Throughout the day on April 4, Fire Department of New York (FDNY) radios crackled every few minutes with a voice repeating the same chilling phrase: “10-37, Code 1”—FDNY shorthand for a victim found dead on arrival.
“This isn’t firefighting, this feels more like the crew on a sinking ship desperately trying to load the boats while the water gets ever closer,” Simon Ressner, an FDNY battalion chief, wrote of that draining day from his station in Brooklyn. His account, which was later published on the nonprofit news website ProPublica, sums up as well as any the experience of emergency responders at the epicenter of the COVID-19 pandemic.
That Saturday alone, 421 New Yorkers died from the novel coronavirus, and more than 1,300 new victims were hospitalized, according to the New York City Health Department. In the following days, the daily death toll would climb even higher. “I thought that surviving September 11, 2001, would be the part of history I would tell my grandchildren,” Ressner reflected, “but COVID has clearly surmounted even that disastrous and heartbreaking day.”
With near daily exposure to the virus, frontline health care workers and first responders have been among the millions of infected globally, and dozens of fire and emergency medical services (EMS) workers have already died from complications related to the virus. According to a database launched by the International Association of Fire Fighters (IAFF), in mid-April, there were nearly 12,500 firefighters across North America quarantined, 700 infected, and six who had died. The actual numbers are certainly higher since many fire districts, including most in New York City, haven’t yet shared their data with the IAFF.
A responder in Germany receives a nasal swab as part of a test for coronavirus antibodies. Worldwide, responders have experienced high levels of COVID-19 infection as a result of their exposure to coronavirus patients. (Getty Images)
At FDNY alone, about 3,000 EMS and fire personnel were out sick during one stretch in early April, which represents about a quarter of the entire EMS membership, and 17 percent of all firefighters, according to local news reports. All the while, the department was setting new records almost daily for call volume, peaking at nearly 7,000 calls per day. A typical busy day is around 4,000 calls, according to FDNY.
Although regions in New York, Italy, and Spain have been hit hardest in the pandemic, as of this writing, responders everywhere have faced degrees of the same overwhelming challenge: how to handle an unprecedented surge in sick and contagious patients while dealing with dwindling manpower and severe shortages in supplies and critical personal protective equipment (PPE). In the US especially, these problems have only exacerbated longstanding concerns about how departments are staffed, supplied, and funded. As they await an easing of the current pandemic, some safety professionals are looking ahead to what they hope can change in order to put agencies in a better, more resilient position when the next large-scale public health emergency hits.
“One of the main lessons so far is that we need to lean harder on our emergency management systems much earlier in the process,” said John Montes, a specialist at NFPA with extensive experience in EMS management and planning. “We need to treat public health emergencies the same way we treat natural disasters.”
MAKING DO WITH LESS
The sidelining of thousands of personnel just as calls skyrocketed has wreaked havoc on an emergency response system that, even in normal times, is designed to operate as efficiently as possible, Montes said. “During a disaster, we generally bring in extra units from places around the country to meet the need, but this thing is so widespread that sharing resources from unaffected areas hasn't always been possible,” he said.
As a result, departments around the world have shifted into crisis mode, adjusting or even discarding longtime codified regulations and enacting untested methods that would have seemed unthinkable just weeks ago. These crisis standards of care, as they’re known, have included everything from reducing the number of personnel required on an ambulance to extending expired medical licenses, having doctors screen and prioritize emergency calls, and even refusing to bring patients to the hospital if the situation isn’t deemed serious enough. Alternative procedures like these have now been implemented by more than 80 percent of US fire departments, according to a survey of 400 departments conducted by the IAFF.
The changes are meant to stretch the limited capacity as far as possible, said Aaron Burnett, Minnesota’s state EMS director. “Some of the regulations that are suspended are things that are almost considered sacrosanct—like requiring an individual on an ambulance to have a certification—but this is designed to allow us to be very nimble,” Burnett explained on a recent webinar hosted by the EMS office of the National Highway Traffic Safety Administration. “If regulations aren't able to adapt to the changing situation on the streets, those regulations can start to become a barrier to effective patient care and can actually get in the way of providing and protecting the health and safety of the citizens.”
While many of these adjustments are planned and rehearsed specifically for such extraordinary moments, other changes have been made unwillingly, often out of sheer desperation. Shortages in medical-grade face masks, gowns, and other protective gear, for instance, have forced responders to take risks they would never have considered during normal operations. Nearly everywhere, masks intended for a single use are now being worn for days or even weeks to extend supplies. In some places, paramedics have resorted to sewing their own protective gowns out of shower curtains, coats, or rain ponchos; others are wearing 3D-printed face shields donated by volunteers or cloth masks knitted by church groups. Some states have even put out guidance instructing fire departments to wear turnout gear and self-contained breathing apparatus (SCBA) on COVID calls.
