CICM SAQ 2015.2 Q22

Question

A health care worker, recently returned from West Africa, presents to the Emergency Department with fevers, vomiting and diarrhoea. Her vital signs are normal on presentation. Blood tests have not been taken, and venous access has not been established.Your state and hospital’s Ebola response plan has been activated, and the patient is due to be transferred to the state quarantine hospital. For logistic reasons this cannot occur for 24 hours, and you (with approval from ICU medical and nursing directors) have agreed to admit the patient to your ICU as this is the site of your hospital’s only suitable isolation rooms.

Your state and hospital’s Ebola response plan has been activated, and the patient is due to be transferred to the state quarantine hospital. For logistic reasons this cannot occur for 24 hours, and you (with approval from ICU medical and nursing directors) have agreed to admit the patient to your ICU as this is the site of your hospital’s only suitable isolation rooms.

Outline your management for this first 24-hour period.

Answer

Answer and interpretation

Ensure appropriate isolation prior to transfer:

  • negative pressure room with appropriate venting activated checked, and operational
  • ante-room with facilities for donning and doffing of PPE,
  • separate toilet and hygiene facilities,
  • adequate PPE supplies
  • ideally staffed by an “opt-in” model
  • rehearse donning and doffing procedures with observed and guided doffing

Ensure appropriate staff safety:

  • intervention and observations to a minimum,
  • blood tests are contraindicated unless sent to a designated laboratory with appropriate containment
    facilities

Specific Patient Management:

  • focussed clinical examination to determine both physiologic disturbance and to look for other diagnoses
    (malaria, typhoid)
  • empiric antibiotics for typhoid etc. and antimalarials
  • strategy to maintain adequate fluid intake (oral, or iv with appropriate precautions)
  • active symptom management of nausea & vomiting, diarrhoea (often profuse), pain
  • no blood tests unless logistics allow

Other:

  • staff welfare and de-brief
  • family support
  • Pass rate: 8%
  • Highest mark: 6.5

Additional Examiners’ Comments:

  • Most answers were very superficial, lacking consideration of the detail needed to describe adequate isolation practices and were not at specialist level.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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