Wednesday, October 15, 2014

Ebola in Texas: Take a Deep Breath Y'all

Alright folks. Here in Texas two nurses have turned up positive for Ebola and it's possible other healthcare professionals who worked with Mr. Duncan, or who will work with the nurses, will turn up infected.

So now what? What does this mean?

Well, We know how Ebola is transmitted and we know how to prevent that transmission. But knowing how, watching a youtube video about it, and putting that knowledge into practice in a frightening real life situation, are very different things.

The reason that personal protective equipment (PPE) works, is because people use it and use it correctly. I really don't think anyone would intentionally treat an Ebola patient in what they knew was an unsafe manner, but there are nuances and subtleties involved with PPE that, if not well understood, can mean the difference between safe and unsafe, and with Ebola the room for error is incredibly small. And while you wouldn't leave the gloves on the shelf when examining an Ebola patient, and you might know that removing contaminated gloves incorrectly is just as dangerous as not wearing them, it's easier to misjudge what it really means to remove those gloves safely than one might think. Without practical experience, it's very easy to think you are doing it correctly.

And Texas Health Presbyterian nurses and doctors got thrown into a very tough situation with a very sick patient and we are hearing that they had no protocols in place. Which also means they hadn't done any real prep in case an Ebola patient showed up. But I doubt that situation is any different than most other US hospitals, so instead of castigating them, we should focus on finding ways to better prepare every US hospital. And I think one of the most important things for hospital supervisors to realize is that thinking that you or your staff are doing it correctly isn't enough. You need to make sure that everyone knows what to do and can do it without fail.

So how do you do this?

Training, drills and testing.

From the beginning of this epidemic, we've been horrified about the number of HCW being infected, and untrained and unsupervised HCWs anywhere are susceptible to infection from an Ebola patient. On October 3rd, Dr. Tom Ksiazek, the most eminent Ebola epidemiologist working today in my opinion, gave a talk about his 6 weeks as the CDC team leader in Sierra Leone and said the biggest problem with PPE (when they had it) where he'd been, was training, especially removal of contaminated PPE and supervision.

And it's clear that, while most US hospitals have the capability of containing Ebola to a handful of cases should it appear, whether they will or won't depends on training and the practical application of what is known to effectively protect against Ebola transmission.

Do HCWs in the US have more training in general than W. Africa? Probably. Are they specifically trained in the dangers unique to the very high profile task of caring for Ebola patients who are exhibiting frightening symptoms and exuding copious amounts of infectious bodily fluids, all while performing medical procedures? Not most of them.

In fact Anthony Fauci, Director of the NIAID, said HCW need more training and that you "gotta have drills". You can't just send an email containing a link to nurses and tell them to learn how to use extensive PPE in their spare time.

So how can you find out if you or your staff are disinfecting correctly, or removing PPE without contaminating yourselves? Someone needs to show you how to do it correctly, let you practice under supervision, then test you. A really effective way to do this is to use a fluorescent powder or liquid that is only visible under UV light. Something like Glo Germ. Toss it around a HCW in full PPE, get it on their gloves and shoe covers and mask - all over the place. Then have them disinfect and remove the PPE as they would in a real life situation. Then illuminate them with the UV light to see what lights up. With Ebola you only need a tiny bit of residual contamination transferred from a finger to an eye to cause an infection.

And then understand that this doesn't necessarily mean that the person was careless or cavalier, but more likely that it's really really really hard to decontaminate and remove contaminated PPE safely. This is why there is a buddy system. This is why training and supervision are paramount.

And if you're a nurse or a doctor and you have any hesitation about whether you're prepared to safely enter an Ebola patient's room, you need to be able to feel like you can bow out without the risk of losing your job. Your supervisor should not only respect your professional assessment, but should applaud you for it.

Can this be contained? Absolutely. But unless someone takes charge and shows people how to do this job safely, there will likely be other HCW infections in the process.

Who should be in charge? Well, hopefully State Public Health Departments will play a role in guidance and training, and hopefully the CDC will also provide some oversight. But if I were a hospital, I would assign a small team of HCW (w/enough for redundancy) specifically to handle potential Ebola patients. This team would be the only staff to have any interaction with any possible Ebola patient, from initial evaluation, to diagnosis and testing and through treatment. This team should be on call and given both on call and hazard pay. And this team should be identified now and trained extensively, before another  Ebola patient arrives at an unprepared hospital door.

But in the meantime I think moving the newest Ebola patient, nurse #2, to Emory is a really great idea. Let THP take a deep breath and regroup, and maybe all of our hospitals can start implementing some protocols that will help us move forward and prevent more infections.




  1. Great. I applaud this and you're right. But... we have experience that so far four healthcare workers outside of west africa (two in Dallas and two in Spain) haven't gotten the training part right. Either that or it's very difficult to follow. So we absolutely need money to be spent right now by the administration in emergency funds to make sure that all HCW have all of the correct PPE AND have all of the correct training. It also bears mentioning that the infectivity of an Ebola patient scales with how close they are to death. Sure a gown, a mask and gloves are probably OK if the person is just showing a little fever, but once they are close to death they are literally a virus factory so the PPE needs to be progressively stronger and the steps required to remove it need to be stricter. This really can't be allowed to be something that can only be handled by special ICUs with advanced equipment or else we'll rapidly run out of the ability to treat patients safely. THEREFORE we also need to be scaling up vaccine production so that HCW are properly protected RIGHT NOW.

    1. Hi and thanks for reading and for the comment! I agree that training is inadequate, and that the funding needs to be there. And while vaccines would be nice, they likely can't be scaled up as quickly as we need for this epidemic so training has got to be the focus.