Ebola: Are We Ready?Commentary by Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS
A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting, and fever since morning. The patient stated that he was at a potluck the night before and thought he ate something that made him sick because he had a foul tasting potato salad. He was unsure if anyone else got sick. The patient glanced at the sign prominently posted at the triage desk. "Tell us if you have traveled outside the United States in the past month." He did not volunteer any information, but when the triage nurse asked him directly, he reported that he returned the previous week from Sierra Leone, where he was volunteering with Doctors Without Borders handling patient intake. Because of this history, the nurse initiated an isolation protocol for patients with symptoms and travel history consistent with possible exposure to Ebola. The triage nurse donned a mask and handed one to the patient, asking him to don it as well. She did not touch him but asked him to go with her to a decontamination room and to wait there until staff could don personal protective equipment (PPE). The patient was also instructed to don a blue plastic gown over his street clothes. He waited in the decontamination room for 20 minutes.
An ED physician and nurse, both wearing full PPE, introduced themselves to the patient and explained why they were dressed in coveralls, powered air purifying respirators, double gloves, and protective leg and shoe covers. They took a history and assisted the patient to a gurney. Outside the room, two security officers cleared the corridor. The physician and nurse pushed the gurney down the secured hallway toward the elevators where they would go up to an isolation room. There seemed to be confusion as to which elevators should be used. At that moment three different elevators arrived on the ground floor, more than 30 staff members (at their shift change) exited the elevators to go home and were surprised to see the two human silhouettes covered head-to-toe in yellow and white spacesuits pushing a gurney occupied by a pale young man, now garbed in an isolation gown, bonnet, and mask, and in considerable distress with vomiting. As the patient arrived in the isolation room, the ED nurse was asked to start an IV, draw blood, and insert a Foley catheter. As the nurse gathered supplies and cannulated the peripheral vein, she asked, "Where is the transfer set?" referring to an equipment tray used in the ED to draw blood from a peripheral IV. As the clinicians soon discovered, this set was not available on the patient unit. The blood was successfully collected using available equipment, yet the procedure to send it to the laboratory was not clear. The specimen was placed in a double biohazard bag and left in the room pending additional instructions about how to transport it to the laboratory.
The critical care team, two intensivists and two nurses, arrived in the isolation room. A trained observer assisted the critical care team as they donned their PPE, a process that took more than 20 minutes. A warm handoff was provided by the ED team as they exited. A warm handoff includes an in-person summary of the patient's history, symptoms, and ED care and decision-making, with an opportunity for the critical care team to ask questions. As the critical care team turned to the patient, he vomited again, became tachycardic and hypotensive, and his oxygen saturation dropped and did not respond to supplemental oxygen. The intensive care unit (ICU) physicians decided the patient needed central venous access and requested supplies and ultrasound. While they often supervise resident and fellow insertions of central lines, attending physicians in the ICU seldom perform insertion themselves. Unfamiliar with the central line kit, they struggled but successfully put a triple-lumen catheter in the internal jugular vein using ultrasound guidance. Sterile technique was breached multiple times as they navigated the central line insertion process in their bulky PPE. At several points in the process as they reached for supplies, their backs were to the patient. An airway was never secured.
Fortunately, this case was only a simulation. Multiple experts observed and provided feedback on the process.
Although the patient was not harmed, he was placed at risk for development of a central line–associated bloodstream infection. Hospital faculty and staff were placed at risk of contamination with Ebola. Yet, this simulation took place in a hospital that was "ready" for a patient with Ebola. The hospital had developed and disseminated guidelines for caregivers and had trained them especially on safe PPE donning and doffing.