Infectious-Disease Outbreak

The Attack One crew is having a busy shift on a beautiful spring Saturday. There have been lots of sports and recreational injuries and almost no opportunity between calls to retrieve and clean equipment or eat a meal. The calls have taken Attack One out of its usual service area, and now the crew’s trying to find a place to grab a quick dinner downtown.

That’s not going to happen: The dispatch tones signal a response to a hotel for a “person who passed out.”

Hotel staff members lead the crew to a guest room. “We have an ill man who passed out in his bathroom,” the manager reports. “He told us he’s conscious now but has been vomiting and having diarrhea.”

They enter the room, where a man lies on the floor in the bathroom. The crew members introduce themselves and offer to help.

“I can’t understand why I am so sick. Is there a bug going around?” the patient asks. He explains he’s been vomiting and having diarrhea for about 16 hours. During an episode of diarrhea, he had intense cramping and passed out in the bathroom. He regained consciousness quickly but called the hotel desk to get him help.

“I was supposed to leave town to go home this evening but was too ill to leave and get on a plane,” he says. “I’m healthy and have never had anything like this happen. I have pain in my belly only before I get diarrhea.”

He goes on to explain that he has no other illnesses or medical problems and has passed no blood. There has been no chest pain, palpitations or shortness of breath. He thinks he had a fever. He has not been able to eat or drink anything since yesterday.

The Attack One crew has developed a practice of having only one member exposed to a potentially infected patient. The paramedic steps aside for an EMT crew member who has donned a mask and gloves. He reports that the patient’s skin is warm and his pulse is a little fast but normal in rhythm. The patient has a soft and nontender abdomen.

The EMT takes a washcloth, douses it with cool water and places it on the patient’s forehead. He obtains a complete set of vital signs, quickly starts an intravenous line and places a dose of the antinausea medication ondansetron in the patient’s mouth to dissolve. The patient is placed on the stretcher, his room secured by the hotel manager, and a hospital selected.

Initial Assessment

A 44-year-old male in moderate distress. He complains of light-headedness, a fever, vomiting, abdominal cramping and diarrhea.

Airway: Patent.

Breathing: No distress.

Circulation: Warm, dry skin.

Disability: No compromise of neurologic function.

Exposure of Other Major Problems: Ongoing nausea and episodes of diarrhea.

Vital Signs

Time                       HR                          RR                           Pulse Ox.

1945                       124                         28                           96%

1953                       128                         28                           98%

2007                       108                         24                           98%

Secondary Assessment, Appropriate to Presenting Condition

The patient has no abdominal tenderness; his skin is warm and dry. He has no rash. On the three-lead cardiac monitor, he has a sinus tachycardia.

AMPLE Assessment

Allergies: None.

Medications: None.

Past Medical History: No significant medical problems.

Last Intake: He is with a group attending a convention in the city. He ate various meals at hotels and the convention center over the last two days. His last intake was at lunch yesterday.

Event: Episodes of vomiting and diarrhea, likely due to a contagious illness. Foodborne source is likely.

Patient Transport and Hospital Course

The patient is still nauseated during transport but does not vomit again. He receives two liters of fluid en route.

The ED staff is unusually interested in the EMS crew’s patient report. They respond that they are prepared for the patient’s arrival in the decontamination area of the ED. When the patient arrives, ED staff members motion for him to be brought into that area, where the staff are gowned and masked. There an emergency physician assesses the man.

The critical test that must be performed is testing his stools to find any virus, bacteria or parasite causing his symptoms. ED staff members ask the patient to provide a sample for testing. He is more than ready to comply, as he’s about to have another episode of diarrhea. A portable toilet is available in the decontamination room, and the staff leave the area to allow him some privacy.

While the EMS and ED personnel are outside, the Attack One paramedic asks the ED physician about the high level of precautions and why patient care is taking place in the decontamination area.

“This is the 10th person we have seen today with these symptoms, all of them with some connection to the meetings going on at the convention center,” the physician says. “We are not sure what the cause is, and on a Saturday we have not contacted public health officials.”

