Thoughts on Ebola

 Working at the hospital and on the ambulance, it has been heavy duty Ebola lately. Memos, flyers, posters, policies, and lots of questions. I have written power points, given talks and had many conversations on Ebola. Every day I read the CDC site for updates, which are numerous. I have even, along with two of my daughters, played an Ebola patient in a hospital drill.

Ebola hasn’t been with us long, but already I am hearing a lot of people have Ebola fatigue. While the actual number of cases in the US is likely to remain small – at least in the near term -- I don't think we have heard anywhere near the last of Ebola.

Ebola is like a serial killer assassin who we believe is coming here to do some killing. We are not certain his target, but we believe, based on his rap sheet, he will most likely come after health care workers. We have set up roadblocks at airports, the most likely place Ebola is going to enter the country. We are quarantining people who are coming in from West Africa. In some states like Connecticut, we are quarantining people even if they are symptom-free, just to make certain Ebola is not hiding out in them. And, thankfully, we are hopefully training all of our responders in the proper use of PPE, and letting them practice in case Ebola shows up in our town and we show up on his scene.

Ebola is a tricky microbe. While he has us all busy up here in the US of A battening down the hatches to keep us all safe, he is doing his really nasty work down in West Africa. We can take all the safeguards we want up here, but unless we can stop Ebola in West Africa, we are going to be dealing with Ebola for a long time. Sure we can limit his damage and contain him in each isolated case that comes to America, but there will be more and more cases here unless we kick his ass in Africa and drive him back into the bats in the jungle from which he likely came.

Think about this. With, at the time only 2,000 cases of Ebola in West Africa, Ebola sent two exports out -— one to Spain and one to Texas. (Imagine if the guy in Texas went to a bar instead of a hospital, and there he got drunk, vomited, stumbled, hit his head, died and then someone lifted his wallet before calling EMS). The cases are increasing exponentially in Africa. People are dying in the streets and in crowded apartments. There are not nearly enough isolation centers to contain all the patients. The CDC has predicted there could be 1.4 million cases by January. 1.4 million. Wow. That's some heavy duty suffering. And for those who care only about this country, how many of those cases will be exported here? Imagine even if they don't get to the US right away, what if they get to India or China, countries that may not be able to contain Ebola like we can? More cases, more exports here. More chance we are in his reach. Millions dead and Worldwide Ebola's red laser on our foreheads the next time we walk into an unknown.

Those of you who have seen the movie World War Z may recall a scene where Brad Pitt and his family are eating breakfast in their home while on the small TV Zombies are eating everyone in sight. Think Ebola. I say load up the transport planes with building materials, IV fluids and PPE gear. Recruit doctors and nurses and paramedics and EMTs and send them in with combat pay. Here's a real chance to be a hero, to make a difference. You can go from being Meat in the Seat up here to Ebola Killer. You think you're an inner-city bad ass with a bullet-proof vest and an ET tube? Imagine yourself with a blue hood and cape on the continent where we all came from. Fighting for the future of civilization. Beat Ebola down in his own hood.

Isolate those with symptoms, give them the best care and most compassion we can, and trace their contacts. Isolate, treat, and trace on and on until there are no new cases – at least until the next time Ebola spills over from the jungle to people. Just as Ebola did last December to a 2 year old village boy. One two year old boy in December. 10,000 Ebola cases today. 10,000 is no easy task, but if we don’t act now, there will be 100,000, then a million. The math won't be working in our favor.

Tired of asking patients if they have traveled to West Africa? What question will be asking a year from now? It depends on how and where we respond today.

STEMI Call

 Years ago my favorite calls were the traumas-- the shootings, stabbings, high-speed MVAs. You were on the clock and there was a task list. You had to c-spine immobilize the patient, get their vitals, put in two large bore IVs, open up the fluids wide, and do it all on the go, as well as getting name, date of birth and social security number on your race to the trauma room.

After the initial rush, they were unsatisfying because the calls were over almost before they even started, and there wasn’t a real sense that what you did for them made any real difference. Their injuries were their injuries. It is hard to fix a bullet to the head, a broken spine or a torn aorta. And eventually we learned that the fluids wide open and even the c-spine were bad for the patient.

