One issue we addressed early on was whether we would allow trainees under our supervision to become involved in direct patient care. Once it became known that we would be caring for these patients, a discussion was held with the faculty who would be responsible for these patients to determine if the fellows on critical care rotations should be involved in direct patient care. Given the uncertainty regarding the care of these patients and the additional scrutiny that these patients were under, it was decided that fellows should not be responsible for direct patient care. This was discussed with the fellows, and they were told that they could assist and be involved indirectly by assisting with documentation and writing orders from the nursing station outside the hot zone and interact with the patient and direct caregivers via closed circuit video link. Fellows were allowed to opt out if so desired, but all volunteered that they wanted to be involved in any way allowed. Over the course of the care of the three patients, seven of nine fellows participated in indirect patient care in some manner. Fellows were trained in donning and doffing PPE in preparation for entering the biocontainment unit.
A major issue that the biocontainment unit had to address prior to arrival of patients was what to do in the event of acute decompensation requiring advanced cardiac life support with CPR. Given the mortality reports from West Africa, the physician staff of the biocontainment unit discussed the risks of caregiver exposure if CPR was done, and it was determined that the risk was too high and the likelihood of survival if CPR was needed was too low. Initially, the physicians discussed this with each patient and next of kin and recommended that the patient be placed on DNR [do not resuscitate] status. As we gained experience with these patients, we realized that intubation and mechanical ventilation could be done safely under controlled circumstances, and we developed a policy for intubation and critical care support but no CPR.
It seems clear from the general experience that patients with the Ebola virus who receive standard critical care therapies early following the onset of fever have better outcomes than did those who received this care late. If the virus is not treated and supportive critical care is not given in the first 6-8 days, multisystem organ failure ensues, and mortality is high despite the best medical efforts. Patients may develop hypoxemic respiratory failure, liver failure, and renal failure, in addition to their nausea, vomiting, diarrhea, and delirium. It seems rational but somewhat unclear that these patients develop a syndrome similar to severe sepsis, with an eventual capillary leak syndrome, and that careful attention to volume status early on can help patients avoid the multisystem organ failure. Unfortunately, optimal antiviral therapy has not been determined, but we will learn more as we gain additional experience and perform clinical trials with potential therapies.
The lessons we have learned thus far are as follows:
1. Assemble and train a team of nurses, respiratory therapists, and industrial hygienists who can operate all aspects of biocontainment.
2. Assemble a group of physicians who can provide care for these patients, including intensivists and infectious diseases specialists.
3. Adhere to guidelines for donning and doffing PPE, and designate donning and doffing partners to assist and monitor every step.
4. Consider central venous access in all patients.
5. Establish policy for resuscitation.
6. Establish a role for residents and fellows, and if there is a role in indirect or direct patient care, provide proper training.
7. Treat as severe sepsis, monitoring volume status and electrolytes carefully.
Editor’s Comment
In this first installment of my tenure as the section editor of Critical Care Commentary, I am extremely grateful to Dr. Craig Piquette and colleagues for providing their first-hand insights on treating critically ill patients with the Ebola virus within one of the United States’ most advanced biocontainment units. While optimal Ebola therapies are yet to be fully elucidated, these early experiences highlight several issues this infection – and other, future epidemic illnesses – may superimpose upon routine ICU cares.
The incremental precautions required when performing invasive procedures in highly contagious individuals such as these, while extensive, are not necessarily surprising. However, these early experiences with the Ebola virus have required unique reflections on our self-imposed limits to providing care. What is the point at which the potential benefit to the patient with the Ebola virus becomes outweighed by the risk of harm to the physicians providing their care? It has convincingly been argued that our sacred oath of “Primum non nocere” requires us to be stewards in preventing harm to ourselves as well as to our patients. Withholding cardiopulmonary resuscitation and restricting the roles of trainees in the care of these patients are provocative examples of our competing interests and certainly merit further considerations.