Q&A with a Virologist: Ebola in the ED at St.Emlyn’s

EbolaThis week Sarah Payne from the North East of England joins St.Emlyn’s. Sarah is no stranger to blogging and is a keen #FOAMed advocate as her bio below clearly shows.

Specialty trainee in Emergency Medicine in the Northern region, currently out of program as a Simulation Teaching Fellow across the Newcastle Hospitals trust and Associate Clinical Lecturer at Newcastle University while studying for MClinEd. Interested in #FOAMed and medical education, particularly simulation and reflective learning. I also tweet on behalf of @NEsimulation, @NEFOAMed and @TASME_Northern. Outside of work my life revolves around being a taxi driver for my kids. Advocate of women in medicine in general and EM in particular.

In addition Sarah is rather conveniently married to a virologist. With Ebola in the headlines she shares her family’s knowledge about this devastating illness…..

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2014-05-24 06.51.19

Sarah Payne

Last year I sat at the Northern Emergency Medicine trainees’ conference and listened to Professor Richard Bellamy, one of our local Infectious Disease Consultants, talk about imported infections.

As he talked about Ebola and other viral haemorrhagic fevers I found myself thinking that this was interesting but ultimately a bit of waste of my time…I mean seriously… Ebola? In the UK? Never going to happen.

Fast forward a year, and we’re facing just that reality. My home turf ED (Newcastle) was the site for one of the Ebola resilience simulations last weekend, and the Infectious Diseases (ID) department is preparing to take cases once the capacity of the Royal Free is exceeded.

Thanks to some very extensive planning and preparation by the ED and ID teams the weekend simulation exercise went swimmingly, but it’s genuinely scary stuff. Particularly so in my household, as I’m married to a Infectious Diseases/Virology doc who works at the same trust. I’ve spent a fair amount of time quizzing him about it over the past few days, and thought it might be useful and interesting information for other ED docs.

Q: What’s the scale of the problem?

A: There are predicted to be tens of thousands of cases in West Africa over the next few months. In contrast, the prediction for the UK is a single figure number of cases. The UK has capacity for 26 beds over the 4 sites of the Royal Free, Newcastle, Sheffield and Liverpool.

 

Q: So are we all overreacting?

A: No. Definitely not.The problems in Spain and Dallas tell us that we need to take this very seriously indeed. Given the potential for even small amounts of air traffic from West Africa and an incubation period of up to 21 days, it is inevitable that we will see some imported cases in the UK. It is clear that these will put health care workers at significant risk unless protocols are rigidly adhered to.

 

Q: How infective is Ebola?

A: The things that are in our favour is that it isn’t infectious by the respiratory route and there isn’t a presymptomatic infectious period. Transmission is by direct contact with bodily fluids only. However, all bodily fluids, including sweat, are potentially infectious, and the infectious dose (amount of pathogen required to cause infection) is very low.

 

Q: So I could catch Ebola from touching a surface that an infected patient had sweated on?

A: That’s a bit dramatic and the honest answer is that we don’t know at the minute. Contaminated surfaces are certainly a risk for infection but this is likely to be predominantly surfaces contaminated with blood or vomit. We don’t know for sure how infectious, for example, a door handle contaminated by sweat might be – if at all.

 

Q: How do you kill Ebola in the environment?

A: It’s sensitive to standard disinfectants such as bleach based products.

 

Q: I noticed in the practice run that the stuff the ED team was wearing looked different from the ID team… What’s that about? Are we at lower risk?

A: The Public Health England (PHE) guidance for managing a high possibility case is double gloves, disposable gown or suit, apron over gown, eye protection and FFP3 respirator (mask). In addition, the CEM guidance advises overshoes as well. EDs should be stocking this kit for suspected cases. The risk of contamination increases progressively as the patient deteriorates, particularly if they develop haemorrhagic complications, so additional measures are needed when nursing a patient for a longer period and that’s why the inpatient team may use different kit depending on how the patient is nursed, for example whether the patient is contained in a trexler tent or not.

 

Q: My concern is people who don’t know they’ve got Ebola – for example those unknowingly in contact with a case who just present with fever. Is this a likely scenario?

A: Over the next few months the most likely scenario is of someone recently returned from West Africa (especially Sierra Leone given the strong links with the UK) developing symptoms shortly after they return. I’d anticipate that this person would recognise themselves to be at risk, be worried and seek healthcare promptly and if they are triaged either via telephone or in the ED, mechanisms should be robust enough to pick up this travel history. The situation of someone becoming infected by person to person transmission within the UK is unlikely because of the very low chance that an index case would go unrecognised in the UK health system. In the event of any case in the UK the relevant Public Health body would activate extremely extensive contact tracing.

