Ebola Face to Face

512984219Trying to understand what it might actually be like to be in an African nation stricken by Ebola virus infection running rampant is mere speculation for most of us.  On PodMed this week, with an eye toward promoting better understanding of the human dimension of this global health crisis, Rick and I depart from peer-reviewed studies to feature a perspective piece in the New England Journal of Medicine: Face to Face with Ebola — An Emergency Care Center in Sierra Leone. Our thanks and kudos to the author, Anja Wolz, R.N., who has been working in this center in Sierra Leone with the international aid organization Médecins sans Frontières, or Doctors Without Borders, for the last seven weeks. What she describes provides a window into the daily ordeal of attempting to stem the tide of this infection. Slideshow recommended.

Anja begins her shifts at the 80 bed Ebola case management center at 6am. The place is staffed 24 hours a day every day of the week in three rotating shifts.  In relating a typical day Anja comments that those who work there are thankful when it rains, because the personal protective equipment (PPE) isn't as hot as it is when the sun is shining. Even so, personnel are limited to 40 minutes of wearing the full regalia because it simply becomes unbearable, yet it is easy to lose track of time with so many tasks to complete in the isolation area. Donning the PPE takes fully five minutes to perform, in the company of a designated dresser, whose task it is to make sure no skin area, however minute, is exposed.  Overalls, aprons, double gloves, two masks, boots; some of these will be sterilized and reused, but the majority are burned after use. Before PPE can be removed those who've been in the isolation areas are sprayed down with a chlorine solution, and removing the garb is as elaborate a ritual as putting it on.

The organization of the care areas speaks to the knowledge of the staff in containing infection. The center is divided into two areas designated low- and high-risk regarding contagion.  Low risk areas include the pharmacy, laundry, laboratory, water chlorination area, dressing area and staff meeting area, while high-risk or isolation areas are those where patients are housed.  These last are organized into suspected, probable and confirmed Ebola cases, and the staff proceed through them systematically beginning with the suspected case area. Patients become sicker in successive tents, and they are also warned about the possibility of cross-contamination amongst themselves.

This points up one of the most poignant aspects of Anja's narrative:  the total lack of human touch between staff and patients, or between patients, even when the patients are children.  She relates the death of two young children in her recent charge, and rues the fact that she cannot touch them. She notes the fear apparent among patients as they learn the results of PCR tests to confirm infection and their subsequent advance to the next tent. Fear, Rick and I note, is just so prominent in this crisis; today the news outlets reported the stoning death of 8 community outreach workers in Guinea because people thought they were conveying Ebola infection.  Even here in the educated and informed US, fear is prominent, although some might argue not prominent enough as we have been rather slow to respond to this crisis.  Hopefully global efforts are underway now.

Other topics this week include generic versus brand name statins in Annals of Internal Medicine, and spinal manipulation and sciatica in the same journal, plus CT versus ultrasound for diagnosis of kidney stones in the ED in NEJM.  Until next week, y'all live well.


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