At the core of the fire service is a unique combination of tradition and innovation.
Our history is filled with solutions that firefighters themselves have developed to overcome the challenges encountered in the course of their duties. And for today’s firefighters, that means stepping up to the many challenges presented by the COVID-19 national emergency.
COVID-19 has presented significant risk to firefighters by effectively turning nearly every call into a hazmat call. All fire departments are now confronted with the problem of how to deliver effective services while keeping their firefighters safe. And once again ground-level firefighters across the country are rising to the challenge by developing tools and techniques to let them continue their vital work keeping communities safe.
Innovation to curb infection
One of the primary problems, especially those providing EMS transportation, is how to protect both patients and care providers from potential infection beyond basic PPE. Part of the problem is that many everyday EMS procedures have the potential to generate significant amounts of infectious aerosols. These include everything from administration of oxygen through simple non-rebreather masks to common ALS procedures, such as nebulized breathing treatments and CPAP devices.
While organizations such as the Center for Disease Control and Prevention (CDC) have provided procedural guidance to minimize risk, much of the guidance is not directly applicable or helpful in field-based emergency services. Simply put, what may work in the hospital won’t necessarily work in the back of an ambulance or in someone’s living room at 3 a.m.
That’s where firefighter ingenuity comes in.
Exhaust fan ingenuity
Firefighter-Paramedic Kari Dickerson of the Hebron Fire Protection District in Kentucky recalled a situation from years ago that led to ingenuity:
“At the very beginning of H1N1, there were concerns that doing neb treatments or CPAP would aerosolize the virus and contaminate everything/everyone in the ambulance. At the time, I was working in a location that had a high prevalence of asthma/COPD/CHF patients, so we couldn’t just NOT do nebs or CPAPs. I couldn’t just sit around and not figure out a solution.
“I remember flipping the exhaust fan switch and making a joke about how I wished we could bring the exhaust to the patient. It kind of snowballed from there. I had a K9 ‘Cone of Shame’ in my trunk from my German Shepherd and a couple rolls of duct tape and a few ratchet tie-downs. About an hour later, we had everything set up. Some of my coworkers thought I was crazy, but when we put it into action, they were impressed.”
The device focused the ambulance exhaust fan directly over the patient’s head to help draw out aerosols immediately as they were generated.
Nick Paproski, a firefighter-paramedic with the Ridgefield (Connecticut) Fire Department and Vintech Management Services, had a similar experience:
“Aerosol generating procedures (AGPs) are now understood to pose a significant risk for exposing medical providers to COVID-19. When I started looking into getting a plexiglass procedure shield, I discovered that no one was making one specifically for the EMS environment. Basically, the ones that are now being mass-produced for hospitals are too wide to fit on EMS stretchers. The other problem is that plexiglass procedure shields take up a ton of storage space that we don’t have on our rigs.
“I mocked up and tested the idea by putting a rescue mannequin on the stretcher and building it around him. I made sure I had enough room to apply the mechanical CPR machine. I even set up the airway mannequin and practice intubating under with the video laryngoscope.”
Fellow Ridgefield Firefighter-Paramedic Timothy Limbos helped refine the idea: “Nick made the first portable version that was made to bring inside the house in the case of a cardiac arrest. While I understood the reason behind it, I saw it as a bit cumbersome and yet another item to bring in along with the bags, monitor, etc. I thought to myself, ‘What about something that can be easily attached to the stretcher and used more in the transport of COVID-19 patients?’”
With his newborn daughter in the neonatal intensive care unit, Limbos says he was constantly thinking of how best to protect himself while continuing to work.
In the end, the crews at Ridgefield developed a device that could be deployed in the field or rapidly attached to a stretcher to provide a protective barrier between patients and the caregivers delivering life-saving interventions.
Patient isolation problems
Some services have gone a step further, creating custom patient isolation areas for use inside their ambulances.
Battalion Chief Cory Sathers of Matanuska-Susitna Borough (Alaska) Emergency Services used a simple drape of painter’s plastic attached to the overhead grab handles in the ambulance to create a large shield that could be quickly dropped if a patient care emergency required it. The interior of the shield was connected to the patient compartment exhaust vent to create a negative pressure area.
“The idea is to provide a safer zone around the patient so we can provide any of the interventions that we normally would, but isolating any of the pathogens from us,” Sathers told KTUU.
Steve Nezat, EMS director for Bossier Parish (Louisiana) EMS, says that in response to safety concerns from front-line medics in his service, they customized a PVC tubing-based patient isolation device, adding ports for medics to attend to patients from outside the device.
Bossier Paramedic Rose Rivera explained how it improves operations: “It is very helpful in isolating the patient and medic from each other and attempting to contain the droplets and other contaminants. I definitely appreciate that our organization has taking our safety into consideration during this time by having these built and installed.”
When asked if she thought the fire service is particularly suited to problem-solving, she replied, “In my experience, we as firefighters have always been able to use the challenge given and innovate whatever equipment that is needed to overcome.”
“When firefighters innovate …”
Tom Bouthillet, battalion chief of EMS for Hilton Head Island (South Carolina) Fire Rescue, agrees: “Firefighters hate two things – change and the way things are. That said, we’ve got some of the most clever and innovative people in the world. When firefighters innovate, it’s a practical application that solves a problem.”
In Bouthillet’s case, that means implementing a variety of innovations, including a vehicle sanitization system using an air compressor and paint sprayer as well as isolation capsules and negative pressure system similar to those used by Bossier Parish and Hebron Fire Protection District.
Bouthillet says that some of the new tools and techniques were first piloted in a reserve ambulance, while others were simply put in place and monitored for success: “The key with this virus is to move fast and keep adapting,” he says, emphasizing that the key to success is, “a preexisting culture of continuous quality improvement.”
As COVID-19 continues to present new challenges to the fire service, new innovations will continue to be implemented. As reports of high-flow oxygen-delivering nasal cannulas were being used in hospitals to treat COVID-19 patients, Firefighter-Paramedic Braden Frame with Lake Travis (Texas) Fire Rescue found that an infant-sized face mask might be used to work in a similar manner in the back of an ambulance to help avoid the need for endotracheal intubation.
While this innovation, like many others, will need to be tested for effectiveness, rest assured that continued challenges will be met with continued innovation from the American fire service as we continue to serve our communities through these difficult times.
Ridgefield Fire Department’s Nick Paproski sums it up: “I have always believed that firefighters are professional problem-solvers. We already work in an incredibly dynamic environment day to day, so, for the most part, we should already be adapted to making changes on the fly. The stumbling block that can rear its head from time to time is tradition. I would never argue that either camp, the innovators or the traditionalists, are supreme, rather that most of the major successes that the fire service has enjoyed throughout its history have come from a balance between these two.”
Note: Innovations and adaptations should be created with the knowledge of department leaders, and before anything is put into use, you should seek approval from the department chief and/or the medical director.