Ebola, Emergency Medicine, and Global Bioethics
Sarah M Winston Bush, MD Assistant Professor
University of Cincinnati Department of Emergency Medicine
A look at the medicine…
What does Ebola look like clinically?
• High fevers • Vomiting • Diarrhea • Fatigue • Loss of Appetite • Abdominal Pain • Headaches
• Myalgias • Cough • Maculopapular Rash • Hiccups
Hemorrhage? • Occurs ~50% of time • GI in origin • Mucosal bleeding • Hematomas • Oozing IV sites • Conjunctival Hemorrhage
http://gudhealth.com/ebola-hemorrhagic-fever.html
http://www.peakprosperity.com/forum/86357/ebola-outbreak-2014
• 80 bed center in Kailahun • Tents of patients – suspected, probable, confirmed • PCR testing can take up to 24 hours • Strict PPE guidelines
– Buddy system – Restricted to 40 minutes at a time in PPE and in the
tents • Treatment – Supportive only • Discharge criteria – neg blood test and 3 days
symptom free
• Common: – Renal Failure – Hypokalemia – Lactic acidosis – Elevated Liver Function Tests
• Uncommon: – Hemorrhage (typically GI)
• Barriers to treatment in West Africa: – Late presentation – Lack of equipment
• PPE • Oxygen • Electrolyte testing • Hemodynamic monitoring • IV supplies and IVFs
– Community mistrust – Communication barriers
Diagnostics • Rule out other common causes
– Malaria – Other endemic infectious diseases
• Ebola test: – Africa – some sites have onsite PCR
testing that can take up to 24 hours – US: Send out test to CDC
Treatment • Supportive care
– IVF resuscitation early • Correct hypovolemic shock and electrolyte
disturbances – Nutrition – Treat concomitant malaria – Prevention of secondary infection
Treatment • Isolation
– Prevent the spread • Role of antibiotics • Experimental drugs?
– ZMapp – Brincidofovir
• Blood transfusion
• 1995 outbreak in DRC • 5 donor pts – IgG and IgM antibodies to Ebola • 8 recipient patients ages 12-54
– Prior to transfusion: • 7/8 treated for Malaria • 3/8 had hemorrhagic symptoms • 8/8 tested positive for Ebola antigens
• 7/8 survived – Pt 8 – never developed IgM antibodies to Ebola despite
transfusion
Here in Cincinnati… • 911 dispatchers have begun screening • EMS has been educated on appropriate
screening & precautions – Immediate application of PPE – Immediate decontamination of ambulances
with bleach to prevent further spread
UCMC Emergency Plans for Ebola
• Goals: – Provide quality care to all patients – Prevent further exposures
UCMC Emergency Plans for Ebola
• Triage: – Flu like illness – Appropriate travel history
• West Africa: – Guinea, Liberia, Nigeria, Senegal, Sierra Leone
• Democratic Republic of the Congo
– Exposure history • Redundancy within the EMR
Immediate Isolation
UCMC Emergency Plans for Ebola
• PPE carts • Assessment and Treatment
– Malaria and other infectious causes • Notification
https://www.greenedu.com/personal-protective-equipment-procedures-online-anytime-courses
Thank you!
References • Baize, et al. (2014). Emergence of Zaire Ebola virus in Guinea. N Engl J Med. 1-8. • Briand, et al. (2014) The International Ebola Emergency. N Engl J Med. 371:13 . 1180-1183. • Decker, et al. (2014). Preparing for Critical Care Services to Patients with Ebola. Annals of Internal Medicine.
www.annals.org. downloaded 10-11-14. • Fowler, et al. (2014). Caring for critically ill patients with Ebola virus disease. Am J Respir Crit Care Med.
190:7 733-737. • Frieden, et al. (2014). Ebola 2014 – New challenges, new global response and responsibility. N Engl J Med.
371:13 1177-1180. • Gatherer, D. (2014). The 2014 ebola virus disease outbreak in West Africa. Journal of general virology. 95,
1619-1624. • Gostin, Lucey, & Phelan. (2014). The Ebola Epidemic: A global health emergency. JAMA. 312:11. 1095-
1096. • Mupapa, et al. (1999). Treatment of Ebola hemorrhagic fever with blood transfusion from convalescent
patients. Journal of infectious disease.179: S18-23. • Wolz, A. (2014). Face to face with Ebola – An emergency care center in Sierra Leone. N Engl J Med.
371:12. 1081-1083. • WHO ebola response team. (2014). Ebola virus in West Africa – the first 9 months of the epidemic and
forward projections. N Engl J Med. 1-15. • WHO. WHO recommended guidelines for epidemic preparedness and response: Ebola Hemorrhagic Fever.
www.WHO.int. downloaded 10-8-14.
• Outcomes:
• From Dec 30, 2013- Sept 14, 2014 – 4507 confirmed/probable cases – Median age 32 years – 318 infected health care workers (151
deaths)
Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo Situation assessment - 2 September 2014 (*)
• Both Zaire species of Ebola – DRC: close to 1995 outbreak in Kitwit, DRC
strain • No connection between the two
outbreaks • Index case in DRC: Pregnant woman
eating bushmeat http://www.who.int/mediacentre/news/ebola/2-september-2014/en/
• Clinical presentation – Africa – US
• Mainstays of diagnosis and treatment – Resuscitation – Supportive care – Isolation
• Plans at UCMC ED – EMS/911
Mode of Transmission • Contact with any bodily fluids
– Airborne transmission never been confirmed
• Percutaneous (ie – the dreaded needle stick)
• Contact with dead bodies
https://www.greenedu.com/personal-protective-equipment-procedures-online-anytime-courses
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