Saturday, August 25, 2018

Ebola: a clear and present danger, if it gets here

The latest outbreak of Ebola in central Africa is looking more and more dangerous.  It's proving very hard to contain, because it's in the middle of a "hot" conflict zone, and medical teams can't move around safely.

Aesop has some trenchant thoughts on the subject.  Here's an excerpt.

Hospitals here ... are utterly, completely, and massively unprepared to deal with this, as the Dallas example proved in about 21 days, and neither they nor the CDC wants to talk honestly about this.

Neither you, I, nor 2M other RNs nor 1M doctors has the slightest effing CLUE about dealing with this (unless they volunteered in West Africa in 2014) and come the day, they're going to make simple mistakes that'll get them dead, along with thousands to millions of their patients.

The suiting up and decon process takes half an hour each coming and going, requires scrupulous attention to detail at every step, unless you want to die, the gear is hot, a lot hotter than most people can work in for more than a couple of hours, and a "simple" pee break requires the entire 30 minute decon, then another 30 minutes to re-suit. It takes two people who do nothing but suit you up, and another who does nothing but monitor you peeling out of it without effing up and killing yourself. So imagine with me a staffing ratio of four people for every one person who can actually render bedside treatment. And you think the nursing shortage is bad now?

Bear in mind the age of the average nurse in the US is something like 50 years old, not 21 or 22. So you'll have people old enough to be retirees in the military, in the equivalent of MOPP Level IV, which is hotter than hell even in an air-conditioned room,  sweating like a pigs, and doing everything through a fogged up facepiece and two layers of gloves, in a rubber suit, with a virus that only has to get lucky once, with delirious feverish patients oozing blood from every orifice onto everything, and coughing a miasma of bloody sputum into the air. Yeah, that should work.

And then, tell me how many CNAs, EMTs, and PCTs are going to risk their lives for $10-15/hr.?

In someone's effing dreams, baby; hospitals will become ghost towns, just like Texas Health in Dallas did. In minutes and hours, not days. You'll have patients and staff going out the fire escapes and jumping down laundry chutes, mark my words.

. . .

Canada has zero BL-IV beds, AFAIK. But hey, free health care! Just like in Ebola clinics in the African bush. Should work out great for them.

Mexico has...wait, you're shitting me, right? Mexico has what you'd expect Mexico to have: a corrupt government, and an overabundance of expendable and illiterate peones. No points for guessing who'll handle clean-up there. Then take the disease home to papi y los niños, Tío Juan and Tía Julietta, y los viejos. Who will cheerfully and unknowingly spread it to all their friends, and pretty soon, you solved the immigration problem by erasing everyone from Tijuana to Tierra del Fuego, except maybe some lucky isolated Indians in the deep Amazon rainforest. ¡Viva!

. . .

In 2014, we had TEN cases here.

We were two Ebola patients away from swamping the lifeboats, and turning any other hospital into Texas Health Presbyterian, which was Tier One disasterpiece theater. They exposed thousands of people, unwittingly. They had the infected guy in once, misdiagnosed it totally, and sent him home. They didn't catch on until he was brought in again in total collapse, and after throwing the entire best the first world had to offer at him, he died anyways. And infected a perfect R-naught of 2 additional victims. Only fate, or a benevolent deity, kept that incident from turning Dallas in[to] Freetown, Liberia in about two weeks, and wiping out their whole ER shift staff that night. Poorly protected clean-up crews in Dallas were pressure-washing the guy's vomit - live, active virus - onto everything within yards of his apartment in suburban Dallas, the day after it happened. Because illegal aliens with a fourth-grade education are the front line in that clean-up, hired by companies with no more sense than God gave a jackass about Hazmat gear, or proper Ebola precautions. In NYFC, they were handling stuff with no PPE whatsoever. Hand to God on that.

Sleep tight, America.

Anyone in health care who isn't concerned whenever Ebola crops up, simply and respectfully doesn't know what the hell they're talking about.

There's much more at the link.  Pungent, profane, and to the point.  Highly recommended reading.

I might add, from a personal preparedness point of view, that this scenario is the ultimate justification for having a couple of months' worth of food stored at home, along with enough essentials to get you through that period without leaving the house.  Self-quarantining your entire family until the worst is over might be the only viable option, if this disease breaks loose in your city.  Even that won't be foolproof, but it'll be a lot better than going out and risking infection.



kurt9 said...

Its a frightening and believable scenario that gets wrong with only one minor detail. Ebola, as far as we know, is not airborne transmissible. Thus, it cannot and will not spread the way as described at the blog you linked to. That is why it did not spread here in '14 even though Obama was more than happy to allow anyone infected in Africa to come here for treatment.

