Ebola: Be prepared #ebola #healthcare #medicine

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This is an email that was forwarded to me that discusses the preparation and planning of caring for an Ebola patient.  Be informed!

Dear Colleagues,

We write to provide a summary of the presentation at IDWeek by Dr. Bruce Ribner on caring for Ebola patients in the US1.  Dr. Ribner led the team at Emory University that cared for two patients with Ebola virus disease (EVD) in August. In light of the recent Ebola cases in Dallas and Spain he agreed that a summary could be provided to assist ID specialists in their ongoing preparedness efforts.

Planning for the care of patients
This involves the entire institution, and needs many sections to coordinate their work. EMS services were an important coordination point for the transport of the 2 patients to Emory. On the medical staff, many types of expertise were needed for clinical management: ID, critical care, anaesthesiology and several other subspecialities. Nursing, environmental management, facilities, security and media relations were all intensively involved ahead of time so that expected roles were defined. Even so, there were times when questions arose after the patients arrived.

Clinical Care
Ebola patients in Africa have only limited clinical evaluations and essentially no laboratory testing due to the lack of any infrastructure to support this. The Emory team was able to make careful clinical evaluations over time in their 2 patients and Dr. Ribner summarized the main points as follows:

1.  Despite weight gains of 15-20 kg, the patients were profoundly hypovolemic due to their low serum albumin and vascular leak with third spacing. Fluid losses in their patients were 5-10 L/day.
2.  Electrolyte losses were significant and included profound hyponatremia, hypokalemia and hypocalcemia. At initial assessment at Emory the patients were one week into illness yet these were their first laboratory determinations. Arrhythmias were noted, and both intravenous and oral electrolyte repletion was necessary.
3.  Nutritional depletion was evident as well.
4.  Ebola virus RNA was detected in blood, urine, vomitus, stool, endotracheal suctioning and semen and on skin. It was not detected in dialysate. Environmental testing in the patient rooms had no detection of viral RNA and included many high touch surfaces such as bed rails and surfaces in the bathroom.
5.  Intensive 1:1 nursing care was necessary around the clock. Patients were monitored continuously and this level of nursing care allowed for rapid response to clinical changes. Nursing and other team members provided emotional support, and as the patients improved, help with self-care and physical therapy.

Experimental Interventions
While there are no approved vaccines or treatments for EVD, the WHO has noted that it is ethically acceptable to consider use of experimental agents. Categories of agents under study include candidate vaccines, whole blood and immune serum, and novel therapeutic agents (monoclonal antibodies, antivirals and RNA-based drugs). Most have not been evaluated in phase 1 human studies and are in limited supply. The Emory team engaged the FDA, CDC and pharmaceutical manufacturers in active discussions as they weighed additional interventions.

Laboratory Testing and Diagnostics
Differences in guidance for laboratory testing were noted between CDC and ASM. The CDC guidance indicates that testing can be performed in a main lab with attendant infection control and analyzer safeguards that are specified by the instrument’s manufacturer, while the ASM guidance specified that point of care (POC) instruments located very close to the patient should be used. The reality the Emory team noted was that if a specimen from one of their EVD patients spilled in the main lab, it would be closed for hours to accomplish decontamination, thus impacting function of the entire hospital. There was realistic concern that technologists would not perform testing on EVD blood. These considerations prompted the Emory team to set up a POC testing area adjacent to the patient care unit2. Lab testing was kept to a minimum.

Surprises in Shipping
Ebola virus is considered a category A agent which requires special packaging and shipping arrangements for clinical specimens. Despite meeting these requirements, the Emory team learned that commercial carriers refused to transport the specimens even when the carriers were licensed for Category A agents.

Staff and Environmental Safety
The hospital safety officer needed to navigate multiple regulatory requirements at the federal, state and local level. Familiarity with the regulatory documents and jurisdiction was necessary.

Personal Protective Equipment
Their staff was trained in the use of PPE that included impermeable body protection (gown, leg and shoe covers), face mask or N95, eye and face protection (goggles and face shield) and gloves. Practical considerations led them to use full body suits and PAPRs. Their decision was based on the need to work for extended periods of time using PPE, the aim of decreasing physical discomfort working in multi-component PPE and the avoidance of difficulties like fogged faceshields. The donning and doffing of PPE was always observed by another staff member, and the importance of adhering to safe removal of PPE was emphasized.

Unexpected Adventures in Waste Management Although the CDC guidance indicates that sanitary sewers are acceptable for patient waste, the local water authority disagreed. The Emory team had to disinfect all patient liquid waste with bleach or quaternary detergents for 5 minutes before it could be flushed. The hospital’s waste disposal contractor would only pick up materials that were certified as free of Ebola virus. As a consequence, the hospital had to dedicate an autoclave and move it to process all materials used in clinical care in order for it to be accepted for disposal as regulated medical waste. By the end of the patients’ stay the autoclaved and boxed materials filled several trailers.

