By George Potter
AUTHOR’S NOTE: The figures of affected persons including mortal victims are accurate up to the date of writing this article, October 17, 2014. It is highly likely that more victims will appear as time goes on.
Ebola is one of the world’s most dangerous contagious diseases: difficult to treat, extremely difficult to treat, and almost invariably fatal to victims. Since the most recent outbreak in December, 2013 in Guinea, more than 4,000 persons have succumbed in Guinea, Ivory Coast, Liberia, Nigeria, and Sierra Leone. Another nearly 8,400 cases have been confirmed in these African nations.
These figures do not include the two Spanish missionaries who were evacuated still alive from their African hospital missions and flown to Madrid, Spain, in August, where both died. They also do not include the recently deceased Liberian who flew to Dallas, Texas to visit his fiancée, also, nor the second case in Dallas, nor the reported cases in the United Kingdom, Norway, France, and Germany, where, at the time of this writing, there has been one mortality and two more infections.
These figures must be added to more than 1,100 fatal victims of the five previous outbreaks of the disease since its first manifestations in the Congo Democratic Republic. The disease is named after an inconspicuous river known as Ebola, a minor tributary of the Congo River of Central Africa. The exact origins or causes of Ebola remain mysterious to investigators, which creates some no minor problems concerning treatment and cures.
Now, what does this mean to emergency responders? A great deal. As we all know, there are thousands of potential biological emergency situations to which emergency service personnel must respond, incidents in hospitals, incidents in pharmaceutical product factories, and other similar activities, and of course, possible bioterrorism. These situations require extensive and more often than not complex multiple agency interactions. If any of these interactions fail, the overall outcome may well become seriously jeopardized or even compromised. This is exactly what happened in Spain during the latter part of September and the first half of October.
Two Spanish missionary/doctors were flown from their missions in Africa to Spain during the summer of 2014. One passed away in mid-August and the other late September. A Spanish auxiliary nurse had volunteered to attend both of these victims. However, something went wrong just after the death of the second victim on September 25, apparently while the nurse was removing her protective ensemble. Even worse, the protocols supposedly implemented for situations involving potential biological incidents went haywire, prior to the moment when the nurse probably came into contact with the virus. From then on, a series of mishaps and mistakes by far too many persons–some in prominent authority positions–took the situation from bad to worse.
All hospitals supposedly have in place protocols created to function in “worst-case scenarios.” These include isolation of infected patients and even personnel attending these, standardized, and certified protective garments–personal protective equipment (PPE) for all persons in direct and in some cases, indirect, contact with the infected patients and/or their immediate environments; control and possible/probable isolation of persons who may have come into contact with the victims; control and decontamination of places where the victims may have entered into including their homes, work places, and others; as well as any vehicles or other means of transport; and above all, strict compliance with the protocol procedures.
In the Spanish case, the established protocols could have been considered as nearly nonexistent. The infected nurse who had been in contact with both of the deceased victims circulated freely in and around the hospital where she worked, as well as the nation’s capital, Madrid and the nearby city, Alcorcon, where she resided with her husband and their dog between the period when she was attending the last deceased missionary and the day when she was diagnosed as being infected, October 6th. During the 11-day period between the second death (September 25th) and the day she was officially diagnosed, she went to a hairdresser in Alcorcon although she was experiencing moderately high fever. That same day, September 30th, she visited her family doctor who diagnosed the fever as being flu and prescribed the common flu treatment drug, paracetamol (acetaminophen). During the following days, the nurse and her husband solicited medical assistance at least three times. The morning of October 6th, her fever increased and her husband called for an ambulance, informing that she had been attending the two Ebola victims. A standard public service ambulance (no specific isolation measures) took her to the Alcorcon hospital. During 16 hours, one of the hospital’s emergency doctors attended her—without wearing adequate PPE. Once examined in the emergency reception area, it was decided that she be transported in properly isolated transport to the Carlos III hospital in Madrid, which has one of the country’s few contagious disease treatment facilities. At this point, at least seven breaches of applicable protocols had occurred.
Once admitted into the isolated contagious disease treatment facility, proper treatment to combat Ebola began, but so did the continuation of errors in protocol application. During the crucial firs two weeks of her treatment in the Carlos III contagious disease treatment facility, her condition worsened and then became stable. During this period, several doctors, nurses, and specialists attended her, all coming in contact with her in one way or another. Personnel were clothed in limited-exposure PPE–European classes 4 or 5–U.S. level C; this situation required at least level B or better level A. The “training” these and nearly all other hospital employees received in donning, working in, decontamination, removing and disposing of protective suits consisted of 20 minutes in groups of 30 or more persons. Any hazmat responder knows perfectly well that this is totally insufficient. During this time frame, nearly 20 doctors, nurses, hairdressers and others who had come into contact with the infected nurse were confined to the contagious treatment center for control. None of these presented symptoms of Ebola. Ten days after her admission in the Carlos III treatment facility, she began to show marked signs of recovery. It is expected that she will remain there for several more days, maybe weeks, until completely recovered. Also during this period, at least four more persons displayed symptoms similar to those of Ebola, but after isolation and in-depth controls and monitoring were found to be unaffected by the virus.
In mid-October, the government assigned the Army’s hazmat and biological warfare response specialists to create and deliver training programs in the use of PPE to hundreds of hospital staff personnel throughout the country. This training began in October, and completely revised and upgraded technical specifications for PPE for use in contagious or infectious treatment environments are expected to be implemented before the end of the year.
Some reports indicated that as many as 12 serious breaches of protocols occurred during this month-long crisis, but it is quite possible that there were even more. Much of the information published in newspapers and expressed in radio and TV broadcasts had to be diligently discovered and “uncovered” from hospital personnel. Many hospital employees participated in public protests over the handling of the situation. The nurse who had made public the inadequacy of the PPE was fired by the hospital where she had been working for several years. The general public and opposition political parties have been outraged by the government´s handling of this situation. Apparently, the lack of adequate PPE was a possible result of the government’s projected privatization of the public health services. However, several positive aspects have resulted from this crisis:
- The importance of the creation, implementation, and compliance with protocols or SOPs
- The need for frequent supervised drills simulating varied possible emergency situations
- Specifications and acquisition of adequate personal protective equipment, including maximum protection levels, and adequate training in donning, working in, decontamination, removal and disposal of PPE
- The necessity to obtain as complete and accurate information as possible concerning the nature of incidents in which biological hazards may be present
- Adequately prepared, trained and equipped emergency response personnel outside of the hospital environment
George Potter is a Spain-certified fire service instructor. He has created and delivered hazmat response training to numerous Spanish public fire services and industrial emergency responders in petrochemical, pharmaceutical, and similar industries in Spain, Portugal, and Algeria.
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