague, Dr. Gregg Margolis at Health & Human Services Office of the Assistant Secretary for Preparedness and Response, or ASPR, and I serve as the co-chairs of the FICEMS Technical Working Group -- or TWG -- which provides - which has provided staff support to FICEMS, and FICEMS and its staff have been actively involved with providing subject matter expertise and guidance to our CDC colleagues and other Federal partners as they carry out their many Ebola related activities.

FICEMS is engaged in many non-Ebola related activities as well, and I would encourage you to view our activities on www.ems.gov. There are lots of Ebola related activities in the Federal government, as you probably know, but I am going to focus on a summary of those that are related to EMS as were recently publicly reported at the FICEMS meeting on December 4th.

On August 26th, the CDC first published the Interim Guidance for EMS Systems and 911 PSAPs for the Management of Patients with Known or Suspected Ebola virus disease in the United States. Staff from FICEMS collaborated extensively with the CDC to provide EMS subject matter expertise as this guidance was developed.

This guidance -- which was widely disseminated by FICEMS member agencies to the national EMS and 911 stakeholder organizations -- emphasized the importance of a coordinated response among PSAPs, the EMS system, health care facilities, and the public health system. The guidance subsequently underwent revisions in October.

The last major revised version of this guidance which reflected input from the stakeholder community, was posted on the CDC website on December 2nd. Additional tools for EMS -- including checklists and other Ebola guidance for EMS -- are posted on the CDC website. We encourage callers to review these documents carefully.

The CDC’s EMS and 911 guidance provides particularly important PPE recommendations for EMS. Today on the call we have experts with hands on experience in planning for and carrying out the ground transport of confirmed Ebola patients. Both Emory University and the University of Nebraska have planned for some time for the transport of patients with highly infectious diseases. And, they have experience in transporting known Ebola patients in the United States.

It is our hope that their lessons learned will be helpful to all of you as you plan your own agency’s responses to transporting patients with Ebola or other highly infectious diseases.

Without further ado, I would like to introduce Dr. Alex Isakov from the Emory University School of Medicine. Dr. Isakov.

Alex Isakov:
Drew, thank you very much, and welcome to everybody on the call. Thanks for hosting this. That goes to all of the organizers, in part because as Drew Dawson had mentioned, the EMS guidance has evolved to be very robust and very complete, but the opportunity for those of us who have done some of the transports of patients with confirmed EVD have an opportunity to make some brief comments and then answer a lot of your questions.

My comments are going to be rather practical in nature, and hopefully that’s helpful to the audience. Just for context, I am a practicing emergency medicine physician. I am also a boarded EMS physician, and I’m the Medical Director for the Grady EMS Bio-Safety Transport Program, and that group at Grady EMS is the one that had collaborated with Emory University Hospital and CDC to develop a program for transport of patients with serious communicable disease over a decade ago.

That partnership was really important, and it’s one that I think can be replicated in communities across the United States -- that partnership between EMS, health care, hospitals and public health -- together working to develop education and training, policies and procedures and the required supervision to make a bio-safety transport program or a transport program that interacts with patients with serious communicable disease and make it work.

Because our experience is that interacting as a healthcare worker -- whether it’s in the out-of-hospital setting or in the in-hospital setting -- is more than just about PPE. It is about education and training. It is about the development of policies and procedures and implementing the appropriate supervision so that the interaction with these patients, the care delivery for these patients, the transport of these patients, can be done in a way that’s safe for the healthcare provider, as well as for other patients and other healthcare workers that might interact.

And I’ll take this opportunity to make a point about the value of education on this issue. It shouldn’t be underestimated for our colleagues in EMS or in the healthcare setting. While both in the EMS and the hospital community there is interaction on a daily basis with communicable diseases like HIV, Hepatitis B and Hepatitis C and others more serious, Ebola virus disease is not something that healthcare workers in the United States have had to consider or had to deal with.

And while the foundation for management of patients with EVD is good infection control practice, providing that education for medics and EMTs around the nature of Ebola virus disease -- how it’s transmitted, what’s required to interrupt that transmission, what kind of treatment is available for those that get the illness, what kind of opportunities to receive vaccine there are, what post-exposure prophylaxis might be available -- is really important. It develops a context for EMTs, paramedics and healthcare workers broadly to interact with these patients in terms that they then understand.

What’s been largely reported about outcomes in patients with Ebola virus disease in other parts of the world where they’re battling public health emergencies is pretty distressing news, and it’s important through education and training to provide some context, some foundation around those points I’ve just mentioned to - for us to be more comfortable in our work environment if we have the need to interact with someone who has the disease or is suspected to have the disease.

Let me take a couple of minutes to describe what the Grady EMS transports looked like and why they looked the way they did on CNN or other media outlets. And what I’m talking about is what you already know − the images of paramedics in head-to-toe impermeable barriers or Tyvek, patients wrapped in impermeable barriers or wearing impermeable suits. Let me describe why those selections were made because we are completely in concert with CDC and other health organizations that advise that standard contact and droplet precautions are what’s required to prevent transmission of Ebola virus disease and perhaps then increasing to aerosol precautions if an aerosol producing procedure is required.

The reason we selected the PPE ensemble that we did was really informed by a number of factors. One, the patients that we were transporting had confirmed Ebola virus disease. Two, we knew these patients were several days into their illness. And what’s reported about Ebola virus disease several days into illness is that these patients can have profound vomiting. They can have profound diarrhea and volume losses. We’re talking about five liters of diarrhea per day. There is a great chance to become or to have a risk for exposure under those circumstances.

