American doc knew he faced tsunami’ of Ebola
4th health care worker with Ebola comes to U.S.
In an August 30, 2014 blog post, Rick Sacra, MD, worried about the "many people in Liberia who are at risk because of the Ebola tsunami that swept through an already fragile healthcare system."
"The healthcare system in Liberia has had to go through a complete reboot after every single hospital in the city of Monrovia closed down to be decontaminated with bleach water as a result of Ebola cases landing in emergency rooms, outpatient clinics and medical wards," he continued. "We hope to gradually increase our services over the next couple of weeks to include children and adults, but we must first make some changes to our building to allow us to triage everyone before they enter the hospital grounds to check for any signs of Ebola. A large shipment of personal protective gear arrived yesterday from our partner, Samaritan’s Purse. This has been one of the key issues in reopening — ensuring that we have adequate protective equipment."
Shortly after that post, the 51-year-old family Ob/Gyn physician began exhibiting signs and symptoms of Ebola, which he probably contracted working long hours in the previous three weeks treating pregnant women and literally saving lives.
"When the patients started arriving, they had often been to several other hospitals and traveled for hours seeking care," Sacra wrote in his blog. "More than 35 cesarean sections were performed to save women and their babies in the first 20 days — sometimes two or three a day. "
Sacra was flown back to the states and admitted Sept. 5th to a specially designed 10-bed biocontainment unit at the Nebraska Medical Center in Omaha. Two of his colleagues with Samaritan’s Purse had undergone successful treatment for Ebola at a similar biocontainment unit at Emory Hospital in Atlanta. By late August, each had recovered and was discharged. As this issue went to press, Sacra was making some progress but doctors said it was too early to give a definitive prognosis. Meanwhile, a fourth health care worker infected with Ebola in Africa was admitted to the Emory biocontainment unit on Sept 9th, though few details were being released.
The biocontainment units at Emory and Nebraska have had years to train and prepare staff to handle infectious disease cases that might overwhelm some hospitals. They were designed according to federal guidelines for handling CDC category A diseases, which include Ebola, plague, anthrax, hemorrhagic fever and smallpox.
"There is anxiety amongst hospital staff in ordinary hospitals about handling Ebola cases," says Philip Smith, MD, professor in the division of infectious diseases at the Nebraska Medical Center. "We have people volunteer to work in this unit and to receive special training. They’re mentally prepared for something like this."
Emory uses a similar system, with a team of volunteers from various specialties ready if the alarm is sounded. "Staff involved in the direct care of these patients received extensive training with demonstrated competency verification," says Nancy Feistritzer, DNP, RN, vice president of patient care services at Emory. "Members of the team all volunteered to care for these patients. Even so, care of acutely ill patients at their most vulnerable can be stressful under any circumstances."
Emory provided staff and physicians caring for the Ebola patients with support through daily team huddles, leader rounding, and hospital chaplains. "The staff support team was present throughout these challenging and stressful times in order to provide emotional and spiritual support for staff," she says.
We want rock stars on this unit’
Even during the ongoing Ebola outbreak in West Africa, more hospital staff have applied to join the Nebraska unit, says Shelly Schwedhelm, MSN, RN, director of emergency trauma and emergency preparedness at the medical center.
"People say, Sign me up — I want to do this,’" she says. "It’s a professional development opportunity and they see it as an opportunity to enhance their skills in other ways."
Schwedhelm doesn’t hire every person who applies. First, she speaks with their managers to learn more about their clinical skills, energy, and ability to be self-directed. "We want rock stars on this unit," she says.
Volunteers have to be experts in their disciplines because they’ll need to learn special skills involving high level of infection control, adds Kate Boulter, RN, lead nurse of the biocontainment unit in Nebraska. The ideal worker in a biocontainment unit is someone who is very detail oriented and a critical thinker, she says. Employees have to follow rules and instructions precisely, as shortcuts and mistakes could lead to exposures and injuries. Team-work is a top priority.
"Each person has a partner who watches them put on their personal protective equipment and take it off," Schwedhelm says. "They hold each other accountable."
The biocontainment team functions as one unit, and everyone involved agrees on decisions and steps taken, says Uriel Sandkovsky, MD, an infectious disease physician and medical director for employee health at Nebraska Medical Center.
Biocontainment team volunteers also have to be eligible to receive the smallpox vaccination in the event of an exposure. "With smallpox you have a four-day window to get vaccinated after exposure, so if we had a smallpox or monkeypox case we could vaccinate them," Smith says.
A watchful eye for symptoms
Emory University developed a comprehensive surveillance program consistent with CDC guidelines to monitor physicians and staff caring for the Ebola patients, Feistritzer says.
"Inclusion criteria were defined as individuals who were involved in direct patient care or those involved in the handling of contaminated blood or body fluids," she says.
The surveillance protocol included taking employees temperature twice daily for 21 days the outer limits of the incubation period -- after their last episode of care for Ebola patients. Also, each employee tracks their own symptoms, including headache, joint or muscle aches, weakness, diarrhea, vomiting, stomach pain, or lack of appetite. They use a log to document and track results and follow a protocol to report any symptoms.
Emory also addressed concerns among patients and other employees through hospital-wide education and communication. The hospital educated staff about infection control practices and the Ebola protocols. They held town hall meetings to provide accurate information and to have clinical experts and hospital leaders answer any questions staff might have, she explains. "Physician and nurse executive teams rounded on each patient care unit to answer questions staff or patients might have had," Feistritzer says.
The Emory website posted educational material with frequently asked questions and regular updates, available to both staff and patients.
As other hospitals prepare for the possibility of admitting an Ebola patient, it’s a good idea to regularly train on the proper use of isolation precautions and personal protection equipment.
"One of our colleagues in the unit has an innovative educational approach where people get into gowns and take care of mock patients," Smith says. "It’s recorded, and supervisors go over the video with employees to reinforce compliance."