A TALE OF TWO CASESA TALE OF TWO CASES

Gary M. Vilke, M.D., FACEP, FAAEMGary M. Vilke, M.D., FACEP, FAAEMAssociate Professor of Clinical MedicineAssociate Professor of Clinical Medicine

UCSD Department of Emergency MedicineUCSD Department of Emergency MedicineInterim Medical Director, San Diego County EMSInterim Medical Director, San Diego County EMS

GoalsGoals

Present two casesPresent two cases Inspire thought Inspire thought

ClinicalClinicalOperationalOperationalTheoreticalTheoretical

Case 1: PresentationCase 1: Presentation

34 yo female postal worker presents 34 yo female postal worker presents with a day of malaise, high fevers, with a day of malaise, high fevers, cough, congestion and worsening cough, congestion and worsening shortness of breath. Today, noted shortness of breath. Today, noted streaks of blood in sputumstreaks of blood in sputum

ROS: Headaches, myalgias, ROS: Headaches, myalgias,

PresentationPresentation

Meds: Tylenol Meds: Tylenol NKDANKDAPMH: MigrainesPMH: MigrainesFH: UnremarkableFH: UnremarkableSH: No travel, no tobacco, no drugsSH: No travel, no tobacco, no drugs

Physical examPhysical exam

VitalsVitalsT:T: 101.8101.8BP:BP: 103/67103/67HR:HR: 120120RR:RR: 2424O2 Sat:O2 Sat: 92%92%

Physical examPhysical exam

WDWN female, appearing mildly WDWN female, appearing mildly toxic and clearly not feeling welltoxic and clearly not feeling well

HEENT dry oral mucosaHEENT dry oral mucosaNeck supple, no meningismusNeck supple, no meningismusChest crackles L base. + retractionsChest crackles L base. + retractionsCoron: tachy with reg rhythmCoron: tachy with reg rhythm

Physical examPhysical exam

Abd: soft, Nontender. No HSM Abd: soft, Nontender. No HSM Ext: No c/c/eExt: No c/c/eSkins: Warm and moist, no rashes or Skins: Warm and moist, no rashes or

lesionslesionsNeuro: CN/motor/sens nonfocalNeuro: CN/motor/sens nonfocal

ImpressionImpression

Otherwise healthy female with Otherwise healthy female with probable pneumonia and early probable pneumonia and early dehydration. Some concerning dehydration. Some concerning physiologic indicatorsphysiologic indicators

CXRCXR

DispositionDisposition

Patient admitted to hospitalPatient admitted to hospital

Blood and sputum CX sentBlood and sputum CX sentIV abxIV abxIV hydrationIV hydrationOxygenOxygen

The next dayThe next day

Your office is called because the Your office is called because the sputum and blood cx of the admitted sputum and blood cx of the admitted patient grew out Yersinia pestispatient grew out Yersinia pestis

What now??!!What now??!!

Case 2: PresentationCase 2: Presentation

10 yo M with recent travel to Korea, 10 yo M with recent travel to Korea, presents complaining of two days of presents complaining of two days of malaise and high fevers that have malaise and high fevers that have improved and now the patient is improved and now the patient is developing a rash and the parents developing a rash and the parents are concerned that it was chicken are concerned that it was chicken pox.pox.

ROS: No ill contacts, No SOB/DOE. ROS: No ill contacts, No SOB/DOE. No CP or abd painNo CP or abd pain

PresentationPresentation

Meds: TylenolMeds: TylenolNKDANKDAPMH: NegPMH: NegSH: No drugs, tob. Social ETOHSH: No drugs, tob. Social ETOHFH: HTNFH: HTN

Physical examPhysical exam

VitalsVitalsT:T: 100.8100.8BP:BP: 122/72122/72HR:HR: 112112RR:RR: 1616O2 Sat:O2 Sat: 98%98%

Physical examPhysical exam

WDWN nontoxic male in NADWDWN nontoxic male in NADHEENT: UnremarkableHEENT: UnremarkableNeck: Supple, no TMNeck: Supple, no TMChest: CTABChest: CTABCoron: Tachy with reg rhythmCoron: Tachy with reg rhythm

Physical examPhysical exam

Abd: soft, Nontender. No HSM Abd: soft, Nontender. No HSM Ext: No c/c/eExt: No c/c/eNeuro: CN/motor/sens nonfocalNeuro: CN/motor/sens nonfocalSkins: Warm and moist, rash as Skins: Warm and moist, rash as

noted primarily on head and noted primarily on head and extremities, sparing the trunk. Noted extremities, sparing the trunk. Noted on palms and all appear roughly the on palms and all appear roughly the same agesame age

RashRash

What now!!What now!!

