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