This episode features subject matter professionals discussing a mnemonic developed to assist First Responders and First Receiver’s when responding to Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Events. We will relate this mnemonic to the current COVID pandemic.
Narrator: Welcome to the disaster management podcast series. Each episode features subject matter professionals discussing strategies and techniques for emergency managers and policy makers to consider as they prepare for respond to and recover from disasters. This series is brought to you by Texas A&M Engineering Extension Service and the National Emergency Response and Recovery Training Center.
Kathy Wall: Hello and welcome. My name is Kathy Wall. I’m a training coordinator with Texas A&M Engineering Extension Service in the EMS and public health program. We have several face-to-face courses in this program including medical management of C burn events, medical countermeasures point of dispensing or pod planning, and response medical preparedness and response to bombing incidents and pediatric disaster response and emergency preparedness. Today we will discuss a mnemonic rapid care and how it can aid first responders and first receivers. I have two very knowledgeable and experienced individuals with me and I will let them introduce themselves. Elden…
Eldon Taylor: Thank You Kathy. My name is Eldon Taylor. I am an associate training specialist with TEEX. I been with TEEX for about six years now. I’ve been a paramedic for about 32 years. I have military experience. I was an intelligence analyst I specialized in what they call weapons of mass destruction and counter-terrorism.
Ryan LeNorman: Thanks for having me on today Kathy my name is Ryan LeNorman. I’m an agency instructor with Texas A&M Engineering Extension Service as well in the emergency medical public health sector. My specialty is in the medical management of chemical biological radiological nuclear and explosive event, and I’ve been a paramedic for approximately 19 years. I was a former flight paramedic and tactical paramedic in my previous positions held.
Kathy Wall: I appreciate everybody participating in this new training method that we’re putting out. Without further ado, Eldon what is different for first responders and receivers when responding or caring to patients involved in some sort of a biological event such as COVID 19 which we are experiencing right now then from a chemical event?
Eldon Taylor: Usually with a chemical agent you have an indicator such as a detectable odor or maybe even a visible vapor cloud that alerts responders and other personnel to what they’re dealing with and they are able to take proper precautions. However with a biological agent there are a few any indicators of its presence and this full scope of an exposure is usually not known for days or even weeks.
Kathy Wall: Interesting. Ryan is there something available for responders and receivers to help them when they respond to an event and care for patients involved with a biological agent?
Ryan LeNorman: Absolutely Kathy. There is a mnemonic out there that we utilize inside of our PER 211 our medical management of see burn event for Texas A&M engineering Extension Service. We actually use a mnemonic called RAPID Care. That mnemonic is actually developed to assist those responders and receivers in managing a response for an event involving chemicals biological radiological nuclear and explosive event. Now that RAPID Care pneumonic actually starts with R which is our recognition. A which is our activation. P which is our protection. I for identification. D for decontamination and the final portion of that is obviously the C for care.
Kathy Wall: Elden how did that RAPID Care mnemonic help someone recognize a biological event like COVID 19?
Eldon Taylor: As mentioned earlier there are usually some indicators that can be detected through observation like smell, carrying a character to help them recognize. If someone has been exposed to a particular type of agent. Recognition of a biological agent exposure can be difficult as the indicators usually are not detected for several days depending on the biological agent that’s encountered. Responders or receivers may have to rely on information they get from the patient, from bystanders maybe even from family members or even a dispatch or a call taker. It is important that they try to give as much information as possible about the patient’s condition in the situation which will assist them from not becoming exposed to biological agent when they arrive on scene or when they’re assessing the patient. They should ask pertinent questions such as the general condition do they look sick how are they acting or are they having signs and symptoms like coughing sneezing vomiting. Maybe even get a chief complaint such as they have a headache are they nauseated they feel dizzy or do they just feel weak. It would also be important to know that there’s more than one person on scene having similar signs or symptoms.
Kathy Wall: Once someone recognizes that there’s a biological agent present who do they activate under those steps of RAPID Care?
Ryan LeNorman: That’s a good question Kathy. When we look back at exactly who we should call or who we should notify what an incidence occurs, we typically have what we call emergency action plans or EAP’s that help us to establish that incident command system or inside the hospital that can be a hospital incident command system. And we start that process typically by notifying the personnel or the departments or even agency of what the situation actually is inside of there. The emergency action plan outlines these steps in managing the incident which include who needs to be contacted and how to begin calling for those additional resources that they’re needed. And then it also pushed us into our assistance from various agencies so if we need federal support or state support neighboring cities as well as local county entities. With biological agent exposure this would include the public health department and the CDC which is our Center for Disease Control and Prevention.
