Table of Contents
NURSING EBOLA
With permission by Peter Kieseker
Please note: Peter wrote this in 2015 and it was initially published in Nursing Review. He sent this to The Nurse Break and gave permission for his story to be heard! Treatment medications and protocols may have changed. This is an indepth look into what nursing during this crises looked like!
To read about Aussie nurses working in Covid-19 Crises GO HERE
About Peter
Peter has worked for many years in health, education, disability, welfare and international aid. He has led multiple emergency aid teams in Somalia, Sudan, Kenya, Cambodia, Serbia and Kosovo and is published in the Australian Peacekeeping Manual in the topic area of “Non Government agencies working with Military Forces in Emergency Situations”. While his daughter was growing up Peter used his generalist education and experience to work as a freelance consultant and trainer. This has included
training assignments in Papua New Guinea, Indonesia, Solomon Islands, Fiji, China, Taiwan, Singapore, Nigeria and New Zealand.
Nursing Ebola
Many Australian nurses have joined or are working alongside the 32 plus international agencies which are currently attempting to stem the Ebola epidemic in West Africa. But what do they actually do? While many international nurses are in administrative, health promotion, training or coordination roles most Australian nurses don’t hide from Ebola; they give direct patient care. This is how Australians – and New Zealanders working alongside them – are nursing Ebola.
What is Ebola?
Ebola is a Filovirus generated viral haemorrhagic fever (VHF) causing severe illness, sometimes associated with bleeding; though with Ebola the incidence of such bleeding is estimated at below 25% of cases and there is some talk in medical circles of it failing true VHF status. What is certain though is that Ebola has a high mortality rate – usually higher than 70%. Like its close kin the Marburg virus the disease likely occurs due to contact with infected animals. It is thought but not certain that fruit bats are the zoonotic agent, be it they being eaten directly or by their infection of bushmeat, such as monkeys and chimpanzees, or by the consumption of fruits partly eaten by the bats.
Once an index case arises transmission to other humans is largely via a patients’ infected blood and body fluids. This places any caregivers at great risk, plus places at risk those communities that practice the washing and touching of their dead.
Breast milk carries Ebola and it remains active in the milk for an unclear length of time. The disease also remains active for up to 3 months in seamen. This creates challenging problems with recovered patients keen to resume life and reluctant to use condoms.
Patients under five are at greatest risk and death is almost certain to an unborn child if the mother is infected. Indeed pregnant patients do poorly and their morbidity rate exceeds the average.
The number of Ebola virus disease (EVD) deaths in West Africa has surpassed 19,000[1]. Among these are many national health workers. A sad early indication and often the first sign of Ebola –and other VHFs – is the death of health care workers dealing with what was thought initially to be a common fever or gastrointestinal condition. This makes the protection of health workers a critical component of Ebola management.
Why the massive effort to deal with Ebola?
The nature and virulence of Ebola render it a disease that quickly transcends the capacity of most African countries to deal with. It spreads quickly and with a 3 -21 day intubation period coupled with international mobility it could quickly escape Western Africa. Much like the deadly Spanish Flu of the 1918 and SARS of the 1990s it represents a global threat and calls for a global response, and many nations have responded. The Koreans are here, as are the Chinese, the Norwegians, Irish, the Indians, the English, the Germans, the Americans, and many African nations; and the Australians and New Zealanders are here. Why are they here?
Perhaps a quote from a Sierra Leonian nurse says it best:
I told my family that much like a soldier that is trained to fight in a battle, I’m a trained nurse and a soldier fighting with Ebola
The battle with Ebola is real and it must be won, and as with all of Australia’s war history it is better to defeat an enemy offshore – in this case, West Africa – then to have to face combat in our own region, or even on our own home soil.
The Nursing
Ebola is fought by identification, isolation and treatment. Once a case or suspect case is identified, isolation is immediate. Disease transmission must be stopped. Once so isolated the disease calls for a strong though basic nursing response. Indeed in the many treatment centres that do not have biochemistry ability high-quality basic nursing is largely all that can be done.
