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On March 12, 2003, Mr. N, a 75-year-old man with a history of serious illness,including a liver transplant and triple-bypass surgery, visited a foot clinic atScarborough Grace Hospital, where he contracted SARS.
These were still early days in the outbreak at the Grace, and the focus remained onMr. T, and on whether he might have tuberculosis. There was concern that somethingunusual was happening at the Grace, but as of March 12 no one realized that a newdisease, later called SARS, was in the hospital, let alone that it would spread amongpatients, visitors and staff.
Mr. N felt unwell a few days after his foot clinic visit, and was admitted to the Graceon March 22. His condition worsened and he needed intensive care the next day.
With the outbreak surging through the Grace, its ICU could take no new patients,and he was transferred to Mount Sinai’s ICU. No one knew that Mr. N had SARSand was bringing it to Sinai. He infected 13 others, including three members of hisimmediate family; a cousin; two close friends, one of whom died; his family doctor;and three nurses, two physicians and one respiratory therapist at Mount Sinai. Sixty-nine Mount Sinai staff also were quarantined, and its ICU was closed to newpatients.292 SARS claimed the life of Mr. N on April 1, 2003.
This is the story of how difficult it was to detect SARS in the early days of theoutbreak, and of the dangers posed by unrecognized patients. On two separate occa-sions, once when he was at the Grace, and a second time at Mount Sinai, expertsacting to the best of their abilities and on the basis of all that was known about SARSat the time examined Mr. N and ruled he did not have it. This does not reflect poorly 292. Mount Sinai Hospital, “Mount Sinai on the SARS Frontlines,” Summer 2003, http://www.mtsi- nai.on.ca/Publications/YHRSummer2003/GoingsOn/SARS.htm SARS Commission Final Report: Volume Two ♦ Spring of Fear on the Grace or Mount Sinai. The Grace and Mount Sinai293 did their best undertrying circumstances, and their staffs worked with courage and dedication.
In hindsight, the experts would have benefited from taking a precautionaryapproach.294 With the benefit of hindsight, the case of Mr. N points to the impor-tance in the future of employing a precautionary approach when fighting a newdisease like SARS that is not well understood, mimics the symptoms of knownillnesses and is particularly dangerous if cases are not recognized and enter the healthcare system.
293. It is worth noting the important voluntary contributions made by Mount Sinai to containing the outbreak. Some of its highly respected experts, including Dr. Donald Low and Dr. Allison McGeer,led the fight against SARS. And, at that time when Ontario’s laboratory resources were woefullyinadequate, Mount Sinai helped to fill that gap. As the Naylor Report noted: With the provincial lab overwhelmed, some hospitals sent specimens directly to the NationalMicrobiology Laboratory, bypassing the usual hierarchy of referral.
The Hospital for Sick Children, Mount Sinai, and Sunnybrook and Women’s had strong plat-forms in polymerase chain reaction technology—an elegant laboratory testing modality thatidentifies microorganisms by analyzing strands of their DNA or RNA. They became the defacto and unfunded referral centres for Toronto SARS testing.
Where there is reasonable evidence of an impending threat to public health, it is inappropriateto require proof of causation beyond a reasonable doubt before taking steps to avert the threat.
As an editorial in the American Journal of Public Health in May 1984 put it: The incomplete state of our knowledge must not serve as an excuse for failure to takeprudent action. Public health has never clung to the principle that complete knowledgeabout a potential health hazard is a pre-requisite for action. Quite the contrary, the histor-ical record shows that public health’s finest hours often occurred when vigorous preventa-tive action preceded the crossing of every scientific “t” and the dotting of everyepidemiological “i”.
Address by the Honourable Horace Krever, International Joint Commission, Great Lakes ScienceAdvisory Board Workshop, Methodologies for Community Health Assessment in Areas ofConcern, Windsor, October 4, 2000.