What the blogger does describe to a "T" is the incompetence of the CDC. From what we saw in '14, they were every bit as bad as described in this scenaro. The other shoe to drop is that hospitals and other large medical centers are intensely "gay" bureaucracies. There is no way in this reality that they would cope any better than the CDC did. Another little detail the scenario left out that actually makes the hospital situation even worse than he thinks is that, until they figure it out that its Ebola, they will assume it is nothing serious and will, therefor, treat the case as a billing event. This means that lots and lots of doctors, nurses, and medical technicians will duck into the room if for no other reason than to run the bill up. All of these people really will get infected if it is an airborne pathogen. In the case of the African guy who was admitted to the hospital in Dallas, no less than 79 people visited his room! That is a billing event!

So, out saving grace is that Ebola is not currently known to be airborne transmissible. That is the only reason why the '14 outbreak turned out to be no big deal at all.

Miguel GFZ said...

The latest strains of Ebola are scary. even though the mortality now stands at "only" 50%, the infection rate has gone up the roof.
If you don't mind me quoting myself:

“The disease was first identified in 1976.
The largest outbreak has been the recent epidemic in West Africa from December 2013 to January 2016 which killed more than 11,000 people.
In 2014, a three-month outbreak of Ebola in the DR Congo killed 49 people.”
I just wanted to add a bit of perspective: From 1976 till 2013 there were 1,948 deaths Ebola or 40 per year in average. From 2014 till 2016 the number jumped to 11,080 for 2,750 deaths per year. And that is with the medical advancements we have including epidemiology protocols.
I have the feeling that crap gets out of Africa in half assed numbers and we get to face up the 21st Century version of the Black Plague.

Jennifer said...

1. Kurt, nobody 'ducks into' an isolation room just for shiggles, let alone to 'run the bill up.' Apart from MDs, staff are completely removed from the billing process; we get paid by the hour and have no desire to be unnecessarily exposed to the creeping crud.
2. what is a 'gay' bureaucracy?
3. Yes, it is 'airborne' when someone coughs or sneezes droplets on you. Hence respirators. There are some instances of transmission that may very well have been airborne.
4. Listen to Aesop. He knows his shit.

Aesop was beating this drum in 14, and ppl should have listened. Our 'isolation' precautions are pure theatre: inconvenient showy and useless. The queries we make when you present at the triage desk? Useless, as the guy in Dallas and doctor idiot and nurse idiot demonstrated. People lie. I personally know of a spotted seven year old who was transported across the canadian border because her parents didn't want to mess up their vacation plans. God only knows how many people I exposed to Chicken Pox. People lie.
Once the symptomatic patient exposed the RN two techs and security guard at the desk, he would be marched past 30 other patients and all the staff, to the only room that had a door. After which, somebody would hesitantly commence isolation precautions. (should we? shouldn't we? in a busy ER, its a major pain in the ass) The hospital has a 'bugout bag' of a small trailer of supplies to be used in case of such an eventuality, but the likelihood of breaking them out in time, or of having enough to last more than half a day is nil. Listen to Aesop.

Jennifer said...

Oh, and Kurt, no matter where you are, don't think it can't happen there. I am in BFE, nothing like Aesop's Gun and Knife Club. My second gig is our local free clinic. One day, the front desk told me that there was a patient out front who needed assistance getting to the back. Odd, as most of our patients are walkie-talkie, or have family to help. I went out to the waiting room to retrieve the patient, and was surprised to find a large family group. None were inclined to help, so after locating the patient, I lifted her and half carried her to the room. She was dead weight. Her dress was peculiar, handmade and very elaborately stitched - not the usual walmart attire. I started making queries, as only one of the group spoke English. It transpired that the patient, who had a fever and cough, had just flown in from a certain East African country having a shall-not-be-named epidemic. But she was fine, family assured me.
The next several days were not easy.
It could have gone SO badly, and was just luck that it didn't. Even rural areas are not safe havens.

kurt9 said...

Hilbillygirl G,

I stand by my comments about Ebola not being airborne. Ebola is actually bloodborne, much like STD's. You have to have blood to blood contact in order for the virus to be transmitted. This is the reason why despite the periodic breakouts in central Africa, it has never really spread to the rest of the world. A real SF-style pandemic would require something airborne like influenza. I do know about Ebola Reston, that infected primates in Reston Virginia in 1989. That was a virus that came from the Philippines (I think) with no connection to Africa.

