“Camels & Bats & MERS Oh My” The Economist May 14, 2014 economist/node/21602198

1. “Camels & Bats & MERS Oh My”The Economist May 14, 2014www.economist.com/node/21602198 Andrea L. Williams, PhD, RN EMS Education Specialist Clinical Associate Professor UW Emergency Education Center & UW-SON

2. Recent MERS–nCoV News Reports CNN Medical Report - MERS CoV Virus Report 4-29-14 http://www.cnn.com/2014/04/29/health/mers-camels/ USA Today Report 5-17-14 http://www.usatoday.com/story/news/usanow/2014/05/17/mers-corona-virus-saudi-arabia-illinois-indiana-infection/9217731/ CNN MERS CoV Camel Report 5-3-14 http://www.cnn.com/2014/04/29/health/mers-camels

3. Saudi Arabia – To prevent Middle East Respiratory Syndrome, Saudis wear mouth and nose masks to watch camels at their farm, outside Riyadh. Photographer: Fayez Nureldine/AFP via Getty Images

4. Objectives • Understand the possible mechanisms of transmission, pathophysiology, signs & symptoms and treatment for Middle East Respiratory Syndrome • Describe precautions that need to occur for pre-hospital & hospital providers

5. Identified in September 2012 Similar to coronaviruses found in bats Isolated in camels in Qatar, Egypt and Saudi Arabia-unknown if camels are the source of the virus Human to human infection in health care workers noted Lab test for active infection and antibody test for previous infection MERS-nCoV: Mechanism of Transmission

6. MERS-nCoV Transmission • Transmitted through the air through droplets from coughing or sneezing • Transmitted through close personal contact: touching or shaking hands • Spread by touching contaminated objects or surfaces and then touching your eyes, nose, or mouth • Transmitted in the Middle East by the same mechanisms when in close contact with dromedary camels used for racing, transportation, food, and as pets. • Virus found in camel feces & urine, unpasteurized camel milk & cheese, and in camel meat • Virus found in camel feces which may be dried and used for fuel.

7. Countries in the Arabian Peninsula with Lab-Confirmed MERS Cases • Saudi Arabia • United Arab Emirates (UAE) • Qatar • Oman • Jordan • Kuwait • Yemen • Lebanon • Iran

8. Countries with Travel-Associated Cases • United Kingdom (UK) • France • Tunisia • Italy • Malaysia • Philippines • Greece • Egypt • United States of America (USA) • Netherlands ***CDC takes back report of MERS spread person to person in U.S.

9. MERS nCoV Cases and Deaths • 562 Cases of MERS CoV worldwide with 180 deaths • Recently spread to Iran • Saudi Health Minister fired after a spike in Mers CoV cases (49 new cases), in April 2014 http://www.cidrap.umn.edu/news-perspective/2014/04/two-mers-antibody-studies-may-help-quest-treatment

10. Middle East Respiratory Syndrome • Middle East Respiratory Syndrome (MERS-nCoV is caused by a novel beta coronavirus that usually causes a severe respiratory illness which has resulted in deaths in ~ 30% of individuals with confirmed infections. It is called a coronal virus because it appears to be surrounded by a crown.

11. History & Symptoms of MERS-nCoV • History of travel to Middle Eastern Countries where MERS-nCoV is prevalent • Upper Respiratory Symptoms Fever Cough Shortness of breath Hypoxemia Pneumonia • Gastrointestinal Symptoms Nausea Vomiting Diarrhea • Kidney Failure

12. Treatment • Supportive Care • No vaccine to date • Researchers have found that monoclonal antibodies - MERS-4 and MERS-27, have strong neutralizing activity against MERS-CoV.

13. Prevention While in Flying • Wash hands often • Avoid touching your face • Avoid close contact with sick people • Don’t share cups or eating utensils. • Clean and disinfect surfaces like door handles, toys, tray tops, etc. • Practice the "Canadian salute" of coughing and sneezing into your elbow.

14. Prevention in Middle East • MERS-CoV can survive for a long time in milk and suggested that consumption of unpasteruized milk, common on the Arabian Peninsula, could be a source of infection. Pasteurization kills the virus. • Don’t drink unpasteurized milk or eat unpasteurized cheese. • Camel meat should be thoroughly cooked, not eaten raw • Don’t drink camel urine (Believed to have medicinal benefits) • What should be done about camel feces dried for fuel?

