Vox Medicus

'Vox Medicus,' is a periodic feature in DOC-Line that provides a showcase for editorials from members of the medical staff. Members of the medical staff are encouraged to submit editorials to Dr. Matt Miller.

This issue’s voice is Michael Grey, MD, Chief Medical Officer, Western Connecticut Medical Group. Attached to Dr. Grey’s editorial about ambulatory practices and Ebola is a moving letter sent from West Africa.

Ebola Virus: The Role of Ambulatory Practices
Then the Lord said to Moses and Aaron, ‘Take for yourselves handfuls of soot from a kiln, and let Moses throw it toward the sky in the sight of Pharaoh.   And it will become fine dust over all the land of Egypt, and will become boils breaking out with sores on man and beast through all the land of Egypt.’ So they took soot from a kiln, and stood before Pharaoh; and Moses threw it toward the sky, and it became boils breaking out with sores on man and beast. And the magicians could not stand before Moses because of the boils, for the boils were on the magicians as well as on all the Egyptians.”
- Exodus 8-9

Few things are as attention grabbing as the outbreak of a fast-moving epidemic with dramatic clinical features and Ebola fits the bill. Humanity’s history and culture have been shaped by epidemic disease and our collective response to epidemics for millennia. The diagnosis of the nation’s first Ebola patient in Dallas Texas this past September was a wake- up call for the nation’s medical and public health communities. That diagnosis started a chain of events that has affected nearly every health care facility and practitioner in the United States.

The Ambulatory Practice

The greatest risk of exposure to an Ebola patient falls on those working in emergency response, emergency rooms, or inpatient facilities. However, experience with previous public health threats, such as SARS, makes it clear that for every individual who is actually sick with the disease, dozens or even hundreds may present to ambulatory practices with concerns about their own risk or that of their families and loved ones.

Closer to home, our own health network has mobilized to address the remote possibility of an epidemic propagated within the U.S. and the more likely continued importation of Ebola-infected individuals during the current outbreak in western Africa.

This editorial is part of our risk communication strategy focusing on the role of community-based physicians in the national preparedness effort.

WCHN Current Recommendations

The crux of any evaluation is the travel and direct exposure history of the patient. Ask “Have you lived in or traveled to a country with widespread Ebola transmission OR have you had contact with an individual with confirmed Ebola within the previous 21 days?”

Of course the vast majority of ambulatory febrile patients do not have Ebola. But, because early Ebola symptoms resemble those seen with other febrile illnesses, triage and evaluation processes should consider and systematically assess patients for the possibility of Ebola. If you assess that Ebola is likely, you should refer the patient to the WCMG infectious disease department at (203) 739-7363 or (203) 739-8310 and explain the findings.

Next, identify symptoms consistent with the diagnosis because completely asymptomatic patients are considered non-infectious. The most important symptom is the presence or absence of fever (documented or stated). Other early Ebola-compatible symptoms (fatigue, headache, weakness, muscle pain, vomiting, diarrhea, or abdominal pain) are found in many viral syndromes.

Patients Scheduling a Sick Visit

To minimize the risk Ebola presents to the staff and patients in your office, patients calling to schedule a sick visit should be screened. Use a practiced script focused on travel to West Africa and existence and level of fever. Tell sick patients who meet the criteria to remain at home and that a member of the infectious disease team will be in touch shortly. Call ID at (203) 739-7363 or (203) 739-8310 and explain the findings.

100% Routine Screening

During this epidemic, all arriving patients should be asked about their West African travel and fever status. Signage may be useful (“If you have travelled to West Africa in the last 21 days, please tell the office staff”). Patients who answer yes to these questions meet the criteria for being at risk for Ebola and their exposure to others should be limited until a more detailed clinical assessment is completed by the infectious disease team.

Office Staff Actions

We recommend providing a mask to the patient, placing that person in a pre-identified “isolation” room (ideally with a phone) and then notifying the infectious disease team. No one from the practice should enter the room. Keep the door closed and have staff remain 3-6 feet from the patient. Donning personal protective equipment should be unnecessary until this more detailed assessment is completed Have a physician at your location contact the WCMG infectious disease department at (203) 739-7363 or (203) 739-8310 and explain the findings from above.

Remain in contact with the infectious disease department to determine the status of the patient. If the patient has been cleared by the ID team, manage them as you would any sick patient without the need for any special precautions. After a positive Ebola assessment by ID, they have the responsibility to notify the local health department and to mobilize all other resources needed to safely manage the patient and all other aspects of care, public health communication, and office and staff concerns.

Looking Ahead

This is a very fluid situation and recommendations will continue to change. For those who would like to read in greater detail about Ebola, I recommend the CDC website: http://www.cdc.gov/vhf/ebola/. I encourage all physicians to consider signing up for CDC’s Health Alert Network which provides rapid communication around a range of public health matters, including Ebola.

Until the outbreak in western Africa is brought under control, the possibility of another Ebola case in the U.S. remains. Until that time, our roles as sentinels in the nation’s medical and public health systems will continue.

