SARS in Toronto!

sixes · Apr 16, 2003

i don't know that things are getting any better but i am also reluctant to say they are getting worse. everyone in health care must be very cautious and regimental about taking precautions. there are no sars cases in kirkland lake yet. it seems to be mostly in toronto and near by communities. i think i heard of some cases as far north as barrie ont. all our hospitals are on alert and everyone entering the hospitals are screened.

many nursing students are in limbo and those of us that were to start new jobs or hospital related schooling are on hold.

here are some new links. sorry i don't know how to get the stories transfered like the rest of my brillant friends on this board.

have a good day and may you all be sars free. i pray every day for you all.

stay home: md

http://www.canoe.ca/torontonews/ts.ts-04-16-0006.html

constant quarantine for dialysis

http://www.canoe.ca/torontonews/ts.ts-04-16-0007.html

how 1 case became 600

http://www.canoe.ca/torontonews/ts.ts-04-16-0008.html

baby born to dying sars mother

http://www.canoe.ca/torontonews/ts.ts-04-16-0048.html

eves:rises above fear

http://www.canoe.ca/torontonews/ts.ts-04-16-0050.html

who say beijing has 100 - 200 sars cases- more than publicly reported

http://www.canoe.ca/cnews/world/2003/04/16/66382-ap.html

fergus51 · Apr 16, 2003

Fatality rates here are not 25%, they are less than 5%. I can't comment on China, cause I don't know about how they are treating the illness.

The latest here is that someone with SARS went to a church function before knowing that he was infected so they are trying to track down the others who were there. It is a definite setback.

steven44121 · Apr 16, 2003

The situation is -- we are now in a new normal. Healthcare delivery will be a pre an post sars world. The public health admits that stringent visitation, screening and most disheartening masks are here to stay until such time as a vaccine is developed.

Masks are horrible, you get sweaty, lightheaded and headachy.

I know I cannot work like this for a long period of time and will look at other options besides hospital nursing if this does indeed continue.

You asked for gut feelings -- well my gut tells me this is getting out of control. Whether or not the recent exposures at a church service can be traced back to the initial cluster, however you say it, the fact is this is community transfer. These people are now in isolation or have sars after going to church. I think we are going to see much worse before we see things get better.

ainitfunny · Apr 16, 2003

AS OF TODAY THE UNITED STATES WAS ADDED TO THE LIST OF W.H.O. ON THE LIST OF SARS "AFFECTED COUNTRIES" MENTIONED IN THEIR "TRAVEL ADVISORY"

Affected Areas - Severe Acute Respiratory Syndrome (SARS)

16 April 2003

Country/ Area

Canada Toronto

Singapore Singapore

China Beijing, Guangdong, Hong Kong Special Administrative Region of China, Shanxi

Taiwan Province*

United States of America Areas not reported*

United Kingdom London*

Viet Nam Hanoi

An "affected area" is an area in which local chain(s) of transmission of SARS is/are occurring as reported by the national public health authorities.

*Area with limited local transmission and no evidence of international spread from area since 15 March 2003 and no transmission other than close person-to-person contact reported.

sixes · Apr 17, 2003

More links

Provinces Holiday Plea

http://www.canoe.ca/TorontoNews/ts.ts-04-17-0004.html

Tests confirm Virus

http://www.canoe.ca/TorontoNews/ts.ts-04-17-0005.html

Beijings hidden cases

http://www.canoe.ca/TorontoNews/ts.ts-04-17-0029.html

City feels Pain

http://www.canoe.ca/TorontoNews/ts.ts-04-17-0030.html

Angry Medics slam order

http://www.canoe.ca/TorontoNews/ts.ts-04-17-0032.html

Scientists confirm cause of SARS

http://www.canoe.ca/CNEWS/World/2003/04/16/66812-ap.html

This is far from over but at least they say they know what to look for and prehaps it won't take long for a vaccine to be developed. All we can do is cross our fingers and pray.

Stay safe everyone and have a great day

Trishrpn · Apr 17, 2003

Hi: I'm new to this forum but I just wanted to post on this subject. I'm an RPN working in a busy emergency dept in Toronto. I've read all 7 pages of discussion on Sars in Toronto and the rest of the world.

I've been very curious as to how nurses/hospitals in the USA are handling suspect or probable SARS cases. Have any American nurses in this group worked with any SARS cases yet?

Here in Ontario, particularly Toronto, we've really been clamping down in our fight against SARS. It feels like a war and as a nurse in the emergency room I can tell you that it certainly feels like I'm one of the front line soldiers in this fight.