Today, my favorite call is the STEMI. It is also a clock and task call, but there are so many more tasks. Plus your recognition abilities are tested and the outcomes are much better. Do your job well and can make a huge difference. Screw up, either missing the recognition or not calling soon enough and the patient will suffer harm.

Here’s my vision of the perfect STEMI:

I get called for an unusual complaint, toe pain or vomiting or something not quite so obvious as “Man clutching chest, says he’s having the big one!”

My sixth sense tells me to do a quick ECG. Within two minutes of arrival, I have the patient’s chest exposed, and am running my 12-lead. It is not a huge honking STEMI with tombstone T-waves. No, it is subtle. Let’s say an isolated posterior, where I spot the inverted T waves in V1-V3. No hesitating a moment, I am on my cellphone simultaneous with tossing four baby aspirin in the patient’s mouth (after of course asking is he has any allergies.) On the phone, I call CMED, and request a phone patch with medical control for the STEMI Alert to my favorite cath lab hospital. As they connect me, I orchestrate getting the patient on the stretcher, after first having him stripped naked and have applied the defib patches, and then of course recovered him with the sheet. We are already moving down the hall when the doctor picks up. “This is Ace paramedic with a STEMI Alert requesting cath lab activation, " I tell him. "I have a 55 year old male with toe pain and a diagnostic 12-lead that shows a posterior STEMI with isolated T wave inversion in V1-V3. He says his father and seven uncles all died of MIs at the same age after experiencing the same symptoms. We’re twenty minutes from your door. I’ll transmit when I get down to the ambulance, but trust me on this one…”

En route, I bang in two large bore IVs, give the patient Zofran and Fentanyl (He’s vomiting now and in 10 of 10 pain that has now moved from his toe to his chest). His ECG has now popped an inferior with elevation in II, III, and aVF. I withhold the nitro to not risk knocking his pressure down. I get all his demographics while explaining to him what will happen at the hospital, how we will go right up to the cath lab and they will put him on the table and run a wire into his heart to clear the blockage. I stop the explanation only long enough to defibrillate him as he goes into sudden v-fib, but because I have the pads on already, I just shock him back to our conversation, missing only the slightest beat.

At the hospital, I hand the demos to the registrar and she chases after us with the bracelet. The ED staff bows as they signal for us to go right up to the cath lab. We are upstairs in a flash, and on to the table, where after the patient signs the consent with the pen I have already strategically put in his hand, cap off, ready to sign. Before we even have our stretcher out of the room, the interventionist (using the radial artery approach) has the wire across the lesion and the patient sighs and says, “Wow, I feel so much better,” and the cath lab doc says, you owe your life to these wonderful public servants. Door to Balloon 9 minutes, beating your old record of 10 minutes. Hats off gentleman!”

That’s how its supposed to go.

Here’s how my last one went.

Dispatched to MD’s office for “Confirmed STEMI.”

Now, keep in mind, I have been to many doctor’s offices for ECG changes that the doctor thought was a STEMI, but clearly were not. “Interesting, doc," I say looking at the ECG he has handed me. "How long has the patient had a pacemaker?” But in this case, the doctor’s office is actually a cardiologists’s office so "Confirmed STEMI" sounds much more likely.

Mentally, I psych myself up for the call. Got to make this qood and quick.

The Fire Department first responders are already there. There are in fact so many of them, I can barely make it the room. Someone hands me a 12-lead ECG and sure enough it looks like an inferior STEMI. ST elevation in II, III, and aVF, slightly less than 1 mm, but with a distinct cove shape as well as slight reciprocal depression in I and aVL.

I look for the patient now, and after clearing the room somewhat I find a fairly athletic looking man in his 50’s sitting comfortably in his chair. I introduce myself and ask how he is doing. “Fine,” he says. "I feel great."

He does not look like a man having a STEMI. I ask him if he is having any pain, nausea, shortness of breath? Nothing. How did you come to be here today? He says he saw his own doctor earlier in the day, and the doctor was concerned with his ECG so he set up the appointment this afternoon with the cardiologist. I ask why he saw his own doctor this morning. He says he wasn’t feeling well yesterday. He says he felt like he had the flu.