SARS Commission Final Report: Volume Two ♦ Spring of Fear On Wednesday, March 19, 2003, one week after visiting the foot clinic, Mr. N beganto develop what physicians thought was community-acquired pneumonia.295 Thenext day he visited his family doctor. The physician looked for signs of fever or respi-ratory symptoms, but didn’t find any. Mr. N had other underlying health problemswhich, at that time, were the focus of attention.
In the next few days, Mr. N got sicker. A cousin who visited him on the evening ofFriday, March 21 recalled that Mr. N was quite ill and had a high fever. The cousinlater became ill with SARS.
By Saturday morning, March 22nd, Mr. N’s condition had worsened. His familydoctor visited him at home, found that his health had declined considerably, andarranged for him to be admitted to the Grace. The following week, the family doctorfelt ill and was eventually diagnosed as a suspect case.
On Sunday, March 23, 2003, Mr. N’s condition continued to deteriorate. A familymember recalled that he was very ill: When I went in to see him on Sunday morning, it was like he was a differentperson. He could not breathe: the nurse said that he had a very bad night.
As Mr. N became more gravely ill, doctors at the Grace decided he needed intensivecare. The Grace intensive care unit was closed to new patients, so Mr. N would haveto be transferred elsewhere.
CritiCall, the provincial agency that manages patient transfers,296 was contacted and 295. “Community-Acquired Pneumonia: Pneumonia caused by any organism found regularly outside the hospital; common organisms include Streptococcus pneumoniae, Haemophilus influenzae, andMycoplasma, as opposed to hospital-acquired or nosocomical pneumonia.” Stedman’s MedicalDictionary, 28th ed. http://www.drugs.com/medical_dictionary.html 296. “CritiCall is a 24-hour-a-day emergency referral service for physicians across the province of Ontario. CritiCall links hospitals and medical resources throughout Ontario, to provide strategichealthcare communications solutions anywhere, any time they’re needed . As a key provincialmedical resource, CritiCall is a fast, efficient, and reliable tool for healthcare providers. We: Provideeffective and efficient resources for all levels of care; Promote accessibility for a greater number ofpeople, at reduced cost; Offer physicians increased efficiency of time-management; Allow govern-ments to increase network efficiency; Provide enhanced disaster planning capabilities; Improvecommunications among emergency services and ambulances and between hospitals.” Source:https://www.criticall.com/info/Default.shtml.
SARS Commission Final Report: Volume Two ♦ Spring of Fear found an available bed at Mount Sinai’s ICU. It put Mount Sinai’s ICU into contactwith the sending physician at the Grace. CritiCall also advised Mount Sinai of theSARS outbreak at the Grace.297 Also at this time, infectious disease experts fromMount Sinai were at the Scarborough Grace Hospital helping with the investigationand response.
Because Mr. N came from the Grace, nurses at Mount Sinai were concerned hemight have SARS.
One nurse who contracted SARS from Mr. N said: We were concerned that the patient had pneumonia and it was consideredatypical community-acquired pneumonia. We were concerned that comingfrom a quarantine hospital, that even if he didn’t have exposure, shouldn’twe still maintain respiratory isolation and quarantine for him . . .
Before accepting Mr. N, Mount Sinai wanted to make sure he did not have SARS,and contacted the sending physician at the Grace, who said: … I remember getting a call back from him [the admitting physician atMount Sinai] saying, You know, we really need someone else to look atthis case.
One continuing problem during the outbreak was determining whether a patient hadSARS or another disease with similar symptoms. Clinicians relied on the case defi-nition, which, at this time, equired an epidemiological link, or epilink as it’s oftencalled, to reach a diagnosis. An epilink provided sufficient evidence of a cause-and-effect connection between a person with SARS symptoms and someone who might 297. An external review by infection control practitioner Carol Goldman, commissioned by Mount Sinai to examine how it handled the case, said: CritiCall called the MSH, ICU attending staff MD to request a transfer of a patient fromSGH to MSH-ICU because of deteriorating respiratory status • CritiCall call taker made specific mention of SARS cases and the investigation occur- ring at SGH and the fact that the ICU was closed (necessitating transfer of patient) SARS Commission Final Report: Volume Two ♦ Spring of Fear have infected them. Alternatively, it might provide sufficient evidence of a directconnection between a person with SARS symptoms and a jurisdiction or locationwhere there were confirmed cases of SARS transmission.
