The Public Safety Group Blog

This is the second post in a five-part series where we'll give you a look inside this important new COVID-19 resource. In case you missed it, we recommend viewing the series in order, starting with Part One.

As an EMS provider, staying safe through the evolving COVID-19 situation involves distinct challenges. That's why the Public Safety Group, in partnership with the American Academy of Orthopaedic Surgeons, is pleased to introduce Evolution of EMS: COVID-19 Guidance for EMS Providers. This unique resource offers strategies and insights designed specifically for you.

In the excerpt below, we look at precautions you can take to protect yourself during periods of potential exposure to the SARS-CoV-2 virus, given the unlikelihood that you will be able to avoid exposure completely.

Evolution of EMS: COVID-19 Guidance for EMS Providers describes the SARS-CoV-2 virus and disease, prevention tactics, vaccine development, treatment, and public health implications, particularly as they affect providers working in the field. It’s not designed to supply everything you need to know about COVID-19, but rather to brief you on key issues and considerations. COVID-19 Guidance for EMS Providers also offers references for learning more and staying up to date. The goal: empowering you to protect yourself, your co-workers, and those you serve more efficiently and effectively.

There are three easy ways to access COVID-19 Guidance for EMS Providers:

• Stay Tuned to the Public Safety Group Blog:
  New excerpts will be rolled out on our Public Safety Group blog on a biweekly basis, free of charge (Part One is available here, Part Two is available below, and Parts Three through Five will be available in the coming weeks)
  
  
• Sign Up to Receive a Free, Complete Copy of the Resource:
  Visit http://go.psglearning.com/COVIDGuidanceNow to request your free copy today. We'll email you a PDF to download as soon as the complete resource is available later this Fall:
  

  I Want to Request My Free PDF:

  COVID-19 Guidance for EMS Providers

• Purchase Physical Copies of the Resource on our Website: 
  Visit http://go.psglearning.com/COVIDGuidance to pre-order your physical copy which will be available later this Fall 
  

Questions? Please contact your dedicated Public Safety Specialist today. 

Part Two: Nonpharmacologic Prevention Strategies
The best protection against COVID-19 is to avoid coming in contact with the virus: an almost impossible task if you spend any time in public areas. As an EMS provider, your risk of exposure is heightened as a result of the unique, interactive nature of your work. The virus has demonstrated its capability to spread rapidly and to infect people without producing symptoms; thus, you will sometimes be interacting with patients who do not seem to be infectious. Given the unlikelihood that you will be able to avoid exposure completely, the next best way to prevent contraction is to protect yourself during periods of potential exposure.

Brief Review of Standard Precautions
Staying safe as an EMS provider starts with following approved guidelines for the larger population. Without these commonsense precautions, all people in the community are at risk for contracting contagious illnesses, such as COVID-19.

Keep Your Distance
SARS-CoV-2, like other coronaviruses, is transmitted predominantly through respiratory droplets and aerosolized particles. Because aerosolized particles are smaller and lighter than droplets, they can travel farther and remain suspended in the air for more extended periods. When an infected person sneezes, coughs, talks, or just breathes, droplets and aerosols containing SARS-CoV-2 are dispersed into the air and can travel at least several feet. If these invisible droplets and microdroplets enter another person’s eyes, nose, or mouth, that person is now at risk of contracting the illness.

The number of SARS-CoV-2 particles that need to be absorbed or ingested to yield disease is still being researched, but the rapid spread of COVID-19 within communities suggests the number may be relatively low. When SARS-CoV-2 enters the body, the virus begins to replicate within cells. A person’s immune system works to stop this replication before it causes significant tissue damage and illness. The ability of a person’s body to effectively ward off the virus depends on both the strength of the body’s immune system and the viral load, or amount of viral particles in the body. Additional factors, such as comorbidity of illness, play a role. Early in the illness, infected people may shed viral particles at a higher rate than later in the illness, after their immune system has been activated (Walsh et al. 2020). Therefore, all exposures must be taken seriously and evaluated appropriately.

To minimize your exposure, take the following precautions:

• Keep your physical distance from others. The greater the distance between an infected person and a noninfected person, the less the chance of exposure. The Centers for Disease Control and Prevention (CDC) recommends maintaining a minimum distance of 6 feet between people in a public space. Keep in mind, the virus can still be spread across that 6-foot space, especially through aerosolized particles. Distance does not prevent transmission of the virus; it just helps to decrease the risk.
  
