Portal de Periódicos da CAPES

Emergency Physicians in the Ebola Epidemic

2015; Elsevier BV; Volume: 66; Issue: 3 Linguagem: Inglês

10.1016/j.annemergmed.2015.05.014

1097-6760

Éric Berger,

Disaster Response and Management

Brian D’Cruz, MD, wasn’t sure what to expect when he arrived in Conakry, the capital of Guinea, last November. Because the country neighbors both Sierra Leone and Liberia, Guinea too had become hard hit by the Ebola virus ravaging the countries to its south. As a member of Doctors Without Borders, Dr. D’Cruz, an emergency physician in Virginia, had come to oversee a 90-bed Ebola treatment facility on the grounds of a hospital. “I won’t lie,” Dr. D’Cruz said. “I was nervous. I knew there were people who come [sic] to treat patients who had gotten sick, and I even knew some of them.” When Ebola was sweeping through Africa and stirring a panic back in the United States, there were no other treatment centers within 600 km of the sub-Saharan facility Dr. D’Cruz was to oversee for 6 weeks. So on arriving, he was surprised to find a scene on the ground that wasn’t all doom and gloom or straight from the pages of World War Z. He recalled walking into the Ebola treatment center through a courtyard where people sat around plastic tables, playing cards, listening to the radio, and laughing. These were patients waiting to be discharged. Here, in the middle of one of the countries with more than 2,000 deaths because of the disease, was life. “It looked like a street scene,” Dr. D’Cruz recalled. “For me, this really hit home. People can survive. It’s not the end of the world. It can be controlled.” The 2014 Ebola outbreak in West Africa was, of course, devastating. More than 10,800 people have died from the disease, whose outbreak was the largest in history, and some countries with already fragile health care systems have seen them shattered. But for emergency physicians who traveled to Africa to treat the disease and support patient care, the message from that continent is not one of doom. Rather, it is more one of validating the global health care system and Western medical practice. According to the World Health Organization, from when the outbreak began in March 2014 through the end of April 2015, there have been 26,290 suspected, probable, and confirmed cases of Ebola in the countries with widespread transmission, Sierra Leone, Liberia, and Guinea. The most cases, 12,387, were in Sierra Leone. The most deaths, 4,608, were in Liberia. By the end of April, the outbreak was being contained but had not ended in these 3 countries. Officials in Africa, the World Health Organization, and the Centers for Disease Control and Prevention (CDC) made some mistakes, but in the end they stepped up to prevent a worldwide pandemic. They succeeded, in part, because of the timely intervention by emergency physicians. Among those watching the worsening Ebola outbreak during the summer of 2014 was Patricia Henwood, MD, who had already traveled abroad to treat global health issues. First as an emergency medical technician and then during medical school, she worked around the world, in Honduras, and Ethiopia. She traveled to Haiti after the 2010 earthquake as an emergency medicine resident at Brigham and Women's Hospital/Massachusetts General Hospital and has since worked extensively in Rwanda and Uganda. As the Ebola crisis deepened, Dr. Henwood knew she would have to go. “It was on my radar pretty early,” she said. “Obviously, it was something I was concerned about.” Gently, Dr. Henwood said, she broke it to her family and rearranged her schedule with the Hospital of the University of Pennsylvania, where she is an assistant professor of emergency medicine. Working through the International Medical Corps, an organization that seeks to deliver urgent care around the world, she traveled in October to Bong County, a region in central Liberia. There Dr. Henwood had 2 primary duties, transport and treatment. Some days she would join a convoy, driving as many as 5 to 6 hours away, to evaluate patients and coordinate ambulance service back to a 50-bed Ebola treatment unit. Some patients were grateful; others resisted treatment. The “ambulances” used to transport patients were essentially pickup trucks with tarpaulins over the back. The treatment unit itself consisted of small concrete buildings covered with tarps. One of the biggest challenges came from the heat, with daytime temperatures near 90°F (32.2°) and high humidity. The protective masks sometimes became soaked with sweat to the point at which the mask would begin to fill up. Sometimes she had to try to breathe through this sweat. There was almost no medical equipment, and for diagnostic tools she was largely limited to tests for Ebola and malaria. Then there were the emotional swings. Sometimes an entire “ward” of more than a dozen patients would be given over to a single, extended family whose exposures could all be traced to a single funeral. Some would live and some would die. She would try to help them, try to manage the death and help them go on living. Like Dr. D’Cruz, Dr. Henwood was nervous before traveling to Liberia, unsure of what exactly to expect. “When you get there, it kind of demystifies things,” she said. “When you get there, you’re just a doctor. There were definitely moments when you thought you were in a movie. But a lot of the time, it was just being a doctor, taking care of patients.” For this kind work, she said, emergency physicians have a particularly apt skill set. Patients presented with all manner of symptoms, and there’s a constant calculus of determining the best care with a given set of resources. There’s also the challenge of dealing regularly with death. “With the combination of physical, environmental, emotional, and clinical factors, it seems like emergency physicians are the most well suited to do this kind of work,” Dr. Henwood said. That’s a sentiment shared by Bobby Kapur, MD, MPH, an associate professor of medicine at Baylor College of Medicine in Houston, who led a team of 6 to Nigeria in September. At the time, the country was dealing with sporadic cases after