Two physicians who treated SARS patients wrote: While the various case definitions caused some degree of confusion inthe organizational response to SARS, front-line clinicians made thediagnosis of SARS based on the presence of three factors: fever, respira-tory symptoms, and an epidemiologic link to someone else with SARS.
The epidemiologic link was clearly the most important criteria andextensive public health resources were devoted to tracking down casecontacts.
The epilink was often difficult to identify.
We used the epilink. The problem was that, as the disease spreadthroughout Toronto, sometimes that epilink was not evident. It was onlyevident in hindsight when you pulled the story together. So if a personcame into your emergency room complaining of fever or a headache or amuscle ache or a bit of a cough, but had no link whatsoever to SARS thatyou could discern, you sent that person home. In actual fact, that personmay have happened to be sitting in the waiting room of a doctor’s officenext to a person who had SARS.298 The sending physician at the Grace asked an infection control expert from MountSinai who was at the Grace helping contain its outbreak to examine Mr. N. Noevidence of an epilink was found. This was a critical element in concluding that Mr.
N did not have SARS.
A study into the case of Mr. N published by the CDC said: Before transfer, SARS was excluded from the differential diagnosisbecause the patient had not traveled, had never left the emergency 298. Interview with Dr. Donald Low in Biosecurity and Bioterrorism: Biodefense Strategy, Practice, SARS Commission Final Report: Volume Two ♦ Spring of Fear department of the referring hospital, and had only had a single recentoutpatient visit to an area of the original hospital in which SARS had notbeen identified.299 An external review300 commissioned by Mount Sinai to examine how it handled thecase of Mr. N summarized the measures taken to rule out SARS before Mr. N wastransferred from the Grace: • Discussion between sending and receiving medical staff about epidemiological links to SARS-MSH was advised no contact to SARSat SGH • Transfer was held until MSH could confer with MSH infection control personnel (who coincidentally were consulting infection controlat SGH and intimately involved in the ongoing investigation) and whoconfirmed that there appeared to be no link301 On March 23rd, the third-floor foot clinic that Mr. N had visited on March 12 wasnot considered an epilink. This would change soon afterwards, as the sending physi-cian at Scarborough Grace Hospital told the SARS Commission: We were being careful. We knew about the chiropody clinic. But we didnot see how that was the link because I don’t believe the 3D staff startedgetting sick until a day or two later. Had he shown up one day later, OK,chiropody, 3D [CCU], it’s close enough, and so we couldn’t see theconnection. And we didn’t know about [Mr. H] at that point. We had todig out this information. Had we gotten the call that [Mr. H] was ill, hecame from the Grace, then we would have said 3D CCU you are a prob-lem now. It would have been raised to a level that we would have saidthere is an epi-link somewhere in here, we’ll find it… Had we gotten that 299. Scales, Green, Chan et al. Illness in intensive-care staff after brief exposure to severe acute respira- tory syndrome. Emerging Infectious Diseases 19,no. 10 (October 2003). http://www.cdc.gov/ncidod/EID/vol9no10/03-03-0525.htm. (Scales, Green, Chan et al., “Illness in intensive-care staff ”).
300. In the aftermath of SARS, Mount Sinai commissioned Carol Goldman, an infection control prac- titioner to review the hospital’s handling of this case. The Commission is grateful that Mount Sinaigenerously shared this frank and insightful document.
301. Carol Goldman, “Infection Control, Critical Review Mount Sinai Hospital ICU,” November 6, 2003 (Goldman, “Infection Control”).
