Condition of Spanish Nurse With Ebola Worsens, Officials Say

[magical thyme]

She believes she may have accidentally touched her face with her glove while removing PPEs. She found out about her diagnosis via the media. At first doctors were visiting her every hour, and then stopped coming into her room at all. I read one report that she is receiving help breathing, so presumably on a ventilator. And her brother says he was told by a doctor treating her that there is not much hope she can overcome the virus.

http://www.nytimes.com/2014/10/10/world/europe/ebola-spain-nurse-hospital.html

MADRID — The Spanish health authorities said Thursday that the condition of an auxiliary nurse infected by Ebola had worsened, three days after she became the first person to test positive for the disease in Europe.

The deterioration in the nurse’s condition came as the authorities announced that one more health care worker had been quarantined, in addition to three others who were isolated overnight at the same hospital where the nurse works.

Yolanda Fuentes, the hospital’s deputy director, told reporters on Thursday that the condition of the infected nurse, María Teresa Romero Ramos, had worsened, without providing details. The brother of the nurse told a regional television station that he had been advised by one of the doctors treating his sister that there was “not much hope” that she could overcome the virus....

...Juan Manuel Parra Ramírez, a doctor who attended Ms. Romero when she was first hospitalized on Monday in Alcorcón, on the outskirts of Madrid, sent an open letter to Madrid health authorities criticizing the conditions in which he tended to her....

...The sleeves of the protective suit he was given were too short, he said, while he learned only through the news media that Ms. Romero had tested positive for Ebola, according to his letter, which was published Thursday by Spanish newspapers."

[magical thyme]

1. oh, and for those who have been blaming her...

"Criticism has centered on just why the medical team that treated Ebola patients included people with relatively low qualifications, like Ms. Romero, who volunteered, and why such staff members were then handed risky duties that involved direct access to the patient, including the removal of infected material from his room.

Unlike registered nurses, auxiliaries typically receive no advanced training and are generally assigned tasks like washing patients or bringing them food."

So she was volunteering, had low-level training, no advanced training and was assigned high-risk duties with direct access to a dying/dead patient.

[dixiegrrrrl]

2. AND

may have had insufficient protection, if what the doctor says is true.

[magical thyme]

3. 10 minutes training and a poster in PPEs, according to one doctor w/30 years experience

Dr Santiago Yus, a specialist in intensive care, echoed Batanero’s concerns, telling El Mundo that he would likely be treating Ebola patients in the coming days. “I’m not ready, I’m not trained,” he said.

The doctor, who has more than 30 years experience, said he had only been given a few 10-minute briefings months before and further questions had been directed to photographs on the wall explaining how to put on and take off the protective suit. This week, he was part of a group of 15 health workers who met with hospital management to warn them about their lack of preparation in facing Ebola.

http://www.theguardian.com/world/2014/oct/08/ebola-spanish-health-workers-poor-training-virus

Frankly, it doesn't surprise me. Budget cuts, management doesn't care because they won't be exposed.

About 2 months ago our lab manager put out a memo or said something in staff meeting (I honestly don't remember any more) reminding us that we need to be gloved even when handling closed tubes. (A lot of the old-timers are really lax). I'm wondering now if that was her idea of a response to some CDC Ebola notice.

[Maru Kitteh]

24. How much training should an RN or an MD need for contact precautions?

It's part of the job description. Ebola is a contact precaution disease like C.diff or MRSA. You need a basic gown, gloves and, for safe measure, a mask and eye protection. Those big haz-mat suits? Totally not necessary and maybe even counter.productive. Those big suits are only fueling panic and conspiracy theories in my opinion.

[magical thyme]

25. the hazmat suits are not worn treating patients; only for handling the corpses and transport

But in photos I've seen of the Spanish workers they look like they are wearing more than even normal OR protection. They are in suits that completely cover them. Of course, now I can't find the picture I remember.

Here is a link to the WHO guidelines for removing PPEs. They don't give details on getting the gown and gloves off without touching the outside.
http://www.who.int/csr/disease/ebola/remove_ppequipment.pdf

The challenge is in getting it off when there may be a droplet anywhere on it.
The stakes are a lot higher than C.diff or MRSA. I'm trusting the word of the doctor with 30 years experience when he says they were given insufficient training.

Remember, too, that she is not a nurse, she is a volunteer aid so not experienced at things like removing gloves without touching the outside. She also is not experienced at maintaining the focus needed to not touch your face, ever. It is extremely difficult to do; we all unconsciously reach to scratch an itch or brush away a loose hair. Even WHO and MSF doctors have contracted it, so apparently made a mistake.

The doctors who have gotten it were so meticulous that they had assistance getting dressed with people watching from behind them to ensure sure no skin was exposed. And yet somehow they've been exposed.

[magical thyme]

26. also, Ebola is not a contact precaution disease 'like C.diff or MRSA'

it is very different in that it is highly virulent -- a very small exposure is all it takes for infection. A healthy immune system will prevent C.diff or MRSA infections.

MRSA is just staph aureus -- a normal body surface bacteria found on everybody -- that has acquired methicillan resistance. A classmate in my microbiology class was a CNA carrying MRSA on her skin, which we discovered when we did susceptibility testing on our own samples in lab. She was not infected, obviously, just carrying it on the surface.

C. diff will be kept in check by normal intestinal flora. People become at risk when antibiotic therapy knocks back their normal flora and C. diff is able to take over.

And of course, both C. diff and MRSA are treatable.

[magical thyme]

32. dawned on me too that if contact PPEs were perfect, MRSA and C-diff wouldn't be rampant

it's the fact that the PPEs are not perfect protection and the humans, even conscientious, intelligent and hard working humans, can make mistakes, that has allowed them to spread.

One thing we were taught in clinical training was never to assume that the lab worker ahead of you have followed all precautions perfectly. We are supposed to, on arrival at our "bench," start by assuming every surface is contaminated and clean it.

Problem with this is in the real world we are short staffed and, in my small lab, work every bench and function practically as an extension of the ED. The one new tech that followed that procedure religiously ended up being disliked by everybody because she would leave a single tech running her ass off from one end of the lab to the other, down to the ED or up to the floors for timed draws, while she walked around cleaning every surface in the lab before chipping in. (Even worse, in the process of cleaning she would manage to accidentally shut down computer interfaces and start timers off, adding to the workload of getting hosts re-connected and sending us running around trying to find the alarm that had gone off that wasn't associated with a timed test. We were happy to see her leave. The next lab she worked at was happy to see her go too. Some lab out in the midwest is stuck with her now.)

[uppityperson]

5. "volunteering, had low-level training, no advanced training and was assigned high-risk duties"? ETA

argh, and who would ever guess anything could go wrong with that?

Do you have a link showing that? Thank you as I'd like to use it to counter "highly trained and properly equipped people are getting it" claim. Thanks.

[magical thyme]

6. the OP link, further down the article

Criticism has centered on just why the medical team that treated Ebola patients included people with relatively low qualifications, like Ms. Romero, who volunteered, and why such staff members were then handed risky duties that involved direct access to the patient, including the removal of infected material from his room.

Unlike registered nurses, auxiliaries typically receive no advanced training and are generally assigned tasks like washing patients or bringing them food.

Some hospital staff members have said the safety protocol was not only inadequate but was also explained only in a single, short training session.

[uppityperson]

20. Thank you, missed that.

[Spider Jerusalem]

7. Not sure why anyone would be blaming her

it's pretty clear that the facility was woefully inadequate for treatment of an Ebola case in the first place (not a level 4 biocontainment facility, no level 4 biocontainment suits for health workers, improper procedures followed regarding waste disposal etc). The whole thing was a clusterfuck and they'll be lucky if this nurse is the only case they have.

[pnwmom]

8. And yet the initial report was that this hospital was "specially selected and prepared" to take care

of Ebola patients. If that is the case, imagine what would happen at an ordinary hospital?

[Spider Jerusalem]

9. The initial report was apparently bullshit.

Since the hospital is not a level 4 facility and the bio-safety suits issued to healthcare personnel were not up to level 4 standard.

See here for instance: http://politica.elpais.com/politica/2014/10/06/actualidad/1412618449_833358.html (Link is in Spanish; says "suits issued were only level 2", with a charming bit of ass-covering from a hospital spokesperson who says "the suits were well-matched to the safety protocol and security measures required for this disease" when they clearly bloody weren't).

[pnwmom]

10. Have any of the hospitals here been using respirators as required by biolevel 4?

I've heard that they haven't -- that face masks have been deemed sufficient.

