As the World Cup begins, the State Department expects anywhere from 5 to 7 million international travelers to visit the United States to cheer their teams to victory. While the only active cases of Ebola are currently contained to the Democratic Republic of the Congo and Uganda, this is a good time to talk briefly about Ebola and five things you need to know if a concerning case shows up in your ED.
A big misconception about Ebola is the idea that patients will present with active hemorrhaging from various orifices. The reality is that early Ebola symptoms are very non-specific and look remarkably similar to many common illnesses seen in the ED every day:
By the time hemorrhage enters the clinical picture, the patient is pretty far along in their disease process and is likely already critically ill. Avoid the cognitive trap and don’t anchor your suspicions to late-stage symptoms alone.
Because early symptoms are vague, the initial consideration of Ebola is going to be almost entirely based on epidemiology. The most obvious scenario will be patients presenting with concerning symptoms and recent travel directly to or from a country endemic for Ebola, or anyone who may have come into close contact with a friend or family member that has recently traced to one of these countries.
While less likely, patients with recent travel through a major international travel hub who develop concerning symptoms should also raise a red flag for further investigation.
It is likely that your ED has at least a few negative-pressure rooms that can be used for infectious disease isolation. If you do happen to have a concerning case come through your doors, isolate that patient as quickly as possible. Ideally, they should go directly to an isolation room from triage and should not be sent back to the waiting room while a negative-pressure room is being prepared.
Regardless of what sort of institution you work at, take every reasonable step to minimize staff exposure. That means the bare minimum of staff to tend to the patient. There should be one dedicated RN and one clinician assigned to the patient. This is not a time for learners, orientees and students. Ideally, this should be a 1:1 patient in terms of nursing care, and for good reason; the nurse should have no other distractions from their cognitive load so they can focus on providing safe and efficient care, have the time to focus on flawless PPE donning and doffing, and also avoid the risk of potentially cross-contaminating another patient or staff member.
Once the patient is isolated, it's also time to contact hospital infection control, your local health department, and notify the CDC of a potential Ebola case
While we all started off practicing hardcore donning and doffing early in the COVID days, I will admit that as the virulence of the virus dropped off, so did my PPE discipline. I found myself quickly throwing up a mask over my face to pop into the room to ask or answer a quick follow-up question. For patients presenting with possible Ebola, this is a very different story.
There is a concept in EMS called “scene safety.” The idea is simple: always ensure you and your surroundings are safe before rendering aid to a patient. The age-old air travel pearl is to put on your own oxygen mask before assisting others. This is the time to make sure you have EVERYTHING that you need before going into the room, and to borrow a military quote: “Two is one, and one is none.” This means that for any medications and equipment you are taking in the room with you, bring a spare.
And whatever clinical situation arises, even if the patient starts choking on their turkey sandwich and needs the Heimlich, you don’t take one foot towards that door till you are in full PPE, head to toe.
The primary initial treatment for patients with Ebola really comes down to supportive care and symptom management. You are primarily going to be treating their fever and significant dehydration from GI fluid losses. This also means being thoughtful and intentional with your orders to minimize staff exposures. These are not the patients to “nickel and dime.” Your orders need to be thought out ahead of time so that you can batch as many nursing interventions as possible into one trip.
Question the necessity of everything that you order. Is that repeat lactate actually going to change your plan? Do you really need that repeat chemistry right now, or can it wait? This is the situation where you want to rely on your clinical gestalt as well as the objective data in front of you. Let the patient's overall clinical picture and vital signs guide your resuscitation. Every order and intervention you place also poses a very real risk of contamination whenever the nurse has to go in and out of the room.
High-acuity, low-occurrence (HALO) procedures are a major part of emergency medicine. Now, while the chances of encountering a patient with Ebola are incredibly low, it also takes a minimal amount of intentional cognitive framework to be mentally prepared if the situation arises.
And during the last outbreak of Ebola, it happened at my shop.
We had a patient with concerning symptoms, recent travel and direct contact in a hot zone brought to our ED for evaluation. He was immediately isolated, and contact was minimized to a few specially trained staff members. The CDC arrived from Atlanta, and the patient was cared for by our global health EM physician team. Ultimately, he was diagnosed with Malaria, and recovered fully at home. I can tell you that was a very scary shift to be working in the ED, not knowing if this was going to be the beginning of a horrific outbreak right in our backyard.
But our team was prepared, took all necessary precautions, and thankfully, it was a good outcome for all involved.
These sorts of situations are thankfully rare, but to quote the famous French microbiologist Louis Pasteur: “Chance favors the prepared mind.”
Stay safe, see you at work.