How can health workers stay safe while treating an Ebola patient?
The CDC is embroiled in a controversy over that very question. After the infection of two nurses at a Dallas hospital, the agency is facing criticism about whether initial guidelines provided to U.S. facilities were stringent enough.
Yet the agency adopted the strictest possible standard when developing a training program for clinicians headed to West Africa, consulting closely with the aid group Doctors Without Borders.
The course runs three days every week through January with about 35 students per session.
The venue is a former U.S. Army base in Alabama that's been rigged to look just like an Ebola treatment center in West Africa. They've got the same orange mesh fencing used to mark off high-risk areas, barrels of disinfectant solution, and, to stand in for patients, plastic manikins laid out on cots. One of them is posed to look as if he's vomiting into a bucket.
And the curriculum? Lots of detailed instructions on how to put on and take off the personal protective gear medical workers must wear, of course.
But when I visited, I also saw how the instructors spend lots of time teaching students how to do ordinary medical tasks in the extraordinary circumstances of an Ebola hospital. They break the tasks up into three days of lessons.
Here's a sampling.
Day 1: How to draw blood from a suspected Ebola patient so you can test for the disease.
This activity is especially dangerous, so precautions are key, says Dr. Michael Jhung, the CDC medical officer heading up the course: "It's a very simple medical procedure and something every clinician knows how to do and has probably done tens if not hundreds of times. But it gets complicated with an Ebola patient because [contact with blood] is one way the virus can get transmitted to a health-care worker." Like other bodily fluids from an Ebola patient such as vomit and waste, blood can have very high levels of the virus. "The consequences can be severe if there's an error or lapse in procedures," he says.
1) Make sure you have all the materials you'll need before you put on your protective suit. And there are quite a number of materials: syringe, vial, band-aid, etc. In a regular medical setting like a doctor's office you can always leave the room to get a missing item. But in an E
bola ward, if you realize you left a tool in the low risk area, you'll lose a total of 30 minutes just taking the suit off to leave, then suiting up again to get back in.
2) Always work in pairs. You and your partner are responsible for continuously monitoring each other — for exposed skin the other person might not notice, for instance, or for slip-ups in procedure. And you'll often need two people to carry out the extra precautionary steps required when working with Ebola patients.
3) Assess the patient's ability to sit still. "Your suit won't protect you from a needle-stick injury. You can wear three or four or even ten pairs of gloves, but a needle will go through all of them," Jhung explains. "So if you think the patient is going to be moving around too much, perhaps because they're undergoing a seizure or they're in so much pain, you might choose not to draw blood at that time."
4) Dispose of the syringe immediately. The minute you've pulled it out of the patient drop it into the sealed disposal container. This is standard practice in any setting, says Jhung, "But if you've done it 500 times you might get a little nonchalant. So we really emphasize it. Not disposing of a sharp" — that's medical shorthand for pointy objects like needles — "immediately is one of those small errors that could be catastrophic in this case."
5) Wash your gloved hands under 0.5% chlorine solution. That's the percentage aid groups working in West Africa have settled on as sufficient. The washing should take place right after you've put the band-aid on the patient. You don't need to wash that long — the chlorine solution kills the virus on contact. But you do need to make sure the solution reaches every part of your gloved hand, including in between fingers to get at any blood that may have spattered on your hands as you pierced the patient's skin or bandaged it.
6) Label and spray. With a water-resistant marker, write identifying information on the tube of blood you've just drawn, then hold it out so your partner can spray the vial with chlorine solution. Spraying must always be done close to the ground, to ensure contaminated fluids hit by the spray don't dislodge and fly into anyone's face.
7) Drop the tube in a bag. Your partner will hold
open a plastic bag. Drop the tube of blood into it.
8) Spray the outside of that bag. In theory it should be free of the virus. But the entire high risk area is considered to be potentially contaminated – particles of a patient's vomit or blood may have landed on the box of trash bags and gone unnoticed, for instance. And the gloves that you or your partner are wearing may still have some bodily fluids on them. So you can't be too careful.
