EMS Provider: Protect Thyself…From SARS and Other Nasty Germs

What began less than a year ago as a few puzzling instances of illness in Eastern Asia has since expanded across the globe. The first cases of SARS surfacing in the United States have federal agencies and health care institutions scrambling to protect our domestic population by dealing with this new disease head-on. The Centers for Disease Control and Prevention (CDC), in collaboration with the World Health Organization (WHO), is working to develop viable safeguards and methods of treatment and containment for this new threat. In the meantime, however, emergency medical professionals—who are perhaps most at risk in confronting the disease—have been operating, for the most part, without practical guidance. In fact, fewer than 20% of today’s EMS agencies and fire services have standard operating procedures to deal with suspected SARS, or for that matter, many other communicable disease entities, such as anthrax, meningitis, chickenpox, and measles.

Public fears of bioterrorism have been escalating ever since 9/11, making it more essential than ever to initiate special procedures that offer protection against these threats—especially for prehospital providers, who put their lives on the line every day. In this high-risk profession, immediate recognition of communicable diseases is paramount, both so that we can take steps to contain a potential epidemic, and so that we’ll know to seek prophylactic treatment if necessary.

What follows are suggested guidelines for infection control of SARS. Information about body substance isolation precautions appropriate for other communicable diseases appears in the TRIPP Enhancement section of this newsletter.

Presentation and transmission

SARS usually begins with a fever (body temperature exceeding 100.4°F/38.0°C), which may be accompanied by chills or other symptoms, including headache, malaise, and muscle pain. Some individuals exhibit mild respiratory symptoms as well. After 2 to 7 days, SARS patients may develop a dry, nonproductive cough, which may eventually become severe enough to cause hypoxemia. In 10% to 20% of cases, patients will require mechanical ventilation. (See the sidebar for information about SARS presentations in children.)

Current evidence suggests that SARS is transmitted by bodily secretions, including aerosolized droplets, so infection can occur through either direct or indirect contact. Close contact, defined as coming within 3 to 6 feet of an infected individual, is deemed necessary for direct infection to occur, but airborne droplets and residual infectious particles left on environmental surfaces create additional hazards. Therefore, you should be prepared to use precautions for contact, residual, and airborne contamination.

Responding to the call

If your unit is called to treat a suspected SARS patient, observe the following precautionary measures:

C       Send the minimum number of emergency personnel to respond to the call.

C       Make sure infection control supplies are readily available on the ambulance.

C       Use a cellular or landline telephone to notify the receiving facility so that they can prepare for a potential SARS patient. Do not identify SARS over an open radio frequency.

What to wear

Wear personal protective equipment at all times during the call. Make sure you’re prepared to follow these precautions:

C       Wear gloves and a disposable fluid-resistant gown or Tyvek suit throughout the call. If your gloves or suit become soiled or damaged at any time, you’ll need to remove them and put on fresh gear, placing the discarded clothing in red biohazard bags. The same procedure applies to other disposable protective equipment.

C       Wear protective goggles or medical face shields whenever you are within 6 feet of a suspected SARS patient. Prescription eyewear, sunglasses, or safety glasses will not protect you against the virus.

C       Use a properly fitted respirator (N-95 or higher) at all times when working within the patient compartment of the transport vehicle.

These precautions apply not only to responders who actually approach or treat the patient, but also to drivers who do not approach the patient, if the driver compartment of the ambulance has any openings to the patient compartment.

Procedures during transport

Observe the following precautions once you arrive on the scene and throughout transport:

C       Avoid eating, drinking, touching your face, or handling contact lenses while in contact with the patient.

C       To maximize air exchange in the vehicle, turn on the ventilation and keep it on throughout transport. The main dashboard vents should be open and the rear ventilation fans turned to the highest setting. Ventilate the driver and patient compartments separately if such a system is available.

C       Patients who can tolerate it should wear paper surgical masks to reduce droplet transmission.

C       Administer oxygen using a nonrebreather mask if it’s needed. If you must perform assisted ventilation, use a bag-valve-mask that’s equipped with HEPA filtration to capture droplets from the patient’s respiration.

C       After completing patient care, remove your gloves and other disposable gear, place them in red biohazard bags, and immediately wash your hands thoroughly or decontaminate them using a waterless sanitizing gel. This should be a priority, as proper hand-washing is the single most important means of preventing the spread of infection. Vigorous scrubbing for at least 30 seconds is necessary to remove infectious contaminants, including protein matter, blood, and secretions.

Cleaning and decontamination after transport

After transporting a suspected SARS patient, the vehicle must be taken out of service until rigorous decontamination procedures are complete.

C       Move the vehicle to a work area designated for medical equipment cleansing.

