Ebola: Rob's questions

Rob McSweeny is a nurse whom I have known since we worked together at Harborview Medical Center in Seattle in the early 1990s. He was my best man at Holly's and my wedding. Rob recently posted several questions about my work in Sierra Leone on Facebook. I decided to use (most of) them as the basis for this post.

Are you guys also giving the IV fluid replacement?

We use intravenous (IV) hydration for people who cannot drink; those who are not alert enough to drink and those who are too nauseated to drink.

Is it Lactated Ringers or a special mix?

Yes, LR – although here it's called RL (Ringer's lactate).

What kind of tape do you use in the sweltering heat?

It's similar to the cloth adhesive tape that you and I used when we were new grads – nurse's duct tape. It's difficult to work with while wearing double gloves.

How do you keep your face mask from fogging up so you can place a line?

I haven't placed an intravenous line since I left the bedside five years ago and don't want to try here. There's not much I can do about my face shield fogging up. Another issue is that I can't wear my reading glasses under my face shield. I can't place a tuberculosis skin test without my readers, so I doubt I'd be able to start a line without them.

Can you give us a more detailed clinical picture? What I imagined to be people bleeding out of every orifice sounds more like cholera from your earlier description.

The U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) are using the term "Ebola virus disease" (EVD) instead of "Ebola hemorrhagic fever." EVD causes disseminated intravascular coagulation (DIC), a hypercoagulable state in which clotting factors are sequestered in small blood vessels blocking blood flow to tissues and organs while leaving the rest of the vascular system deficient in clotting factors. People with EVD are also thrombocytopenic. In short, people are more likely to bleed, but frank bleeding is seen in a minority of patients. The most blood I've seen was from a patient with a nose bleed.

Patients with EVD look "toxic" – similar to patients with sepsis.

How long do you spend on the floor working, I mean overheating?

I usually shoot for an hour. An hour and a half is pushing it for me.

Who built your facility?

It's commonly referred to as "the Red Cross treatment center." It appears that the part of the ETU used as the suspect ward used to be a Red Cross clinic. We were told that it had been built by the British military, but there's no sign of either the Red Cross or the British military now.

Suspect ward

I hear on NPR that rapid response teams are being sent into the bush as a way to isolate outbreaks. Rapid response meant a very long walk the lady said.

I heard that too. We are supposed to visit some of the "community care centers" (CCC) in the district but, so far, only one person from our group has made a trip out. The CCCs that we are visiting are accessible by road.

Don't burn out. You're not such a young buck any more you know.

I pace myself. I usually take it easy for an hour or so after doffing my personal protective equipment (PPE). I usually make no more than two trips into the treatment area in a day. There are plenty of other tasks that need to be completed outside of the treatment areas. As Dirty Harry said, "A man's got to know his limitations."

PPE doffing area, confirmed ward in the background

What do you use to replace your electrolytes?

I drink oral rehydration solution (ORS), but I dilute it in 1.5 liters of water instead of 1 liter. I was drinking about 9 liters of fluid a day when I first started working in the ETU. I think I'm down to 6 liters per day now. I've had some muscle cramps a few days ago and suspect I may have been a little hyponatremic.

What do you eat at work and after work?

Most of our meals come from the only restaurant in town – fish, chicken, peanut soup, rice, beef stew, chips (French fries). I sometimes eat lunch with the local staff in the canteen at the ETU – usually peanut soup over rice or some type of chopped leaves over rice. Lately I've been ordering papaya and fried plantains for lunch. There's no kitchen in the guesthouse where we've been staying.

Would you recommend volunteering at an ETU as a way to lose weight?

I recommend working in an ETU as a way to help end this epidemic. I couldn't tell you if I've lost any weight while I've been here.

How many nationalities are you working with and why are you writing on whiteboards in English and not French?

Other than the local staff most of my colleagues are U.S. citizens. One of the nurses is French but a U.S. citizen. She spent ten years working at Harborview – long after you and I left.

Sierra Leone is Anglophone.

Incidentally, Seattle Times, October 6, 2014: Harborview open to emergency Ebola cases

Thanksgiving dinner with Paul Farmer, one of the founders of Partners In Health:

 

References:

Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Elsevier.

Hartman, A. L. (2013). Ebola and Marburg virus infections. In, A. J. Magill, D. R. Hill, T. Solomon, & E. T. Ryan (Eds.) Hunter's tropical medicine, 9th Ed. [Electronic version]. Elsevier.

