Saturday, November 29, 2014

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:


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.

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