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Defending the front lines during the COVID-19 pandemic: Protecting our first responders and emergency medical service personnel

      This is the first wave of COVID-19, indicating an impending second wave set to emerge in the coming winter [
      • Moreno J. Edward
      Fauci: second wave of coronavirus ‘inevitable’.
      ]. Along with the concern for additional outbreaks, studies are showing inconclusive evidence regarding the effectiveness of antibody-mediated immunity in those recovered from COVID-19 [
      ‘Immunity passports’ in the context of COVID-19.
      ]. The possibility of reinfection combined with another wave of COVID-19 further supports the need to protect our frontlines. The number of COVID-19 cases continues to rise to 1,053,036 infected people and a quarter-million deaths [
      COVID-19 map.
      ]. Given this situation, it is imperative that our frontlines are protected physically and mentally.
      Though EMS protocols were established for an infectious disease outbreak, the magnitude of this crisis left our first responders with significant safety considerations [
      • Isakov Alexander
      • J. H. (TRACIE)
      EMS infectious disease playbook.
      ]. This raises the question of how first responders ought to respond to calls during this pandemic to prevent patient-to-patient and patient-self transmission. Since only 43.8% of COVID-19 patients present with a fever, EMS must proceed with caution [
      • U.S. Department of Health and Human Services
      COVID-19 pre-hospital/emergency medical services (EMS) resources.
      ]. The use of PPE at all times is crucial to the protection of our frontlines, however, there is a massive PPE shortage [
      • U.S. Department of Health and Human Services
      COVID-19 pre-hospital/emergency medical services (EMS) resources.
      ,
      • Ranney M.L.
      • Griffeth V.
      • Jha A.K.
      Critical supply shortages — the need for ventilators and personal protective equipment during the Covid-19 pandemic.
      ]. The incredible global demand for PPE has led to worldwide shortages. Our frontlines are experiencing a lack of adequate N-95 respirators, gloves, face shields, and gowns [
      • Ranney M.L.
      • Griffeth V.
      • Jha A.K.
      Critical supply shortages — the need for ventilators and personal protective equipment during the Covid-19 pandemic.
      ]. In an effort to address this gap in supply and funding, the government increased PPE orders and provided $100 million dollars specifically for EMS to purchase PPE [
      COVID-19 appropriations legislation with funding for AFG expected to be enacted.
      ].
      Current EMS PPE strategies are focusing on reducing the number of responders needed to successfully care for a patient [
      • Center for Disease Control (CDC)
      National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
      ]. To reduce risk and PPE use, implementing designated triage centers adjacent to hospitals can expedite COVID testing while restricting possible routes of transmission to EMS staff. Another suggestion involves the use data collection to identify and track hotspots in the city while still working diligently with dispatch to determine the caller's risks of having COVID-19 [
      • Center for Disease Control (CDC)
      National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
      ]. When aware of hotspots, EMS personnel can make informed decisions. A further recommendation focuses on analyzing the data from the current outbreak to better diminish the impacts of the second wave [
      • Center for Disease Control (CDC)
      National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
      ]. With more data analyses, EMS can enforce proactive strategies to increase their efficiency without increasing their personal health risks.
      One EMS institution designed a workforce protection program that includes: wellness screenings before each shift, PPE worn during the entire shift, check-ins for those out sick, rapid testing for those with symptoms, Return to Work program, and providing Hotel Housing options [
      • U.S. Department of Health and Human Services
      COVID-19 pre-hospital/emergency medical services (EMS) resources.
      ]. These EMS resources work to consider the safety of both the frontline workers as well as their families to preserve the EMS workforce.
      Our most valuable resource is our first responders themselves. Without proper PPE our frontlines are at high risk of infection [
      ‘Immunity passports’ in the context of COVID-19.
      ,
      • U.S. Department of Health and Human Services
      COVID-19 pre-hospital/emergency medical services (EMS) resources.
