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OVERSEAS DELIVERY

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     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.

Patient Care
     The patient is evaluated quickly by the medic and found to be febrile and dry, with a fast heart rate.

     "Attack One medic to Attack One driver. I have a very ill patient, and we need full PPE and our IV setup and medications for treatment. Please get the EMS supervisor to the scene to assist with management of this incident."

     The patient is near the rear of the aircraft, and the flight crew suggests he be removed out the rear service door. Airport security and immigration officials need to approve such arrangements for international passengers, and after a briefing from the Attack One medic, they facilitate that pathway for removal.

     The ill passenger's friend is also interviewed by the Attack One medic. He feels completely well, with no fever, diarrhea, abdominal pain or cramping. The Attack One crew and airport EMS supervisor agree that the friend should remain on the plane, and the supervisor and responding public-health official will interview him more extensively to determine if and where he should be evaluated further.

     The Attack One crew has a transport medic available near the aircraft exit, the stretcher at the bottom of the stairs. The supervisor will meet the public-health official, and arrangements will be made to hold the flight crew and passengers, if it is deemed necessary. The ill passenger will need rapid transport and care, and the Attack One crew will need to communicate with the EMS supervisor regarding the results of hospital testing.

     The passenger is assisted to the stretcher and placed in the ambulance. The Attack One medic will be the sole provider of care, so he dons a gown, mask, goggles and shoe covers as he enters the rear compartment. The patient needs an intravenous infusion of fluids and medicine for his nausea, so the medic retrieves the necessary items from the jump bags and places the bags in the front of the rig--no need to contaminate anything else in the patient care area!

     The receiving hospital has to be notified quickly; a phone call to the ED lets staff start preparing for the patient. The ambulance will be placed at the end of the EMS entrance, and the ED staff will signal when they are prepared for the patient to be brought in. An IV line is started, and the patient given a bolus of fluids and medication for the nausea. En route, the supervisor notifies the medic that public-health and CDC officials have made arrangements for another state public-health official to go to the ED to assist with testing. The plane's crew and passengers are being held at the airport until certain dangerous diseases have been tested for.

Hospital Course
     The ED is prepared for the patient's arrival, and staff appropriately gowned and masked before he's brought in. Once in the ED, the patient is assessed by the emergency physician. He is febrile, 104°F, but feels much better after the two liters of fluid given during transport. The critical tests that must be performed are of his stools and blood to find the virus, bacteria or parasite causing his problems. The concern is for life-threatening infections with things like Ebola, the Marburg virus or Lassa fever.

     Rapid testing procedures have been preplanned, and those progress quickly while the patient receives further care. The Attack One medic cleans himself and all exposed equipment thoroughly, then remains in the ED for the test results.

     After an hour, official word comes from the state public-health lab: The cause is a serious, but not contagious, bacteria. The Attack One medic quickly relates this to the airport crews, and the public-health and CDC officials convene and release the passengers, crew and aircraft. The lavatory facility and patient's seats will need extra cleaning. The patient's friend must be transported to the hospital to receive a screening for the involved bacteria, but will not need to be considered contagious. The EMS supervisor arranges for that.

     The patient remains hospitalized for three days, requiring antibiotics and a large amount of fluid to recover. He is ultimately released in good condition.

Management of Exposed Individuals in the Public Transportation System
     The quick action of the flight crew here isolated a patient with a dangerous set of symptoms. The airport had a preparedness plan for these types of interactions. The local public-health agency was available for immediate consultation and would communicate directly with the Centers for Disease Control and Prevention (CDC) regarding arriving international passengers. The plan called for the passenger to be placed in protective isolation and removed to a designated hospital, then meet with a public-health official, have necessary testing performed and receive appropriate treatment and referral.

     The plan also called for the crew and other passengers to be held until the sick passenger was examined and the presence of a dangerous contagious disease determined. Public-health officials in such cases have full authority to determine when passengers and crew can be released.

     Serious contagious diseases involving fever and bloody diarrhea originating in Africa have a variety of causes, and some are very infectious and deadly. The Attack One crew was aware that those diseases are spread in a variety of ways. They determined that when dealing with a potentially infectious patient, only one crew member would provide medical care and treatment, and the others would remain away from the patient and provide support from a safe distance.

     In an incident involving the public transportation system, there will be great concern from crew members and other passengers. EMS providers should be sensitive to their needs and follow the lead of public-health officials in quarantine matters, especially involving international transportation.

Case Discussion
     Modern trends of global business, rapid travel and dangerous microbes can intersect anytime at an unexpected location near you. The names will change--Ebola, SARS, extremely drug-resistant tuberculosis, pandemic H5N1 influenza--but dangerous agents can appear in any community in the world with lightning speed. If and when this happens, it is likely that emergency providers will be engaged in the care of the initial patients.

     Immediate emergency care may alter the initial patient's outcome, but of greater importance is the interaction with public health. In any community, there are a group of dedicated caregivers responsible for the health of the bigger population and, particularly as it relates to EMS, the identification, prevention and control of contagious diseases. Every EMS organization must know the 24/7 communication link to the responsible public-health entity in its service area. The local public-health agency will access its state counterpart for certain incidents. Some state public-health agencies have combined to create an easy-to-use 800-number access point; others have numbers that should be attached to every EMS clipboard.

     Except in a few locations, access to the CDC is accomplished through the local public-health agency. Providers working in ports, immigration areas and other sites that have CDC quarantine stations will understand the process for direct access to those stations, but essentially all other EMS providers will work with local public-health officials to notify state public health or the CDC.

     Actions by EMS crews in contagious disease incidents can dramatically alter patients' outcomes and either stop a contagious outbreak or facilitate its spread. This case demonstrates the benefit of limiting exposure to as few individuals as possible.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

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