The paramedic is a little surprised but offers to help: “This is the first illness patient our crew has managed today, but I will check with our communication center to see about other EMS calls that might be related to some kind of outbreak. If you have seen 10 patients already just in this ED, we need to let public health know now. I am going to get an EMS supervisor here to help, and we will get some movement on this right away.”

The emergency department is too busy for the physician and charge nurse to be much help, so the Attack One paramedic begins the process of notifications and information gathering. The Attack One EMTs complete specific documentation for this patient and gather additional information about how long he has been in the city, where he’s been for meetings and who else around him has reported illness. The patient provides some valuable information, including that some of his coworkers are also ill with gastrointestinal problems today. They are staying in their hotel rooms, trying to recover.

That information makes the EMTs uncomfortable, and they report it immediately to the paramedic. The paramedic has made two phone calls, both of which produced more concerning news: The EMS supervisor is aware of several more EMS calls for GI illnesses today, and the dispatch supervisor knows of at least five persons transported from downtown hotels with illnesses so far. The dispatch office will review the day’s calls to compile a complete list. The EMS supervisor heads to the hospital.

The paramedic reports these developments to the emergency physician, who asks that the EMS chief and medical director be contacted and involved. He also instructs the charge nurse to notify the hospital’s infection control officer.

The wheels are turning.

The EMS supervisor has the paramedic call the local public health office and ask for the on-call specialist to be paged. The Attack One EMTs have called the hotel rooms of the other sick workers, who are both ill with symptoms of vomiting and diarrhea. They both are willing to come to the hospital, so an ambulance is dispatched to treat and transport them.

The paramedic is itching to do some detective work, but it’s already a busy Saturday evening for the EMS system, so he prints out all the information he has gathered to turn over to the public health officer who will be coming to the hospital to begin the formal investigation. This hospital, although working a busy Saturday evening, is willing to accept any other patients who are ill, so the EMS supervisor puts out a general message to the ambulances on duty that all patients with GI illnesses are to be transported to this hospital, and the supervisor is to be notified for each one.

The public health officer returns his page and is at the hospital in minutes. He arranges for rapid testing of the specimen from the ED and collects all the information the EMS supervisor and Attack One paramedic have in hand. The Attack One crew members have cleaned themselves and all exposed equipment thoroughly and return to service.

A few hours later the public health officer notifies the EMS supervisor that the likely cause of the outbreak is a norovirus. This pesky virus causes very uncomfortable symptoms of vomiting and diarrhea, cramping and dehydration, but it’s not a life threat. This also means that more serious causes of illness, like intentional poisoning, are not present. There are more than 50 victims already known and likely to be more, including some who probably completed their business and left the city.

The state public health office and the CDC will be notified. A media briefing is prepared for the 11 o’clock local news. The original patient is treated overnight in the ED and released in the morning.

The state public health lab ultimately tests multiple specimens from a number of patients and four days later identifies a single strand of norovirus as the source. It is likely from a food source at the convention center, but no more specific site can be identified. All victims recover without complications. No EMS staff get the illness.

Case Discussion

In this period of global dangers, rapid travel and germs both old and new, EMS providers must be aware of unusual patterns or single instances of high-priority bugs. The names will change: norovirus, influenza, Ebola, MERS, tuberculosis, measles, etc. Emergency providers will likely be engaged in the care of initial patients and may be called upon to identify unusual events or possible outbreaks.

EMS providers are familiar with immediate emergency care of the initial patient, but of greater importance is notification of and interaction with the local public health agency to find patterns, outbreaks or intentional events. Every EMS organization must know the emergency communication link to its local public health department. In most locations access to the Centers for Disease Control and Prevention (CDC) occurs through the local public health agency. EMS providers in ports, immigration areas and other transportation sites will have direct access to a CDC quarantine station.

EMS actions in contagious-disease incidents can dramatically alter the course of the event. This case demonstrates the benefit of using EMS sources to find ill individuals and start the process of investigation, even on a weekend.

Learning Point

Care of individuals who are likely part of an infectious-disease outbreak should be coordinated with the hospital personnel. EMS providers should be prepared to work with the local public health agency for identification of patients, reporting of unusual circumstances and patterns of illnesses, and sharing critical information.

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.