  
• Avoid group gatherings. Given the nature of respiratory transmission, it is understandable that when people gather in groups, there is a greater likelihood of virus transmission. Avoiding large groups and gatherings in enclosed places further decreases the possibility of transmission (Figure 2-1).
  

Figure 2-1: How one group event impacted multiple COVID-19 transmissions.
Reproduced from James, Allison, Lesli Eagle, Cassandra Phillips, et al. 2020. “High COVID-19 Attack Rate Among Attendees at Events at a Church—Arkansas, March 2020.” MMWR Morbidity and Mortality Weekly Report 69: 632–35.

Wear a Mask
The CDC recommends wearing a cloth mask when in public. The purpose of cloth masks is primarily source control—that is, to reduce the chance of the wearer spreading respiratory droplets and aerosols. The mask should not inhibit breathing and should cover the nose and mouth completely.

Keep in mind, cloth face masks may not protect the wearer from contracting the illness if exposed. When an infected person wears a cloth face mask, the number of infectious droplets and aerosolized particles released into the surrounding air are reduced.

If a person wearing a cloth mask comes in contact with an infected person not wearing a mask, the infected droplets and particles from the infected person can spread to the mask wearer. Viruses are tiny and can travel through the cloth mask and then be inhaled by the wearer. Additionally, cloth masks rarely make a tight seal around the nose and face, allowing additional routes for transmission. This is why it is important for anyone who goes out in public—especially when physical distancing is not possible—to wear a mask. Masks reduce respiratory droplet transmission between two people most effectively when both people are wearing a mask (Figure 2-2).

Figure 2-2: Properly wearing a cloth mask helps prevent disease spread.
Jones & Bartlett Learning.

Recommendations for properly wearing a cloth mask include the following:

• Before applying the cloth mask, wash your hands thoroughly for at least 20 seconds. If the virus was transferred onto your hands, your hands could transfer the virus to your mask, and you may then inhale the virus.
  
  
• After washing your hands, place the mask over your nose and under your chin. The mask should fit as snugly as possible to the side of the face.
  
  
• When removing the mask, do not place it on a potentially contaminated surface.
  
  
• Wash cloth masks frequently. Using a washing machine or washing by hand using a mild bleach solution are both effective cleaning methods. Dry the mask by using a clothes dryer or hanging it to air-dry. Be sure to follow manufacturer instructions for cleaning.

Prevent Surface Transmission
It is known that SARS-CoV-2 can live on surfaces, including door handles, tabletops, and writing utensils (such as pens), for long periods. Early evidence suggests the virus can survive up to 24 hours on cardboard, and 2 to 3 days on plastic and stainless steel (van Doremalen, Bushmaker, and Morris 2020).

Viruses living on surfaces cannot jump onto people. They travel via a living organism, known as a vector. A vector does not cause disease itself but instead is a conduit for transferring disease from one place to another or one person to another.

People become vectors if they carry the virus and transmit it to a surface through respiratory droplets and aerosolized microdroplets. If an infected person coughs, sneezes, or in any way transfers respiratory emissions to a surface, another person may then touch the surface and acquire the virus. If that person then touches his or her eyes, nose, or mouth, the virus may move to that person’s respiratory tract and potentially infect the person.

Precautions to help prevent surface transmissions include the following:

• Wash your hands frequently. Hand washing is the most effective method of inhibiting virus transmission from surfaces. Hands should be washed frequently and after coming in contact with potentially contaminated surfaces. Wash your hands as follows:

  1. Place your hands under running water.

  2. Once your hands are wet, use soap to help release the microbes from the skin. There is currently no evidence that using an antiviral soap is more or less effective than regular soap.

  3. Rub your hands together for at least 20 seconds, bringing the soap to a lather. It is essential to scrub your entire hand, including the back of the hand and between the fingers. The area under your fingernails can also harbor bacteria and viruses.

  4. Rinse your hands under clean running water.

  5. Dry your hands with a clean towel, or let your hands air-dry.

• Avoid touching surfaces unnecessarily. When in public, such as stores and restaurants, use automatic doors, do not rest or lean on counters, and bring personal pens or styluses instead of using items available to the general public.