These patients were also coming off of a transcontinental flight of 14 hours duration. So the Grady EMS team is applying total head-to-toe skin coverage with some type of impermeable material -- Tyvek in this particular case -- and wore a Powered Air Purifying Respirator, not because it was required strictly by CDC guidance to do it just that way, but because the patient’s condition and their risk or the risk of being exposed to vomitus and diarrhea was great enough that the paramedics elected to go with head-to-toe impermeable barrier protection or head-to-toe Tyvek and a hooded PAPR strictly for that head-to-toe protection.

There are some other benefits that the medics got from wearing that particular ensemble. In having exercised this over a few years, that ensemble was more comfortable for them. It decreased the likelihood that their visual protection -- or their face shields -- would fog so they were assured visibility.

It also helped prevent any errors in trying to wipe sweat from your brow. And this is in part very operationally oriented, the reasons why these types of PPE ensembles were selected. My colleagues who are presenting today will demonstrate that other PPE ensembles are also as effective in preventing transmission.

And the CDC guidance as was most recently updated in December for patients that have confirmed EVD recommend this kind of head-to-toe Tyvek protection to prevent exposure to skin and mucous membranes of infected bodily fluids and blood. And this is effective in preventing transmission of EVD from one individual to another.

Other implementation of barrier drapes on the ambulance, suiting the patients to prevent any diarrhea or other infected bodily fluids from coming in contact with environmental services or healthcare providers was also implemented. And all of this really just to decrease the likelihood that healthcare providers or environmental services would become contaminated with infected bodily fluids or blood and make it easier ultimately to disinfect the ambulance at the end of the mission.

You saw that some of the patients that we transported were actually walked into the hospital. Why would we walk a patient with Ebola virus disease from the ambulance into the hospital? Strictly because it was logistically reasonable to do so. It - one, a clinical decision was made that the patient could tolerate being ambulatory. Two, it helped us limit the number of healthcare workers among the EMS team that would have to make patient contact.

So with an ambulatory patient it was possible to have just one healthcare worker make patient contact as opposed to two or three or four, and that just helps manage the risk better.

Further, it was the most direct route into our isolation unit at Emory University Hospital. By walking the patient we were able to limit the space that was required for that patient or person to interact with.

It was the most direct route into the hospital and that helped us also manage risks of contamination of other environmental surfaces, and it certainly helped us prevent any exposure to other healthcare workers or patients or others that would be unprotected and shouldn’t be in contact with that patient.

Now, a very important point which I want to make with the couple of minutes that I have left is that the spectrum of PPE really should depend very much on the condition of the patient and the operational environment, and of course how the EMT or paramedic was trained to apply that PPE ensemble.

Not every patient that has suspected Ebola virus disease or has had a concerning travel history and fever needs to be met with a paramedic in full head to toe Tyvek and a draped out ambulance.

There’s a variety of PPE ensembles that would be valuable. Let me share that from - what is written in peer reviewed journals and we’ve learned from our ID colleagues is that patients later in the course of their Ebola virus disease illness become really a much greater risk for contagion or transmissibility of that disease.

Their viral loads are higher and they’re also more likely to share fluids because of the possibility of vomiting or profuse diarrhea or perhaps even bleeding from cutaneous stick sites.

That’s very different than a patient who has recently returned from an Ebola affected country and then just develops fever. As you may know, individuals who’ve traveled from Ebola affected countries are being screened and monitored in the United States for development of fever or signs and symptoms of illness.

And it’s possible that a health department will identify someone who has recently traveled from Sierra Leone and develops a fever to 102 for example but is absent any nausea, is absent any vomiting, is absent any active diarrhea.

And the patient who simply has fever poses as you might imagine a much less risk of transmitting illness than one who is profoundly ill, having uncontrolled vomiting and diarrhea, perhaps hypotensive, perhaps altered in their ability to interact with the crew because of hypotension.

Those are very different patients and they, I believe, require a very different type of PPE to interact with. And our team has not only transported patients based on CDC guidance in head to toe coverage and protection of mucous membranes in the way that I described earlier, but we’ve also moved individuals who just like I’d mentioned had come from an Ebola affected country, developed some fever and then by applying appropriate PPE that would be consistent with standard, contact, and droplet precautions safely move that patient without any concern that they would contract an illness.

And what does that look like? Well that looks like something much more typical: double gloves, some type of impervious gown, a surgical mask, and a face shield to protect the eyes.

That is also in the CDC guidance and completely appropriate level of protection to achieve standard, contact, and droplet precautions for a patient recently returned from an Ebola affected country perhaps simply complaining of fever and in need of transportation to an evaluation center where further evaluation can take place.

And so the point that really should be made again is that PPE ensembles really should be driven based on the patient’s condition, as well as the operational environment that the EMS agency is going to be working in.

Last point for me is destination. Healthcare partnerships are very important. Knowing which healthcare facility patients are being brought to not just with confirmed Ebola virus disease but those that may require further evaluation is important for EMS.

And developing some relationship with that health system around communications, pre-arrival communications, arranging space so that the ambulance can be promptly disinfected after a patient transfer and having a means by which the waste that’s generated from that transport can be properly managed all can happen in partnership with the healthcare agency that - or the healthcare institution that the EMS agency’s transporting the patient to.

And we know that for EMS it goes then beyond the patient transfer. Then the ambulance needs to be decontaminated and disinfected using an EPA registered disinfectant or the appropriate dilution of household bleach.

And at the conclusion of the disinfection the proper doffing or removal of the PPE should be achieved. And that’s best achieved we believe by using a prescribed method that’s been practiced and exercised, and is also then supervised or observed by someone else knowledgeable in that doffing procedure to help prevent inadvertent breaches in that procedure and an inadvertent exposure to infected bodily fluids or blood.

The last important piece for which there’s good CDC guidance and has been our practice is monitoring of the healthcare worker after the mission to ensure that the - if they were to develop fever or they were to develop any other signs or symptoms that they could be quickly evaluated by public health and the healthcare facility to ensure that there’s no chance that they’ve contracted the illness in the course of their care of the patient.

