Approach to COVID-19 for EMS services and providers.

1. COVID–19 : AN APPROACH
FOR EMS
Bryan Johnson NRP, TP-C

2. DISCLAIMER
COVID-19 is a new disease process that we have
little experience managing. This presentation is
based on the latest information available, as well
as best practices from expert consensus. As new
information arises, these facts and guidelines are
subject to change. I will do my best to update
and circulate this as these changes occur. This
presentation does not supersede local or state
policy and is solely informative in nature. Please
keep yourself advised on the latest information
by visiting the following sites:
Centers for Disease Control and Prevention
World Health Organization
EMCRIT by Dr. Scott Weingart

3. TERMINOLOGY
Epidemic Vs. Pandemic
An epidemic is an uncontrolled outbreak of a
serious disease within a defined region. A pandemic sees
worldwide spread of this disease
Quarantine Vs. Isolation
A quarantine restricts movement and contact of a
person with a suspected illness that has not been confirmed.
Isolation is the practice of separating someone with a
confirmed illness from the healthy population.
Person Under Investigation (PUI)
A person under investigation is an individual that
meets screening criteria for a communicable disease. This is
used as a tool to deduce who needs further testing.
Person Under Monitoring (PUM)
This is an individual who has no signs or
symptoms but has known risk for an exposure to a
communicable disease.
Social Distancing
The practice of avoiding congregate settings and
maintaining a distance of approximately six feet from one
another.
Epidemiologist
One who is an expert in the branch of medicine
which deals in incidence, distribution and possible control of
a disease.

4. WHAT IS COVID-19?
COVID-19 is the name
of the disease state
that arises due to
infection from the
SARS-CoV-2 virus. This
virus belongs to the
family of
coronaviruses.
Coronaviruses get their
name from their shape
which is crown like
(corona in Latin is
crown). Most other
types of known
coronaviruses cause
nothing more than the
common cold. Other
well-known
coronaviruses that were
particularly deadly were
MERS and SARS.

5. WHERE DID
THIS
DISEASE
ORIGINATE?
Chinese authorities detected an outbreak of
SARS-CoV-2 in December of 2019.
Researchers believe that this virus is zoonotic
in origin and was transmitted to humans via
an intermediary animal. Currently, this animal
intermediary is believed to be a Pangolin. The
initial transmission occurred in a market
located in Wuhan. Wuhan is the capital city of
Hubei Province located in the People’s
Republic of China. Since initial infection, the
virus has spread rapidly through respiratory
droplet transmission. Currently, the outbreak
has been classified as a pandemic.

6. WHAT IS THE CAUSE
FOR CONCERN?
This novel coronavirus is
particularly virulent,
infecting many people in
rapid fashion. In
conjunction, mortality
rates continue to surpass
that of the seasonal flu.
Generally, the seasonal
flu has a mortality rate of
0.1%. This coronavirus is
projected to have a
mortality rate of between
0.5% and 2%. While this is
concerning, even more
alarming is the projected
rates of hospitalization,
which reaches between
10% to 20% of the
infected population. This
will further stress an
already prestressed EMS
and healthcare system,
possibly overwhelming
available resources.

7. PUTTING THE
PANDEMIC IN
PERSPECTIVE
Leading epidemiologists predict
this virus may infect
approximately fifty percent of the
United States’ population. Even
more disconcerting, they predict
there may be close to one million
resulting deaths. In 2018, the flu
killed approximately 37,000
Americans. Even at its worst, the
flu kills approximately 70,000
Americans. This is precisely why
we must stop perpetuating that
this virus is “just like the flu”.

8. WHAT DOES
COVID-19 LOOK
LIKE CLINICALLY?
COVID-19 produces a range
of symptoms which are most
commonly constitutional and
respiratory in nature. A
clinical pearl is that patients
may by hypoxemic without
outward signs of respiratory
distress. Less commonly,
this disease state can
produce gastrointestinal
symptoms. The most
specific and sensitive
symptoms include fever,
cough, myalgias and
shortness of breath. **THE
ABSENCE OF ONE OR MORE
SYMPTOMS DOES NOT
EXCLUDE THE

9. SCREENING
FOR COVID-
19
To the right was the initial
screening tool for suspected
infection. We now know that
this virus is now largely
community acquired and
travel, as well as known
exposure, is not requisite for
high suspicion of this
disease. Known exposure
and travel is still important
to screen for due to it
increasing risk even further.
Also, keep in mind the
previous chart. Some will
present with GI symptoms
and other constitutional and

10. ASSESSING PATIENT RISK OF
MORTALITY
As stated previously overall risk of mortality is markedly higher than
that of the seasonal flu. This risk of mortality disproportionately
effects the following populations and people with the following
diseases:
 The elderly - specifically over 60 and risk increases as age increases (4.8% for 60-
69, 9.8% 70-79 and 18% 80+, based off data from China)
 Hypertension – possibly people prescribed ACE inhibitors due to virus entering via
ACE-2 channels
 Cardiovascular disease
 Obesity
 Cancer
 Pre-existing respiratory conditions – Asthma, COPD, Asbestosis, history of
smoking, etc.
 Other typical risk factors such as diabetes, ESRD, immunocompromised patients,
etc.

