Emergency Medical Services (EMS) Agency

CASE OF THE MONTH – JULY 2019

Case Presentation:

Paramedics respond to a home where a 43-year-old male is complaining of fever and body aches.  His friend reports that he has had fever, headache, muscle soreness and fatigue for the past several days and seems to be getting worse.  According to the friend, he arrived in Los Angeles 9 days ago and they think he may have “caught something on the plane” given his long overseas flight.  He is visiting friends in Los Angeles and planning to return home to the East Coast next week.  The patient is lying down in the bedroom but is alert and able to answer questions.

EMS personnel should ask about his travel history.  A travel history should be an essential part of this patient’s assessment.  It is very possible that EMS personnel won’t know the travel history of a patient prior to arriving on scene.  For patients that have recently traveled internationally, it is important to keep a broad differential diagnosis and consider uncommon causes of febrile illnesses that are endemic to other parts of the world and that may be communicable.  In this patient, EMS personnel should keep a distance of at least 6 feet or more until a travel history is obtained.

When asked about recent travel, the friend tells paramedics that the patient is a journalist and has traveled to Kenya and the Democratic Republic of Congo (DRC) with layovers in Europe.  He left the DRC 11 days ago.  The friend is quite worried stating, “at first I thought he just had the flu.  I know there is Ebola there.”

The ongoing 2018-2019 outbreak in the DRC is currently the second largest outbreak in history, exceeded only by the West African Ebola outbreak of 2014-2016.   As of June 11, 2019, the World Health Organization (WHO) reported a total of 2084 EVD cases, with 1990 confirmed and 94 probable cases.  A total of 1405 deaths were reported, including 1311 deaths among confirmed cases. Overall 67% of cases will result in patient death1.

 

The risk assessment for the DRC and its region remains high, but the global risk assessment remains low2. However, half of the deaths occur in the community, either in homes or health care facilities not equipped to handle Ebola, potentially increasing the risk of transmission2. The high rates of population movement from outbreak affected areas to other areas of the DRC and to neighboring countries also enhances the risk1.

It is important that EMS personnel and base hospitals are able to identify, isolate, and inform the appropriate authorities of a suspected Ebola patient. If Ebola is suspected, EMS personnel must protect themselves by donning the appropriate level of PPE. Face shield, N95 mask, outer gown, gloves, and boot covers are recommended for “dry patients”(patients in the initial phase of the disease not exhibiting “wet” symptoms, such as vomiting, diarrhea, and/or bleeding). If a patient is exhibiting “wet” symptoms, EMS personnel must don the appropriate level C or level B PPE ensemble, which may include, a powered air purifying respirator (PAPR) with hood and coveralls or a self-contained breathing apparatus (SCBA). If PPE is not readily accessible, a safe distance of at least 6 feet must be kept between EMS personnel and the patient.

 

Once the appropriate level of PPE is donned, no more than 2 EMS personnel should have direct contact with the patient. EMS personnel should isolate the patient by ensuring that others on scene do not come in close contact with the patient.

 

In Los Angeles County, EMS personnel must inform the appropriate authorities by calling the Medical Alert Center (MAC) at (866) 940-4401 to report a suspected Ebola patient. Base hospitals must also call the MAC if they receive calls from the field on suspected patients. The MAC will place the caller in contact with the Department of Public Health Acute Communicable Disease Control (DPH-ACDC) Administrator on Duty (AOD) to determine if the patient is a true suspected EVD case. Arrangements for transport to an ETC will be initiated by DPH-ACDC AOD if needed.

A person becomes infectious once signs and symptoms of the disease begin to manifest. The incubation period for the virus is 21 days, however, symptoms appear on average within 8 to 10 days of exposure3. Signs and symptoms of EVD occur in three phases: Initial, gastrointestinal, and late. In the initial phase, patients present with non-specific flu-like symptoms: fever, fatigue, muscle soreness, and headache.

In the gastrointestinal phase, patients present with abdominal pain, nausea, vomiting, and diarrhea. Bleeding from mucous membranes, such as the nose, mouth, eyes, and anus may also be present.

In the late phase, patients begin to deteriorate with neurological manifestations, such as confusion, depressed consciousness, and seizures, along with massive internal bleeding, and multi-organ failure.

A patient that presents with any of these signs and symptoms and a positive travel history to the DRC, should be considered a suspected Ebola patient. The appropriate actions must be taken to protect personnel and prevent the spread of the disease.

Based on travel history and symptoms, EMS providers determine that this patient is a suspected Ebola patient.  Paramedics don appropriate PPE for this patient with “dry symptoms”:  N95 mask, face shield, gloves, outer gown and boot covers. The patient is isolated from others in the home.  The patient’s vital signs are BP 135/76, HR 134, RR 24, O2Sat 99%.  The MAC is contacted.

In 2014, the Department of Health and Human Services (HHS) recognized the need to improve the nation’s Ebola response capabilities. As a result, Congress appropriated emergency funding to ensure that health care systems are adequately prepared to respond and medically treat suspected and confirmed Ebola patients4.