That monitoring is very important. A few points to close with and you’ve heard many but it’s worth to - worth reiterating them. One, the epidemic currently is in Sierra Leone, Liberia and Guinea.

Perhaps Mali comes into that group as well but that’s four countries in a large continent. And we should all remember in EMS and in healthcare that these are the countries where the Ebola outbreak and epidemic is and not in other African countries.

And we should be clear about making that distinction as health care providers in our local communities. And contracting the illness requires direct contact with infected bodily fluids or blood, which is a very important point.

And the foundation of transmission interruption is good infection control practice, which we can all execute well with proper education and training. Asymptomatic individuals are not contagious - very important point for us to understand and to share with our colleagues nationwide as we manage concerns around travelers from Ebola affected countries coming into the United States.

PPE should reflect patient condition and the operating environment. Another important point - case fatality rates in the United States will be better than what’s reported in affected West African countries because of the robust resources we have here in the United States and our ability to provide critical care.

And the last - very last point before I turn it over to my colleague, John Lowe from the University of Nebraska, is that while - what we’ve been talking about here in the last 15 minutes is Ebola virus disease.

For EMS, and for hospitals and for healthcare workers, it is not just about Ebola virus disease. What’s important is that we’re having an opportunity to have a really close look at our infection control procedures, the education and training provided to EMTs, paramedics, and healthcare workers in the hospital setting, our policies and procedures around infection control, and how well we are executing it.

And not only is that going to serve us well for the management of individuals who may have become exposed to Ebola virus or may have Ebola virus disease, but it’s going to serve us well in our next flu pandemic. It’s going to serve us well in our next SARS-like outbreak.

And everything we are doing today, whether we see a suspect Ebola patient in a community during this outbreak or not, we are ultimately going to be better prepared to manage serious communicable diseases now and in the future. With that I’m going to turn it over to my colleague John Lowe at the University of Nebraska. Thanks again for your time.

Dr. John Lowe:
Thanks Alex. And I want to thank the organizers again for holding this call. It's been apparent that the EMS issue is definitely on the forefront of a lot of clinicians' minds throughout the country.

Recently I've had the pleasure of assisting the CDC in a number of site visits to some of the 35 hospitals that have been evaluated to be potential Ebola treatment centers. And that has provided a great learning experience not only for our biocontainment unit but a number of the federal stakeholders involved in this issue as well.

A few things that Alex said that I want to highlight because they really resonate with us and our experience here. First and foremost is that this response is more than just PPE. I think it's important to note that one of the hallmarks of our biocontainment unit, the training and procedures and education has really evolved over the last nine years to focus on a spectrum of diseases.

And so a number of the elements that both our colleagues at - both Alex and I will share with you today are adaptations of protocols and procedures that were developed for a spectrum of diseases and then tailored with the current response as necessary.

I just want to point out that - so the experiences that we'll share come from transporting three patients known to be infected with Ebola virus that were transported from Liberia and Sierra Leone.

We were given approximately 72 hours’ notice prior to arrival on the ground of those patients. So obviously the amount of preparation and pre-planning that we got would be a little bit different or distinct from cases presenting in the community. But nonetheless and I think it's important to note that the same principles hold true in terms of infection control, PPE, and the other public health measures that you would implement.

All of our SOPs, procedures and policies that are in place for Ebola have been developed over the last nine years predominantly through research conducted in conjunction with our EMS provider, our main EMS provider at Omaha Fire Department and our biocontainment unit all the way from our donning and doffing procedures.

I can assure you that we have researched these through simulation ad nauseam to develop what all of our stakeholders felt was the most appropriate methodology for putting on and taking off personal protective equipment with the equipment that we had selected to use and in our operational environment, which I think it's important to note that the CDC guidelines really points to your ability to establish not only the appropriate PPE but also the appropriate competency to utilize that PPE.

So as I said, we have had the experience to transport three patients - three patients with distinct disease progressions and acuity upon arrival. And this has really played into the approach that we take both within our biocontainment unit and with our EMS partners on implementing PPE.

So we take a risk-stratified approach to implementing PPE. We also have utilized similar to what you've seen with Emory, the head to toe impermeable barriers with the powered air purified respirators. And that was really born out of the patient progression and symptomatology upon the patient presenting here in Omaha.

Also would like to point out that we did handle one patient transport with just N95, goggles, and then the Tychem head to toe fluid impermeable suit effectively. But for the same reasons as what Alex mentioned earlier, really occupational safety issues, not so much the infection control issues, we felt that that level of PPE provided a more than adequate infection control. But when you get into these hot environments and you're working closely with the patient in a fairly intense scenario, as you can imagine, the occupational safety issues with goggle fogging and sweating come into play that can be resolved with a PAPR or powered air purified respirator.

Also of note - we've also had the experience dealing with the patient isolette or a patient isolation unit that can be placed on a gurney or hospital bed to provide a HEPA filter, patient isolation in transit.

And we received a lot of feedback in interacting with our partners throughout the U.S. about the potential of these units. We've elected to use the isolator only - in only one of the three transfers. And that was really guided by a number of considerations that I think are important.

The first being that the complexity to set up and operate these isopods raises the level of complexity for your transport. You have to have a level of competency to set up and operate and provide care within that isolator.

Once a patient is placed within one of these isolettes, there's a certain level of difficulty to add additional medical equipment or medical devices into your provision of care.

So you have to have a really good understanding of the level of acuity of the patient and what type of procedures will be required in route prior to placing the patient in the isolette because although there are access ports to put additional items in the isolette once it has been sealed for containment, it's really difficult and timely and difficult to work with. So I wanted to make sure that we stressed those issues.