15. New Prevention Guidelines Qatar June 2014 Qatari has put into effectstandards for protection of camel workers. • Frequent hand washing • Use of protective facemasks—although temperatures of up to 50°C make this almost impossible • Use of protective clothing and gloves

16. Prevention of Transmission to Healthcare Providers • Airborne Infection Isolation Room (AIIR) • Limit the number of healthcare providers present during the aerosol-generating procedures (ETT placement) to only those essential for patient care and support. • Conduct the procedures in a private room and ideally in an AIIR Gloves • Gowns • Eye protection (goggles or face shield) • Respiratory protection that is at least as protective as a fit-tested NIOSH-certified disposable N95 filtering face piece respirator. • If a respirator is unavailable, a facemask should be worn. In this situation respirators should be made available as quickly as possible • Monitor healthcare providers for 14 days after the last known contact with the sick patient. • Healthcare providers should stay home when sick!

17. Do Not Eat Anything You Cannot Positively ID “Every mushroom is edible, but some only once." • Galerina autumnalis • Brown cap, small fragile ring on the stem. The lower part of the stem is usually darker brown, sometimes with little tufts of hyphae. Above the ring the stem is usually lighter tan in color and lacks ornamentation. The gills are ~ the same color as the top of the stem and darken with age. The mushrooms are only about 2-5 cm in diameter and the stems are usually less than 2 inches (5 cm). The spore print is a rusty brown.

18. False Chanterelle • False Chanterelle, is an orange funnel-shaped mushroom which has been confused at times with the true chanterelle • Orange cap up to 8 cm across, initially convex but becoming funnel-shaped. The decurrent gill-like structures are orange, rib-like folds and forked. The orange stem is ~ 5 cm high and lacks a ring • The spore print is white.

19. Chanterelle Look-a-like Mushrooms • Jack O'lanterns grow in large groups with the stems attached. Chanterelles are usually solitary or in a small bunch with separate stems. • Jack o'lanterns are more orange, less yellow. • Chanterelles will always be near trees due as they are mycorrhizal fungi. Jack O'lanterns may appear where there are no trees.

20. False Chanterelle “Poisoning” Symptoms • Tom Volk, a leader in mycology from the University of Wisconsin, describes the False Chanterelle or Jack-o-lantern mushroom poisoning as, "Omphalotus olearius won't kill you - it will just make you wish you were dead."   Due to vomiting and diarrhea for several days after ingestion.

21. Isoxazole Derivatives Poisoning • Mushrooms - Amanita muscaria , A. pantherina , A. gemmata , A. cothurnata , A. frostiana , A. crenulata, A. strobiliformus , Tricholoma muscarium • Symptoms occur 30 minute to 2 hours after ingestion, and last for several hours.

22. Symptoms of Isoxazole Derivatives Poisoning • Nausea and vomiting are quite common, • Central nervous system effects: confusion, visual distortion, a feeling of greater strength, delusions, convulsions, drowsiness, fall asleep and can not be roused. In rare cases the coma-like state can last for more than 24 hours. • No deaths in 100 years • Spontaneously awaken

23. Case Presentation • A 24 y/o calls 911 with complaints of abdominal pain and sweating. On arrival to the scene or on arrival to your ED you find the patient to be diaphoretic, with drenching sweats, copious salivation and lacrimation, as well as crampy abdominal pain. He vomits twice and has another episode of diarrhea. Otherwise, his vital signs were stable. His pupils were measured at 3 mm bilaterally and were reactive to light. On auscultation of the lungs, there were coarse crackles up to the mid lung bilaterally. • What is your differential diagnosis? • A 32 y/o family member calls 911 after having episodes of crampy abdominal pain with diarrhea and vomiting as well as blurred vision 2 h after consuming the mushrooms. She also had profuse sweating, lacrimation, and coarse crackles

24. Inocybe species, Clitocybe dealbata - Muscarine Symptoms of Poisoning • GI Symptoms • 20 minutes to 4 hours of ingesting the mushrooms, and include nausea, vomiting, cramps, and diarrhea • Muscarine Symptoms –SLUDGE-M • Excessive salivation, sweating, tears, lactation (in pregnant women), severe vomiting and diarrhea. May be accompanied by visual disturbances, constriction of the pupils, irregular pulse, decreased blood pressure, and difficulty breathing. Death can occur from respiratory failure.