Medication regimes are routinely protocoled and caring for patients through PPE is largely limited to ADLs and fluid replacement; with oral fluids being preferred where possible due to the increased risks from IV. Fluid resuscitation, and prevention and correction of electrolyte abnormalities, can reduce fatalities. Within established ETCs (Ebola Treatment Centres) determination of IV fluid requirements remains a medical decision.
In most centres, there is very limited capacity for any interventions with even stethoscopes being impossible to use. However at another extreme, the Italian aid agency, Emergency, has set up a full intensive care facility within air-conditioned buildings. Here central lines, catheters, intubation, blood gasses and more are routine; despite the increased risk to care staff. In the aid world, this causes heated debates around the ethics of 1st world care for a few vs. more basic care for the many.
In the case of Ebola, neither approach is proving statistically superior with death rates in all approaches being similar; such is the nature of the disease.
Rosters
Rosters vary between ETCs but typical is 2 mornings working 0700 to 1330 followed by a 12-night hour shift followed by 2 days off followed by 2 afternoons working 1300 to 1930 again followed by a 12 hour night and 2 days off. To this must be added up to an hour travelling time between accommodation and ETC. The drive is interesting – for the first twenty times – because of the many impossible to list sights and sounds of Sierra Leone with its hugely varied population. But soon – due to poor roads and tiredness – the novelty of ladies carrying dozens of eggs balanced on their heads, or a man carrying great sheets of timber likewise balanced, or the kids washing clothes and themselves in the creek, or farmers tilling fields, all loose out to sleepiness.
Triage
Key questions at triage are whether the person is a health worker or have they cared for someone sick; these being the most vulnerable groups. Attendance at a funeral, visiting sick friends, or having someone ill or die in the family or close community also trigger alarm bells. AVPU is also a basic consideration.
Triaging follows a simple flow chart. Essentially if a patient has had a history of contact with a suspect, probable or confirmed case of Ebola, coupled with a history of fever, then they are likely to suspect.
Alternatively, fever with no known contact plus 2 of any of the following symptoms raises the index of suspicion: nausea/vomiting, diarrhoea, conjunctivitis, intense fatigue/weakness, anorexia/loss of appetite, abdominal pain, muscle pain, joint pain, headache, difficulty breathing, difficulty swallowing, skin rash, hiccups (a peculiarity of Ebola and the presence of which indicates a very poor prognosis), and/or unexplained bleeding.
The Ebola symptomology is wide and varied, and it duplicates many other conditions, especially Lassa fever and Malaria. Hence people are often admitted to either the suspect or probably ward depending on the level of symptom acuity. Here they have and await blood test results. These test will reveal – usually within 24 hours dependent upon closeness to laboratory facilities – positives or negatives for both Ebola and malaria. If the blood test is negative for Ebola, and the symptoms have been present for more than 3 days, the patient is discharged. If the test is negative but the symptoms are under 3 days in duration they wait another 72 hours for a repeat blood test. Positive patients are transferred to the confirmed ward. During triage a baseline visual acuity test is conducted to measure any possible loss of vision; this being one of the more notable after-effects of Ebola.
A secondary – and critical – part of triaging is contact tracing. If a person is found positive great efforts are made to trace all their contacts and monitor the same. Early identification can help break a transmission chain and bring early intervention to any newly discovered cases.
PPE
Personal Protective Equipment is fundamental in Ebola nursing. The virus is spread by contact with body fluids and with excessive diarrhoea & vomiting being an ever-present feature, and bleeding occurring in approximately 25% of cases, the risks of contamination are high.
PPE varies in form but basically begins with heavy rubber boots, strong coveralls, a surgical mask, a hood with an additional mask, a strong apron, inner gloves of one colour and taped outer gloves of another colour – so any slippage is quickly realised – and goggles. Some agencies use a face visor instead of goggles but there is a concern here for projectile vomiting, and of children’s hands getting under the visor and making contact. For the experienced nurse dressing – donning – takes about 15 minutes.
Sierra Leone is hot and few centres have any cooling devices. Wearing PPE quickly raises body temperature and one becomes rapidly saturated. In all but the air-conditioned Italian facility time in PPE is limited to about 40 minutes – depending on individual endurance. People from northern Australia initially do better than those from southern states but this tends to even out once acclimatisation occurs; a process initially aided by light exercise.
