Ebola: What A First Responder Should Know
By James E. Winslow, MD, MPH
With the ongoing Ebola outbreak in Western Africa, it is important for EMS personnel to be familiar with characteristics of the disease, how to screen for it, how to protect themselves, and how to care for these patients. The chance of taking care of an Ebola patient is quite low. There have been only two patients in the United States who have been exposed to and contracted the disease within this country. There were two additional patients who were exposed to Ebola oversees and then developed the disease after arrival in the United States. In total this means that only four people have developed Ebola while in the United States. Given that the U.S. is a country of 300 million, this means that there is a very low risk of a healthcare worker being exposed to a person with Ebola and an even lower risk for the general population. That being said, it is the role of EMS personnel to train in how to recognize, care for, and work safely around possible Ebola patients. In this way EMS can help ensure that the United States is kept safe from an Ebola outbreak.
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The CDC has recently released a great poster on the top 10 things to know about Ebola. Perhaps the most important fact to reiterate is that Ebola is not airborne. There is no evidence to suggest that it can be contracted by coughing or sneezing. Although it is possible to be exposed if a patient coughs or sneezes directly in another person’s face spraying them with large droplets. Another important fact that should be repeated is that patients are only contagious if they have symptoms. In addition, there have never been reports of dogs or cats carrying Ebola. Currently, all travelers from an affected country must arrive through one of five airports where they are both screened and put in contact with the Centers for Disease Control. This is why a travel ban is not a good idea. If there were a travel ban people would simply try to sneak into the country and avoid the screening mechanisms. This would make preventing an outbreak much more difficult.
A suspected Ebola patient is defined as a person who within the past 21 days before the onset of symptoms has had residence in or travel to an area where Ebola transmission is active in West Africa. Currently the specific countries include Sierra Leone, Guinea, Mali and Liberia. The patient must also present with a fever, headache, joint and muscle aches, weakness, fatigue, vomiting and diarrhea, stomach pain, lack of appetite or bleeding. If a patient meets the definition of a suspected Ebola patient then prehospital personnel should utilize their agency Ebola specific protocols. Emergency Medical Dispatch should screen all patients for travel to an affected part of Africa and for the symptoms of Ebola. If a caller screens positive than responding personnel should be notified and they should wear appropriate personal protective equipment before entering the scene. The incubation period for Ebola is from two to 21 days with eight to 10 days being the most common. Often times the earlier the onset of symptoms the more severe the disease course will be.
Appropriate use of personal protective equipment will protect providers from Ebola. Unlike the flu, Ebola is only spread by direct contact with blood or body fluids. Droplets cause the flu to spread easily when people cough, sneeze or talk. Personal Protective Equipment used when caring for a patient with suspected Ebola should not allow any exposed skin. A PAPR or N-95 can be used, but if an N-95 is used there must be a full-face shield and there should be no exposed skin. All personnel should extensively practice the doffing and donning of personal protective equipment. Whenever doffing and donning is complete, a checklist should be utilized and a safety monitor must watch the entire process to be absolutely sure it is done correctly. Health care workers can contract Ebola if they accidentally contaminate themselves while removing their personal protective equipment.
Care of the Ebola patient is very similar to the care of a patient with a flu-like illness or gastroenteritis. Early in the course of Ebola the patient usually appears well. In this phase he or she may only have a fever and mild complaints. At this stage he or she are less contagious. Later in the illness the patient may develop vomiting and diarrhea. At this stage the patient will be more infectious. The care of the Ebola patient mainly includes supportive measures. If possible, EMS should avoid invasive procedures. The danger of a prehospital worker needle stick while starting an IV is extremely high, so if possible, oral hydration should be utilized. Also, aerosol-producing procedures should be avoided since they may greatly increase the risk to healthcare providers. Such procedures include intubation, CPAP or BiPAP, suctioning and nebulizers.
EMS agencies should coordinate with their area hospitals ahead of time to verify which hospitals can accept possible Ebola patients. EMS agencies should notify the receiving hospital as soon as possible if they might bring a suspected Ebola patient to that hospital. Once EMS arrives at a hospital the crew should not enter the hospital until told to do so by hospital staff. It is very important that planning take place ahead of time.
Obviously it is important to educate all EMS personnel about the care of the Ebola patient. Extensive planning and training should also be done. The care of the Ebola patient can be done safely if appropriate screening is done, PPE is worn correctly and basic infection control techniques are applied.
More information can be found at the CDC Ebola website, http://cdc.gov/vhf/ebola/.
Dr. Winslow graduated from Emergency Medicine residency from UNC-Chapel Hill in 2002 and completed his EMS Fellowship in 2003. He has worked at Baptist Hospital in Winston-Salem for the past 11 years. He has served as the Chair of the North Carolina College of Emergency Physicians EMS Committee, which developed the standardized guidance document for EMS in North Carolina. He was appointed as the Medical Director of the NC Office of EMS in 2011. Before serving as state medical director he was Assistant Medical Director for Forsyth and Orange County EMS in North Carolina and Medical Director of Person County EMS. This document contains all protocol, procedures, and policies for all EMS agencies in North Carolina.
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