SARS Commission Final Report: Volume Two ♦ Spring of Fear call [about Mr. H] the minute they knew about it, Mr. N would not havegotten to Mount Sinai or would have gone under certain circumstances,special care.
The external review said that those who concluded that Mr. N did not have SARSdid the best they could under the circumstances: The knowledge of the outbreak was known, and it seems that prudentsteps were taken to determine if SARS was a diagnosis to consider.
Attending staff in the ICU made careful inquiries from both [the Grace]critical care staff and those infection control/epidemiology personnelconducting the investigation. Based on their conclusions that noepidemiological link existed between this patient and any SARS patientat [the Grace], it was determined that this patient had [community-acquired pneumonia] not SARS, and isolation precautions were not indi-cated. I believe that at the time this would have been the only conclusionto make.302 Mr. N was admitted at Mount Sinai at 8:18 p.m. and was placed in ICU room1803.303 When he was wheeled into the ICU, he was placed next to where a nursewas sitting. Her face was on the same level as Mr. N’s. She later came down withSARS.
When the patient first came in I had the patient adjacent to the room …the patient arrived by ambulance without warning onto the unit so wedidn’t have a chance to mask.
And the patient actually came in, was kind of wheeled in, like level to me,and I can basically turn around and there he was. I had no mask on. I hadno idea at what time the patient was actually going to be arriving.
302. Goldman, “Infection Control.”303. Goldman, “Infection Control.” SARS Commission Final Report: Volume Two ♦ Spring of Fear So I didn’t have a chance to prepare. And neither did any of the otherpeople on the unit .
This nurse was not on duty during the balance of Mr. N’s stay at Mount Sinai, andhad no further exposure to him.
And I didn’t have any mask, I didn’t have any gloves. So I don’t reallyknow for sure when exactly I contracted the virus. But that was mybiggest, my most vulnerable time was at that time. Other times I hadmask, gown and gloves when I was in the room.
The next day concern returned that Mr. N might have SARS. A medical article said: After about 14 hours in the ICU, clinical suspicion of SARS resulted inthe use of isolation precautions.304 Because of the growing unease, experts from the infectious disease departmentreviewed the diagnosis of SARS, and Scarborough Grace Hospital was called todetermine Mr. N’s appointments prior to his getting ill and try to identify anyepilinks.
According to the external review, the experts from the infectious disease departmentconcluded: • That no epidemiological link occurred with SARS cases at SGH, but recommended that confirmation should be made by interview withwife to confirm that patient did not visit ER between March 7-14 • Agrees with Dx [diagnosis] of CAP [community acquired pneumonia] 304. Robert Maunder, Jonathan Hunter, Leslie Vincent et al. “The immediate psychological and occu- pational impact of the 2003 SARS outbreak in a teaching hospital.” Canadian Medical AssociationJournal, April 16, 2003. www.cmaj.ca on Apr. 16, 2003 305. Carol Goldman, “Infection Control.” SARS Commission Final Report: Volume Two ♦ Spring of Fear Mr. N’s condition deteriorated during the course of March 24th. One of the physi-cians who treated him said: … his respiratory status was progressively getting worse.
A nurse who had looked after Mr. N on the night of the 23rd recalled: Next night [I] came in looking at him and thinking this patient is verysick. Went into room, he looked very, very ill. I thought, this fellow needsto be intubated.
By the evening of March 24th his breathing had become so laboured that doctorsdecided he needed to be intubated, a procedure in which a tube is placed into thewindpipe, “to open the airway to administer oxygen, medication, or anesthesia.”306 About one-quarter of SARS patients had to be intubated. Intubations of SARSpatients were inherently risky because the procedure could aerosolize the patient’srespiratory secretions, thereby creating tiny droplets of moisture that can carrymicroorganisms.307 As noted earlier, on March 17th four health workers at the Grace who had intubatedan unidentified SARS patient contracted the disease. No directives had been issuedafter the Scarborough Grace intubation by the Provincial Operations Centre alertingstaff to the dangers of this procedure.