We also took the route in terms of coordination and communication, which P. J. Schenarts will hit on in a little bit greater detail. With our transports we elected to have a follow vehicle for the ambulance in each transport.

And in this follow vehicle we had a liaison from the biocontainment unit; so someone with advanced knowledge in environmental infection control and decontamination; the medical director for the EMS squad; and then a shift supervisor for the EMS squad as well. And what this allowed was radio communications from those individuals to the attending paramedic in the back of the ambulance.

As you can imagine, we want to physically isolate this patient and that provider for the safety of the public and to contain the disease. But what we don't want to do is completely isolate that attending paramedic in making decisions on an island.

So in doing this, by having that support system in the following vehicle in radio contact had just allowed a greater level of assurance that that attending paramedic wouldn’t be put into situations where they would be having to make exceptionally difficult choices without proper consultation and approval.

In terms of delivery of patient to hospital and this is something that has come up with a number of facilities that we have interacted with, it is important to really point out and practice and define the roles that the hospital or healthcare organization will play and the EMS organization will play in that transport to hospital handoff of patients.

The route that we had elected to take and this was through dialogue over the course of nine years was that the attending paramedic would be the attending healthcare provider until the patient was delivered into the isolation room within the hospital.

So essentially the attending paramedic from the ambulance all the way into the isolation room, stayed with the patient. Once the patient was placed into the isolation room, that paramedic was then doffed out of their equipment outside of the room by biocontainment unit personnel.

This is a decision that we came to early. Although all of our staff that are involved in this transport have a high degree of competency in utilization donning and doffing of this personal protective equipment, we felt most confident that having that attending paramedic doffed by the healthcare staff that have an exceptionally high level of competency in doffing.

And then also have that attending paramedic processed out of the biocontainment unit which has additional levels of assurance such as a shower out procedure.

That if we were to have that personnel doff their equipment anywhere else it would have taken a little bit longer and have been done in a less controlled environment at least with respect to additional shower out procedures and things.

In terms of decontamination we have a dedicated team at the hospital that has practiced regularly decontaminating ambulances. They do this in a controlled access facility. It is a huge garage.

And essentially that team is a two man team with a third person observer. And the third person observer is really a concept that we integrate into almost all aspects of these transports.

Whether it be donning and doffing or decontamination, we have a third person there just as an outside set of eyes to make sure that nothing is being overlooked or missed with respect to our standard operating procedures.

With that I will turn it over to Dr. Schenarts to talk a little bit more about the coordination.

PJ Schenarts:

Thank you, Alex and John. I am PJ Schenarts. I am the Medical Director for Omaha Fire Rescue. And what I am going to do today in our very brief time so we leave enough time for questions is I am going to hit upon four areas.

The first is the community presentation. The second is going to be a brief discussion of our screening protocol which is probably not much different from everybody else’s. We are going to talk about our risk stratified response here in Omaha.

And then lastly I am going to touch upon some of the lessons that we learned in the transport of the known patients and how we applied those to our community response.

So I am going to start first with the community response. So prior to putting together our own response within our community for suspected and known patients, we recognized that there was a lot of fears amongst the public. EMS providers and physicians and nurses likewise share a lot of these same fears so we recognize that.

We developed a communication strategy which prior to implementation or even writing our protocol so that we could address these concerns in a proactive manner.

We got basically every surrounding EMS agency in our region to come together along with police, the health department, 911, and other groups such as our folks out at the airports to come together so that we could discuss sort of their concerns and understand. Do a needs analysis, if you will, as to what their needs are and what questions needed to be answered.

At each of these we had the health department or Dr. Lowe give a brief overview as to what Ebola was and what the risks were so that everybody was operating from the same sheet of music.

What we recognized very early on was that there was really a lack of comprehensive understanding of what this all entails. Things like the waste and the decontamination are items of concern that aren’t routinely addressed in basic EMS care.

Once that was done we went to work putting together a screening protocol. I would concur with what Alex said is the CDC recommendations are excellent. And we have tried to mirror those and take those into account.

And as I believe it was Drew recommended or somebody that there is guidance provided on the CDC Web site with checklists and stuff. I would highly recommend them or those assets to each of the providers.

Our screening, I will move to our second point screening. Our screening protocol is not much different than probably everybody else’s. If they have symptoms of headache, joint pain, muscle pain, weakness, diarrhea, vomiting and in some cases bleeding.

That is our first tier. Those are suspected or we consider those basically flu-like symptoms. And our response there are protective gear is just what would be prudent. Gloves, gown, eye protection, shoe covers, face mask.

If on the other hand, they have that first tier and they also have either travelled to the affected countries or have a patient known to have contact with an Ebola patient. We have activated what we call our Ebola response team.

Here in Omaha our concerns were and I am sure Emory would share these same concerns in that we were worried that we would have people potentially show up at our airport who knew about our biocontainment unit and were staff from our biocontainment unit who had a breach of protocol and would need to be transferred.

Those were our two big areas of concern and we thought we might be a little different than some EMS agencies in that regard.

So let me move to our risk stratified response. Basically if we have a patient who meets those true criterias we actually move our communication strategy from radio to cell phone. That way we don’t have press and everybody showing up who are monitoring, you know, scanners and things like that.

The people who respond on that response team are myself as the medical director, the shift supervisor, and the paramedics who arrive on the scene.

We also have a prepositioned, prepped out ambulance and a group of volunteers who will go out and pick up those patients when they are suspected.

I would reiterate what Alex said earlier. That is probably an overabundance of caution that the standard droplet protocol is perfectly appropriate.

However, out of an abundance of caution and also recognizing that our EMS providers needed some extra confidence in the system. That is why we ended up in that scenario.

We also have a protocol for what happens if a person is pronounced dead on the scene which I can discuss in the question session if somebody needs us to.

