Adapting to COVID on a Rural Ambulance Service

Before I delve into the topic of COVID-19 and how it affected my city, my departments, and my staff, I want to give a brief background about the International Falls Fire/Rescue/EMS, our departmental structure, and my role within it. International Falls is a small town in Northern Minnesota that sits on the United States/Canadian border. Our city is the largest in Koochiching County and serves as the natural hub for the immediate area. We share close working relationships with our neighbors to the North and other entities in our county. The city operates a fire department and an ambulance service housed in the same facility. The fire department is a combination department made up of four full-time engineers and 25 paid-on-call firefighters. The ambulance service is similar, with six full-time paramedics and 20 paid-on-call EMT’s. My position in the City of International Falls is Fire Chief, Ambulance Director, and Housing Official.

Like many others, COVID and the whole idea of a worldwide pandemic crept up on me. It started in the media, in countries on the other side of the world. It was fairly quiet to start and a really long way from home, so I was not concerned. Then it started migrating into European countries and got a little more attention, but I was still in denial that we would not have to deal with this. There might be the typical random cases in the country from world travelers, but probably not in Minnesota and definitely not in International Falls. Then it started in the United States. Slow at first and nowhere near home. I thought maybe I’d better start educating myself a little bit and paying closer attention to the news. I kept thinking, “I guess it could happen, but it won’t be that bad, right?” Big mistake! In about a month, this went from a watercooler conversation about that “thing” in China to emergency declarations, stay at home orders, masking orders, supply chain issues, and something dubbed the “new normal.” WOW!

Protocols
Before COVID-19, the International Falls Ambulance Service had protocols for highly infectious patients. Throughout the years, this has been modified to more precisely fit a specific situation. Case in point, a few years ago, we changed the protocol specifically for Ebola. It was suspected that due to the international border that we live on, we had the potential to deal with an Ebola patient. Part of the protocol was to have and use proper PPE. We had the basic framework in place to handle COVID; we needed to make small revisions. This was made more accessible by referencing the CDC guidelines and information distributed through the Minnesota Department of Health.

PPE and Supplies
Our service was well stocked on PPE before COVID, and we were slightly ahead of the curve in pre-buying supplies. In the weeks leading up to the hysteria, I had my supply officer load up on supplies. I also visited the local big box stores and bought additional supplies, including masks, face shields, and gloves. Along with the regional EMS systems, the State of Minnesota did a great job of further distributing supplies to healthcare providers. The State of Minnesota set up a supply chain utilizing these regional groups as distribution points for the local service providers. They used a rudimentary system of calculating need – based on average run volumes, burn rates, and survey tools sent to providers. This eliminated hoarding and established a threshold for deciphering between needs and wants.

Once the nation accepted the fact that there would be shortages, we saw a few really cool things happen. People became creative out of necessity, and entrepreneurs saw opportunities. The PPE market became a marketplace of new products or at least a new spin on existing products. Do-it-yourselfers stepped up and created items, sometimes from hand with household items. This created an excellent environment for tapping into local resources, including civic groups, community action groups, faith-based organizations, and volunteers.

Locally, anybody that could sew was making homemade masks. Our community created a “clothesline” system to help distribute homemade masks to people that didn’t have them. The idea was simple. In a few designated areas, people installed a clothesline with clothespins on it. People that were making homemade masks would make them individually package them in a Ziploc® bag or a vacuum pack bag and place them on the clothesline. Anybody that needed a mask would then go to one of these locations and take what they needed from the clothesline.

During this time, I often spoke to my former high school shop teacher. He was constantly sending me ideas. One of them was a 3D printed mask that utilized a piece of an N95 as a filter insert. The N95, when cut properly, would produce four filter inserts for his masks, thus getting four times the use out of one N95. The plastic part of the mask he printed was easy to clean and held up to disinfectants and sanitizers. Because it was a computer file sent to a 3D printer, he could treat it like a photocopy and print it in different sizes (90% or 95%) to accommodate the wearer. He made enough for my entire staff. (Figures 1, 2, and 3.)

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Another idea he sent me was a simple layout for sewing your gowns out of Tyvek house wrap. When we received our first shipment of gowns that we were lucky enough to order, we opened the box and immediately realized they were a subpar product. The local area was getting well covered with homemade masks at that point, so we asked a few local people who were producing the masks if they could make gowns from the layouts. I went to a local hardware store to buy the Tyvek, and when the owner asked what I needed it for, he immediately donated the roll and proceeded to show me the industrial style sewing machine he just purchased at an auction! We used the roll to make gowns, which got us through until we received our next shipment.

Janitorial and Cleaning
I wanted to address this separately from supplies because I felt it was kind of its own animal. It can be treated the same in the aspect of shortages with wipes, cleaners, and bathroom tissue, but different because we saw new technologies emerge, or at least step into the spotlight. The two specific items our service purchased were electrostatic sprayers for disinfecting and UVC lights for sanitizing.

