Probably one of the most interesting things about caring for a high-risk Ebola patient is that you find out a lot about yourself and your co-workers. You discover that you are actually willing to go through with treating the patient, and that your staff is willing, too. Not happy about it, but willing.
You find that you might feel a little anxiety about the case and process, but it doesn't show on the outside any more than it does in a code situation or caring for a critically ill patient.
The triage nurse picked up on the patient's possible Ebola in triage, and wheeled her into a designated room (our only ED room with a private bathroom that also happens to be equipped for negative pressure). The wheelchair stayed in the room, as it was supposed to according to protocol. The triage room was used by a subsequent patient before it was closed, exposing a communication lapse with the registration desk.
The triage nurse became the patient's primary nurse; a second nurse functioned as her relief and as the personal protective equipment (PPE) buddy for both of us. This worked well, except, of course, it took the three of us out of circulation for the next hour. Others had to pick up the slack, and other patients probably had to wait longer, just like in true emergencies.
It was interesting deciding which physician would care for the patient. No residents or advanced practice providers are allowed to care for Ebola patients because they would have to be supervised by an attending, which would increase the number of exposed providers. Would the attending be the healthy but mildly out of shape 63-year-old (me) or the healthy 32-year-old marathoner? The former has grown children and may be more expendable, but the latter has the presumably healthier body and better immune system, yet has young kids at home. I bit the bullet without discussing it. But what if the young marathoner were single with no kids and I were married with children still at home? Another partner later said I was the right choice. Maybe he doesn't really like me.
It took a while to don PPE. The type keeps changing. I changed into scrubs from my usual dress pants and uniformed scrub top, and then slowly put on the equipment. It was mildly challenging to get it off the right way, too, and my buddy coach helped a lot. We used the cordoned off hallway as the anteroom but ended up with questions about a doffing pad and contaminating the anteroom.
It helped to take a paper copy of the screening symptoms and risk criteria into the room with me, so I could be sure to gather all the proper information. We now have this as a template on the electronic medical record on the computer in that room.
The nurse and I had normal surgical masks, but she had placed an N95 mask on the patient. The patient later complained about how stifling it was. It certainly is.
My patient was a young missionary who hosted two Liberian missionary friends in her home for a week. They became ill with fever, vomiting, and diarrhea before leaving her house for a driving trip in the United States (and they didn't have cell phones). My patient became ill three days later with a measured fever of 102°F, vomiting, diarrhea, headache, throat irritation, and aching knees. She had a fever in the ED of 100.2°F oral, pulse of 120 bpm, and moderately infected scleral conjunctiva. The CDC screening definition is 100.4°F, but the route is not specified. Fever is officially defined by most authorities as a rectal temp of 100.4°F. The oral equivalent is 99.4°F. Confusion reigned.
Officially, she is a low-risk patient because she hadn't traveled to infected African countries nor had direct contact with known Ebola patients. I used my judgment to say otherwise, labeling her high-risk because the Liberian missionaries' Ebola status was unknown, and they were ill. Our screening question might need to be modified:“Have you traveled to or been around anyone ill who has traveled to ...?”
We needed communication in the room because no one could go in or out. A wired telephone line and cheap corded phone that could be thrown away was the best option. If that had not been available, we would have used a wireless phone and equip the room with a charger.
Because we use an electronic health record, it wasn't clear if we should use the computer in the room to register and document the patient. Scanning for meds was also a question. I'd really like to use it and maybe just keep the computer and monitor covered, and use a plastic cover for the keyboard or just throw it away after. Otherwise, we're back to paper and pen, but these can't be taken out of the room. Then we'd have to dictate notes over the room phone to someone.
We learned that we needed extra scrubs in the anteroom and a small IV kit with bags of saline and tubes for blood draws to go with us into the room. We've never been able to get point-of-care testing for our ED, but this may be a good argument for that.
We can get an Ebola blood test back in five hours, which means we'll probably keep the patient in the ED to minimize exposure to other health care providers. A room across the hall was reserved for family members, which took eight percent of the ED's rooms out of circulation, kind of like our psychiatric patient holds waiting hours to days for beds.
I called the Critical Event Officer after I assessed the patient. I think before and after might have been better. Outside the protocol, I also called the infectious disease attending, the hospital medical director, and the ED medical director. We're still debating how that should work.
My patient's outcome? I was informed it was a drill as I was dictating my detailed note on the patient one hour into her case. My relief was noticeable, as was my annoyance that I had “wasted” an hour and would get no real work credit (just like a disaster drill). The test patient actually didn't know that she was ill with an early viral syndrome. Her eyes were red from leaving in her contacts overnight. She convinced me.
And the drill convinced me that it was a valuable exercise. I now feel much better prepared, and so does my ED.Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.