11. PROJECTED
STAGES OF
ILLNESS
Initial stage consists of viral replication over a a period
of days. This immune response occurs but fails to
contain the virus. During this stage there are relatively
mild symptoms or no symptoms.
The second stage is the process of adaptive immunity.
This leads to falling titers and increased inflammatory
cytokine production resulting in tissue damage. This is
generally when patients begin to deteriorate.
Clinical conundrums produced due to patients being
relatively well for many days and then acutely
deteriorating.
Important to consider initial symptoms do not predict
future clinical course.

12. PROJECTED DISEASE COURSE
INCUBATION PERIOD IS A
MEDIAN OF 4 DAYS POST
EXPOSURE, HOWEVER,
CAN RANGE FROM 1 TO
14 DAYS.
SHORTNESS OF BREATH
WILL APPEAR AT A
MEDIAN OF 6 DAYS POST
EXPOSURE.
INITIAL HOSPITAL VISIT
AND ADMISSION AT A
MEDIAN OF 8 DAYS POST
EXPOSURE.
INTUBATION AT A
MEDIAN OF 8 -10 DAYS
POST EXPOSURE.
TRANSMISSION OF VIRUS
MAY OCCUR UP TO 14
DAYS POST RESOLUTION
OF SYMPTOMS.

13. WHAT IS THE
TREATMENT?
There is no specific treatment for COVID-19.
Experimental treatments using anti-viral therapy
are being trialed in hospital settings. No data is
currently available regarding the efficacy of
these treatments.
Treatment of these patients is largely supportive
but also focused on treating underlying
pathology exacerbated by this virus, as well as
the complications from this virus.
Please use treatments judiciously as most are
not without consequence. This is not to say
withhold treatment but understand what the
sequelae are. For example, steroid use increases
viral shedding and may increase risk
transmission, risk of further deterioration and
length of ability to transmit virus. Understand
that oxygen therapy is not without risk. Nasal
cannula, non-rebreather, nebulizer, CPAP and
BVM adjuncts can result in aerosolization of
airway secretions increasing risk for
transmission. Also, be especially cautious when
using suction. This list is not exhaustive and
please use good clinical judgement and common
sense when treating PUI and PUM patients.
**FLUID RESTRICTED RESUSCITATION IS
RECOMMENDED AS LARGE QUANTITIES OF
CRYSTALLOIDS HAS SHOWS INCREASED
MORTALITY**

14. SARS-COV-2
FACTS
Amount of people infected with virus is
grossly underreported due to factors such
as lack of testing and broad spectrum of
clinical presentation.
Clinical spectrum can range from
asymptomatic to death resulting from
infection.
Elderly and persons with comorbidities are
overrepresented in mortality rates.
Appears that younger population,
specifically under 10 years old, have some
sort of immunity to virus. This is possibly
due to infection from other coronavirus
types. Children remain a vector.
Complications from virus are largely
pneumonia and ARDS. Possible
phenomenon of “cytokine storm”.
Polymerase chain reaction (PCR) testing is
presumed to be approximately 75%
sensitive and 100% specific in symptomatic
patients.
Reported large false positive rate, up to
50%, in PCR testing of asymptomatic
patients.
Public health strategy has moved from

15. SARS-COV-2 FACTS
The vast majority of infected, patients >80%,
do not require hospitalization.
Of those who are hospitalized,
approximately 10-20% were admitted to the
ICU.
Of those approximately 3-10% require
intubation.
Of hospitalized patients approximately
2– 5% die.
All studies show that with proper PPE, the risk
of transmission to healthcare workers is
extremely low. To be clear, zero cases have
been reported in most studies.