an infected Liberian man arrived by airplane from Lagos, Africa's most populous city, with 21 million inhabitants. Dr. Kapur’s team traveled to Lagos and the Niger Delta to meet both with residents and medical providers to dispel myths about the disease, answer questions, and help develop protocols for dealing with Ebola. “In almost any country in the world, when outbreaks like these occur we are going to be the front line providers,” Dr. Kapur said of emergency physicians. “Maintaining our high levels of training and preparedness is really important.” In late October, after 20 cases and 8 deaths, the World Health Organization declared an end to the Nigerian outbreak. “This is a spectacular success story that shows that Ebola can be contained,” the health organization stated, crediting the Nigerian government for swift action, strong public awareness campaign, and early engagement of traditional, religious, and community leaders. On the ground, Dr. Kapur said he agreed with these assessments. “We learned a lot about the need to have unified public messaging and very good coordination between the public and private sectors.” There were striking differences in the Nigerian and US reactions to the disease, he said. In Nigeria, there’s a strong central government and state hospitals. Leaders sounded the Ebola alarm, and the medical infrastructure answered. In the United States, hospitals have a lot more autonomy, and in addition to federal oversight, there are state and local governments who have input. Then there are the CDC and state and city health departments. “We have multiple layers of jurisdiction when it comes to public health,” Dr. Kapur said. There are obvious advantages of more local control and fully democratic societies, of course, but coordination of these multiple jurisdictions should be included in outbreak disaster planning, he said. One of the biggest problems the emergency physicians who traveled to Africa encountered was not on that continent, but back in the United States. Dr. Kapur and his team returned to the United States before the case of Eric Duncan, who first arrived at Texas Health Presbyterian Hospital in Dallas in late September, sparked widespread concern and hysteria about the disease. However, later on Dr. Kapur observed a dichotomy in the way physicians returning from Africa were treated and how those who cared for Ebola patients in the United States were viewed. “It’s interesting how we made a distinction between doctors who traveled over there who cared for patients, and physicians who cared for patients in the United States,” Dr. Kapur said. “We didn’t quarantine doctors here, but we did doctors who came back from Africa. I just can’t fathom why we made that distinction. A nurse in Nebraska, or a doctor at Emory, they weren’t told to stay home. I don’t think we have explored that issue enough.” Dr. Henwood, who made 2 visits to Liberia, recalled watching from afar in October as people in Hazmat suits deployed to apartments in Dallas and there were calls for severely restricting travel to and from Ebola-stricken countries. “It was challenging for me because during that time in October when all of this was unfolding, it was not very clear what was happening back in the states,” Dr. Henwood said. “We weren’t sure if we were even going to be able to come back into the United States at that time. It was unfortunate because it was distracting. It became something for people to really have to plan out, where were they going to stay, and so on.” She noted the differing restrictions in Pennsylvania and, just across the border, New Jersey where Gov. Chris Christie implemented a severe quarantine policy and categorized travelers flying into Newark Airport into 3 tiers: high risk, some risk, and low risk. Dr. D’Cruz, who practices emergency medicine at Inova Fairfax Hospital in Virginia and finished working in Guinea in January, simply spent the 21-day period abroad to avoid the United States restrictions. Was he nervous during that time? “Every time I felt a little warmer, I worried a bit.” But like most foreign physicians who traveled to Africa, he’d been careful. There was no physical contact with other people aside from when suiting up, and he watched what he ate. “I knew when I left that I hadn’t had any exposures that would really put me at risk for Ebola,” Dr. D’Cruz said. The work itself was extremely difficult. Like Dr. Henwood, he struggled with the heat. He could spend only an hour inside his suit at a time. Dehydration was the main concern. He’d lose about a liter of water in an hour, and at the end of that time his boots were filled with sweat. Still, it was hard to come out of the patient wards after such a short period. “Everyone,” he said, “wanted to stay in longer than they should have.” It was the little things he noticed most. Most mornings he’d get to the treatment facility shortly after sunrise, suit up, and then try to do rounds. The experience was far removed from that of an emergency department in Virginia, where a patient presents with an illness, maybe they’re not breathing, and a physician can order a radiograph or a computed axial tomography scan, and so on. In Guinea, it might take 30 minutes to suit up after a patient arrived. And then he couldn’t even use a stethoscope because of the suit. “It was really frustrating at times,” Dr. D’Cruz said. “I didn’t miss the CT [computed tomography] scanner or lab tests so much, but not being able to listen to a heart or lungs was really difficult to get used to.” At the end, the lesson he brought back to the United States is that medicine works; with proper practices and procedures, the disease can be controlled. Ebola didn’t spread in the United States, and after some mistakes were made in Africa, the disease is being controlled there. After his 6 weeks in Guinea, more people than ever were playing cards, smiling, and living after infection when Dr. D’Cruz finally came home. “The thing I would tell other doctors is that, even with a disease as scary and threatening as Ebola, it is very, very possible to protect yourself and take care of your patients.”