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Mom, I Think I'm Really Sick

Attack One responds to a report of a "person ill" in a dormitory at the local university. This is an uncommon call for the crew, as the students generally receive excellent medical care at the Student Health Center, and transportation for students with illnesses or minor injuries is handled by the university transportation system. The evening is quiet in the dorm. A young man is lying quietly, flat on his back, in the small room he shares with another student.

"Headache, nausea, fever..." You've seen a lot of these kinds of calls during this cold winter. Even through your gloves, you appreciate that the young man is febrile. He says he took acetaminophen an hour ago, and has been trying to take fluids but is too nauseated. His symptoms developed about six hours ago. He has no cough, sore throat or earache; no chest or abdominal pain; no vomiting or diarrhea. He tells you others around him have been ill with upper respiratory infections. No recent travel, no rashes. He does have a severe headache, and as you noticed walking in, he had darkened the room because his headache worsens with light. This is the first time he has ever had a severe headache. His neck hurts when he bends it or turns his head.

You are the only crew member to enter the room, and now you're grateful your partner had to lag behind to bring equipment. This young man is quite ill, with a headache, stiff neck and high fever, but without the respiratory symptoms common in winter. Your immediate concern is that he has meningitis, and your bigger concern is whether it's a contagious form of the disease.

You back out into the hallway, letting the patient know you're preparing for his transportation to the hospital. Then you radio your partner.

"Attack One medic to Attack One driver. I have a very ill patient, and we need full personal protective equipment, a mask for the patient and only our oxygen for treatment. Please call the EMS supervisor to the scene to assist with management of this incident."

You ask a passing student to get the dorm supervisor. Before returning to the room to finish your evaluation and prepare the young man for transport, you have to don PPE. Meningitis is spread by respiratory droplets, so your protection will be optimized by wearing a gown, goggles, gloves and an N95 or higher mask, as well as asking the patient to wear a mask over his face and wash his hands.

Once you don your PPE, you're aware that people around you will be concerned for their safety. Dormitories are very tight quarters, usually with shared rest rooms, study areas and dining halls. Contagious diseases are much more easily spread in such an environment. Your concerns need to be immediately shared with the dorm supervisor, and if they're verified, your EMS supervisor is going to need to make some public-health contacts.

The other Attack One crew member arrives, and you both gear up in the hallway. You ask your partner to remain outside the room, and you take one of your plain masks and a bottle of alcohol-based hand cleaner into the room. Your partner offers to brief the resident dorm advisor, keep others out of the room and notify passing students why you're dressed in your protective wear. You would also like to find the patient's roommate, who would have to be considered at higher risk because of the close quarters.

When you re-enter the room, the patient is sitting up on the bedside. He is wearing only a pair of shorts, and you notice some areas on his legs that look like bruises. The patient cannot remember any recent trauma that would have caused these. This prompts you to ask if you could examine him for other rashes. To do so, you will need to have the room lights on. As you flip on the overheads, the patient makes you aware how the light worsens his headache. You ask him to put on the mask and wash his hands with the cleaner. You then examine him further and find a few small bright red spots on his chest. His lower legs have four or five dark-blue to purple splotches that are not tender. You find no ticks or breaks in the skin. His mucous membranes are moist. His chest is clear, and he is not coughing.

You noted that his pulse was high, and his pulse oximetry is only 94%. He is not a smoker, and you can identify no reason for his oxygen level to read this low. You place an oxygen cannula in his nose under the mask he's now wearing.

With these examination findings, you are even more concerned about the very serious and contagious form of meningitis. With a short transport time to the hospital, your decision is to forego placing an intravenous line, notify the ED and remove him rapidly. There is no immediate indication of hypovolemia, so an IV line will not be beneficial in administering fluid, and the close contact with the patient will increase your exposure.

Your partner has the stretcher ready in the hallway, and the patient is able to walk slowly to it. The EMS supervisor and dorm leader clear the hallway, an elevator and the lobby to allow you rapid egress and prevent further exposures. You remain at the head of the cot and meet your partner in the lobby to assist you to the rig. Only you go into the patient cabin.

On the way out, you give a quick confidential report to the EMS supervisor. She shares your concerns and offers to take care of the incident scene and make the necessary contacts at the school. She'll meet you later at the ED.

You call ahead to the emergency physician: "I'm concerned this young man has meningitis. We'll wait at the ambulance entrance until you clear us to enter the ED. The patient is in a mask and has cleaned his hands. My partner has had essentially no exposure, so he will accompany the patient into the ED."