      ,
      COVID-19: strategies for optimizing the supply of PPE.
      ]. The PPE shortage cultivates role strain as first responders, must consider their duties to their patients versus their personal safety as well as the wellbeing of their loved ones [
      • Santarone K.
      • McKenney M.
      • Elkbuli A.
      Preserving mental health and resilience in frontline healthcare workers during COVID-19.
      ]. Addressing this concern, a suggestion is to hire non-EMS drivers in effort to conserve the workforce. In addition to conserving the workforce, it is possible to expand the front lines through the use of telemedicine [
      • Whiteside T.
      • Kane E.
      • Aljohani B.
      • et al.
      Redesigning emergency department operations amidst a viral pandemic.
      ]. By appropriately advising patients when and where to seek care, the EMS patient burden is decreased [
      • Whiteside T.
      • Kane E.
      • Aljohani B.
      • et al.
      Redesigning emergency department operations amidst a viral pandemic.
      ]. Following suit like other EMS institutions, the use of portable decontamination systems, particularly the use of vaporized hydrogen peroxide is recommended [
      • US Department of Homeland Security
      Portable ambulance decontamination systems market survey report. September.
      ].
      To further safeguard the health of our EMS team, their mental wellbeing must be bolstered. The effectiveness of EMS is significantly impacted as more deficits in job performances occur as stress and other negative mental health issues arise [
      • Regehr C.
      • Leblanc V.R.
      PTSD, acute stress, performance and decision-making in emergency service workers.
      ]. There exist stigmas and barriers to mental health care for first responders, causing an increased risk in chronic conditions such as PTSD [
      • Haugen P.T.
      • McCrillis A.M.
      • Smid G.E.
      • Nijdam M.J.
      Mental health stigma and barriers to mental health care for first responders: a systematic review and meta-analysis.
      ]. EMS personnel also experience high levels of stress and depression [
      • Regehr C.
      • Leblanc V.R.
      PTSD, acute stress, performance and decision-making in emergency service workers.
      ,
      • Haugen P.T.
      • McCrillis A.M.
      • Smid G.E.
      • Nijdam M.J.
      Mental health stigma and barriers to mental health care for first responders: a systematic review and meta-analysis.
      ,
      • Substance Abuse and Mental Health Services Administration
      Disaster Technical Assistance Center Supplemental Research Bulletin First Responders: behavioral health concerns, emergency response, and trauma.
      ]. Such health concerns can lead to incapacitated first responders, reducing the workforce [
      • Haugen P.T.
      • McCrillis A.M.
      • Smid G.E.
      • Nijdam M.J.
      Mental health stigma and barriers to mental health care for first responders: a systematic review and meta-analysis.
      ,
      • Substance Abuse and Mental Health Services Administration
      Disaster Technical Assistance Center Supplemental Research Bulletin First Responders: behavioral health concerns, emergency response, and trauma.
      ]. Increasing mental health resources now can prevent current and future burnout and reduce the chronicity of mental health concerns [
      • Haugen P.T.
      • McCrillis A.M.
      • Smid G.E.
      • Nijdam M.J.
      Mental health stigma and barriers to mental health care for first responders: a systematic review and meta-analysis.
      ]. The National Volunteer Fire Council provides a webinar mini-series titled Reset and Recharge [
      COVID-19 information and resources for EMS.
      ]. Additionally, EMS.gov hosts a web page for mental health resources [
      • EMS.gov
      Coronavirus/COVID-19 resources for EMS.
      ]. These resources promote building staff-staff and family-family bonds in order to foster peer support during this pandemic. With peer support, EMS and first responders can connect with additional resources while also providing each other with a source of mental/emotional support.
      During this pandemic, our frontlines have taken on a huge role in serving and caring for the population. We must take the necessary steps in providing ample resources and strategies for our EMS. Preparing for the next wave of COVID-19 includes anticipation of workers' needs, flexible plans and sustainable protocols and equipment [
      • U.S. Department of Health and Human Services
      COVID-19 pre-hospital/emergency medical services (EMS) resources.
