COVID-19 and Emergency Medical Services in Northern New York

Mark Deavers & Melissa Brook

In August 2020, during the middle of the COVID-19 pandemic, an ambulance crew is dispatched to an unresponsive male patient. It is their agency’s first call in almost 36 hours. The crew responds and finds an elderly male who is barely responsive with rapid shallow breathing. The patient’s wife states that he cut his hand while working in the shed last week and she thinks the wound has become infected. The crew investigates and sees a poorly healed 4-5 inch cut on the patient’s left hand, yellow puss is oozing from his hand and red lines are traveling up his left arm. The patient’s wife states that he has been sick for 4 or 5 days with vomiting and chest pain but he refused to go to the hospital because he was afraid of contracting COVID.

She found him collapsed on the floor this morning and thinks he may have fallen after getting up during the night. After their initial assessment, the EMS crew measures the patient’s heart rate, blood pressure, oxygen saturation, exhaled carbon dioxide, and blood sugar. The crew administers oxygen to support the patient’s breathing; they complete and interpret a 12 lead EKG, obtain IV access, and give the patient IV fluids.

The ambulance crew then wraps the patient in blankets and lifts him to a stretcher. He is moved an ambulance and the crew transports him to the nearest hospital. Over the 15-minute trip, the crew continues to administer oxygen and IV fluids and they alert the hospital that they are bringing in a patient with possible sepsis, an infection that may have spread throughout his organ systems. The patient is then flown to a larger trauma center where he is admitted on IV antibiotics and remains in the hospital for 5 days until the infection is under control. He is discharged with another 10-day course of oral antibiotics, he receives daily wound care to manage the infection in his hand, and he attends follow-up consultations with a cardiologist to assess any damage the infection may have inflicted on his heart.

While this a fictional example, ambulance services across Northern New York witnessed cases like this throughout the COVID-19 pandemic. Minor or routine medical events became complicated and even life threatening because patients fearing COVID-19 avoided seeking medical care. These conditions could have been entirely preventable if treated appropriately and earlier. While most of these patients did not have COVID-19, their fear of contracting and spreading the disease to their families dissuaded them seeking medical help when they needed it.

The concept of 911 medical emergencies is straightforward. Someone has an emergency, they call 911, a dispatcher answers, and then an ambulance responds. EMS responders spend hours training and preparing to respond to emergencies to support our communities; we then transport our patients to the hospital while providing high quality out-of-hospital care. When the news of COVID-19 hit, we spent days and months preparing to address the crisis. We were told the calls would come in faster than we could handle and we would be rapidly overwhelmed. We trained with the limited information available. We did what we could to obtain personal protective equipment for our crews, despite the rising costs on our shoestring budgets, we adapted and changed our care protocols, and then we waited, and waited. In metropolitan areas, the 911 calls were coming in faster than dispatch could send ambulances but in rural areas we saw our lowest call volumes in a decade.

The lack of emergency calls can be attributed to the fear our communities had about COVID19. But emergencies did not go away. In fact, emergency medical services were still needed but in different ways. Routine medical care was ground to an almost complete halt while people sheltered at home. Years of public education invested in getting patients to seek assistance early, to recognize signs of life threatening illness, and to trust healthcare providers fell by the wayside. People who were to afraid to go to the hospital stayed home. When the 911 calls did come, many of them were too late.

This isn’t what we trained for. This isn’t why we had advocated early recognition of strokes, heart attacks, and other medical emergencies. We are here to help people and to improve outcomes not to watch at-risk patients stay home and wait to seek medical care until they are horribly sick. Patients missed important appointments, didn’t get refills of important medications, didn’t get labs drawn, missed cancer screenings, avoided physical therapy treatments, and missed follow up care. Some of these effects will be seen in the months and years after the pandemic is over.

We sat in our stations, frustrated for lack of a mechanism that would allow us to help housebound patients. We were also afraid – afraid for our staff, our selves, and our families. Unlike hospitals, ambulances are not engineered with robust negative pressure systems, there are no specialty areas to don and doff PPE, and no special bay at the hospital after a call to adequately clean our ambulances. Yet, unable to treat patients in their homes we took patients into our ambulances and drove them to the hospital.

