Germs of Service

Morning chores are more enjoyable when they follow a good breakfast and are performed in group fashion. The Attack One crew has a full checklist of cleaning responsibilities for the morning, and they’re finishing up when the dispatch system requests they respond on a report of a “person ill.”

The crew walks up to the front door of a nice home and are greeted by a person who identifies herself as a visiting nurse caring for a patient who is very ill. She leads the crew to an upstairs bedroom, where the ill woman is upright in a hospital-style bed. She is pale and has the appearance of a very sick patient in respiratory distress. They note she has no visible hair, and her head is covered neatly by a colorful scarf.

One of the EMTs gathers history from the visiting nurse while the two paramedics begin to interview and assess the patient.

“Headache, nausea, vomiting, and now I’m having trouble breathing,” the woman reports, her voice frail. “I am just so sick!”

The patient goes on to report that she had recent surgery for an aggressive cancer in her right breast and is on therapy that has caused her to lose all of her hair. She has been nauseated and lost her appetite, but in the last few days she’s also been vomiting and had loose bowel movements. Her doctor wants her to be admitted to the hospital, but she wants to stay at home, so a visiting nurse has been assisting her.

“I don’t want to be in a hospital because there are too many sick people there,” she states. “I’m worried I’ll get their illnesses.”

The paramedic crew leader notes that concern and says they will treat her carefully and take precautions to keep her from getting more ill. In her head the paramedic thinks, Why did we have to have all our cleaning duties today? We’re probably covered in infectious material from getting everything out and moving it around!

“We will back away for a moment and put on our protective gear on,” she offers to the patient, “and allow you to put on a mask that will reduce your chance of breathing in any infections.”

The patient replies, “I was too short of breath to wear the mask I have with me. Will you be able to help?”

“Yes, ma’am,” the paramedic replies as she finishes tying on her own mask and gown and gloves. “We will give you oxygen underneath the mask to assist your breathing, and only put your mask on if you are comfortable.”

The patient is knowledgeable enough of the process to ask for an N95 mask for herself, understanding that on her face it will protect her from inhaling potential infectious agents. With that information, the paramedics offer to explain everything they do and ask for her input on anything that would make their treatment more effective.

Initial vital signs show a low pulse oximetry reading and high pulse and respiratory rates. Her blood pressure is only palpable. They share the results with the patient and let her know how concerned they are about the values.

The paramedics apply oxygen via a cannula, and when the patient says that makes her less short of breath, they hand her an N95 mask and ask her to put it on when she is comfortable (and take it off if she feels worse).

“Ma’am, we need to give you some fluids. Do you know where you might have a vein to start an IV in?”

“I have only a port in my chest. My veins are all in bad shape.” She points to the dressing on her left chest, which covers a device that allows her treatments to be injected into her central veins. It is neatly in place. The paramedic notes a dressing on her right chest also and asks if she needs to look at that site, where the woman’s surgery took place.

“I do not want you to disturb that area,” the woman says. “The visiting nurse checked it and changed the dressing early today. It had been infected, and I don’t want it open any more than is absolutely necessary. I can tell you that at 6 this morning it looked much better, and no signs of infection are present.”

“Our protocols do not allow us to use a port for treatment,” the paramedic says. “Can we look for another vein?”

“How about if the visiting nurse starts the fluids in the port? She is qualified and does the infusions I get for my treatment.”

“We can do that, if the nurse is comfortable.”

They call the nurse from the other room, and she says she’s capable of starting a fluid infusion by attaching the EMS tubing and fluid to the sterile port on the patient.

While that is set up, the paramedic asks the patient if she wants treatment for her nausea and vomiting and if she needs anything for pain. Those medicines will have to go through the port also. The patient asks if they can treat her nausea, and then she’ll take her own oral pain medicine, which is the most effective for her and gives her the fewest side effects.

The nurse connects the intravenous saline to the port, and they administer the available antiemetic through the tubing into the patient.

The oxygen has improved her pulse oximetry reading, and the patient says she’s less short of breath, even with the N95 mask now on her face.

“What else do you need for the trip to the hospital?”

“I don’t really want to go at all,” the patient says. Then she begins to cry.

“Ma’am, we will take great care of you and make sure we turn you over in the emergency department to people who will do the same,” the paramedic assures her. “Which hospital did your surgery and is directing your treatment?”

The patient and crew agree it would be best for her to go to the hospital where the surgery took place, even though it is not the closest hospital.

The patient says she feels better during transport, to the point where she takes her pain medicine and asks that the oxygen be turned down a little. Her vital signs continue to improve.

A report is called ahead to the ED, with a request that they put the patient in a room appropriate for her possible infectious problem and have their personnel in protective wear. This patient has the symptoms of sepsis, so the paramedic specifically includes that in the verbal report.

Hospital Course

The ED staff are appropriately gowned and masked to initiate their patient care. The patient is in less distress than on presentation to EMS but continues to move slowly and speak softly. She is transferred to the patient stretcher and hospital oxygen. She offers no new complaints to the ED nurses and physician.

A rapid workup finds she has a serious infection, and she’s immediately given fluids, antibiotics and support for her low blood pressure. She is transferred to the oncology unit, and with meticulous care is able to recover from the illness and finish her cancer therapy. As soon as possible, she returns home.

Case Discussion

This patient had a severe infection as a result of her weakened immune system. There are many infectious causes that can bring on the damage related to sepsis, including bacteria, viruses and fungi. Sepsis results from the body’s immune response to the infection. The infection triggers an overwhelming immune response, causing widespread inflammation, small blood vessel clots and the shift of fluids, which results in inadequate perfusion and then impaired blood flow to organs, including the brain, kidneys, liver, gut and lungs. In severe cases where sepsis is not diagnosed and treated appropriately in the early stages, multiple organ failure and death are common.

Individuals with an increased risk for sepsis include the following:

• The elderly, especially those with chronic illnesses;

• Patients with immune weaknesses, such as those on cancer chemotherapy, the malnourished, those having certain disease processes such as HIV, and those on steroids;

• Patients with indwelling catheters, lines and ports;

• Newborns, infants and young children.

Systemic inflammatory response syndrome (SIRS) is a systemic response to infection that may be identified by the presence of any two of the following criteria:

• Temperature higher than 100.4ºF or lower than 96.8ºF;

• Heart rate greater than 90 beats per minute;

• Respirations greater than 20 breaths per minute;

• High white blood cell count (done at the hospital);

• High lactate level.

EMS evaluation and treatment of sepsis and other serious infectious problems will include full evaluation of vital signs, including blood sugar. A full examination should include looking for a site of infection. Perform the usual airway evaluation and secure the airway if necessary. Deliver oxygen to keep pulse oximetry great than 95%. A few EMS systems can measure blood lactate levels via fingerstick; if available, do that.

EMS protocols are often developed to begin treatment and notify the hospital so staff there can prepare for rapid evaluation. Most patients with sepsis are severely volume-depleted. Administer saline, with one or two IV lines established. Monitor the patient to make sure they do not develop worsening shortness of breath or rales. If either occurs, stop the fluid bolus and maintain the IV at KVO. In certain circumstances where there are long prehospital times and the patient shows continued signs of poor perfusion, you may need to administer two or more liters of saline.

Rapid transport is indicated for the elements of evaluation and treatment that have to be performed at the hospital. Even with excellent emergency care, sepsis still has a high incidence of morbidity and mortality.

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.