Hi, I'm Alex Isakov. I'm an associate professor of Emergency Medicine and the director of the section of Prehospital and Disaster medicine at Emory University. I'm going to be presenting to you today EMS, emergency medical services, and the transport and management of patients ill with Ebola virus disease. This is an important topic. While we have a raging epidemic of Ebola virus disease in West Africa and there have been patients that have been brought back to the United States for care, there's a component of that care that happens before the patient arrives at the hospital, and that's in the field of emergency medical services, or pre-hospital care. I am also boarded in emergency medical services. It's medicine's newest specialty of medicine specifically where physicians are involved in the care and the direction of care of patients in the out-of-hospital setting. The objectives from my talk are to just give an overview of the issues that EMS and public safety have to grapple with in the management of patients with not just Ebola virus disease, but all serious communicable disease. I'm going to emphasize the importance of the EMS or emergency medical services, relationship with the hospital and the care of patients, special considerations for the transport and management of patients ill with Ebola virus disease in the United States or other western countries. Lessons learned from our experience in transporting patients with confirmed Ebola virus disease, and implications for overall community preparedness. Emergency medical services deal with serious communicable pathogens everyday. In the care of patients, they are exposed to hepatitis B, hepatitis C, HIV, Clostridium difficile, methasone resistant staph aureus. In the course of their daily work, they interact with patients that may have or are confirmed to have any of these serious communicable diseases. But in caring for patients with Ebola virus disease or individuals who recently returned from travel to an Ebola-infected country, somehow something was different. What is different? Ebola virus disease is not something familiar to pre-hospital health care workers or hospital health care workers in the United States for that matter. The Ebola virus disease is largely recognized or known by those health care providers in the United States is something they'd seen on television read about in a news magazine. And what they read sounds pretty daunting. Ebola virus disease is often fatal. The case fatality reports have been as high as 90%. This is the worst outbreak in a four decade history of tracking this disease, and we have an epidemic of unseen proportion in West Africa which has been described an international health emergency that needs to be managed. All of that given, an unfamiliarity with Ebola virus disease in the United States understandably raises anxiety and concern, not just for the healthcare workers that might interact with these individuals, but also for the general public. And this unfamiliarity presents a gap that needs to be closed so that we can be best managing patients returning the the United States with Ebola virus disease by our EMS and our hospital health care workers. The principle of safely managing a patient with Ebola virus disease or any serious communicable disease is good infection control practice. And we must perform good infection control practice daily in the care of patients. So what's wrong in health care today? Well, as is also found in the hospital setting, EMS compliance with strict infection control practice is a bit wanting. EMS crews don't comply with hand hygiene recommendations regularly. Their compliance with standard infection control precautions and equipment disinfections has been described as suboptimal. And environmental samples have demonstrated growth of drug resistant organisms and serious organisms. This is also true in the hospital setting, which identifies another gap. That while we have a need to perform our care of patients with strict infection control practices to prevent transmission of illness from one patient to another or from acquiring it ourselves as healthcare workers, the experience that we have in the healthcare setting is our ability to comply with existing infection control practice, is not great and needs to be much improved. And this is another gap that needs to be closed for us to care safely and effectively for patients with Ebola virus disease or other serious communicable diseases. Over 12 years ago, the CDC and the Emory University Hospital collaborated to develop a special isolation unit, the Serious Communicable Disease Unit for care of patients with serious communicable disease. The primary mission of that unit was to provide support for CDC workers who, in the course of their occupation might become in contact with a serious communicable pathogen. Those workers might be labratorians in a biocontainment laboratory facility they could be field workers that have gone to assist in other country and their public health department in the outbreak of a serious communicable disease. In any case, CDC workers needed to have a place to come back to be evaluated and cared for, should they actually contract the illness. And Emory University and Hospital, Serious Communicable Disease Unit and its infectious disease group reached out to Emory Emergency Medicine, and essentially said our unit is not fully capable unless we have a transport component for the care of these patients in the out of hospital setting. An ability, a capability to bring these patients to bring these patients to the hospital, safely transfer their care, and do that in a way that doesn't put the health care worker in the ambulance or others at risk. And 12 years ago, that program was developed. And so how do you take a workforce that is unfamiliar with certain serious communicable disease and has demonstrated, broadly as an industry some compliance