NYSDOH Commissioner's Order on EVD Preparedness

[SteveC7010 58]

I am wondering why none of you have started to talk about this here? Have you not seen it yet?

https://www.health.ny.gov/diseases/communicable/ebola/docs/commissioner_order.pdf

It contains the actual order from DOH plus specifics required of hospitals, ems responders, and ambulance services. If you have not read it yet, I urge you to download the entire pdf and read it in its entirety. IMHO, this is going to have a major impact on every ems responder, but in particular the volunteer services may be even harder hit than others. I suspect many volunteers are going to be unwilling to comply with the initial and the ongoing requirements. This may to even more true of those volunteers who are not at least CFR's or EMT's.

Most material referenced in the order can be found on this page:

https://www.health.ny.gov/diseases/communicable/ebola/#ems_providers

[hawkbase 21]

Good Info. Thank you for posting!

[antiquefirelt 994]

Pretty interesting. Our guidance in Maine has been fairly lackluster, basically mirroring or referencing CDC Guidance. I could see issues developing and implementing policies in the 10 day window, though its unlikely many will have any "patients" within that time frame. The bigger issue is how we ensure our people know they may be dealing with suspected Ebola (we can still say it here!) before they make patient contact. This requires quality questioning and honest answers. It's not feasible to suit up for every call, nor warranted. I'm still of the mind that a suspected Ebola patient should not be transported in a public EMS bus. Isolate, plan the transport and care, then use designated assets who are proven to be trained equipped and compliant. Improper handling could result in a widespread public health crisis.

[SteveC7010 58]

Pretty interesting. Our guidance in Maine has been fairly lackluster, basically mirroring or referencing CDC Guidance. I could see issues developing and implementing policies in the 10 day window, though its unlikely many will have any "patients" within that time frame. The bigger issue is how we ensure our people know they may be dealing with suspected Ebola (we can still say it here!) before they make patient contact. This requires quality questioning and honest answers. It's not feasible to suit up for every call, nor warranted. I'm still of the mind that a suspected Ebola patient should not be transported in a public EMS bus. Isolate, plan the transport and care, then use designated assets who are proven to be trained equipped and compliant. Improper handling could result in a widespread public health crisis.

I see problems on all fronts. First and foremost, seasonal influenza and Ebola have the same symptoms, especially in early stage. That implies that we could easily end up putting on the suit for a lot of calls in the months ahead.

Problem #1 brings us rapidly to #2. Given the generally wide proliferation of seasonal influenza, we may not be able to use dedicated ambulances. As much as your suggestion has much merit, the numbers might not allow it.

#3 is tied to #1 and #2: Suiting up this often could easily place a financial burden on agencies big and small. One of the commercials in our area is not in the best of financial shape right now. The added cost could be the straw that breaks....

Your comment on the questioning prior to patient contact is dead on. I worked my career in a high volume, top-notch 911 operation. They were 100% EMD trained and experienced. Every request for medical assistance went through EMD. Additional focused questioning in that environment is not really much of an issue to implement, and just as easy to devise and implement effective ways to pass positive indicators on to the EMS responders without raising public alarm. However, that is not the case everywhere. Many counties have bare bones, small 911 operations even though they are central dispatch. No EMD, not enough personnel on duty to do EMD if they had it, and dispatch systems that don't utilize digital paging, MDT's, and similar alerting systems that would keep this information off the regular voice radios.

I see a huge problem in the volunteer EMS community with every aspect of this.

[antiquefirelt 994]

I see problems on all fronts. First and foremost, seasonal influenza and Ebola have the same symptoms, especially in early stage. That implies that we could easily end up putting on the suit for a lot of calls in the months ahead.

Problem #1 brings us rapidly to #2. Given the generally wide proliferation of seasonal influenza, we may not be able to use dedicated ambulances. As much as your suggestion has much merit, the numbers might not allow it.

Clearly these are some of the bigger issues. I agree and was thinking more that a true suspected Ebola case (not just flu-like symptoms) such as physical symptoms with travel to the affected region or other indicators would warrant the "special response units". Trying to use the physical symptoms alone won't work.