Basically, maybe what I will share now is some of the lessons we learned. I would concur with what’s been stated earlier. The operational environment is very important. Alex touched upon his patients walked off the aircraft.

We had three different experiences in that. Our first experience, the patient walked off the aircraft extraordinarily slowly and weak. And in retrospect we had wished we had used a stair chair to get them off the aircraft. It was raining that day and that probably in retrospect would have been a better lesson.

Our second patient bounded off the aircraft on a nice sunny day and was on the stretcher before we could even turn around. And that was very different than our last patient who was non-ambulatory and we had to take off in an isopod in the snow and ice.

A couple of lessons we learned there is the use of a flatbed truck was helpful. The metal plating on the truck is slippery and the ice so we put some blankets down so nobody slipped.

We used an A frame ladder to get onto the truck and then we lowered the patient off of the truck.

The other sort of pragmatic things we learned. Dr. Lowe talked about the importance of having the paramedic in the back be the attending to the patient but being in communication with myself as the medical director and that was done on a secure channel on the radio.

We found that actually taping an earpiece into the paramedic in the back was helpful so that they could hear what was going on and being communicated without breaking protocol.

Two last points, one is it is very important for the EMS providers to remember the optics of the situation. In one case we exited somebody off the aircraft.

We were probably 60 feet away from the patient but with a high telephoto lens it looked like we were sitting on the stretcher with the patient. So I think public perception is as important here because there are a lot of unfounded concerns.

Lastly, our monitoring protocol for our paramedics. The biocontainment unit and the University of Nebraska had both been very helpful in that.

They basically call in twice a day with temperature reading and that has given both the paramedics as well as those who share the stationhouses a lot of confidence.

Lastly before I turn this over to Loretta for questions I would like to thank two people. One is I would like to thank Alex from Emory. When we were getting our first patient Alex could not have been more helpful and I would extend out at least on behalf of the Omaha Fire Department.

If people have questions in the moment that there is some way we can help you, we are all a brotherhood together and I think we are always willing to help.

So with that I am going to turn this over to Loretta for the question- and-answer session.

Loretta Jackson-Brown:
Thank you. I would like to take the time to thank our presenters for providing our COCA audience with such a wealth of information.

We will now move in to the question-and-answer portion of today’s call. As a reminder, questions are limited to clinicians who would like information on EMS transportation of suspected or confirmed patients with Ebola.

If you have a media question, please contact CDC Media Relations at 404-639-3286 or send an email to media@cdc.gov. We will now open up the lines for the Q&A session. Operator?

Coordinator:
Thank you. We will now begin the question-and-answer session. If you would like to ask a question, please press star 1. Please ensure your phone is unmuted and clearly record your name when prompted. To withdraw your question please press star 2.One moment please to see if we have any questions or comments. University of Iowa your line is open.

Man:
Yes, good afternoon, this is the University of Iowa Hospitals and Clinics. We are very pleased to participate on the call today and thank everyone for their participation.

Question for the folks in Omaha, for Omaha Fire specifically. With the use of the isopod in this last patient we were curious what you did with the isopod after you were done with the transport. Did you dispose of it or try to decontaminate it in some way?

And second, when you drape your trucks do you do a full ceiling to floor draping? Walls, ceiling, floors, everything overlapped just like some protocols have said?

And then finally, do you use anything like UV light or fogging of any kind for final cleaning? Thank you very much.

John Lowe:
All right thanks for that question. Yes, so the first question that you had about the isolette. We did in fact, so the isolette goes all the way into the patient room where the patient can be removed from the isolette.

At that point this is somewhat unique to our situation. But we were able to cut the isolette up into three pieces and then process it out of our biocontainment unit with our solid waste stream which I will be brief.

But essentially it gets bagged a number of times in autoclave bags and then it is autoclaved out of our unit through a pass through autoclave, put in from the dirty side, take out from the clean side once it is sterile.

So yes those are one use. We have never had any protocols for reuse of those isolettes. Just because from a decontamination standpoint they can be somewhat problematic.

In terms of decontamination of the ambulance. How we drape it and Alex if you want to speak to your draping as well too. We do not drape the ceiling. We drape the side walls and the floor very similarly to the methodology used at Emory.

Although the material that we use is a 6 mil plastic where we basically put a, one envelope into the ambulance that has been cut to fit. So it is essentially one solid piece of 6 mil plastic.

We do use as a final disinfection step - so we have the plastic barrier which would be the primary site of contamination. That is taken out similar to how you would doff a fluid impermeable suit where it is rolled over itself and then put in the biohazard bags.

We then do a manual disinfection with hospital grade disinfectant for the entire interior of the ambulance. And then as kind of a final step of assurance we have selected to use UVGI, so ultraviolet germicidal irradiation.

We are aware of others that use vaporized hydrogen peroxide or other gases. It is important to note that these tertiary methods are just that. They are not replacements for manual disinfection because all of these gaseous methods or UV methods, if you have copious amounts of organic materials, dirt or even bodily fluids, the studies are pretty clear that they have limited efficacy against pathogens with other contaminates.

Alex Isakov:
And I'll just quickly complement John's comments. At Grady EMS in Emory, we apply the barrier drapes to the walls and floor.

We don't apply it to the ceiling for two reasons. We're viewing that ceiling as relatively low risk for contact with diarrhea or vomit.

But also that the ceilings of our ambulances are fairly flat surfaces, also impermeable and easy to disinfect with an EPA disinfectant wipe that's effective against Ebola virus. The Ebola virus is not a very hearty virus.

And these EPA registered disinfectants are the appropriate dilution of household bleach actually, really inactivate that virus very effectively. And for that reason while we always assess the ambulance to determine how contaminated it may be.

