Case of the Month
December 2006

73-year-old female — Nausea and vomiting

Dispatch

"Aid 51, to a 73 year old female, nausea and vomiting at a care facility"

En route your crew discusses the following considerations:

• Causes of nausea and vomiting
• Body substance isolation
• Facility history

While en route the dispatcher updates you stating the patient is in room 232-A at the Sundown Retirement Center.

Scene Size-up
You arrive at the facility and are met at the front by a staff member. They hand you a copy of the patient’s record and lead you up to the second floor. On the way you are told that she has been ill for the past 24 hours, but now she cannot keep any food or fluid down. You are also told that she is the third resident to become ill in the past three days.

When you arrive at the patient’s room you find the patient in bed and an attendant is near-by cleaning up a small puddle of vomit. The attendant is wearing gloves but no other protection. The patient is laying in bed on her right side. Her eyes are closed but she is moaning and occasionally saying ‘oh, Lord, oh Lord, oh Lord’.

Initial Assessment
She appears mildly diaphoretic with pink skin. Her eyes are closed, but when you state her name she opens them, looks to you, and responds appropriately. Reaching down you find a weak radial pulse at 100 bpm, it is regular. She has a blood pressure of 102/P.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Need for ALS care?

Initial Treatment
You decide that the patient is NOT SICK based on the time of onset and the patient’s overall appearance but you have a heightened index of suspicion (IOS) that things could change.

You apply a nasal cannula at 4 liters per minute and continue your assessment.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

As you are evaluating the patient, she vomits once again. There is nothing remarkable about the vomit, other than it is primarily bile as she has already emptied her stomach with prior vomiting episodes. Unfortunately, as is often the case, some of the vomitus adheres to your duty boot and pant leg.

The decision is made to transport the patient to the local ED for further evaluation and treatment. Your team moves her onto your stretcher and wheels her out to your BLS transport. The transport is unremarkable, with exception of the patient defecating on the gurney three blocks prior to arrival at the hospital. She is placed in the care of the ED staff and you and your crew turns to the task of preparing for the next run.

What is the ‘stomach flu’?
The ‘Stomach Flu’ is a term that is given to several different forms of gastroenteritis. It is most often viral in nature, and despite the common name, it is in no way related to true influenzas which are primarily respiratory in nature. Other than viruses, gastroenteritis can also be caused by bacterial infections or by other tiny organisms.

In most cases the symptoms are relatively mild and pass after a few days, however in more severe cases the patient may suffer from dehydration, electrolyte imbalances, or other complications, - such as the inability to keep down and absorb vital medications. The young and the old are at greatest risk for the more severe complications.

Most viruses associated with gastroenteritis are spread through the vomit or stool of the infected patient. Many of these viruses, such as Norovirus, are extremely contagious and can survive outside the body for long periods of time. For this reason it is very important to us proper body substance isolation during patient care and when cleaning equipment afterwards. Gloves are not enough. Aerosolized particles form vomit or stool can carry the disease to the next victim, therefore masks and goggles are essential in this environment.

Let’s re-examine this scenario and find the places where viral spread could take place.

1. When the crew arrived at the room an attendant was cleaning up vomit utilizing only gloves for protection. He is still at risk for transmission from aerosolized particles. If this person does not properly clean his hands and forearms after taking care of the vomitus on the floor, he is at risk of spreading the disease to other residents or to co-workers.
   
   
2. While evaluating the patient she vomited on your pants and boots. Often we walk though contaminated areas and do not consider the risk of our exposure. Boots can harbor a virus for long periods of time. Contaminated fluids can sink into porous materials or into the seams and crevices of the boots, making decontamination very difficult. Your pants are a risk also. Depending on how long you wear them after a call and where you wash them at, you may put co-workers, other patients, or even family members at risk.
   
   
3. ‘Code Brown’ on the stretcher! Of course this needs to be cleaned immediately and completely. Feces are a huge infectious threat by being an excellent medium for the transfer of viruses, bacteria, and other dangerous organisms. Once the pad on the stretcher is soiled the entire framework of the gurney should be disinfected. Like the boots, be particularly careful in cleaning all the crevices and seems of the gurney and pad. While working on your equipment you should be dressed at the same level of protection as when you were treating the patient who soiled it. And, of course, clean yourself up after cleaning up the equipment.

According to the CDC the best way to cut down on the spread of infections is through thorough hand washing. Even if you wear gloves when you treat patients, the hands need to be washed afterward. A simple rinse with warm water won’t do!

Steps to proper hand washing:

1. Hands should be washed using soap and warm, running water
2. Hands should be rubbed vigorously during washing for at least 20 seconds with special attention paid to the backs of the hands, wrists, between the fingers and under the fingernails.
3. Hands should be rinsed well while leaving the water running.
4. With the water running, hands should be dried with a single-use towel 5. Turn off the water using a paper towel, covering washed hands to prevent re-contamination.

A few words about Norovirus
Norovirus is one of several viruses that can cause gastroenteritis. In recent years we have seen outbreaks of Norovirus at restaurants and catered meals (36% of cases), nursing homes (23%), schools (13%) and cruise ships and other vacation settings (10%), to name a few. In most individuals it is a mild illness that lasts a few days, but in those who are elderly or in poor health it can be devastating and, occasionally, fatal.

Norovirus can be spread by as few as 100 virus particles. The virus can survive freezing and temperatures up to 140 degrees Fahrenheit. It can be spread by any surface that has been contaminated by vomit or feces, including, but not limited to, hands, food, fluids, counter tops, equipment, or clothing. An individual with Norovirus can spread the disease from the time of onset of symptoms until three days after he/she has recovered from the disease.

Norovirus is only one of the diseases we seek to protect our selves from when assisting sick or injured patients. Whether it is Hepatitis C, HIV, or the common cold, we must always be diligent in taking the proper precautions and using effective body substance isolation so that we may return home healthy and safe