• Wipe and disinfect all commonly touched surfaces. This process is becoming routine in public spaces. For example, many stores have incorporated the standard of wiping the handles of shopping carts after each use. These habits also should be practiced in private homes and office spaces.

• Use gloves appropriately. Some people wear gloves to stop virus transmission when in public. Wearing gloves may limit the transmission of the virus onto the fingers, but the virus will still exist on the glove and can transfer the virus to other objects touched, such as wallets, purses, and eyeglasses. To wear gloves as an effective protective barrier, remove and discard them after touching each potentially contaminated surface, and before touching other objects. Keep in mind, inappropriately using gloves can actually help spread the virus.

In addition to following these suggestions, it is important to keep your hands away from your face and mucosal membranes. Avoid rubbing your eyes, licking your fingers, biting your fingernails, and placing your fingers in your nose. Remember Even if hands have been washed thoroughly, the virus may maintain a small presence in the crevasses of the hand and under the fingernails. Touching a mucosal membrane may result in a person contracting the virus.

Additional PPE Considerations for EMS Providers
As part of day-to-day activities, health care workers have a higher likelihood of being exposed to people who are knowingly or unknowingly infected with COVID-19. This risk is especially high for workers serving in emergency departments, on ambulances, and in fire departments. For example, a patient experiencing an unrelated emergency (such as a heart attack) may have COVID-19, even if the person is not presenting with COVID-related symptoms.

When providing patient care, you typically cannot maintain a 6-foot distance, and thus have an increased risk of exposure. But you can take extra precautions to avoid becoming infected. Where possible, minimize patient contact until you can assess potential infection or exposure and take appropriate actions, such as masking the patient and/or moving the patient to a well-ventilated area. In all cases, use appropriate protective equipment that is properly cleaned and decontaminated.

Use a NIOSH-Approved Respirator or Face Mask
As mentioned, cloth masks, and even simple surgical masks, do not effectively prevent the wearer from contracting COVID-19. They are useful primarily as a method of source control. For greater protection, the CDC recommends that health care workers who may be exposed to COVID-19 wear a fit-tested N95 filtering mask or respirator certified by the National Institute for Occupational Safety and Health (NIOSH) (Figure 2-3).

Figure 2-3: Wearing a NIOSH-approved mask.
Getty Images.

The material in an N95 mask has a tighter weave that more effectively filters out the virus, and the design fits more closely around the nose and mouth. However, its effectiveness requires a correct fit and proper handling:

• Have your N95 mask fit-tested. To effectively block virus droplets from entering your mucous membranes, the N95 mask should be fitted to your face. Fit-testing is required by law (OSHA regulation 1910.134) and is commonly done by the provider’s employer. It can involve trying several different mask models to obtain a proper seal. When self-testing a fit, follow recommended guidelines and consider removing any facial hair that interferes with a tight seal. Keep in mind, breathing can be more difficult than usual because of the facial seal and the tight weave of the mask (Figure 2-4).
  
  
• Follow facility or agency guidelines regarding N95 mask disposal or reuse. Some medical facilities have policies in place to clean and reuse N95 masks and respirators because of their short supply. If you are asked to reuse an N95 mask, the mask should be discarded after it becomes visibly soiled. The CDC does not currently recommend that non–health care workers wear N95 masks.
  

Figure 2-4: Self-testing a respirator fit.
Jones & Bartlett Learning.

If N95 masks are difficult to obtain due to a supply shortage or other constraints, EMS providers may wear other, equivalent face coverings, such as elastomeric respirators, powered air-purifying respirator (PAPR) devices, or self-contained breathing apparatus (SCBA) face pieces. Elastomeric respirators are half face-covering masks with replaceable filtering cartridges (Figure 2-5). The masks are commonly made of plastic or rubber and fit the face tightly.

Figure 2-5: An elastomeric respirator.
© Anton Starikov/Shutterstock

SCBA face pieces are commonly used to enter into smoke-filled structures (Figure 2-6). Although not usually practical, these devices can be used in place of N95 or other face masks when working with patients who are, or may be, positive for COVID-19. Both of these face coverings should be disinfected after every use and in accordance with manufacturer recommendations.