As a recipient of the Hospital Preparedness Program (HPP) Ebola Preparedness and Response Activities funding, the Los Angeles County Emergency Medical Services (EMS) Agency, together with the Department of Public Health (DPH), worked to establish a coordinated system to respond to Ebola and other emerging infectious diseases (EID). This system includes a robust EID response network of four medical facilities capable of treating Ebola patients, three ambulance companies designated for transport, and six specially designed high-risk ambulances (HRA) dedicated to transports these patients.

Ebola Ambulance inside Ebola ambulance

 

There are four medical facilities designated to care for patients with Ebola or other EID – Cedars Sinai Medical Center (CSM), Kaiser Permanente Los Angeles Medical Center (KFL), Ronald Reagan UCLA Medical Center (UCLA), and Children’s Hospital Los Angeles (CHLA). CSM is the Regional Ebola Treatment Center (RETC) designated by the federal government, and can take two patients from anywhere within HHS Region IX: California, Nevada, Arizona, Hawaii, American Samoa, Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall Islands, and Palau. KFL and UCLA are state designated Ebola Treatment Centers (ETC) capable of accepting a single patient anywhere within the state of California. CHLA is an Ebola Assessment Hospital (EAH) for pediatrics. An EAH can evaluate and care for a patient for up to five days until a diagnosis is either confirmed or ruled out. Once confirmed, the patient is transferred to an RETC.

The high-risk ambulance providers are McCormick, CARE, and American Medical Response (AMR). These ambulance providers have personnel trained in donning and doffing of EID personal protective equipment (PPE), breach protocols, and spill management. They also participate in exercises and drills with the regional ETCs and EAH by familiarizing themselves with patient drop off location and practicing patient hand off and communication with hospital personnel.

Each ambulance provider has two HRAs strategically deployed throughout Los Angeles, Orange, and Ventura counties. These ambulances are specially designed for easy cleaning and disinfection. The driver compartment is completely separate from the patient compartment with its own ventilation/HVAC system so that the driver does not have to wear PPE. These high-risk ambulances have been described as a negative pressure room on wheels. The patient compartment remains relatively cool, which is especially beneficial for those in PPE since over heating is a potential risk while working in PPE.

EVD Guide –click the image for more detail

Figure 1. 911 EMS Provider Ebola Virus Disease (EVD) Patient Assessment and Transportation Guidelines

Paramedics contact the Medical Alert Center (MAC) at (866)940-4401 and report the patient as a suspected Ebola patient.  The MAC places EMS personnel in contact with the Department of Public Health Acute Communicable Disease Control (DPH-ACDC) Administrator on Duty (AOD) to discuss the case.

DPH confirms that this patient is a suspected EVD patient and arranges for a high-risk ambulance (HRA) to be dispatched to the scene.  The patient is transported to a Regional Ebola Treatment Center (RETC) or further evaluation.

EMS personnel remain on scene until the HRA arrives providing patient care as indicated with appropriate PPE and continuing to isolate the patient from others.  When HRA personnel arrive on scene, EMS personnel relinquish care, safely doff PPE, and document the patient encounter per departmental policies.

EMS personnel with direct patient contact immediately follow up with their department’s occupational health services and healthcare worker monitoring is initiated by DPH-ACDC for 21 days post exposure.

EVD is a highly infectious and deadly disease, but through education and awareness of the resources available within the county, the spread of infection can be prevented.

There is a current EVD outbreak in the Democratic Republic of Congo (DRC).   The risk assessment for spread of EVD in the DRC and its region remains high, but the global risk assessment remains low.  Persons with symptoms and confirmed travel to DRC within 21 days meet suspected EVD criteria.

2.  EMS and base hospital personnel must be able to identify, isolate and inform appropriate authorities of suspected EVD patients.

3.  If a suspected EVD patient is encountered by EMS in Los Angeles County, this must be reported IMMEDIATELY to the Medical Alert Center (MAC) at (866)940-4401.

4.  The MAC will coordinate communication with DPH and deployment of a HRA if indicated so that a suspected patient can be transported to an appropriate receiving center equipped to care for a suspected EVD patient.

References

1. Ebola virus disease – Democratic Republic of the Congo Disease outbreak news: Update. June 13, 2019 (n.d.). Retrieved from https://www.who.int/csr/don/13-june-2019-ebola-drc/en/

2. Ebola outbreak in DRC: Crisis Update May 2019. (n.d.). Retrieved from https://www.doctorswithoutborders.org/what-we-do/news-stories/news/ebola-outbreak-drc-crisis-update-may-2019

3. Center for Disease Control and Prevention, Ebola Virus Disease. May 22, 2018. https://www.cdc.gov/vhf/ebola/symptoms/index.html

4. Hospital Preparedness Program Measure Manuel: Implementation Guidelines for Ebola Preparedness Measures, Version 8, U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, May 2017. Accessed on: May 18, 2017. [Online]. Available: https://www.phe.gov/Preparedness/planning/sharper/Documents/hpp-mmi-guide-ebola-508.pdf