However, the risk of intubating SARS patients did not go unnoticed at the CDC. OnMarch 20th, four days before Mr. N’s intubation, it issued the following warning: Procedures that induce coughing can increase the likelihood of droplet 306. “An endotracheal intubation places a tube into the windpipe (trachea). This is done to open the airway to administer oxygen, medication, or anesthesia. It may also be done to remove blockages orto view the interior walls.” Source: Medline Plus Encyclopedia, a service of the U.S. National Libraryof Medicine and the U.S. National Institutes of Health.
307. “The process of creating very small droplets of moisture (droplet nuclei) that may carry microorgan- isms. The aerosolized droplets can be light enough to remain suspended in the air for short periodsof time and facilitate inhalation of the microorganisms.” MOHLTC, “Final Report of the InfectionControl Standards Task Force: Non-Acute Institutional Settings,” March 2004, p. 6 SARS Commission Final Report: Volume Two ♦ Spring of Fear nuclei being expelled into the air. These potentially aerosol-generatingprocedures include aerosolized medication treatments (e.g., albuterol),diagnostic sputum induction, bronchoscopy, airway suctioning, andendotracheal intubation. For this reason, healthcare personnel shouldensure that patients have been evaluated for SARS before initiation ofaerosol-generating procedures. Evaluation for SARS should be based onthe most recent case definition for SARS.308 Even if the CDC’s warning had been distributed to staff at Mount Sinai, it is notcertain this would have made a difference. The health workers who intubated Mr. Nat Mount Sinai did not think he had SARS. The CDC warning was based on recog-nizing SARS.
Late on the evening of March 24, 2003, a resident attempted to intubate Mr. N, butwas unable to do so.
I knew beforehand going in it would be very difficult and it was. So atthat point, I knew I had to ask for help and I called an anesthetist in tohelp me. So a staff anesthetist and an anesthesia resident came up toassist me in securing the patient’s airway.
The staff anesthetist was worried Mr. N might have SARS. He was told the infec-tious diseases consultation earlier that day had ruled out SARS.
Even at that time, though, we did not think this patient had SARS.
That’s the thing actually. Even at that point, it was believed that he was apatient severely immunocompromised and just crashing with a commu-nity-acquired pneumonia. Even in my mind I remember and that, notclicking in that this patient truly had SARS.
308. CDC, “Infection control precautions for aerosol-generating procedures on patients who have Suspected Severe Acute Respiratory Syndrome (SARS),” March 20, 2003, 7:00 PM EST SARS Commission Final Report: Volume Two ♦ Spring of Fear The resident said that it’s not unusual for severely ill elderly patients to get as sick asMr. N was that night: And was there any suspicion, did you have any suspi-cion that maybe he had SARS? He was an elderly patient and patients dealing with acommunity-acquired pneumonia can get very sick andthat was my impression.
Five health workers were in the room during the intubation: the anesthetist, themedical resident, a postgraduate medical trainee, a nurse and a respiratory therapist.
The anesthetist, the medical resident and the nurse got SARS. The anesthetist andthe nurse wore gowns, gloves and surgical masks. The medical resident wore a gown,gloves and an N95 respirator, although he had not been fit-tested or trained in its use.
. . . the patient’s respiratory secretions were splashed onto the uncoveredcheek of one of the healthcare workers.309 I remember at one time I got sprayed with secretions.
One health worker who got SARS said his face was very close to Mr. N’s during theprocedure: The patient was breathing, almost into my face. I was wearing the facemask, but I did not have goggles … this patient was in respiratorydistress… and my face is not too far away from his, trying to put in abreathing tube.
309. Scales, Green, Chan et al. “Illness in intensive-care staff ”.
SARS Commission Final Report: Volume Two ♦ Spring of Fear Five of the six health workers who caught SARS at Mount Sinai, including the threewho were in the room when Mr. N was intubated, had direct contact with him. Thesixth health worker, however, was on the same floor as Mr. N but does not appear tohave gone anywhere near either him or an earlier SARS patient who was admitted toMount Sinai on March 13.
