Emergency service workers should limit resuscitation efforts to some cardiac arrest patients to reduce firefighters’ and medics’ exposure to the coronavirus while still providing care to sick patients, according to new guidelines issued by the El Paso County Board of EMS Medical Directors.
Under the guidelines, first responders can end CPR earlier than they would typically if they believe their efforts are futile, said Dr. Stein Bronsky, co-chief medical director at El Paso County American Medical Response.
“We’ve always wanted to do everything, because why not? What if you can have that one-in-a-million save that everybody would be really happy about?” Bronsky said. “But in this day and age, when those types of procedures like resuscitating someone in cardiac arrest create an extremely high risk and exposure to the providers, we have to balance the risk to the providers against the known save rates on some of these patients.”
The committee — about 12 medical professionals who oversee the majority of EMS and fire districts in El Paso and Teller counties — issued the guidelines April 13 after seeking feedback from local first responders and analyzing data that helps predict which patients are most likely to benefit from resuscitation efforts.
Bronsky, an emergency medical physician at Centura Health, said the changes were also based on projections that the infection rate would spike in the Pikes Peak area and drastically jeopardize first responders' ability to do their jobs.
“No one has a crystal ball, so you have to plan for the worst but be realistic about it,” he said, citing New York City, where thousands of first responders became infected with the virus and slashed the amount of ambulances on the city’s streets. Nearly 20% of the FDNY's EMS staff was out sick, including those diagnosed with COVID-19, NPR reported this week. A similar percentage of NYPD officers had tested positive for the virus earlier this month, according to CNBC.
To limit exposure among first responders, New York state officials directed rescuers not to try to revive anyone without a pulse during the pandemic, the New York Post reported. Previously, paramedics were advised to spend up to 20 minutes trying to revive someone in cardiac arrest. The controversial guideline was later scraped.
While the interaction with COVID-19 patients is high for first responders in Colorado Springs, none had tested positive as of Friday, said Dr. Matt Angelidis, co-medical director for Colorado Springs Fire Department and AMR.
The use of personal protective equipment among medics, as well as the new guidelines, were proactive measures to help balance the risk for first responders, said Angelidis, who is also the UCHealth EMS medical director.
The guidelines recommend medics only use chest compressions and avoid mouth-to-mouth resuscitation for adult cardiac arrest patients. Rescuers can also apply masks with a continuous flow of oxygen, which work in a similar way to those carried on airplanes in case the cabin pressure drops.
A covering should be placed over the patient's mouth and nose to prevent exhaled air that could contain droplets with the virus.
Though a majority of the reaction was positive, the board received some criticism from first responders who didn’t agree that the guidelines were appropriate for all cardiac arrest patients, Angelidis said.
“We had to come back and make it very clear to them: These are guidelines, and I think that immediately alleviated the far majority of negative feedback,” he said. “We recognize that it was a missed message from us as we were very urgently trying to get these changes out.”
The guidelines were tough to swallow for several firefighters, who are often relentless in finding a solution to a problem before giving up, said Dave Noblitt, president of the Professional Firefighters Association, IAFF Local 5.
Before coronavirus concerns, firefighters used to work cardiac arrests for up to an hour, if necessary, Noblitt said.
“It’s really difficult to turn our hearts off and say, according to the data, the science, the numbers, these are the probabilities and outcomes. Our hearts say, 'No, we want to do everything we can possibly do, because what if? What if the one-in-a-thousand or one-in-a-hundred-thousand probability of something happening, happens?'
“Firefighters want to fix things and it is really hard to say, we’re going to hold short."
Per guidelines, medics should not try resuscitating an unwitnessed cardiac arrest patient who is 73 years of age or older, who is showing signs and symptoms of COVID-19 and has a nonshockable heart rhythm.
Even so, EMTs can use their discretion, Noblitt said.
“That’s the reason why our paramedics go through so much training — to be able to make those decisions that are critically important to the patient and give them the best chance, but at the same time, realizing that resuscitation efforts just will not be successful,” he said.
New safety equipment has also helped reduce transmission between a sick patient and a first responder in an ambulance.
UCHealth donated more than 50 “Airway Safety Boxes” to EMS agencies and hospitals across southern Colorado, Angelidis said. The clear, plastic hood is placed over a patient’s head during intubation to provide an extra protective barrier.
Angelidis said they are also waiting to receive filters that can be applied to a patient’s breathing device, so that the virus is not spread around the ambulance or into the faces of firefighters or medics.
Ten days ago, he thought that all intensive care units would be overrun and unable to provide emergency care. Instead, the rate of spread within the community has slowed significantly over the last week.
As new equipment and new information about the spread of the virus become available, protocols will be revised, he said.
In the meantime, firefighters and paramedics will continue working with gnawing fear of becoming infected, Noblitt said.
“It does weigh on first responders’ minds, but at the same time, we do what we can,” he said. “We take the appropriate precautions, utilize all of the PPE available to us and we step out to do what we were called to do, which is to provide the services to the citizens.”
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