OVERSEAS DELIVERY

     The Attack One crew will be having an unusual shift this day: They have been assigned to cover their city's international airport, in conjunction with a large event happening on-site. Airport EMS is a difficult assignment, with many patients having unusual presentations and high expectations for service. The Attack One crew has a great deal of respect for their peers who do this job routinely. Airport days are typically busy, and many patients come in "boluses" as flights arrive. The early-morning hours are typically busy with international flights. This morning the call is dispatched as a "man ill on an incoming flight."

     The Attack One crew meets the arriving plane at the jetway. When the door opens, the lead flight attendant is obviously unhappy. "We have a very ill man," she reports. "He has a high fever, nausea and bad diarrhea--I think it's bloody."

     These are very important symptoms, particularly in a person who's been traveling. "Where is the patient?" the medic asks.

     "We put him and his travel companion by the lavatory in the back of the plane," the attendant says. "After he told us he was ill, we isolated the lavatory for his use only. He is lying across the seat now because he feels too ill to get up."

     In public transportation settings, it is important that other passengers, crew members and bystanders not be unnecessarily frightened by the actions of EMS. The crew must be calm, professional, quiet and protective of the ill patient and his/her confidential medical information. Boarding an aircraft with full personal protective equipment is naturally alarming to uninvolved individuals on the plane, so airport EMS providers tend to approach patients in a standard way, remove them from the plane and don PPE along with them in a more private environment.

     Here, the Attack One crew members need to do a quick assessment to determine the condition of the patient and his possible contagious nature. They have developed a practice of exposing only a single member to potentially infected patients, so one heads to the rear of the plane while the others stay at the entrance. It is agreed with the lead flight attendant, and then the captain, that all passengers will be held on the plane until the ill passenger has been checked.

     The paramedic makes his way to the patient, a young man lying across two seats, pale and sweaty. A male friend is attempting to keep him calm and cooled with a wet washcloth.

     "Do you understand English?" the medic asks. "I am here to help you."

     The man can communicate with broken English. The paramedic introduces himself.

     "Where have you been, and what happened?" he asks.

     The man reports a high fever that developed about 24 hours ago, just before he and his friend boarded a flight in southern Africa. He then developed nausea and diarrhea. After a couple of hours, the diarrhea became bloody. His past medical history is completely clean, with no prior problems in his gastrointestinal tract. His abdomen is cramping and he has intense nausea, but he has not vomited. He reports no cough, sore throat, earache, chest pain or shortness of breath. The man reports that his African travel had included areas that were very remote, and he had consumed foods and water from those areas. His concerns about infections led him to quietly report his current symptoms to the lead flight attendant.

     Many airlines have online medical direction available from trained travel-medicine consultants with expertise in emergency care. The lead flight attendant and pilot consulted with their airline's medical direction service, and were advised to isolate the patient, report the matter to airport EMS and contact public health. The flight crew had isolated the patient, placing him near a lavatory and restricting it for his use only. The patient's friend had accompanied him throughout his travels and was displaying no symptoms, but the crew asked him to remain away from the other passengers as a precaution, and to report any symptoms if they developed. For the remainder of the trip, the ill passenger had severe cramping and bloody diarrhea and was unable to eat or drink.