The everyday fight against Ebola

An Australian RN describes in detail the daily routines, procedures and precautions for nurses in Sierra Leone caring for patients with the deadly Ebola virus.
By Peter Kieseker

Many Australian nurses have joined or are working alongside the 32-plus international agencies attempting to stem the Ebola epidemic in West Africa. But what do they do?

Most Australian nurses give direct patient care. This is how Australians – and the New Zealanders working alongside them – are fighting Ebola.

The nursing

Ebola is fought by identification, isolation and treatment. Once a case or suspected case is identified, isolation is immediate. Disease transmission must be stopped. Once 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 Ebola Treatment Centres (ETCs) determination of IV fluid requirements remains a medical decision.

In most centres there is 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 gases and more are routine, despite the increased risk to care staff. In the aid world, this causes heated debates around the ethics of first-world care for a few vs more basic care for the many.

In the case of Ebola, neither approach is proving statistically superior. Death rates in all approaches are similar. Such is the nature of the disease.

Rosters

Rosters vary between ETCs but typical is two days working 7am–1.30pm, followed by a 12-hour night shift, then two days off followed by two afternoon shifts 10am–7.30pm, followed again by a 12-hour night shift and then two days off. Add to this an hour travelling time between accommodation and ETC. The drive is interesting – the first 20 or so times – because of the many 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 cloths and themselves in the creek, or farmers tilling fields, loses out to sleepiness.

Triage

The key question at triage is whether the person is a health worker or has cared for someone sick, these being the two most susceptible groups. Attendance at a funeral, visiting sick friends or having someone ill or recently dead in the family or close community also trigger alarm bells. The AVPU scale is also a basic consideration.

Triaging follows a simple flowchart. Essentially, if a patient has had a history of contact with a suspected, probable or confirmed case of Ebola, coupled with a history of fever, then they are probably suspect.

Alternatively, fever with no known contact plus two of any of the following symptoms raises the index of suspicion: nausea/vomiting, diarrhea, 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 poor prognosis), and/or unexplained bleeding.

The Ebola symptomology is wide and varied, and it duplicates many other conditions, especially malaria and the also deadly Lassa fever. Hence people are often admitted to either the suspect ward or the probably ward, depending on level of symptom acuity. Here they have to await blood test results, while ensuring they do not come within two metres of any other suspect person. These results will reveal – usually within 24 hours, depending 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 three days, the patient is discharged. If the test is negative but the symptoms have been around for fewer than three days, they wait another 72 hours for a repeat blood test. Patients who test positive are transferred to the confirmed ward. During triage, a baseline visual acuity test is conducted to measure any possible loss of vision, as this is 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 and monitor all their contacts. Early identification can help break a transmission chain and bring early intervention to any newly discovered cases.

PPE

Personal protective equipment (PPE) is fundamental in Ebola nursing. The virus is spread by contact with body fluids. Excessive diarrhea and vomiting are an ever-present feature of Ebola, and bleeding occur in about one-quarter of cases, so 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 with them there is concern about projectile vomiting, or children’s hands getting under the visor and making contact. For the experienced nurse, donning PPE 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, which is aided at first by light exercise.

Undressing from PPE – doffing – takes longer then dressing. It follows a very slow and deliberate sequence in order to minimise the risk of coming into contact with possibly exposed materials. After standing in a 0.5 per cent chlorine boot bath for a strictly timed minute, gloves are washed and the whole person – except goggles and face – is sprayed with a 0.5 per cent chlorine solution. Then, in a sequence constantly punctuated with hand washing, 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 per cent chlorine, which does not burn skin, whilst standing in another strict one-minute boot bath of 0.5 per cent chlorine. One comes out sweating and smelling like a swimming pool, but chlorine is highly effective against Ebola.

Team handover

Team handover is usually a noisy affair. Sierra Leoneans speak loudly – really loudly – 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 Leoneans to adjust to.