issues with regards to strict infection control practice? Well, what you do is you provide education and training and special policies and procedures to make sure that everything is working as it should so that the patients can be cared for effectively and safely. Some of that education goes directly at providing familiarity and knowledge to the health care worker about serious communicable diseases like Ebola. Most of these illnesses, whether it's Ebola, smallpox, SARS a virulent strain of a novel influenza these are things that raise anxiety and concern because most health care workers are not familiar with them. So we provide familiarity through education about the nature of those illnesses. What their incubation periods are? What the clinical syndrome is? And importantly, how the illness is transmitted from person to person? And with an understanding about how an illness is transmitted from person to person, then strict infection control measures can be implemented to provide for the safety of the health care worker when they're caring for that patient. And these are familiar subjects to health care workers. Standard precautions and transmission based precautions like contact to droplet in aerosol, these are concepts well known to health care workers, even if they're not implementing them perfectly every day of the week in the care of their patients. But for care of patients with serious communicable disease, an understanding of that infection control and how to implement it carefully is, is vitally important. Other information that's provided through education. Is what vaccines or immunizations is available for that particular virus or bacteria. What prophylactic measures are available in terms of medications that might be used if you were to be exposed? What type of treatment is available should you contract the illness? All of that information empowers the health care worker, whether they be a paramedic in the out of hospital setting, or a nurse, physician, or a tech in the in hospital setting, and that kind of education is provided for the health care worker for them to be more effective at what they do. Training in strict infection control measures is a broad subject that is also part of the education and training process, with particular attention to the application of PPE or personal protective equipment. The selection of Personal Protective Equipment is directed a bit by risk assessments for just exactly what risk the patient poses to the healthcare worker that's interacting with them. It may be that the patient has just recently returned from travel to an Ebola affected country and has fever, or at the other end of the spectrum, the patient may have confirmed Ebola virus disease several days into their illness, with copious vomiting and diarrhea. And those two scenarios, while requiring personal protective equipment application and strict infection control procedure, really demand two different types of personal protective equipment. In one picture, you see a, a paramedic dressed in face shield, surgical mask, gown, double gloves and booties, to protect himself in a manner that's consistent with standard contact and droplet precautions. This would be appropriate in interacting with an individual who has recently returned from travel from an Ebola infected country and perhaps had fever. This is a category of patient we call a person under investigation. They're awake, they're lucid, they're able to follow commands, they simply have fever, they do not have confirmed Ebola virus disease. So that is a possibility. And so to provide the appropriate level of PPE, a more easy to apply and working ensemble is appropriate. Alternatively, for the patient that has confirmed EVD, who has returned from an Ebola infected country, several days into their illness with vomiting and diarrhea, then absolute care to protect the healthcare worker from any exposure to that vomit, to that diarrhea, to any infectious bodily fluids while they're caring for that patient is paramount and requires a, a higher or different level of personal protective equipment. You'll see our healthcare team in, in these cases fully dressed in Tyvek or an impermeable barrier from head to, head to toe, with a powered air purifying respirator providing filtered air into the into the hood assembly that the healthcare worker is, is wearing. Why do we do that? We did it because we knew that we had to comply with the recommendation to be careful, to not be exposed to large droplets of vomit or blood or other infectious bodily fluids in the care of these patients. And we also recognized over many exercises and trainings in the ten years that we've been considering this, then the heat July heat in Atlanta typical goggles will fog, paramedics will sweat no matter how disciplined they are, they will have a, a desire or they'll have a reflex to wipe sweat from their brow, all unacceptable in the care of a patient that has a serious communicable disease. And so we took the added measure of safety to provide head to toe impermeable barrier protection and the power air purifying respirator and hood and the Tyvek suits that you see there, afforded that protection and was really the most operationally comfortable and feasible way to approach the transports of these patients. The key take home point is really that the personal protective equipment applied for the health care worker should be guided by the working environment and the risk of whether the patient actually could even have been exposed to EVD when they are presenting with some illness, and two, what the clinical syndrome looks like. Further, we train our health care workers to properly take off or doff their personal protective equipment. This is a risk point in caring for a patient, especially for one that is in quotations wet, or a patient with EVD who is vomiting or having diarrhea, the possibility to have exposure to that