A Kootenai County ambulance backed into a far corner parking garage at Providence Sacred Heart Medical Center on Thursday.
The back doors opened to reveal two EMTs in head-to-toe personal protective equipment, white body suits with full hoods and clear screens where they can see out. They hopped out and began to lower a patient to the ground.
The parking garage driveway was too steep, however. Without missing a beat, the EMTs hopped back in the ambulance, moving it and parking a bit lower on the steep driveway to help smoothly get the patient out of the back of the vehicle.
Someone would take note that backing all the way up that driveway wouldn’t work in a real-time emergency. This is what these training drills are for.
On Thursday, hospital, public health and local EMS providers in Spokane and Kootenai counties ran a full-scale exercise to practice transferring a patient with a highly infectious disease from Kootenai Health to the special pathogens unit at Sacred Heart.
It’s an effort that requires a lot of coordination, teamwork and timing, and something that the pandemic has crystallized as necessary for future outbreaks.
“We all have an enhanced understanding of how important it is,” Christa Arguinchona, manager of the special pathogens unit, said.
Sacred Heart Medical Center has the only special pathogens unit in the Pacific Northwest, a federally funded unit to treat highly contagious pathogens, for the four-state region covering Alaska, Washington, Oregon and Idaho. The Obama administration established these units nationally, largely during the Ebola outbreak that began in 2014.
The unit in Spokane had never activated officially until the COVID-19 pandemic began and four cruise ship passengers were federally required to quarantine at the facility in early 2020.
Local EMS and hospital teams had prepared for that with exercises that practiced transferring a patient from the Spokane airport to Sacred Heart.
Special pathogens units around the country are a part of a national research network that enabled Sacred Heart to activate clinical trial research quickly in 2020. Patients with COVID-19 arrived at Sacred Heart on a Friday, and by Monday, the facility was ready to go with a double-blind Remdesivir study intended to determine if the antiviral drug was useful against the new outbreak, Arguinchona said.
Subsequently, the Spokane unit was used as a COVID-19 overflow unit, and at times, a COVID-19 intensive care unit to treat the sickest patients during the most intense waves of the pandemic.
As case counts in hospitals retreated, some medical teams went back to their normal operations, including the special pathogens unit.
Preparing for a potentially deadly pathogen takes care, work and, above all, time.
Nurses, environmental services, lab technicians and security staff at Sacred Heart can join the special pathogens unit team, which does regular drills and training to prepare for unusual and disaster-type medical emergencies. They volunteer to be on the special pathogens unit team and are paid for their work. Recruiting from different parts of the hospital to create a multidisciplinary team is important, Arguinchona said.
On Thursday, the scenario was set: A patient with Nipah virus, a zoonotic virus found in some fruit bats most recently in Bangladesh and India with no treatment, had arrived at Kootenai Health. The team at that hospital coordinated with their health department, local EMS transport and the special pathogens unit. At Sacred Heart, Arguinchona called team members and got them into the unit to suit up in their multiple layers of protective equipment.
The transfer from the ambulance team to the hospital team occurred in a quiet, old corner of the hospital. The elevators were switched to manual operations and the stairways secured. In a short hallway, the patient was moved from gurney to hospital bed as two nurses, also clad in head-to-toe personal protective equipment, received the patient.
Once on the unit floor, in a negative airflow room, the real work began. Everything the patient touched was assumed to be contaminated.
Jamie Jerald and Jaired Hudson, the two nurses treating the “patient” had to work methodically and synchronously to get the patient’s wrappings, which might have the virus on them, off the hospital bed without getting contaminated themselves.
Caring for a patient and maintaining sanitary control is challenging, and things moved slowly. About 20 minutes into the drill, their supervisor threw them a curve ball: the “patient” had vomited, complete with fake vomit poured over Jerald’s foot and across the floor.
The cleanup was meticulous, and Hudson had to move around Jerald quickly all while trying to make sure the patient was doing OK.
At times, the two nurses struggled to hear each other.
Arguinchona said this should be fixed when the team gets headsets that fit inside their PPE. For guidance on Thursday, the team had a phone in the room connected to a nurse who watched them from cameras set up in the room. The monitor nurse would give them guidance and answer questions when they needed help.
Another nurse in full PPE stood ready to help them safely take off their PPE when they exited the patient room or step in and help if necessary.
In the meantime, the Kootenai EMS team was getting rid of their potentially contaminated PPE back in the parking structure with the help of hospital staff, who can safely discard waste at the hospital’s new San-I-Pak, a steam sterilizer and waste disposal for waste considered contaminated with infectious material, purchased with federal pandemic funds and through a partnership with the Department of Health.
When the exercise ended, both nurses had to go through the laborious and step-by-step process of taking off their PPE in a methodical way as to not infect themselves or others. The whole process took at least 10 minutes, with hand sanitizer use and cleanup between steps.
After the exercise, both observers and participants talked about what worked and what didn’t. Those conversations will help tweak steps in the process or serve as guidance that the team will incorporate into their playbook for next time.
What else did they need in the room and forgot to place there? Did the step-by-step processes written down actually make sense in action? These are questions the team will answer in the coming weeks in order to upgrade preparedness plans.
The timing of the exercise is important. While coronaviruses represent a threat in the pathogen world, there are lots of other viruses and diseases that pose a threat to communities if they appear in the region.
In late April, a Colorado man was diagnosed with H5N1, an avian bird flu. He was the first person in the United States to be diagnosed with that specific group of avian flu viruses.
Arguinchona said that diagnosis made their exercise even more timely and underscores the importance of beginning to train again.
“We’ve been in (COVID-19) response for so long that feeling like we can go back to planning and preparedness is awesome,” she said.
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