As you all probably know by now- By March 27th we were under order from the Health Dept to carry out

Isolation precautions on all suspected cases (I believe our hospital was

already doing that) and for all staff in Toronto Emergency Dept's to begin

wearing protective Respiratory Isolation gear at all times in the dept. By March 29th the order was changed to cover not just the city of Toronto but

all of Ontario, and all non-essential personnel, volunteers and visitors

(except in palliative, severely ill, or Maternity (the father) cases) were

not to be allowed into the hospital. We are also only allowing employees

to enter and exit the hospital by one door; visitors that are allowed in -

enter and exit by another door, and Emerg patients only are allowed to

enter through the emergency entrance. Everyone is being screened for SARS before entering the hospital- temperatures are taken, questionnaires filled out, everyone is given a mask that they must wear at all times (except when eating) and health care workers are given isolation gowns to wear. In Emerg we are now supposed to be wearing the N99 mask, but of course they usually don't have these masks.

So, for the last 21 days, when I've been working, I've had to wear

Isolation gowns, gloves, goggles and heavy duty masks. We generally work

12 hour shifts in the Emerg dept so wearing all this extra gear for the

whole shift makes for an even longer day. I believe they have also shut down or restricted the ventilation systems in our emergency dept and Isolation ward so with all this gear on and lack of air circulation it's very hot.

On top of that when we are caring for a person that is in Isolation as we try to determine if they are a suspect or probable case we double glove, wear goggles, double gown, wear a hair net and put a light surgical mask over our N95 or N99 mask. Work ups on suspect cases of Sars in the emerg take approximately one hour with ecg, initial blood work, then secondary Sars Work up blood work and swabs, plus starting IV etc. We are almost always close to passing out from overheating and lack of 02 by the time we come out of an isolation room or area.

The first masks that we were

issued didn't have a special vent on the front so we were breathing our own carbon dioxide all day ... picture working for 12 hours with headache and nausea and with the added distraction of realizing that you keep forgetting things- ie going into a room with only one item when you should have brought 5 ... this too was a side effect of the first masks we had to

wear. Now the masks we are wearing have the special vent ... but wearing

a mask all day has made many of us develop skin problems or worse allergic

reactions (some of the masks have rubber or latex at the bridge of the noseand or are filled with fiberglass). Plus even with the vent we still suffer from lack of O2 and side effects from that.

Toronto is listed as the most diverse city in the world .. we are a

melting pot of many different cultures and nationalities. At the best of

times this can make caring for an ill person difficult simply because of

language barriers ... in the Emerg dept it's very important that these

people have someone with them that can translate or be their spokesperson

as far as care goes. Now, unless the patient really can't understand or

speak English at all their relatives are not allowed in ... and if a

relative is allowed in only one is allowed in for a very short time. So we are dealing with irate relatives due to the restrictions (not just for the patients that can't speak English well!), very unhappy patients that would likely do better if they could have visitors or someone there to speak up for them regarding their care, and naturally we are likely getting overwhelmed with phone calls from relatives regarding patients that they are not allowed in to visit with. We have police officers and security guards at all the entrances to help us deal with screening anyone coming into the hospital and to deal with the problems that these restrictions have caused the

hospital (ie violent irate patients and visitors).

It's all very stressful! And I've probably only told you half of it ...

if I went into every detail this post would be 10 times longer than it

already is! I'm not too worried about getting SARS ... I mean it's a

frightening illness since we don't really know what we are dealing with yet

and we don't have any definitive tests for it. As everyone who works in

health care in Toronto Hospitals has been doing for the last 21 days I've

been taking isolation precautions (ie the masks, gowns, gloves and

goggles), and since everyone else is doing this I probably stand a good

chance of coming out of this even healthier than I started since I'm also

protected from everyone elses' cold, flu etc germs, as well as SARS. :)

The emergency dept is not quite as busy as it usually is- there are

less stubbed toes and minor illnesses that should be seen elsewhere anyways coming in ... but the people who are coming in are generally very sick ... so it's a mixed blessing ... less patients but sicker patients and always

the possibility that someone coming in will have SARS.

Someone asked:

(1) Are things calming down in Ontario? Getting back a bit to normal, or perhaps developing a "new normal?"

It's a new normal and we'll likely be doing this for quite a while.

Things are not calming down, I believe they are getting worse. I last worked on Tuesday and we had a total of 7 suspect or probable cases come in on my 12 hour shift ... 5 cases came in within a 45 minute period. It was horrible and shocking to see so many come in so fast. Two of the 5 that came in around the same time are definitely probable cases, one had apparently had a relative die the day before with a suspect or probable case of sars. There is still no report in the news of any additional deaths due to Sars this week ... so I don't know if this case was ruled out or what .... but there seems to be some discrepancy in the number of cases (probable and suspect) and deaths that I've been hearing about (and in some cases seeing (probables) and what is being reported in the news.

Or are things getting a desperate feeling of getting out of hand?

Hard to say ... we have a number of people in quarantine in this city ... more and more are put in quarantine each day. The latest news is that a condominium in the east end of the city is being quarantined because of a suspect case (maybe 4 cases- missed the full update).

