Two weeks ago at our community hospital, after we concluded a nearly two-hour standing room only Ebola preparedness meeting, I practiced donning and doffing the personal protective equipment (PPE) for Ebola cases.
PPE is the protective wardrobe health workers wear when examining a patient with a contagious infectious disease. Each disease has a different level of transmission and requires an appropriate level of protection. I wear gloves 25 times a day to examine each patient I see. (Not all doctors do this; in my specialty of infectious diseases, though, it is prudent.) I dress in a gown a dozen times when entering a room of a patient with antibiotic resistant bacteria like MRSA. I place on a mask a few times a day when I suspect that the patient has the flu or tuberculosis.
The risk of infection often times is to patients when health workers carry infectious agents like MRSA on their hands or clothes from one patient room to another or into the community leading to an outbreak of resistant bacteria. On other occasions the risk is to the health care workers of acquiring diseases such as flu, TB or meningitis from the patient.
Ebola poses both these risks. In fact, Ebola in America has completely overturned the thinking and practice of isolation precautions by its highly infectious nature. One billion Ebola virus particles are in two drops of blood, and it has a mortality rate of 70 percent.
In my hospital’s administrative boardroom, with guidance from “my buddy” the infection prevention nurse, I began my Ebola PPE practice. I first placed on the impervious booties and leg coverings, then the blue plastic impervious gown, then the N-95 mask, then the face shield, then head covering, and then two pairs of gloves.
A few weeks ago I thought that this was all overkill. But after I learned that two Dallas nurses has contracted Ebola even with their protective gear, I wonder if this is sufficient. After a few minutes in the total body covering, I felt sweat on my neck. If I breathed heavily my face shield fogged up and when I walked across the room my boot and leg covers began to come off exposing my pants. A splash on them would mean that I could carry the virus home, putting my family at risk.
“My buddy” guided me through each step. Then I soaked my hands in water — as if I had a viral or blood exposure — and began the task of undoing the protective covering. First, removing the soiled gloves, replacing them with new ones, and then removing my head covering, gown, boot covers, face shield and mask, making sure to only touch the insides or backsides of the coverings. On three occasions the nurse stopped me from contaminating myself.
“It’s not easy,” another nurse who was on a hazardous material team remarked with a concerned look.
“So how can we do this better?” I asked. “We need practice.” While theoretically all hospitals should be able to manage an Ebola patient, in practice it is not possible. In my opinion, we cannot train hundreds of hospital staff including doctors, nurses, phlebotomists, and X-ray technician in meticulous isolation procedures.
I believe we need to treat every Ebola case under a hazardous material protocol, not as a hospital infectious disease isolation management protocol. A hazardous material management protocol requires a specialized team, specific equipment and trained practices. We need a local Ebola treatment center and a trained Ebola treatment team at one facility in each metro area, just as we have trauma centers and trauma teams. The Centers for Disease Control and Prevention is developing regional centers and will deploy rapid response teams however, we need to be prepared locally because Ebola will be a concern for months if not years and its course may be unpredictable.
One such team per metro area should be sufficient since we are unlikely to see thousands of cases of Ebola in America — as there are in Africa. Funding for training and preparing such a team could be shared by all the local hospitals because in large part it will save them tremendous internal resources to prepare for extensive hospital management of such patients and disruption if a patient has to be admitted to their facility
However, with such a team, local hospitals and emergency rooms cannot drop their guard. All hospitals, primary care doctors and minor medical clinics would serve as triage units to help identify and isolate potential Ebola cases, because this is where patients will come first. Locally, health departments, hospital executives and infectious disease experts need to quickly meet and develop an Ebola management center and a team, if a case occurs in their city.
The past two weeks has taught me an important lesson. Either we are underestimating the infectiousness of Ebola or overestimating our ability to protect our health care workers with our present protocol and training. Or what is more troubling — it may be both.
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