Undressing from PPE –doffing – takes longer than dressing. It follows a very slow and deliberate sequence in order to minimise the risk of coming into contact with outer -possibly exposed – materials. After standing in a 0.5% chlorine foot bath for a strictly timed minute gloves are washed and the whole person – except goggles & face – is sprayed with 0.5% chlorine. Then in a sequence constantly punctuated with handwashing comes the removal of outer gloves, apron, goggles, hood, overalls, mask and inner gloves, followed by extensive boot spraying, and finally washing of now bare hands in 0.05% chlorine while standing in another strict minute boot bath of 0.5% chlorine. One comes out very sweating and smelling like a swimming pool, but chlorine is highly effective against Ebola.
Team handover
Team handover is usually a noisy affair. Sierra Leonians speak loud – really loud – and multiple conversations are the norm. It takes a while for Australians to adjust – just as the Australian practice of listening quietly at handover takes a while for the Leonians to adjust to.
The handover itself is held at outdoor but shaded whiteboards where the 4 category of patients – suspect, probably, confirmed and convalescent – are discussed according to their individual needs.
The clinical state of each patient is scored via a rough guide that allows for some degree of monitoring of progress or decline. The scale ranges from 1 to 5; 1 – convalescent, 2 –symptomatic (independent), 3 symptomatic (requires assistance), 4 severe symptoms (requires assistance+++) and 5moribund. A 1-3 dehydration score is also allocated by clinical appearance and skin rebound.
Regular Rounds
A form of regulated rounding takes place in Ebola wards. All entries into the Red Zone – the wards of Ebola patients – represent risk and hence entries are planned and regulated. Regular entries consist of medications and doctors rounds, fluid and food rounds, and ward hygiene rounds. It is stressed to patients in suspect and probably wards not to move out of their 2-meter bed space. This is because some might be Ebola positive while others Ebola-free. With Ebola ever ready to cross-contaminate patients need to protect themselves from contact with others.
What this very necessary form of controlled entry means however is that patients are often alone in the wards, and this is one of the tragedies of Ebola; patients usually die alone and lonely. Family cannot be there, and nurses or staffs usually aren’t either. It is not uncommon to enter a ward for a fluid round to find a patient who seemed to be doing reasonably well laying deceased and rigid. One of the characteristics of Ebola is the rapid – approximately 20 minutes – the onset of rigor.
The ‘NO TOUCH’ policy also applies to all staff. There exists a strict interpersonal distance to be maintained in all aspects of life – be it work, home, shopping or walking a street. There is little opportunity for close relationships in an Ebola campaign and often the only touch received from another human being for the entire duration of the mission is the hugs team members give each other when protected in full PPE.
Medications
There is no effective medication against Ebola. Work is proceeding at a pace to find a vaccination and indeed at the time of writing a vaccination trial is being commenced. However, a set regime of medication is followed, with several additional medications occasionally trialled in an effort to find the right combination.
Standard with any admission if Oral Rehydration Solution (ORS) at a rate of 1.5l TDS. ORS – the proven saviour in cholera – is used due to the massive gastrointestinal fluid loss with EVD. Such losses contribute to hypovolemic shock, serve electrolyte abnormalities and high mortality.[2][3] While ORS can be made up at village level, a commonly used commercial ORS comes in 20.5 g sachets containing Glucose 13.5g, Sodium chloride 2.6 g, Trisodium titrate dehydrate 2.9g & Potassium chloride 1.5g.
Other regular medications are Cefixime 400mg b.d. to counteract any of the co-infections which are common in Africa. To fight the also very commonly occurring malaria Artesunate/Amodiaquine 100/270, 2tabs nocte is usually administered for 3 days; unless a rapid test is available to disprove malaria.
In all patients, consideration is consistently given to paracetamol, tramadol, morphine, ondansetron and omeprazole.
Patients who cannot manage oral medications are treated with IV Ceftriaxone, Artemether (80mg/ml loading dose at 3.2mg/kg od IM day 1, followed by maintenance dose 1.6mg/kg od IM days 2-5), ondansetron 8mg TDS IV, and morphine 5-30mg TDS SC/IM/IV.