Kathy Wall: How can someone use this RAPID Care nemonic to protect themselves and others from a biological agent?
Ryan LeNorman: There are several measures that come along with this which you can take to protect yourselves and protect others from exposures. First of all anyone who’s been exposed or possibly exposed should be isolated in an effort to contain the transmission and disease and to others. Those that have already been exposed to this incident obviously need to be pulled to the side or put into a location where they can be monitored and advised of their current situation. That isolation period can be up to 14 days for COVID 19 and to prevent the exposures to themselves the person should wear the appropriate PPE or personal protection equipment which helps to reduce that possibility of exposure and infection later on.
Kathy Wall: Elden how does PPE as Ryan just spoke of, protect someone from exposure to biological agents?
Eldon Taylor: Well there are different levels of PPE and for a biological agent they would protective are being exposed usually it’s designed to protect the person who is wearing the PPE from being infected either through an open wound in the skin or from absorption through the mucosal of the nose or the eyes or the mouth or even through inhalation into the respiratory tract. There are multiple levels of PPE a person could wear.
Kathy Wall: Eldon, what are the levels of PPE that you’re talking about?
Eldon Taylor: National Institute of Occupational Safety and Health which is also called NIOSH, has identified four levels. Basically A, B ,C and D.
Kathy Wall: Eldon can you describe the PPE for each of those levels for everyone to understand and also for protection of COVID 19?
Eldon Taylor: Of course. Level A which just recognizes the highest level of protection utilizes what we call a fully encompassing protective suit. It’s very thick and it provides splash and vapor protection for most hazardous material. So that sort of protection is with a self-contained breathing apparatus on SCBA which you see a lot of firefighters learning and handling a fire. This level of PPE would not be practical for responders or anyone caring for somebody with COVID 19 affected patients because the wearer would be very limited because of this fully encompassing suit of the over their head and they have very limited visibility and communication to the SCBA basket protective hood. The gloves that are one are also very thick in not a whole lot of dexterity is available. It would be impossible some of the try to start an IV or to take vials of the patient. The level B is similar to the level A except is not fully encompassing and a lot of times the suit is not a stick it’s made of lighter material it’s allowable for clinical splash protection as well. Usually it’s worn when they identify the type of agent that they are dealing with. The suit also utilizes a SCBA for respiratory protection as well but it is worn outside of the suit and not inside like the level A. But again dexterity level is very low because of the fact you were in very thick glove so you would not be able to get very good IVs form vitals on a patient. Level C is an over garment not as heavy as our thick as you might find in your level A and level B and it provides moderate splash protection from more not as acidic chemicals and from body fluids such as blood saliva and vomit. It is often referred to as body substance isolation or BSI protection. Your respiratory protection is divided by what is called an air purifying respirator or an APR or a powered air purify dressing area which is also a PAPR. This level provides sufficient protection for most of your biological agents and not from chemicals it is worn by a lot of your first responders and your receivers. They protect your airway more by using a HEPA mask or what is known as a high efficient particulate air mask which is called an n95. N 95 it’s designed to filter 95% of airborne particles between one to five microns in size. The personnel must be fit tested to determine the appropriate size masks which will provide them with proper respiratory protection. If they have any type of hair on their face as it such as a beard or they haven’t shaved, this will inhibit the ability to get a good seal on that type of mask. The PAPR is very comfortable and easier and you have to worry about a seal with that.
Ryan LeNorman: Elden I don’t mean to stop you there for a second but I just want to add I’ve noticed that there’s been a significant deflector than 95 availability but also an influx of what we call the KN95 mask. Now the n95 and KN 95 typically filter out approximately 95% of the particles however the only difference as far as naming is the KN 95 is our Chinese certification. There are a little slight differences between the mask and what they can and cannot contain inside that mask but as far as filtration ability the KN 95 s and the n95 s are equal.
Eldon Taylor: Thanks Ryan that’s good information glad you touched on that. Level D is usually what people wear a normal day at work. The lowest level protection it’s not something you’d really want to wear when you’re taking care of a patient who may be infected with COVID 19.
Kathy Wall: Ryan how can someone use the RAPID Care mnemonic to identify a biological agent like COVID 19?