The patient brought his cell phone with him and asks to call his parents, who live in another state. That little voice that helps you from time to time says this is an appropriate request.

"Mom, I think I'm really sick..."

Hospital/Management

You remain outside the ED while staff inside complete preparations for the patient. Once they're appropriately gowned and masked, the ED staff motion him in. You don't enter until you've removed your protective equipment, washed your hands and face and donned a clean mask.

Inside, the patient is assessed by the emergency physician and found to be febrile, at 103ºF. His mental status has deteriorated since your initial assessment. The bruising on the lower extremities has extended to most of both lower legs. His airway fails, and he is intubated. He is immediately given steroids, antibiotics and fluids. His blood pressure falls, and a norepinephrine drip is needed to support his circulation. His spinal tap is very cloudy, and the organism found is called Neisseria meningitidis, the relatively rare but devastating cause of severe and contagious meningitis.

While the patient is being treated, the hospital's infection control nurse arrives and interviews the medics to begin tracing other exposures. The young patient has one roommate and a few close friends, including a girlfriend. They've all had close contact with him in the last 24 hours. The dormitory supervisor contacts the Student Health Center, and the center's medical director comes to the hospital for direct communications. The other students are all contacted, brought to the hospital and given the information about their friend's contagious disease. Preventive treatment is given to each.

The patient goes on to develop further complications, and one leg is amputated, but he's ultimately discharged from the hospital. A long rehabilitation period and prosthesis eventually allow him to return to school.

Summary/Discussion

Quick action by the first-in paramedic limited the exposure of all other emergency personnel in this case, so he was the only one who needed preventive treatment. No further meningitis infections occurred in the dormitory or on campus during the winter.

Several bacteria, notably Neisseria meningitidis and Streptococcus pneumoniae, can produce very aggressive meningitis. Neisseria infection is most common in dormitory- and barracks-related meningitis, and it can produce an illness that evolves over minutes to hours, as with this patient. It can result in circulatory collapse, breakdown of the capillary vessels (which causes the petechiae and purpura found on the patient) and death.

Neisseria meningitidis is carried in the pharynx and spread by droplets. For this reason, persons in close contact with the patient are treated with antibiotics that will pass readily into the pharynx and eradicate the bacteria. Rifampin is the most commonly prescribed antibiotic for this; it is well known for causing the urine of the person taking it to turn bright orange.

Actions by the EMS crew in contagious-disease incidents can dramatically alter the patient's outcome and either facilitate spread to others or stop a contagious outbreak. This case demonstrates the benefit of limiting exposures to as few individuals as possible. Respiratory diseases spread by droplets are contained when the patient dons a mask; emergency providers should do the same. The crew in this case also facilitated the public-health response by early tracking of responsible persons at the campus and preventing any further exposures once the suspicion of a contagious disease was in their minds.


INITIAL ASSESMENT
A 19-year-old male in acute distress. He complains of a headache and is dyspneic.
Airway: Patent.
Breathing: Moderate distress.
Circulation: Cool skin.
Disability: No compromise of neurologic function.
Exposure of Other Major Problems: A few small red spots on the chest. Bruises on both lower legs, without a history of trauma.

VITAL SIGNS 7:35pm - Heart Rate 120, Pulse Ox 94%, Respiratory Rate 28
7:48pm - Heart Rate 128, Pulse Ox 96%, Respiratory Rate 28

SECONDARY ASSESMENT
Appropriate to Presenting Condition
The patient is febrile by touch. No thermometer is available. He has no signs of trauma, but developed bruises over his lower legs over the last few hours. His mental status is clear, but he prefers not to communicate due to severe headache. He keeps his eyes closed, as light exacerbates the headache. His neck has limited flexion due to pain with movement. He has a mild sore throat, but no obvious enlarged lymph nodes in his neck. His chest is clear, and he does not cough. His heart is regular and abdomen nontender.

AMPLE ASSESMENT
Allergies: None. Medications: Acetaminophen given about an hour prior to activating EMS. Past Medical History: No significant medical problems. Last Intake: Ate a small amount at 1730 hours and vomited afterward. Event: Illness. (If E represents Exposures, he states that others in the dormitory have had flu-like illnesses over the past month.)

Learning Point: Meningitis with emergency-personnel exposure. Scene

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