Lessons From a Near-Pandemic

     The discovery of H1N1 infections in the U.S., including in two teenage boys near San Antonio, led to many meetings among authorities across the San Antonio region. In San Antonio and the region served by the Southwest Texas Regional Advisory Council (STRAC)—which joins healthcare entities in 22 southwest Texas counties to facilitate disaster management and trauma, cardiac and stroke care—public health officials faced tough decisions. These included dilemmas about closing schools and banning public gatherings, when and how to distribute antivirals, and identifying those individuals needing testing. Hospitals wrestled with overloading already stressed EDs and protecting their own populations.

     We in the EMS community also faced issues. As medical directors responsible for the prehospital care of the citizens of San Antonio and well-being of over 1,600 firefighters in San Antonio and Bexar County, our list of questions grew hourly. How should we keep our people safe? Should precautions include PPE for every patient encounter? What is considered exposed and at-risk? When should personnel be placed on antivirals for prophylaxis, and how will it be funded? Will we treat their families too? How do we educate everyone to the gravity of the situation and importance of wearing their PPE without causing panic?

     We knew we may face difficult ethical choices, too—choices like who would or wouldn't be given transport to the hospital if the system became overwhelmed, or respiratory treatments such as nebulized albuterol or intubation if the risk of exposure to medics became too great. In the end, we did what we do best: We planned and developed protocols for foreseeable issues. The following are a few of our lessons learned.

• Stay in the know—Fortunately, our city has an experienced OEM to regularly bring stakeholders together. We collaborate in planning and preparation and during disaster operations. Our public health department (the San Antonio Metropolitan Health District) was the lead agency and worked with STRAC. They kept us current through daily conference calls and face-to-face interactions. We monitored updates from the CDC, Texas Department of State Health Services and our regional public health office. Tracking hour-to-hour changes in recommendations allowed us to make decisions effectively and confidently.
• Collaboration—We realized the importance of remaining current with guidelines from local, regional, state and federal partners, and discovered the benefits of close collaboration with public health, emergency management, hospitals and other EMS services in our area. An integral part of our efforts was frequent conference calls with regional partners through STRAC, which managed a Regional Medical Operations Center within the combined city/county EOC. Activating the RMOC let us make quicker decisions in accordance with directives from Metro Health and guidance from the CDC, hospitals and surrounding EMS agencies.
• Control rumors—Stop them early. We squelched one early concerning possible exposure of a dispatcher's wife by an allegedly infected dental hygienist. Neither the hygienist nor the dentist was infected. Witnessing our fast, accurate response, employees were slower to panic with the next rumor.
• Information accessibility—The best way to disseminate information to our medics and firefighters was through written memos. We compiled background advisories on H1N1 that were distributed throughout the region. We also distributed real-time information to crews as they responded to runs. We developed a list of questions for dispatchers to ask 9-1-1 callers. If a caller confirmed signs or symptoms consistent with influenza-like illness (ILI), it was reported to the responding crew, reminding them to don PPE and maintain appropriate distances during initial assessment. Our electronic medical record was modified to include a menu for ILI, which allowed near-real-time tracking of transported ILI patients.
• Anticipate—Fortunately, we never made any ethically difficult decisions regarding altered standards of care. However, such decisions were planned for. We began developing load/no-load criteria and guidelines for who should receive respiratory treatments.

     In conclusion, we made some hard decisions, and in doing so established a reliable, substantive working structure coordinating resources on multiple levels. If there is a next time, we believe we will easily fall into step and quickly collaborate to implement the appropriate protocols and decisions.

     For more on the San Antonio response to the H1N1/swine flu outbreak, as well as additional resources, visit www.EMSResponder.com/swineflu. If you would like to share how your agency responded, e-mail nancy.perry@cygnusb2b.com.

     Emily Kidd, MD, is assistant medical director with the San Antonio Fire Department and an assistant professor at the UT Health Science Center at San Antonio.

     Craig Manifold, DO, is medical director for the San Antonio Fire Department and an assistant professor at the UT Health Science Center at San Antonio.

     Eric Epley, NREMT-P, is executive director of the Southwest Texas Regional Advisory Council for Trauma and director of the Regional Medical Operations Center.

     W. Nim Kidd is a district chief with the San Antonio Fire Department and emergency manager for the city of San Antonio.