“We’re in disaster mode,” Pieter Maes, a firefighter and emergency medical technician with the Brussels Fire Department in Belgium, told NFPA Journal in late March. “We have to improvise and think outside of the box.” Maes has created a new website, covidfirstresponse.com, to collect and share information submitted by responders around the world about the creative ways that they are stretching their limited resources, even if it means those solutions lack code compliance and come with a use-at-your-own-risk caveat. It includes crowdsourced information about crafting filters for SCBA masks, methods for disinfecting PPE, instructions for 3D printing gear, and much more.
To aid in the effort, NFPA has also released a tip sheet with guidance drawn from NFPA 1581, Standard on Fire Department Infection Control Program, which outlines several measures that responders can take to minimize their exposure while also conserving PPE. This includes having dispatchers ask patients to meet responders outside, if possible, where the risk of virus transmission is lower, as well as instituting protocols to save the most high-level PPE, like N95 respirator masks, for the highest-risk calls.
LEARN SOMETHING NEW Four key takeaways of NFPA 1581 (NFPA Journal video)
LESSONS LEARNED
While these crisis standards have been necessary to get response agencies through this unprecedented moment, most experts believe that the normal routine protocols for staffing and caring for patients will mostly return once the pandemic is over. That does not mean, however, that everything will or should go back to how it was, Montes said. As it has done with so many other aspects of society, the COVID-19 crisis has illuminated some of the pain points inherent in the US emergency response system, and onlookers are hopeful that this could lead to several systematic changes.
One fissure that’s been exacerbated during the pandemic is the inadequacy of how emergency medical services are funded, Montes said. Unlike hospitals and the rest of the health care system, which receive funding from Medicare/Medicaid and private insurance for care given to patients, EMS and fire-based EMS are paid in most cases only for transporting patients to the hospital.
However, during the pandemic, paid and volunteer EMS agencies have stepped up by offering free COVID-19 testing and by caring for patients outside of hospitals to ensure that medical facilities don’t collapse under the volume. A survey published April 21 by the National Association of EMTs found that more than 60 percent of EMS agencies are using these treat-and-release protocols rather than transporting, but that an astounding 87 percent of those agencies are not getting paid for those services.
“This has been a huge issue that responder associations are battling,” Montes said. “Fire departments and EMS providers are blowing through budgets buying PPE and doing all of these things that help the health care system survive, but they’re getting nothing for it, which is wild. It is not right.”
Another longstanding issue that has only worsened under the weight of the pandemic is the plight of volunteer fire and EMS agencies, which make up about 80 percent of departments in the United States and service about a third of the population. Departments already suffering from shrinking membership and growing demand for services have been crippled further by an inability to hold fundraisers or recruit and retain new members during the current emergency. “Some departments may not have the savings to continue to operate,” Jonathan Dayton, the vice president of the Allegany-Garrett Volunteer Fire and Rescue Association, told a local newspaper in April. Calls for more state and federal funding for these agencies will likely grow louder, especially as residents see how indispensable these services are during the pandemic, Montes said.
Lastly, one of the most visible failures in response to the COVID-19 crisis has been the inability to procure and distribute enough equipment to supply frontline workers. In the recent IAFF survey, 58 percent of fire departments reported that state officials are unable to supply them with needed PPE. Although researchers and academics will debate the many causes for this shortfall, the importance of having a cohesive strategy from the get-go is already a clear lesson, Montes said. Response experts think in the future it would be wise to handle the response to public health emergencies much like we do natural disasters and implement longstanding emergency management systems much sooner in the process.
Typically, when a disaster like a hurricane hits, state and federal emergency management systems are activated, triggering a systematic approach for collecting and allocating resources to the affected areas, as outlined in NFPA 1600, Standard on Continuity, Emergency, and Crisis Management. If run as designed, the federal government leverages its substantial buying power to procure equipment at the best prices and then distributes it down the chain in a targeted way based on needs data. That approach has been implemented only sporadically during the pandemic and much too late, Montes said, putting federal and regional emergency managers at a significant disadvantage.
“Instead, we have a system where entities are bidding against each other—health care networks are bidding against states, and government entities like fire departments are bidding against private EMS providers for needed PPE,” he said. “Where the PPE goes isn’t necessarily based on who needs it the most. The lesson for the future is to treat these public health emergencies like disasters and engage emergency operations—the FEMAs of the world—sooner.”
JESSE ROMAN is associate editor at NFPA Journal. Top photograph: Getty Images