1. A TALE OF TWO CASES Gary M. Vilke, M.D., FACEP, FAAEM Associate Professor of Clinical Medicine UCSD Department of Emergency Medicine Interim Medical Director, San Diego County EMS

2. Goals Present two cases Present two cases Inspire thought Inspire thought Clinical Clinical Operational Operational Theoretical Theoretical

3. Case 1: Presentation 34 yo female postal worker presents with a day of malaise, high fevers, cough, congestion and worsening shortness of breath. Today, noted streaks of blood in sputum 34 yo female postal worker presents with a day of malaise, high fevers, cough, congestion and worsening shortness of breath. Today, noted streaks of blood in sputum ROS: Headaches, myalgias, ROS: Headaches, myalgias,

4. Presentation Meds: Tylenol Meds: Tylenol NKDA NKDA PMH: Migraines PMH: Migraines FH: Unremarkable FH: Unremarkable SH: No travel, no tobacco, no drugs SH: No travel, no tobacco, no drugs

5. Physical exam Vitals Vitals T:101.8 T:101.8 BP:103/67 BP:103/67 HR:120 HR:120 RR:24 RR:24 O2 Sat:92% O2 Sat:92%

6. Physical exam WDWN female, appearing mildly toxic and clearly not feeling well WDWN female, appearing mildly toxic and clearly not feeling well HEENT dry oral mucosa HEENT dry oral mucosa Neck supple, no meningismus Neck supple, no meningismus Chest crackles L base. + retractions Chest crackles L base. + retractions Coron: tachy with reg rhythm Coron: tachy with reg rhythm

7. Physical exam Abd: soft, Nontender. No HSM Abd: soft, Nontender. No HSM Ext: No c/c/e Ext: No c/c/e Skins: Warm and moist, no rashes or lesions Skins: Warm and moist, no rashes or lesions Neuro: CN/motor/sens nonfocal Neuro: CN/motor/sens nonfocal

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

9. CXR

10. Disposition Patient admitted to hospital Patient admitted to hospital Blood and sputum CX sent Blood and sputum CX sent IV abx IV abx IV hydration IV hydration Oxygen Oxygen

11. The next day Your office is called because the sputum and blood cx of the admitted patient grew out Yersinia pestis Your office is called because the sputum and blood cx of the admitted patient grew out Yersinia pestis What now??!!

12. Case 2: Presentation 10 yo M with recent travel to Korea, presents complaining of two days of malaise and high fevers that have improved and now the patient is developing a rash and the parents are concerned that it was chicken pox. 10 yo M with recent travel to Korea, presents complaining of two days of malaise and high fevers that have improved and now the patient is developing a rash and the parents are concerned that it was chicken pox. ROS: No ill contacts, No SOB/DOE. No CP or abd pain ROS: No ill contacts, No SOB/DOE. No CP or abd pain

13. Presentation Meds: Tylenol Meds: Tylenol NKDA NKDA PMH: Neg PMH: Neg SH: No drugs, tob. Social ETOH SH: No drugs, tob. Social ETOH FH: HTN FH: HTN

14. Physical exam Vitals Vitals T:100.8 T:100.8 BP:122/72 BP:122/72 HR:112 HR:112 RR:16 RR:16 O2 Sat:98% O2 Sat:98%

15. Physical exam WDWN nontoxic male in NAD WDWN nontoxic male in NAD HEENT: Unremarkable HEENT: Unremarkable Neck: Supple, no TM Neck: Supple, no TM Chest: CTAB Chest: CTAB Coron: Tachy with reg rhythm Coron: Tachy with reg rhythm

16. Physical exam Abd: soft, Nontender. No HSM Abd: soft, Nontender. No HSM Ext: No c/c/e Ext: No c/c/e Neuro: CN/motor/sens nonfocal Neuro: CN/motor/sens nonfocal Skins: Warm and moist, rash as noted primarily on head and extremities, sparing the trunk. Noted on palms and all appear roughly the same age Skins: Warm and moist, rash as noted primarily on head and extremities, sparing the trunk. Noted on palms and all appear roughly the same age

17. Rash

18. What now!! Check your own pulse Check your own pulse Take a deep breath Take a deep breath Think happy thoughts Think happy thoughts Get back to the task at hand Get back to the task at hand

19. Check chart on wall

20. Pull Bioterrorism Response Plan Dust it off Dust it off Open it Open it

21. What not to do!! Do not panic Do not panic Do not expose more people than already have been exposed Do not expose more people than already have been exposed Do not send the patient to the ER Do not send the patient to the ER

22. Key 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.usamriid.army.army.mil/education/ www.nbc-med.org/ie40/Default.html www.dhs.ca.gov/ps/dcdc/bt/index.htm www.hopkins-biodefense.org

23. Smallpox References Barquet N, Domingo P. Smallpox: The triumph over the most terrible of the ministers of death. Ann Intern Med 1997;127:635-642. 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.

24. Smallpox References Franz 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.

25. Smallpox References Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: national surveillance in the United States. N Engl J Med 1969;281:1201-1208. Lane JM, Ruben FL, Neff JM, Millar JD. Complications of smallpox vaccination, 1968: results of ten statewide surveys. J Infect Dis 1970; 122:303-309. McClain D. Smallpox. In: Sidell F, Takafuji E, Franz D, eds. Medical Aspects of Chemical and Biological Warefare. Washington, DC: Borden Institute, Walter Reed Army Medical Center;1997:539-558. Neff JM, Lane JM, Pert JP, Moore R, Millar JD, Henderson DA. Complications of smallpox vaccination, I: national survey in the united States, 1963. N Engl J Med 1967;276:1-8. Ruben FL, Lane JM. Ocular Vaccinia. An epidemiologic analysis of 348 cases. Arch Ophthalmol 1970;84:45-48.