infectious diarrhea or or vomit, on the protective equipment is, is real. And if, a healthcare worker takes that personal protective equipment off in a manner that is not well thought through, not well exercised, it's possible that they could have an inadvertent exposure. And that's just not acceptable in caring for a patient with serious communicable disease. So specific training is provided to the health care worker in the out of hospital setting, as well as in the hospital to properly take that personal protective equipment off. The receiving facility for patients whether they have, are suspected of having Ebola virus disease or confirmed as having Ebola virus disease is very important. The relationship between the EMS provider and the hospital, and the exercises and training and the the SOPs or standard operating procedures that are developed between the ho, the ambulance service and the hospital, are really key to having a true, smooth transition of care from the prehospital care team to the in hospital care team. That includes a number of things. What entrance to this health care facility will the patient come to? How will it be secured? What's the shortest route of entry to the patient care area, so that other parts of the hospital aren't exposed? This is important, because it's important for the EMS team and for the hospitals to not just provide for the care and safety of the patient that's being transported, but also for other patients in that hospital, and visitors. And through consideration of these issues, and development of good sta, good policies and procedures, and good education and training, this can be done safely. Now, what we've seen when watching the transport of patients in a high-profile manner, is that the cameras often stop when the patient is transported into the hospital and stay there. The ambulance then leaves that scene but not to go back into service but to consider then how best to decontaminate, disinfect, and clean that ambulance so that it can go back into regular surface, service, and then also to have the health care workers come out of their personal protective equipment in a way that's safe. Bag all of that biohazard waste and put it in the appropriate regulated waste stream. There are ways that the EMS workers try to protect and make it easier to perform that mission. One is they isolate the driver compartment from the patient-care compartment such that the driver compartment is, is always clean. If you've ever looked in a regular ambulance, ambulances aren't designed for easy decontamination and disinfection. There are drawers. There are cabinets. There's other equipment. There are nooks and crannies that would make it nearly impossible to properly decontaminate and disinfect that ambulance in any timely manner if a patient was to vomit or to have profuse diarrhea that spilled out into the patient compartment. So to make it easier to decontaminate and disinfect the ambulance, barrier drapes are applied so that if there is actually, an exposure to vomit or diarrhea in that patient compartment, it can be easily removed. Then, the disinfection and decontamination of the ambulance is done according to standard operating procedures. All that waste is bagged and disinfected so it can be passed off to the isolation unit at the hospital for proper disposal, which includes autoclaving, meaning you're basically, bringing that trash to a high enough temperature to kill any pathogen in that trash, and then move it into the regular, or the regulated waste stream where it goes onto incineration. We also learned a fair bit about taking patients off of the. Specially equipped aircraft, the G3, that's operated by partners in Phoenix Air we have to have procedures for receiving those patients if they're ambulatory or non-ambulatory or requiring to be supine or laid flat, because they can't tolerate being upright. Procedures to do that safely and transfer that patient to the care of the ambulance transport team have to be considered, and they have been in exercises and training. In some cases you'll see we've walked patients into the hospital. That seems a bit unusual for someone with a serious communicable disease, but it was all in consideration of also a need to protect the environmental surfaces of the hospital and protect the patients and visitors to the hospital, and so the most direct route of entry into the hospital is preferred. And if a clinical decision is made that a patient's able to ambulate, then we do that in an effort to limit exposure to other environmental areas of the hospital in transferring that patient into the serious communicable disease unit. If we have to provide a, a stretcher for a patient we will, and you can see that we can put the patient in a shroud if needed to collect diarrhea with Ebola virus disease. In the fifth or sixth day of illness you may put out five liters of diarrhea a day, and in the transport phase, the more of that, that can be collected, preventing exposure to healthcare workers, caring for that patient or the environmental services in the transport vehicle, the better. So things like barrier shrouds are of use. You will also see a picture of a transport isolette or an isopod. This is a way to completely secure a patient and have everything including their vomit and diarrhea, any droplets that they might generate completely sealed in an isolette, but as you might imagine that makes patient access more difficult. It's logistically more difficult, and properly disposing of that isopod is much more challenging then simply disposing of a shroud or the personal protective equipment that the patient and the healthcare workers might wear. So while having that capability is we think a good idea it's not the panacea, it's not the answer to all serious communicable disease transport. There are other questions that come up in the transport of patients with serious communicable disease, and