Sunday, November 2, 2014

International Mutual Aid's Mission

International Mutual Aid is a nonprofit organization started by a group of medical professionals.  We are coordinating with local government, WHO, and involved Non Government Organizations (NGOs) to provide direct medical care in West Africa.  This is a rapidly evolving situation which demands flexibility and willingness to adapt to realities on the ground.  With that in mind, our provisional treatment model is detailed below.

Due to the magnitude of the epidemic, losses of local clinicians, and collapse of local healthcare infrastructure, there is an acute shortage of trained clinicians in West Africa.  The current Expat Clinician-intensive care model is expensive and difficult to sustain long-term.  Control measures have so far successfully reduced cases only in Liberia; EVD is unlikely to be eradicated from West Africa in the near future.  Our goal is to augment current efforts against EVD in West Africa by mobilizing civilians to assist in patient care.  Properly trained civilian healthcare providers are already used with great success in various sorts of underserved areas: examples include EMS systems worldwide and Last Mile Health in Liberia.  In the US, soldiers are trained to start and maintain IVs and IOs during an 8 hr course.  During a disaster situation, with similar accelerated training, appropriate supervision, and ongoing education, civilians are capable of providing care such as IV maintenance, cleaning, feeding, and moving patients.  In every town in America, EMS technicians - often civilian volunteers - extend the reach of the doctor far beyond the hospital, by implementing standardized treatments under his direction.  While it takes a doctor to diagnose and treat the myriad tropical diseases that are seen in the West African setting under normal conditions, it is IMA's belief that the EMS Model can be used to provide treatment for a single epidemic disease such as EVD during a public health emergency.

IMA is deploying a small team of expat clinicians who will train, equip, and lead a team of local frontline healthcare workers (FHWs), most of them non-clinician civilians.  With careful supervision, working alongside our expat clinicians, our FHWs will assist in providing basic supportive care to patients in a CCC-scale isolation unit.  The team will work under the supervision of a single physician Medical Director and a small number of RNs and/or Paramedics.  IMA will focus on EVD treatment until the epidemic is brought under control.  After this, IMA plans to establish an expanded training and support program, to allow FHWs to provide access to basic medical care in their villages.  

IMA will use a standard EVD treatment protocol: MUST. For IMA’s purposes MUST- Maximum Use of Supportive Therapy- consists chiefly of oral and IV rehydration, treatment of secondary infections (antimalarials/antibiotics), and transfer to a higher care facility when possible.

Though the Ebola response is accelerating, many areas of Sierra Leone remain underserved.  CCCs are designed to promote local access to EVD care, but they can become foci of transmission if not properly managed.  IMA will ensure that our CCC not only limits EVD transmission, but also improves patient survival, through the following:

1) Engineering controls: Promoting effective isolation of non-confirmed EVD cases through facility layout and regulating movement of patients, visitors, and health workers.  Ensure supply and correct use of PPE.
2) Leadership: Our expat clinicians will provide careful training, supervision, and ongoing re-inforcement of proper PPE use and correct technique for basic patient care skills.
3) Treatment Protocol: Define a simple MUST Protocol that can be carried out safely and uniformly, using minimal imported personnel.

It is our hope that our treatment model will offer a realistic way of getting as many patients as possible into Ebola treatment centers early.  We believe this is the best way to slow the spread of Ebola - a disease which has shut down the healthcare systems of several nations, and may become a permanent endemic issue in West Africa.  Getting patients into treatment centers improves their survival chances, frees them and their loved ones from the fear of spreading the infection, and insures them compassionate, non-judgemental care.

Availability of treatment for health needs other than Ebola has plummeted.  One of our primary aims is to reduce the burden on multi-purpose hospitals and clinics, allowing them to resume their normal mission of treating complications of pregnancy, trauma, heart attacks, malaria, typhoid, and much more.  As the epidemic is brought under control, IMA will shift our focus to supporting efforts to rebuild local healthcare systems and reduce susceptibility to future outbreaks of Ebola and other epidemic diseases.

