Monday, January 19, 2015

Ebola: Altered standards of care

I thought I was done talking about Ebola for a while.

I've been preparing to go back to writing about vaccines and vaccine-preventable diseases but was asked to speak to a bioethics class at Pacific Lutheran University about my work in Sierra Leone. I decided to post some of what I plan to discuss instead of writing about another subject that's near and dear to my heart: meningitis.

There are a number of things that I've been reluctant to discuss publicly. I've tried to keep my posts about Ebola relatively positive. I haven't discussed the gruesome scenes and situations that I saw in the Ebola treatment unit (ETU), but it requires no stretch of the imagination to understand that those of us working in the ETU were troubled not only by some of the things we saw there, but also by some of the decisions we had to make.

I went to Sierra Leone because I believed that my clinical and educational background prepared me for that work. I spent most of my bedside career working in critical care units and am comfortable with end-of-life decisions and care. I worked neurology/neurosurgery where I saw people suffer devastating injuries and illnesses that left them with permanent disabilities. I worked in resource-poor settings in Africa. I went to Sierra Leone fully aware that ebolaviruses are highly lethal and that epidemics of Ebola virus disease (EVD) are associated with high mortality. I went with the understanding that I would see people die.

I've also been involved in emergency preparedness planning and am familiar with altered standards of care in mass casualty events. Mass casualty events are those in which the number of people requiring medical care exceeds local capacity. One example that has been used in training exercises in which I've participated is a chemical spill in a small city where the number of people exposed is greater than the number of hospital beds available, ambulances needed to transport the victims to the hospital, and the number of personnel needed to care for the injured both at the scene of the accident and in the hospital. In this scenario the injuries vary in severity. Some people have only minor injuries and do not need immediate medical attention; some people have severe injuries and require immediate medical attention; and some people have severe injuries and are unlikely to survive even with immediate medical attention. In altered standards of care, the focus shifts from caring for the most severely ill or injured first to allocating personnel and equipment to caring for those who are most likely to survive with the goal of saving as many lives as possible. This means that emergency responders and health care personnel must determine who will not receive life-saving care and will die.

There were times when I had to decide whether to spend the limited amount of time I had in the ETU giving oral rehydration solution (ORS) to someone who was too weak to sit up but was able to drink or spend that time with someone who was unresponsive and could not drink. This was not a decision I had to make frequently and, once we had enough people working at the bedside, it was a decision that I no longer had to make.

I can't say I'm sure I always made the right decision. On the other hand, I have no doubt that there are people who are alive today because I stood at the bedside holding patients in a sitting position with one hand and a cup of ORS to her or his lips with the other. My purpose in doing so was not only to rehydrate that patient, but also to lead by example; to establish a standard of care for our patients in the ETU. With good reason, many of our local staff were reluctant to provide hands-on care to our patients. They had watched their friends and colleagues die from the disease. One of the trainers in the Ebola safety course I took before going to Sierra Leone told us that the purpose of personal protective equipment (PPE) is to allow us to touch our patients.

I recently participated in a conference call with some of my colleagues from the ETU, one of whom, a nurse with critical care experience and who had previously worked in Africa, expressed a sense of helplessness at not having the resources needed to provide life-saving care to every patient in the ETU. In critical care and in most patient care settings, our focus is on the needs of the individual patient. For those working in an ETU, our objective is to safe lives, however, in an Ebola epidemic, the primary purpose of holding and treatment facilities is isolation; removing infected or potentially infected individuals from the community to prevent transmission to others.

I'm scheduled to speak to the bioethics class a week from today.

My fifteen minutes of fame:

Agency for Healthcare Research and Quality. (2005). Altered standards of care in mass casualty events.


Two guys at the hardware store
Two guys waiting for breakfast


  1. Good article, well written in your usual plain style. I can only imagine that touch itself had a healing effect even if it was from a great plastic Viking. Question: why not have used a naso-gastric tube to hydrate the unresponsive patients? Seems a reasonable engineering fix to expand the triage criteria and such a time saver as well.

    1. That's a good question, one that Paul Farmer raised during our Thanksgiving dinner with him. The simple answer is that we didn't have NG tubes, at least, not while I was at the ETU. Also, people with EVD are thrombocytopenic (low platelet count) and have disseminated intravascular coagulation (DIC), so they are at higher risk for bleeding. For that reason, I would be hesitant to try to place and NG in someone who is severely ill with EVD. Other people, including Paul Farmer, have different opinions on the subject. There's a list of reasons not to use NG tubes in people with EVD on this page: