Unmasked

     There have been a lot of calls for ill people lately. An outbreak of an infectious disease that causes severe breathing problems and death has occurred overseas, and is now affecting small numbers of people in the metropolitan area. Several have died. Now Attack One responds to another report of a patient short of breath. The dispatcher relays that this patient had, a week ago, returned from a job-related trip to a country having widespread outbreaks of the disease.

     The Attack One crew dons their gowns, goggles and N99 masks as they arrive on scene. The EMS dispatcher has asked the patient and her family to meet them on the front porch of the house, and she is there as the crew arrives. Per protocol, they ask if the patient will also don a mask. The patient is in moderate respiratory distress, and as she coughs they can hear wheezing. One crew member approaches and assesses. The others gather information from the family. The department's revised protocol for respiratory distress calls for the crew to transport without starting a nebulizer treatment, and to start a saline lock only if it does not require the paramedic to be in close proximity to a coughing patient. This patient is given subcutaneous epinephrine for her wheezing.

     The same paramedic remains in the passenger compartment of the transport medic unit, and the family is asked to drive separately to the ED. Under the revised protocol, the patient is to be transported to a designated receiving emergency department, and an extensive report is given to the ED staff regarding the patient and her potential infectious disease. "Bring the patient into the ED," the ED nurse advises. "Confirming to bring the patient into the ED," the paramedic responds. "We have a mask applied."

     It's a rapid transport, and as the crew pulls up at the hospital, they notice a lot of media vehicles and cameras gathered near the emergency department entrance. Reporters film the crew as they offload the patient and enter the ED. There they encounter an ED staff member who asks about their patient's chief complaint. This staff member is not in any personal protective equipment.

     "This is the patient we called about five minutes ago," the paramedic states, "with the difficulty breathing and the potential infectious disease." The staffer asks the crew to wait for a moment…then the charge nurse approaches and asks the crew to take the patient back outside.

     They walk the stretcher and patient back into the evening air. The media cameras are still rolling, and the reporters are puzzled at what they're seeing. Aware of patient privacy rules, they don't approach the patient or Attack One crew, but request a statement from the hospital's public information officer, who is on scene doing an interview. She defers, but offers to have the issue addressed later by a clinical person from the ED.

     After a few minutes the charge nurse comes out, pulls the mask off the patient and interviews her in the ambulance parking area. The nurse is wearing no protective mask, gloves, goggles or gown. She then asks the crew to move the patient into a certain room in the emergency department. At the request of the Attack One paramedic, the patient places the mask back on her face. She's then moved into the room, a report is given to the ED staff, and the stretcher and equipment pulled back outside to be thoroughly cleaned.

     As the crew completes their report, they see the charge nurse and hospital PIO setting up for an interview in front of the cameras. The first question to the nurse: "Why did you tell the patient to come back outside, and why aren't you doing what the EMS crew was doing?"

     It is a very uncomfortable interview, with many questions about the hospital's and emergency department's policies on managing patients with this dangerous infection. The media note how the nurse is not in protective wear, interviewed the patient at a close distance without a mask, had staff members moving into the patient's room without masks, and took no precautions to keep other patients or staff members away from the room. They note that the nurse answers one question by saying the hospital would be using N95 masks, while they observed the EMS crew using N99 masks.

     The Attack One crew watches the interview on the news that night. It's part of a pointed and critical story about the hospital's infectious-disease practices. The hospital spokespersons are not portrayed as knowledgeable about the disease. The media had even encountered a hospital staffer casually walking out an employee door at the end of his shift. When asked if he was being careful in his work related to potential patients with this deadly disease, he asked, "What is that?"

     The EMS providers send a note to their supervisor about the interaction, to advise that the media may be seeking a corresponding story about the prehospital approach to the disease. The supervisor calls back immediately and asks for details about the incident. Concerned about this inconsistency in practice, she places a call to hospital administrators, hoping to leave a message requesting a meeting the next day. Instead, her call is immediately forwarded to the hospital CEO.

     At 1 a.m., a crisis meeting occurs with the hospital's CEO, other chief officers, emergency department nursing and physician directors, infection control officers, PIO and the EMS service. The Attack One crew is asked to attend. By the time everyone emerges two hours later, there's been an immediate change in procedures for the hospital. Procedures will now be exactly consistent across all departments, and consistent with the EMS approach to potential victims of this infection. The group has outlined the screening tools for the disease; a procedure to secure hospital entrances and limit visitors; the use of masks and other personal protective equipment; modifications in the use of nebulizer treatments; and communication with any EMS patient arriving on the hospital campus. Worksheets are prepared to outline the process, and a complete set of documents will be prepared to explain it to staff, patients and visitors. A designated group will work overnight to prepare an educational program for all hospital staff for release when the day shift comes to work, and the CEO will appear on the morning news to explain the hospital's procedures to the community. He will also convene a group of all the hospital leaders in the region to establish a consistent regional approach to management of these patients.

     Within three days, the regional emergency system has crafted a single document outlining procedures for communication, screening, patient management, PPE utilization and patient and family interaction. It is modified as more is learned about the disease and its spread, but results in consistent approaches to care and reduction of infectious potential to healthcare workers.

     The patient had severe pneumonia related to the infectious disease. She ended up on a ventilator, with a long hospital course and rehabilitation period. One of her family members contracted the same disease, and also had a prolonged course in the ICU. No EMS or hospital staff contracted the disease.

     Infectious diseases are an ongoing challenge for all facets of healthcare. A key management principle: Don't expose the emergency workers, and don't let the care of the patient be compromised! World travel allows conditions conducive to spread of unusual organisms at a very rapid pace. Emergency workers should share consistent approaches to infection control.

     James J. Augustine, MD, FACEP, is an emergency physician from Washington, DC. He serves as deputy chief-assistant medical director for Washington, DC Fire and EMS. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at James.Augustine@dc.gov.

     A 48-year-old female in moderate distress. She has a productive cough with green sputum and mixed blood.

     Airway: Patent. The patient can tolerate breathing with a surgical mask on her face.

     Breathing: Increased respiratory rate, audible wheezes and use of accessory muscles.

     Circulation: Good capillary refill.

     Disability: No deficits.

     Exposure of Other Major Problems: Recent travel to a country undergoing multiple outbreaks of a severe infectious respiratory disease, with deaths in the patient population and among healthcare workers.

     Family members are at risk for the same disease and are asked to drive to the hospital in a separate car. Once there, they are asked to sit in an isolated area of the ED waiting room.

     Allergies: Penicillin.

     Medications: None known.

     Past Medical History: No history of problems.

     Last Intake: Ate breakfast.

     Event: Severe and potentially infectious respiratory disease.

     Learning Point: Infectious diseases are an ongoing challenge for all facets of healthcare. Emergency care system personnel are particularly at risk, because each workday brings new patient interactions and opportunities for exposure. World travel allows conditions conducive to the rapid spread of unusual organisms. EMS and emergency department providers are well served by shared and consistent approaches to infection control.