The Tuesday after Easter 2003 was a typical, busy, acute admitting day until I received an unexpected phone call from a member of our emergency response team regarding the admission of a suspected severe acute respiratory syndrome (SARS) case under my care.

The patient was a Hawke’s Bay resident who had recently returned from a tour of China. She had phoned her general practitioner (GP) after becoming ill with sweats, myalgia, a severe cough, diarrhoea and a fever of 39 ºC. Both the patient and GP suspected SARS. Her GP contacted the hospital to arrange an assessment, where X-rays confirmed a patchy, peripheral, right upper-lobe consolidation consistent with an atypical pneumonia. She therefore met the World Health Organization’s (WHO) criteria for ‘Probable SARS’.

To minimise the number of staff involved in her case, the patient was isolated and cared for by a small pool of nurses. After the initial screening, as the most senior doctor responsible for her care, I performed all subsequent medical assessments, usually late in the day after other patients had been reviewed.

Her failure to respond to beta-lactam and macrolide antibiotics within 48 hours and the negative results of subsequent investigations for other causative organisms supported the diagnosis of probable SARS. Her corona virus PCR was negative, but this is the case in more than one third of SARS patients. Her condition gradually improved and once afebrile for 72 hours she was discharged. This was seven days after admission and she was sent home to convalesce in seclusion for a further 10 days. After discussion with Ministry of Health officials she was subsequently officially notified to WHO as New Zealand’s first case of ‘Probable SARS’.

What did we learn from this experience?

We were lucky to have a model patient who secluded herself at home on her return from China, rang her GP instead of visiting him, followed all instructions and did not require intensive intervention. She advised her own family not to visit and coped remarkably well with the initial isolation in hospital and the more prolonged and challenging seclusion at home, alone. An uncooperative patient or a large family demanding access would have significantly magnified problems for the clinical staff. While Medical Officers of Health have some powers to detain uncooperative, infectious patients, enforcing these powers would be problematic.

Our systems worked! As I had not taken part in the local preparations for managing SARS it was gratifying to find that the necessary systems and protocols were already in place when personally called upon to care for a SARS patient. Ongoing support from the infection control team was readily available and any outstanding or unexpected issues were promptly resolved with full management support.

The professionalism of the nurses was outstanding. All readily volunteered and were well supported by their colleagues. Each nurse was effectively in isolation with the patient for their entire shift, although they had a second adjacent isolation room that was kept free for use during their breaks. At a subsequent debrief, those involved confirmed that caring for this patient had largely been a positive experience, although the more extroverted found the social isolation from their colleagues for an entire shift somewhat challenging.

With the deaths of healthcare workers overseas so widely publicised, some staff, predominantly those not working in the isolation unit, initially expressed uncertainty regarding their responsibilities, including their ability to refuse to care. A memo promptly addressed these issues with a copy of a NZ Nurses Organisation statement quoting relevant professional bodies and legal requirements including the employer’s responsibility to provide a safe work environment.1 These clear and definitive statements were helpful for all disciplines, not just nurses. Fulfilling one’s professional obligations is easier when the necessary protocols and infection control measures are readily available and our facilities include modern negative-pressure rooms in the isolation and intensive care units. Without these facilities and support, staff caring for patients with SARS would face a challenging dilemma of balancing their professional responsibilities to patients against the risk to their health and their responsibilities to their families, colleagues and subsequent patients. Medical and radiography staff, unlike the nurses, continued to treat other patients.

SARS, a new, serious and global illness about which information is rapidly evolving, was a fitting disease to be taken up via the Internet and email. The term ‘SARS’ was first used only eight weeks before our patient’s admission. It therefore doesn’t appear in any textbooks or print journals available in our hospital library and no local doctor has experience in its management. Despite this, regular information updates were available via emailed medical newsletters,2 and an email journal alert arrived two weeks before our patient was admitted allowing access to a paper describing the clinical, laboratory and radiology findings in 138 cases.3 This was subsequently useful in determining if our patient’s findings were consistent with the suspected diagnosis. The Hong Kong Hospital Association web site provides access to invaluable, hard-earned, practical advice for coping with SARS,4 while official information is also available from the WHO and Centres for Disease Control and Prevention web sites.5,6 All of these sources of information were readily accessible from any clinical workstation within the hospital.

A good clinician–patient relationship is the cornerstone of therapy and requires effective communication and the gaining of trust. This is difficult to achieve when adhering to guidelines to minimise all non-essential patient contact and when one’s facial expressions, words and touch are hidden behind goggles, mask, headgear, gown and gloves. Overcoming some of these obstacles requires commitment and lateral thinking. Effective telecommunication links between the isolated patient and nurse and those staff outside the rooms were important. Maintaining two sets of notes and drug charts (one predominantly used by nursing staff inside the isolation room and the other outside) added to the complexity of management and the risk of inadvertent error. Isolation precautions and our strategy of avoiding exposure of junior medical staff also added to the physician’s workload during a holiday period and at a time when acute admissions are steadily rising in most hospitals. Experience from Hong Kong confirms that breaches of infection control measures are more likely if staff are rushed or overworked. It is important to monitor and, if necessary, reduce the workload of staff involved in caring for patients with SARS.

