On the Front Lines of Bioterrorism

IT'S an ordinary day at the hospital where you work as a nurse. You've seen fairly run-of-the mill cases: colds, a minor bronchial infection, and two people with the flu. A patient checks in with a fever, body aches, nausea, and chills, as well as a rash consisting of dense, firm lesions. Suspecting chickenpox, you don't overly concern yourself with donning personal protective equipment because you had chickenpox as a child. After taking the patient's history and vital signs, you leave him waiting for the doctor, who also suspects chickenpox. The patient is released with some Ibuprofen and an antihistamine.

A few days later, you learn this patient has died. The local Health Department is notified and discovers that smallpox, not chickenpox, was the cause of death. Meanwhile, others are showing up at your hospital with identical symptoms to the victim's; his death has sparked an immediate, worldwide bioterrorism alert. Your community is in an uproar, and because you didn't wear appropriate PPE or isolate the victim, you have exposed yourself, as well as other health care workers, to the deadly virus. But how were you to know? Why would you have suspected smallpox on such an ordinary day?

To help prevent scenarios such as this from happening, the Institute for Biosecurity within the Saint Louis University School of Public Health recently released a "Bioterrorism Preparedness for Nurses" CD-ROM training program. Terri Rebmann, a registered nurse and the infectious disease specialist for the institute, said the new program helps compensate for what has been an abysmal lack of training resources specific to the nursing profession. "We found that nurses really don't have a lot of bioterrorism education being offered to them, and what is being offered is almost exclusively based on the medical mode: Here's how you diagnose smallpox, here's how you diagnose anthrax. Well, that's not really the best approach to take," said Rebmann.

That's why the training program, which she helped to create, focuses on how to manage exposures to infectious diseases--but from a nurse's perspective, not a doctor's. Nurses need to be able to identify (but not necessarily diagnose) an infectious disease so they can better protect themselves and other people exposed to the patient. This would involve choosing the correct PPE, isolating the patient, and knowing whom to call next should there be a real bioterrorism event.

The CD emphasizes that nurses need to be aware of their critical role in the emergency management cycle of a potential bioterrorism attack, a threat that has loomed ever larger because of the post-9/11 anthrax scare and the more recent SARS outbreaks. In a bioterrorism situation, nurses and other health care workers will become first responders: They will be the first people exposed to the victims and making immediate life-and-death decisions, often without knowing the exact nature of the infectious disease they are dealing with. "As a nurse," said Rebmann, "you're faced with these patients and trying to decide how you're going to take care of them and, potentially, their family members and anyone else who has been exposed. So it's really the public health community there on the front lines forced to take some kind of action before they really know what's going on."

The lecture portion of the training program features video clips that depict improper and proper treatment of PPE and other protective measures such as hand washing--procedures that might be taken for granted in everyday circumstances when the threat of bioterrorism or infectious disease is not considered imminent. The clips stress that the order in which these procedures are carried out is crucial in preventing the spread of contamination, but unfortunately it is often commonly overlooked. Washing your hands after examining a patient is completely nullified if done before removing a mask or gown. According to the CD, it took only one health care worker's improper removal of PPE to spread SARS to a number of individuals in a Canadian health care network in 2003.

The program features three main components: a lecture, interactive training modules, and an extensive reference and resource section. In addition, nurses can obtain a certificate of completion or continuing education credit by taking pre- and post- tests, which are sent to the institute and scored. The actual training content of the CD lasts approximately two hours, though it is divided into smaller sections of 10 to 20 minutes each, indicated in parentheses to the side of a section's title. This allows a user to know the length of a particular segment before watching it, a convenient feature for busy nursing professionals. The program's script is included on the CD so someone can give a live training presentation to a group.

Watching the CD does not, of course, guarantee you'll be steadfastly vigilant for bioterrorism attacks if nothing has been reported to the authorities. "If you don't expect it to occur, you're not going to be looking for it," Rebmann said, but she emphasized the training seeks to heighten a nurse's personal risk perception, as well as his or her ability to identify the signs of a bioterrorism event. The hope is that a nurse who has participated in this training will be able to see a smallpox rash or symptoms of anthrax and be suspicious, even on an ordinary day.

For information about "Bioterrorism Preparedness for Nurses," call 314-977-8257 or visit www.bioterrorism.slu.edu.

This article originally appeared in the July 2005 issue of Occupational Health & Safety.

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