To me it's like the "Suspicious Package" threat assessment: we can't treat every unattended back pack or box like a true bomb without some credible threat to corroborate it, otherwise the system would be crippled. If we had to treat every possible sign or symptom without credible corroborating information as to the threat, we'd still be working off our backlog of "white powder" incidents from 2001/2002. We need to ensure the persons who have the very first contact via telephone or in person have proper protocols to question and develop a risk assessment by which to then select the most appropriate response.

[AFS1970 504]

We have been given the new EMD guidelines for Ebola however the similarities to the flu brings up an interesting point. We have not been told when to switch over to this new card. Since the first symptom is breathing related, do we question every difficulty breathing call for African travel status? Do we wait for more than one symptom to be mentioned? If we hear one symptom, do we ask about the others regardless of chief complaint? Basically nobody knows the answers and we are all flying by the seat of our pants.

[Ga-Lin 86]

I found it interesting that there was never any mention of concern for the EMS providers that brought Pt. 1 (Mr. Duncan) ? to the hospital the 2nd time. The first time he walked in on his own and, as we found out later, was sent home.

[SteveC7010 58]

I found it interesting that there was never any mention of concern for the EMS providers that brought Pt. 1 (Mr. Duncan) ? to the hospital the 2nd time. The first time he walked in on his own and, as we found out later, was sent home.

I don't think there is mention of any specific providers in other states in the Commissioner's Order & Requirements. Let's keep this to the topic, OK?

[Jybehofd 85]

I like it that there are emd protocalls to fallow and all i don't mean to bash dispatcher but we need more of them especially in westchester. because on a daily basis it seems like calls don't get emd. so what if the ebola patient doesn't get emd? should we wear full ppe for the sick call? i know that its not as wide spread as it is in africa and it is tightly under control here. Just a food for thought. But I am not too worried about it just yet.

On a different note, why can't we just have an automatic diversion to an approved ebola hospital ? why risk local hospitals and risk the staff there? if the patient doesn't have it and only has a bad case of the flu whats the harm? if they do have it and pass while transporting won't you want that ambulance crew at that hospital anyway? bets getting another crew possibly exposed and another ambulance exposed too? just some thoughts nothing more. but we could use some training in decon, I personaly have some and talking to others its kinda scary. I would prefer going through a decon wash line then just taking things off. and always with a buddy.

[SteveC7010 58]

More info is beginning to flow out of NYS DOH BEMS. My Chief passed an email to me that contained a number of documents. Several were repeats of stuff we've already seen but there were three new ones.

First, a cover letter from BEMS to all agencies: NYSDOH BEMS Cover Letter FINAL 10-22-14.pdf Nothing spectacular in it, but it's short and sweet and much easier to digest for the average squad member.

Second, an Ebola training guideline. Nothing new in it, and the info is mostly cut and paste from other stuff we've already seen like the CDC PPE guidelines. But it is much more concise with only a few hyperlinks. I think it is much better as a handout to the average provider. NYSDOH BEMS Ebola Training Guideline FINAL 10-22-14.pdf

Last, and probably most useful is a single page document called the Pre-Hospital Screening Guide for Ebola Virus Disease. It's a flow chart of questioning that should make it fairly easy for an EMT or higher to determine if they're dealing with a problem or not. I'm printing up several of them, and we'll have one on the bulletin board and one on the PRC clipboard in the ambulance, and maybe one on the wall somewhere in the ambulance as well. We'll make sure all of our responders have a copy, probably digital. NYSDOH BEMS Pre-Hospital Screening Guide for EVD FINAL 10-22-14.pdf

For everyone in NYS, you should be seeing some or all of these documents in the days ahead.

My Chief also advised me that there was a conference call scheduled for 4 PM today (Thursday the 21st) that would involve BEMS, our Region, and several more folks. We speculated that the results of that conference would likely have some impact on our training and implementation program. But we're in a wait and see mode on that.

One other concern that popped up in conversation today was the availability of PPE in general. Since there are so many different types and products out there, each agency, especially us smaller ones, will likely settle on one PPE system. Training and proficiency maintenance on multiple types of PPE systems is just not going to be feasible for many of us. But, with the anticipated probable shortage of all this stuff in the weeks and months ahead, we may be in a Catch-22 situation.