And I'm pleased to say that with our transports, we believe because of the measures we took to prevent environmental surface contamination that our ambulance interior compartment was largely pristine even at the end of a transport. Between the barrier drapes and the appropriate application of the EPA disinfectant we were comfortable that that was an adequate means of disinfecting that ambulance and making it one of the cleanest ambulances in America when we were done without the tertiary application of a disinfectant by way of UV or aerosolized hydrogen peroxide.

Coordinator:
The next question comes from Dr. Andrew Byrne. Your line is now open.

Dr. Andrew Byrne:
Thank you very much for this informative conference. I really have two questions.

The first are the circumstances that caused you to go from a droplet protection PPE to the use of the PAPR. That's the first question.

And then the second question -- each of the cases of transfer that have occurred in the country have been single patient at a time. And I haven't heard any discussions of what happens in the circumstance of multiple individuals that have a traumatic exposure with PPE.

One could imagine a placement of Ebola infected blood in an IED kind of device that explodes and involves a number of individuals. Haven't heard of any individuals not in an infectious disease sort of a mode but one that requires surgical interventions or multiple people at one time. Are there any protocols that deal with that circumstance?

P.J. Schenarts:

This is P.J. Schenarts, Dr. Byrnes. Thank you for your question.

You know what, I don't know, and maybe Alex knows. I don't know of any protocols to deal with what you describe as a weaponization of Ebola so that we'd get multiple patients.

At least here at the University of Nebraska surgical intervention is not being considered. That's off the table should somebody need it.

What happens in, you know, a mass casualty event with this, I'm not sure anybody has a real answer for that at this point. I don't know whether Alex has a comment on that.

I know, before I turn it over to Alex I'm going to let John here respond to the droplet precaution question.

John Lowe:
Yes, so the scale up from droplet to use of PAPR for us - and I want to reiterate that for one of our transfers of a known Ebola patient -- a known patient with Ebola virus, we did use a closer to contact precautions than a PAPR precautions. And it worked just fine.

The decision for with these known transports for going to PAPRs was really just for the occupational safety of that attending paramedic. As soon as they start to perspire, the N95 and goggles become uncomfortable.

And we're all humans. The first thing you do is reach up to adjust that.

And that induces a new element of risk that we just don't see with the PAPR. So we have gone to for transfer of patients known to be infected with Ebola virus to a PAPR only approach.

Now again I think that what we're talking about with droplet would be that stratified approach for suspected or persons under investigation. And that would be driven predominantly by symptoms.

Again within the back of the ambulance we're in pretty close proximity with the patients. So if we had symptoms where there was a strong likelihood for active fluids, active fluid movements during that transport, we would probably - we would go towards the use of the PAPR just to limit potential exposure of our personnel. Alex?

Alex Isakov:
Yes John I'll echo what you've said. First CDC guidance the way it's written is completely effective at interrupting transmission of Ebola virus disease.

So for a patient that has confirmed EVD and has vomiting and diarrhea if you can apply a PPE ensemble that provides head to toe skin coverage and appropriate mucus membrane respiratory protection. However that's accomplished that will prevent transmission.

And just echoing John’s comments the reason we did use hooded PAPR was somewhat driven by paramedic comfort and some operational considerations. Just to reiterate them by wearing the hooded Tyvek PAPR, we could achieve head to toe skin protection.

We could achieve mucus membrane protection. We were protected against eye protection, fogging, and we protected against the provider reaching up and trying to wipe sweat from their brow.

And our mission if you recall the first one was first week of August, it's hot and humid in Atlanta. And our experience from first patient contact to terminal disinfection of the ambulance can be something like a three hour mission.

And so paramedic comfort was definitely driving our use of the hooded PAPR. But clearly not absolutely necessary.

There are other PPE ensembles that would work. On the other question around some kind of a mass casualty event, I'll say that we've been mostly focusing on what we'd consider probable scenarios.

So very probable in our environment that we could be called to transport the next patient with confirmed EVD. Very probable that we would get a call from public health for our EMS agency or one of our colleagues' EMS agencies to go and transport a patient that has recently come from an Ebola affected country and has developed fever or otherwise known as a person under investigation.

But far less probable that this would be used as some kind of a method for delivering mass or producing mass casualties. And so I'm with John and J.P.

No particular focus on that scenario at this point.

Andrew Byrne:
Thank you very much.

Coordinator:
John Edwards your line is now open. Karen Greely your line is now open.

Karen Greely:
Hi. We are from Loma Linda University Children's Hospital in Southern California. And I have several of my transport team members here.

And we're curious about how a critical care neonate or pediatric patient would be transferred if the acuity required a specialized team.

Alex Isakov:
That's an excellent question. And I'll be the first out to give my colleagues some chance to think about it.

Our - I'll tell you our team when it was conceived 10, 12 years ago was really focused on support for the CDC workforce that would be at risk for potentially being exposed in a laboratory or field environment. And so for our team, pediatric considerations were actually not in the scope of our work.

Since then we've had to consider the possibility of having to transport at least a pediatric patient in our environment. And I mean since our paramedics are also familiar with management of pediatric patients in the course of their routine 9-1-1 work we have a basis and a foundation for that.

I would say it does not address the neonatal transport question that you've raised. And there has been some dialogue with our pediatric emergency medicine and pediatric critical care colleagues about this.

But I don't have a definitive answer for you other than if there was a community that was working to develop that capability especially for transport of a neonate a lot of what you've heard on the call today would apply, particular around education, training, policies and procedures, and the relationship that I think is so critical for the transport agency to have with the treating facility to work out the logistics that would be required for a smooth transition of care.

John, P.J. do you have something to add to that?

John Lowe:
Yes so I just had a few things to add to that. First being that I am aware that CDC is actively putting together guidance -- I believe it's been drafted and it's through the - it's going through the vetting process right now.

