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