Common Sense Ebola Measures Save Lives in Africa, Teach US

Jim Kling

October 28, 2014

AUSTIN, Texas — There are things healthcare workers are doing in Africa that professionals here in the United States are not when dealing with Ebola, and that is encouraging infection, warned a physician speaking here at CHEST 2014.

Lewis Rubinson, MD, from the University of Maryland School of Medicine in Baltimore, described the setup at an Ebola treatment center in Kenema, Sierra Leone, where he worked.

Conditions at the center were chaotic and unpredictable, Dr Rubinson explained. The situation required healthcare workers to be consistent and vigilant in their approach because patients who seemed to be faring well could suddenly vomit.

Thirty healthcare workers at the site have already contracted the Ebola virus, and nearly 20 have died. Yet there are healthcare workers who have performed in these conditions and remained uninfected.

Dr Rubinson talked about professionals, including a nurse at Kenema, who remained virus-free after 6 weeks of treating patients. "They have the skills to teach you," he said.

There has been much discussion about using observers to ensure the proper donning and doffing of personal protective suits. In Africa, things have been taken a step further. "We had people who commanded you," said Dr Rubinson.

"You're tired and at risk of making mistakes, so even if you've done the process day in and day out, you're not allowed to do anything without someone ordering you where to stand, how to put your arms out," he said. "They're not passive observers," Dr Rubinson emphasized. "Someone actively takes over safety for you."

With Military Precision

This is a critical measure, Dr Rubinson said, but "that message has been lost in the United States."

"I could never predict when someone was about to vomit on me," he reflected. "You need to do procedures the same way every single time. Everything needs to be choreographed."

This discipline can be very difficult to maintain. "You can get very distracted. If you see a young kid dying, you might want to risk your safety to help, but the rest of the patients will be harmed" if you fall ill and can't contribute to their care, he pointed out.

In a separate presentation, Michael Connor Jr., MD, from Emory University School of Medicine in Atlanta, who treated Ebola patients at his hospital, suggested that the traditional ethics of the doctor–patient relationship is challenged by Ebola. This can take a terrible toll on healthcare workers.

"I will step out on a limb ethically and say it might be that healthcare worker safety supersedes patient outcome because, ultimately, we have to care for other patients, and if we can't, that's a problem," he said.

Another critical issue in the United States is identifying which patients in an emergency department setting are at high risk for Ebola. It is important to be vigilant looking for infections, but there is a risk for overexuberance. For example, a patient arriving from a country like Sierra Leone presenting with stroke symptoms could get flagged for concern about Ebola, even if that patient had no contact with anyone who was ill.

In the United States, "the hospital community, together with the public health community, has to figure out how to manage people so we don't have inadvertent injuries due to withheld treatment because we were isolating someone for Ebola," said Dr Rubinson.

Improvements to diagnostic guidelines would help, he said. The public health system is designed to rule in patients who have a specific illness like Ebola, rather than rule out patients who don't and who need to be treated for something else.

"The more important thing for American hospitals is to identify the person we don't think has Ebola and get confirmation that they don't have it," said Dr Rubinson, "so we can go back to giving them usual care."

The Quandary of Quarantines

Quarantines that have been implemented in New York and New Jersey could create more problems than they solve, said Josh Mugele, MD, from Indiana University School of Medicine in Indianapolis. "I worry that it's going to affect people's willingness to travel to Africa and take care of those patients," he told Medscape Medical News.

A quarantine could also drain resources. Any effort to quarantine doctors and nurses takes them temporarily out of circulation. "They cannot do their critical care jobs, they cannot do their emergency department jobs; it could put stress on the system," said Dr Mugele.

Influenza season could complicate efforts to identify and rule out Ebola cases because symptoms can overlap. "The fortunate thing about Ebola is that upper respiratory symptoms are not the predominant feature," said Dr Rubinson. More worrisome would be if this year's influenza epidemic has a strong gastrointestinal component. In that case, "it'll be really hard to differentiate" Ebola from influenza, he said.

It would be helpful if Ebola screening guidelines included duration of symptoms. Ebola is an acute disease with short-duration symptoms. Diarrhea or vomiting that has been happening for weeks is very unlikely to be Ebola, Dr Rubinson explained.

"The CDC guidelines get the conversation started, but they aren't constructed in a way that reflects how clinicians manage patients," he said. "We're using epidemiologic criteria to make clinical decisions. We need to modify these criteria to reflect how clinicians think, to make them useful to move someone up or down the scale in terms of the likelihood of having Ebola."

Dr Connor and Dr Rubinson have disclosed no relevant financial relationships. Dr Mugele is a consultant to the Indiana State Department of Health.

CHEST 2014: the American College of Chest Physicians Meeting: Presented October 27, 2010.

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