You are dispatched to the scene for a 26 year old male who is experiencing flu like symptoms. When you arrive on scene you find the male sitting upright, coughing. The patient states that he has had a headache for the past two days and that it has constantly gotten worse having a temperature; he states that he has been really sore, and has not been able to eat anything without bringing it back up for the past two days as well. Now how many paramedics, or other medical professionals, would disregard this as a bad case of the flu? The symptoms above certainly do sound like a simple case of the flu. What if it was not? What if it was something more deadly? Would you be more cautious if the patient presented with a rash, with a fever that has lasted more than three days, unexplained bleeding from mucous membranes, skin, and or the gastrointestinal tract?
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II. Epidemiology/ Pathology
Typically any medical professional would take the latter of the two patients more serious because the patient is experiencing more severe and typical symptoms of the Ebola virus. The Ebola virus is a fairly fatal disease that researchers know little about. There are roughly four or five different strains of the virus, the most deadly of which is the Ebola-Zaire (EBO-Z) virus (National Center for Infectious Disease, 2009).
EBO-Z was first discovered in 1976 when an outbreak occurred in Yambuku, Democratic Republic of Congo (DRC) (Academic Kids, 2005). A forty-four year old school teacher named, Mabalo Lokela, had just returned from a trip to Northern DRC and was originally diagnosed with Malaria because of his high fever and was given a shot of quinine (Academic Kids, 2005). His symptoms did not ease with the aid of the shot and a week later he began to vomit uncontrollably, had severe diarrhea, had trouble breathing, and a severe headache. Later, he began to bleed from his nose, mouth, and rectum, and then died unexpectedly from the unknown virus, only 14 days after the original diagnosis of malaria (Academic Kids, 2005). Soon after the Lokela died, there were more patients that came into the hospital with similar symptoms. The first outbreak consisted of 318 patients with 280 fatalities (King, 2010). There have been many more outbreaks since 1976 with about the same results; the virus is known to be 50-90% fatal (King, 2010).
To microbiologists/pathologists the Ebola virus is still somewhat of a mystery. They do not know where the Ebola virus originates from or its source in nature (Sanders). It is thought that the viruses may be zoonotic, meaning that they are transmitted to humans from animals; however any and all attempts to trace the virus back to its original source have failed (Sanders). Microbiologists do know that when a person is infected with the Ebola virus it is then spread from person to person through direct contact with infected blood, secretions, organs, or semen (Sanders). Many healthcare professionals are infected with the Ebola virus after caring for these patients. The first epidemic, as discussed above, was thought to be caused by reusing the same needles for different patients (Sanders).
Ebola is found to have an incubation period of about four to ten days, before the first symptoms show up (Brown University, 2004). During the incubation period the Ebola virus infects dendrite cells, macrophage cells, and monocytes. When these cells become infected the body’s immunoresponse is then compromised because these cells that are infected are now ineffective for fighting the pathogen (Brown University, 2004). Macrophages, monocytes and dendrite cells are used in fighting off foreign pathogens, macrophages and monocytes are also known as types of white blood cells. The infected white blood cells could then become carriers or vehicles for the infection, allowing it to spread quickly throughout the body (Brown University, 2004). When spread through the body the Ebola virus then causes what is called Viral Hemorrhagic Fever (VHF).
Some of the initial symptoms of the Ebola virus/ VHF are fever, chills, muscle cramps and or aches (eMedTV). The symptoms then progress in a matter of days into more serious symptoms such as vomiting, shortness of breath, headache, abdominal pain, edema, and coma (Academic Kids, 2005). Then the symptoms peak when external bleeding occurs and a rash appears covering the entire body (Academic Kids, 2005). These last two symptoms are considered to be the diagnostic indicators of the Ebola virus. After these appear patients typically either get better or become worse until one of two extremes happen (Academic Kids, 2005). There is no vaccine for Ebola and patients that have Ebola are only given supportive care to stop the symptoms or ongoing issues that are directly related to the infection (eMedTV). They are given fluids to help prevent dehydration, and are given various antibiotics to help their body fight the infection (eMedTV). Patients either become healthy again or proceed to get worse until they die. Sadly, the most common outcome is death (Academic Kids, 2005).