Attached is one physician's moving observation from the front line in West Africa sent to us by Dr. Majid Sadigh, WCHN's Global Health Doctor. We believe all members of the Medical Staff will find inspiration in this doctor's words and experience.

Michael R. Grey, MD, MPH
Chief Medical Officer, Western Connecticut Medical Group

A Girl Waters Flowers

In between the rain showers, I sometimes see a young girl walk out of her home across from my hotel to water a large plant growing out of a felled tree. She scoops the water gently out of a bowl into her hands, dropping the water onto the plant's leaves with an indulgence as though she has all the time in the world. Even though this region lies at the outskirts of Monrovia, Liberia, a spot now known on the map for the involvement of the Ebola epidemic, there is little to suggest the catastrophe claimed by American media. Of course the schools have closed, but that has permitted steady streams of boisterous children out of doors, the cheery sounds of play mingling with the quick rhythm of their drums as they amble up and down the otherwise largely deserted streets. There are large drums of water outside every building and inconspicuous signs issued by the public health department informing the community of do's and don'ts. Thus Ebola has become something known to these communities, rather than something to fear. So life continues in spite of close losses and quieter streets-- people have moved forward with their tasks and relationships in spite of no longer being at liberty to touch one another.

My own day is full of these small observations of the world around me. Ten days have passed since I first arrived as one of the health care workers supported by AmeriCares to staff the first American Ebola Treatment Unit (ETU) in Buchanan, Liberia. I work alongside members of the United States Armed Forces whose commitment to the lives of the Liberian people has instilled newfound respect for these young, brave Americans. Daily reports from the local media of the decrease in seroprevalence of Ebola in blood samples collected from nearby communities demonstrate how this epidemic is slowly becoming less sinister, more manageable, not just for those of us who work here but those who live here, those whose minds turn to the welfare of plants and whose bodies shake to the turn of a West African drum beat.

The Landscape of Medicine

Though clinical medicine, global health ventures, even life in Africa, are not new experiences for us, we find ourselves in an entirely new clinical landscape. With the backing of decades' worth of medical knowledge crafted by scientists and health care workers internationally on the subject of Ebola, we are all of us still in training, trying to grasp the totality of our roles. For one, we are not only physicians and health care workers charged with the task of providing care to the sick, but we are public health officers who must preserve the health of the community. Protection of the community exists on multiple levels, be it the community at large or as smaller units, for example a mother and her child in the treatment centers--one who is infected and the other who is not, setting limits on a tradition of healing that has always been about the human touch, now done infrequently, and through layers of fabricated plastics and vinyls. There have been too many emotionally charged clinical scenarios to name singly.

Recent literature highlights the link between new cases of Ebola among health care workers to breaks in the protocol, an oversight in some step of hygiene. We work in a chain, forming the rows of a beehive that ultimately make up a honeycombing pattern of connectivity. My survival is contingent upon my colleague beside me, on his/her attention to detail and maintenance of protocol every minute we prepare to both enter and exit a treatment unit. We all rely on one another in a way that extends beyond the clinical relationships that exist in the inpatient setting in the United States. While back at home, I invest in open communication with nursing staff and trust that the overnight resident will call in the event of uncertainty, my life does not rely on them, nor is it threatened by chance oversights. Thus it is with love and a fierce devotion that we make our ties and work alongside one another, meticulous, like a mother towards her child.

Thus as I face a patient, flailing with the delirium and confusion of sickness, I cannot help but think what would happen if my protective layers are accidentally punctured, if I am thus contaminated beyond the ability of sanitizing myself--not because of what it would mean to me, but for all those others who count on me.

Even while this experience treads new ground, it also resonates of centuries' old narratives as dark as ever took place in the history of medicine. As infected people are ostracized from their communities, placed in isolation, in the corners of buildings, out of the light, their faces don with suffering of the deformed leper and the hooded figure of the plague. The dreaded hiccup and bleeding eyes and gums that signal certain end in these Ebola patients has come to rival the black eschars, the inflamed contorting lymph nodes, the truncated limbs of bubonic plague and leprosy in their power to evoke dark, even mystical powers of evil. Suffocated by these misplaced associations, the patients are cast away as if unclean and full of sin, to suffer in the seclusion of their punishment, banished by God as by humanity, only hoping for a modicum of compassion.

It is with compassion that many of us came to this land, along with a sense of purpose to use the science and the literature to guide our treatment of patients and to halt this disease. Yet no matter how rigorous our training or how much we cling to the data, fear, health and personal issues have escaped and overcome some individuals in our group. With heavy hearts, they have packed their bags and returned to the sanctity of their homes, though they are likely still as stuck as those of us who remain, in the immediacy of what is transpiring. Even as some leave the effort, others are joining. On Tuesday, November 11, five of us--two doctors, two hygienists, and a nurse supervisor -- leave for Cuttington University in Bong County for training in an ETU, so that we can return and train others, to ultimately open and run an ETU in Buchannan, the 3rd largest city in Liberia. We are filled with anticipation, to push forward with the pull of momentum.