16. HOW IS THIS
VIRUS
TRANSMITTED?
Primary human transmission is from
person to person via large droplet.
This risk is typically regarded as
being within six feet of the patient.
Airborne transmission is
controversial and there is no
evidence that this is possible under
normal circumstances. Special
consideration should be taken when
performing procedures that can
produce aerosols. Contact
transmission has also been
demonstrated via “fomite to face”
route. The virus, in droplets from
infected patients, are speculated to
survive up to ONE WEEK on surfaces
and could potentially last longer.
Typically a person touches a
contaminated surface and then
proceeds to bring that hand in

17. HOW DO WE
PROTECT
OURSELVES?
Prescreening is being performed by
dispatchers based off predetermined
questioning. Ideally, dispatch will notify you
of a potential exposure risk prior to reaching
your destination. PPE should be donned prior
to entering a destination or encountering a
potentially infected person. Prescreening
may fail to identify a hazard. If identified
during clinical exam or other scene
information, retreat will be made in order to
don proper PPE. During routine patient
contact, current recommendations include
donning eye protection, a surgical mask,
gloves and a disposable gown. If performing
an intervention or procedure that carries a
risk of aerosolization of airway secretions
(nebulizer treatments, CPAP, intubation, any
oxygen therapy), an N95 respirator is
recommended. Some guidelines are
recommended covering of hair and shoes,
however, is not universally accepted at this
time. Paramount to keeping yourself from
contamination is proper doffing of PPE after
potential exposure. The latest infection
control guidelines can be found here.

18. INFECTION
CONTROL
Mitigating your risk can be accomplished by
simple procedures:
All potentially contaminated
equipment and surfaces must be thoroughly
cleaned. Thankfully, this virus is killed rapidly
with standard cleaning and disinfecting
procedures.
Basic hand hygiene is of paramount
importance.
Attempt to avoid touching your face
(nearly impossible).
Being vigilant in laundering any
clothing after possible or known exposure.
Donning appropriate PPE.
Doffing PPE effectively and at the
appropriate time.

19. TRANSPORT
CONSIDERATIONS
Consider hospital
capabilities in your
service area.
Guidance can always be
provided by contacting
medical control.
**PRENOTIFICATION OF
RECEIVING FACILITY IS
A MUST**

20. HOW DO WE PROTECT
OUR FAMILIES AND
FRIENDS?
Unfortunately, our exposure
to this disease puts our
friends, family, patients and
anyone we encounter at risk.
We can mitigate this risk by:
 Proper hand washing
techniques and frequency.
 Ensuring proper PPE is
utilized at work.
 Removing work clothing at
work / showering at work (if
possible).
 Removing work clothing in
initial household entry area
and showering upon
entering your home.
 Disinfecting equipment and
worn items such as watches,
stethoscopes, keys, etc.

21. DISPELLING MYTHS
A vaccination will be soon available.
Even optimistic projections predict a vaccine will be
available and approved in approximately one year.
Conservative estimated see a commercially available vaccine in
18 – 24 months.
Antibiotics are an effective treatment.
This disease is viral in nature, so antibiotics are not
effective. Antibiotics will only improve outcomes if a patient is
suspected to have a coinfection.
Herbal and other remedies are effective treatments.
There is no current literature supporting this claim.
Pets can be a vector of transmission.
No current literature supports this claim.

22. DISPELLING MYTHS
The elderly are only affected by this disease.
While they are disproportionately represented in
mortality rates, young and healthy people can become severely ill
and even die from infection. Furthermore, all persons have a duty
to take precautions as to lessen their ability to infect the at-risk
populations.
This virus will die as warmer months approach.
There is no current evidence to support this.
Furthermore, other epidemics occurred primarily during the
warmer months. While it is true that flu season ends during
warmer weather, we do not know if this will translate to this virus.
Packages from high risk countries should not be handled.
All evidence shows no risk and no cases of infection
from handling packages sent from countries with known novel
coronavirus outbreaks.
Routine facemask usage will lower my risk of catching this virus.
No current evidence supports this claim. On the
contrary, these masks may serve as a surface for the virus to live
and, if not removed properly, infect a person through mucous
membrane contact.

23. WHAT DO WE TELL THE
PUBLIC?
EMS is often the first healthcare
provider patients and families
contact. Due to us being public
figures, people seek guidance from
us regarding situations such as this.
Avoid mass gatherings and practice
social distancing.
Be diligent in basic hygiene.
Masks are not recommended for
general use and do not decrease
infection risk of population.
Mass purchasing of medical supplies
decreases availability for those who
need them.
”Panic purchasing” has widespread
effect.
Utilize hospital only if severe
symptoms occur, medical advice
should initially be sought by
telephone.
Self isolation / quarantine with OTC
medication therapy is best practice
for those with mild, moderate
symptoms.
PCR testing will not occur in most
people, especially those who are
asymptomatic.
Most importantly, ensure the public
that EMS is always prepared and
capable to answer their call.

24. QUESTIONS,
CONCERNS,
COMMENTS
This topic is extremely important to me,
as it should be to you. I am a street
paramedic just as most of you are. If
there are any questions, comments or
concerns please do not hesitate to
reach out to me. If you have any
suggestions, best practices or other
information I would love to hear from
you.
Contact information:
 Cell - 516-425-2715
 Email - BJohnson6272@gmail.com