The Widdershins

Archive for October 9th, 2014

Good Thursday, Widdershins.  Welcome to the big, wide, wonderful world of Level 4 pathogens.

Ebola is not new – the first cases were described in 1976.  June of 1976 brought an epidemic in the Sudan;, then another erupted in August in Zaire, which is now known as the Democratic Republic of the Congo.  The Ebola virus is named according to various sites where the various epidemics began.  The Ebola River contributed the name of the virus, then Bundibugyo (BDBV), Tai Forest (TAVF), Sudan (SUDV), Reston (RESTV), and Zaire (EBOV) lent their name to the five known types.  All but the Reston can infect humans with varying degrees of severity. Ebola Zaire is the worst of them, and sadly is also the one currently running rampant in West Africa.

EBOV has the highest mortality rate, averaging 80-90% in previous epidemics.  Since many of these episodes occurred in less than desirable medical settings, I cannot help but believe that a more controlled environment would have better results.  Nigeria has eradicated the problem by using barrier nursing and proper burial techniques.

Please understand that EBOV is spread through contact with body fluids from an actively infected person.  Body fluids include urine, feces, blood, saliva, and stomach contents.  In an abundance of caution, many also include sweat and tears in this list.  Essentially, EBOV is spread the same way as AIDS and Hepatitis, but there is a much shorter period before the disease becomes apparent, and a much smaller window of opportunity for treatment.  You will not get Ebola because you sat next to someone whose cousin’s next-door neighbor’s best friend sat three rows behind a person who later developed Ebola,  (Don’t laugh.  I used to get calls at the hospital of a similar stripe whenever meningitis came to town.)

So here we find ourselves with the index case having already died, and a contact en route to the hospital with some early symptoms.  Clearly, the home team fumbled the kick off and need to regroup.  As a nurse who spent twenty or so years at triage, I am still shaking me head over the first ER visit, when Thomas Eric Duncan spoke to the triage nurse at Dallas Presbyterian.  The nurse apparently documented that he had a history of foreign travel, sent the chart and the patient back for treatment, and things went downhill thereafter.  Now, the earliest symptoms of EBOV are generic – fever, abdominal pain, general malaise – and could be a zillion other things, but Mr. Duncan’s point of departure was a really big red flag that somehow got missed.  Of course, the hospital initially blamed the nurse (it’s always either the bloody nurse or the will of God), then made the horrifying discovery that she had documented appropriately.  Then it was the fault of the EMR that the screen did not interface with the physician’s, then it was something else.  Of course, I have to ask myself why the nurse never followed up on this.  I can absolutely promise you that if I thought I had triaged an Ebola patient, I would have been on that phone asking questions at regular intervals.

It all goes downhill from there.  Mr. Duncan’s poor family needed intercession from CDC and PHD to get him re-admitted to the hospital, at which time they found themselves trapped in an apartment full of contaminated linens, towels, floors and the like without the supplies to clean it up.  Of course, that would presume that they had the knowledge base to knew how to do a terminal disinfection.  We don’t think that the virus lives all that long outside of a host, but it can’t be terribly pleasant.

Nursing staffs should know how to care for an Ebola patient, as they are taught from the time that they are students how to maintain Secretion Precautions.  We cover our hair, wear long disposable gowns with snug cuffs, double gloves and a mask.  In these cases, a mask with an eyeshield would be even better, as eye splashes are a nasty way to transmit pathogens.  What nurses are currently objecting to – and most strenuously – is that they see staff members at Emory as well as decontamination techs suited up like a casting call for Ghostbusters while someone hands them a paper gown and a box of gloves. I can’t blame them one bit.  Someone is going to have to pony up the funds for top quality gear, or we will have few nurses. There’s already a shortage, so if we make them sick/kill them off/scare them away, it will be really counterproductive.  A police sergeant who never touched anything while delivering an order of quarantine has developed some symptoms, so the old “abundance of caution” principle is now in high gear and he has been hospitalized.

We had a similar sideshow in Miami over the weekend.  A twelve year old who had arrived from Africa to go on a cruise developed flu-like symptoms and presented to a local hospital for treatment.  Said local hospital decided to rule out Ebola and transferred him to Jackson Hospital.  A number if my friends still work there, and told me that everyone got all suited up at 8 am, then waited.  And waited.  And waited.  Seems that the Mayor of Miami Beach and the Governor needed to make speeches prior to transfer, and Fire Rescue decided to line their unit with plastic.  Somewhere around 2 the patient arrived, just before the initial – and negative – blood test came in,  Chalk it up to a drill, folks.

Here’s the problem, as I see it.  Hospitals, health departments and CDC have all had funding slashed. All have fewer people working harder.   CDC is now worrying about seat belts and auto safety as well, rather than spending full time concerning themselves about controlling disease.  They virtually eradicated malaria, so we know  they can do it.  We have no Surgeon General because the Repubs are horrified that the nominee has the temerity to consider gun safety a health issue.  The whole thing looks ominously like the early days of AIDS when we missed the bus completely, only now we’re not even certain who’s driving.

There’s also the tiny problem of how to treat this.  There are few effective remedies, but some show promise.  The initial cases were treated with convalescent serum and an Ebola-specific antiviral.  They did well, but there apparently is no specific anti-viral left.  Convalescent serum is gleaned from the blood of someone who has made a recovery from Ebola, and I doubt that there is a current donor pool of any size. There is another drug which failed Mr. Duncan, but may have better results if used earlier in the course of the illness.   It’s a good opportunity to track the pharmacology, establish a treatment protocol, and strive to establish a good supply of whatever seems to work best. .  A vaccine would be even nicer, but a high level of cooperation between drug manufacturers and government will be needed, and recent history suggests that this may not go so well.  A nurse in Spain has died from EBOV, which demonstrates that the virus has found its way into Europe.  This will not make screening any easier. As of now, traveler’s from West Africa are screened and asked to see a doctor if they develop symptoms within 21 days. Adding travelers from Europe to the mix will blow those numbers through the roof.

For now, let’s just cross our fingers and hope that this brings out the best in mankind.

This is an open thread.

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October 2014
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