IMA will be conducting all of our emergent-phase operations with an eye to laying the groundwork for long-term solutions. The final shape of the outbreak curve remains a mystery, and prolonged low-level transmission may result in ongoing shortage of general medical care in affected countries. West African healthcare systems, already weak, have been dealt a heavy blow by Ebola.  Even before the epidemic, Western-level access to healthcare was many years away.  While the long-term goal is a physician-/hospital-intensive, developed-world level of care, right now West Africa needs healthcare models that are functional in current conditions.  Last Mile Health in Liberia is setting an excellent example of such a system.  IMA’s long term goal is to train and organize existing talents, and to partner with existing healthcare providers, to build a similar frontline healthcare organization in underserved communities of Sierra Leone.  Specialized Ebola training is only the first step.  Frontline health care workers, fully trained to practice in their own villages, can do an enormous amount to link villages to regional clinics, and to prevent, diagnose, and treat myriad health issues.  Potential village-level care includes healthy pregnancy support, childhood immunizations, ensuring compliance with treatment regimens, identification of patients in need of higher care, initiation of patient transport, and frontline control measures against malaria, pneumonia, meningitis and much more.  Additionally, frontline healthcare workers will be in an excellent position to identify and help control any future Ebola outbreaks at an early stage.  Community-sourced FHWs, familiar with traditional practices and fully integrated into local social and power networks, are perfectly placed to provide a bridge between the village and regional clinics.

While our FHW selection process will be primarly merit-based, IMA has a special interest in EVD survivors.  In the case of Ebola survivors who are able to work, paid FHW employment has several potential benefits:

1) Access to good nutrition, psychological support, and treatment for residual effects, necessary for full recovery
2) The extra safety margin of apparent immunity to Ebola Zaire
3) Enhanced community acceptance due to status as a wage-earner and source of help for those who are ill
4) Any measure that increases acceptance of EVD survivors will indirectly promote the best possible solution for EVD orphans: adoption into Sierra Leone families.

In the face of potential exponential disease growth and a rapidly evolving public health crisis, we have five  priorities: 1) Courageous Patient Advocacy and Compassion 2) Safety 3) Speed 4) Simplicity 5) Sustainability.  We will be streamlining and expediting our operation by simplifying care guidelines, seeking the help of civilian organizations and local leaders, and when possible using existing structures and supply chains put in place by other NGOs, including Project Cure.  Our safety plan includes formal ETU training for our expat volunteers, formal, ongoing on-site education for our local staff, religious use of appropriate PPE, and adherence to WHO-recommended safety measures currently employed by MSF, PIH, and IMC.  

This is a unique situation that demands adaptability and flexibility.  We have no doubt that our current treatment model will have to be adjusted to fit realities on the ground.  Medical and moral decisions will be based on expert advice and consultation with our healthcare partners operating in West Africa.  The only thing that is not negotiable is our commitment to the safety of our personnel and the well-being of our patients, their families, and their communities.

Why Paramedics and not just MDs and RNs?

After spending 1-2 years in school, US Paramedics make field diagnoses and treat patients with only remote supervision of a doctor, providing advanced interventions such as IOs, intubation, nasogastric tubes, chest decompression, emergency tracheostomies, cardioversion, and cardiac pacing.  They also give several dozen medications in the US, including adenosine, diltiazem, metoprolol, morphine, versed, RSI cocktails, and much more.  Paramedics are accustomed to working in hazardous, high-stress environments, with minimal support, and are often faced with the need to improvise.  They are trained in the use of HazMat PPE.  They are committed to the safety of their crews, but also to rapid, effective response using the materials immediately available.  Paramedics often treat patients for hours or, in the case of rescues, days, before they reach a hospital         

On the use of survivors as patient care technicians:

Working in an Ebola treatment facility is a hot, physically tiring, and emotionally exhausting job.  Western-style infrastructure is lacking and in many current facilities proper PPE is not always guaranteed.  Even in facilities where the most stringent of safety precautions are used, mistakes inevitably occur and lead to exposures of staff.