Early in the pandemic, transporting a patient with a suspected case of COVID-19 was considered “contact” even if the crew had fully donned personal protective equipment including N95 facemasks. Each crew was then quarantined and taken out of service for two weeks. The policy showed a complete disconnect and a remarkable lack of understanding between public health and EMS. Fortunately CDC guidance reversed this policy but only after quarantine polices exacerbated the exodus of volunteers from EMS and the pandemic made it impossible to attract and train new entrants. For three or four years before the start of the pandemic, rural EMS was on the brink of failure. After COVID, there is fear that this may be a point of no return for many small rural agencies.

In other areas of the country, there is an infrastructure that allows for EMS to be integrated into public health. New York is not one of those states and St. Lawrence County is not one of those counties. EMS providers have been trained to do complex assessments, draw blood for lab tests, conduct EKGs, treat basic wounds, provide routine medications, and follow up with patients and providers. But when these services were most needed our healthcare infrastructure was unable to innovate.

Our communities quickly adopted and adjusted to new technologies for school, talking to friends, shopping, and working from home. But we did not consider EMS assisted telemedicine. Our EMS agency saw so many ways we could have been of assistance. We knew which of our patients were at higher risk, we knew the patients we visit regularly, we knew which patients we could help. But our region had no mechanism or process that would enable us to help the very patients with whom we already had existing, trusting relationships.

On the one hand it seems simple, why didn’t we just drive around and meet our patients? Why not phone patients and arrange weekly check ins with them? The answer is policy-driven. New York State and St. Lawrence County only allow EMS to visit patients if we have been dispatched from 911 services. We have no authority and most importantly no ability to provide assistance unless a patient calls 911 and our EMS agency is officially dispatched to an emergency call.

How could things be different? How could our health system have leveraged our existing patient relationships, advanced training, and community knowledge? How could we have better avoided a situation where sick patients hid at home avoiding medical care while talented and caring EMTs and paramedics sat under-utilized in fire stations and rescue squads?

The calls we did answer had similar concerns. We comforted scared patients and families who were afraid their loved one would contract COVID if they went to the hospital. We tried to advocate for safer procedures and policies to protect patients and pre-hospital providers from incidental exposure. We tried to convince patients to attend routine medical appointments. Patients with chronic lung problems could easily screen “potential positive” for COVID-19 and were told to wait at home, rather than come to clinics so as not to infect the offices. Patients were directed “to seek emergency medical care” only when their symptoms were dire.

A close friend of ours experienced this personally: When faced with a seasonal asthma exacerbation, she was unable to obtain medication that would manage her symptoms unless she was physically seen by her primary care physician. Yet, when she reported asthma-like symptoms to her physician she was quarantined and forced to wait for COVID-19 test results. Her test was one of hundreds in a backlog of tests that were slow to be processed. In the time she waited, her symptoms turned from a simple asthma exacerbation to more serious bronchitis and our health system offered her no ability to consult a clinician to treat a known and relatively routine yearly problem outside of an emergency room.

The “F words” are how we describe the early days of COVID. Frustration and fear. Frustration knowing there were so many things we could do better. Frustration knowing there was no way we could change, adapt, or accomplish better patient care under the way EMS is structured in New York State. Frustrated as we watched EMS in other jurisdictions transition to  “Community Paramedicine” practices wishing we could do the same.

We watched with awe and jealousy as community paramedics in other jurisdictions treated patients in their homes, usually via a video telemedicine consult with an emergency physician. Community paramedicine programs send trained paramedics to patients’ homes. The paramedic conducts an initial patient assessment and then arranges a telemedicine consultation between a physician and the patient. These home visits can alleviate patient anxiety and fear and can result in patients being treated in the safety and comfort of their own home. With the physician’s guidance, the paramedic provides care, draws labs, and helps patients get prescriptions, all from the safety of their living room. This time tested, value proven approach to community care has been proven in much of rural America. Could it have improved patient care and saved lives in Northern New York?

Rural paramedics know the highest risk patients in their communities, not just for contracting COVID-19, but the highest risk patients that need medical care on a routine basis. Rural paramedics know the name, address, age, and anxieties of these patients and their various and comorbid diseases: diabetes, congestive heart failure, and chronic bronchitis. We know the medical needs in our communities better than anyone. We know which patients have difficulty taking their medications and those who cannot afford their medications. We know which patients miss their follow up appointments and who routinely miss their dialysis appointments. We know which patients should not be out in the community because they have a high risk of negative outcomes from COVID-19.

