Patient Assessment & Treatment during COVID-19

Introduction
If you are a medical provider on an active Search & Rescue team, you probably have updated protocols and personal protection equipment for approaching, assessing, and treating patients in the wilderness due to COVID-19. But what if you are not a medical professional? How should you prepare for and respond to backcountry incidents? Can the threat of infection be mitigated? How do you assess the risk? Should you respond at all?

Before venturing into the backcountry by yourself or with family and household members, take some time to assess the personal consequences should you or a member of your group contract COVID-19 while assisting someone from another party. Do you have a chronic respiratory problem or disease? Is your immune system compromised? Risk of death from COVID-19 increases significantly with age if you are older than 60. Where do you fit in this spectrum? The outcome of your analysis will affect what you choose to carry with you and how you conduct yourself during a backcountry incident. Should you decide you want to assist others, you will likely need to add personal protection equipment to your first aid kit (see below for details).

Assessment & Treatment Guidelines
Below are guidelines on what to take with you and how to mitigate your exposure should you decide to respond to a backcountry injury or illness involving a stranger:

Scene Survey

• Limit on-scene personnel to only those essential for patient care.
• Assess and treat patients outside and upwind—rather than in an enclosed space like a tent or shelter—when it is environmentally safe to do so.
• Stop 6-10 feet from the patient and cover your face. In order of preference based on the level of protection provided: (1) use a N-95 or KN-95 respirator; choose a design that folds flat and fits into your first aid kit; both masks should be individually sized and fit-tested for safety and to comply with OSHA requirements. (2) Use a surgical mask. (3) Use a cloth mask. (4) use a buff. Wash or sanitize hands before removing your mask. Assume the used mask is contaminated and isolate it from your other gear for later disposal or, if cloth, washing. Wash or sanitize your hands again.
• If possible, wear gloves while assessing and treating patients. While you cannot get COVID-19 through contact with a patient's blood, you can via physical contact with infected respiratory droplets. If you wear gloves, exert care in their removal. Wash or sanitize them before removing your eyewear, mask, and gloves, wash or sanitize your hands after you are done. Isolate the contaminated gloves and mask from other gear for later disposal. If you choose not to carry or wear gloves, wash or sanitize your hands regularly. In either case, studiously avoid touching your mouth, nose, or eyes.
• Wear eye protection. You may become infected if respiratory droplets contact your eyes. In order of preference, use a face shield (unlikely to be carried unless you are part of a SAR medical team), goggles (recommended) or glasses with side protection, regular prescription or sunglasses. Remove and wash.
• Consider wearing nylon rain gear (in place of the gowns worn by EMS providers and health care professionals). Remove and clean or store separate from other equipment and wash at home. Wash and sanitize your hands.

Primary Survey

• If the patient is awake, and there are no apparent Basic Life Support problems that need your attention, have them cover their mouth and nose to reduce the spread of any respiratory droplets. If you have extra surgical or cloth masks in your first aid kit, consider asking them to put it on. Another less reliable option is to ask them to improvise a face-covering using a bandanna or buff.
• If the patient is not awake, check to see if they are breathing and have a pulse. If they have both, place a mask over their mouth and nose.
• Rescue breathing and CPR carry a high exposure risk. Chest compressions expel respiratory droplets and, without rescue breathing, are rarely effective. An N-95 mask offers the best protection against droplets; however, you cannot wear a mask and give rescue breaths. If you elect to give rescue breaths, use a simple face mask with a one-way valve and filter. In considering CPR or rescue breathing, you must balance your exposure risk (a combination of your health and available equipment) with the patient's chance of survival. In the backcountry, patients who develop cardiac arrest due to a primary respiratory problem—drowning, lightning, snow avalanche—may sometimes be resuscitated with CPR. In contrast, patients who develop cardiac arrest from traumatic or medical mechanisms rarely survive even with the best field and hospital treatment. Compression only is a viable option; if you choose this route cover the patient’s mouth and nose with a surgical mask (preferred), cloth mask, or buff and wear a fit-tested N-95 or KN-95 respirator (preferred) or surgical mask. (Refer to the video below.)

Secondary Survey

• Ask the following questions during your SAMPLE history: Have you limited your in-person interaction with people and adhered to the physical distancing, mask, and hand-washing guidelines? Has your sense of smell or taste diminished recently? Are you experiencing—or have recently experienced—diarrhea, nausea, or vomiting? Do you have—or have you recently had—any flu-like signs or symptoms: muscle aches, fever, dry cough, or felt unusually tired? Have you been in close contact with someone who has been sick in the last two-three weeks? If yes, were they tested for COVID-19, and if so, did they test positive?
• Take a full set of vital signs. People infected with COVID-19 may be asymptomatic or present with a fever greater than 100.4º F (38º C), elevated pulse and respiratory rates, and an oxygen saturation level below 94 percent.

Focused Spine Assessment

• Complete a focused spine assessment; no additional tactics are necessary.

Treatment
If you choose to respond and treat a person who is not a member of your household, keep in mind that even with professional-level personal protection equipment and training, you cannot eliminate all exposure risk. If there is a high degree of community spread in your area or you have reason to believe that this was a high-risk patient:

• Remove the clothes you were wearing while treating the patient and put them in a plastic bag for washing later.
• Wash or take a shower.
•  Self-quarantine for two weeks.
• Follow-up with your patient to see if they develop signs and symptoms of a COVID-19 infection. If they do, especially if they test positive for COVID-19, report the exposure to your health care provider, and follow their recommendations.

Evacuation

• As much as possible, maintain physical distancing during evacuations; patient and litter carries are not risk-free; if possible, wear a surgical or cloth mask.
• Communicate the patient's COVID-19 status to any new providers before their arrival on the scene or receipt of the patient when transferring to a higher level of care.

First Aid Kit
In addition to what you normally carry, consider the following:

• Hand sanitizer. Consider having each person in your party carry a small container.
• Gloves. Consider carrying multiple pairs.
• Surgical masks. Consider carrying at least two, one for you and one for the patient. Members of your party should also carry individual masks.
• Protective eyewear.
• Plastic garbage bag(s) for contaminated clothing.
• Sized and fit-tested N-95 or KN-95 respirators. Optional.
• Pulse oximeter. Optional. Some persons with COVID-19 do not develop respiratory distress and present with low oxygen levels that may only be detected with a pulse oximeter.
• Soap. Optional. Soap and water are better than hand sanitizer if your hands are dirty.

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