Hoenen, T., Groseth, A., Falzarano, D., & Feldman, H. (2006). Ebola virus: unravelling pathogenesis to combat a deadly disease. TRENDS in Molecular Medicine, 12(5), doi:10.1016/j.molmed.2006.03.006.

Kortepeter, M. G., Bausch, D. G., & Bray, M. (2011). Basic clinical and laboratory features of filoviral hemorrhagic fever. Journal of Infectious Diseases, 204(Supple. 3), S810-S816.

Ebola: stigma

Friday was my first day off since arriving in Port Loko. I spent the day getting caught up on some reading I had started before leaving the U.S., listening to some great music, and going for a long walk. While I was out I bought some vicious looking chilies. I had seen okra in Freetown and hoped to find it here but didn't. Eventually, we're supposed to move into a house with a kitchen and I'll want to make gumbo.

 Saturday we discharged several Ebola survivors from the confirmed ward; people who had recovered from Ebola virus disease (EVD). That was the first time survivors had been discharged from this Ebola treatment unit (ETU) since it opened.



The door on the right is the exit from the confirmed ward. The one on the left is the exit from the suspect ward.

Although discharging Ebola survivors was a cause for celebration, I will not post photographs of patients on this blog or any other social media. Survivors in this epidemic and in previous epidemics have been stigmatized and even become the victims of violence.

During previous Ebola epidemics in Central Africa, survivors were turned away from their homes, abandoned by their spouses, and their children were not allowed to touch them. Survivors were harassed and suffered discrimination. Children whose parents died were left to fend for themselves, becoming heads of households (Davtyan et al., 2014; De Roo et al., 1998; Hewlett & Amola, 2003; Hewlett & Hewlett, 2005).

Health care personnel have also been stigmatized and victims of violence (Hewlett & Hewlett, 2005). Today I talked to some of the nurses at the ETU about their experiences. Several nurses told me that they had been forced to leave their homes. Another said her fiancée had stopped calling her.

 

 

Many of my colleagues from the U.S. have also experienced discrimination because of their work in the Ebola epidemic response. One of the physicians I worked with was asked not to return to her apartment for 21 days after leaving Sierra Leone. A firefighter I met was harassed by her coworkers. Several of my colleagues quit their jobs to come here after their employers refused to allow them time off. Several people have told me that they are not welcome at their families' holiday celebrations.

I am fortunate. My colleagues at the health department have been very supportive of my decision to come to West Africa to work in Ebola response. They also understand that my risk of becoming infected with the ebolavirus is extremely low and that, even if I were infected, I could not transmit the virus until I developed symptoms of EVD. As far as my fellow nurse epidemiologists are concerned, I could return to work immediately after I return to the U.S. from Sierra Leone, provided I take my temperature twice daily and report any symptoms to the local health jurisdiction, that is, my colleagues at the health department. In fact, I am one of the people who will monitor other travelers returning from countries affected by Ebola.

I am reminded of the stigmatization and abuse that people infected with HIV (or perceived to be infected with HIV) suffered at the beginning of the AIDS epidemic as the result of fear of disease and misunderstandings of its modes of transmission. EVD and AIDS are both frightening diseases. Both diseases tend to affect specific populations (Davtyan et al., 2014). There are no vaccines available for either HIV or Ebola. Unlike HIV infection, there are currently no drugs available to treat EVD.

I have tried to address concerns about EVD in these posts. All of the responses I have received so far have been very positive. I am extremely grateful for the support and prayers that I have received from my family, friends, colleagues, and community. I hope that the support that I have received will be extended to others who have made sacrifices to work in this epidemic.

References:

Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Global Health Action, 7(26058). http://dx.doi.org/10.3402/gha.v7.26058.

De Roo, A. D., Ado, B., Rose, B., Guimard, Y., Fonck, K., & Colebunders, R. (1998). Aurvey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences. Tropical Medicine and International Health, 3(11), 883-885.

Hewlett, B. L. & Hewlett, B. S. (2005). Providing care and facing death: nursing during Ebola outbreaks in Central Africa. Journal of Transcultural Nursing, 16(4), 289-297.

Hewlett, B. S. & Amola, R. P. (2003). Cultural contexts of Ebola in northern Uganda. Emerging Infectious Diseases, 9(10), 1242-1248.