I think that if scientific researchers have to use respirators, then they should be standard equipment for medical personnel as well -- but they aren't.

[Spider Jerusalem]

12. Not Dallas, no

Emory University has level 4 containment rooms and level 4 biosafety suits (which was where the Ebola patients treated at Emory went). Given proper observation of hygienic procedures (no ungloved contact, etc) then filtration masks are deemed sufficient, apparently: http://www.livescience.com/48106-ebola-isolation-hospital.html

The problem in Spain seems to have partly arisen because proper procedure wasn't followed (but then that's another argument for treating Ebola patients in level 4 facilities where extreme vigilance around potential transmission vectors is standard procedure, rather than in hospitals where it really isn't and where staff don't have the training for it).

[LisaL]

15. Dallas hospital isn't one of the four biosafetly level 4 hospitals.

So we have to wait and see how the nurses and doctors who treated Duncan come out of this.

[Spider Jerusalem]

18. which is why I said "not Dallas"

[Yo_Mama]

21. CDC hasn't recommended that

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html

All persons entering the patient room should wear at least:
Gloves
Gown (fluid resistant or impermeable)
Eye protection (goggles or face shield)
Facemask
Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to:
Double gloving
Disposable shoe covers
Leg coverings

[LisaL]

14. Then they shouldn't have brought two patients who were near death (and died anyway) into their

country.
Now this young woman is likely going to die (since she apparently has multiple organ failure).
She was also out and about for a whole week while showing symptoms, potentially infecting other people.

[magical thyme]

4. per her brother, she's intubated and on a ventilator.

also is getting anti-bodies via plasma from recovered patients.

[magical thyme]

11. per Telegraph, she's suffered multiple organ failure; nurses are cancelling contracts & calling out

Psychological counseling?!?! How about giving them fucking decent training, with practice, on how to decontaminate and un-suit after treating a patient?!?

http://www.telegraph.co.uk/news/worldnews/ebola/11152715/Spanish-medical-staff-refuse-to-treat-Ebola-patients-amid-fears-of-infection.html

Scared medical staff in Madrid refused to treat possible Ebola patients on Thursday for fear of becoming infected themselves, as the condition of the Spanish nurse who contracted the virus deteriorated further.

Although no formal absentee figures have been released, a number of nurses and health technicians have formally resigned from their posts, while others have made excuses to avoid going into work.

“A lot of people are calling in sick,” one member of staff told El Pais newspaper. “They are saying they have period pains, or that they feel dizzy. People are anxious and can’t be expected to work like that.”

Staff members who have agreed to work in the hospital’s isolation ward are receiving psychological counselling.

[LisaL]

13. What can go wrong if you bring Ebola patients into the country?

I remember this very same scenario occurring now was laughed about by some posters, saying it's not going to happen.
But it did. It was so predictable.

[magical thyme]

16. if you bring them in knowingly, using biohazard 4 transport to biohazard 4 treatment facilities

staffed by biohazard 4 professionals, they'll have a good chance of survival and not spreading it to anybody.

If you bring them in stupidly, late stage and too late to save, without properly training and equipping the staff, you'll spread it around.

And if you don't properly monitor asymptomatic patients from at risk countries -- which now includes Spain and possibly Macedonia -- you'll risk spreading it around.

[LisaL]

17. Apparently the hospital in Spain was not biosafety level 4.

They brought in two elderly patients near death. There was no hope for them whatsoever.
All they accomplished is infecting this poor woman and who knows who else.
And of course killing her dog.

[magical thyme]

19. definitely not. no regular hospital is and I don't trust the assurances. We have 4 in the US

that were specially chosen and had separate wings designed years ago to care for researchers in the event of accidental exposures. We have one plane in the US specially equipped to transport a single patient at a time. The staff's at those hospitals have trained for 12 years to care for them.

I don't believe that Brantly, Writebol or Sacra waited until their temps were 101.5 to isolate themselves and get tested. They were monitoring their temperatures twice/day. As soon as they started to rise, they isolated themselves, got tested and started treatment immediately.

[Yo_Mama]

23. CDC guidelines are Level 2, though.

If one of these numerous suspected cases did test positive, they'd be cared for using CDC guidelines. And the isolated/suspected cases are all being cared for using CDC guidelines.

http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
.
I think you're right, but CDC has not been overly intense about this:
http://www.cdc.gov/vhf/ebola/hcp/patient-management-us-hospitals.html

Are U.S. hospitals ready to care for patients with Ebola virus disease (EVD)?

