Monday, Nov. 2, 2009 | Got fever and a cough and think you need to go to the ER right away? From the moment you call 911 in San Diego County, the swine-flu pandemic will affect every step you take in the world of emergency medicine.

At first, paramedics won’t touch you or even come within six feet. When they do get closer, they’ll be wearing protective masks called respirators and eye shields. So will the doctors and nurses at the hospital once they realize what’s potentially wrong with you.

And that’s not all. Plenty of other changes are afoot, from the drugs that paramedics might give you to the decontamination of the ambulance after you leave. Even life in the ER waiting room is different now for sick patients suspected of having swine flu.

There’s reason for all this extra caution, which is aimed at making sure you don’t infect anyone else. Swine flu, also known as H1N1, has killed 27 local residents and hospitalized 417 people. San Diego’s death toll accounts for about three percent of the country’s deaths, even though just one percent of the nation’s population lives here.

To protect themselves, paramedics are essentially using the same precautions they would against infectious tuberculosis — something they hardly ever see, said Dr. Bruce Haynes, medical director of emergency services for San Diego County.

Of all infectious disease threats facing paramedics, he said, “H1N1 is really the biggest and most prominent.”

Here’s what will happen if you call 911 about possible flu symptoms:

The dispatcher will ask about your symptoms and warn paramedics if you seem to have a case of swine flu. There’s a good chance you do: If you’re suffering from the flu right now, it’s most likely that you’ve been infected with the virus known as H1N1 since the usual seasonal flu hasn’t arrived in force yet.

When paramedics arrive, they’ll be on guard from the moment they set eyes on you.

When responding to a call, paramedics used to “just walk right up to a patient, put their hand on their wrist, take their pulse and ask how they’re doing,” said Wayne Johnson, chief operating officer for San Diego Medical Services Enterprises, which provides ambulance service in San Diego and several other local communities.

That was before swine flu.

Now, paramedics across the county adhere to a “Six-Foot Rule” when they suspect a patient has a respiratory illness. “If you’re six feet away even without your protective equipment for a short period of time, you’re not likely to get infected,” said Haynes, the county official.

If a patient has possible flu symptoms, the paramedics put on N95 respirators. They began wearing the respirators instead of ordinary masks about a month ago. Paramedics will put on eye shields too. Many paramedics hate to wear them, and forget to put them on.

The paramedics will be watching carefully to see if you’re throwing up. If you are, they might give you a shot of a drug called Zofran or administer it through an IV. This is new: paramedics recently began using the drug to calm vomiting. That will help you and help them too: it protects paramedics from being infected by any germs you may spew out.

Then it’s off to the emergency room.

General procedures haven’t changed all that much at the ER, said Dr. Jake Jacoby, an attending physician at UCSD Medical Center’s emergency medicine department, although he is on the lookout for not-so-obvious cases of swine flu.

“The key here for me is that when I come across a case and all of a sudden I start to suspect influenza when no one else had, it’s my job to make sure the rest of my team in the emergency department masks up and gloves up,” he said.

Those masks aren’t the typical lightweight surgical type. They’re N95 respirators, the same ones the paramedics are using. They’re heavier and more difficult to breathe through than surgical masks.

Once you’re in the ER, you’re more likely to have company. Palomar Medical Center in Escondido, for example, is reporting record numbers of 220 to 240 emergency patients a day, up from the usual 180, said spokesman Andy Hoang. Many patients think they have flu symptoms.

At UCSD Medical Center, the ER is seeing about 10 to 12 cases of flu a day, which Jacoby said is unusual for this time of year. It appears that the cases are swine flu because seasonal flu hasn’t begun circulating.

If you appear to have a serious case of swine flu, you might be whisked to a special quarantine room, perhaps one in which the ventilation system is reversed: air is sucked out, not pumped in, so germs don’t spread.

The ambulance you arrived in might go into a type of quarantine too, especially if you made a mess.

Thanks to swine flu, ambulances in San Diego now undergo a routine deep-cleaning via an anti-microbial fogger, like the one you might use to kill pests in your homes. The ambulances make one or two visits a month to a fire station in the Kearny Mesa area where they are hooked up to a machine that fills them with a germ-killing fog.

“It decontaminates everything, gets into the cracks,” said Johnson of the city’s ambulance service. “It kills everything. It’s like fogging your house.”

But if someone makes a mess, the ambulance goes directly to decontamination, Johnson said.

As for you, back at the ER, it’s possible your case of suspected swine flu is mild. If so, you may be sent to the waiting room and told to wear one of those surgical masks until a doctor can see you.

At UCSD Medical Center, at least, you will follow orders regarding that mask, never mind if you feel terrible and don’t feel like it.

“You’re going to be told to wear it,” Jacoby said, “and you’ll wear it.”

Randy Dotinga is a San Diego-based freelance writer. Contact him directly at and follow him on Twitter: And set the tone of the debate with a letter to the editor.

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