Wearing full barrier gear on a sunny Hawke’s Bay day also required dedication and stamina as this involved working in one’s own mini sauna. Glasses would steam up behind goggles eventually, compounding the difficulties of attending to patient care. Medical assessments were comparatively brief and therefore bearable, but nursing staff often spent two or more hours at each stretch coping with significant physical discomfort.

The health of all staff involved was monitored regularly, while they were working with the patient and for the 10 days following their last contact. This included taking temperatures twice daily, official daily calls by occupational health staff, and numerous informal enquiries from colleagues. It was difficult to avoid developing a hypochondriacal tendency every time a meeting room became hot and stuffy or a cough occurred. During the monitoring period one of the nurses developed a cold, which resulted in her temporary isolation at home and anxiety for her, the rest of her colleagues and hospital management until it was confirmed that this was an ordinary, coincidental illness. A certain amount of psychological robustness is desirable in all staff involved with caring for infected patients.

Public interest in SARS was high at the time and two days after her admission the media became aware of our patient. Unfortunately, the release of a tour-group photograph to the local paper and its subsequent use on television breached her privacy, causing considerable distress and compounding management of her condition. Staff had to deal with enquiries from non-existent relatives and some media representatives who stated that they would identify our patient and that we would not be able to stop them getting a photograph of her. Protecting the patient’s privacy involved shutting the curtains, aggravating the sense of isolation for her and the nurses. Coping with seclusion and recovery from a potentially fatal and infectious illness is, psychologically, challenging enough without the added stress of possibly being identified and subject to public scrutiny. The identification of the whole tour group undoubtedly added to their stress and at least one member of the public, outside of Hawke’s Bay, phoned for advice after identifying their neighbour on television. Hopefully, having got the first case under our belt, future NZ patients and their clinicians will not be confronted with such intense media interest.

The clinicians actively involved in our patient’s care were also keen to maintain their own privacy. A number of educational facilities in NZ were banning well students who had been to Asia for their holidays. None of us wanted to encounter the local schools’ attitudes towards the children of those caring for a probable SARS patient. Some family members were not initially told of our involvement and others not until the finish of our 10-day monitoring period for the sake of minimising unnecessary worry. Doctors and radiographers involved were also still working with other patients. Members of the infection control and management teams who were knowledgeable about our patient’s care and condition but not physically involved were therefore expected to liase with the media during the monitoring period.

Once the admission of a probable SARS case to the hospital became public knowledge, concern within the local community surfaced. Some patients arrived at the hospital wearing masks and others cancelled outpatient clinic appointments. Staff members were reminded not to go shopping in their uniforms while on the way home because of enquiries from strangers about their potential involvement. Hysteria was not restricted to the public; a senior medical locum also allegedly cancelled their agreement to work at the hospital for similar reasons.

At the end of the day our patient still remains a probable, but not proven, case of SARS. When a sufficiently sensitive and definitive test arrives it may show that her atypical pneumonia was not actually due to SARS and that the efforts involved in her management were possibly unnecessary. However, experience in Hong Kong, Singapore and Toronto tell us that we cannot afford to get it wrong and that we must approach all such patients as potential SARS cases till proved otherwise. Our experience in Hawke’s Bay, as in the vast majority of other countries affected, confirms that with systems in place, good screening and meticulous attention to infection control it is possible to successfully isolate and manage travellers who return with suspected or probable SARS and so avoid local outbreaks. The disease is, therefore, manageable. The consequences, medically and economically, if we were to fail and allow local spread to occur are potentially horrendous. When dealing with SARS an ounce of prevention is definitely worth a pound of cure.

Author information: John Gommans, General Physician, Hawke’s Bay Hospital, Hastings

Acknowledgments: Coping with SARS requires a team effort. Thanks are especially due to nursing and other clinical colleagues directly involved in this patient’s care and other Hawke’s Bay DHB staff, including management, who were involved in planning, preparation and support roles before and during this time. Thanks to international colleagues and journals for their willingness to freely share crucial information. We owe a huge debt to fellow health professionals throughout the world, especially those dealing with outbreaks at some personal risk and to those in the early days who paid the ultimate price. Finally, thanks to our patient for her fortitude and cooperation, which included reviewing this article.

Correspondence: Dr John Gommans, Hawke’s Bay Hospital, Private Bag 9014, Hastings. Fax: (06) 878 1319; email: john.gommans@hawkesbaydhb.govt.nz