Duncan is now on a ventilator

[magical thyme]

I remember Brantly started having trouble breathing and thought he was dying when he changed his mind and asked to have the 1st dose of Zmapp after all.

http://www.nbcdfw.com/news/health/Dallas-Ebola-Patient-on-Ventilator-Nephew-278116781.html

Thomas Eric Duncan's nephew, Josephus Weeks, told NBC News earlier on Saturday that Duncan "is now on a ventilator."

[MohRokTah]

1. I haven't heard anything about the special new drub they used on the two envangelists.

Is he not receiving the drug?

I'd guess not.

[magical thyme]

2. they ran out of Zmapp.

They gave I think 2 doses each to Brantly and Writebol, and then some to a Liberia doctor and maybe the British nurse. And then they ran out. They didn't have any for Sacra, but Brantly was the same blood type so donated plasma.

They are making more, but it depends on growing tobacco, which moves at its own pace, not our demands.

I'm wondering if any recovered patients over here can't donate blood to him. Maybe wrong type.

[JimDandy]

6. I bet Zmapp suddenly shows up for the NBC camera man. n/t

[magical thyme]

7. I'll take that bet. They didn't have it for Dr. Sacra. It won't be available for several months. nt

[JimDandy]

8. I am such a cynic any more due to

racial inequities in this country.

As an aside tobacco companies have warehouses of dried tobacco. Does Zmapp production require fresh leaves?

[LisaL]

11. You can not produce ZMapp from dried tobacco.

It's produced from a special genetically engineered tobacco plants, not just any regular old tobacco.

[JimDandy]

12. Thank you! n/t

Last edited Sat Oct 4, 2014, 09:26 PM - Edit history (1)

[LisaL]

9. Sacra was given a different experimental drug.

Tekmira drug. Apparently there is plenty of that one. I wonder if they are trying it on Duncan?

http://www.nbcnews.com/storyline/ebola-virus-outbreak/doctor-recovering-ebola-got-experimental-tekmira-drug-n209191

[magical thyme]

15. I'd forgotten about that. The link says there's still a very short supply.

That was from about 2 weeks ago. Wonder if that supply has been used or is available.

[pnwmom]

28. Well, he didn't lie and he acted responsibly, isolating himself and self-reporting.

[JimDandy]

31. Yes, let's withhold medicine from everyone who lies

because they are scared and want to live.

Good grief...just sickening.

[pnwmom]

32. I don't think they'll withhold medicine from anyone unless they don't have it.

And if they're down to their last dose, I assume they'll give it to the person in otherwise the best health and most likely to benefit.

[JimDandy]

37. Best health is a better criteria than who did or didn't lie. n/t

[JimDandy]

13. Hmm CNN now saying Zmapp can be made available to Mr Duncan

if his family wants it.

[magical thyme]

16. I wonder where that came from. As of yesterday, there was none available

The US government is scrambling to start production of the experimental Ebola drug that is viewed as the most promising medical treatment in the fight against the virus.

The ZMapp serum was used to treat two American missionaries who recovered from Ebola, but is not available for the Dallas man currently fighting the disease as the limited supplies made for clinical trials ran out in August.


Read more: http://www.businessinsider.com/the-us-is-scrambling-to-produce-the-experimental-ebola-drug-zmapp-2014-10#ixzz3FEDD2rmU

[JimDandy]

19. I don't know where it came from. And that was a very oddly

worded statement relayed by the CNN reporter from info out of a CDC press conference call(?) Can't link to the segment, but it's at the top of CNN's mobile version page.

Eta got reporter's source wrong

[magical thyme]

20. ok, here is a link to CNN. They don't specify Zmapp but just experimental treatments in general

they said that everything that is available is being made available to him. Zmapp isn't available, so maybe it's the Canadian treatment.

http://www.cnn.com/2014/10/04/health/ebola-us/index.html?hpt=hp_t1

[longship]

3. Apparently none left.

It was an experimental treatment to begin with. It takes weeks to make. All the doses were used when the first cases came to our shores. Plus, there is no epidemiology that supports that it even works beyond normal care because there are no double blind clinical trials, which in any case, especially for Ebola, would be unethical.

