Case of the Month
February 2008

82-year-old male — patient assist

Dispatch
Your BLS unit is dispatched in a non-emergency mode to an 82-year-old male in an adult family home who fell and needs assistance getting back into bed.

While en route the dispatcher notifies you that a care provider will meet you at the front door.

En route your crew discusses the following considerations:

• Reasons for falls in the elderly
• Geriatric trauma
• Possible hip fracture

The Assist
You and your crew arrive at the home and are led to an elderly male who has fallen between a bed and his walker. The caregiver states that he fell during a transfer from the bed to the walker. He went down slowly and was not injured.

You and your partner quickly assess the patient and find no obvious injuries, but you do notice he feels very warm to the touch. The caregiver states that he has been ill the past few days and started taking antibiotics earlier in the day.

You lift the patient from behind with your arms under his arm pits, while your partner lifts his legs. You notice moisture under his arms and a rash or irritation of the skin where you touched him, however you are not concerned. Your team places him on the bed and you quickly re-evaluate finding no trauma. Your partner writes down the information needed for a report and your crew leaves the scene.

A Week Later
A week later your 8-month-old daughter develops a penny-sized boil on her back that looks like a large pimple. Your wife schedules an appointment with the pediatrician and goes to the office the next day. At the pediatrician’s office the boil is lanced, drained, and a swab is taken. Your wife is told that the results should come back in a couple days, but it looks like a staph infection. In the meantime the pediatrician instructs her to keep the wound covered and watch for signs that she is developing a temperature or the surrounding tissue becomes red.

A few days later the lab results reveal that your daughter has a skin infection of methicillin-resistant Staphylococcus aureus, also known as MRSA. She is placed on oral antibiotics and the physician tells you to keep her wound covered. You should also continue to monitor her for spread and for respiratory issues.

In a discussion with the pediatrician it is realized that you may have been colonized with MRSA from the 82-year-old patient you assisted the previous week and your daughter may have contracted the infection from you.

Fortunately your daughter’s infection clears up completely after a week or so and you do not develop an infection, but you have a new appreciation for infectious disease control.

What is MRSA?
MRSA is a strain of Staphylococcus aureus (SA) that is resistant to treatment by many antibiotics. It is often treatable, but different strains are susceptible to different antibiotics, so sampling and evaluation of the wound are very important to the proper treatment of each individual case. If an infection goes untreated it could become fatal.

Typically the most dangerous infections result when the infection is able to enter the blood stream or the lungs. MRSA used to be rare outside of healthcare facilities; however, its occurrence in the general community is rapidly rising. As time goes on various strains of SA will likely become resistant to antibiotics commonly available to us, so it is important that you use proper measures to minimize the spread of SA as well as other infectious diseases.

What does a MRSA infection look like?
MRSA looks much the same as any form of SA or many other skin conditions for that matter. Most commonly it appears as a skin lesion resembling single or multiple pimples or boils. Sometimes the affected tissue will ooze pus and crust over. Occasionally there will be a rash. 

These can occur anywhere on the skin, but tend to form towards moist warm regions such as the armpits or groin. The nasal passages are another common area where MRSA or SA can reside. Not all persons who have MRSA or SA on their skin will develop an actual infection. These people are considered to be “colonized” and can carry the bateria for well over a month, unwittingly spreading it to others. This is why it is important to use barrier protection and wash your hands afterwards when caring for patients in the field—you may get something from them or they may get something from you!

How is MRSA or SA spread?
SA is one of the most common forms of skin infections in the United States. It is estimated that 25% of the population is colonized by SA and about 1% by MRSA, however some studies suggest these numbers are conservative. 

MRSA or SA usually are spread by skin to skin contact. The presence of a leaking wound on the infected person heightens the likelihood of disease transfer when compared to exposure to a person who is simply colonized with the disease.  Likewise an open wound on the receiving person increases the chance that contact with the disease will result in infection instead of mere colonization. 

MRSA and SA also can be transmitted by shared objects such as contaminated surfaces, shared clothing, gym towels, or razors. Also, MRSA and SA can be spread by close living quarters or by contact sports. Most skin infections of both SA and MRSA are easily treated and controlled; however, MRSA and SA can lead to infection of the blood stream, heart valves, or the lungs, any of which can be fatal. 

How do I prevent the spread of MRSA or SA?
Some common sense steps can go a long way to prevent spreading the bacteria. 

1. Wash your hands! Hand washing is the single best way to reduce the risk of spreading any infection. Wash for at least 20 second using soap and warm water. When in the field wash your hands with an alcohol-based hand cleaner (minimum 60% alcohol).

2. Use barrier protection. Wear gloves and eye protection when contacting all patients; in addition, consider the use of gowns and masks any time you believe significant splash or respiratory contaminates are possible.

3. Keep wounds (including your wounds) covered and avoid touching open wounds or wound dressings of others.

4. Keep it clean. Disinfect all equipment that comes into contact with a patient. Interesting enough, in a 2006 sampling of a west coast ambulance services almost half the ambulances tested positive for MRSA on one or more surfaces. The contamination was more frequently found in crew work areas than in the areas contacted by patients!

5. Keep personal items personal. Don’t share towels, sheets, razors, clothing, or athletic equipment.

6. Shower after athletic games or personal contact. Anytime you have unprotected physical contact, whether in contact sports or patient treatment, shower with soap and water, and don’t share towels.

7. Use antibiotics appropriately. Some health professionals believe MRSA is the direct result of the misuse of antibiotics.  When antibiotics are used unnecessarily, bacteria can develop resistance to antibiotics. If you are prescribed an antibiotics and you do not complete the full regimen, the bacteria may not be destroyed completely and can develop a resistance to it. 

MRSA
CDC (external website)