Class News

Sam Francis ’64 on EMS in the time of coronavirus

My how things have changed!

A little monograph by Sam Francis ’64

May 7, 2020

I was asked by a classmate to write this piece because I have served for many years on a local ambulance squad (though I stopped riding recently due to a minor orthopedic issue). My classmate thought this account might encourage other classmates to contribute their own stories of the roles they’re playing in the pandemic.

All of a sudden, in the blink of an eye, everything changed.

In New Jersey on the Ides of March, 2020, there were no coronavirus deaths. Two weeks later, on April Fools’ Day, there were 81. Everyone sheltered in place. It wasn’t enough. Two more weeks, on income-tax day, 277 more dead. May Day, 330.

Approaching 10,000 deaths in New Jersey, second in the nation. No end in sight.

THAT WAS THEN
Standard uniform pre-coronavirus

THIS IS NOW
Standard PPE during the pandemic

For 18 years I’ve been a member of the Chatham (NJ) Emergency Squad, the 90-member volunteer ambulance squad serving Chatham for 84 years without ever charging a penny. Over 200 hours of training to certify and periodically recertify as an EMT.

In addition to EMT service, I’ve been ambulance driver, crew chief, Electronics Equipment Manager (radios, pagers), IT Manager (website, electronic medical records), Finance VP, President, Captain, and other odd jobs. Stick around long enough in a small organization and you do it all.

You also see it all. Twelve hundred calls a year. Sickness, falls, car crashes, amputations, diabetic emergencies, psych emergencies, broken arms and legs, pains and sprains, burns, anaphylactic shock, strokes, heart attacks, cardiac disease and cardiac arrest, hypo- and hypertension, hypo- and hyperthermia, hypo- and hyperglycemia, seizures, choking, apnea and dyspnea, altered mental status, syncope. Even a childbirth or two. I never personally had the joy of one of those, but we do have stork decals on our ambulances.

Each member’s routine involves 12-hour shifts once or twice a week. The crew of three or four gathers in the ready room and waits for their pagers to go off. Typically, three calls during a day shift, 7am to 7pm, fewer at night. Lights and sirens to the scene, assess the patient, vital signs, splint and bandage if necessary, CPR for cardiac arrest, then onto the stretcher and off to the hospital. Restock the ambulance and wait for the next one.

In 18 years of service, I never once put on a mask nor saw another EMT do so. Never any need, except for the annual N95 fit-test required by OSHA.

When off duty, you’re never off duty. If the pagers go off while the duty crew is on a call, all off-duty members respond solo to the scene, day or night, coordinating by radio with each other on the fly, self-organizing a pick-up team. Someone pulls a rig and you’re in business. Who’s in charge? Whoever gets to the scene first. We’re all cross-trained and qualified to be crew chief if it comes to that.

That’s all there is to it.

So along comes the coronavirus. What changes?

To begin with, there’s no more congregating in the ready room. It’s as unwise for EMTs to congregate as it is for everyone else. If one EMT were to become symptomatic, contact-tracing would identify all the other EMTs recently exposed to that EMT, and all the others exposed to those. The symptomatic EMT would self-isolate until recovered, and all others would self-quarantine for 14 days. That could put a squad completely out of business in a New York minute, even in New Jersey. It’s well to minimize EMT-to-EMT contact.

So we’re very cautious. The stand-by posture nowadays is to have only one EMT in the ready room and the remaining duty crew at home in a state of readiness. In case of dispatch, all crew members respond directly to the scene, where personal protective equipment (PPE) and distancing keep any infected EMT from infecting the others.

At the scene, it used to be that the first responders to enter the premises would be the police. Patrol always arrives before the ambulance, since the cop cars are always on the road. The cops used to apply oxygen or start CPR if necessary, then breathe a sigh of relief when the ambulance arrived. But nowadays the cops wait outside, interviewing the patient through the door to gather information to pass to the EMS crew chief. Then one EMT in PPE enters the premises to assess and provide patient care. If more than one EMT is required inside the premises (as for CPR or a femur fracture, for example), one or two other EMTs don PPE and enter the scene to help.

We used to do CPR on the way to the hospital, but no more. We now do CPR on scene until the patient dies or spontaneous circulation returns, at which point we transport. The hospital system has enough resuscitation cases without our bringing in another one. We only transport patients whom we've resuscitated. The others are now pronounced on scene.

On the way to the hospital, only the patient and one EMT in PPE are in the patient compartment. A second EMT without PPE drives the rig, isolated from the patient compartment. The others go home, ready to respond again. At the hospital the crew doesn’t roll the patient into the ER, as had been the practice, but instead waits for hospital staff to come out and fetch the patient. ERs are chaotic scenes these days and there’s no need to add to the chaos or to chance further contamination of stretcher or crew.

Then the EMTs in PPE undergo the complex procedure of safely doffing PPE (gloves, face shield, goggles, gown, N95 mask). It’s a slow, seven-step process, including washing hands three times. Have you ever tried to take off clothing without touching the outside of your clothes?

Then the ambulance is cleaned and disinfected using a combination of cleaning solutions, disinfectant wipes, an electrostatic disinfectant sprayer, and a UV germicidal lamp. This rigmarole is very time consuming when done carefully, as it always is. You can't be in a hurry. Our calls used to take a little more than an hour between dispatch and return to service. Now they can take as long as three hours.

So far, this combination of gizmos, gadgets, products, processes, protocols, and paranoia seems to be working. As of this writing, no squad member has become symptomatic.

You might think that our call volume would be soaring as the coronavirus wreaks havoc and the hospitals are hammered. Quite the opposite. Our April call volume was down 14% relative to a year ago. Many people are choosing to stay home instead of calling 911, partly due to fear of the hospital and partly due to medical advice to stay home and self-isolate. If you have only two of the coronavirus symptoms (dry cough and fever), stay home and tough it out. But when you develop the third symptom (shortness of breath), it’s time to go.

Postscript: We are hanging in there with respect to PPE supplies despite unprecedented usage, serious shortages and disruptions in the supply chain, the lack of a Federal stockpile or meaningful response, and the outrageous, unexplained, undefended, indefensible, and unforgivable Federal interception and seizure of PPE shipments purchased by and intended for local jurisdictions. ’Nuff said. End of rant. I’m OK now. Back to business.