Media and Communications
Three key messages were used to manage the tsunami of media attention: first, that the Emory team had expertise in treating serious infectious diseases; second, that the staff and hospital were trained and prepared to care for the patients; and third, that the preparations included protection of Emory patients, staff and the community. Patient confidentiality was also underscored. For the hospital staff, multiple communications were done, using town hall meetings, email and other modes. For inpatients and all new admissions, letters were given that explained the situation and reiterated the key messages, and senior administrative leaders delivered the messages as well answered questions. No decrease in admissions or elective surgeries at the hospital was noted.

Lessons Learned
Patients with EVD can be safely cared for in developed countries with appropriate safeguards. This opportunity affords close clinical observation and experience in clinical management that could be relayed to facilities with lesser infrastructure. Communication, both internal and external, is critical to  manage the situation surrounding a hospitalized EVD patient.

The Society thanks Dr. Ribner and his team for their astute observations, their compassion and their willingness to share what they have learned.

Sincerely,
Marguerite A. Neill, MD FIDSA, Chair, Rapid Communications Task Force, IDSA

References

1.  Ribner BS. Treating patients with Ebola virus infections in the US: lessons learned. Presented at IDWeek, October 8, 2014. Philadelphia PA
2.  Hill CE, Burd EM, Kraft CS, et al. Laboratory test support for Ebola patients within a high-containment facility. Lab Medicine 2014:45(3):e109-111.

Guidelines from the AMA

When the bark is louder than the bite

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In residency, you learn to deal with many different personalities. ¬†This ranges from super sweet and helpful to utterly cruel and egotistical. ¬†At MGH, our CA-3 year was¬†spent running the call schedule on night call (the first-call experience). ¬†It’s a terrific experience in prioritizing as well as organizing your team to prepare for what rolls through the OR doors. ¬†Fast forward 4 years and now I’m in private practice.

While¬†running the schedule on call, I get a call from the trauma surgeon saying a patient with an epidural hematoma needs to come to the OR emergently and couldn’t wait for another anesthesiologist to be called in from home (home call gives an anesthesiologist 30 minutes to come into the hospital for an emergency). ¬†So, I made the executive decision to pull the anesthesiologist from the elective suboccipital craniotomy case to do the emergency. ¬†It was a crani to crani and neuro to neuro switch… meaning the neuro team and crani trays were already open and ready to go. ¬†It made the most sense in my mind. ¬†Of course, without missing a beat, the “elective” neurosurgeon showed complete disdain¬†of my decision. ¬†To add fuel to the fire, he proceeded to berate the OR nurses, myself, and staff to¬†make sure his displeasure was known. ¬†I stood by my decision because it was the best decision for the emergency craniotomy patient who could have potentially died. ¬†Secondly, I chose not to call in my final anesthesiologist for an elective case as we would have gone on “trauma bypass”. ¬†This means that no traumas or emergencies could come to our hospital. ¬†The “elective” neurosurgeon became more livid by the minute. ¬†2.5 hours after he was supposed to start his case, I finished my first case and was able to get his case started.

Now, who does an elective suboccipital craniotomy for tumor case on a Saturday? ¬†Secondly, he decides to do this in a sitting position — this has it’s own sets of risks. ¬†He needed a precordial doppler, which our hospital did not have, so we called for it from our neighboring sister hospital. ¬†In the meantime, I had another plan…that was to put down a TEE probe to monitor for venous air embolism (VAE). ¬†After speaking to the patient and family, I proceeded to explain the risks/benefits of arterial line, central venous line, transesophageal echo, mechanical ventilation, blood transfusion, and intensive care unit stay. ¬†It’s always a lot for the family to comprehend, especially while meeting them for the first time. ¬†However, it is our job as anesthesiologists to make them comfortable and calm their fears.

**This picture taken from a google search for “precordial doppler”. ¬†It is not my own.**

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**This picture taken from a google search for “precordial doppler”. ¬†It is not my own.**

We get to the room and proceed with vital signs monitoring. ¬†Uneventful induction and intubation. ¬†A right internal jugular vein central venous line is placed (mainly to use as a Bunegin-Albin catheter). ¬†¬†TEE probe placed to look for air in RV and possibly air lock and RV failure –> VAE. ¬†Radial arterial line placed and transduced at the level of the head. ¬†Pt was placed in Mayfield pins and positioned in steep sitting position with reverse Trendelenberg and flexing the legs up. ¬†Neuromonitoring commenced looking for changes in sensory and motor signaling.

All throughout the case, the TEE showed various amounts of air coming through the right side of the heart:

IMG_6787.PNGWith greater amounts of air, there would be a detectable decrease in blood pressure as well as end-tidal CO2. ¬†While the right ventricle was still capable of pushing blood forward, I simply increased the blood pressure pharmacologically and increased the patient’s volume with normal saline from the IV. ¬†Rarely does one get to see this TEE view as most of these cases are monitored non-invasively via pre-cordial doppler or ETCO2 and BP.