I have him strip down and get him in a gown, then attach him to my monitor and start taking him down to the ambulance. I did not get a chance to speak to the doctor directly, but the staff tells us to take him to the cath lab at their affiliated hospital. They will be expecting him.

In the ambulance, I do my own 12-lead so I can transmit it to the hospital. Not certain that I have to, since the patient is apparently already scheduled to go there, but it is protocol, and you never know. I do my 12-lead and it looks like this:

I look in the lower left at my inferior leads and I only see elevation in one lead, and the corresponding lateral depression is gone. I re-check my placement. It is pristine. I ask the man again about how he feels and he says he is fine. No symptoms. I ask about family history. None. I start to wonder if maybe the 12-lead placement in the doctor’s office was screwed up. I transmit the 12-lead calling in a STEMI alert, telling them we are en route to the cath lab. I mention that the patient is asymptomatic and my 12-lead is no longer showing the clear STEMI the doctor’s office ECG was. They tell me they are familiar with the patient and I should continue to the cath lab.

Meanwhile, I am trying to get an IV, and having difficulty. The first blows. On the second, the catheter bends on the patient's tough skin. On my third shot I have dropped from an 18 to a 20 to a 22 which is all I can fit in the one vein I can find in the wrist. At least this one is good.

I ask the patient again how he feels and he assures me he has never felt better. I open my mouth then and say, well, maybe his arteries will come out clean and this all just a better safe than sorry deal. I feel great, he said again, putting conviction into it.

When we arrive at the ED, their first question is did we patch? Most certainly. I have the name and social security and DOB all set for the registrar, but they are training a new registrar and tell us to wait. When I tell them we are supposed to be going right up the cath lab, I am able to leave my piece of paper with them so they can enter it.

Up in the cath lab, the team is waiting for us. They ask if we have registered the patient and we say yes, we left the information with the registrar. They demand to know why the patient doesn’t have a bracelet on. We repeat that we registered them. More argument until someone announces the patient's name is in fact in their system now so they can begin their procedure. The doctor comes over and I hand him the ECG and tell him the patient is asymptomatic. He stares at the ECG as well, then begins the questioning. At first the patient denies the symptoms, then under grilling he confesses that it feels like someone is sitting on his chest, and that he was sweaty earlier and also felt nauseous. My partner and I just shake our heads and remain silent. It never ends. The man has a hairy chest and the leads are coming off. One of the nurses plucks at them so my partner goes ahead and takes the man off the monitor as we prepare to move him to the table. Another nurse looks at me and demands to know why I took him off the monitor before they hooked him up to theirs. Again, I just shake my head, thinking why are you yelling at us?

We get him over then sure enough, as they look for what kind of access I obtained, they see the 22 and the harassment starts anew. "A 22! That's all? A 22!" We don’t bother to stay to watch the procedure. We just pack up our stretcher. On the way down in the elevator, I say to my partner, "10 times I asked him if he felt anything but fine." "What are you going to do?" my partner says.

The call is completely unsatisfying. Last time we went up that lab we were heroes, treated like honored guests. Today we are just bumbling delivery workers. I sit in the ambulance and stare at the ECG. I still can’t figure it out. There is elevation where there should be depression and no elevation where there once was. It takes me 10 minutes of starring at it to figure it out.

The first six leads are completely scrambled.

Lead I is where Lead II should be, lead II is where aVR should be, lead aVR is where III should be, lead aVR is where III should be, aVL is where I should be, and aVF is where aVL should be.

F-me, I say. Can you believe this?

I think what would have happened is I had this guy on the street, presenting like he was, denying any problem and this was his ECG. I would never have called it a STEMI. Good thing he was already booked for the cath lab.

Back at the base, I report my monitor malfunction and have the monitor reprogrammed. I go into archives and I am able to retrieve the 12-lead now in the proper order.

In 20 years, I have never seen anything like this. I find an ECG from earlier in the day and see it too was scrambled. I find one from two weeks before with the same monitor and it was proper.

I can only think of 2 explanations. 1. There was a computer glitch or 2. Someone went in and reprogrammed it.

You get so used to seeing things a certain way, you don't notice the lead labels anymore.

Ebola

 Virginia suddenly started dying from what turned out to be the only strain of Ebola that doesn’t affect humans. A great read and thriller that I highly recommend.