And there was another nurse. She didn’t have any contact with thepatient, she was on the other side of the unit. She didn’t have any contact,direct contact, with either of the patients. We still don’t know how shegot it.
While no one knows for certain how this nurse got SARS, a medical study noted apossible link between this nurse and one of the physicians involved in intubating Mr. N.
SARS developed in one quarantined health care worker (a nurse) whohad not entered the index patient’s room; the disease did not occur in anyother healthcare workers who had not touched or had close contact withthe index patient. The nurse was present in the ICU for 18.75 h (twoshifts) during the patient’s admission. Of note, after the endotrachealintubation of the index patient, the physician who performed this proce-dure entered the room where the nurse was caring for another patient.
Neither the nurse nor the physician recalled direct contact, and they werecertain that the physician had changed gloves and gown before roomentry. This nurse had no other epidemiologic risk to explain the develop-ment of SARS.310 The study also suggested a number of possible transmission routes, including airbornetransmission: 310. Scales, Green, Chan et al. “Illness in intensive-care staff ”.
SARS Commission Final Report: Volume Two ♦ Spring of Fear In the second case, transmission could have occurred in a number ofpossible routes. The nurse may have come within sufficient range of theSARS patient to be exposed to large droplets. Recent reports indicatethat the virus may survive for several hours on fomites or in body secre-tions (12) and raise the possibility of transmission by indirect contactwith contaminated objects or of inadvertent carriage and spread byanother healthcare worker. Fecal transmission is unlikely as the patientdid not have a bowel movement during his stay. True airborne spread mayalso have occurred. Although evidence does not support this route oftransmission for the SARS-associated coronavirus, existing literaturesuggests that other coronaviruses may be spread by an airborne route incertain circumstances.311 Mr. N Is Transferred to Toronto General Hospital After the intubation, the nurses attended to Mr. N. One nurse told the Commission: … he was very, very nice. He helped us turn and he was very good. So Isuctioned his mouth. I remember doing all that. Cleaned him. Wecleaned his sheets because it’s very messy after an intubation.
Late in the evening of March 24th, the possibility again arose that Mr. N might haveSARS, and he was transferred to nearby Toronto General Hospital at about 4:30 a.m.
on March 25. According to the external review, Mr. N’s chart said he was transferredbecause “SARS precautions requiring.”312 2358hrs – waiting for transfer to a more secure isolation facility as SARSis being considered because of patient’s contact at SGH.313 The decision to transfer Mr. N appears to have been prompted by the rising numberof SARS cases at the Grace. The external review said: 311. Scales, Green, Chan et al. “Illness in intensive-care staff ”.
312. Goldman, “Infection Control.”313. Goldman, “Infection Control.” SARS Commission Final Report: Volume Two ♦ Spring of Fear Now infection control is concerned about the increasing number ofpeople developing SARS at [the Grace] and therefore the decision ismade to increase the management of the patient to full isolation withnegative pressure isolation room.314 One senior hospital official told the Commission the suspicion that Mr. N mighthave SARS increased after the intubation: And there was no suspicion at the time he was intubated that he couldhave SARS. It was felt that he was compromised because of his trans-plant, and the reason he had pneumonia was, he was a very severelycompromised patient.
Endotracheal intubation required fiber-optic placement. That the extentof the outbreak at the referring institution was larger than originallyappreciated became apparent at this time; therefore, the patient wastransferred to another facility for placement in negative pressure isolationfor possible exposure to SARS.315 On the morning of March 25, after Mr. N was transferred to Toronto General, someof the Sunny brook nurses who cared for him had a sense of foreboding. One nursewas so concerned that before going home she called her husband to take specialprecautions and make sure their children did not come near her: So I told everybody, you bet, you watch, we’re going to be quarantined.
