Major Incidents, Patient Care

Treating the Ebola Outbreak in Western Africa

Issue 6 and Volume 43.

Ogweno and his team brought as many as 25 patients a day to the ETU. Photos courtesy Elvis Ogweno

Working in EMS on an Ebola mission means you’re the first contact with the patient and the family. What you tell them matters a lot.

When visiting a contaminated home, our team, which consists of a driver, two hygienists, one paramedic, and one psycho-social nurse, has to perform both donning (i.e., putting on) and doffing (i.e., taking off) our personal protective equipment (PPE) in the field.

Before entering the house, we run through a PPE checklist: Scrubs, gum boots, gloves, Tychem suit, mask, hood, apron, goggles, and gloves (again).

“Ready?” I ask the hygienist assisting me.

She shakes her head and grabs a small strip of duct tape, covering the space between my hood and goggles where a thin slice of skin was showing.

“Now you’re ready,” she replies.

The temperature in most parts of Liberia is just over 80 degrees F. The humidity is even higher. I feel the sweat collecting between my skin and the suit, pooling in my boots and along the bottom of my goggles as I slowly follow the one of the hygienists, who’s also dressed in full PPE, into the patient’s house (i.e., the high-risk zone).

It feels far more like we’re scuba diving in a hot spring than a conducting a normal inter-facility ambulance transfer in the city, but that’s exactly what we’re doing.

A few moments later, I meet my suspected Ebola patient, a young man who had wandered away from his bed during the night and is now lying on the ground near the edge of the bed.

He’s tired and confused. He doesn’t know where he is, or why there are two men in what look like space suits towering over him.

The hygienist with me calmly reassures him, and together we help lift him to his feet and guide him back to his thin mattress.

He’s profoundly weak, and, as we walk, I notice that his pants are soaked through with diarrhea—a hallmark of the disease.

We lay him down and urge him to drink some water mixed with oral rehydration salts.

I begin to complete a patient care report (PCR) to find out if the patient meets the case definition.

I then see another patient crawling in the next room, and I assume it’s a relative of the patient I’m currently diagnosing.

It seems that, by sharing their belongings, food, and living so close together, the whole household has been infected.

I start to feel exhausted from the heat, but I can’t give up because I need to finish the complete assessment and diagnosis before we load the patient into the ambulance for transfer to the Ebola treatment unit (ETU).

I minimize communications with the patients to save energy and start using hand signals to communicate with my teammate.

The rest of the team, not dressed in full PPE, remain outside the house at a distance (i.e., the green zone). However, we maintain communications if we need assistance or additional equipment.

After diagnosis, the three patients are led into the ambulance (i.e., the red zone). With every step the patient takes, the hygienist sprays chlorine to kill the virus.

From a distance, the psycho-social nurse talks to the patients and explains where we’re taking them and what will happen at the destination. He also encourages the patients to continue drinking water—an important component of Ebola care.

The rest of the family is left behind as we start our journey back to the ETU.

After finishing our transport of the three family members, they’re handed over to the awaiting ETU nurse and the ETU’s hygienist team—all of whom are dressed in full PPE. Finally, the team cleans the ambulance and then leaves it to dry, so we’re ready for the next call.

Ogweno training the Ebola rapid response team how to survive the heat while wearing full PPE.

Ogweno training the Ebola rapid response team how to survive the heat while wearing full PPE.

Ebola Rapid Response Team

In August 2014, I signed up with International Medical Corps, a U.S.-based non-governmental organization (NGO), to lead a team designated for transporting both suspected and confirmed Ebola patients and blood specimens in Liberia.

When I arrived in Liberia and was assigned to be the ambulance coordinator of the first two-ambulance team on Sept. 15, 2014, I became a pioneer in the transport of suspected Ebola patients.

This was also the date that the second Ebola treatment center was opened in the country.

My team would travel via helicopter to the most remote villages to treat sick people who couldn’t otherwise get treatment. We also used ground-modified double-cabin pick-up trucks as ambulances.

Within two hours of our arrival in a village, we would set up a rapid isolation unit to isolate the suspected patients, and keep the rest of the village safe from being infected.

No one knew how to transport an Ebola patient; it was trial and error. I had to make sure every one of my staff was safe. I dressed in PPE every day, and would go out into the field to show my staff how to do the job, and show them that they could trust me to keep them safe.

We stood by our training and our policies and everyone stayed safe.