Figure 2-6: An SCBA face piece.
© serhii.suravikin/Shutterstock

Keeping Your Environment Safe
As an EMS provider, you must ensure that you are protecting yourself from COVID-19 and are not exposing others to the virus by unintentionally carrying it on your clothing or equipment.
After caring for a patient, it is vital to clean and disinfect the equipment and ambulance. The PPE worn on a call should be removed and discarded or cleaned between calls. Disposable equipment such as masks, gowns, aprons, and face shields should be replaced.

If you have reusable masks, such as elastomeric respirators, or are asked to reuse your N95 mask, closely adhere to cleaning instructions before wearing them again. If personal clothing becomes contaminated following contact with a patient infected with COVID-19 (or any patient with an infectious disease, for that matter), clean the garments thoroughly as soon as possible. Standard laundering in a washing machine is completely effective for addressing potential contamination due to COVID-19.

Use Eye Protection, Isolation Gowns, and Gloves
In addition to an N95 mask, the CDC recommends that health care workers wear eye protection, isolation gowns, and gloves, which need not be sterile. (Figure 2-7).

Figure 2-7: Eye protection, isolation gown, and gloves.
Jones & Bartlett Learning.

Eye protection may consist of goggles or a face shield that covers the front and sides of the face. EMS providers should clean goggles and face shields after each patient interaction, using a recommended disinfectant or alcohol-based wipe.

An isolation gown or apron helps prevent the transmission of the virus to the health care provider’s clothing. Before responding to a call, you should know what size gown fits you, and train in donning (putting on) and doffing (removing) the gown. After caring for a patient, the gown or apron should be removed and discarded.

PPE Safety
PPE gear is effective only when used appropriately. Keep the following in mind:

• • Gowns are single-use. They should be discarded after caring for the patient.
    
    
  • Gowns should not be worn from one patient to another. They should be donned before caring for a patient and doffed after caring for the patient. After removal, the gown should be discarded.
    
    
  • Gloves should be worn when caring for patients. Like gowns and N95 masks, gloves are single-use and should be discarded after caring for the patient.
    
    
  • If reusing goggles and face masks, clean them after every use with a recommended disinfectant or alcohol-based wipe.
    

Remove PPE Equipment Carefully
It is crucial to doff protective gear with caution, adhering to proper technique. After your equipment has potentially touched virus particles, you can easily come in contact with these particles if you do not remove and dispose of items in the correct order. Follow CDC recommendations, and consider using the buddy system to monitor these steps carefully:

1. Remove your gloves first, ensuring not to contaminate your hands. With one gloved hand, grab the outside of the other glove and slowly pull it off. Avoid touching your bare hand. Hold the removed glove in the fist of your gloved hand. With your nongloved hand, grab the inside of the other glove and slowly remove it, capturing the first glove inside the second glove. Discard the gloves in the trash.
   
   
2. Untie or tear the gown and remove it downward, from the shoulders first. Discard the gown in the trash.
   
   
3. Wash your hands thoroughly for at least 20 seconds.
   
   
4. Remove eye protection and face mask. Follow agency or facility policy for disposal, decontamination, or reuse (Figure 2-8).
   

Figure 2-8: Donning and doffing PPE.
Jones & Bartlett Learning.

Following approved guidelines, both those suggested for the general public and those specific to health care providers, can effectively protect you and those you serve from infection. Visit the CDC and WHO websites for more information and updates on protective equipment and procedures.

Another piece of the COVID-19 prevention puzzle is vaccine development. We’ll take a look at vaccine strategies and considerations in “Part 3: Vaccine Development,” the next excerpt from COVID-19 Guidance for EMS Providers.



References

Argyropoulos, Kimon V, Antonio Serrano, Jiyuan, Hu, et al. Association of initial viral load in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients with outcome and symptoms. American Journal of Pathology. 2020;190(9):1881-7.

Harvard Medical School. COVID-19 basics. https://www.health.harvard.edu/diseases-and-conditions/covid-19-basics. Accessed October 13, 2020.

van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. New England Journal of Medicine. 2020;382:1564-7.

Walsh, Kieran A., Karen Jordan, Barbara Clyne, et al. SARS-CoV-2 detection, viral load and infectivity over the course of an infection. Journal of Infection. 2020;81(3):357-71.