Zmapp was used as a compassionate expediency, an exception. The few doses they had are gone.

The fact of the matter is that all previous Ebola outbreaks burnt out fairly quickly. The virus is just too efficient for its own good. It is simultaneously not easily transmitted -- not at all until symptoms appear -- and so quickly deadly that the virus has little time to spread.

What's happening in West Africa is a perfect storm of abject ignorance, lack of medical facilities, and broken governments. For Christ sakes, they even attacked Ebola clinics to free the patients. Stupid!

[TwilightGardener]

4. His organs need maximum oxygen, due to the nature of the disease process and

how microclots develop and cause tissue death, plus he may need help to maintain his airway, so it's for the best. It will allow him to rest and oxygenate and conserve energy, and will allow suctioning so he doesn't aspirate.

[magical thyme]

5. I'm guessing the clotting preceeds or is the front end to the hemorrhagic phase

I remember reading a description that reminded me of DIC. I wonder if the hemorrhaging is a result of running out of platelets and coag factors, leaky veins due to loss of blood pressure, or a combination.

[TwilightGardener]

10. I'm guessing it's more similiar to the type of thing that happens with certain types

of sepsis and bacterial meningitis, which in my understanding is when the pathogen in one way or another causes widespread damage to the linings of the blood vessels, thus causing clotting and then further vessel breakdown and leakage. But you might be right that maybe it's more similar to DIC, which I understand to be more of an overall aberrant response of the body's clotting mechanisms due to any number of causes. In other words, direct pathogen (or pathogen's toxic metabolic byproducts) injury to vessels, vs. crazy clotting response that uses up all clotting factors and then causes you to bleed out. That's pretty much the limits of my old nursing knowledge, right there. But considering the universal breakdown/lysis of cells in an ebola patient's body, and the massive metabolic demands, I'd be surprised if he wasn't on a vent in ICU.

[magical thyme]

14. I just remember reading a description in the last week or two that reminded me of DIC, with

crazy clotting, the difference being that the clotting is located mostly within the liver and kidneys where it attacks versus being disseminated.

It could be a combination of effects. It's pretty drastic, from some photos I've seen. They also break out in rashes that fill with blood. At this point Brantly had the rash I think on his torso and maybe his arms too.

[uppityperson]

23. From what I've gathered, it is an overly done immune response, followed by DIC clotting,

leading to multiple emboli causing organ injury (liver, kidneys, brain, digestive tract) followed by lack of clotting (factor or platlets, not sure) causing bleeding internally and massive bruising. Treatment involves large doses of heparin to minimize the clotting, and supportive measures while the body tries and heals itself.

Simplistically put. Most of the damage is connective tissue, with resulting fucking up of everything else. Techno-jargon there.

[TwilightGardener]

27. Sounds plausible to me.

[uppityperson]

29. I should've been a researcher. Would love to read a full pathophys write up. Hmmm. for later viewing

on what all happens, how and why. Hmmmm.

i know, wiki, but a start, references below to look at later.

http://en.wikipedia.org/wiki/Ebola_virus_disease

Endothelial cells, macrophages, monocytes, and liver cells are the main targets of infection. After infection, a secreted glycoprotein (sGP) known as the Ebola virus glycoprotein (GP) is synthesized. Ebola replication overwhelms protein synthesis of infected cells and host immune defenses. The GP forms a trimeric complex, which binds the virus to the endothelial cells lining the interior surface of blood vessels. The sGP forms a dimeric protein that interferes with the signaling of neutrophils, a type of white blood cell, which allows the virus to evade the immune system by inhibiting early steps of neutrophil activation. These white blood cells also serve as carriers to transport the virus throughout the entire body to places such as the lymph nodes, liver, lungs, and spleen.[46]
The presence of viral particles and cell damage resulting from budding causes the release of chemical signals (to be specific, TNF-α, IL-6, IL-8, etc.), which are the signaling molecules for fever and inflammation. The cytopathic effect, from infection in the endothelial cells, results in a loss of vascular integrity. This loss in vascular integrity is furthered with synthesis of GP, which reduces specific integrins responsible for cell adhesion to the inter-cellular structure, and damage to the liver, which leads to improper clotting.[47]