9) Bag it again, spray it again. Take a second plastic bag, and spray the inside — just in case that first bag wasn't sprayed as thoroughly as necessary. Then drop the first bag into the second bag.
10) Spray the outside of the second bag.
11) Walk to the laboratory area of the hospital.
12) Just before you hand off the bag, spray it one more time. That's a precaution
in case it came into contact with contaminated fluids as you were walking the bag to the lab. "Possibly along the way to the lab someone could set the bag down to take care of a patient in an emergency situation, or they could bump up against a patient," says Jhung. So spraying the bag one last time before handing it over to the lab is "just a good practice to get into."
13) Bag it again for safety's sake. A lab worker will hold open a third bag for you to drop the second bag into.
DAY 2: Cleaning up vomit or stool
Technically a sanitation or hygiene worker performs this task, not a clinician. But clinicians need to know the basics in case they need to pitch in — and so they can tell if the facility they're working in is following proper safety procedures.
1) Chlorine is your friend. That's a phrase that CDC instructors tell their students to remember. "The take-home point is that if there's any doubt about what you should do about a spill, you should put chlorine solution on it," says Jhung. But he adds that it's important not to use too powerful a spray — you don't want to send fluids flying around. Better to gently pour or spritz the chlorine solution onto the affected area. This is the first step to take regardless of where the vomit has landed: floor, bed linens, etc. After about 10 to 15 minutes the liquid portion of the waste should be decontaminated.
2) Wear thick dishwashing gloves. They allow for less fine motor movements than the exam and surgical gloves worn during medical procedures. But dishwashing gloves are stronger and less likely to tear.
3) Deal with any solid bits in the fluid by using a "chuck." Jhung describes a chuck as a large cloth with the consistency of a diaper. First moisten it with chlorine solution, then lay it on top of the solid waste. Wait 10 to 15 minutes so that some disinfection can take place
4) Pick up the chuck and the solid bits it's covering. Put the cloth, with the bits, in a plastic disposal bag.
5) Spray or pour chlorine solution into that bag.
6) Put the bag in another bag. Close the first bag, spray the outside, and place it in a second bag.
7) Spray and dispose. Spray the outside of the second bag with chlorine solution and walk it over to the hospital's waste disposal area — often an incinerator.
8) Tackle the remaining liquid. The liquid portion of the waste can now be mopped up with paper towels — as long as the liquid has been thoroughly covered with chlorine solution for 15 minutes, any virus in it will have been killed.
9) Dispose of materials. Any paper towels used should be placed in a plastic disposal bag and taken to the waste disposal area.
DAY 3: How to admit a suspected Ebola patient into the ward.
1) Gear up. Interviewing a patient requires less protective gear than treating a patient. Eyes need to be covered with goggles or a clear mask, and you'll need to wear gloves. But a head-to-toe suit is not required as long as you can remain at least three feet away from the patient.
2) Suit up if necessary. If the patient's symptoms and history suggest Ebola, you need to suit up fully before escorting the individual into the suspect case area. As with cleanups, dishwashing gloves should be worn for this job.
3) Get a stretcher if needed. If the person cannot walk on their own power, you will need four people and a stretcher. The team will lift the patient onto the stretcher.
4) Spray the ground. Use a chlorine solution to spray the area where the patient was standing or lying as thoroughly as possible so as to cover any bodily fluids that may have run off of them.
5) Carry the patient into the ward on the stretcher. Then immediately hand the stretcher over to hygiene workers, who will need to decontaminate it with chlorine spray before it can be used again.
6) Check for any breaches in your protective gear. Jhung says you are most likely to dislodge gear and expose skin when you are carrying a person or helping them onto a bed. Even if you have no reason to think you touched an Ebola patient's fluids, if you notice any skin showing or any tears in your suit or gear at any time while you are in the high risk area, you and your partner must immediately exit the high risk area and take off your suit in accordance with the usual careful removal procedures taught in the course.
Jhung stresses that this class is just an introduction to the basics. Aid groups that run Ebola treatment units, like Doctors Without Borders and International Medical Corps, require clinicians to work under the close supervision of a mentor at a real facility for several weeks before they are considered fully trained.
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