http://www.tfmetalsreport.com/comment/437365#comment-437365
The Ebola Potential Hits Home in our Emergency DepartmentThe public realization that Ebola is here in the USA has been like an electric shock through our hospital’s emergency department and EMS staff. We are stunned--standing motionless like the deer in the headlights. What do we do? We have absolutely no workable protocols in place for how we would deal with patients suspected of Ebola infection. Absolutely none. Our usual infection control procedures have evolved around the agents we traditionally face: aerosol and blood borne pathogens (Influenza, TB, Hep C, HIV) which require one approach, and low lethality contact pathogens (C. Dif, MRSA and VRE) another. But when a high-lethality pathogen like Ebola shows up, spread by contact, blood, large droplet spray, and is known to persist on surfaces for hours—we have absolutely no effective procedures in place. This is completely new.
Imagine this scenario: An African standing in front of the triage nurse in the ER lobby says: “I am just returning from Sierra Leone where I cared for my mother who just died of Ebola. I have a fever and headache and feel really weak. I need to lie down right now.” Then she vomits and slumps down onto the floor.
The act of vomiting puts large infectious droplets into the air splattering all surfaces within several feet. The nurse and EMT at the triage desk should assume that the droplet spray covers their clothing, hair, exposed skin, eyeglasses and shoes. The triage staff needs to immediately stop work, go take a shower, change clothes and shoes before returning to patient care. (How would you feel about having your blood pressure checked by a nurse and using equipment known to be covered in an Ebola infected droplet spray?)
Problem #1: There is no staff shower readily available. (The hospital was not designed for Ebola care.) Most workers do not have a change of clothes (though extra scrubs can be found in the OR) and none have a change of shoes. What are our viral disinfectant procedures for staff showers? What becomes of the washcloth and towels used? How about the surfaces of the bathroom itself? Would you be comfortable showering in a shower last used by an Ebola splattered person?
Problem #2: The area around the triage desk including the walls, computer, blood pressure cuffs, chairs, scales, clipboards, floor and desks are now infected. Paper forms, ball point pens, measuring tapes, penlights must all be discarded. The area is unusable pending decontamination. This is the type of break in usual-procedures that also brings the care of non-Ebola patients to a halt.
So, lets imagine housekeeping gowns up in PPE, sprays disinfectant and wipes the surfaces down with a rag. How about the computer monitor and keyboards that can’t be sprayed? What do we do with the now infected rag? It cannot go into the regular laundry. How do we handle infectious linens?
The plastic suits (the personal protection equipment--PPE) are only useful when coupled with decontamination. The outer surface of the housekeeper’s gown becomes covered with infectious droplets. She needs decontamination—an assistant who can spray her down with dilute Clorox and carefully help her out of the gown so that she does not touch the outer surface during the removal process. (I understand that removal of the PPE is the most dangerous part of patient care.) Where do we do this? Outside the department entrance on the sidewalk? This is the only place I can think of. This should work until winter snow begins to fall. Again, the hospital was not designed with this process in mind. The gowns must be hung up to dry as they are infectious until dry.
Problem #3: Back to our patient, who is lying on the floor of the hallway covered in vomit with a very low blood pressure? The vomitus covering her skin and clothing is ladened with Ebola virus and HIGHLY infectious. For a health care worker to touch the vomitus with bare skin would be suicidal. Only those dressed in a plastic PPE suits should even consider contact. We will need 4 people to “suit up” in PPE gear (10-15 minutes), lift the patient on a gurney and roll her down the hallway to a patient care room. Then, these people must step into a bucket of bleach to decontaminate their boots, then proceed directly to the decontamination area without walking through hallways or touching or being touched. Decontamination and “de-suiting” will take another 30 minutes and the time of several more “hygienists.”
Problem #4: Managing vomitus and diarrheal stool, of high infectivity, on the floors and walls of high use public hallways. What is the disinfectant solution to be used? Can the mop itself be reused? How long does the floor need to dry? How will we function with the main hallways closed for decontamination? Where do we dump the dirty mop water? In the public sewers? And, again, the housekeepers need decontamination.