for Ebola virus disease and for others, we have standard operating procedures that we've shared online for other EMS agencies to emulate. We don't have open sharps in the vehicle, we avoid aerosol producing procedures because we try to decrease the likelihood of aerosols being generated. We're cognizant that some patients that we receive, because we are an Ebola treatment facility at Emory University, have come from far away places, like Liberia or Sierra Leone, and have been on a plane some 14 hours to arrive in Atlanta. They've had volume losses, they may have electrolyte abnormalities, like hypokalemia or hypomagnesemia, which put, puts the patient at risk for cardiac arrhythmias. Being prepared to manage those is very important. If you'd asked some a year ago how far they would go in the management of a patient with Ebola virus disease in terms of critical care intervention, some may have answered that care of Ebola virus app, care of patients with Ebola virus disease when they're critically ill, may be futile because the case fatality rates are so high. That's been proven wrong. With the appropriate expertise and the appropriate resources available, outcomes from Ebola virus disease can be much better. And they are proving to be much better in, in areas where those resources and expertise are available. We know now that patients have been on ventilatory support, on a ventilator. They've required or they've received IV medications to support their blood pressure. They've received dialysis, all critical care interventions afforded to patients with Ebola virus disease. Those patients subsequently walked out of the hospital and are, are well today. What that means to all us in the in-hospital as well as out of hospital setting is that critical care interventions are appropriate for patients with Ebola virus disease, and we need to prepare to resuscitate them if they're in our care. My closing thoughts. Today, Ebola epidemic is still active in Sierra Leone, Guinea, and Liberia. And until that epidemic is completely resolved, with no more patients with active Ebola virus disease, we will continue to have to prepare for returned travelers and management of patients with Ebola virus disease in the United States. So, what we have done here in the US is very important but tru, dealing with Ebola virus epidemic in West Africa and having the resources and ability to manage that epidemic and have it come to an end is, is paramount. Other things to remember that should give us some comfort in interacting in the community and with other patients in the in our environment, patients that may have become exposed to Ebola Virus are not contagious until they develop symptoms. So that means in travelers who've come from Sierra Leone, Liberia, or Guinea that don't have symptoms should not be regarded as contagious. And that should make it easier for us to deal with travelers that have come from those countries in a way that's respectful of their, their privacy and their dignity and their, their freedom to move about their business on a daily basis. Another thing that informs our processes and procedures is that the risk of transmission of Ebola virus disease increases with the severity of illness, because the viral loads go up and the likelihood of sharing infectious bodily fluids increases as well. The primary infection control principle is preventing exposure to blood and infectious bodily fluid. That's key. Everything we've talked about, policies, procedures, education, training, appropriate personal protective equipment, how to put it on and how to take it off, is all to prevent exposure to infectious bodily fluid is the prime, principle objective of all our activity there. PPE should reflect patient condition and operating environment as described before. And the supervised process, supervising healthcare workers, EMS or in the hospital, in removing their personal protective equipment and the disinfection of, of environmental services, is really advisable, because it decreases the likelihood that a step will be skipped and there is an inadvertent exposure of a healthcare worker to an infectious bodily fluid. And finally, regionalization of care, in much the same way as we see in, in for other health conditions, meaning they're in, in the spectrum of healthcare in a community, there will be hospitals and clinics and other healthcare providers that simply need to recognize when someone that they're interacting with has perhaps traveled to an Ebola infected country and has signs and symptoms. Recognize it so that individual can be isolated and then transferred to another part of the regionalized system of care for testing. And should that individual actually have confirmed Ebola virus disease, transfer to a treatment facility that has demonstrated the competencies to be able to care safely for patients with confirmed Ebola virus disease, through the entire course of illness. It's a regionalization of care that we see implemented for trauma victims. It's a regionalization of care that we see implemented for patients that have ST segment elevation, myocardial infarctions. It's the same type of regionalization of care that we'll often see for ischemic stroke patients and it is most appropriate as well to consider regionalization of care for patients with serious communicable disease, especially those where it's been demonstrated that specific competencies are necessary to safely care for the patient, to get good results and to provide for the safety of other patients in the, in the healthcare environment. Thank you very much for your attention to this segment. I hope that in conclusion, you recognize the value and importance of integration of effort between public health, EMS, and the hospital, in the care of not just patients with suspected or confirmed Ebola virus disease, but for all serious communicable diseases that we may need to face in the future.