Ryan LeNorman: Kathy when we’re identifying these particular biological agents like COVID 19 and others around there we usually require samples to be taken from infected patients and then sent to a lab for testing such as the Center for Disease Control and Prevention or some of your state sponsored labs or even local labs. However someone may be able to identify that these by strictly observing a patient signs and symptoms. Signs and symptoms for biological agents are usually within two categories general and differential. General signs and symptoms are described as something that we might typically use this blue light and are mostly caused by the initial immune response. On top of that these signs and symptoms can include low-grade fevers between 99 to 100 degrees Fahrenheit, runny nose sore throats headaches, aching muscles etc…
Kathy Wall: Specifically what kind of signs and symptoms would you see in a person with COVID 19 that are different from the general flu like you just described.
Ryan LeNorman: Most of us we quickly refer to the flu like and we utilize it in in a lot of instances but if you go to the Center for Disease Control and Prevention or CDC.gov/coronavirus you can find these general signs and symptoms for the COVID 19 virus and how they’ve been described and most of the time they’re described as a fever with an old temperature above 100 point 4 degrees Fahrenheit, a non-productive dry cough chill, muscle pain, headache loss of appetite and sore throat. But as the disease progresses differential signs and symptoms can be present as the patient’s condition becomes typically worst. Differential signs and symptoms for COVID 19 can include but they’re not limited to difficulty or labored breathing persistent pressure in the chest, nausea vomiting and a loss of taste or smell in some patients.
Kathy Wall: You mentioned flu-like symptoms for your adult patients so how do these adult symptoms differ from those in pediatric patients and how can our providers quickly recognize those possible pediatric patients?
Ryan LeNorman: Those clinicians are aware pediatric patients often times present differently from our adult age patients. There are a further list of the symptoms I’m about to present for pediatric patients on the CDC website but a few of these symptoms could include vomiting, diarrhea, feeling tired, bloodshot eyes and a rash. Again these are just a few but it’s still important to understand that if the pediatric patient is experiencing trouble breathing, pain or pressure in the chest that doesn’t go away, new confusion, inability to wake or to stay awake, a bluish tinge to the lips or face or severe abdominal pain that patient needs to seek immediate emergency care. Now some of the latest research on COVID 19 has also brought a new diagnosis disease called multi-system inflammatory syndrome in children or otherwise known as the MISC. This is a condition where different body parts can become inflamed including the heart, lungs, kidneys, brain, skin, eyes or the gastrointestinal organs. We do not yet know what causes MISC or multi inflammatory syndrome in children, however we know that many children with this have had the virus that causes COVID 19 or had been around someone with COVID 19. MISC can be a serious even deadly but most children who were diagnosed with the condition have gotten better with medical care. CDC is still learning a lot about MISC and how it affects children. So we don’t know yet why some children have gotten sick with MISC and others have not. We also don’t know if children with certain health conditions are more likely to get MISC.
Kathy Wall: Ryan you mentioned difficulty breathing and labored breathing is there some other significant signs and symptoms someone should be observant for if they think someone has COVID 19?
Ryan LeNorman: Absolutely Kathy. Especially in those involved in the medical field we can utilize something like oxygen saturation monitoring. Using a SPO2 monitor this can be used for patients suspected of having diagnosed with COVID 19. They’ll have a gradual decrease in that SPO2 or oxygen saturation reading. Current studies have shown that some of these patients with COVID 19 have adapted to the decrease without having any breathing difficulty or shortness of breath. Now this findings may determining the actual progression of the illness and infection difficult as these individuals do not typically seek medical care in a timely fashion.
Kathy Wall: Eldon what other information is important to collect when you’re trying to diagnose someone with COVID 19?
Eldon Taylor: Probably one of the most important things you need to get from a patient as possible or from a family member or somebody who is familiar with the patient history, basically when did the signs and symptoms begin, does that patient have any pre-existing conditions such as congestive heart failure diabetes bronchitis or something like that and has a patient knowingly been exposed to anyone diagnosed with COVID 19 within the past 14 days.
Kathy Wall: Elden would a patient who’s exposed to COVID 19 need to be decontaminated before they’re treated?
Eldon Taylor: Oh no. The primary purpose of decontamination is to remove contaminants to minimize the harmful effects to both the patient and the person that is helping them like the responder at the time of the exposure. With any biological agents such as COVID 19 patient exposure occurs unknowingly and by the time signs and symptoms begin patient decontamination is unnecessary.
Kathy Wall: If the patient does not need to be decontaminated should a responder or receiver who has come in contact with the person with COVID 19 be decontaminated?