III. Impact on Pre-hospital Medicine
How does the Ebola virus affect pre-hospital providers? As stated above many of the hospital workers also became infected from caring for patients that were diagnosed with the Ebola virus (National Center for Infectious Disease, 2009). When working in the field many times the pre-hospital provider could be the first person to have contact with these patients. While paramedics and EMT’s are trained to expect the unexpected they may not know what to expect for patients that are infected with Ebola and have viral hemorrhagic fever. If the patient called 911 when the symptoms first appeared providers may not even suspect that Ebola could be the cause of the illness. As a provider you have that direct contact with the patient, you are exposed to the droplets, the blood, and the coughs. While an Ebola outbreak is fairly uncommon the medical providers involved with any patient presenting with “flu-like symptoms” should not just disregard the patient, the medical provider should keep that thought of what if it is Ebola.
Some ways that the medical provider can protect themselves from becoming infected from not only the Ebola virus but any other virus/ bacteria is by wearing appropriate personal protective equipment, such as gloves, masks, and/or goggles (Center For I, 2003). If patients are coughing you can either put a mask on them and yourself or simply put them on oxygen via a nonrebreather, to ensure that they are being oxygenated as well as attempting to contain any droplets which could be passed through the air. Also, to help prevent an epidemic, medical providers should decontaminate their ambulance using an appropriate cleaner after the patient is transferred to the hospital (Speers, 2003).
After insuring that your scene is safe and you have appropriate personal protective equipment you would want to approach your patient and start your assessment.
Patients that present with the early stages of Ebola are sometimes overlooked. There is no way of differentiating Ebola from any other illness when it is in the early stages. When receiving patients with these symptoms Paramedics should perform a medical assessment, gain a SAMPLE history and OPQRST as needed. Vitals, including a blood glucose level, should be obtained every ten minutes. Patients should be placed on 15 liters of oxygen via a nonrebreather and if presenting with dehydration, try to obtain an IV access and give a fluid bolus 500mL’s. In the field there is not much that you can do to help patients, so you would want to monitor them and give them supportive care until you get to the hospital (eMedTV).
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If they are in the late stages of the Ebola virus and are bleeding then you would adjust your medical assessment to fit the needs of the patient. If the patient is bleeding from the mucous membranes and it is copious amounts then you as the provider would want to suction the airway to make sure it is intact. If they are managing their own airway then put them on 15 L nonrebreather if not then consider assisting the patient’s ventilations with a bag valve mask device. Check for major bleeds throughout the body to make sure they are not bleeding anywhere else. Next you would want to place the patient on an EKG monitor because the dehydration could cause an electrolyte imbalance causing arrhythmias or problems with the heart. You would then want to make sure you listen and palpate the abdomen to make sure they are not bleeding into their abdominal cavity (which is fairly common with the Ebola virus/ hemorrhagic fever.) Obtain IV access and if presenting with dehydration or shock give a fluid bolus after listening to the lung sounds (ensuring that the lungs are clear) (eMedTV). A potential issue that could occur when you are treating the patient that is in the final stages of VHF could be that you are not able to obtain an IV because they infiltrate due to the dehydration. If this is an issue, consider an intraosseous site. Obtain and recheck vitals every 5 minutes especially if they are bleeding and/or presenting with shock signs and symptoms. Consider giving an antiemetic if they are nauseated (eMedTV). Other than the above treatment you would want to take the patient to the nearest, appropriate facility and alert the medical staff that you have a patient that possibly is infected with the Ebola virus or Viral Hemorrhagic Fever.
V. Ethical and Social Issues
Some ethical or social issues that should be considered for patients would be whether or not to contact the CDC or the local health department about exhibiting these symptoms. Also, if the outbreak was in your community a major ethic issue could be whether or not to inform the community of the possible outbreak. Some social issues could be asking with whom that person has been sexually active or been in contact with for the seven to fourteen days. Another social issue for this virus may be simply public education or awareness, giving out flyers, or pamphlets which educate about the Ebola virus and/or viral hemorrhagic fever.
Even though an Ebola epidemic is rare, its rarity should never be taken for granted, especially with a mortality rate of 50-90 percent. This disease, as we discussed, is fairly new and some researchers are not yet fully aware. Pre-hospital providers should at least know the signs and symptoms so they can be aware of what to look for and what to expect from patients that present with these symptoms. All medical providers should be educated in the signs and symptoms to help prevent from becoming infected and spreading the infection. As with all diseases, education and awareness is the key.
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