Problem #5: Impact on the families of hospital workers. So the shift is over, its time to go home. The healthcare worker (HCW) knows that they have been splattered with secretions from Ebola infected patients. They think that probably they have been careful enough. (Though there is a faint memory of brushing a bare arm against a wall where a vomiting patient had passed…..) They have done their best, decontaminated, showered, dried off, changed clothes. Was it enough? Do they go straight home and climb in bed with their spouse? Do they hold their children, kiss them goodnight, cook diner for them? Or is it prudent to stay away from their families for 7-10 days (average incubation period is 6-7 days)? We are considering 10 days of quarantine after EACH WORK SHIFT. And most doctors and nurses work 4-5 days a week, they would cease to live with their families for the duration of the epidemic? Will the hospital or community provide Ebola HCW housing?
Pregnant HCWs. Ebola sepsis produces hypotension and shock. Even if the mother survives the fetus is unlikely to. Many of our nurses are pregnant.
Husbands, will weigh the risks and impacts of losing their HCW spouses. I am absolutely certain that many, especially young mothers, will decide to leave patient care until the epidemic has passed.
The reality is that all Ebola care is voluntary. Hospitals will realize this up front and ask for volunteers, or find out the hard way when HCWs do not show up for work.
[I posted on facebook about the Ebola epidemic several which apparently opened the topic up for discussion. Several physicians and nurses have privately confided that they will not be doing any Ebola care for any reason. “Who will raise my children?” “Martyrdom against an epidemic of this ferocity has no purpose and will do no lasting good.” “The day the first Ebola case arrives will be my retirement day.” “This should have been stopped at the border.” “Will I clean up the sh*t of a stranger who is dying anyway, knowing that my own children will have to be raised in some orphanage? Hell no!”]
This portends a sudden, and completely foreseeable, collapse of our hospitals should we attempt to provide care for significant numbers of Ebola patients in the hospital setting.
My conclusions are that if the Ebola epidemic becomes significant:
1. There will be a sudden, immense attrition of hospital workers.
2. Attempts to mix Ebola care with traditional hospitals will cripple the entire hospital by disrupting all of the usual procedures. The result is that no-one, not even non-Ebola cases, will get hospital care.
3. Dedicated Ebola care centers and home care by the families of patients will be adopted, not because they are great, but because the alternatives are so unworkable. Most Ebola care is supportive, IV fluids, cleaning, feeding. An unused National Guard dormitory might be a decent place for this.
I’m not worried. Obola says it’s under control. I mean, if you can’t trust Obola, who can you trust?
Basically if things transpire as outlined, we would be not so different than West Africa after all. Well, we have fabric covered chairs, and they have those plastic chairs that can be hosed off. That is different.
Good news all around.
God help us.
*sigh*
Excellent insight into a typical medical facility.
It highlights the importance of keeping it out as much as possible so that our systems are not overtaxed and from this writing, you can see the worry.
IMO, in addition to doing what we must to keep it at bay..in the longer term, we have to stop it at the source, because if we don’t we will all be going down in the sinking ship on a global scale.
We won’t then be taking about Africa any more. We will be taking about any number of other countries as it spreads and destroys.
Can we keep all of them out as well? I think we would lose that fight eventually. Certainly our economy will have crashed by then, and it will be Katy bar the door..
Finally, someone 'gets it'.
In my work environment, there is a substance which while not necessarily hazardous, seems to get everywhere if not strictly contained.
Since that environment includes everything from working with heavy equipment to microscope work in the lab, to working with a computer, fastidiously containing the material is a must, otherwise things get messy all around.
It makes one aware of horizontal, vertical, and other surfaces which need to be policed habitually, and that a little dab can be spread to a host of locations by unconscious acts.
Hence, I understand the hazard of fomites very well, even though what I am dealing with is not a lethal bioagent, just messy. It splatters, too...and I have been 'nailed' (accidentally) by someone who turned with a pressure washer still going and thoroughly splattered me.
Experience has taught me to avoid touching what does not need to be touched, especially where the substance is abundant, and to be ever alert for its presence. The alternative is ruined clothing, the potential to ruin equipment, and far too much time spent cleaning instead of getting the work done. While that is a relatively minor inconvenience and far from potentially lethal, it has been an education.
Most people are oblivious when they enter such a work environment, and those who have not, with the exception of a few germophobes, generally have no clue.