The number of cases in Canada (mainly Ontario) jumped to a total of 303 suspect and probable cases (126 probable) on April 16th. The 4% death rate that is being reported ... I don't believe it ... in Ontario where we have been most affected by SARS we currently have 122 probable cases with 13 deaths which is a 10.6% death rate.

I'm stressed and yes I'm worried about this. I was extremely stressed when I came home from work this past Tuesday, but I'm prepared to start a new round of shifts tomorrow.

As I said I have no illusions of this going away any time soon. I feel the measures we are taking in Ontario are the correct measures to prevent the spread of this disease, unfortunately compliance with quarantine and or people not realizing that they were in "at risk" situations have compounded the situation.

(2) What do you think might happen down here?

If the health care system is starting to see probable and suspect cases in the US (and we know that they are) I strongly believe that if you aren't taking similar measures as we in Toronto are you will have major outbreaks of SARS. Especially within the healthcare system (i.e. nurses) if they are not wearing masks and isolation gowns etc at all times in "at risk" depts like emergency depts.

Whew! This is a long introduction to this nursing forum! Hope it's not too long, and that it has let some people know what it's like to work in the emergency dept and deal with SARS cases.

I'm looking forward to hearing more opinions on what is going on with SARS in different areas. Trish

BTW I think I might be allergic to the masks ... well I hppe that's what my symptoms are ... I'm wheezy and often have a sore throat these days ... don't feel too bad otherwise and If I have several days off between shifts these symptoms calm down ... so I am hoping it's allergies! Better not be anything else! Also- I have crohns so I do worry about my immune system and it's response to Sars and all that's going on but so far I seem to be maintaining my health.

RNonsense · Apr 17, 2003

SARS nurses told to wear goggles

Health worker may have contracted disease through eyes

Lori Culbert

Vancouver Sun

Thursday, April 17, 2003

All health-care workers should wear goggles while treating people with probable cases of SARS, the provincial health officer is recommending after a B.C. nurse contracted the virus from a patient.

Dr. Perry Kendall said it is possible the 44-year-old nurse at Royal Columbian Hospital may have contracted the virus through her eyes while treating a person with a probable case of SARS for two days.

"There's a possibility of droplet spread, I guess, to the surface in the eye. That's one hypothesis. We are now recommending that goggles be routine in nursing symptomatic persons with probable SARS cases," Kendall said.

The B.C. recommendations go beyond Health Canada guidelines, which advise doctors and nurses to wear goggles during procedures in which SARS patients could spray blood or other bodily fluids, but not necessarily in everyday care.

"We have perhaps some evidence here that just nursing an individual who is highly infectious may be an exposure procedure, so we're extending -- just to be on the safe side -- precautionary measures. We are going beyond what is recommended in the [federal] guidelines," he said.

B.C. is following in the footsteps of Ontario, home to most of the Canadian SARS cases, which passed new provincial guidelines Monday that require anyone treating a probable patient to wear goggles.

A Health Canada spokeswoman said Wednesday there are no immediate plans to change Ottawa's guidelines.

The infected nurse -- the first case in which the virus has been spread from one person to another in B.C. -- followed Health Canada rules by wearing a gown, gloves and a mask, as well as washing her hands, while treating the SARS patients.

Kendall is confident that with the addition of goggles, the equipment will protect health care workers as long as they are vigilant in its use.

While a specific type of face mask is required to fend off SARS, any type of medical goggle can be used. Goggles are considered more effective than safety glasses because they are tight to the face.

Kendall said the case of the infected nurse doesn't mean the public needs to wear goggles or is at any greater risk.

But he acknowledged there is always the chance of secondary spread in the community.

Kendall does not want to see a repeat in B.C. of a recent situation in Toronto, in which an infected person was misdiagnosed and sent back into the community, eventually causing more than 500 members of a religious group to be quarantined.

He stopped short of saying mistakes were made in the case of the Royal Columbian nurse, but noted she was at home when her symptoms emerged -- the most contagious time for a person with probable SARS -- but had not been diagnosed at that point.

"She reported ill towards the end of the incubation period. With hindsight, it would be nice to think in the future we would recognize that and get the report in to the public health authorities a little quicker," Kendall said.

Dr. Patricia Daly, director of communicable-disease control for the Vancouver Coastal Health Authority, said no different action plan is needed now that B.C. has its first case of SARS spread from person to person.

"There has always been the possibility of secondary spread, we had been fortunate [before] that we hadn't had any cases," she said. "Our plan was always ... to limit that secondary spread."

A detailed investigation has been launched into how the nurse caught the virus, but it will require an interview with the woman once she is feeling better.

Daly said she does not yet know if a lack of goggles could explain the transmission of SARS, but added health care workers should be safe as long as they use the gear properly. They should not, for example, touch their face or scratch under their masks or goggles before washing their hands.

"We're still confident that if you follow all those practices, that you will be protected," she said.