Eldon Taylor: That’s a pretty good question. COVID pathogens have been found to survive on various materials for as long as 72 hours. It is important that personnel who are in PPE that are caring for and known infected patient or possibly infected patient put on their PPE or in other words donning or take off their PPE called donning appropriately to prevent exposure to infectious pathogen that may have contaminated their PPE. The CDC has put out guidelines on a proper donning and doffing a PPE which can be found on their website. The area around a patient the COVID 19 should be cleaned thoroughly with a prescribed disinfectant. All infected clothing bedding and other materials should be handled for guidelines for clean and disposing of hazardous waste.
Kathy Wall: Ryan for a patient that has been exposed to a patient with COVID 19 from a field perspective and then also for our receivers our first receivers how would they be cared for?
Ryan LeNorman: The last portion of our mnemonic is care and that care involves managing all your available resources for treating multiple patients. And that includes triaging or sorting them and according to the severity of their condition and triage assists in categorizing these patients appropriately by assigning them a priority level typically associated with the numbers 1 to 4 would be our different levels that we could do.
Kathy Wall: Elden what Ryan talked about with triage and priority what are their priorities and how would we triage COVID 19 patients.
Eldon Taylor: As I mentioned earlier the person assessing the patient could assign a priority as 1 through 4. A priority patient would be signed either with a number 1 or what we call a red designation which is considered immediate and the patient is treated and if needed transported. The next level would be at level 2 patient or we designate as a yellow patient is considered to be manageable with the available resources we have on hand and they are treated and transported accordingly but it can be delayed until all of the priority 1 patients have been taken care of and transported if needed. And then we get to our level 3 we refer to them as our green patients are even sometimes as our walking wounded. These patients are usually fairly healthy not sewing a lot of signs and symptoms are not very severe so they can usually wait until all of these prior to one and part of two patients have been taken care of. And then we have those patients who are very ill it may not be able to survive. They are usually given a priority 4 designation or a what we call a black tag and they will receive supportive care and dependent on the available resources to help them to be comfortable as possible and relieve any suffering.
Kathy Wall: Ryan patients that are being transported by ambulance triage are screened before arriving to a hospital or at a medical facility what would be done?
Ryan LeNorman: As these patients are transported I want to reiterate that it’s very important that we follow our local guidelines or local protocols that are in place and I don’t want any of this to be construed for guidelines for replacement, however if you’re going to transfer a patient with COVID 19 it’s typically going to take place inside the ambulance to a hospital setting and that hospital personnel can actually screen or triage the patient via telecommunication or radios with that ambulance crew. Information they can collect from those ambulance crew will usually include the patient’s chief complaint their current signs and symptoms, vital signs, medical treatments that have been performed and pre-existing medical conditions and a history of the possible exposure to COVID 19. Once they’ve received this information it’s going to help them determine where that patient needs to be taken to receive the appropriate treatment and what personal protective equipment and other protective measures need to be taken when handling this patient.
Kathy Wall: Very good some great information. Ryan in summary can you break down that RAID Care mnemonic for us again and very briefly tell us the individual steps?
Ryan LeNorman: Let’s summarize RAPID Care very briefly we first start with our R recognize and that’s the responders a receivers ability to have a high index of suspicion for any patient with a sign or symptom that may indicate that they’re infected with COVID 19 or even some other biological agents. Then we perform our A which is our activate. We activate the agencies or facilities with the infection identification or illness protocol that we utilize from our settings. Then we fall on our P which is our protections. Protection is probably one of the most important concepts that we need to understand and we will determine by the agency or facility protocol with CDC guidance what personal protective measures and personal protective equipment we should be utilizing for being exposed. Then we falter identify. So identify the possibly ill patients or infected patients or it exposed individuals. We’re not just identifying our possibly ones that are ill we need to identify all those that could be potentially exposed to this individual if at all possible. Then we strictly move to decontaminate so we may have to decontaminate these sick individuals if needed with EPA approved disinfectants followed by our care, so we’re actually performing our care of these symptomatic patients with whatever medical procedures that were available to us.
Kathy Wall: Thank you Elden is there anything you’d like to add to that as well?
Eldon Taylor: No I think Ryan covered everything.
Kathy Wall: Perfect I hope this is helpful for everyone. This is a fairly interesting mnemonic. It’s a very quick process to get through each one of these steps and I hope this is going to be helpful.
Narrator: Thank you for listening to the Disaster Management Podcast Series brought to you by Texas A&M Engineering Extension Service and the National Emergency Response and Recovery Training Center. If you have any questions or ideas for future episodes please contact [email protected] or visit teex.org for information about training near you.