When COVID-19 or other illnesses strike, Harvard’s EMTs can be crucial in getting those who have been infected to the nurses and doctors who can treat them. But the job also puts them at risk. A given patient may or may not be infected by the COVID-19 virus, Harvard Ambulance Service Director Jason Cotting told the Press recently. “So we have to assume everyone’s infected.”
That assumption has led to changes in the way EMTs suit up before going out on a call, in how they approach their patients, and in the personal protective gear they have had to acquire. But the nightly scenes on TV of stricken and stressed first responders in New York and other major COVID-19 hotspots have not been repeated in Harvard. In fact, says Cotting, call volume for the service is half what it was before the state orders shut down businesses and schools and sent nonessential workers home.
Jason Cotting, director of the Harvard Ambulance Service. (Photos by Lisa Aciukewicz)
Cotting and his wife, Karen, a pediatric physician, moved to Harvard in 2010. At the time, he was technical director at the Stoneham Theatre in Stoneham. “But I always had an interest in emergency medicine,” he told the Press. Shortly after moving to town, he spotted a sign outside the Public Safety Building on Ayer Road inviting residents to join the service. “I signed up,” Cotting said. By 2011 he had completed his training and was a fully qualified EMT. In 2018 he was appointed director of the town’s ambulance service. He is a member of the Emergency Management Team directing the town’s response to the COVID-19 pandemic.
On an overcast Friday afternoon last week, the Press met with Cotting in the ambulance bay of the public safety building to get his perspective on the COVID-19 crisis, and to hear how he and the ambulance crew are dealing with it. The two-year-old ambulance glistened beneath the overhead lights. Cotting was wearing his blue ambulance service uniform, a pair of medical scissors sticking out of a side pocket. Unlike his interviewers, he did not wear a face mask, but he kept his distance.
How does it feel to be on the front lines of this crisis?
I don’t particularly feel like I’m on the front lines because, as you can tell from our call volume, this is not a particularly busy time for Harvard EMS. We have some members who are emergency department nurses in city hospitals. EMS services in places like Worcester and Boston or the surrounding areas where they are run ragged—they’re on the front lines. And frankly, I haven’t run as many calls lately as many of the EMTs who work here. So no, I feel like I’m ‘in the rear with the gear.’
What has your call volume been like?
Our call volume is normally 1.2 calls per day—on average. It’s normal for that to fluctuate dramatically. I could get five calls in one day and then nothing for several days. Right now we’re more like 0.4. So, less than half. That means people aren’t getting sick or injured. We’re certainly seeing fewer car accidents. People don’t seem to be exerting themselves outside, getting hurt.
How many COVID patients have you transported?
A, I can’t answer that; and B, I don’t really know, right? Because the COVID status of most people is unknown. I know the number that we’ve transported who have subsequently tested positive. But I have no idea how many people we could have transported who are asymptomatic, which is why we all need to be practicing social distancing and wearing masks with patients when we are in the enclosed ambulance.
Have you and the rest of the EMT squad been tested?
No, we have not. If there were massive amounts of testing going on, we might get tested as a precaution. But right now, tests are prioritized for symptomatic people; if we’re not symptomatic, we’re probably not going to get tested.
According to the Massachusetts Department of Public Health, the test is only validated for use with people who have symptoms. A negative test in somebody who’s asymptomatic doesn’t necessarily mean anything. We have access to priority testing if we are sick. But if we are sick, we’re not going to run ambulance calls. Because we typically don’t work regular shifts, and many of us, when we’re on duty, never come [to the Public Safety Building], we ask our members to self-evaluate. If they’ve got any symptoms—cough, fever, malaise, you know, fatigue, whatever—they just remove themselves from duty.
Have you had any volunteers not want to go out on calls because of the risk of exposure?
I’ve heard that desire expressed.
Do you have the number of trained volunteers you need to handle the call volume?
Yes. We’ve suspended the entire Bromfield cadet program just to reduce [the number of] trainees. We’ve only got a handful of adult provisionals who are still in training, and their patient contact is going to be determined by the needs of the call. So they’re not automatically going to get to make patient contact simply because they’re around.
We often run with three EMTs on board. The minimum is two. The third is often added when we have a driver who’s not an EMT, and we have several of those who contribute a lot of time.
What’s different about suiting up for a call during this crisis?
We’re wearing surgical masks and most of us are wearing some form of eye protection on every call, which we wouldn’t normally do unless the patient exhibited some signs of illness. And any patient who can tolerate a surgical mask is going to receive one on every call.
And then if we respond to a call that either we suspect could be COVID, anything with respiratory symptoms or respiratory complaint, or anything that we suspect could be infectious disease based on screening questions that the dispatchers are asking, then we wear an N95 respirator, eye protection, either splash-proof goggles or a face shield, a full isolation gown. Gloves. Though it’s not required, we can wear a head covering, too.