So there actually, Karen, should be some solid CDC guidance coming out on both of those pediatric transport issues that you've raised. A few highlights from what I think we may see in the future in terms of guidance is a focus on dedicated pediatric transport teams utilizing a dedicated pediatric transport provider.

So again dealing with personnel that have a high level of competency and expertise providing whether it be an intensive level of care or a different level of pediatric care in transit. There's also some focus on utilization of a car seat if available either provided by the patient or the, you know, referring hospital and what might or might not be done with that car seat post transfer.

There is a focus on not utilizing PPE donned by the patient in this case just because of the difficulties in fit and access to the patient to provide care.

And more of a focus on utilization of those isolettes or a - there's another type of isolette aside from the one that fits on the patient gurney. And it's one that is very similar to the draping protocol used by Grady and Omaha that essentially encapsulates the entire rear end of the patient care compartment and puts it at negative pressure with HEPA filters.

So those are two focused areas of means to isolate the patient. The other major issue and everything that I've been involved with to date has really focused on individual transport providers making the decision in terms of parental accompaniment of the pediatric patient.

And again working through the issues of infection control or keeping the patient calm and as happy as possible. Hopefully those help.

Karen Greely:
Thank you.

Coordinator:
Our next question comes from Kimberly Edwards. Your line is now open.

Kimberly Edwards:

Yes, we just had a couple questions about how you may deal with the human remains or transport them if they needed to go to a facility outside of your hospital?

John Lowe:
So this is John at University of Nebraska Medical Center. We have a fairly detailed protocol which should be coming out here pretty quickly.

It's been approved for publication but I'll give you the 10,000 foot view of that. For the last nine years we have drilled with a BSL4 containment system for patient remains.

It's effectively an aluminum fabric barrier that you heat seal closed. So we utilized that as our primary level of containment for human remains.

The human remains would be placed into that barrier and it would be heat sealed. We've worked out through our drilling which is different from manufacturer recommendations that if you just use one outer heat seal layer then you're left with two edges outside that heat seal that present a difficulty in decontaminating.

So we actually do two heat sealed edges. And then we cut down the outer heat sealed edge.

Then as we move those remains out of our biocontainment unit -- so our high level isolation unit -- we have designated hot, medium and cold zones with respect to contamination. And when the remains being packaged already in that BSL4 level containment system reach the edge of one of those zones they are handed from one team to another team into an additional fluid impermeable human remains bag.

By the time it comes out of our isolation unit, our biocontainment unit, it is packaged in three layers of fluid impermeable layers. And can be transported with no PPE.

And our arrangements, we've had an existing relationship, memorandum of understanding with a local crematory to where we accompany remains as well as law enforcement. But yes, more of that operating procedure will be coming out shortly.

That's kind of the 10,000 foot explanation.

P.J. Schenarts:
This is P.J. Schenarts from Omaha Fire. If we were to have a patient die on the scene outside of a hospital, our protocol is actually to contact the Douglas County Health Department which is our local health department.

And then we would probably utilize the protocol that John just outlined for you. We’re very fortunate here that we have a biocontainment unit that we can draw upon for that. I’m not sure that may be applicable within your jurisdiction. But that’s how we would handle it here.

Coordinator:
Our next question comes from David. Your line is now open.

David Gerstner:
Yes. This is David Gerstner with Dayton, Ohio MMRS. I’ve got two questions about PPE.

One is we’ve had a couple of situations where we had to involve law enforcement for cases of suspect EVD that turned out not to be real. But has anyone looked at appropriate PPE for law enforcement that allows them access to the tools of their trade?

My second question is: what about modifications for PPE as we move into the very cold weather season? And I’d appreciate any comments from your panel. Thank you.

P.J. Schenarts:

This is P.J. Schenarts again from Omaha Fire. We’ve had that debate and question with respect to law enforcement bantered around.

Law enforcement is very, very different operationally as well as just pragmatically. They don’t carry the equipment that the fire department does. They frequently only have gloves on board.

Our response with our law enforcement should we end up in that scenario is to really have the fire department take the lead and have the response team take the lead.

The question really comes up for us -- and I’m not sure we have completely settled on this -- is what do you do with the uncooperative patient who refuses transport. Now clearly those patients can’t refuse transport. The public health has jurisdiction over that. But in the, you know, 30 to 90 minutes that it takes for that to happen that’s a really, I think, dicey period.

And I’m not sure whether Alex has any recommendations on that. But that is still an open question, I think, in our book as to what do you do with a hostile patient who’s combative, who is refusing transfer. It’s a very, very difficult problem.

Alex Isakov:
Yeah. I agree. This is Alex. It’s a difficult presentation.

Again, you know, it’s interesting that you’d had a scenario or more than one scenario in Dayton where a patient was uncooperative but then later was proven not to have EVD from what you’ve presented. It may even have been proven that the individual had no plausible exposure to EVD.

I think one thing that’s helping at least in even approaching that scenario is that as the active screening of travelers from Ebola-affected countries has been put in place and public health is actively monitoring individuals who have recently returned from Ebola-affected countries, it’s easier to identify which personal encounters actually pose any risk at all for exposure to Ebola virus.

So I’m not sure if you follow the - if I’m presenting this in a way that you can follow the logic. But the relationship between your response agencies and public health may actually yield access to information about who is being actively monitored and who actually may have had any risk of exposure to EVD which would allow you to approach that situation in a more informed way.

That’s just an idea. I know that may be sometimes difficult to operationally implement just because these situations can be very dynamic. But that’s - I put that out as something to explore with your public health authority in your community about identifying who’s being monitored and has a legitimate travel history that would given them any risk of exposure to the virus at all.