25. Treatment of Muscarine Poisoning • Supportive care • Atropine

26. 2014 Muscoda Morel Mushroom Festival • 2014 Muscoda Morel Mushroom Festival

27. Case Presentation • The Communication Center dispatches you to the home of an elderly couple (or an elderly couple arrive in the ED), who are complaining of headache, severe nausea, vomiting and diarrhea a couple of hours after eating Morel mushrooms they picked in the woods near their home.

28. Gyromitrin Poisoning Symptoms • Symptoms occur within 2 to 24 hours after eating a False Morel/Gyromitra esculenta s • Headaches • Abdominal distress • Severe diarrhea, and vomiting • In severe cases, liver and kidney damage • Red blood cell damage • Convulsions & coma can occur

29. Gyromitrin Poisoning Treatment • Supportive Care • Gastric decontamination with activated charcoal may be beneficial within a few hours of consumption. • Treat severe vomiting or diarrhea with intravenous fluids. Monitoring of methemoglobin levels, electrolytes, liver and kidney function • Dialysis • Blood transfusions for hemolysis of red blood cells • Methylene blue for methemogloinemia • Vitamine B6 Pyridoxine for neurologic symptoms • Folinic acid replacement

30. Case Presentation • You receive a 911 call or the 55 y/o female is admitted to your ED with complaints of severe abdominal pain and bloody diarrhea. They are lightheaded with dizziness. • What are your concerns? • What is your differential diagnosis?

31. Amanitas - The Death Cap & the Destroying Angel • Mushrooms : Amanita phallodies, A. ocreata, A. verna, A. bisporigera, Conocybe filaris, Galerina autumnalis, G. marginata, G. venenata, Lepiotia castanea, L. helveola, L. josserandii & close relatives. • Account for 90 percent of all poisonous mushroom cases. • Amanitas have a bulbous base • Death Cap • Caps are generally greenish in color, with a white stem and gills. • The Death Destroying Angel smells sickly sweet • White stalk and gills • Bulbous base • The cap can be pure white, or white at the edge and yellowish, pinkish, or tan at the center. • Has a partial veil, or ring (annulus) circling the upper stalk, and the gills are "free," not attached to the stalk. • The most telltale of the features is the presence of a volva, or universal veil,

32. Mechanism and Symptoms of Amanitas Poisoning • a-amanitin slowly attacks the enzyme RNA polymerase in all body cells, particularly the liver. Ultimately affects the central nervous system and kidneys. • As little as 1/3 of the cap may be eaten resulting in death

33. Stages & Symptoms of Amanita Poisoning • First stage is a latency period of 5 to 24 hours after ingestion, in which the toxins are actively destroying the victim's kidneys and liver, but the victim experiences no discomfort. There may be a feeling of unease • Second stage is a period of about 24 hours characterized by violent vomiting, bloody diarrhea (cholera-like), and severe abdominal cramps. • Third stage is a period of 24 hours during which the victim appears to recover (if hospitalized, the patient is sometimes released!) • Fourth stage is a relapse, during which kidney and liver failure often occurs, leading to death. There may be more than one relapse.

34. Amanitas Poisoning Treatment • Fluid and electrolyte replacement • Oral activated charcoal and lactulose • IV penicillin • Combined hemodialysis and hemoperfusion in two 8-hour sessions some with "IV thioctic acid, others IV silibinin • Milk thistle

35. Prevention of Mushroom Poisoning • Only eat mushrooms you have positively identified yourself. • Identify mushrooms a second time during preparation and cook them properly, unless you know that the species can be eaten raw. • Do not combine mushroom types. • Retain a sample of any mushroom you are not well-experienced with for analysis in case of poisoning. • Inform yourself about deadly mushrooms that are look-alikes of edible ones. "Deadly twins" differ regionally, so take into account regional variation. • Do not gather mushrooms that are difficult to identify, unless you have expert knowledge. • Consume only a small amount the first time

36. Mushroom Safety Tips • Be cautious with white-capped mushrooms or mushrooms with white gills; this eliminates many hard-to-identify species, including several deadly species. • Do not eat wrinkled, brain-like, or saddle-shaped mushrooms. • Beware of any mushroom with a ring on its stalk or any mushroom that grows out of a cup or has an enlarged base. • Avoid LBM's. Species of Little Brown Mushrooms can rarely be determined by non-professionals. • Avoid Boletes which have red pore mouths or which bruise blue or taste bitter. • Do not eat any puffball that is not pure white and uniform in texture inside. • Keep each species that you collect in a separate container. • Be aware that some mushrooms cause reactions when consumed with alcohol.

