Multipatient Medical Event Tests Wake County EMS

At 9:26 a.m. on Saturday, February 13, 2010, the Raleigh-Wake (NC) Emergency Communications Center (RWECC) received a call from an individual reporting that a large number of children who had eaten together at a convention were beginning to get sick. While the caller advised that EMS was not required, the dispatch supervisor notified Deputy Fire Marshal Charles Ottaway, the county fire, rescue and emergency management duty officer, of the call.

As Ottaway headed to the nearby EMS district chief's office, RWECC dispatched Raleigh Fire Department E-1, along with Wake County EMS-1 and MEDIC-94, to a report of a person with respiratory distress on the eighth floor of the Sheraton Capital Center Hotel, just two blocks from EMS headquarters and across the street from the Raleigh Convention Center--right where the sick children had been reported. A YMCA "Youth in Government" convention was under way, with approximately 1,500 high school students and 250 adult advisors and volunteers in attendance. Units arrived three minutes later, at 9:36.

The respiratory distress patient's primary complaint involved nausea, vomiting, and diarrhea. EMS personnel were also told there were perhaps 150 to 200 young people who had become sick since the prior evening. While Raleigh Fire personnel assumed incident command and began exploring the possibility that hazardous materials were involved, advanced practice paramedic Gene Lambert assumed the position of EMS branch director. At 9:48, Lambert requested the dispatch of an EMS "third alarm" assignment. Each EMS alarm brings four ambulances, a district chief and an additional advanced practice paramedic to the scene. A third alarm also alerts EMS command staff and the system's EMS physicians (System Director Dr. Brent Myers and Deputy Medical Director Jose Cabanas).

By 9:50, a triage area had been established in the Gallery Room, a banquet facility on the second floor. At 10:08, RFD Battalion Chief Rob Johnson advised that hazardous materials were not suspected, and command was passed to EMS District Chief Jeff Hammerstein. The command post was established in a conference room on the hotel's first floor, with representatives from EMS, fire, law enforcement, the hotel, the American Red Cross (providing first aid standby to the convention) and YMCA event leadership.

The triage area was receiving a steady stream of high schoolers suffering from nausea, vomiting and diarrhea, some to the point of dehydration. By 10:30, Myers decided that those needing treatment would be treated on site, so a treatment area was established in the hotel's third-floor Oak Forest banquet room, under the direction of Cary Area EMS paramedic Chris Adams, treatment group supervisor. Myers and Cabanas worked in the treatment area, with Myers alternately serving as a technical specialist in the command post. Triage criteria were established to identify those who could be released to return to their rooms to rest and hydrate (categorized as green), those who required on-site treatment with fluids and antiemetics (yellow), and those who required hospital transportation (red). Community hospitals were contacted and instructed to turn on their "MCI radios" and switch to channel MC-HOTEL, the designated hospital coordination talk group. The hospitals were updated on the status of the incident every 30 minutes thereafter.

At 10:55, Assistant EMS Chief Jon Olson, the operations chief, arrived, was briefed and assumed command of the incident. Hammerstein, whose regular collateral assignment is as the EMS Division PIO, was reassigned as the incident PIO. Shortly thereafter, with senior paramedic Ray Fetchko serving as search group supervisor, teams composed of EMS medics, firefighters and hotel staff, armed with a convention room assignment list and hotel master keys, began a room-to-room search for sick conventioneers who hadn't sought help. They found several additional sick persons and directed them to the triage area for assessment. EMS Division Chief Joe McLean, logistics officer, was summoned from home and traveled to the EMS warehouse, where he assembled and delivered cases of IV fluid, antiemetic drugs, and PPE for triage and treatment personnel.

At 11:45, personnel from Wake County's Community Health Division were on scene, followed by epidemiologists from North Carolina Public Health Regional Surveillance Teams. They identified a foodborne illness as a high probability, and suspected norovirus. At 12:16, EMS transported the first of what would ultimately be five patients to hospitals, and clinical affairs chief Ryan Lewis assumed the duties of transportation officer.

By 2:15 p.m., nearly 140 patients had been triaged. Forty required treatment. The triage and treatment areas were consolidated, and RFD and RPD resources demobilized. Nearly 100 public health surveillance questionnaires were completed. By 3:59, the last patient was transported, and nine minutes later incident command was turned over to Community Health officials.

Lessons Learned

On Wednesday, February 17, officials conducted a full debriefing, with participation from EMS, RFD, RWECC, Wake County Community Health, Six Forks EMS and Eastern Wake EMS. While all agreed the incident had gone well, participants recorded a number of "lessons learned" for future reference:

• Procedures should be developed for managing foodborne illness outbreaks. Public health surveillance forms need to be carried aboard EMS supervisor and major-incident units to facilitate timely interviewing and release of those involved.
• Public safety and public health incident management personnel need to practice working together, particularly in command post operations.
• When on-duty EMS personnel are used for on-site treatment, the system must maintain several fully staffed and "ready to go" ambulances in order to timely serve those requiring transport.
• Body substance isolation precautions and incident personnel accountability could have been better. While EMS is fully equipped for at-scene accountability, somehow this function was overlooked during this unique incident. In addition, while gloves were used by EMS personnel for patient contact, masks were not. Furthermore, we must develop a means to ensure disease is not transmitted via ink pens and other vectors used by multiple patients or patients and paramedics.

For more photos of the incident by Wake County EMS photographer Mike Legeros, see here.

Brent Myers, MD, MPH, FACEP is the Director and Medical Director of the Wake County EMS System and a member of the Board of Directors of the National Association of EMS Physicians.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMO is the Chief of the Wake County EMS Division, President-Elect of the National EMS Management Association and an editorial advisory board member for EMS Magazine.

Jonathan Olson, MBA/MHA, EMT-P is the Assistant Chief - Operations of the Wake County EMS Division. Chief Olson served as the incident commander for this event.