Ms. P, aged 29 years, was a newly graduated nurse practitioner when she took her first job in a rural primary health clinic on federal land. The clinic was located in the same building as the area’s only hospital, emergency department, and long-term nursing facility.
Ms. P began working there in early spring, and shortly thereafter, it was anticipated by health authorities that the following winter would bring a potentially serious H1N1 flu epidemic. To address this potential threat, a task force was formed, including representatives from the clinic, the hospital and other local agencies.
One of the task force’s primary concerns was to protect the fragile patient population in the nursing facility. By late spring, the task force had come up with a protocol for how to deal with area residents who were experiencing flu symptoms. Signs that read, “STOP: If you have any flu symptoms, DO NOT ENTER the building! Go home and call XXX-XXXX,” were posted on the clinic door and around the building. Calling the number would connect the caller to a recorded message that advised those with symptoms of H1N1 flu virus on what to do.
In particular, the recorded message stated: “…if the sick person has a temperature of 100 degrees and other flu symptoms, you should call our clinic. DO NOT GO there… Please call first. They will then advise you what the next step should be.” The message continued, “When should you seek emergency medical care? Like going to the ER? You should seek medical care right away if the sick person at home has difficulty breathing or chest pain; has signs of dehydration such as dizziness when standing, absence of urination, or in infants, a lack of tears when they cry; is less responsive than normal.”
The message also provided advice as to where to obtain further information (a Centers for Disease Control and Prevention website) and concluded “… if you or your loved one have any of the serious symptoms described, or just cannot figure out what the best thing is to do… then, and only then… call the clinic’s hotline at XXX-XXXX.”
Ms. P was one of the clinicians assigned to handle the hotline calls and she was instructed to ask patients about their symptoms, and specifically, if they were experiencing chest pain and breathing problems, shortness of breath, dehydration, fever for more than 5 days, dizziness or fainting spells, and difficulty eating. In particular, the task force was most concerned about chest pain and shortness of breath, which could be red flags indicating pneumonia, rather than flu.
One Friday, Mrs. O, aged 52 years, who ran a childcare center in the town, began feeling tired and worn out, but she assumed it was due to a hard week. The next day, she was feverish, dizzy, and vomiting. She took Tylenol for the fever but could not keep down any liquids. She assumed she had caught something from one of the children with whom she worked—a common hazard of her job. On Sunday, Mrs. O felt ill and achy and could not get out of bed. The Tylenol did not seem to be helping, and her temperature was 104 degrees. Still, neither she, nor her husband or adult daughter, called the clinic or the hospital. Monday came, and Mrs. O still felt unwell and was experiencing chest pain. On Tuesday, still feeling terrible, and short of breath, Mrs. O asked her daughter to call the clinic. Ms. P answered the call.