References
Smith, Tara (2005). Ebola (Deadly Diseases and Epidemics). Chelsea House Publications. ISBN 0-7910-8505-8. http://en.wikipedia.org/wiki/Special:BookSources/0-7910-8505-8
Jump up ^ Sullivan N, Yang ZY, Nabel GJ (2003). http://jvi.asm.org/content/77/18/9733.full.pdf "Ebola Virus Pathogenesis: Implications for Vaccines and Therapies" (Free full text). Journal of Virology 77 (18): 9733–9737. doi:10.1128/JVI.77.18.9733-9737.2003. PMC
http://dx.doi.org/10.1128%2FJVI.77.18.9733-9737.2003
http://en.wikipedia.org/wiki/PubMed_Central
http://www.ncbi.nlm.nih.gov/pubmed/12941881224575. PMID 12941881.


ETA another link, reading it now, good article
http://jvi.asm.org/content/77/18/9733

Several lines of evidence suggest that the viral GP plays a key role in the manifestations of Ebola virus infection. The transmembrane form of GP targets the Ebola virus to cells that are relevant to its pathogenesis. Specifically, GP allows the virus to introduce its contents into monocytes and/or macrophages, where cell damage or exposure to viral particles may cause the release of cytokines (34) associated with inflammation and fever, and into endothelial cells, which damages vascular integrity (48) (Fig. 1). Thus, sGP may alter the immune response by inhibiting neutrophil activation, while the transmembrane GP may contribute to the hemorrhagic fever symptoms by targeting virus to cells of the reticuloendothelial network and the lining of blood vessels.

(clip)

FIG. 1.
Host immune responses to Ebola virus and cell damage due to direct infection of monocytes and macrophages cause the release of cytokines associated with inflammation and fever (A). Infection of endothelial cells also induces a cytopathic effect and damage to the endothelial barrier that, together with cytokine effects, leads to the loss of vascular integrity (B). Transient expression of Ebola virus GP in human umbilical vein endothelial cells or 293T cells causes a reduction of specific integrins (primary molecules responsible for cell adhesion to the extracellular matrix) and immune molecules on the cell surface. Cytokine dysregulation and virus infection may synergize at the endothelial surface, promoting hemorrhage and vasomotor collapse.

[TwilightGardener]

34. So immune response (cytokines) plus direct damage to endothelium is what causes

the clots and leaks. Grim but interesting stuff, thanks for posting.

[uppityperson]

40. Some people think I am weird but I like to find out about things, find it interesting

you are welcome. If you or Barack_America or anyone comes up with more, I'm glad to read it.

[Barack_America]

21. Plus precise control of his acid-base.

I'm shocked he wasn't on a vent already. Fighting this disease must be amazingly metabolic. He's probably been horribly tachypnic for days. Hopefully his kidneys are holding up and this isn't a volume overload situation.

[TwilightGardener]

22. Yep, blow off more CO2, or less, as needed. It must be hard to manage this guy--

tube feedings are out, so parenteral feeding, gut lining's going to go leaky, kidneys getting clogged with lysed cell products...pressors...albumin...all draped in plastic and latex and goggles--just an ICU nurse's idea of a really shitty shift.

[uppityperson]

24. In full isolation setup.

[TwilightGardener]

25. Hot, cumbersome, takes twenty minutes to do something that usually takes 5, and

these poor employees have got to be at least a little concerned or paranoid for their own safety.

[Barack_America]

26. I'm surprised they ever classified him as "serious condition"

I would've wanted to keep this guy in the ICU, fully lined up, and thus technically "critical". Not only because I would fear he could crash at any moment, but this would be the last guy I would want to scramble to get a line in if he did. From what I've read about the pathophysiology of Ebola, this tends to be the point in the infection where massive lymphocytic lysis occurs, which made my eyebrows raise when I heard he went on the vent. Hopefully just to rest him and his kidneys are holding up. And his liver too, ugh. Nasty, nasty disease, it apparently even triggers an adrenal insufficient state.