The unidentified nurse's last day of work was April 3, and she was scheduled to go back to the New Westminster hospital April 9, but was feeling fatigued and called in sick. She remained home until the 14th, when she became more ill and checked herself into the hospital.

During the time she was feeling ill, she came into contact with about 30 people, including her family, and those individuals are under home quarantine.

Because people with SARS are believed to be contagious only after symptoms appear, there is no fear she spread the virus to her co-workers.

None of the people who were put into quarantine after contact with B.C.'s three other probable cases of SARS has developed any symptoms.

Dr. Robert Parker, deputy medical health officer for the Fraser Health Authority, which includes the Royal Columbian, said his region is also investigating how the nurse contracted the virus while following all the proper procedures -- but he noted the measures are only as reliable as the people practising them.

"No procedure you put in will be absolutely, 100-per-cent perfect all the time. And people are only human," Parker said. "So at times you may get a secondary case in a health care worker who is doing their job but perhaps getting exposed to the virus."

He said other doctors and nurses at the hospital are concerned about the nurse's health, but have not refused to work with any suspected SARS cases.

Since a team of B.C. scientists discovered the genetic code for SARS, labs around the world are scrambling to develop a test sensitive enough to detect the virus. It isn't clear when that work will be complete, or when a potential vaccine will be found.

On Wednesday, Dutch researchers announced they had produced the disease in monkeys by infecting them with a recently discovered coronavirus, producing the final piece of evidence that the virus is the cause of the outbreak.

"We now know with certainty what causes SARS," said Dr. David Heymann, executive director of the World Health Organization's Communicable Diseases programs. "With the establishment of the causative agent, we are one step closer" to developing more effective preventive programs and treatments, he said.

Health Canada reported Wednesday 303 probable or suspect cases of SARS in the country, and 13 deaths in Ontario.

In B.C., there are four probable and 38 suspected cases of SARS.

All four of B.C.'s probable cases -- one in each of St. Paul's, VGH, UBC Hospital, and Surrey Memorial -- are in stable condition. One is on a ventilator, and the others are breathing on their own.

- - -

And a few thought living off credit cards was a bad idea

:rolleyes:

RNonsense · Apr 17, 2003

Nurse first case of SARS contracted here

Steve Berry

The Province

Wednesday, April 16, 2003

A nurse has become B.C.'s first health-care worker to come down with SARS.

The 44-year-old acute-care nurse, who became ill while looking after a patient at Royal Columbian Hospital, is the third probable case of Severe Acute Respiratory Syndrome in Vancouver, and the fourth in B.C.

Hers is the first SARS case transmitted in B.C. The others who have come down with the sometimes-deadly virus are travellers who caught it in Hong Kong.

The nurse had limited contact with others before going into hospital. Her contacts -- fewer than 30 -- have been located and are in a 10-day quarantine.

"They will go on 10 days of home quarantine and we will monitor them every day for temperature and signs of symptoms," said Dr. Patricia Daly, the Vancouver Coastal Health Authority's director of communicable disease control.

Health authorities are concerned because the nurse apparently took all precautions against infection and yet still became ill.

"She seemed to have followed all the appropriate infection-control procedures," said Dr. Robert Parker, deputy medical health officer with the Fraser Health Authority. "That's the worrying thing. She obviously got it somehow."

Parker added that an investigation is under way to see what procedures were followed.

"It's very much of a concern for the Royal Columbian staff, both for themselves and for their co-worker and friend," he said.

Other staff at Royal Columbian are likely beyond the incubation period and no more infections are expected, said Parker.

"There are no other exposures at Royal Columbian that I know of," said Parker.

The nurse, a Vancouver resident with a family, is in St. Paul's Hospital in stable condition. She is not on a ventilator, as are some others who are infected in B.C.

B.C. Nurses Union president Debra McPherson pointed out last night that nursing is a dangerous profession.

"The day-to-day work of a nurse is such that they are exposed every day," said McPherson, who added that all precautions seemed to be in place to deal with SARS. "We just don't know enough about it yet. The precautions that are available, based on the knowledge we have now, are being used."

A stroke of luck prevented the possible further spread of the disease. The nurse, whose last day of work was April 3, was on days off when she became ill and did not return to work before going to St. Paul's Emergency on Monday with the SARS symptoms -- fever, fatigue and cough.

"She did not work while she was ill, which is a good thing," said Daly.

The nurse looked after a SARS patient at Royal Columbian for two days. The patient had picked up the disease in Hong Kong.

"There is no risk to the general public. We're not seeing cases spring up in the community," said Daly. "The only cases we've had are travellers, and now this health-care worker. It isn't easily spread."

Health Canada yesterday reported 296 probable or suspect cases of SARS in Canada. There have been 13 deaths in Canada, all in Ontario. There are 37 suspect cases in B.C.