In the early days of the pandemic, we worried about how our home-bound patients would get their medications and their lab work. As the fear of contracting COVID-19 abated, we worried more, as we saw these high risk patients returning to normal activity, some suffering from quarantine fatigue. We saw these patients out at the grocery store before our shifts and while they walked around our neighborhoods for exercise. We saw them grow comfortable that the pandemic had passed and left rural upstate New York relatively unscathed. We worried more, because many people in rural areas have close ties to their families, we had seen the small smoldering areas of COVID19 in our communities, not enough to cause concern for the general public, but close enough for us to still be cognizant of its presence.

As the second (and third) wave gripped parts of the nation, rural areas were still managing the consequences of a first long-drawn-out pandemic wave. Through all of this we recognized again and again that EMS was not being used to our full potential. Symptomatic patients were forced to contact EMS (whose personnel risked their own health) in order to be transported, tested, and then receive a diagnosis at the local ER. Why not simply test patients in their homes? Why not follow up with them, conduct daily check-ins, and help treat some of their more minor symptoms while they healed at home? Why not save space in our over-taxed hospitals for the most sick and allow people with minor and moderate cases to be treated at home?

Once the pandemic took hold in Northern New York, our public health system, already strapped for resources, buckled and nearly broke from the influx in cases. Patients were not being contact traced for 7, 8 or even 10 days after an initial exposure resulting in dozens of more exposures. A nearby college had mass testing after researchers found COVID-19 in the campus wastewater. Locking down the campus and quarantining everyone put large groups of people in closed quarters while public health struggled to test them all. All the while, EMS was sidelined.

We need to take a hard look at how the EMS system is designed in rural New York. At the early stages of the COVID pandemic many states issued temporary authorization for EMS to “treat in place, ” provide at home COVID testing, and eventually provide people immunizations at home. The idea of “triaging” patients out of transport is not unique in many other countries, However, in America the EMS system is built to foster patient transportation. Picture this: A patient with shortness of breath is met at home by a paramedic who evaluates the patient, does a rapid COVID-19 test, consults with a physician through telemedicine, delivers respiratory treatment, and antibiotics, then helps the patient to make an appointment with their primary care provider. In many parts of the world this already happens. However in rural New York this is a novel and perhaps even impossible idea without plans, polices, education, or funding. Yet, the public trust and understanding are already in place. For over a decade, community paramedicine, mobile integrated healthcare, or mobile medicine has been proposed as an option for preventative care and treatment for minor conditions in rural areas, however medical unions, hospital associations, hospital finance offices, and regulators fight the idea.

So how does this help during a pandemic? The system exists, the infrastructure exists, and the training exists. The worried well, the minimally symptomatic, and those who require minimal treatment are treated at home. This frees up emergency and inpatient beds for those who actually need them.

In a robust community paramedicine system, EMS would have the ability to continue to serve their community. We would be able to assist patients in refilling medications, keeping continuity of care with their primary care provider, and ultimately, hopefully, be called to our patients in need before it is too late. Our patient relationships would be more than just a “ride to the hospital.” We would be a lifeline for patients to safely access care when they otherwise are unable to leave their homes. The pandemic has opened doors for many services to be delivered to the homes of people in need; if Uber is able to deliver dinner, why can’t we, as a system, deliver health care to someone’s living room?

Our experiences with COVID-19 taught us that not everyone who calls 911 needs to be transported to a hospital; that hospitals do not function at their best when they are inundated with patients seeking primary care, diagnostic tests, or reassurance; and that patient care suffers when our medical systems are unable to innovate, evolve, and transform to meet new challenges and societal dynamics.

We look ahead to a new community-based EMS system that will allow patients to receive care where they are comfortable and where it is best for them. We look toward to a system that will allow members of our community to have their questions answered at home, allow for home-based follow-up care, routine check-ins, lab draws, and welfare checks. Incorporating technologies such as telemedicine, we can provide a conduit to a safe and reliable health encounter. EMS providers in Northern New York are committed to our communities and their health and welfare. For all the tragedy COVID-19 caused, it also pointed toward an improved out-of-hospital community healthcare system that puts patients at the center of their care.

Mark A Deavers is a Paramedic and Director of Gouverneur Rescue. Melissa Brook is a Paramedic with Gouverneur Rescue. For more information, please see www.gvrs-ems.org