Our operations were carried out only during daylight hours, due to the risks of driving at night and having to put on PPE without adequate lighting.

On an average day in West Africa, we would bring as many as 25 suspected Ebola patients to the ETU within 10 hours.

Ogweno dressed in full PPE, ready to enter the red zone.

Ogweno dressed in full PPE, ready to enter the red zone.

Impact on Healthcare Providers

For decades now, Ebola has captured the public’s imagination with its exotic name, high fatality rate, and the fear that it can cause people to bleed from odd places. Until recently, though, if you asked any global health expert about the diseases that keep them up at night, Ebola wouldn’t have made their list.

What makes Ebola different from so many other public health threats is the effect it has on healthcare providers, and, as a result, on the entire healthcare system.

Ebola alone didn’t cause catastrophe in West Africa. Fear played a part in it as well. Every day in Liberia, I heard stories about people dying of perfectly treatable diseases, since many hospitals and clinics had shut their doors: A woman in labor who bled to death; a baby half-delivered due to the lack of a midwife; a driver who crashed his truck and was left to die because there was no functioning trauma center; a young child who seized and died from malaria—after his mother had visited multiple hospitals and clinics, all of which were closed.

To put it bluntly, Ebola kills EMTs, paramedics (referred to in most African countries as “ambulance attendants”), nurses and doctors, almost preferentially.

This shouldn’t be surprising; Ebola is spread by contact with the body fluids of symptomatic patients—and nobody has more contact with the body fluids of sick people than medical personnel.

Ogweno with the Ebola rapid response team.

The toll that Ebola has taken on clinicians and public health professionals alike means that the very people who once calmed their patients’ fears, who assured us that everything was going to be okay if we only kept calm and did as directed, were now running scared themselves, and that’s frightening indeed.

Ebola, though, isn’t all that frightening. It can be destroyed with weapons as simple as chlorine, alcohol, soap, detergent and sunshine.

With the right precautions in place, including protective equipment and triage protocols to identify those most likely to have the disease, healthcare workers can safely treat patients of all types without the fear of dying themselves.

Ultimately, the local EMTs, paramedics, nurses and doctors bore the brunt of this epidemic, working long hours responding and caring for desperate patients without the proper protection, watching as their colleagues fell ill around them. The vast majority of them were more than willing to come back to work once their safety was ensured by the introduction of protective equipment and protocols.

When the public saw healthcare providers saving lives, unafraid to treat Ebola patients, they were suddenly more willing to bring themselves and their loved ones to the hospital early, before the disease had a chance to spread.

When transmission stopped, the epidemic stopped, and life in West Africa returned to normal.

As brave and heroic as they are, there simply weren’t enough trained EMTs, paramedics, doctors and nurses in West Africa to stem the tide of this epidemic on their own. And because the necessary protective equipment is expensive, the impoverished countries of West Africa couldn’t afford it on their own, and sought support from NGOs like ours.

A suspected Ebola patient is loaded into a makeshift ambulance.

Elijah

When the Ebola outbreak was at its height in Liberia, I met a 12-year-old boy named Elijah. A call had come into the ETU around 4 p.m. regarding a sick boy who’d been waiting for an ambulance for more than a day.

Despite the fact that the call had come in past the daylight curfew for deploying ambulance teams, we decided it was important to pick up the young patient immediately.

After a five-hour drive to the small village, we arrived to find that Elijah was displaying the classic symptoms of Ebola.

After dressing in PPE, I diagnosed him, completed the PCR and loaded the patient in the ambulance. We arrived back to the ETU around 1 a.m., where Elijah later tested positive for Ebola.

I felt a special responsibility for the young boy. Every day, I would dress up in full PPE and enter the ETU to make sure he was eating and taking his medications. If he hadn’t eaten that day, I sat with him and helped him eat.

I was impressed by Elijah’s steady improvement; it gave me more motivation to go out and help the needy every day. Within a few days, he started to sit outside in the sun, and a few days after that, he was running around in the yard.

After three weeks, we did another test, which came back negative. Elijah was a survivor. He was soon discharged to go back home.

On the day he was discharged, he told me that he had heard that a person infected with Ebola could receive the blood of an Ebola survivor and be cured.

I explained the science behind this process to him. He told me, ‘If you ever get Ebola, I’ll volunteer to give my blood to save your life.’’

It was the most memorable moment for me throughout the entire outbreak.

When visiting a contaminated home, the Ebola rapid response team has to perform both donning (i.e, putting on) and doffing (i.e., taking off) PPE in the field.