Over the years I have followed the periodic outbreaks of the Ebola virus that all were fairly quickly extinguished. I also read another great book called The Coming Plague: Newly Emerging Diseases in a World Out of Balance by Laurie Garrett about emerging infectious diseases, which I also highly recommend.

There are few who are not aware of this current outbreak of Ebola, which continues to escalate and for the first time reached this county with a patient found in Texas, although most believe this additional cases that may reach us, will be fairly easily contained because of the health care structure here, higher sanitary standards and the cooler climate. Let us hope so.

Let me try now, based on what I have read to describe how the Ebola outbreak happened and why it has been so bad, as well as make some predictions for the future.

Ebola may have lived in the jungle for millions of years. Although its natural reservoir has not been found, most believe it likely lives in bats. A bat with Ebola eats some fruit, which it drops while flying. A chimpanzee picks up the fruit and eats it, getting some of the bat's saliva in its mouth, and then the chimp gets sick and dies. Perhaps in more recent days, a hunter comes along and eats meat from the freshly deceased chimp. The hunter gets sick and dies alone in the jungle, or returns to his isolated village where half the tribe will die because they believe they have angered the spirits. Life goes on.

Fast forward to the modern world. The jungle has been deforested, roads have been built. The dead monkey is now brought into the village, where it is eaten by several people, who infect other members of their families. Hand washing is not a norm in their culture. One of them, who does not yet know he is sick, takes the road to the next village, where he becomes ill and spreads the disease to others. Soon Ebola is in the city, and the fear is it is next on an airplane and landing in New York City or an airport near you.

Typically, in past cases as soon as there has been an outbreak, health workers have quarantined the sick and traced all of their contacts. This time the system broke down. There weren’t enough workers and in some cases the workers who all arrived in yellow suits spooked the villagers who thought that perhaps the workers were the ones spreading the disease. People hid in the jungle or hid their symptoms. Some visited a bush doctor who declared she could heal the sick. There was lots of hands on attempts at healing. She died along with most she had contact with. In one area armed men attacked a quaranteen center believing the doctors were evil. Other health workers were macheted to death by those who blamed them for the outbreak. Infected patients fled.

Ebola is spread by body fluids -- saliva, blood, vomit, feces, urine, perspiration and by prolonged touching of the dead body. In Africa, when someone dies there is a lot of touching and cleaning of the body. Also, in Africa, the hot humid climate contributes to perspiration and makes cleanliness difficult. There is a lack of medical supplies and beds for sick patients. They die because Ebola cripples their immune systems, the vomiting and diarrhea lead to dehydration. They are ravished by infections, their organs fail. Bodies are not disposed of properly. The virus spreads again.

The Americans who have gotten the disease and survived likely survived not because of the “miracle drug” they received, but because they got first rate medical care, hydration, electrolyte replacement, and antibiotics in a timely fashion. Fluid replacement is critical to survival.

Many fear the the worst case scenario is if this strain of Ebola mutates (Ebola as an RNA virus is subject to constant mutation) into an airborne contagion. There reportedly was a study that showed the virus was passed by pigs to monkeys through a respiratory droplets, but I have also read that they don’t know that the disease might not have been spread in another manner, passed by unclean conditions in feces from one stall to the next.

I am currently reading a third recommended book called Spillover: Animal Infections and the Next Human Pandemic by David Quammen. Ebola is a zoonotic disease, meaning a disease that has jumped from animals to humans -- like SARS, avian flu, rabies, Lyme Disease and Hanta Fever. According to Quamman, these zoonotic diseases are becoming more and more prevalent as we humans disrupt the natural world and allow these diseases the opportunity to catch a ride on humans. He cites a great example of the opportunity for a disease to jump to humans. Cities and villages disrupt the forest, bats now live in closer contact with humans. A farmer builds a giant pig stockade under a mango tree that is home to many bats. A sick bat eats a mango that drops to the pig pen. The pigs eat the saliva infected fruit. The pigs live in close quarters with each other and then are shipped all over Asia, again stored in tight dirty quarters. Feces is spread from one pen to the next. A rule of epidemics is population density increases the threat of the spread. Walla!