      ,
      • Ranney M.L.
      • Griffeth V.
      • Jha A.K.
      Critical supply shortages — the need for ventilators and personal protective equipment during the Covid-19 pandemic.
      ].

      References

        • Moreno J. Edward
        Fauci: second wave of coronavirus ‘inevitable’.
        TheHill
        thehill.com/homenews/news/495215-fauci-second-wave-of-coronavirus-in-fall-inevitable
        Date: 29 Apr. 2020
        Date accessed: April 28, 2020
      1. ‘Immunity passports’ in the context of COVID-19.
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      2. COVID-19 map.
        Johns Hopkins Coronavirus Resource Center
        coronavirus.jhu.edu/map.html
        Date: 30 Apr. 2020
        Date accessed: April 30, 2020
        • Isakov Alexander
        • J. H. (TRACIE)
        EMS infectious disease playbook.
        2017: 86 ([accesses April 30, 2020])
        • U.S. Department of Health and Human Services
        COVID-19 pre-hospital/emergency medical services (EMS) resources.
        ASPR TRACIE
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        Date: Apr. 2020
        Date accessed: April 29, 2020
      3. COVID-19: strategies for optimizing the supply of PPE.
        Centers for Disease Control and Prevention
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        Date: 22 Apr. 2020
        Date accessed: April 30, 2020
        • Ranney M.L.
        • Griffeth V.
        • Jha A.K.
        Critical supply shortages — the need for ventilators and personal protective equipment during the Covid-19 pandemic.
        N Engl J Med. 2020; 41: 1-2https://doi.org/10.1056/NEJMp2009027
      4. COVID-19 appropriations legislation with funding for AFG expected to be enacted.
        National Volunteer Fire Council
        www.nvfc.org/covid-19-appropriations-legislation-with-funding-for-afg-expected-to-be-enacted/
        Date: 30 Mar. 2020
        Date accessed: April 30, 2020
        • Center for Disease Control (CDC)
        National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
        (Updated March 10, 2020)
        • Santarone K.
        • McKenney M.
        • Elkbuli A.
        Preserving mental health and resilience in frontline healthcare workers during COVID-19.
        Am J Emerg Med. 2020 Apr 15; (S0735-6757(20)30258-8)https://doi.org/10.1016/j.ajem.2020.04.030
        • Whiteside T.
        • Kane E.
        • Aljohani B.
        • et al.
        Redesigning emergency department operations amidst a viral pandemic.
        Am J Emerg Med. 2020; https://doi.org/10.1016/j.ajem.2020.04.032
        • US Department of Homeland Security
        Portable ambulance decontamination systems market survey report. September.
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        PTSD, acute stress, performance and decision-making in emergency service workers.
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        • Haugen P.T.
        • McCrillis A.M.
        • Smid G.E.
        • Nijdam M.J.
        Mental health stigma and barriers to mental health care for first responders: a systematic review and meta-analysis.
        J Psychiatr Res. 2017; 94: 218-229https://doi.org/10.1016/j.jpsychires.2017.08.001
        • Substance Abuse and Mental Health Services Administration
        Disaster Technical Assistance Center Supplemental Research Bulletin First Responders: behavioral health concerns, emergency response, and trauma.
        2018: 1-15 ([accesses April 30, 2020])
      5. COVID-19 information and resources for EMS.
        National Volunteer Fire Council
        www.nvfc.org/coronavirus-19-information-and-resources-for-ems/
        Date: 23 Apr. 2020
        Date accessed: April 30, 2020
        • EMS.gov
        Coronavirus/COVID-19 resources for EMS.
        www.ems.gov/projects/coronavirus_covid-19_resources.html
        Date: 2020
        Date accessed: April 30, 2020