Handover itself is held at outdoor but shaded whiteboards, where the four categories of live 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 for convalescent; 2 for symptomatic (independent); 3 for symptomatic (requires assistance); 4 for severe symptoms (requires a great deal of assistance) and 5 for moribund. A 1–3 dehydration score is also allocated by clinical appearance and skin rebound.

Regular rounds

A form of regulated rounds 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 the suspect ward and probably ward not to move out of their 2-metre 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 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 staff usually aren’t either. It is not uncommon to enter a ward for a fluid round and find a patient who seemed to be doing reasonably well lying deceased and rigid. One of the characteristics of Ebola is the rapid – about 20 minutes – onset of rigor.

The ‘No Touch’ policy applies to all staff. There exists a strict interpersonal distance to be maintained in all aspects of life – be it a 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 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 pace to find a vaccination and, indeed, at the time of writing a trial is being commenced. A set regime of medication is followed, with several additional medications occasionally trialled in an effort to find the right combination. (see breakout, previous page)

The deceased

At nursing handover a sixth category of patient, ‘in mortuary’, is too common a 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 Leonean practice of washing their dead that has been largely responsible for the spread of the disease.

Double body bags and extensive chlorine are used, along with strict procedures. The deceased are often presented for viewing to their loved ones – behind a 2-metre-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 a 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 developing-world conditions, but survival is possible, with ETC rates running from 30–50 per cent. For those who do survive, immunity appears to be gained, though it is unknown for how long and whether effective against all strains of the disease. In Sierra Leone, battle is being done only with the Zaire stain of Ebola.

The discharge of a survivor is a happy event for all. The person is given a survivors kit consisting of new clothes and goods because all they brought with them will have been 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 simply to 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 sufferer is often stigmatised and ostracised. To counter this, a Survivors are Our Heroes 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 publicly 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’s not all work. Sierra Leone is populated by intelligent, welcoming, friendly – and loud – people. There are museums and buildings 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 six weeks, the time goes quickly and the experience is worth it from a nursing and cultural point of view.

Ebola is being fought and fought hard at considerable expense. But the global risk it poses justifies the fight. What Australians and New Zealanders are learning whilst working with Ebola will result in a pool of nurses skilled, knowledgeable and experienced in working in highly infectious quarantine situations; skills that will be needed where viruses that disrespect all persons can travel rapidly on wing and ship.

Medicines against Ebola

Standard with any admission is Oral Rehydration Solution (ORS) at a rate of 1.5l three times a day. ORS – the proven saviour in cholera – is used due to the massive gastrointestinal fluid loss. Such losses contribute to hypovolemic shock, severe electrolyte abnormalities and high mortality. Whilst ORS can be made up at village level, a commonly used commercial ORS comes in 20.5g sachets containing glucose 13.5g, sodium chloride 2.6 g, trisodium titrate dehydrate 2.9g and potassium chloride 1.5g.

Other regular medications are Cefixime 400mg twice daily, to counteract common co-infections. To fight the also common malaria, Artesunate/Amodiaquine 100/270mg, two tabs at night, is usually administered for three 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 intravenous Ceftriaxone, Artemether (80mg/ml loading dose at 3.2mg/kg once daily IM day 1, followed by maintenance dose 1.6mg/kg once daily, intermuscular, days 2–5), ondansetron 8mg three times a day IV, and morphine 5–30mg three times a day, subcutaneous/intermuscular/intervenous.

One trialled medication – used sporadically – is the potent antidiarrheal loperamide, which also has antiperistaltic and antisecretory effects. The rationale is that reducing diarrheal losses might allow correction of negative fluid balance, reduce hypovolemic shock, limit electrolyte losses and improve survival. However, the ‘reluctance to use loperamide for EVD diarrhea may be based upon the perception that there is not benefit for the secretory diarrhoea observed in cholera or concern of the risk of toxic megacolon when used for some bacterial inflammatory causes of diarrhea such as Closterium difficile’.

Peter Kieseker is an RN who was part of the Aspen Medical team at the Australian-flagged Ebola Treatment Centre in Sierra Leone.

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