Outbreak Hotel

The Attack One crew has been busy this shift, with the impact of a widespread influenza outbreak leading to a lot of ill patients in the community. In the early morning hours, dispatch reports a “person ill and short of breath.”

“My wife is just too ill to take to the hospital by myself, and our children are also starting to cough and run fevers,” the man at the home’s front door reports. His wife sits on the couch in the front room, and on first appearance looks ill.

During the outbreak the Attack One crew is utilizing an approach where only one member is exposed to a potentially infected patient. The paramedic converses with the patient from about six feet away; the rest of the crew remains outside the house.

“What is bothering you the most?” the paramedic asks.

“I am so short of breath, and having shaking chills with my fever,” the patient reports.

The paramedic introduces himself, dons an N95 mask and asks the patient if she would mind doing so also. “We’re doing this on all encounters with ill patients during this flu outbreak, so we can protect both the patients and the members of our crew,” he tells her. “We will put you on oxygen to assist your breathing, and that will go underneath the mask.”

The patient appreciates the explanation. She says she’s been ill for two days, but the symptoms worsened while she was teaching at her school today. She has no other medical problems, no prior history of lung problems, does not smoke and has no history of asthma. Many of the children and staff members at her school have also been ill. She has not received an influenza immunization.

The Attack One paramedic does a quick assessment that includes obtaining a pulse oximetry reading and listening to the woman’s lungs. He can detect the warm temperature of her skin even through his gloves. She is wheezing and has a lower-than-expected pulse oximetry reading. He directs the crew members to prepare to give a nebulizer once the patient is moved into the ambulance.

She insists on walking to the stretcher, which the crew has placed outside the front door. They cover her to get through the cold night air and deliver her quickly into the ambulance. The paramedic, wanting to ensure that nothing else is occurring to make the woman and her family ill, asks the patient and her husband to have quick transcutaneous CO-oximetry readings to check for carbon monoxide poisoning. The results on both patients show very low levels of carboxyhemoglobin.

“That quick test showed that neither of you have been exposed to carbon monoxide. We make sure to check that when several family members are ill,” the paramedic tells the husband. “We will transport your wife to the hospital, and you can meet us there when the family member coming to watch your children arrives.”

Patient Care

The crew quickly places the patient into the ambulance and starts the nebulizer treatment, and the paramedic dons a gown and goggles in addition to his mask because he will stay with the coughing patient in the back. He also notes the young woman appears dry, but she is not nauseated or vomiting, so there is no immediate reason to give intravenous fluids.

After requesting to be taken to the closest community hospital for care, the patient closes her eyes. It’s an easy request on many days, but tonight will be difficult. As the ambulance begins to move, the driver notifies the dispatcher that they will be transporting one patient to the hospital she requested. The dispatcher acknowledges the message but reports the hospital is on diversion status, and the crew will need to select another. The driver requests a second hospital by name and is told that too is on diversion. The dispatcher finally volunteers that almost all regional hospitals are on diversion, and only one some distance away is receiving ambulances.

The driver passes that information to the paramedic, who then asks if that hospital will be OK with the patient. She nods, but then opens her eyes and becomes concerned. “What about my husband? He is going to our closest hospital and will not know where I am. And his phone is turned off—what are we going to do?”

After some negotiation and conversation with the dispatcher, an arrangement is made to have a local police officer go to the home and inform the husband that his wife is being transported to the farther hospital. That officer will confirm delivery of the message to the dispatcher, and then the dispatcher back to the ambulance.

Diversion has been a major issue before in Attack One’s system, and the paramedic promises to let the EMS supervisor know about the issues related to this patient and communication to her husband at the end of his shift.

The paramedic delivers a rapid notification to the appropriate receiving hospital. The emergency department staff asks if the patient can be masked on arrival and prepared for a significant wait. Because so many other hospitals are on diversion, the ambulance traffic has been heavy in the overnight hours.

Hospital Course

The ED is very busy on the patient’s arrival. The ED staff performs an assessment, finding her febrile at 104ºF. They conduct a rapid influenza test, which is positive. Before the Attack One crew can complete its documentation, the patient has been to x-ray and found to have pneumonia. Her wheezing is treated with repeated nebulizer therapy. She will be admitted to the hospital.

The patient actually deteriorates in the next day and needs treatment in Intensive Care. She remains hospitalized for 10 days, requiring the use of antiviral agents and antibiotics and support on a ventilator. She is released in fair condition and needs home therapy before she can completely recover.

Case Discussion

In January the CDC reported the entire United States was at its highest level of flu outbreak. There have been a number of fatalities. The population affected this year largely has been older, including some nursing-home outbreaks. EMS systems have been busy across the country, as have hospitals and their emergency departments. With an older population affected by the viruses, symptoms prompting EMS activation have included shortness of breath, chest pain and high fever. In many cases acuity has required hospitalization, which puts pressure on available inpatient beds, and some urban areas have had problems with hospital diversion.

Infectious diseases are a continuous challenge to EMS providers. There are a variety of agents of concern, which include viruses, bacteria, fungi and other agents. There are natural and bioterror agents that have affected EMS operations and require active prevention programs. Within every EMS agency there must be a program and leaders dedicated to the identification, prevention and control of contagious diseases. Every EMS organization must establish links to the responsible public health entity in their service area. This agency will access the state public health organization (and CDC) for information about important agents.

EMS leaders have developed policies for mitigating the impact of seasonal viruses. Many EMS personnel receive vaccines. Great operating practices help staff avoid contagious diseases: Don’t get within six feet of ill patients unless it is needed; place masks on ill and coughing patients; wash hands and keep them away from the face; get appropriate rest and exercise. These good habits allow EMS providers to remain confident as a contagious disease becomes concerning, and able to reassure their families they will not bring any bugs home.

Seasonal disease outbreaks also challenge the capabilities of regional healthcare systems. The operational problem becomes emergency departments’ capacities to receive patients, whether they are suffering from the contagious illness or any other emergency condition.

The diversion issue has a broad base. It is a function of:

• Reserve capacity of the hospital in terms of beds, patient care staff and equipment;

• Buffer capacity, mainly in the ED, when larger-than-normal influxes of patients occur;

• Planning and scheduling, so the hospital reduces the volume of elective services when acute care beds and staff are not available;

• Illness among hospital staff.

All hospitals have the potential for diversion. In urban areas where hospitals are closer to each other, it is typically felt that diversion carries less of a penalty for community patient care. However, in areas where a single hospital stands geographically isolated, there will be significant transportation issues for patients and their families if care needs to be diverted. These isolated hospitals must be extraordinarily well prepared for patient fluxes and utilize diversion rarely.

As in this case, the EMS system can have a difficult job in understanding and conveying the diversion message. Dispatch centers may need significant clarification of what form of diversion is taking place, how long it will last and how to effectively communicate the message to EMS units in the field. Many 9-1-1 dispatchers are police or civilian personnel and must be given explicitly worded diversion messages to deliver.

Some areas have established policies that eliminate diversion, rerouting or patient offload delays. In these communities regional planning leads to development of improved system status management, with tools that are utilized by the EMS system, hospitals, the major payers and the general medical community. These systems provide a comprehensive toolbox for identifying key community resources and communicating their status to providers. These allow the regional health system to operate more efficiently while still enabling the community to access excellent care at peak demand times.

Over time Internet-based status management programs and a hospital bed “spot market” system will tie together large regions for healthcare delivery and make bed availability brutally efficient. There will, however, always be a concern about the management of unplanned needs and disasters.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.