I have several friends who, having been admitted to hospitals, have experienced having it turn into a billing event. I do know that 79 people entered that hospital room in Dallas before they figured out it was Ebola.

D.J. Schreffler said...

I work at the lab in Austin that did all the Ebola testing the last time it made it to Texas, so seeing news coverage of outbreaks worries me.

Peter said...

A big part of the problem is that Ebola is merely the latest (and the nastiest) variant of what's generally known as West African Hemorrhagic Fever. The class includes Lassa fever (which I've had), Marburg virus, and others, some of which have no name at all. Some are more survivable than others.

The problem is, they all have similar viral signatures. Things may have improved since my experience with Lassa fever, but back then, a blood test could only indicate that you had hemorrhagic fever - not which one. That took more blood tests, usually in a major center, with real problems getting blood samples to them in a condition to be tested, thanks to transport bottlenecks (not to mention refrigeration, etc. - in Africa, often there isn't any). So, a simple blood test of that vintage (as I said, they may have better ones now) would reveal a hemorrhagic fever, but one wouldn't know whether it was the really deadly one (Ebola), the pretty deadly one (Marburg), or the merely 50% deadly one (Lassa). Not fun.

I have no idea how quickly, or how accurately, modern blood tests can distinguish between the various "grades" of West African Hemorrhagic Fever. I hope they've improved since my last experience with them.

Peter said...

Sorry - typo - that should have read that Lassa Fever is about 5% deadly, not 50%.

Beans said...

Kurt, as far as we know Ebola is not airborne, but it has been shown in trials to be capable of being aerosolized in a blood mist, such as when someone has lesions in the throat and they break while coughing. Or, well, when someone shoots someone with Ebola. Not airborne-airborne, like pollen, but airborne like mist. Spray and drift patterns are what are important here.

All of the information that Aesop is preaching was being suppressed by our own government during the previous administration. The way all of it was handled was a national embarrassment bordering on the extremely criminal, and if a Republican administration had acted so, the MSM and the Dems would have rounded up a suitable rabble and stormed the castle, so to speak.

The way the Ebola outbreaks have been handled have just emphasized how unprepared we as a nation are. We can't handle the hemorrhagic fevers found here in these United States, such as plague, Hanta, yellow fever, let alone the more exotic and deadly viruses from Africa and Asia.

We as a nation have lost the will to act in a sane and forthright manner when these viruses come up. Just look at the way we handled AIDS, which has been a complete, abject failure as an example of successful viral control measures. When 'civil rights' trump common sense and species survival, then the society is lost. We're dead, we just don't know it.

Some of the diseases being brought to this country by illegals and refugees would have had those seeking entry as late as the 1950's forcibly quarantined or turned away entirely. Our lax health standards and immigration laws are the medical pistol we're playing Russian Roulette with.

Doomed. Doomed we are, unless we act like 'meanies' and 'evil oppressors' and start treating this stuff like the imminent end of the human race they all (the viruses, bacterial infections, good old plagues) are.

As to how quickly modern blood tests can distinguish between the various strains, well, by the time you are testing, it's too late. And all the tests don't handle well any major shifts in the viral shell. They tend to be too specific to certain strains. So do most anti-virals, be too strain specific, that is.

Best way to handle is rapid and complete quarantine and isolate suspected persons. Just the very thing that hasn't happened in Africa, South America, Central America, Asia and in our large cities.

Aesop said...

To Peter,

Thanks for the link.
Knowing your site, my apologies for the language.
Bleep whatever you like when excerpting.
I plead Marine Corps, and General Patton.
But I yell because I care.

As for the article, I emphasize here, too, that Kivu 2018 is not(yet) 2014 in Guinea/Liberia/Sierra Leone. Pray to a merciful God it does not become as bad, let alone worse. Or get here.

And for kurt9,
A little learning is a dangerous thing...
Ebola is not bloodborne like HIV of Hep C, nor airborne, like pneumonic plague or TB, but it is droplet precautions, at minimum, and that was enough to kill 50-60K people in 2014. Not 11K.

(Anyone can do the math for themselves. There are currently 17K survivors from 2014, and the kill ratio in Africa was 80%. Not 40-50%. 17K is 20% of 85K infectees. By definition then, something like 68K were not survivors. WHO and MSF acknowledged publicly, if diplomatically obscure, that the countries involved were lying about the "official" numbers from Day One to the end of the outbreak, by a factor of 1/4-1/3 of the actual tally.)