[SteveC7010 58]

I like it that there are emd protocalls to fallow and all i don't mean to bash dispatcher but we need more of them especially in westchester. because on a daily basis it seems like calls don't get emd. so what if the ebola patient doesn't get emd? should we wear full ppe for the sick call? i know that its not as wide spread as it is in africa and it is tightly under control here. Just a food for thought. But I am not too worried about it just yet.

On a different note, why can't we just have an automatic diversion to an approved ebola hospital ? why risk local hospitals and risk the staff there? if the patient doesn't have it and only has a bad case of the flu whats the harm? if they do have it and pass while transporting won't you want that ambulance crew at that hospital anyway? bets getting another crew possibly exposed and another ambulance exposed too? just some thoughts nothing more. but we could use some training in decon, I personaly have some and talking to others its kinda scary. I would prefer going through a decon wash line then just taking things off. and always with a buddy.

The flow chart I mentioned in my previous post should help responders to decide when to suit up.

I do know that even the smallest counties that do not do EMD are now being provided with the CDC's guidelines for PSAP's. The expectation is that most will go along with the protocols, but that's still to be seen. However, I don't think any dispatcher wants to be the one who forgot to ask the Ebola questions when it matters most.

As for automatic diversion to an approved Ebola treatment hospital, let's remember that this is a great big state. 6 out of the 8 approved hospitals are downstate, NYC, and LI. Only two are upstate; one in Syracuse and one in Rochester. So for you folks downstate, automatic diversion is a pretty good option and a reasonable choice.

However, upstate has a much different picture. I'm in the southern Adirondacks and about 2 1/2 hours from Syracuse. Anyone north of me, all the way up to the Canadian border, has a much, much longer trip, easily 5 or 6 hours. Diverting to an approved hospital is not an option, especially for the smaller squads with only one or two ambulances and relatively few responders. There's a lot of conversation at the moment about how to deal with this troubling situation.

[velcroMedic1987 330]

The flow chart I mentioned in my previous post should help responders to decide when to suit up.

I do know that even the smallest counties that do not do EMD are now being provided with the CDC's guidelines for PSAP's. The expectation is that most will go along with the protocols, but that's still to be seen. However, I don't think any dispatcher wants to be the one who forgot to ask the Ebola questions when it matters most.

As for automatic diversion to an approved Ebola treatment hospital, let's remember that this is a great big state. 6 out of the 8 approved hospitals are downstate, NYC, and LI. Only two are upstate; one in Syracuse and one in Rochester. So for you folks downstate, automatic diversion is a pretty good option and a reasonable choice.

However, upstate has a much different picture. I'm in the southern Adirondacks and about 2 1/2 hours from Syracuse. Anyone north of me, all the way up to the Canadian border, has a much, much longer trip, easily 5 or 6 hours. Diverting to an approved hospital is not an option, especially for the smaller squads with only one or two ambulances and relatively few responders. There's a lot of conversation at the moment about how to deal with this troubling situation.

So contact a commercial provider for the transportation to a designated center if the patient is stable and doesn't require immediate emergent treatment.

It is absolutely an option since nobody says you have to do the transportation yourself.

[SteveC7010 58]

So contact a commercial provider for the transportation to a designated center if the patient is stable and doesn't require immediate emergent treatment.

It is absolutely an option since nobody says you have to do the transportation yourself.

If only it were that simple. First, there are only two agencies with CON's for our area. Us and a small commercial outfit that is in deep financial trouble. Yes, we could call them, but there's no guarantee that they will even be available and if they are, that they will accept the run.

It's even worse to the north. Distance to an EVD hospital is greater, and they are backed up by the same commercial outfit that we are.

And even if BEMS granted some kind of waiver on the CON system for the EVD crisis, we still have limited options. If us little guys are dealing with a PUI or worse, we can be pretty sure that the larger squads and the commercials are dealing with even more. Their availability is doubtful at best. If they'd even accept the job would be even more doubtful.

There are other commercials in the region but they do not have CON's for our area. I suppose we could meet them at the border, but by then we've already contaminated the ambulance so we might as well go all the way.

In all fairness, all of us here need to be conscious of the great differences of these things around our state. What works well in the more populous areas won't fly in the rural and wilderness areas. What we do up here on a routine basis would be laughed at or scorned in other areas.