EMS World

MAR 2013

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CASE REVIEW | By James J. Augustine, MD, FACEP Outbreak Hotel When flu floods a community, where can a sick patient go? THE ATTACK ONE crew has been busy this shift, with the impact of a widespread infuenza 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 frst 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 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 infuenza 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-thanexpected 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 paramedic converses with the patient from about six feet away." 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 fuids. 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 Initial Assessment A 32-year-old female in acute distress. She is able to communicate and complains of fever, cough, muscle aches and chest pain. ❯ Airway: Patent. ❯ Breathing: Mild distress, with congested cough and wheezing. ❯ Circulation: Hot, dry skin. ❯ Disability: She appears exhausted but responds to verbal stimuli. ❯ Exposure of Other Major Problems: Other family members are ill, and she is a schoolteacher. VITAL SIGNS 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 fu 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 Copyright granted for this article for days, but the symptoms worsened while department use she was teaching at her school today. only up to 20 She has no other medical problems, copies. no prior history of lung problems, 16 MARCH 2013 | EMSWORLD.com 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 Time HR RR Pulse Ox. 0225 132 32 90% 0233 128 28 96% 0243 108 24 98% SECONDARY ASSESSMENT, APPROPRIATE TO PRESENTING CONDITION The patient is febrile to touch, and her mucus membranes are dry. She has a congested cough, which improves after a nebulizer treatment. AMPLE ASSESSMENT ❯ Allergies: None. ❯ Medications: Acetaminophen, azithromycin (a common antibiotic), cough medicine. ❯ Past Medical History: No significant problems. ❯ Last Intake: Unable to eat for past 24 hours. Taking less fluid than usual. ❯ Event: Illness. If E represents Exposures, she reports that many students at her school are ill with the flu, and her family members are also starting to report flulike symptoms.

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