Ebola Working Group International Teleconference Q & A

The Ebola Working Group International Teleconferences allow EMS Leaders to participate in an international forum with special guest experts, a situation report describing significant Ebola preparations for the upcoming week, and in discussions regarding their agency’s work or experience in Ebola management so attendees can harvest best practices.

Each teleconference has a significant Q&A session. The Q&A is considered by many to be at least as valuable as the guest speakers’ presentations We provide the Q&A content here for quick reference.

The questions are arranged in logical groups, and many questions were asked on more than one call, so we have included each guests’, presenters’ or attendees’ answer for each question. After each webinar, new questions and answers will be added to this page, so please check back often.

Please keep in mind that not only do the answers represent the opinion of the person providing them, but specifically their opinion at that time, and may have changed, or may have been different if they had time to research and prepare. Regardless, the Paramedic Chiefs of Canada do not endorse the individual answers, but rather are providing them as a service to interested EMS providers.

We encourage you to view the recordings of our webinars (click here) and for more information about the series, individual webinars and links to information and recordings, as well as other information provided during or for the webinar).

We offer our most sincere thanks to Charlene Vacon of Urgences-santé for getting this started, to Julie Bourque and Craig Pierre of Ambulance New Brunswick for continuing her work, to Katelyn Gilligan of FirstWatch for her part in harvesting the questions and answers, and to our webmaster, Carrie Anderson for making them available in a user-friendly format online, these questions and answers are provided here for quick reference.

(Click down arrow to view answer.)

Air ambulance

1. What special considerations do you suggest for Ebola patients requiring medevac with a flight time near 4 hours in a fixed wing aircraft?

Chief Rupp (October 16, 2014): In the US, there is only one carrier that can transport patients with EVD. In Omaha, the focus for the Fire Department and partners was on patient transport from the aircraft to the Biocontainment Unit.

Dr. Lowe (October 16, 2014): Phoenix Air has a contract with the US government for transports of EVD patients. There are few FAA approved air medical isolation units available for these patients. Phoenix Air has their own isolator that was constructed for their aircraft through a contract with the CDC. In this type of transport, those involved in air medical transport may consider a PAPR along with a Tyvek suit in case there are a significant number of fluid events during the transport.

 

Ambulances, transport and equipment

1. What do you do when responding to a 911 call with a person demonstrating the signs and symptoms of Ebola? Do you transport with the responding crew and ambulance or wait for the special response unit? If the 911 crew transports and treats the patient, what kind of PPE do they use?

Dr. Isakov (October 23, 2014): Identification of patients with risk factors at the 911 call centre is key. If there are risk factors identified. in the 911 system, each institution has to adopt its receiving practice. This should include approaches to isolating patients and ensuring the level of PPE required to prevent exposure to infectious bodily fluids.

It is preferable for scheduled transports to deliver the patients directly to the isolation unit.

If you have a patient with symptoms coming from an affected area, it is more likely that patients from Africa have Malaria. or some other diarrhea producing illness PPE is still required. Exercise clinical judgement. YOu may be concerned about Ebola, but there are other diseases as well. I need to apply standard, contact and droplet precautions. I can tell if the patient looks like they are going to vomit or not.

2. Was consideration given to use devices like the iso-pod instead of draping the rig?

Dr. Isakov (October 23, 2014): Grady EMS practices with wrapping patients as well as with the isopods. If a patient has a tremendous amount of diarrhea, wrapping the patient helps to contain it sot that the infectious bodily waste does not spill over onto the floor and become more hazardous to the paramdics. WE ask patients to put on an adult diaper and use a Tyvek suit. If they are not able to put on a Tyvek suit, we use the impervious wrapping. WE ask the patient to wear a surgical mask in case they have respiratory symptoms. Our experience with isopods is not great. We have trained with isopods that are designed for long-haul flights and very expensive. We have practiced with one that costs about $2300 and is powered by PAPRs. The challenges with these are getting the patient into and out of it. It is difficult to manage the patient inside the isopod. If there is a large amount of vomit or stool, it becomes difficult to deal with. And, if you put a patient with even a hint of claustrophobia, as a patient it is going to be very difficult to stay in that confined environment for any length of time. Patients in the isopods that are intubated and sedated can be transported in the isopod. But the four patients transported by Grady to date did not need intubation or sedation.

Chief Rupp (October 16, 2014): The isopod was available and would have been used if either patient was vomiting or had excessive diarrhea. Neither patient had these issues, so we did not use the isopod. The isopod adds a level of complexity to patient care that was not necessary for these cases.

For both patients transferred to Omaha, the EMS service had about 48 hours notice to prepare. There was considerable coordination between the state, public health, police, emergency management, and EMS. The Biocontainment Unit provided all the expertise including providing the PPE and draping of the ambulance. The draping is a single layer of 6mm plastic, 25×100 feet. Emory uses a different type of material to drape the ambulance.

