High Risk Infectious Disease Response Team Notes: My name is Patrick Auger I have been working as a Paramedic for the last 25 years. The last 20 years within the air ambulance program in Ontario as a Critical Care Paramedic. I have a Bachelor of Health Science in pre-hospital care and a Masters degree in Emergency Management with my study focus on Deploying Health Emergency Response Teams. I also have a post graduate diploma in medical education and have recently completed my study requirements for my masters in medical education. Patrick Auger BHSc, MEmgt, MEd(c) CCP

Introduction & Background Notes: Currently I am based out of our Nations Capital primarily working Rotor Wing Critical Care. In our program with move patients via fixed wing, rotor and ground with a mandate to transport patients at the critical care level.

Population & Call Volume 13,678,740 38.5% of Canada’s Population Approximately 21 000 calls for service per year Notes: 13 Operational Bases 8 dedicated Rotor wing aircraft 4 dedicated Fixed wing aircraft 4 dedicated Critical Care Land vehicles

Introduction & Background Notes:

Scope of Practice Adult/Pediatric and Obstetrical Critical Care Transport. Example of skill set Rapid Sequence Intubation Difficult & Advanced Airway Management & Tools (Air-traq, Bougie, Needle Cric etc.) Mechanical Ventilation Needle thoracostomy Intravenous, Intraosseous, umbilical vein catheterization Gastric tubes and foley catheters Gastroesphageal balloon monitoring Chest Drainage Systems X-ray, Lab, 12 interpretation Arterial/central line maintenance & monitoring Transcutaneous & Transvenous pacing Blood product administration

Emergency Medical Assistance Team & Paramedics Notes: In Ontario with have a medical field unit that was originally developed out of SARS back in 2003. We have several of our Paramedics including myself that have been members of this specialized team for the last 12 years. The Paramedics on this team have received additional training in such topics as Advanced Hazmat Life Support Incident management Emergency management Medical effects of ionizing radiation and CBRN. We have provincial and national exercises and have completed some some operational deployments. It is interesting because the focus of the Provincial exercises were radiation and nuclear focused from about 2011 until the fall of 2014. You see we were living in a post 2011 or post Fukishima world. Of Course all of that changed in the all of 2014.

CBRN Trained Paramedics Notes: This is a training session or exercise of some of our CBRN trained Paramedics. A Provincial program which was developed for cold Zone CBRN back in 2004 related to the terrorist of events of 9/11 As the recommendations and information was coming out from our chief medical officer of health along with the CDC and WHO what we were able to observe and infer is that the PPE that was being recommended and utilized along with the procedures looked a lot like how we had been practicing for a CBRN incident over the last decade. So we were fortunate that we had some in house expertise and we ended up meshing our CBRN procedures with out infectious disease procedures and we brought on an initial team of 10 Paramedics.

EVD outbreak in West Africa 1st cases notified in march 2014 August 8th WHO declared a Public Health Emergency of International concern. Notes: The current outbreak in West Africa, (first cases notified in March 2014), is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976. There have been more cases and deaths in this outbreak than all others combined. It has also spread between countries starting in Guinea then spreading across land borders to Sierra Leone and Liberia, by air (1 traveller) to Nigeria and USA (1 traveller), and by land to Senegal (1 traveller) and Mali (2 travellers). The most severely affected countries, Guinea, Liberia and Sierra Leone, have very weak health systems, lack human and infrastructural resources, and have only recently emerged from long periods of conflict and instability. On August 8, the WHO Director-General declared the West Africa outbreak a Public Health Emergency of International Concern under the International Health Regulations (2005).

Ebola Virus Disease (EVD) A severe, often fatal illness Transmitted to people from wild animals and spreads through human to human transmission Average EVD case fatality rate is around 50%. Varied from 25% to 90% in past outbreaks

What were we asked to do…. Transport confirmed EVD cases that required advanced or critical care. Notes: Train a team of Paramedics to safely move persons under investigation or confirmed cases requiring either advanced or critical care during transport.

PPE Training Donning Requirements Challenges of fit Fit Tested N95 Goggles Face shield Hood Full body barrier protection Double Gloves

PPE Training Safety Officer with Checklist Doffing Requirements Prevention of cross contamination Step by step process to remove PPE under the direction of a safety Officer Notes:

Validating Training Notes: We validated our training and exercises by purposely trying to contaminate our Paramedics and equipment with glow germ. We used a black light to demonstrate how they could quickly cross contaminate objects and people around them.

Challenges of PPE for Paramedics Heat Stress Work Rest Cycles Inside the suit is a microenvironment Inside Temperature Humidity Air currents Increased metabolic work Reduction in speed, thought and alertness Donning Patient Care Doffing Rest Notes: PPE surrounds the individual Paramedic in a unique microenvironment with its own temperature, humidity, air currents, sounds odors and problems. The protection of PPE does not come without a price. PPE of this level possesses high thermal insulating properties (They retain heat), coupled with low moisture permeability (they allow only a slight loss of moisture, thus maintaining a high level of humidity within the protective suit. These conditions lead to heat stress. Metabolic work needed to perform a task when wearing PPE is far greater than the metabolic work needed to perform the same task without PPE. Environmental influences on heat regulation within PPE include environmental temperature, humidity, wind velocity (convection) and the way the PPE is constructed (vapor proof versus nonvapor proof, impermeable versus semipermeable material, one-piece versus two piece) If the task is performed in a sunny area then radiant energy from the sun in the form of infrared rays provides additional heat accumulation. Consequences of heat stress include reduced psychological functions including reduction in speed of thought, alertness and reaction time. Vision is reduced secondary to condensation of sweat on the transparent part of the face piece.

