+Flea-Borne Typhus? — October 18, 2018
Los Angeles County Department of Public Health (LAC DPH) has identified a number of cases of flea-borne typhus associated with the homeless population in downtown Los Angeles and the Willowbrook area of Compton.
LAC DPH states, “flea-borne typhus, also known as murine or endemic typhus, is a disease transmitted by fleas infected with Rickettsia typhi or Rickettsia felis. Flea-borne typhus is endemic in LAC with cases detected each year. In recent years, the average number of cases reported to LAC DPH has doubled to nearly 60 cases per year; however, geographic clusters of the size are unusual. Most cases occur in the summer and fall months. In LAC, the primary animals known to carry infected fleas include rats, feral cats, and opossums. People with significant exposure to these animals are at risk of acquiring flea-borne typhus.”
When should EMS providers suspect typhus?
What are recommended actions by emergency departments and other hospital-based clinicians?
Consider a diagnosis of flea-borne typhus in patients with a non-specific febrile illness with headache, myalgia, rash, and laboratory abnormalities including leukopenia, thrombocytopenia, and elevation of hepatic transaminases, without alternate identifiable etiology.
Long Beach Health and Human Services
Pasadena Public Health Department
Are there concerns about contracting the disease if EMS or hospital personnel care for such patients?
If fleas are noted, consider removing clothing and place in a biohazard bag.
+Fentanyl Exposure for EMS Provider — August 30, 2018
Fentanyl use as a drug of abuse has increased in the United States. EMS providers are increasingly likely to encounter fentanyl in the line of duty.
Facts to know:
Signs and symptoms of fentanyl exposure include:
If exposure occurs:
If an EMS responder exhibits signs or symptoms of fentanyl exposure:
US Customs and Border Protection: https://www.youtube.com/watch?v=6Yc9lSaSKls
Safety Recommendations for First Responders Handout: https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final%20STANDARD%20size%20of%20Fentanyl%20Safety%20Recommendations%20for%20First%20Respond….pdf
+Seasonal Infuenza — January 8, 2018
+Hepatitis A Outbreak in Los Angeles County — September 21, 2017
The Los Angeles County Department of Public Health has notified the Emergency Medical Services (EMS) Agency of 10 cases of Hepatitis A amongst our homeless population or others at risk for Hepatitis A infections.
In San Diego County 421 cases of Hepatitis A infections including 16 deaths, primarily affecting homeless persons, injection and non-injection illicit drug users and individuals in dense living conditions with shared restrooms, were reported since November 2016.
At this time we recommend that all EMS Provider Agencies and Police Departments notify their staff who have direct contact with individuals from the identified population, of this outbreak and the need for vigilance relative to PPE use and hand hygiene. Although hand hygiene should be a part of daily clinical care both for the protection of the provider and the patient/client, outbreaks such as these bring this practice into the forefront of prehospital care. Hepatitis A virus is spread by oral contamination with feces which occurs when a person puts their contaminated hand in their mouth. This transmission can be prevented by PPE and good hand hygiene practices. These same practices are important for law enforcement personnel to follow to prevent exposure to disease.
The Center for Disease Control (CDC) recommends the following best practice related to hand hygiene and use of gloves for health care providers:
When and How to Wear Gloves
When Should an EMS providers and Law Enforcement Personnel Use Alcohol Based Sanitizers or Wash Hands
When using alcohol-based hand sanitizer:
Each EMS Provider Agency should alert their providers to the CDC recommendations on who should be vaccinated against Hepatitis A.
Currently the Hepatitis A Vaccine is recommended for the following persons aged 1 year and older:
The Hepatitis A vaccine is currently given to all children after 1 year of age – this occurred after 2000 – thus many of our EMS providers and law enforcement personnel may be unvaccinated. The Hepatitis A vaccine is given in two injections 6 months apart and confers 25 year immunity in most adults.
For the latest updates and recommendations please visit the EMS Agency website at:
Under Important Notice on the landing page is an area listed as Hepatitis A Update. You can click on this to be linked to the most current information from the Department of Public Health. If you have specific questions please send them to HepAinfo@dhs.lacounty.gov and EMS Agency staff will get back to you with a response.
In this update I will:
Congenital adrenal hyperplasia or CAH are any of several types of genetic diseases (autosomal recessive) that can result in excessive or deficient production of sex steroids or cortisol. This can have a profound effect on the reactions of the body to stress including infection.
Any of the following stresses to the normal physiology of a patient with CAH or other diseases of the adrenal gland can result in life threatening consequences:
IF LEFT UNTREATED CAN RESULT IN DEATH
The boy’s vital signs:
Sister states she tried to give the child a double dose (stress dose) of hydrocortisone (Solu-Cortef®) by mouth as prescribed by the physician, but the child immediately vomited it up.