The original patient diagnosed with SARS in B.C. was seen at Vancouver General Hospital March 7. That patient is still on a ventilator but is in stable condition.

The patient at Royal Columbian was transferred to Surrey Memorial and is stable, as is the patient at University of B.C. Hospital.

For more info on SARS, contact the SARS line at 604-708-5300. If you feel you have symptoms or have been exposed, call the B.C. Nurse Line at 604-714-4700.

--------------------

http://www.canada.com/vancouver/

RN4ev'r · Apr 18, 2003

The hospital I work in is one hospitals in Toronto. We have had 50% of the SARS patients admitted to hospital in our facility, according to what we have been told. To date, there has been no staff members contracting SARS. All the precautions everyone else is taking, gowns, gloves, masks and googles, are being used. We are also screened before entering. I do not understand why staff in other hospitals have contracted SARS. Is there more contamination in the community or is there something else we should be doing for infection control as we have just been lucky so far?

epaminondas · Apr 18, 2003

sixes, fergus, steven, Trish, RN4ev'r,

Thank you for the "you are there" perspective.

It is extremely helpful. Particularly the information on masks.

Mask questions:

Actual mask preferences: N95s, N99s, or N100s?

3M or other manufacturers?

Standard (valveless) or valved?

Is everyone wearing a standard paper mask over their N95 (or whatever) mask? (a new idea to me).

Are you getting new N95 (or whatever) masks every day? Or reusing the ones you have?

Storage of used masks: if you put them in a bag overnight, won't they just self-contaminate?

Anybody using the electrical ("space suit") HEPA head gear? I hear that they are noisy and would probably scare your patients into the next county - but they may alleviate the complaints about decreased PO2 that we are hearing with the N95 masks.

Other questions:

(1) What percentage of Ontario SARS victims are Health Care Workers?

From news and other sources, I have seen the following reported (corrections are welcome!):

(a) Hanoi-France Hospital outbreak - approximately 90% Health Care Workers.

(b) Initial Hong Kong outbreak at Prince of Wales Hospital - initially approximately 60% Health Care Workers and medical students. Hong Kong infection rate in general now running at about 24% Health Care Workers.

(d) United States - infection rate approximately 3% Health Care Workers. :-)

(e) China - unknown. Lotsa health care workers reported affected, but the official Chinese data is largely considered unreliable.

(f) Canada - unknown.

Two things about the above:

One - despite plenty of information on this matter in regard to other outbreaks, I have not seen any information on Health Care Worker infection rates from Ontario.

Musta missed it.

Could someone please clue me in?

Two - I do find the U.S. statistics (3%!) most heartening. :-)

But, uh - is the U.S. really that good?

I hope that this is not just an artifact of this being early in the infection cycle.

_________________________________________________________________

(2) Is everybody showing up for work?

At one point around half of nurses and other hospital workers in Vietnam and in Hong were reported to be staying home: "Asian Nurses Stay Home, Imperiling Respiratory Patients" by Lawerence K. Altman, The New York Times, March 21, 2003.

The international WHO doctors were saying that the local nurses on the ground were wrong to stay home. The WHO doctors were saying this safely from their offices in Vienna.

In the discussions at our hospital, about half of the female nurses have declared outright that they are not coming in if SARS hits the hospital. Each of these nurses then says "I have children."

Point made. That is the end of their discussion.

None of the guys has said any such thing.

They just stay quiet.

The way our ladies say it - it is as if they are seeking agreement or approval for their cowardice in advance.

Or disagreement - so they have someone to react against.

I just reply "I understand what you are saying" in a very noncommittal way - and they each read into it whatever they choose.

I have never seen this before. The fear in the air.

Aggressive fear.

It is becoming my impression that feminine cowardice is a very social phenomenon.

Something to be shared.

Guys, on the other hand, keep their mouths shut.

Why declare cowardice in advance - particularly if you may never need to act on it?

Best to leave such a decision until such time when the decision may actually be needed.

A day which, if one is lucky, will never come.

But the guys are also keeping their eyes on the exits.

I understand the view that we have a sacred trust and duty to stand by our patients through thick and through thin - and that anyone who does not do so is abandoning that trust in a terrible and dishonourable way.

On the other hand, I understand the point of view that this is each person's decision to make for himself.

It would appear to me that the different views are irreconcilable. You either feel one way, or you feel the other.

Me?

I have never had any desire to be a dead hero.

But I am not sure that I am brave enough to run.

It looks like courage and cowardice may not be simply flip sides of the same coin.

I wonder how many people in this world have become heroes because they did not have the courage not to be?

________________________________________________________________

Sorry to wander off like that - but watching SARS head towards us with all the speed of a twenty foot high wave of molasses gives us a lot more time to think about it than you probably have on the front lines.

The waiting is wearing thin.

I'll almost be glad when it finally gets here.

Funny to think that we may one day long back for of our current state of uncertainty.