And I remember calling my husband in the wee hours of the morning tosay, please have the kids out of the house; I don’t want you near mebecause when I come home, I’m just going to take my clothes off, throwthem out and shower because I think I’ve been exposed to SARS. And Ihad concerns for my family because I thought, I’ve been in there, cleanedhim up after intubation.
314. Goldman, “Infection Control.”315. Scales, Green, Chan et al. “Illness in intensive-care staff.” SARS Commission Final Report: Volume Two ♦ Spring of Fear So when I came home, I sterilized myself in hot water and walkedaround the neighbourhood to clean out my lungs. I remember going for awalk for hours and hours, just trying to breathe in air … because I wasafraid.
Another nurse who attended Mr. N the night of March 24and got SARS said she alsohad a bad feeling. “It played on my mind,” she recalled. After an overnight shift, sheoften looked in on her elderly parents before going home. She called her father andsaid, “I have a bad feeling.” She decided not to visit with them that day and wentdirectly home. As we see time and again throughout the story of SARS, the intuitionof front line staff proved to be right. In this case, the fears of the staff at Mount Sinaiwere realized, when they later learned that Mr. N had SARS.
One day later, on Wednesday, March 26, 2003, Mount Sinai told staff in a bulletinthat an unidentified patient was under investigation as a possible SARS patient: Today we have identified that a patient who was transferred fromScarborough Grace to our ICU late Sunday evening March 23 andsubsequently transferred out of MSH in the early morning of TuesdayMarch 25 is under investigation for possible exposure to SARS.316 … the next day, the head of our ICU was quite concerned about the factthat someone was transferred from a hospital where all this was going on.
We had a meeting with our senior administrators the next day and it wasdecided that we had to treat him as if he had SARS and we decided tosend him about 75 health care workers who may have had contact withhim in the ICU during those 31 hours so maybe that was Tuesday morn-ing and 4 days later we admitted about 7 health care workers with fevers.
Once the risk for SARS was identified, all patients in the ICU wereconsidered to have been potentially exposed. To prevent spread of SARS,we closed the ICU to admissions and discharges and implemented strict 316. Mount Sinai Hospital, “SARS Update,” March 26, 2003.
SARS Commission Final Report: Volume Two ♦ Spring of Fear respiratory and contact precautions for all remaining patients. We quar-antined 69 healthcare workers who were considered to be at high risk fordeveloping SARS.
On the basis of our understanding of disease transmission, we arbitrarilydecided that persons at high risk included anyone who had entered theindex patient’s room or who had been in the ICU for >4 hours during thepatient’s 30.75-h stay.317 The case of Mr. N caused Mount Sinai to institute a number of other measures,including closing its ICU and cancelling most surgical procedures.
It is important to distinguish between systemic flaws and the skill and dedication ofthose who worked within a health system fettered by those flaws. In examining thecase of Mr. N, the external review concluded: The old adage that hindsight is 20/20 must be made in this case.318 The experts who examined Mr. N and ruled out SARS on two separate occasionsacted in good faith on the best information then available according to the standardsthat prevailed at the time. They did their best under difficult circumstances.
With the benefit of hindsight, the story of Mr. N points to the importance of theprecautionary principle as a lesson for the future, particularly if faced with a new,little-known disease that is so problematic in its diagnosis. It illustrates that theprecautionary principle was not as sufficiently integrated into the system thatresponded to SARS in Ontario as it was in Vancouver, and it demonstrates the conse-quences of this systemic flaw.
It also shows the importance for the future of employing a precautionary approachwhen fighting a new disease like SARS that is not well understood, shares the symp-toms of known illnesses, and is very dangerous if cases are not recognized and enterthe health care system.
It is better to be safe than sorry. Action to reduce risk should not await scientificcertainty.
317. Scales, Green, Chan et al. “Illness in intensive-care staff.”318. Goldman, “Infection Control.”

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