Since the well-acknowledged transmission pathway and precautions required are news to you, I'm afraid you're not tall enough for this ride yet. Sorry, but there it is.

From the CDC page:
"Who this is for: Healthcare personnel in any healthcare setting. The guidance is most relevant for hospital staff caring for a patient under investigation (PUI) or patient with confirmed Ebola virus disease (EVD).

What this is for: Guidance to help healthcare personnel follow standard, contact, and droplet precautions when caring for a PUI or patient with confirmed EVD."

"Aerosol Generating Procedures (AGPs) •Avoid AGPs for patients with EVD.
•If performing AGPs, use a combination of measures to reduce exposures from aerosol-generating procedures when performed on patient with EVD.
•Visitors should not be present during aerosol-generating procedures.
•Limiting the number of HCP present during the procedure to only those essential for patientcare and support.
•Conduct the procedures in a private room and ideally in an Airborne Infection Isolation Room (AIIR) when feasible. Room doors should be kept closed during the procedure except when entering or leaving the room, and entry and exit should be minimized during and shortly after the procedure."

Mere mouseclicks can get you the same recommendations from the WHO, Medicins Sans Frontieres, and the Canadian Ministry of Health.

From the Hong Kong Centre For Health Protection page on the subject:
"Isolation precautions for suspected EVD cases before transferal
In addition to stringent standard precautions, additional isolation precautions (contact, droplet, airborne**) should be adopted when caring suspected or confirmed EVD cases with particular attention to avoid any exposure to the patient’s blood and body fluids and unprotected contact with the contaminated environment.
**Initiate airborne isolation precaution if patient has cough, vomiting, diarrhoea or bleeding, or for aerosol-generating procedures such as endotracheal intubation or cardiopulmonary resuscitation."

They indicate a minimum N95 respirator for working around Ebola Virus Disease(EVD) patients.

Aesop said...

How does droplet transmission occur?
"Given the number of infections that can travel through the air, it’s horrible when someone coughs over us. But according to research by scientists at the Massachusetts Institute of Technology, it’s not just the person next to us we should worry about: coughing spreads droplets as far as six metres, and sneezing as much as eight metres. These droplets stay suspended in the air for up to 10 minutes."

From BBC Science Focus page

Like cab drivers dying of acquired Ebola simply from having infected EVD patients in their cabs to take them to hospital in Liberia and Guinea wasn't a major league clue. And they didn't get it from french-kissing their fares. They simply breathed the same air in a car with an infected person. WHO guidelines (and the CDC, before they tried to downplay fears by squelching science) stated that 5 minutes in the same room within 10 feet or so of someone with EVD was enough to list you as a suspected infected person.

Look, there's already enough superstition and ignorance out in the big wide world, and enough stupidity on the planet about Ebola to kill us all ten times over. If we could dig up 68,000 corpses in West Africa from 2014, they could tell you.

Please refrain from adding any more noise to the signal than you already have. When any half-dozen, let alone all medical journals and resources will confirm you're wrong, you're wrong.

That exact type of uninformed supposition is how it got here last time, how it spread to two other people after that (who will carry it probably for life, and go blind at some point, even though they "survived" Ebola), and only transferring them and the American Ebola outbreak problem to the BL-IV ward at Emory, plus incredible good fortune and nothing else, nipped that infection chain in the bud, here.

Two more active Ebola cases from Dallas would have flooded the lifeboat.

We get even twenty cases here in rapid order, and we're liable as not to lose thousands or millions of people, cripple the country from panic, and alter the world in profound ways you cannot even begin to imagine.

The internet is your oyster; educate yourself.
That's all I ask.

McChuck said...

Isolate. Quarantine. The entire region. It's not nice, merely necessary.

Aesop said...

And BTW, the "79 people" number?

Just spitballing, but I'm betting that was the total number of contacts during his hospital stay, until he finally died.
He had two successive ER visits, the second time he was brought in in full collapse, and then went to ICU and isolation there.
Between signing in the first time, triage nurse, doctor, nurse, tech, billing clerk, just on the first visit, then a virtual full code in the ER the second time, plus paramedic transport, multiple doctors nurses and techs the second visit, then ICU with 3 doctors and 2-4 nurses and 2-4 techs a day, 79 contacts is basic math for a multi-day ICU stay. You'd need two or more people at a time just to shift him on the bed, and more if we're talking 20-something 95 pound ICU nurses.
So you're out of touch with normal staffing and care patterns as well.

Some of us do this for a living.

He didn't get a conga line of 79 people in his ER bed on one visit, he had 79 contacts total in the several days at 2-3 shifts/day it took him die, from first visit to morgue.

