The ED evaluated a total of 53 patients with possible exposure, with John Scott, DO, personally evaluating almost all of those individuals. Having a single physician evaluate and oversee the patients presenting with an unusual disease is a very effective way to achieve consistency and manage patient and family concerns. Most with symptoms were complaining of blurred or double vision and difficulty swallowing. Several only complained of nausea. Almost all had normal initial neurologic exams. Those who were symptomatic had ptosis and difficulty swallowing and phonating. This progressed rapidly to respiratory failure and the need for mechanical ventilation.

The medical staff leadership organized a coordinated approach to patient care. The first patients who arrived utilized all of the ICU resources, so regional coordination was organized with all adult and pediatric hospitals in the Columbus, Ohio, area. Subsequent ill patients were stabilized and transferred to those hospitals. A large number of ambulances were staged in the ED parking lot to provide expedited transport. As of the last report from the state department of health, 21 patients were confirmed to have botulism, and 10 additional cases were suspected.

If your department’s resources are overwhelmed by an outbreak, have ambulances standing by to take stable patients to nearby emergency departments.

Working in conjunction, infectious disease consultants, neurology, the hospitalist group, public health officials, and Centers for Disease Control and Prevention (CDC) experts mapped a uniform patient approach. The local hospitalist staff was expanded, and the plan called for all exposed but asymptomatic patients to be admitted for careful observation. Those who refused admission received phone calls every six to eight hours to check on their status. Two patients left the ED against medical advice, and one was found collapsed after a status phone call went unanswered. He was found in extremis and was resuscitated and intubated after his home was entered.

Diagnostic evaluation and treatment also required an extensive and coordinated approach. No local diagnostic testing was available to establish a diagnosis; clinical criteria were used. The Ohio Department of Health, working with experts from the CDC, coordinated to acquire and utilize the antitoxin. An event with this many patients requires the use of antitoxin from storage sites in various places, all coordinated through the CDC. Because supplies were limited, treating physicians had to allocate the antitoxin to those most in need.

Lessons Learned

The exemplary response to this event began with the teamwork of the ED staff at Fairfield Medical Center. The emergency response required all clinical and support staff of the ED to work with patients and families to establish the risk and degree of exposure, coordinate the need for aggressive care for those who required immediate support, and arrange for admission and transfer. ED leaders worked with regional fire and EMS personnel to locate victims and provide lifesaving care. As with other public health emergency events, there were a number of “worried well” who had to be reassured and released.