Beyond that I think what J.P.said about it being difficult for law enforcement and public safety, to some extent it is. There’s protection obviously afforded by gloves. There’s certainly protection afforded by use of goggles that protect mucous membranes or even a mask and in some education about infection control practice, some benefit obviously in safe distances for conditions that can be transmitted by contact and droplet.

But all of those - all of that understanding doesn’t necessarily, you know, result in or provide all the answers that you’re looking for. I think that first strategy of working with public health to identify who may truly be at risk for having any exposure to the virus at all will help, I think, manage those situations maybe prospectively.

Drew Dawson:

This is Drew Dawson. I would also just mention that the Department of Homeland Security Office of Health Affairs is working with the CDC and NIOSH now to come out with some specific guidance for law enforcement. So I think you can expect to see that in the near future as well.

John Lowe:
This is John Lowe. Just to answer your question about winter consideration, winter weather considerations for PPE, so as P.J. mentioned in his presentation we did have the opportunity to transport a patient in snow conditions. And one of the adjustments that we made to our PPE ensemble, so typically we utilize fluid-impermeable boot covers that come up to about the knee and are adhered or attached to the fluid-impermeable suit with tape. We made an adjustment based off of the consideration for ice and conditions for slipping and we utilized - since this is a fire department EMS service all of our personnel had issued fireman boots. So we utilized those essentially in place of the boot covers where they were adhered to the fluid-impermeable Tychem suit just as the boot covers are but provided a much higher degree of protection against slipping and falls.

Coincidentally those are autoclave-able. And our facility does have a chemical dunk tank that’s large enough to process out those significantly sized boots as well.

Loretta Jackson Brown:
Okay. Operator, we have time for one more question.

Coordinator:
John Edwards, your line is now open.

John Edwards:
Good afternoon and thank you. Two real quick questions. One -- and I really appreciate the presentation today, it was excellent and very helpful. Has there been any discussion with any of your groups on the Tychem versus the Tyvek suits or the need for it or anybody that’s brought that up as a concern?

And then two, you talked about your - the training teams themselves. I was just curious. For these known patients that are actively ill was there any additional training or requirements for these transfer crews over just your ordinary advanced life support crews? That’s it.

Alex Isakov:
Great questions. This is Alex. I can respond to those first.

In terms of additional education and training we - because we have a dedicated team that supports the Serious Communicable Disease Unit at Emory University Hospital in conjunction with CDC, we did provide additional education and training.

The focus of it was really not only focused on Ebola virus disease but a range of serious communicable diseases, their modes of transmission, treatment options, vaccine availability, post-exposure prophylaxis opportunities for a range of serious communicable diseases to give the paramedics and EMTs a comfort level about the nature of those illnesses and then give them the tools they need to protect themselves and interrupt transmission. So then that included training in various PPE ensembles and additional training in SOPs for movement and interaction with those individuals.

John, did you want to add anything from your perspective or PJ…

John Lowe:
Yeah. So I would add to that just as, you know, I think that our experience has been the same and there’s additional training both just in - and from an informational standpoint for a spectrum of diseases that we would reasonably admit patients into our high-level isolation unit for. So these are really focused on modes of transmission and dynamics of those organisms and then also additional training for sure with donning and doffing personal protective equipment so that we can assure a level of competency in not only putting on and taking off the equipment but also providing care in that environment.

P.J. Schenarts:
One of -- this is P.J. Schenarts again -- one of the things we did in addition or have been doing since our second transport where we had really the same team twice -- and that was just by happenstance cause that team was on -- is we’ve been really trying to spread the experience level around so that the third transport really was an all-new crew so that everybody knew what -- except for myself -- so they could have that experience and develop some institutional memory as to how to transport these patients. That was very helpful.

Alex Isakov:
Yeah. This is Alex. Just to - because I think this is an important topic. I said it at the beginning of my presentation but I want to reiterate the point. I think that additional education and training that’s provided for EMTs and paramedics that might come in contact with a patient with EVD or some other serious communicable disease is really important. It’s important because it gives them a context with which to mentally manage the fact that they’re transporting a patient with a serious communicable disease that has recognized outcomes that sometimes are not favorable.

And my opinion would be that putting a completely uninitiated EMTs and paramedics in that scenario is definitely a recipe for anxiety. And if the provider has anxiety they’re at greater risk, I think, for making an error in the execution of their duties. So we found that education and training really increases comfort level among providers.

And the State of Georgia has taken that seriously. And their state of EMS in conjunction with public health has developed a program where this education and training is being offered regionally in the state in an effort to develop a network for transport of individuals with serious communicable disease. And that program’s being well received.

My last answer to the first question that was posed around Tychem versus Tyvex, we actually do utilize a Tychem suit. But the selection of our suit was really around - it was based on trial and error with the ruggedness of the material and how easily it or how well it withstood the operational environment of patient movement and having to be in that suit for maybe up to three hours at a time.

And we found that it so happened that that Tychem suit was - because of the laminate and because of the material was very rugged. And it tolerated the work that the medic had to do very, very well in addition to the fact that because it’s so impermeable it allowed us to take an extra measure of caution in wiping down the exterior surfaces of that PPE with an EPA-registered disinfectant wipe prior to doffing just to decrease the likelihood of inadvertent exposure to bodily fluids or blood. John or J.P., any comments on that?

John Lowe:
You know, we really - I think you summed it up pretty much how we were going to so that was a good answer.

Loretta Jackson Brown:
So on behalf of COCA, I would like to thank everyone for joining us today with a special thank you to our presenters, Dr. Isakov, Dr. Lowe and Dr. Schenarts. The recording of this call and the transcript will be posted to the COCA website at emergency.cdc.gov/coca within the next few days.

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Thank you again for being a part of today’s COCA call. Have a great day.

Coordinator:
This concludes today’s conference call. Thank you for participating. You may disconnect at this time.

END