________________________________________________________________

Trish,

You asked:

>

I am wondering, too.

Nothing here. Just waiting. And waiting.

The following gives you an idea of our level of readiness. It is probably about what would happen here:

http://www.pilotonline.com/news/nw0326che.html

I guess that it's nice to get your picture in the paper, but I kinda wonder how people are going to treat you if you do.

And I also wonder about lab and x-ray and admitting and housekeeping and . . . .

Here we are thinking about what to do. But there is a strong desire to not look silly, to not be paranoid. To not get ready.

After all - SARS is not an American problem. More likely to be hit by lightning. Don't be silly!

And that is all probably true.

Most preparation is now going on through informal networks. From below, not from above.

I am told that the Infectious Control Committee has never met. That it is a paper committee - there only for hospital accreditation, not a reality. I do not know whether that is true, or no.

Perhaps it will meet if and when there is a case in the state.

The safety committee met and the subject was brought up - infection control brought it up, to some interest. People - floor nursing, ER, radiology, lab - have now gotten N95 masks fit. We are ordering goggles. Extra this and extra that now in the supply pipeline. And just thinking through things -

E.R. protocol now includes asking people with symptoms about travel. But no masks on at the front door.

Starting to think about talking about the matter with EMS personnel.

Our trigger point is when the first case hits the state.

Then things will start to get moving.

But I like to think that it will never happen here.

Anyway - thanks again. Any information from the front lines - above and beyond newspaper reports - would be most appreciated.

All the best,

Epaminondas

___________________________________________________________________________

Oh - the latest from Hong Kong:

Dear All,

I have been asked why I have stopped posting.

Another hospital in HK has received 600 SARS patients. The ICU has been expanded from 14 to 46 beds.

Unfortunately 4 of the 6 dedicated ICU docs and 25% of that hospital's ICU nurses have contracted SARS.

I was asked to go over and implement strict infection control measures and sort out clinical management.

I am now responsible for a 46 bed ICU, which now has several hundred relatively inexperienced nurses, 20 docs (some with ICU experience), and 42 patients all very young with MOF.

All staff are completely unfamiliar with each other, that hospital's ICU routines and how that hospital works. I have introduced some structure and systems all in the name of SARS.

The infection control aspect was easy but compliance is only 99%.

Clinical management - well that's another very confusing story.

As you can imagine I am a bit busy.

Regards to all

XXX XXXXXXX >>

Trishrpn · Apr 18, 2003

Thanks for your reply epaminondas, I'll try to answer some of your questions and give you some thoughts to ponder ... hopefully some of the others who are in affected hospitals will also reply.

Masks- I haven't found a Mask that I prefer. We don't have much choice in the matter- we get what we are given when we check in each day. Occasionally there is a choice of two or three masks but most often there is only one type. I haven't seen the N100's, we've been working mainly with the N95's and N99's. Only those of us working in Emerg, Sicu or CCU get N99's when they are available. Otherwise we use N95's.

Anyone working in patient care area's must wear an N95 mask (or higher depending upon the area that they work in). They have changed the regulations slightly now so that hospital workers that don't work in patient care areas do not have to wear a mask (but everyone still does). Staff that don't work in patient care areas can wear standard surgical masks or the duck bill masks, and anyone that is even just walking through a patient care area must wear a mask of some type. Anyone working in a patient care area wears the masks that are valved, although the valveless variety are available as well. All patients are given standard surgical masks to wear, and any patients with respiratory symptoms are given N95's.

Patients entering through Emerg are given a mask when they are screened outside the hospital prior to entering the hospital. On the rare occasion when a relative is allowed in with them (ie critically ill patient or someone who can't speak English at all, or the parent of a sick child) this person is also screened and given a Mask. Basically no one gets into the hospital unscreened or unmasked, although as I've said, staff that do not work in, or walk through patient care areas do not have to wear masks at this time.

We are given a new mask each shift. If that mask becomes soiled or damp we can replace it, but if it remains intact they consider it good for the whole shift. When working with patients in Isolation we put a standard surgical mask over or N95 or higher mask. Originally they said we had to change the N95 mask but now they say that we should just protect the mask with a surgical mask and only discard the surgical mask after working with an isolation patient. Many of us are not convienced that this will protect us so we often change our N95 masks too. (provided that there is a good enough supply to do so! That's another problem!)

As far as I know no one is using the HEPA head gear in our hospital.

We've been told to try to keep our goggles and to bring them back to the hospital for each shift, not to throw them out after a shift. We've been told to wash them with soap and water.

I really don't know what percentage of Ontario Sars victims are health care workers.