C       Clean the driver compartment thoroughly according to the vehicle manufacturer’s recommendations.

C       When decontaminating the patient compartment and reusable equipment, wear disposable gloves, a disposable gown, and a face shield, and use an EPA-registered hospital disinfectant. Clean the stretcher, railings, medical equipment and control panels, adjacent flooring, walls, and any work surface or reusable equipment that could have been either directly or indirectly contaminated.

C       If you suspect that reusable patient care equipment has been contaminated, place the items in a biohazard bag labeled for decontamination. They should be decontaminated according to the manufacturer’s instructions and checked for proper operation before being placed back in service.

C       If fluid spills occurred during transport, cover them with an absorbent material, then remove the material and cleanse the area with disinfectant.

C       Dispose of all used cleaning and absorption materials in biohazard bags.

Note: Never use compressed air to clean the ambulance or any reusable equipment, as this could aerosolize infectious particles.

Postincident follow-up

After transport, file an infectious disease report that lists

C       The date and route of transport

C       The duration of transport

C       Names of all EMS providers who responded

C       Specific duties performed, including estimated duration of direct patient care provided

Monitoring personnel

EMS managers should monitor personnel who were involved in the call for at least 10 days, either directly or by telephone. As long as there is no evidence of fever or respiratory illness, responders may remain on duty during this period. If signs or symptoms associated with SARS should arise, however, affected personnel should immediately seek medical evaluation and be placed on administrative leave. Such instances must be reported to the local health department and the CDC.

Summary

As the first newly emerged, serious, and contagious illness of the 21st century, SARS has alarmed both health officials and the public with its rapid and unexpected spread. It illustrates just how quickly infection can proliferate in a highly mobile and interconnected world. Following simple but scrupulous infection control procedures can greatly reduce the personal risks involved in patient care and decrease the likelihood of a pandemic.

Where to go for more information

If you have questions about caring for a suspected SARS patient, you can call the CDC’s 24-hour hotline (770/488-7100) for immediate assistance.

If you’d like to find out more about SARS and its impact on EMS, check the following Web sites:

http://www.sickkids.on.ca/healthcareprofessionals/custom/paeds_sars.asp

http://www.westhawaiitoday.com/daily/2003/Apr-24-Thu-2003/news/news3.html

http://www.health.state.ny.us/nysdoh/sars/sars_ems_advisory_04-18-2003.pdf

http://www.cdc.gov/ncidod/sars/

http://www.withthecommand.com

http://www.state.ma.us/dph/cdc/epii/sars/EMSadvSupple.htm

http://www.health.state.ny.us

http://www.who.int/csr/sars/en/

The authors are all on the staff of the Center for Pediatric Emergency Medicine. Ms Rothman is the research assistant/communications specialist, Ms Treiber is the executive director, Dr Tunik is the director of research, and Mr Skomorowsky is the paramedic education specialist.

SARS in children: special considerations

The primary findings required to meet the case definition for SARS are

C       Exposure—that is, a history of (a) exposure to someone who has the disease, or (b) travel to an area where the disease is present, or (c) contact with someone who has traveled to an area where the disease is present

C       Fever

C       Respiratory symptoms

Broadly speaking, the signs and symptoms seen in infants and children infected with SARS are similar to those seen in adults; however, the overall presentation may vary in accordance with unique aspects of pediatric anatomy, physiology, and response to the environment. (See the Developmental chapter in the TRIPP). [Mark: Can you link this to the Developmental chapter of TRIPP-ALS?]

Always remember to consider the whole picture when assessing the patient: A child who presents with rhinitis but has no history of exposure and no other signs or symptoms consistent with SARS should not be considered suspect.

Infants and young children

Primary symptoms:

C       Fever exceeding 100.4°F (38.0°C) via oral or tympanic measurement or rectal equivalent

C       Cough, respiratory distress, tachypnea

Additional symptoms (may precede primary symptoms):

C       Lethargy, irritability

C       Loss of appetite

Older children

Primary symptoms:

C       Fever exceeding 100.4°F (38.0°C) via oral or tympanic measurement or rectal equivalent

C       Cough, respiratory distress, tachypnea, dyspnea, difficulty breathing

Additional symptoms (may precede primary symptoms):

C       Loss of appetite

C       Headache, malaise, fatigue, myalgia (occurring up to 24 hours before onset of fever)

C       Diarrhea

C       Confusion

In some cases, headache may resolve, with fever, chills, and shakes starting shortly thereafter. Respiratory symptoms may not develop until 2 to 3 days later. Some patients have a period of improvement for 24 to 36 hours after fever resolves; fever then returns and symptoms worsen.