Mr. Miles (October 23, 2014): Emory uses an impermeable, non-slip material that we get at the home improvement store. It’s a drop cloth you would use for painting.

Todd Stout (October 30, 2014): I don’t know if you’ve seen the two previous webinars but that’s something that they are watching and we are expecting from Emery a list from Grady hospital EMS, a list of their actual items that they use, for example they use not a plastic type draping in the ambulance but something from a large hardware store that’s fluid impermeable but not slippery like plastic. We’ll try to get that list together.

3. Do you have any training aides for the Iso-Pod?

see also: Nebraska Biocaontainment Unit http://app1.unmc.edu/nursing/heroes/mpv.cfm?updateindex=91&src=yt

4. Were all the supplies removed from the ambulance before draping?

Dr. Isakov (October 23, 2014): Most supplies are removed but those that are not are covered by the draping. The draping is an impervious material. We also have a policy that whoever is in the back of the ambulance with the patient is the only one who has patient contact. No one who has made patient contact can be in the front or driver compartment.

Dr. Lowe (October 16, 2014): Everything was stripped from the ambulance. From transporting the first patient to the second, Omaha learned to make accessible the medical equipment that would be needed. The equipment was bagged in thin plastic bags before the transport. It kept all the equipment clean if it did not need to be used. If it needed to be used, it was easily accessible; the paramedic only needed to take the medical supplies out of the plastic bag. It made decontamination easier. In addition to the wrapped medical supplies, there was a biohazard bag to use as a vomit bag, extra gloves in case the paramedic had to change gloves, biohazard wipes for a spill event, absorbent towels. Extra patient care gloves were put in the cab of the vehicle in case the driver had to intervene. In that case, Omaha would bring in a standby paramedic to act as the driver.

Omaha uses packing lists and procedure lists for the three main phases of patient transport: preparing the ambulance, PPE and patient packaging, and decontamination.

5. With everything sealed by the draping, how do you maintain climate control in patient compartment?

Dr. Isakov (October 23, 2014): The exhaust is turned on the patient compartment and the climate controls are turned on in the driver compartment. We cut holes where the exterior vents are. We don’t run the climate control in the patient cab.

6. Has the standard direction from Health Authorities been to routinely dress the Pt. in PPE?

Chief Rupp (October 16, 2014): Both patients were wearing a Tyvek suit, mask and adult diaper.

7. Interested to know what tools folks are using to take temperature in the field?

Kate Keller: oral thermometers with plastic single use sheath covering

Aileen Boyd: Tympanic thermometer

mike: Braun Thermoscan

REMSA: Temporal thermometers-REMSA

keith: Digital Oral thermometer

Steve Henderson: Braun Thermoscan Tympanic Thermometer with ear probe covers

8. How are the ambulances decontaminated and placed back into service?

Dr. Isakov (October 23, 2014): Unlike usual missions, the mission is not over until the ambulance and the paramedics are properly decontaminated. The decontamination is facilitated by isolating the patient compartment. To wipe down the ambulance we use a Clorox wipe that only requires one minute of surface contact.

The entire process is supervised: decontamination of the ambulance, doffing of PPE and disposal of biohazardous waste. The response team includes the two medics, and a supervisor and an EMS physician in a chasing SUV. WE limit the number of people making contact: one medic makes contact and tends to the patient. The driver never makes contact. The supervisor and physician deal with the logistics and communications with partners. Having the EMS doctor on scene is practical for onsite medical control questions or clinical judgements.

The whole team is responsible for decon and doffing. These people need to be properly trained and educated, and then all the steps are supervised to help eliminate exposure.

Active surveillance is provided to the transport team after the mission. For Ebola this is a 21 day period. Our transport teams have not had any symptoms. Medic surveillance can start and then stop if there is a negative diagnosis of Ebola. Public health will have recommendations on monitoring.

Chief Rupp (October 16, 2014): The Biocontainment Unit assisted with decontamination. They have a special building near the hospital where the ambulance was taken. The plastic wrapping the ambulance for the first patient was too big to all fit into the autoclave. For the second patient, it was carefully cut into 3 manageable sized pieces as it was taken off the walls of the ambulance. The walls were wiped down (not sprayed) by two cleaners wearing PPE. Spraying may aerosolize particles. After wiping the inside of the ambulance, a UV light was used for 10 minutes. The ambulance was kept out of service for 24 hours, and then returned to service.

Dr. Lowe (October 16, 2014): Just outside the ambulance, there was a hot zone created by laying down a sheet of plastic. No one wearing PPE was allowed to step beyond that zone, and no one not wearing PPE was allowed into the zone. The person taking pictures was standing 20 feet away. The pictures are used to document the process. The photographer is also tracking the checklist to make sure that the decontamination team does not miss anything.