Washington State Department of Health. (2014). Interim guidance for local health jurisdictions regarding follow-up of asymptomatic persons with potential exposure to the Ebola virus. http://www.doh.wa.gov/Portals/1/Documents/5100/420-132-Ebola-LHJ-MonitoringGuide.pdf.

 

Ebola: oral rehydration solution (ORS)

Greetings from Port Loko, Sierra Leone. Chris, Jennifer, Larry, Nahid, who is a physician who joined us in Freetown, and I arrived here a week ago. We've been working in the Ebola treatment unit (ETU) 10 or more hours every day. A new crew of nurses and doctors arrived a few days ago, so now we're able to work overlapping six hour shifts. This is the first time I've been able to sit down, listen to music, and write a post. I'm tired, sore, and a little sunburned, but I enjoy the work that I'm doing.

I could tell you heartbreaking stories of the deaths that I've seen here. Several people die in the ETU every day. I've chosen not to write about those deaths in this post.

Two of the most prominent features of Ebola virus disease (EVD) are vomiting and diarrhea. Death from EVD is usually due to dehydration and loss of sodium and potassium, electrolytes that are required for normal cellular function. There are no medications that treat the viral infection itself, so treatment of EVD is aggressive replacement of water, sodium, and potassium. That can be achieved using intravenous (IV) fluids but, for most people with EVD, the risks associated with IV rehydration outweigh the benefits.



Today I discussed the risks and benefits of ORS versus IV fluids with the staff of the ETU

Oral rehydration solution (ORS) is a mixture of water, sugar, and salts. The ratio of water, sugar, and salt in ORS increase the absorption of water from the intestines into the blood vessels. ORS has been proven to reduce mortality from diarrheal diseases.



ORS

There are few published studies of the effectiveness of ORS for the treatment of EVD. It would be a simple hypothesis to test, but it's very difficult to collect data in an ETU. Most of the evidence supporting the use of ORS for the treatment of EVD is anecdotal – the observations of people who have treated people with EVD with ORS. Rather than tell you about the deaths I've seen inside the ETU, I want to tell you my anecdotal observations.



Jennifer reporting data from the ETU

It can be challenging to administer ORS to a person with EVD. They are often lethargic, have muscle and joint pain, and don't want to sit up to drink. Administering ORS to a person in that condition can be time-consuming and require a lot of coaxing. Some patients are nauseated, so they can only tolerate small amounts of ORS. Of course, there's also a language barrier. Many of our patients speak or at least understand Krio, the lingua franca of Sierra Leone. Krio is an amalgam of English and several African and European languages. I do my best to imitate Krio and seem to be able to get my message across.



Krio: "Together we defeat Ebola to come out of Sierra Leone"

A few days ago I spent some time giving ORS to a young woman. She was very lethargic and reluctant to sit up and drink, but I was persistent. I asked her brother, who was in the bed next to hers, to encourage her to drink ORS. I came back later to find her bed empty. My heart sank; I thought she had died, but I was told that she was outside walking around. A few days ago I didn't know if she would survive. Now I'm convinced that she will. Today I saw another patient up walking around who had previously looked severely ill. Again, he is someone I thought might die but now believe that he will survive.

There are other factors that influence a person's likelihood of surviving EVD. Survivors tend to mount an antibody response to the virus earlier and much more effectively than people who die from the disease. I can't say with absolute certainty that ORS saved the lives of these two patients and others I have watched improve over the last week but, like others who have treated people with EVD, I believe it greatly improves a person's chance of survival.

 

Partners In Health

References 

Atia, A. N. & Buchman, A. L. (2009). Oral rehydration solutions in non-cholera diarrhea: a review. American Journal of Gastroenterology, 104(6), 2596-2604.

Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Elsevier.

Kortepeter, M. G., Bausch, D. G., & Bray, M. (2011). Basic clinical and laboratory features of filoviral hemorrhagic fever. Journal of Infectious Diseases, 204(Supple. 3), S810-S816.

Mahanty, S. & Bray, M. (2004). Pathogenesis of filoviral haemorrhagic fevers. Lancet Infectious Diseases, 4(8), 487-498.