No Condition is Permanent

There was a dire need for the international community to stop treating this crisis like a horror movie—closing its eyes tightly until the scary part is over—and instead treat it like a real humanitarian disaster that required an adequate input of monetary, logistical and human resources.

A sufficient supply of experienced international aid workers, including EMTs, paramedics, nurses, doctors, epidemiologists, sanitation engineers, lab technicians and logisticians, provided with the proper protection and resources, could have brought this particular crisis to a halt in a matter of months.

It’s true that most humanitarian emergencies can’t be solved by humanitarians alone, but the Ebola crisis in West Africa was an exception to the rule.

Ebola Myths and Facts

Myth #1: Ebola is universally fatal.

Ebola can certainly be fatal, but not universally so. The case fatality ratio for Ebola and its close cousin, the Marburg virus, varies greatly depending on the setting.1 The first recorded outbreak of these diseases, which occurred in Germany and Yugoslavia in 1967, had a mortality rate of 23%. This is high by any standard, but far lower than the 53–88% mortality seen in subsequent outbreaks in sub-Saharan Africa over the next 40 years.2, 3

This first outbreak also occurred before anything was known about the disease, and before the widespread availability of EDs in Europe. When it comes to the likelihood of dying from any disease, geography matters.

Myth #2: Ebola isn’t treatable.

There are actually several effective treatments for Ebola that can help support individuals through the worst phases of the disease and increase their chance of survival. These treatments include early and careful resuscitation with IV fluids; blood products such as packed red blood cells (PRBCs), platelets, concentrations of clotting factors to prevent bleeding; antibiotics to treat common bacterial co-infections, respiratory support with oxygen (in severe cases, via a ventilator), and powerful vasoactive medications to counter the effects of shock. Modern diagnostic equipment can help doctors and nurses continuously track vital signs to rapidly detect and manage new complications of the disease and stay one step ahead of the virus. Access to emergency and critical care services could help save patients with Ebola, as well as those affected by these and many other more common killers.

Myth #3: Ebola is the most contagious disease, and will spread rapidly across the U.S. if it enters the country.

Ebola isn’t the most contagious disease known. It’s not airborne and it’s not spread by aerosols (small droplets that float through the air). This makes it less contagious than a host of other diseases, such as measles, chicken pox, tuberculosis, or even the seasonal flu. To the best of our knowledge, Ebola is spread only by close physical contact, especially with bodily fluids. So, unless someone on the subway vomits, defecates, or bleeds on you, they aren’t going to be passing Ebola onto you.

In a medical setting, all that’s required to prevent the spread of Ebola from patient to healthcare provider to patient is the use of “contact precautions,” which include gowns, gloves and regular hand-washing after every patient contact.

These precautions are already the standard in the intensive care units of all U.S. hospitals where patients with Ebola would be treated.

Myth #4: We need to give experimental Ebola drugs to as many Africans as possible to help stem the outbreak.

Any human given an experimental treatment that hasn’t yet been proven safe and effective in humans is, by definition, being experimented upon. Experimenting on humans, even those in poor countries, isn’t necessarily a bad thing.

Conducting research in resource-limited settings is part of what I do for Partners in Health. However, every person enrolled in a medical research study is entitled to the same basic international ethical protections—and people in poor countries actually deserve special protections.

Myth #5: Nothing can be done to help Africa—it’s just too poor.

The true tragedy of the Ebola outbreak is that most Africans lack access to the very same medications, equipment, and skilled physicians and nurses that have been available in the U.S. and Europe for several decades. Access to these things could have prevented the current epidemic from raging out of control.

These very same measures could also be used to reduce mortality from the variety of other diseases, aside from Ebola, currently killing Africans each day.

ReferenceS

1. About Marburg hemmorhagic fever. (Dec. 4, 2013.) Centers for Disease Control and Prevention. Retrieved May 3, 2018, from www.cdc.gov/vhf/marburg/about.html.

2. Mboup S, Musonda R, Mhalu F, et al: HIV/AIDS. In Jamison DT, Feachem RG, Makgoba MW (Eds.), Disease and mortality in sub-Saharan Africa, 2nd edition. The World Bank: Washington, D.C., 2006.

3. The leading causes of death in Africa in 2012. (Oct. 31, 2014.) Africa Check. Retrieved May 3, 2018, from africacheck.org/factsheets/factsheet-the-leading-causes-of-death-in-africa/.