Yes – any U.S. hospital that is following CDC's infection control recommendations and can isolate a patient in a private room‎ is capable of safely managing a patient with EVD. CDC recommends that U.S. hospitals isolate the patient in a private room and implement standard, contact, and droplet precautions.
What should U.S. hospitals do if they have a patient with suspect EVD?

Early recognition is critical for infection control. Healthcare providers should be alert for and evaluate any patients suspected of having EVD who have (see EVD case definition):

A fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage;

AND

Risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats or nonhuman primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is the most common cause of febrile illness in persons with a travel history to the affected countries.

When should patients with suspected EVD in U.S. hospitals be tested?

CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure such as (See CDC's laboratory testing guidance):

percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases).
If a patient in a U.S. hospital is identified to have suspected or confirmed EVD, what infection control precautions should be put into place?

If a patient in a U.S. hospital is suspected or known to have Ebola virus disease, healthcare teams should follow standard, contact, and droplet precautions, including the following recommendations:

Isolate the patient: Patients should be isolated in a single patient room (containing a private bathroom) with the door closed.
Wear appropriate PPE: Healthcare providers entering the patients room should wear: gloves, gown (fluid resistant or impermeable), eye protection (goggles or face shield), and a facemask. Additional protective equipment might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.
Restrict visitors: Avoid entry of visitors into the patient's room. Exceptions may be considered on a case by case basis for those who are essential for the patient's wellbeing. A logbook should be kept to document all persons entering the patient's room. See CDC's infection control guidance on procedures for monitoring, managing, and training of visitors.
Avoid aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 or higher filtering facepiece respirator) and the procedure should be performed in an airborne infection isolation room.
Implement environmental infection control measures: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is of paramount importance, as blood, sweat, vomit, feces, urine and other body secretions represent potentially infectious materials should be done following hospital protocols.

Why do responders in Africa wear so much personal protective equipment (that can include full body suits) for this Ebola outbreak when CDC says hospitals here could safely manage the care of an Ebola patient without a full body suit?

There are important differences between providing care or performing public health tasks in Africa versus in a U.S. hospital.

In field medical settings, additional PPE may be necessary to protect healthcare workers. In some places in Africa, workers may not have the ability to prepare for potential exposures. For example, in some places, care may be provided in clinics with limited resources (e.g., no running water, no climate control, no floors, inadequate medical supplies), and workers could be in those areas for several hours with a number of Ebola infected patients. Additionally, certain job responsibilities and tasks, such as attending to dead bodies, may also require different PPE than what is used when providing care for infected patients in a hospital.

[LisaL]

28. CDC guidelines would appear to be inadequate.

Apparently neither Mr. Duncan nor Spanish nurse initially had fever high enough to be considered for Ebola.
Yet both of them had Ebola.
Mr. Duncan is already dead and the nurse sounds to be near death.
Neither of them was treated for Ebola right from the start because they weren't diagnosed.
Mr. Duncan for several days, nurse for the whole week.

[Yo_Mama]

29. Yes, but the first HC provider the nurse saw

says he was never told she had cared for Ebola victim.

And Duncan apparently never told the hospital in TX that he had been exposed to a dying person in Liberia. I think in either case the doctors would have reacted differently if they knew - they would have isolated and tested earlier, although CDC treatment guidelines would have dictated nothing medical until they started vomiting/diarrhea.

Also, both probably are having such severe cases because of their degree of exposure. The nurse is now very seriously ill.

[LisaL]

30. Even if provider was told,

neither Mr. Duncan nor the nurse fit the guidelines for suspected Ebola cases (because their fever was lower than what's in the guidelines).
So guidelines are inadequate.

[Yo_Mama]

31. Yes, they are.

CDC has not changed them, but HC providers are using a different set of standards, which accounts for all the new sets of tests being run. Most will be negative, but not applying the higher standard of caution will eventually kill people.

[pnwmom]

22. As post 21 points out, the CDC isn't recommending biosafety level 4 precautions,

even though Ebola is classified as biosafety level 4.

[LisaL]

27. But the nurse was infected and sounds to be near death.

Whatever precautions that hospital was taking clearly was not enough.
And they might have spread the virus around Spain because the nurse was not diagnosed for a week.