 

Greetings from Freetown, Sierra Leone

Chris, Jennifer, Larry, and I arrived in Freetown last night. The first thing everyone had to do after getting off of the plane was wash our hands in chlorinated water. We were given a health screening form to complete. Our temperature was checked before we were allowed to enter the baggage claim area. The airport is across a bay from Freetown, so we took a twenty minute boat ride to get to the city. Upon arrival at our hotel, we had to wash our hands in chlorinated water and our temperature was checked before we were allowed to enter the lobby.

After a briefing at the hotel this morning, we were driven to Connaught Hospital. Riding through Freetown, I was struck by how normal everything looks. People are going about their business as usual, they smile and greet each other, and children are playing. I shouldn't have been surprised. As of November 7^th, there have been 4,862 cases of Ebola virus disease (EVD) in Sierra Leone, a country with a population of 5.74 million people. If you're looking for the sick and dying, you won't find them on the streets of Freetown.

This is a beautiful city. It's topical Africa; the hills are lush green, and there are pleasant beaches. Right now the weather is very similar to summer in New Orleans. The temperature is in the 80s and it's very humid (balmy!).

 

Upon arriving at the hospital we were required to wash our hands in chlorinated water and our temperature was checked before we were allowed through the gates.

After another briefing, we were taken to the Ebola treatment unit (ETU) where we donned personal protective equipment (PPE). I'm pretty heat-tolerant. I enjoyed riding my bicycle in New Orleans in the summer, but wearing head-to-toe PPE in this weather is very uncomfortable. Within a few minutes of donning my PPE my scrubs were drenched with sweat.

 

Jennifer in PPE

 

If you expect me to say something like, "Nothing can prepare you for the first time you see a patient with Ebola," you're going to be disappointed.

I've read several descriptions of the clinical presentation of EVD. In general, there's nothing in the appearance of a person with EVD that distinguishes it from other acute febrile illnesses. That's one of the problems early in an Ebola epidemic. Health care providers are often exposed to ebolavirus before anyone suspects that the ill patients they are seeing have EVD. People with EVD look like they could have malaria, typhoid fever, or any number of infectious diseases that are common in developing countries. Confusing the issue even more, Lassa fever, another viral hemorrhagic fever, is endemic in this part of Africa.

It's not my intention to minimize the seriousness of this disease. It's just not like what you might have seen in a movie. People with EVD are severely ill and the mortality of EVD is extremely high. Most people who die from EVD die because of dehydration and electrolyte disturbances from vomiting and diarrhea. The term "hemorrhagic fever" can be a little misleading. Although bleeding can be part of the clinical picture, not all patients with EVD bleed and most bleeding is into the gastrointestinal tract.

Once we returned to the hotel, we washed our hands in chlorinated water and had our temperatures checked before we were allowed in the lobby.

My beautiful wife and son on Skype

 

CDC Ebola safety training course

 

I spent the last three days at the Center for Domestic Preparedness in Anniston, Alabama. This is a busy place. There are several groups of students here wearing different colored badges. I'm one of the people with a green badge. We're here for the Center for Disease Control and Prevention (CDC) Safety Training Course for Healthcare Workers Going to West Africa in Response to the2014 Ebola Outbreak.

The course includes lectures on Ebola virus disease (EVD), its transmission, epidemiology, treatment, infection control, and disinfection. The focus of the training is preparing health care professionals to safely work in Ebola treatment units (ETU) in West Africa. Our afternoons are spent in a mock ETU where we practice putting on ("donning") personal protective equipment (PPE), working in PPE, and, most importantly, removing ("doffing") contaminated PPE safely. There is a lot of bleach used throughout the process.

 

Each time we go through we partner up with another person, assist each other with donning PPE, ensure that there are no breaches (exposed skin or tears in the material), and ensuring that our partner remains safe while in the ETU. On Tuesday only did I learn that the sleeves of an extra large Tyvek coverall are too short for my arms, the back ripped open while I was working in the ETU. I'm very glad that I learned that here and not in Sierra Leone.

I've met the three other people who are going to Sierra Leone with me through Partners In Health. I've also met dozens of other remarkable health care professionals who will be working in West Africa, most of whom have previous experience working in Africa and/or developing countries in other parts of the world.

 

Chris, Jennifer, Larry, and I will spend a couple of days in Atlanta and then leave for Sierra Leone Saturday. We should arrive in Freetown Sunday evening.



Jennifer, Larry, Chris, and me: before