Just a little history here ... Our first case of Sars visited China in Febuary, she and her family returned to Canada near the end of Febuary (24th?) and she began to develop symptoms of the illness on Febuary 27th and I believe she was hospitalized on March 1st, however she died at home on March 5th. By this time her husband and her son were also exhibiting symptoms and I believe the hospital where they were cared for was beginning to suspect that this was a contagious disease but they might not have fully known at that time what they were dealing with. The World Health Organization didn't put out it's Global Alert until March 12th which was a full 7 days after we'd had our first death here. I believe that almost all of the cases that we have here in Toronto with the exception of a couple of other Sars victims who had also travelled to Asia can be traced back to these first three cases (the first family). Now, because the hospital and health care workers didn't know what they were dealing with when these first cases occured in Toronto no isolation measures were taken during the initial stages, which means that numerous health care workers and likely patients in the emerg and other patient care areas of the hospital were exposed to the SARS virus. Affected members of this family also visited a doctors office or medical clinic and I believe that some of the people there were affected too. Not everyone who was exposed has become ill with SARS but most were definitely affected on that they had to be quarantined once we knew what we were dealing with. It's that initial two week period from the families return from China until the WHO Global alert that has caused the majority of our SARS cases here in Toronto. Once that initial hospital knew what it was dealing with isolation precautions were put into place, but by that time there were many people exposed to the infection. Still, I'm not certain at this time how many health care workers have actually become ill with SARS like symptoms, I believe that the numbers will still end up being on the low side when all is said and done.

This article from the New England Journal of Medicine has a breakdown of the intial cases here in Toronto:

http://content.nejm.org/cgi/reprint/NEJMoa030634v1.pdf

I realize that you are happy to hear that so far only 3% of US health car workers have been affected by SARS but there are a few things to consider with that figure. your population is about 10 times higher than the Canadian population ... so how many health care workers exactly is 3% of your health care workers?

In an article in the New York Times I read today that the US is now reporting only the probable figures on the world health organization website (I don't see that change the numbers still reflect your total probable and suspect cases) which is now supposedly only 36 cases. We have 126 probable cases across the country and we've had Sars here since the end of Feb. From what I've found it seems that Sars really didn't hit the US until two or three weeks later than it hit us ... so we've been fighting it or working with it almost twice as long.

It's unfortunate that Sars hit us in Toronto so hard, but once we knew what we were dealing with we went into high gear. As I've described in my two posts to this forum today everyone is wearing masks in the hospitals- patients and staff, and we are screening everyone who enters the hospital before they even get inside. I'm 100% convinced that if we weren't taking this so seriously that things would be much worse here.

From what you've said and from what I've gathered from reading posts and articles about SARS in the US it doesn't sound like the hospitals there are taking this infection quite as seriously as I think they should be. I've seen several posts that state no protective or isolation measures are being taken until the patient is actually in the hospital and presents with symptoms and states they've had recent travel to an affected area. Only then are they given a Mask and put into isolation. This is scary!!!!!

We've just had a whole church congregation of 500 people put into quarantine because of a slip up. A gentleman passed away here in Toronto on the first of April. This man had orginally gone to the hospital on March 16th (the hospital where this all started in Toronto). His son was present in the emerg with him. Shortly after their visit to emerg on march 16th, health officials here in toronto decided that anyone that had been in the hospital emerg and other specific areas needed to go into a 10 day quarantine because of possible exposure to another Sars victim that had been there at that time. I'm not sure if the man that I'm discussing was admitted to the hospital on his visit to emerg or was released, but either way the son voluntarily quarantined at home for 10 days. Then the father died and 5 days after his death and 2 days after his funeral it was decided that his dealth was caused by SARS. What wasn't known at that time was that another son had briefly visited the father and son in Emerg on March 16th. The second son was never quarantined because it wasn't known he was in emerg that day, and I suppose he never put two and two together and realized he'd had an "at risk" exposure on that brief visit. Well to shorten this story ... the second son who was never quarantined was a member of the Church congragation that just had to be quarantined earlier this week. This son is now sick with Sars like symptoms as are 28 other members of that congragation (BTW the people that visited the funeral home on April 3rd also had to be quarantined).

The point I'm trying to make in all this is that the father and sons became ill because they were exposed to another person who happened to have Sars symptoms at the time they were all in the emergency dept. Now remember one son was only in the hospital briefly.

I just think the fact that your hospitals in the US are not giving out masks and that the health care workers are not at least wearing masks in "at risk areas" at all times, is simply asking for trouble. From our experience here it doesn't seem like it takes are very long unprotected exposure to possibly cause illness. That's why were are protected at all times and why we have masks on every patient coming into the hospital.

Yes everyone in my hospital seems to be showing up for work. No one seems to be too scared to come in. We are protecting ourselves and we *should* be safe. I do know that no health care worker that has been wearing protective gear has been infected ... any health care workers who have been affected had unprotected exposures (ie prior to the WHO global alert). That's the main reason why I'm concerned that there might not be enough preventative protective measures being taken in the US.