One trailed medication – used sporadically – is the potent antidiarrheal loperamide; which also has antiperistalitic & antisecretory effects. The rationale is that reducing diarrheal losses might allow correction of negative fluid balance, reduce hypovolemic shock, limit electrolyte losses, and consequently improve survival. However, the ‘reluctance to use loperamide for EVD diarrhoea may be based upon the perception that there is no benefit for the secretory diarrhoea observed in cholera or concern of the risk of toxic megacolon when used for some bacterial inflammatory causes of diarrhoea such as Clostridum difficile[4]’.
Passing
At nursing handover, a fifth category of patient, ‘in mortuary’, is a too common listing. The deceased are discussed at length because preparing a body for transfer to the International Red Cross sponsored burial teams is a complex logistical exercise.
Great care is needed because it is in the deceased that the disease is at its most virulent. Indeed it is the Leonian practice of washing their dead that has been largely responsible for the spread of the disease.
Double body bags and extensive chlorine is used, along with very strict procedures. The deceased are often presented for viewing to their loved ones – behind a 2 meter high and wide double fence. At this point prayers – Islamic or Christian and sometimes both – are said by family members who are accompanied by family liaison personnel known as health promoters. Once viewing is completed the deceased are zipped and resprayed. Although the body, especially the face, is heavily sprayed when being transferred from a bed space to body bags, the face of the deceased is never sprayed in front of relatives. All this procedure is of course completed in full PPE.
Discharge
Ebola has a high mortality rate, especially in third world conditions, but survival is possible with ETC rates running between 30 -50%. For those that do survive immunity appears to be gained; though it is unknown for how long and if effective against all strains of the disease. In Sierra Leone battle is only being done with the Zaire strain of Ebola; others exist.
The discharge of a survivor is a happy event for all. The survivor is given a ‘survivors kit’ consisting of new clothes and goods due to all they brought with them being destroyed. Additionally, household goods and food are supplied – the latter via the World Food Program – as much of their household may have been destroyed due to decontamination processes. Survivors are also often invited back to give hope to confirmed cases and to simply celebrate being alive.
One of the most important aspects of recovery is reassimilation within family and community. People are justifiably scared of Ebola and any known suffer is often stigmatised and ostracised. To counter this a “Survivors are our Hero’s’ campaign is being conducted via all forms of media. However, the proven best way to overcome the rejection survivors experience is for doctors and nurses to accompany them to their homes and be seen publically hugging and embracing them; these are joyful, wonderful moments and the only other time one can safely touch a fellow human being.
Time off
It is not all work. Within the restrictions of no-touch Sierra Leone is populated by intelligent, welcoming, friendly, – and loud – people. There are museums and building and basic shops to visit, beaches to walk along, and just simple everyday African life to observe. There are also a few ‘western’ style venues to attend when culture shock becomes a little too much. Mostly though it is work and sleep and work and sleep. But as most nurses are in-country for 6 weeks the time goes fast and the experience is worth it both, from a nursing and cultural points of view.
Ebola is being fought and fought hard and at considerable expense. But the global risk it poses qualifies the fight. What Australians and New Zealanders are learning while working with Ebola will result in a pool of nurses skilled, knowledgeable and experienced in working in highly infectious quarantine situations; skills that may likely be needed where viruses that disrespects all persons can travel rapidly on wing and ship.
Peter Kieseker
RN –graduate of 3 years from The University of the Sunshine Coast and pre Ebola an Emergency Nurse, Nambour Hospital
Written in 2015 – Treatment medications and protocols may have changed.
[1] http://www.who.int/csr/disease/ebola/situation-reports/en
[2]Chertow DS, Kleine C, Edwards JK Ebola Virus Disease in West Africa – Clinical Manifestations and Management N Engl J Med 2014;DOI: 10.1056/NEJMp1413084
[3] Lyon DM, Mehta AK, VakeyJb et.al Clinical Care of Two Patients with Ebola Virus Disease in the United States. N Engl J Med 2014;DOI:10.1056/NEJMoa1409838
[4] Koo, HL, Koo DC, M
You must be logged in to post a comment.