Do you worry about bringing the disease home?
I mean, everybody does. I treat this uniform as contaminated now. When I go home it goes directly into the washing machine; I don’t hang around in it. My boots stay outside. I wear a head covering on any of those calls. You might have seen on TV, there’s [emergency] docs who’ve shaved their heads. I haven’t done that, haven’t gone that far yet. But it’s a worry for everybody. Almost everybody on this service lives with somebody else. My wife happens to be a physician who’s still seeing patients, so she’s more likely to bring it to me than the other way around.
Does the service have all the protective equipment it needs?
We had a critical shortage of gowns and face shields. But we were able to stock up very quickly on both of those. For gowns, we requested support through Massachusetts Emergency Management Agency and MDPH. And both of those organizations were able to help us out. So we have 75 or 80 now, so that would support a significant uptick in call volume.
We have acquired face shields from several sources, including the Lions Club and a former theater colleague [Becki Gray of BeNT Productions in Clinton] whose fabrication shop is shut down because the theater industry is shut down. Ambulance crew member Mike Dempster has a background in medical device manufacturing. So we reverse engineered one of our commercial face shields and sent [Gray] the design. We had 60 face masks within a week.
There’s no ‘special sauce’ to a face shield. It’s just about keeping any sort of respiratory droplets from hitting my face. And then I’m going to throw it away. I don’t really want to decontaminate a face mask and use it again. Whether they would be suitable for a nurse who needs to wear it for 12 hours, it didn’t matter to us. We need to be able to wear it for 45 minutes and throw it away. We’ve got tons of those.
What can a patient do to help?
If they’re able, walk [to the ambulance.] [If] they’re able, be near the door so we can speak to them from outside. If they can’t, [perhaps] they have a family member who can do that so we don’t have to go into the home. When it’s possible, we have the dispatcher ask them to do that. And the dispatchers are screening. They’re asking everybody if they have a cough, if they have a fever, if they have known contact with a COVID patient. The dispatchers also have the addresses of all of the known positive tests so that they can let us know if there’s precautions needed at that address.
What impact has the closing of the ICU unit at Nashoba Valley Medical Center had on your call handling?
On our day-to-day practice, none. The only way we even figure that into our thinking is if we have a patient that we’re pretty sure is heading to the ICU, we would go to Emerson instead of NVMC. From most points in town the difference in transport time is only a couple of minutes. And we certainly have been advised that we can bring any patient to Nashoba that we need to, that they’ll be stabilized there, and then they’ll get a secondary transfer, you know, to another facility if they need it.
Our affiliate medical director, the head of emergency medicine at Nashoba, advised us that they have an ICU nurse on every shift. They are prepared to accept critical patients and stabilize them. And then they’ll get transported out. But if we were sure a patient needed that [critical care], we would only go to Nashoba [to save] time.
What worries you the most?
We know that protected exposures are unlikely to result in infection. I feel pretty confident that our local hospitals are able to support any patients that we bring them, and that we’re going to be able to meet the needs of the town in the short term. You know, I think that we’ve all got questions about what the next steps are going to be as a state and as a country. And I have those same questions.
Have you been affected by the town’s freeze on nonemergency spending?
No. Anything [we purchase] is going to be exempt. Also we’re planning to switch to an enterprise fund [a nonrevolving fund to collect payments the HAS receives from insurance companies for transporting patients]. Our appropriation is funded out of that fund. No, It hasn’t affected us at all. And we haven’t—other than buying some PPE that we wouldn’t necessarily need—we haven’t had huge expenses. Because our call volumes are down, our revenue will end up taking a hit, but we haven’t had to pay EMTs who are on those calls.
So do you wake up at night thinking about what’s going on?
I did early on, when we had not addressed our gown shortage and our face shield shortage. That was stressful to me. Now, I’m comfortable that we know how to do this and we’ve got the gear we need to do it.
What message would you like to leave with readers?
I would just really appreciate it if everybody maintains their social distance—or their physical distance, I should say. Socially, you should really try to stay engaged [with] people so you can maintain your mental health. That’s what I’d like to see.
I won’t go down a [grocery store] aisle that has another person in it. Not because I’m personally all that afraid of getting infected, but because we all need to make sure we don’t become vectors [i.e., transmitters of the disease.]
The ultraviolet light inside Harvard’s ambulance above the stretcher is used to disinfect the interior after all surfaces have been thoroughly wiped following a call.
Editor’s Note: The Press interviewed HAS Director Cotting on April 17. The transcript of the interview has been shortened and edited for concision and clarity.