So that's ID, critical care, nephrology, heme/onc, GI and endocrinology. Any of the medicine sub specialties NOT going to be consulted on this guy?

[TwilightGardener]

30. If they're lucky, no neurology or cardiology, I guess! With the combined critical care and huge

isolation requirements and staffing and waste disposal, you could see where this could quickly eat up a lot of resources if you had multiple patients in one city, even in the US.

[Barack_America]

35. Absolutely.

I was thinking of the amount of waste a simple C diff patient generates and trying to extrapolate that for Ebola. Imagine just intubating him, do you really get that X-ray for tube placement? "Okay, everybody ungown and exit for the film....now everybody re-gown and come back...we'll just leave the machines in here for the daily imaging."

Honestly, if I was making the call, I'd probably stick the ID fellows in there with him and let the others treat remotely. This is all lab values anyway. As much as I believe in the physical exam, I'd take someone else's word on breath sounds here.

You're right, I forgot cards!! May his trops stay low! If they did get consulted, cards would probably just say, "demand ischemia" and hang up the phone. Ain't no way they're taking this guy to the cath lab!

[TwilightGardener]

36. If he has a brain bleed, due to the disease or heparin, does he go to CT? MRI?

Just would totally suck to have more than one of this guy at a time.

[Barack_America]

39. Hopefully those folks they're quarantining stay clear.

They should honestly take them someplace else if they become symptomatic though. I don't see how this hospital could handle it.

[pnwmom]

33. I wonder why they didn't have him in ICU from the beginning? Is that a problem

when they need to keep a patient in isolation? I read somewhere that they'd set aside a whole ward for him.

[TwilightGardener]

38. They probably have an ICU set-up, wherever he is, but just didn't declare him critical

until they intubated him. He is someone who would go bad and "crump" very quickly.

[notadmblnd]

17. I thought I read that they were out of Zmapp and that duncan would not be getting any.

Don't know if that is actually true or not.

[magical thyme]

18. I just provided a link stating that. The article is dated yesterday and based on everything I've

seen, that is correct.

They ran out of Zmapp before Dr. Sacra was brought back here, so didn't have any for him. It takes months to produce.

[customerserviceguy]

41. I think he's on the way out

the only question is, how many will he take with him? And the really f'd up thing is that they'd likely be his own family members.

[magical thyme]

42. time will tell. they will give him full support. late in the disease, even though there is massive

lymph loss to lymphocytosis, apparently patients do generate some new lymphs that are functional. It's a matter of keeping the patient alive long enough, and minimizing organ damage, to be able to respond. They figure if it's 70/30 with limited resources, it's 50/50 here. They can support the impacted organs as necessary.

[customerserviceguy]

43. Any guesses as to how much this all costs?

Not just his treatment, but all the other work the hospital has to do because he's a 'famous' patient, with PR and dealing with reporters, and extra security? Would the figure of a million dollars a day be way out of line?

[magical thyme]

44. not a clue.

But I'm sure this is not cheap.

[customerserviceguy]

45. It's a good question

Especially if you add in all the other stuff, such as the costs of security and taking care of the needs of the people possibly infected who are being watched after now, and the costs of removing all potential contamination.

His little vacation jaunt is going to suck up a lot of resources that could have been used in other ways, particularly to help sick people in our country, and used things that could have been shipped to West Africa to fight the disease there.

How many of these infected travelers are we going to let into this country before our leadership says, "Enough!"?

[magical thyme]

46. there are significant costs to be had with banning travel as well.

I don't know what they are, but expect it would impact various trading partners. So is not considered an option.

[customerserviceguy]

47. Then someone needs to explain them

Because I can't think of any great losses that would result from shutting down air travel to and from West Africa. Anything shipped from that region would most likely come out by boat, and it's not difficult to keep a ship at sea for two or three weeks.