Via the UNC Health Care Newsrooom: Dispatch from Guinea: Containing Ebola. This is a remarkable series of letters from Dr. William Fischer II, who was invited by WHO to try to reduce mortality in the Guinea Ebola outbreak. This June 10 letter is the last in a series he wrote during his three weeks in Gueckedou. You should read them all.
I’ve just made the 2-hour trip by truck from Gueckedou to the dirt runway of Kissidougou and I’m trying to process all that has happened over the past three weeks.
I’m told this is the first time that WHO has specifically sent critical care clinicians into the field to try to help improve the clinical care of critically ill patients. They have sent countless physicians into the field as epidemiologists, anthropologists, and infection control and prevention experts who have done amazing work to provide care and stop disease transmission but sending critical care specialists is somewhat new. Ultimately, I think that this has demonstrated real promise and I think we’ve also learned a couple of things:
1. Ebola-related mortality can be reduced immediately with early, aggressive critical care management. While vaccines and specific antivirals would be extraordinarily helpful, the majority of patients are presenting with low blood pressure and shock that is responsive to aggressive fluid resuscitation.
I believe the key; however, is not just in the recognition of shock and institution of early aggressive fluid resuscitation, but also in the constant reassessment and modification of therapy as needed which is a defining feature of intensive care medicine.
Additionally, while vaccines and Ebola-specific antivirals are years away, aggressive supportive care is possible now. Improved mortality rates from augmented clinical care will result in enhanced trust between patients and providers and ultimately earlier recognition of those that are sick and decrease transmission.
2. The fear of Ebola is almost as dangerous as the virus itself. I truly believe this is a significant barrier to improving the clinical care of patients infected with Ebola. The most difficult part of this mission for me was the week prior to leaving Geneva for Guinea. I was consumed with how this virus is portrayed (90% mortality, bleeding from every orifice, decimated villages, etc.) rather than what we know about this virus (it is caused by a virus that is readily transmissible, has hemorrhagic complications of varying degrees in 50-60% of the time, and is potentially survivable with aggressive clinical care).
Fear is incredibly inhibiting to both healthcare provider recruitment and with contact tracing – two critical pieces in the struggle to control an outbreak. Patients fear the isolation zone because their experience has been one sided: friends and family members go in with common symptoms of diarrhea and vomiting and leave in a body bag with absolute restrictions on touching the body.
Additionally, trying to recruit physicians to come to a resource-limited environment to fight a virus that is synonymous with death has been difficult, to say the least. But the data on transmission and our experience with this virus tells us that transmission can be interrupted with effective infection control interventions.
I look back at my own recruitment and remember a conversation that I had with Rob Fowler in which I said, “if you don’t get me on that plane soon I’m going to think my way out of this.” It was mentally exhausting worrying about my ability to contribute, my own safety, and the effect this mission would have on my family.
In hindsight, getting on that plane was both incredibly difficult and one of the best decisions I’ve made professionally. Destigmatizing this infection is just as crucial as providing intensive clinical support as both will lead to patients presenting earlier in their illness and increased numbers of healthcare workers to assess and reassess patients.
3. There is an incredible strength in the combination of structure and flexibility. Healthcare organizations are not only capable of working together but it is abundantly clear that we are stronger together than apart. MSF and WHO are incredibly capable organizations that separately provide great work but together they can be both synergistic and heroic.
Without the structure of MSF, I would not have been able to solely focus on patient care, and without WHO, MSF would continue to provide great clinical care but hopefully will benefit from subspecialty expertise. There remains; however, a tremendous need for organizational and regional coordination to ensure this crucial synergy.
The location of this outbreak has profound geopolitical implications and as a result I’m concerned that this epidemic is far from over. I’m leaving with both hope that critical care support can improve outcomes of Ebola infection and some sadness that I’m leaving before the end of the epidemic.