Modification of PPE for High Risk Infectious Disease Team Notes: Powered Air Purifying Respiratory Glasses Tychem Suite Level 4 Gown Triple gloved (Colour Coded Booties/Boots Hydration Pack

Powered Air Purifying Respirator (PAPR) Positive Pressure System APF 1000 Flow Pattern – Hood – Suit – outside Cooling effect Powered Air-Purifying Respirators Has several advantages including: Minimal mobility restrictions Small size Easily maintained Minimal cardiovascular effects Lightweight Do not have to fit test individual They typically filter 4 – 6 cubic feet of air per minute (cfm) or 113 – 170 litres per minute. Can be as high as 9 cubic feet per minute or 250 Litres per minute. The greatly increased volume of flow of filtered air created within the facepiece of the respirator by the blower would create an outward flow of air, should a faceseal leak occur. This outward flow of filtered air would significantly decrease the possibility of inhalation of any significant amount of unfiltered toxic atmospheric air, especially in the hooded variety. All PAPRs are considered Positive Pressure respirators The inner shroud is placed inside the protective suit whereas the outer shroud is draped over the chest on the outside of the protective suit. The large volume of air created by the blower forces a small amount of filtered air into the inside of the protective suit, and in the event of blower failure the air within the suit would act similar to a reservoir bag and provide a reservoir of questionably filtered air (remember Level C suits do not have to be vapor impermeable). An advantage to the hooded PAPR is that a small amount of filtered air is blown into the protective suit. This air is then exhausted to the outside atmosphere; consequently there is a small amount of filtered air movement that is always from the 1. hood to the 2. inside of the suit 3. to the outside of the suit. This flow pattern and velocity of filtered air decreases the potential for ingress of toxic atmospheric air into the suit. Another advantage is that the PAPR creates a rather rapid current of air within the hood and to a much lesser degree the protective suit. This gives a cooling effect (convective and perhaps evaporative) to both the head and possibly the body.

Checklists Issues Donning Doffing Engineering Controls Safety Officer Patient Preparation & Packaging Biocontainment Work Rest Cycles Notes: We created checklists to be utilized by both the team members but also the safety officer as well. The purpose was to introduce consistency of practice in the area of donning and doffing as well as increased proficiency with the utilization of specialized equiipment.

Visual Guides Notes: We took things a step further beyond checklists and developed some visual guides as a learning tool and form of reference that all team members could refer too. It was much easier for recurrent training when team members were able to refer to not only the steps involved but also what either the process of procedures was supposed to look like.

Visual Guide – Bio-Bag Notes: The negative pressure containment vessel or bio-bag is an example of a specialized piece of equipment that we created a visual guide for. Not only was it important that our Paramedics be able to set-up the bio-bag but we needed to outline how it was to be utilized in our work context. That is the movement of an EVD patient requiring critical care. For example the standardized placement of infusion pumps, cardiac monitor and transport ventilator. All access lines in and out needed to be pre-determined. From a capabilities standpoint we learned for example that we needed extensions for some of our lines and only certain ports would accommodate a ventilation circuit.

Personal Kit List

Team Framework Modular & Scalable Team Leader Paramedic Crew 1 Crew 2 Crew 3 Safety Officer Note: Team configuration can change based on distance requirements and work rest cycles.

Patient Preparation & Packaging Patient Transport Patient Transfer of Care

Patient Preparation & Packaging Patient Transport Donning Crew 1 Patient Preparation & Packaging Patient Transport Patient Transfer of Care

Patient Preparation & Packaging Donning Crew 2 Doffing Crew 1 Patient Transport Patient Transfer of Care

Patient Preparation & Packaging Donning Crew 2 Doffing Crew 1 Patient Transport Donning crew 3 Doffing crew 2 Patient Transfer of Care

Patient Preparation & Packaging Donning Crew 2 Doffing Crew 1 Patient Transport Donning crew 3 Doffing crew 2 Patient Transfer of Care Doffing Crew 3

Patient Preparation & Packaging Donning Crew 2 Doffing Crew 1 Patient Transport Donning crew 3 Doffing crew 2 Patient Transfer of Care Doffing Crew 3 Decontamination and Bio Containment

Call Organization – Major Issues Patient Information Designated Driving Route Designated Security Access & Ingress Donning Area/Location Identified Patient Care Plan Equipment & Ambulance Preparation Duration of transport & estimated work/rest cycles Doffing areas & Bio-containment Support Vehicles & Recovery area

Donning Principles Safety Officer Check Time Documented

Patient Preparation & Packaging Tubes & Lines Prepared All potential Infusion Medications anticipated

Patient Preparation & Packaging Ingress & Egress Access

Patient Preparation & Packaging

Patient Transport Egress issues Patient Loading

Two Ambulances Mitigate Logistical Challenges Primary Ambulance Support Vehicle/Secondary Ambulance

Checklists & Safety Officer Designated Marked Area Doffing Principles Checklists & Safety Officer Designated Marked Area

Doffing Principles Rolling outer layer

Red Biohazard Bags & Container(s) Doffing Priniciples Colour Coded Gloves Red Biohazard Bags & Container(s)

Doffing Principles Reusable Equipment

Doffing Principles Suit Size very important

Bio-containment Everything Wiped Down Sealed Drums

Recovery Phase After Action Report Decontamination Lessons Learned Corrective Action Plan Vehicle Decontamination Equipment Decontamination Supply Replacement

Questions?