That's about 20/day over 4 days, for a guy bleeding out of every orifice, requiring total care, delirious, and with projectile vomiting and explosive diarrhea, clean-ups needed on Aisle Ebola multiple times per shift, around the clock.

Just starting an peripheral IV on the guy would take two people holding him so you don't stick yourself when he's delirious and puking, plus the nurse doing the IV start, times probably 3 or more IVs to get fluid and medicine into him, and then probably a full team and doctor in ICU inserting one of more central lines.

Once you look at it that way, 79 seems rather low-ball; I'd have figured 100 or more, until you realize it's Ebola.
At that point, you assign a full team just to him, to minimize the number of separate contacts. Even then, the docs usually rotate Q8 hours, and the staff Q12, so that's probably 11/day, minimum, just in ICU, not counting any specialty consults, like infectious disease, renal, gastro, etc.

But people given the short straw like that tend to call in sick the second day, so you usually have to "share the love" among staff, so nobody gets the Death Room on every shift.

That's not a "billing event", that's called "standard-of-care". Anything less would be prejudice and gross professional negligence, in a lawsuit-inducing manner.

And looking it up, he was in the hospital the second time for 10 days, before he died.

If you'd known that up front, that 79 number wouldn't sound so remarkable, would it?

Internet, my friend. It'll answer a lot of questions.

Aesop said...

And the reason Ebola has seldom left Africa is simple economics:
Out of 1.2B people here, less that 1% (and probably less than 0.1%) can afford the price of an airplane ticket out. Call it 12M out of 1,200M people.

With an annual income on most of the continent averaging about US$1K/yr, and GDP per capita of >US$1K in most of the afflicted countries, that's not very surprising.
There are only ten or so countries out of 53 where the per capita GDP gets to a bare low 5-digit number. And that's average. Actual incomes are vastly lower than that. In DRC, the garden spot of the bunch, an average income would be US$78/wk, with most of that going just to buy enough food not to starve.
In Liberia, 51st out of 53 African nations in per capita GDP, the weekly take-home average is all of US$14/wk. Fourteen bucks.

Tough to afford flying economy class on Southwest Airlines at that price. You couldn't even ship yourself as cargo via UPS at their lowest price tier for that.

Poverty is what's keeping it there, nothing else.
And bear in mind, that means the guy in Kinshasa airport or Cairo doing screenings is some customs clerk pulling down maybe US$100/wk, maybe 1/4 of that, who regards bribes as a perk, not an affront or criminal offense.

Duncan was the exception in 2014, and look what that got us, with just one actual case.
(I didn't mention it in the previous post, but the reason it took half a day toget him from the ER to ICU was they first had to evacuate every other ICU patient to other hospitals, to make theirs available to care for Duncan.
And then the two nurses the sloppy CDC "protocols" infected.

One guy wiped out the entire ICU for a nearly 1000-bed major hospital in our 9th largest US city.

If the virus gets to a major city with an international airport, bend over and kiss yourself goodbye.

Ten guys with means go ten different ways, and it's Contagion, except with no deus ex machina vaccine in Act III.

Larry said...

Ebola may be sexually transmissible. At least it has shown up in semen up to two years after recovery. A mutated strain was definitely airborne transmissible in a monkey facility in Reston, VA, a number of years. Fortunately, that mutation rendered an infection little worse than a common cold. We won't always be so lucky.

Unknown said...

Greetings from North of the 49th.

Thought I'd let y'all know, there's a vaccine now, developed in Canada at the Canadian government microbiology lab . Being used in the field now, as circumstances allow. Seems they'd licensed it to a small parmaceutical company in Iowa, who sat on the license agreement for 3 years without doing anything. (No enough profits in 3rd world epidemics?) until Merk took it over.


Calgary, Alberta

Nuke Road Warrior said...

In a former life I was a Radiological Control Technician. One of the many parts of my job was to evaluate the radioactive contamination hazard and specify the appropriate type and level of protective clothing. When I saw the clothing and masks that the health care workers were wearing when the ebola patients were transported to the US for treatment, I cringed. For an unknown concentration, suspected airborne contamination levels, and near lethal consequences, I'd go with a full face respirator, possibly supplied air, full coverage waterproof coveralls, booties and gloves and hoods with taped openings. I hate to tell medical professionals, and crime show writers but scrubs and surgical masks don't provide much protection for the wearer. If we really are faced with a contagious disease outbreak I am afraid our infrastructure and preconceptions will cause lots of unnecessary deaths.