What can the paramedics do?
Per State of California Title 22, Division 9, Prehospital Emergency Medical Services, Chapter 2, EMT 100063: Scope of Practice of EMT Assist patients with the administration of physician prescribed devices including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices
Please see attached Presentation for further information
+The End of Life (AB15) Impacts on EMS System — June 20, 2016
TO: The EMS Community
As many of you are aware, in late 2015, the California Legislature passed the End of Life Act (AB 15), which became law on June 9, 2016. This Act allows for terminally ill patients in California who are mentally competent adults to voluntarily request and receive a prescription for medication to end the patient’s life at a time of their choosing. This allows for a patient to have some control over the end of their life and gives patients dignity and comfort at the time of their death.
The law outlines many safeguards for the patient and includes language that the patient may rescind his/her wish to take the aid-in-dying drug at any time.
In order to prepare the EMS system to care for these patients with respect for their wishes, there have been modifications to a number of key EMS Agency policies including Reference No. 814 “Determination/Pronouncement of Death in the Field” and Reference No. 815 “Honoring Do Not Resuscitate Orders”, Physician Orders for Life Sustaining Treatment, and the End-of-Life Option (Aid-in-Dying drug).
Please review these updated policies on our website under Resources/Prehospital Care Manual. Note a couple of new resources within Reference No. 815: Reference No. 815.3 provides an example of an attestation that the patient intends to take the Aid-in- Dying Drug within 48 hours. An attestation may or may not be available at the time EMS arrives at a home of a patient who has taken the aid-in-dying drug. Reference No. 815.4 is an algorithm, which is intended to provide guidance on the management of these patients. The goal is to honor a patient’s end-of-life option and provide comfort and guidance to the family.
We must also work collaboratively as EMS and hospital-based providers to make the best decisions on care and transport for the patient, and their families.
Marianne Gausche-Hill, MD, FACEP, FAAP
Medical Director, LA County EMS Agency
+Zika Virus — June 15, 2016
Zika virus is a flavivirus spread by the bite of the Aedes mosquito and is related to denque, yellow fever and West Nile viruses.
Originally reported in Uganda, the virus has now spread to many parts of the world including the United States (See Figures).
Incubation is 2-12 days and only 20% of patients bitten develop symptoms. Transmission between humans can occur via blood transfusion or sexual activity. Symptoms include fever, rash, conjunctivitis, joint pain, headache, and generalized weakness.
One of the most publicized complications is microcephaly in babies born of women infected with the virus during pregnancy (generally in the first trimester of pregnancy). Greater than 4000 cases have been reported in Brazil and now in other areas of the world.
Treatment of the disease is symptomatic meaning treating the fever and symptoms with acetaminophen (Tylenol) and other supportive care such as IV fluids if dehydrated. Ibuprofen (Motrin) should be avoided as co-infections with dengue do occur and use of nonsteroidal anti-inflammatory agents, such as ibuprofen, may increase risk of progression to hemorrhagic fever.
Testing for the virus can occur from blood, urine or cerebrospinal fluid specimens sent to local health departments. http://www.cdc.gov/zika/hc-providers/index.html
EMS providers should use universal precautions or standard infectious disease precautions (gloves and mask) when evaluating and transporting these patients to the emergency department. Exposure to blood or bodily fluids should be reported per normal guidelines and no additional precautions are necessary. Questions regarding exposures can first be directed to the Medical Alert Center who can contact Public Health.
Cases from the Field
* An Altered Toddler: What’s The Cause — June 2020
* COVID-19: Considerations for Critical Patients –May 2020
* WIRELESS MONITORING DEVICES – IMPLICATION FOR EMS — March 2020
* LIGHTNING STRIKE — January 2020
* EPINEPHRINE IN CARDIAC ARREST — December 2019
* BRUE —October 2019
*RADIATION EXPOSURE AND CONTAMINATION — September 2019
*ANAPHYLAXIS AND ALLERGIC REACTIONS – August 2019
*EBOLA VIRUS DISEASE – July 2019
*TREAT AND REFER – June 2019
*BURNs – May 2019
*PEDIATRIC RESUSCITATION – April 2019
Check out these prior ECG cases, click HERE
Please click HERE to submit:
*Suggestions for future cases and ECGs
Marianne Gausche-Hill, MD, FACEP, FAAP
EMS Agency Medical Director
Tel: (562) 378-1600
Fax: (562) 941-2306
Nichole Bosson, MD, MPH
Assistant Medical Director
Dorothy Habrat, DO
Medical Driector, PTI
Tel: (562) 378-1570
Fax: (562) 944-6091
Denise Whitfield, MD, MBA
Medical Director, Education and Innovation