Although this may not be of interest to everyone, I’ve had enough specific questions to warrant a post about it. Plus, it’s my blog and I want to, so deal with it. My goal here is to be entertaining enough for the mildly interested, clinical enough for the healthcare-inclined and comprehensive enough for the future Ebola worker (I hope there are some of you out there). However, if you’re an epidemiologist with nothing better to do than read my blog please cut me a break. Just a nurse here.
Note: I owe much of this information to the Department of Defense course on “Working in an ETU”. Much thanks to them for helping me to organize it in a helpful and informative way.
Ebola is a type of virus known as VHF or “viral hemorrhagic fever”. For the non-medical among us, hemorrhagic is how hospital people say bleeding. We say it because we don’t want our patients to know what we’re talking about, and to sound intelligent. Specifically, it is part of the filoviridae family of viruses, which is Latin for “hair virus”. This is simply because it’s shaped like a hair – side note: maybe Latin dying out wasn’t that big of a loss. Some of the other viruses in the same family of VHF include Dengue fever, yellow fever and Lassa hemorrhagic fever. You may know yellow fever as the disease that caused President George Washington to flee the nation’s capital city in 1793, or the immunization that Walgreen’s charges $140 for. Otherwise, you’d be forgive for never hearing of them.
The initial cause for the outbreak is not quite clear, but the most likely theory is that infected fruit bats transmitted the disease to animals, which human beings then ate and transmitted to one-another. Score one for PETA.
In addition to eating the infected “bush meat” as they call it here, (rats, antelope, apes, wild pigs, etc.) the disease is transmitted by contact with the blood and body fluids of infected individuals. It’s also found in the breast milk of infected women and the semen of infected men for up to three months after the symptoms are gone. Here in Liberia, it seems like the disease initially spread due to the customs and culture surrounding the treatment of the sick and dead. The family primarily is responsible for cleaning and caring for a sick family member, and so were frequently changing soiled bedsheets and emptying vomit buckets without proper protection. Also, death and burial is a very intimate process here, and as such the loved one’s dead body is frequently handled by family and sometimes even kissed.
A common misconception is that Ebola can exist in the air or can absorb through the skin. It can only enter through mucous membranes including eyes, nose, mouth, broken skin or genitals. If the little bugger does get in, the “incubation period” (when it starts growing in the new place) lasts between 2-21 days before the person gets symptoms. The average is about 11 days. This is why people are “quarantined” for 21 days- if they have the disease, it’ll build up to where you’ll get sick before then. Otherwise, you’re good.
The person who isn’t showing symptoms isn’t infectious, because the moment the disease is strong enough to make you sick it’s strong enough to jump to someone else, but not before. The first things you’ll probably see are fever, muscle or joint aches, headache, abdominal pain, diarrhea, conjunctivitis (eye redness) or interestingly enough, hiccups. If they have the disease late, they’ll be having lots of diarrhea, vomiting, confusion or bleeding from multiple places (although this happens in less than 30% of cases, so it’s not super reliable). The number one way people die of Ebola is called shock, which basically means your body is so depleted of fluids (including blood), that it can’t transport oxygen to the parts of your body that need it. This can be because of infection (septic shock), too much bleeding (hemorrhagic shock) or dehydration (hypovolemic shock).
When someone in Liberia has any of these symptoms, they’re instructed to come to the Ebola Treatment Unit. We meet them, interview them in full protective gear and ask about their symptoms – called triage. In order to admit them to the ETU, we have to have reasonable suspicion that they do really have it- because if we bring them in, their chance for catching it goes way up. As such, multiple organizations have come together to give us five specific criteria on what a “suspect case” is. First, they had contact with a known Ebola patient and have a fever of over 38 C (100.4 F for us ‘Mericans). Second, if they have contact with a known Ebola patient and three symptoms. Third, the fever and three symptoms. Fourth, any unexplained bleeding or for females, a miscarriage. Lastly, any unexplained death. If a patient fits any of these five, we admit them to the ETU and place them in the “suspect ward”. One of the first things we do is draw a blood test called a PCR (polymerase chain reaction) which is what we use to check for Ebola. We also run a blood test for Malaria (RDT-rapid diagnostic test), because its symptoms look exactly the same. While we’re waiting for the results, we do everything we can to prevent the patient from getting shock. Though individual doctors can order things depending on what they have access to, our primary medications are (non-medicals forgive me for a moment):
Paracetamol (aka Tylenol) for fever,
Morphine for pain,
Metaclopramide for nausea/vomiting,
Omeprazole for heartburn/GERD,
Diazepam for convulsions and anxiety,
Phenobarbital for a loading dose of anti-seizure medication,
D50 for low blood sugar,
Haloperidol for confused and aggressive patients,
Misoprostol for hemorrhage in pregnant women,
Oral rehydration salts,
Ceftriaxone, Gentamycin and Metronidazole for antibiotics,
Artemether, Artesunate and Mefloquine for antimalarials,
And of course, Lactated Ringers and Sodium Chloride for hydration.
There’s many more medications that would be useful for these patients (like ondansetron, promethazine, vasopressors, blood products or even oxygen.) but they’re either too expensive or not widely available out here.
Any time we enter a patient’s room, we have to wear PPE (personal protective equipment) to make sure we don’t come in contact with any of their body fluids. We have a very specific suit and materials we have to put on and take off in exactly the correct order, so as to avoid this (taking the gear off has been shown to be the most frequent way healthcare workers get the disease, including the famous America nurses who contracted it.) Also, ebola is actually quite a weak disease, and can be killed with alcohol or chlorine water. The latter is cheap and is used in tremendous amounts in the ETU: corpses and body fluids are sprayed with it, hands are washed in it, equipment is soaked in it, etc. There are workers called hygienists, whose job it is primarily to mix the chlorine water and make sure the area and patient are cleaned up. These are predominantly Liberian nationals.
Anyway, if patients PCR test is negative, they have to be symptom-free for 3 days, show signs of improvement and have a second negative PCR test. Then, they are told to watch for symptoms and discharged. If the PCR is positive we then begin aggressively treating the symptoms with the aforementioned medications and interventions and move them to the “confirmed ward”. Because Ebola patients can’t infect one another, they’re usually all together in a room. From then on, it’s just supportive care and helping with symptoms. As soon as they meet the three criteria mentioned above, they are discharged as well (unfortunately, lots of them don’t as the death rate is currently around 41%). They are given education, a social worker gives them an “ebola-free” certificate to ease the worries of family and friends, 90 condoms and vitamins. Patients are all tracked and sent to a centralized database to keep record of the cases.
So that’s a really shortened version of how the ETU works. It gets more complicated when you get into it more, but hopefully that sheds a little light on how it works, for the interested.
For more light reading: