by Aleta Smithson RN, BSN, Risk Management Consultant

Are you always going to know the answer(s) to every situation that might arise in your facility? The answer to that question is “NO”. The purpose of this article is to help you remember that there are many resources available to you in unusual situations, and in the event you might encounter one, make sure that your staff knows how and where to research for the answer(s).

Please follow along with me as I tell you a very scary, true story that happened a few months ago. This situation did not occur in Alabama, but the state will remain anonymous.

One sunny afternoon, a young mother took her two year old son outside to play in the backyard. The child immediately put on his boots that were kept on the patio outside the back door. Within a few minutes the child started shaking his foot and telling his mother that something was in his boot. The mother took the boot off and looked inside but did not see anything and put the boot back on the child. About 20 to 25 minutes later, the child kept shaking his foot and saying ouch. The mother took the boot back off the child and started shaking the boot upside down. After several hard shakes, a bat fell out of the boot onto the ground. The mother screamed and immediately called the pediatrician’s office. The nurse told this mother to take the bat and the child to the hospital’s emergency department immediately.

After arriving at the hospital’s emergency room 30 minutes later, the mother told the triage nurse what had happened and tried to give her the bat that was now in a tupperware container. The triage nurse told the mother to hold onto the bat and for them to have a seat in the waiting room. Four hours later they were called back to the treatment room and the mother told the emergency room physician the story. The ER physician examined the child’s foot and could not see any evidence of a bite mark of any kind on the child’s foot. The bat was taken to the main ER desk. The ER physician kept telling the mother that he did not know what to do and that he had never been in a situation like this before. Two hours later, after no treatment to the child, the ER physician came back in the room to tell the mother that they could go home. He had made a call to animal control and they would come get the bat and take it to the only place in that state (5 hours away) to be tested for rabies. The ER physician also told the mother not to worry, that the bat was alive, looked well and it was not foaming at the mouth or anything. He also said that they had 10 days before any kind of treatment had to be done if any to the child and the rabies test results would be back within 48 hours after the bat was tested. Discharge instructions to the mother were to call back at 1000 to check on the status of the bat.

The mother was very worried about her child and what she had been told, so when they got home (in the wee hour of the morning); she started searching on the internet for any information about bats and rabies. The more she searched, the more concerned she became, which led her to call the pediatrician’s office as soon as they opened. The mother told the nurse what the ER physician had said. The nurse said that the pediatrician was not due to be in for another hour and she would talk to him as soon as he arrived. The mother then called the ER to find out the status of the bat, as she had been instructed to. A different ER physician told the mother that the bat was still alive and doing well and that animal control had not picked the bat up yet. He also told her that he had made a few calls and found out that the bat had to be killed and placed in a special container to be driven to the place (5 hours away) to be tested, and he just hated to kill the bat. The mother was even more scared and frustrated and offered to come and kill the bat herself and drive the bat 5 hours to take it to be tested. The ER physician refused for her to do that and told her that there was plenty of time; that they had 10 days before any treatment, if any had to be started on the child.

The pediatrician called the mother as soon as he arrived at his office, after hearing the story from the nurse. He gave the mother a telephone number of the Infectious Control Clinic (located directly across the street from the Hospital Emergency Room) and instructions for her to call and tell them that her child needed to start the rabies series today. He also told her that he was not certain what to do, but that if it was his child that is what he would do.

The mother called the Clinic and was told by the receptionist that they did not have an opening for another week. The mother told her the story of the bat and what the pediatrician had told her. The receptionist asked her if the bat bit the child. The mother told her that she was not sure, but that the child had walked on the bat with it in his boot for 20 to 25 minutes. The receptionist then told the mother that she would have to get the physician to call them because they did not have an opening.

Within 10 minutes of hanging up the phone, the mother received a call from the physician at the Infectious Control Clinic. He asked the mother to tell him exactly what had happened and she did. He told her to be at the clinic at 1330 and the child would have to start the rabies series that day and explained the series in detail to her. The mother was frantic and told him that the ER physicians told her they had 10 days before anything had to be done and that she had just called the ER and found out that the bat was still sitting on the ER desk. The physician told her that the rabies series had to be started within 48 hours after exposure. He then told the mother that he would take care of getting the bat sent to be tested.

The mother took her child to the clinic as scheduled that day. The Infectious Control Physician introduced himself and explained the whole procedure to the mother. He told the mother that he was going to report the ER physicians because the clinic was part of the hospital and the clinic’s telephone numbers for 24 hour service are posted everywhere in that ER. The child was given the first rabies series, which consisted of three shots. The next rabies series was due two days later and they were given an appointment. The clinic physician told them that hopefully the test on the bat would be completed before then and if the bat did not test positive, the child would not have to have any more of the rabies series. He also told the mother that statistically, almost all unusual encounters with a bat meant that the bat had rabies.

Just before leaving to go to the clinic for the next rabies series two days later, the clinic physician called her to tell her he had just received the test results from the bat and the bat was negative for rabies. The child did not have to receive any more rabies shots.

SOME FACTS ABOUT BATS AND RABIES:

*Bat bites may be invisible to the naked eye (some bites are seen, others or not)

*Since you may not see a bat bite, ALL unusual close encounters with bats are considered “rabies exposure” (example: finding a bat where you sleep, etc)

*In most cases, rabies treatment must be started within 48 hours after exposure when there is exposure to a bat. If it is a bite from a vaccinated pet post exposure, prophylaxis will only start if the animal dies during the quarantine

*There is only one known human survivor of rabies (14 years old girl in Wisconsin lived after being bitten by a rabid bat)

Thankfully, there was a happy ending to this story. But, can you see the calamity of errors and lack of trying to find the answer(s) to this situation?

Was this situation a sentinel event (Near Miss)? I’ll let you be the judge.

By the way, did I forget to tell you that this 2 year old boy is my grandson? He is, and is doing well. I was involved in this situation from the beginning and started my own research in the wee morning hours, when it seemed to me that no one there was trying to get answers.

I would like to personally thank Dr. Mel Stephens DVM, State Public Health Veterinarian in the Alabama Department of Public Health, Zoonotic Disease Branch, who took my phone call and told me more than I ever wanted to hear about bat statistics and rabies. He told me everything that had to be done to get the bat tested and how the bat had to be killed, packaged and sent as well as my grandson having to start the rabies series that day. He also wanted me to call him back on the entire outcome.

In summary, if an unusual situation comes into your emergency room or clinic and you are not sure what to do, or do not know what to do, please make sure you do your research and make some phone calls. We will be happy to assist you in any way we can. Also, keep major websites available at computers and important phone numbers posted. The internet is a wonderful research tool if you know the correct web sites to use. Remember: Time may be critical!