However,, PHE guidance would change if the epidemiological risks shifted significantly. Also, as a general principle of any febrile returned traveller it is good practice to consider the need for PPE, and to seek advice early. Also remember that universal precautions make a huge difference, particularly in early cases.

 

Q: So what do you look out for?

A: It’s difficult. The initial symptoms are non specific and flu-like with fever or a history of fever. The disease then typically progresses through diarrhoea and vomiting to haemorrhagic manifestations such as easy bruising. By that point they’re likely to be pretty ill. At the minute the key is the travel history and fever.

 

Q: So what do I do as an ED doctor if I have a patient with fever and a travel history from west Africa?

A: Well, hopefully you’re not reading this with a patient like that in your department!

All EPs should know where the PPE is, how to don PPE and more importantly how to remove it correctly. You also need to know which is the designated holding room in your ED. In terms of PPE training, different trusts are probably at different stages, but it’s reasonable to think it should be happening across the country over the coming weeks. It can take up to 15 minutes to put on your PPE and you should have someone check it before you go into the room. It’s also unpleasant to wear; although it can be worn for up to 3 hours at a time, in reality it’s very uncomfortable and difficult to tolerate for more than an hour or so. Taking PPE off is also something that needs to be carefully done and practised as the items need to be removed in a specific order to prevent contamination.

The patient should be immediately isolated and someone will need to suit up and assess the patient to make a risk assessment before liaising with your local Virology/Microbiology or Infectious Diseases consultant. Local arrangements will differ and it’s important that you know what they are. You will be expected to take routine bloods and malaria films in the ED unless your hospital can immediately divert to an ID bed. The College of Emergency Medicine has produced an excellent flow chart which you can download and display in your ED.

 

Q: What happens to the bloods? They must be pretty high risk for the lab.

A: Most routine analyses are run on large automated machines. The risk of transmission from these is considered very small due to the large volume of dilution involved, therefore initial samples can be run on normal automated analysers. The lab staff should be made aware as there are implications for sample handling and waste disposal. It’s up to the ED consultant to decide what tests should constitute essential investigations but I’d think as a baseline you’d be sending your standard ED sick patient package plus malaria investigations. Remember it’s more likely that this patient has something other than Ebola.

Your local infection Consultant will then arrange transfer of samples to Porton Down to test specifically for Ebola. Bear in mind that the patient may well remain in the ED until that test is performed, and this could be up to 12 hours.

 

Q: Are there any treatments for Ebola?

A: Not specifically. There are a couple of experimental drugs which may be tested in the field over the next few months but they’ve been very much rushed out and it remains to be seen whether they will be effective. The mainstay of treatment is supportive care.

 

Q: If you’re caring for a patient with suspected Ebola and you get blood on yourself, what do you do?

A: You mean other than panic?! (Don’t do that!) You’d need to liberally wash the area first of all, and then inform your national Public Health Body (Public Health England, Public Health Wales, HSC Public Health Agency in Northern Ireland,  Health Protection Scotland, or the Health Protection Surveillance Centre in Ireland) . You’d  be subject to active monitoring for the next 21 days,

 

Q: What does that mean? Would you be quarantined?

A: You’d have to take your temperature twice a day and phone it to the relevant public health body. Quarantine arrangements are unclear at present and will be decided on a case-by-case basis. Staff who’ve managed an Ebola patient with no recognised breach in PPE should undertake passive monitoring i.e. self monitor for symptoms for 21 days. That might change in the light of the Spanish and Texan cases.

 

Q: Do you think there is a risk that people will become blasé about it?

A: I’d hope not, with a mortality rate of over 50%. We need to take this seriously. Everyone should read advice for the UK in addition to the relevant local advice. Some of the information produced by Public Health England is relevant to the whole of the UK but if you live in other parts of the UK or in Ireland be aware of your national public health body too.

PHE & Dept of Health Guidance – click here

England – click here

Scotland – click here

Wales – click here

Northern Ireland – click here

Ireland – click here

2014-05-24 06.51.19Brendan Payne

 

vb

Sarah Payne & Brendan Payne

 

Further reading:

  1. UK Ebola guidance from College of Emergency Medicine
  2. Ebola Special at FOAMCast (US guidance): Blog & Podcast
  3. NEJM Ebola information
  4. Lancet Ebola information
  5. Ebola Editorial by US ED Resident Jeremy Faust at Slate

 

 

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