The electrostatic sprayers became a HUGE regret on my part as the leader of my organization. Our local janitorial supply company representative tried to sell me a Clorox 360 since about September 2019. This was a little bit on the expensive side, being a non-budgeted item for me at the time. Every two weeks, he would stop to get his order and remind me that he sold that item. He even referenced “that thing in China” at one point in his pitch. I finally relented and allowed him to set up a demonstration in December 2019. I was impressed. The machine appeared to do everything he stated it would; I could see this being an excellent addition to our service. I told him I would order after the turn of the year when I was working off a new budget. January 2020 went by, and we were into February. COVID-19 was quickly skipping by possibility and moving into reality. I called him up to order the machine; back-ordered at least six months! I told him to put me on the list and quickly researched other manufacturers. I found one, Victory Innovations, in Minnesota. I quickly ordered two of their sprayers. I lucked out, but this proved to be one time I wished I would have just listened to the salesman and not been so skeptical. In the end, we purchased and received the two Victory sprayers, and, as promised, the Clorox 360 arrived at the end of July.

What does an electrostatic sprayer do? It electrically charges the liquid product that it is dispersing, causing it to cling to the surfaces it hits statically. This action enhances product coverage by getting to all sides and in the hard to reach places of the items being sprayed. Thus, the system uses less product and produces better coverage compared to using a handheld spray bottle. Again, we bought from two different manufacturers. Both are good, and I am not advocating for one over the other; I am advocating for the idea and the principle behind it. The electrostatic systems are great for ambulance decontamination and can also be used for offices, meeting rooms, etc.

The second item is a UVC light. I think the marketed intent of the light is to sanitize an area. They are sold with the intended purpose of hanging in the back of an ambulance or being moved through the ambulance like a handheld wand. When the issue of mask shortages came about, there was some intrigue in the medical field with reusing N95 style masks and how to sanitize them effectively. A favorable solution was to use the UVC lights to achieve this. One of the problems that arises is the question of 360-degree exposure. To solve this problem, we built a simple plywood box and lined it with foil tape creating highly reflective surfaces on all sides. We then hang the masks in the box with clothespins attached to the elastic straps of the mask. (Figures 4, 5, and 6.) There is some discussion on the effectiveness of UVC lights for sanitizing N95 style masks for reuse. The most significant part of the debate seems to revolve around the time of exposure to the light. I would recommend that anybody using these lights for this purpose do their research and come to their own conclusions.

Figure 4

Figure 4

Figure 5

Figure 5

Figure 6

Figure 6

We came up with a reasonably easy way to manage and minimize the burn rate of the masks. Each person starts their shift with an N95 style mask. They are given a brown paper lunch bag and told to write their name and draw five boxes on the bag. After each use, the mask is returned to the bag, and an X is placed in one of the boxes. When all five of the boxes are filled, the bag with the mask is put in a container to be sanitized using the UVC lightbox. This works well for routine responses dealing with non-suspect patients. We do give latitude to the employees to deviate from this system when they feel it is necessary. If they were to contaminate, soil, or destroy the mask, it could be discarded at any time, and new masks are always available to them.

Staffing
Staffing was a terrifying ordeal at first; there was undoubtedly much fear of the unknown. Step one was getting a handle on the hysteria, misinformation, and plain old information overload that EVERYONE was dealing with. It took time to get the employees settled down. Rightfully so, they were scared. Our organization fit the standard bell curve concerning emotions: 80% of my employees were worried, but were willing to be educated, wear the proper PPE, and come to work to do their jobs safely; 10% were scared to death and swore they were locking themselves in their houses come hell or high water; and the remaining 10% were the ones that believed this was a hoax or a government conspiracy of sorts and unwilling to listen to anything COVID-19 related.

The State of Minnesota required all businesses and municipalities to create preparedness plans for dealing with employee safety, employee screening, and facility concerns. This helped calm the waters for the employees. We had a plan, we had a screening procedure, we had large quantities of proper PPE, and most importantly, we had useful information coming to us from trusted sources. By the middle of March 2020, I had daily meetings with other city and county officials. We had regional meetings with other ambulance services and healthcare providers. We had meetings with state officials and representatives; everybody started to get the same message and the same information.

Now we wait. Even when cases first sshowed up in Minnesota, it took two to three weeks to get our first positive test in Koochiching County. Another two weeks past and not a second case. Speculation in the community was that the first case was a false positive. Then the county got the second confirmed case. I say this with hesitation, but it was precisely what the community needed at the time. The community was now on board, all of the plans went into place, and there was a general sense of seriousness about the situation.

A Few Changes to Our Service
One of the most significant changes to come from COVID has been the environment at the station. Up until COVID, we never locked the door at the fire station. Members and their families were always welcome to stop by and visit over a cup of coffee or show their children the trucks. Unattended children would be given a Mountain Dew and a candy bar. We had to secure the station, make sure masks were worn in common areas, try our best to social distance, and enhance our cleaning routine. With that, I had to send out an email to the membership telling them that for the first time, the door is locked, don’t come here if you don’t have specific business, and do not bring your kids to the station. That was an email that I never dreamed I would have to send. Our welcoming station went into lockdown, and the general feeling of the station and its members changed. The group lunch that used to take place nearly daily around the kitchen table has changed. People now eat at different times and sometimes in other areas altogether. In recent weeks, we have resumed having some meetings at the station. They are held in the truck bay with chairs set at a minimum of six feet apart with everyone wearing masks. I try to remind everyone we are doing all of this to protect our community, protect our families, and protect ourselves. Someday we will return to a more familiar setting.

Koochiching County has a population of just over 13,000 people. As of early October 2020, Koochiching County has had 131 positive cases of COVID-19, three deaths, and nearly 2,000 total tests completed. The International Falls Ambulance Service and the International Falls Fire Department have had 0 employees test positive for COVID-19. I am thrilled with that number!

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