Check your own pulseCheck your own pulseTake a deep breathTake a deep breathThink happy thoughtsThink happy thoughts

Get back to the task at handGet back to the task at hand

Check chart on wallCheck chart on wall

Pull Bioterrorism Response Pull Bioterrorism Response PlanPlan

Dust it offDust it offOpen itOpen it

What not to do!!What not to do!!

Do not panicDo not panicDo not expose more people than Do not expose more people than

already have been exposedalready have been exposedDo not send the patient to the ERDo not send the patient to the ER

Key web sitesKey web sites

www.sdcms.org www.emansandiego.org www.bt.cdc.gov www.medepi.org/sfdph/bt/syndromes/

index.html www.usamriid.army.army.mil/education/

bluebook.com www.nbc-med.org/ie40/Default.html www.dhs.ca.gov/ps/dcdc/bt/index.htm www.hopkins-biodefense.org

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Bicknell WJ. The case for voluntary smallpox vaccination. N Engl J Med 2002; 346:1323-1325.

Bremen JG, Henderson DA. Poxvirus dilemmas-Monkeypox, smallpox, and biologic terrorism. N Engl J Med 1998;339:556-559.

Centers for Disease Control and Prevention. Vaccinia (Smallpox) Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. Atlanta, GA: CDC; 2001:RR-10.

Fauci AS. Smallpox vaccination policy: the need for dialogue. N Engl J Med 2002;346:1319.

Smallpox ReferencesSmallpox ReferencesFranz DR, Jahrling PB, McClain DJ, et al. Clinical recognition and management of patients exposed to biological warfare agents. Clin Lab Med 2001;21:435-473.

Henderson DA. Smallpox: Clinical and epidemiologic features. Emerg Infect Dis 1999;5:537-539.

Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: Medical and public health management. Working group on Civilian Biodefense. JAMA 1999;281:2127-2137.

Jahrling PB ZG, Huggins JW. Countermeasures to the reemergence of smallpox virus as an agent of bioterrorism. Emerg Infect 2000;4:187-200.

Smallpox ReferencesSmallpox ReferencesLane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: national surveillance in the United States. vaccination, 1968: national surveillance in the United States. N N Engl J MedEngl J Med 1969;281:1201-1208. 1969;281:1201-1208.

Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: results of ten statewide surveys. vaccination, 1968: results of ten statewide surveys. J Infect Dis J Infect Dis 1970; 122:303-309.1970; 122:303-309.

McClain D. Smallpox. In: Sidell F, Takafuji E, Franz D, eds. McClain D. Smallpox. In: Sidell F, Takafuji E, Franz D, eds. Medical Aspects of Chemical and Biological Warefare. Medical Aspects of Chemical and Biological Warefare. Washington, DC: Borden Institute, Walter Reed Army Medical Washington, DC: Borden Institute, Walter Reed Army Medical Center;1997:539-558.Center;1997:539-558.

Neff JM, Lane JM, Pert JP, Moore R, Millar JD, Henderson DA. Neff JM, Lane JM, Pert JP, Moore R, Millar JD, Henderson DA. Complications of smallpox vaccination, I: national survey in the Complications of smallpox vaccination, I: national survey in the united States, 1963. united States, 1963. N Engl J MedN Engl J Med 1967;276:1-8. 1967;276:1-8.

Ruben FL, Lane JM. Ocular Vaccinia. An epidemiologic analysis Ruben FL, Lane JM. Ocular Vaccinia. An epidemiologic analysis of 348 cases. of 348 cases. Arch OphthalmolArch Ophthalmol 1970;84:45-48. 1970;84:45-48.