With regard to Ebola, he makes an interesting observation. He says Ebola is not very contagious but extremely infectious. By this he means, you can sit in a crowded room with someone with Ebola and perhaps no one else in the room will become infected, but should you give the Ebola patient an Iv, and accidentally prick your finger, you could be dead in seven days without proper care.

Generally Ebola is not contagious until it turns symptomatic. The fear again is someone who is not symptomatic gets on a plane, and becomes symptomatic shortly after landing. (One of the American doctors had been scheduled to return home a few days before he became sick, but was delayed so he was still in Africa when he became symptomatic). When someone fits this scenario, what if they believe their symptoms are not due to Ebola, but perhaps a common cold or the flu? What if in fear, they deny their symptoms instead of seeking immediate help. We need to be ready.

What are the symptoms of Ebola? The key early symptoms are fever, sore throat, and body aches, followed shortly after by abdominal pain, vomiting and diarrhea. GI and mucosal bleeding comes later. Some people develop a rash. Patients will go into shock before death, and become listless. Oddly, hiccups can be a telltale sign.

For EMS providers, according to the latest CDC advisory, we should be on the alert for patients who are both symptomatic and who have risk factors such as recent travel in an area ravaged by Ebola.

As I mentioned because it is an RNA virus, it mutates easily. Perhaps it may mutate into a less lethal disease, which while good on one hand, would mean it would then have a greater chance of spreading and staying alive in humans, while causing great although not as lethal suffering.

One of the books I read said we need to not view Ebola as invading our world, but as humans living in Ebola and other microbe's world. We are both prey and a vehicle for Ebola’s survival. If it kills us too efficiently without finding a way to spread to others, it will not survive in humans.

Two things I predict in the near future, we will see more Ebola cases in the US. With luck, these people will be quarantined(the government has this power), and their contacts checked, and excellent care given them, and the spread will be minimal. Nigeria has reportedly done a great job at halting the spread of the disease in their country through such measures. Liberia and West Africa lack the infrastructure to do this, thus the disease continues to rise there, and will until sufficient resources gain traction. I also predit shortly after out first case of Ebola in Texas, we will experience an even greater number of Ebola scares or false alarms that will test us.

What will you do when the dispatch comes for the man vomiting blood recently arrived from West Africa? What will your partner and the first responders do? How will the hospital staff react? How will your friends and family react to you when you tell them about the call? Will they even let you in the door? Or maybe out of fear for your family, you won’t want to possibly risk infecting them. Where will you go? (It is good to keep in mind if you are exposed, you have time to go home have a nice family dinner, and then back your suitcase before you are at risk of infecting your family.)

Chilling times.

I don’t think Ebola will be the end of the world for us here. The fact that for the most part the disease doesn’t spread until it is symptomatic (although it stays in the semen of men who have recovered from Ebola and can be passed sexually for up to six weeks) heightened awareness, cooler temperatures, different habits, hand washing, and a strong public health structure should protect us.

I said at the beginning I would make a prediction for the future. Here it is. At some point in the future, a super deadly disease will come out of the jungle and wreak havoc worldwide. Imagine an Ebola like illness that spreads through the respiratory route but stays hidden in the body while still being contagious. HIV came out of the jungle, caught a ride on a dirt road to the city or came downriver on a canoe, and then jumped a plane to the modern world, and 30 million have died with another 30 million infected. The coming plague that Laurie Garrett writes about in her book and the others have talked about may be among us one day. I don’t think Ebola is it. From what I have read, what experts fear the most is a pandemic flu that spread across the world in a matter of days.

All we can do is plan and prepare.

Here is the latest CDC guidance:

EMS patient assessment criteria for isolation/hospital notification are likely to be:

1. Fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding.

AND

2. Travel to West Africa (Guinea, Liberia, Sierra Leone, Senegal, Nigeria or other countries where Ebola transmission has been reported by W HO) within 21 days (3 weeks) of symptom onset.

If both criteria are met, then the patient should be isolated and STANDARD, CONTACT, and DROPLET precautions followed during further assessment, treatment, and transport.

IMMEDIATELY Report Suspected Ebola Case(s) to Receiving Facility.

Source-CDC

Check out these links for more CDC Ebola Advisory Information:

Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients with Known or Suspected Ebola Virus Disease in the United States

CDC EMS Checklist
Stay safe.