37. Wisconsin Creates New Crossbow Season • “With the official signature of Governor Scott Walker the dawn of a new age is finally upon Wisconsin hunters.  Once only legal for hunters age 65 or older, or those with physical disabilities preventing them from using a compound or traditional bow, crossbows will now be legal for hunters of all ages throughout the state's archery deer hunting season.”

38. Longbows, Crossbows, Composite Bows & Arrow Injuries • A Wisconsin man was injured when fired the crossbow and stuck his thumb in the path of the bow string.  In so doing, he severed part of his thumb. EMS and first responders had a difficult time locating the amputated part, which could not be attached. • Injury prevention education – Teach users to, “Never allow your fore-grip hand’s fingers or thumb to move above the barrel’s flight deck or into the bow string or cables’ release path.”

39. Types of Bows

40. Crossbow Injury

41. Case • A 16-year-old boy sustained a penetrating injury to his left wrist and hand from a broken arrow shaft. This occurred when a hollow carbon fiber arrow broke while he was attempting to shoot it from a compound bow. The shaft of the arrow, broken at its mid portion, entered the left wrist

42. Arrow Injuries

43. Treatment of Patient with Arrow Impalement • Xray • CT scan to map the track • Surgical Removal

44. Pre-hospital & Emergency Treatment of Arrow Impalement 1. Stabilize the arrow/treat as an impaled object by applying adhesive tape or another stabilizer to the base of the shaft. 2. Wrap a clean towel or gauze around the base of the shaft, and then apply direct pressure on the bleeding wound. 3. Assess for and treat airway, breathing issues and shock 4. Avoid moving or bumping the arrow during transport. 5. Provide a duplicate arrow if possible to healthcare providers. A duplicate arrow will help medical professionals determine the size and shape of the arrow and know if they have retrieved all the pieces of the arrow from the victim.

45. Pro’s and Con’s of Crossbow Hunting • Pro’s - Crossbows allow hunters to get out in the woods more often, and allow them to be more successful hunters. • Pro’s - Crossbow hunting has increased hunting license revenue and has increased the number of bow hunters. • Pro’s – Crossbows provide an effective game control management tool. • Con’s – Increased harvest of deer will decrease the numbers available for gun season. • Con’s – Bow Season may need to be shortened in the future due to increases in harvest affecting long bow hunters. • Con’s – Rifle hunters will move to crossbows shifting more hunter’s into Bow Season resulting in shortening of the season.

46. Flood Warnings are in Effect for Nearly all of the Local River Gauge Sites in Southern Wisconsin. www.youtube.com/watch?v=5ibCL6zMeOk

47. Firefighters Save 2 from Truck that Rolled into Flooded Ditch – Ashley Luthern Milwaukee Journal Sentinel June 18, 2014 • Two men were injured when their truck rolled over on Highway 41/45 on Wednesday morning and landed in a flooded ditch, the Germantown fire chief said. • "They were very lucky it didn't end up upside down because they could have drowned," Fire Chief Gary Weiss said.

48. Firefighters Save 2 from Truck that Rolled into Flooded Ditch • Firefighters had to deal with chest-high water in the ditch from heavy rainfall and crossed the ditch by laying ladders across the water to the truck.

49. Flash Flooding in Wisconsin • LAKE DELTON, Wis. — Flash floods inundated a southwest Wisconsin town Monday for the second time in 10 months, while 60 miles away an embankment along a man-made lake gave way, unleashing a powerful current that ripped homes off their foundations. • The swollen Kickapoo River engulfed nearly the entire village of Gays Mills, WI, forcing about 150 people to evacuate. The town was reduced to a grid of canals with cars submerged up to their windows and parking lots looking like lakes, just as it was last August. http://www.youtube.com/watch?v=JME8XU8rZNI

50. Flash Flood Statistics • Thousands of Wisconsinites live along rivers that are periodically swollen from melting snow or rains associated with thunderstorms • Flash flooding is the Number One killer during thunderstorms • One of the most common and widespread of all natural disasters • 84 Americans died from floods in 2013 • Six inches of fast moving water can move a vehicle & knock over an adult • Two feet of water is enough to make most cars float • At least a couple people in Wisconsin had to be saved from raging waters in April 2014 Flooding in McFarland, WI