When a staff member is infected, it has a negative emotional impact on other staff members, as well as potential recruits for the organization.  It prompts NGOs to pull out of Ebola-affected areas, and dissuades new NGOs from taking their place.  It creates expensive medevacs and fosters unease in the countries and communities to which infected staff return.

Several pieces of scientific literature (see Links) suggest that those who have recover from Ebola achieve persistent immunity against the strain with which they were infected  (The West African epidemic is caused by the Zaire strain).  There is even evidence that some individuals may be exposed and acquire immunity without ever becoming symptomatic.  More than one expat health worker has been very public about their belief that they are now at least relatively immune to the disease. 

According to WHO, Ebola has infected 10,000 - 20,000 people, and killed 70% of them.  That means that there are 3,000 - 6,000 Ebola survivors.  It is reasonable to assume that most of them continue to inhabit the homes and villages in which they were exposed.  After recovering, many provide care for family and neighbors infected with Ebola.  Not a single survivor has reported being re-infected with Ebola.

As IMA understands it, the current recommendation is that survivors work in the same level of PPE as regular providers.  Any change in this standard should properly be the result of very serious consideration by medical experts and an interagency ethics committee.  In the course of the West African epidemic, several measures have been approved emergently, measures which have not gone through the usual period of pre-approval testing.  As with ZMapp and Ebola vaccines, the decision of whether to change survivor PPE standards would be the result of a risk-benefit analysis.  It is possible that the natural epidemiological course of the epidemic has already created a far more thorough study of survivor immunity than could ever be achieved artificially.

At present, IMA feels that there is enough evidence of immunity to justify preferentially employing survivors as medical technicians.  So long as only those who have demonstrably survived Ebola and have recovered sufficiently to withstand the rigours of working in fully encapsulating equipment are used, we feel this adds an extra layer of protection to our operation.  For a high-profile example of an Ebola survivor who has returned to medical work, see British nurse William Pooley. 

In the hypothetical event that WHO and the Ministry of Health determined that survivors could safely work in Basic Precautions (in this instance gloves, boots, an apron, face shield, and a surgeon's mask would be an example), the game plan would be drastically changed.  Survivors have weakened immune systems and need to be protected from diseases such as respiratory infections, but PPE for this purpose is far simpler and less expensive than that currently used against Ebola.  Funds now spent on vast quantities of specialty PPE could be used on more medications and more medical facilities.  Time spent with patients would increase and physical stress on technicians would be reduced.  Interventions such as IV rehydration which are now often withheld due to safety concerns could be given with much less risk to both patient and caregiver, resulting in better outcomes.  Seeing human faces rather than plastic hoods would make clinics less frightening places for patients and families.  Less fear and higher survival rates would hopefully attract more patients earlier to treatment facilities, thereby reducing transmission in the community.

Visions of a seemingly vast pool of potential survivor technicians must be tempered by the realization that the bulk of current survivors are newly recovered.   Ebola is often a devastating disease with a long convalescent period, during which survivors tend to have weakened immune systems, are prone to infections such as pneumonia, and thus staff would need to be supported with antibiotics, etc. if they took ill.   Additionally, evidence is emerging of "Post-Ebola Syndrome" - a cluster of symptoms that includes visual impairment, aches, and fatigue.  Survivors have also just been through a frightening ordeal.  They may have lost loved ones and livelihoods, and be shunned in their communities.  Personal disaster affects different people in different ways.  To some it becomes a source of inspiration.  It is only a minority of survivors who are physically strong enough and psychologically willing and able to work as patient care technicians.  These are the people we will seek to employ.  As the epidemic goes on, the number of such people is one of the few resources that will increase.

No comments:

Post a Comment