Lastly, this patient had a great outcome. ¬†A 2cm x 2 cm hemangioma was resected with minimal disruption or trauma to surrounding tissue. ¬†2 hours after a lengthy 4 hour surgery, the patient was sitting with their family… communicating and interacting with them. ¬†All motor and sensory intact.

Pearls from this case:

1) Always do what is best for the patient. ¬†When a life-and-death situation presents itself, it gets priority. ¬†Period. ¬†It doesn’t matter what pressure or temper tantrums you get from outside parties. ¬†Make the best clinical decision. Organize a plan. ¬†Stick with it.

2) Find out the surgeon’s plan. ¬†This case was not booked in sitting position. ¬†Some of these cases are done in prone position, which makes the likelihood of VAE significantly lower than in sitting position. ¬†Knowing the surgeon’s plan of attack is critical to an anesthetic plan.

3) Read. Read. And read more. ¬†Although I’ve been out of residency and fellowship for 4 years, cases will always¬†test your knowledge as well as make you learn new skills/techniques to better your plan. ¬†Take the time to do your best. ¬†Always review. ¬†Medicine is a lifelong learning career.

4) Don’t sweat the small stuff. ¬†The “elective” neurosurgeon who raised such hell at the beginning of the case was thanking me for my help and expertise by the end of the case. ¬†Learn as much as you can from your residency. ¬†Take the knowledge gained and let your clinical acumen do the talking. ¬†There is no room for ego when taking care of a patient. ¬†Your ability to be well-read, well-trained, and well-respected will dictate the tone. ¬†No fluff is needed when you bring 100% to the table. ¬†Don’t be intimidated by the loud bark.

The beauty of anesthesia

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These parents were so sweet. Sloane was their fourth baby, and they barely made it to the hospital. They left their camera at home and their cell phone just went to 0% charge. I asked if it was ok to use my cell phone and then send them pics so they could capture this special day. (In a hospital setting, permission and patient consent is everything). I love deliveries because the little babies are so precious… Innocence captured in such a happy moment.

Little notes from patients like this truly make my job incredible!

Keep calm: page anesthesia!

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Anesthesia is a pretty social field in medicine. ¬†Even though you can be stuck in a room with no windows for hours on end, one can typically have good conversation with the people in the room (nurses, scrub techs, surgeons, assists, reps, etc.). ¬†Typically, it’s a jovial atmosphere. ¬†Well, while checking-in with our schedule runner (the czar) a call came through that someone needed to be intubated upstairs. ¬†

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Luckily, I was in between cases and decided to run upstairs to assess the situation. ¬†I see a rather obese gentleman appearing a bit mottled in color. ¬†The vitals monitor said SpO2 90%. ¬†The patient was on a bipap machine. ¬†His belly was heaving up and down with each breath…making it appear that he was using a lot of effort for each breath. ¬†I called for the intubation supplies. ¬†Sadly, this gentleman had suffered from a cerebellar stroke a week ago and they had attempted an extubation a couple of hours prior to my arrival. ¬†Needless to say, his respiratory effort was wearing me out…and I had already huffed and puffed my way up several floors of stairs (my preferred method of solo transport). ¬†Once the supplies were ready, it was go time. ¬†Labs checked out ok. ¬†He seemed to be moving all extremities appropriately, despite his stroke. ¬†All systems go. ¬†After the drugs were pushed through his central line, I took¬†a look and quickly suctioned his posterior oropharynx — there was mucus covering his glottic opening. ¬†Once it was cleared, I skillfully maneuvered the endotracheal tube through the vocal cords and secured his airway. ¬†The end tidal CO2 detector changed color appropriately and bilateral breath sounds were established. ¬†For those crucial few minutes, everything around me seemed to halt. ¬†I consciously let out a sigh of relief and thanked the RT and nurses who were present in the room for their help. ¬†The beauty of my job is that it’s ever changing. One must be flexible enough to adapt to different types of cases as well as challenging anatomy and situations. Plus, I get to meet all types of people from all walks of life. Therein lies the reason why I love my job.

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Adversity

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After A While
by Veronica A. Shoffstall

After a while you learn the subtle difference between holding a hand and chaining a soul
And you learn that love doesn’t mean leaning and company doesn’t mean security.
And you begin to learn that kisses aren’t contracts
and presents aren’t promises
And you begin to accept your defeats
with your head up and your eyes ahead with the grace of a woman, not the grief of a child
And you learn to build all your roads on today
because tomorrow’s ground is too uncertain for plans
and futures have a way of falling down in mid-flight.

After a while you learn that even sunshine burns
if you get too much.

So you plant your own garden and decorate your own soul
instead of waiting for someone to bring you flowers.

And you learn that you really can endure
that you really are strong
and that you really do have worth
And you learn and you learn
with every goodbye you learn…

‚ô•

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