Ebola: Barrier Nursing

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Ebola certainly dominated the headlines in 2014. Our service, like most others, did in-house training guided by the health region in order to prepare for its unlikely appearance in our community. It bothered me that we were just now designing an updated PPE/provincial care algorithm. There are many other highly infectious diseases that perhaps should have had us thinking ahead long before now (measles for example, especially considering the growing anti-vaccine movement. If you visited my post “Vaccinate My A$$”, you know how I feel about that.) However, I was also glad we were taking the threat seriously. We learned and collaborated on the challenges of donning and doffing heavy, high level PPE and how it applied to ambulance services. We also talked about techniques for providing care for someone highly infection- or, barrier nursing.

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I felt uncomfortable with the hands-off care model at first, especially since I happen to live in a resource-rich area of the world. I’ve been spoiled by high-tech monitors, sensors and gadgets. If we used any of this equipment in an Ebola case it would subsequently have to be isolated and destroyed. If you know how much medical equipment costs…well, no service is that rich. We wouldn’t even be able to use our stethoscopes! (It would compromise our PPE). Initially it felt like being told that I could someday have a very ill patient and I wouldn’t be able to use my skills to asses and care for them. However, after finding an article on EMS1.com titled, “How to asses an Ebola patient with just your senses” I realized how untrue that was.

Highlights from the article outline some of the basic care we provide so routinely we often take it for granted. It also reminded me to hone up on some old-school BLS skills I had been taught, but have been somewhat replaced by modern technology.

Airway, Breathing, and Circulation

There is a reason the ABCs come at the beginning of our assessment, they provide vital life signs. Luckily they are easy to assess without equipment! Most likely we use these techniques with all our patients already. “If the patient is breathing, their airway is open… Look at the patient and notice the rate and quality of the respirations? Fast or slow breathing? Full or shallow breaths? Near death, the Ebola patient may have Kusmall respirations. If the skin is pink, he is oxygenating well; if it is blue, he is not.” 1

A patient’s pulmonary status may be compromised for a variety of reasons, including additional medical problems. “You can assess for pulmonary dysfunction without any tools by simply placing your hand centered on the chest. Close your eyes and feel the breathing. Up and down motion is good. In a dark environment, this is how you can determine the rate. Can you feel the patient using all his muscles to breathe? If so, he has labored breathing. Let your fingers rest in the intercostal spaces of the rib. Can you feel intercostal retractions with inspiration? If so, the patient is wheezing…Can you feel gurgling? If so, there may be pulmonary edema.” 2 Although mild or early stages of pulmonary compromise may be difficult to catch; these techniques should give good insight to life-threatening developments.

In regards to circulation the article states, “With Ebola, dehydration, hypovolemia and shock are the big killers, so evaluating circulatory status is critical…check the carotid and radial pulses. Absent radial with positive carotid suggests hypotension. The same is true for a cap refill that is greater than two seconds. [Also] check for “tenting” of the skin. Tenting suggests dehydration. Tenting and absent radial pulse suggest hypotension from dehydration, while good skin turgor with hypotension suggests hypotension from shock.”3 Fluid boluses or the administration of a dopamine drip may be appropriate- refer to your own standards of care.

In may sound redundant but assessing a patient’s mental status is typically done equipment-free through AVPU (level of consciousness: alert, alert to verbal, alert to pain, unresponsive). You can also assess their orientation through questioning (person, place, time, event). Their responses can be correlated to their oxygenation status, cardiac output, etc.

You can also gain important information just by chatting with your patient or knowledgeable caregiver. Discussing changes in their voiding (urine or feces) will provide clues to their organ function and level of dehydration. Frank blood in the feces suggests the virus has caused hemorrhagic damage. “Urine output tells us that Ebola has not yet caused end organ failure (a critical finding if we are going to give potassium for hypokalemia secondary to vomiting and diarrhea). Furthermore, based upon the color of the urine, we can determine the extent of dehydration caused by the vomiting and diarrhea. Dark urine is serious dehydration, while light urine suggests lack of dehydration. Touching the head will give us an idea about fever.” 4 Thermometers are cheap, available, and do not compromise a caregivers PPE, so they may be available for use in the infectious setting.

Beyond that, “Supportive therapy with attention to intravascular volume, electrolytes, nutrition, and comfort care is of benefit to the patient. Intravascular volume repletion is one of the most important supportive measures.” 5 The human body naturally defends itself against the Ebola virus so the patient care focus is on giving the body time to win the war.

PPE for life!

Medic15

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Ebola Screening Tool: screening_tool_20141209

Other Good Site Reads

https://vanessajunkin.wordpress.com/2013/12/10/vaccinate-my-a/

http://www.cdc.gov/vhf/ebola/hcp/caring-for-ebola-suspects.html

http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html

http://www.nejm.org/doi/full/10.1056/NEJMe1412744

Resources

1, 2, 3, 4 http://www.ems1.com/ems-products/education/articles/2038161-How-to-assess-an-Ebola-patient-with-only-your-senses/

http://emedicine.medscape.com/article/216288-treatment

Images

https://www.facebook.com/photo.php?fbid=10152776120126047&set=pcb.10152776120536047&type=1&theater

http://www.bbc.com/news/health-29612367

http://prehospitalresearch.eu/?p=3315

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