If people in your hospital are saying already that they will not come in if SARS hits the hospital that is possibly due to the fact that not enough measures seem to be being taken at this point to protect health care workers and patients from exposure to this illness. If those measures were in place already as they are here I would hope that you would be hearing less statements like that.

As I said the US has the advantage of watching how we deal with this disorder. I would hope that your hospitals would learn from what we are doing, and any mistakes that were made in the beginning by us due to our not knowing what were werer dealing with initially. By the time this hit the US you knew what it was, and it's still a hard disease to diagnose, it's not always easy to spot ...

The staff that are expressing concern are likely very worried. You ask "why declare cowardice in advance- particularly if you may never need to act on it?" But if no preventative protective measures were being taken here I would be afraid too.

As long as I feel like the measures we are taking are effective I plan on continuing on and working. I love my job and hope this resolves itself in the near future ... but I also fear that I'll be wearing a mask for a long time to come because I don't think this disease is going to settle down any time soon. I don't feel that I really have a choice in the matter ... I mean all the hospitals here are chronically short staffed, and now with this health care disaster in the works it's even worse ... how could I not work? They need me.

It's an unusual situation and one that I hope we never have to face again. Here in Toronto we are comparing this to how we would react if there were an act of biological terrorisim in the city. What we've found is that in some ways we were prepared ... when we knew what were wre dealing with we went into full alert (our hospital is in Code Orange which is our external disaster code), and for the most part all the plans made in advance of such a disaster have been effective. I do know that we have learned that we need to have triple the amount of supplies stored away though (ie MASKS!).

Sorry to wander off like that - but watching SARS head towards us with all the speed of a twenty foot high wave of molasses gives us a lot more time to think about it than you probably have on the front lines.

And that's why I'm trying to ring the warning bells. That wave is coming and if you don't treat it like the health care disaster it is (or as you would a biological threat for example) you might end up in even worse shape than we are here in Toronto. I'm not trying to be an alarmist, I just fear that if you don't start wearing masks and also putting masks on everyone that comes through your hospital doors soon this will really get out of hand. I think what we have been doing here with the masks and isolation gowns is really all that has kept this from getting totally out of control ... some fear that even with the measures that we've taken that it might be becoming out of control.

The article that you linked in your post http://www.pilotonline.com/news/nw0326che.html

was interesting. It's great tht that doctor was really up to date on his information, and that he took action as quickly as he did. It was a lucky call. :) I also wonder how long that patient sat in the waiting room etc ... you have to wonder, if it really was SARs, just how many people were exposed to that patient before she was placed in isolation.

Here we are thinking about what to do. But there is a strong desire to not look silly, to not be paranoid. To not get ready.

Yeah On March 27th when we all started wearing masks and gowns and gloves all the time the media started to wonder if we were overreacting, and I guess some of us health care workers did too ... but believe me, no one thinks we are overreacting now.

Our trigger point is when the first case hits the state. Then things will start to get moving.

It will be too late by then ... this is a global illness.

It's like the article that someone posted earlier about the fact that they will start wearing Goggles in British Columbia when dealing with Sars isolation patients because Sars infected droplet molecules might have infected a nurse through her unprotected eyes. Duhhhh! We've been wearing Goggles here in Ontario when caring for suspect SARS cases for three weeks! British Columbia is in Canada ... they know very well what we are going through and what we are doing here in Ontario ... if that nurse did become infected because she wasn't wearing goggles it wasn't due to lack of knowledge, it was because her hospital or province hadn't recommended/demanded that goggles be worn. What I'm trying to say is that they saw what was going on here and they must have watched and waited ... and now perhaps a nurse is paying the price for their lack of action.

Thanks for the information from Hong Kong- it's interesting to find out what's happening on the front lines there too. Are health care workers all wearing N95 masks there too- all the time I mean?

Ok gotta go to bed! I have to work in the morning. Hopefully tomorrow is a better day at work than Tuesday was.

Trish

sixes · Apr 18, 2003

Trish thank you for the wonderful post . i have printed the Identification of SARS in Canda link you provided I was having a hard time reading all 11 pages.

I think everyone should read this article it is a wealth of info.

I hope you have a good day at work, Hoping everyone has a Happy Easter. To those in quarantine my heart goes out to you. God will forgive you and love you all the ore if you stay home and pray instead of breaking your isolation.

Here are some more links

It'll be a long weekend

http://www.canoe.ca/TorontoNews/ts.ts-04-18-0004.html

The selling of TO

http://www.canoe.ca/TorontoNews/ts.ts-04-18-0005.html

Tourism workers reeling

http://www.canoe.ca/TorontoNews/ts.ts-04-18-0006.html

Economy may feel chilly touch of scare

http://www.canoe.ca/TorontoNews/ts.ts04-18-0007.html

SARS in sewer

http://www.canoe.ca/TorontoNews/ts.ts-04-18-0038.html

Kuala Lumpar lifting ban on Canada