Chief Seals (October 9, 2014): Dallas took the ambulance out of service while researching how to decontaminate it. The paramedics did a standard decontamination with the anti-viral and germicidal sprays and Lysol spray. They realized later that they did not wipe down the glucometer. There was no evidence of blood on it; however, it is possible that there may be micro-droplets after a glucometer stick. Out of an abundance of caution, the CDC is following the patients who were assessed with that glucometer. The ambulance was decontaminated again before it went back into service.

9. When using an N95 or simple surgical mask on those suspect patients, a lot of us were thinking it was a second barrier, are you saying there is a negative affect by using those?

(Richard Alcorta, November 20, 2014): Yes. This issue is with this that if you look at the N95 systems, many of them have a blow off valve. So the N95 filters the air coming in because you’ve had it fit tested on you. But when you exhale, it actually goes through a blow off valve or a bypass if you will which then basically does no filtration. It is not blocking any of the exhaled droplets or the aerosolized fluids. A regular surgical mask is filtering droplets coming in and going out. So don’t put an N95 on the patient.

10. My understanding is EMS may take up to 40 minutes to prepare to respond PLUS up to an hour to respond to some locations, so 911 caller may not see EMS for almost 2 hours, correct?

(Richard Alcorta, November 20, 2014): That’s incorrect. Allow me to help bring clarity. That was for the monitored patient by our health departments. So this is a traveler if you will that has been detected and they have then been monitoring this person every day, that person either calls in and says I now have a fever or has been contacted by the health officer and they say they have a fever or they have diarrhea etc.

We now have somebody who is not deathly ill – not a 911 call. This is an individual we can then get either a commercial service to go get or a local 911 that can take some time to prepare to respond to go get. If, on the other hand, we talk about the PUI from 911 call, that is still going to get a local real time prompt EMS response. They will arrive donned appropriately in PPE equipment while responding. This is not a 30 or 40 minute situation. They are going as quickly as they possibly can.

 11. Are the 10 Haz-Tac units still on dedicated standby? If so, how will you make the decision to stand down those teams?

(Captain Paul Miano December 4th, 2014): At this current time because the call volume for fever travel, about 3 week ago we dropped down from 10 to 5 units and just starting yesterday we went from 5 to 2 units. It will be fire department operation along with the doctors that work in the fire department that determine how much longer we’ll keep them on the standby.

12. In decontamination, what do you do with the materials hanging off the medics such as belts, radios, etc.?

(Captain Paul Miano December 4th, 2014): Any equipment that we can dispose of, we do. Those belts are BBP rated material so we can spray those down with bleach. Everything that you see right now minus those suits and gloves and booties are back in service and they were back in service by the next day. What we did was, we elected to have one member be the patient care provider and be within that 3 foot range and the other member as you can see the one being sprayed, he has a tapped pouch and what we did was we put a grease pencil there and we created a laminated check sheet and basically here in New York we have patient care reports that we fill out as we take care of patients and we realized that if we bring that into the home, it’s not going to be used by use again so we developed a laminated card that had all those questions that we would ask and we use a grease pencil, we fill out the laminated card and we keep that card with the patient, in this case Dr. Spencer. This way, the hospital had all that information as well because our crews do not go inside the hospital. We do the hand off outside and we would of not been able to give a report the nurse or the Doctor so we wrote everything down on this laminated card. The pencil went in the garbage and when the hand off was done we started the decontamination procedure.

(Edward Bergamini December 4th, 2014): Also those canisters that you see on the back of the packers are considered waste, we throw those away. You see they are very robust canisters it’s just that’s what we had in stock in New York city. All the units, every the fire unit and every EMS unit has one canister for daily use if they need it. It’s a very robust canister, we have since ordered thousands of P1 filters to be used in there instead because the cap 1 canisters are obviously expensive and the P1 filters are cheaper. Again it’s not that an N95 won’t work, we wanted to a full face piece respiratory protection just to avoid touching mucus membranes on the face.

Follow up question: What to do with materials hanging off the belts such as radios etc. ?

(Captain Paul Miano December 4th, 2014): We carry one radio in and again that radio is just for communication back to the Haz-Tac officer outside. This way he can make notification. Again when we go in, we start to interview the patient and it turns out they haven’t returned from Liberia three days ago but three months ago from the Dominican Republic, we relay that back over so we can stand down the rest of the resources that are coming in.

(Edward Bergamini December 4th, 2014): I would also like to add, the equipment is hard surface. Also, the vast majority of the four patients we transported for fever travel that were stable, there were no visible bodily fluids. We do wrap the patients; they are fitted with a mask and were no visible fluids in the vehicle. You are looking at a very low risk at this point. If things were questionable and there was excessive contamination we might make a decision at the scene. I do have enough equipment that it doesn’t always have to be re-used. Also, in New York City we have taking to using a fogger with a very dilute chlorine dioxide to disinfect the rear of the ambulance. It’s not something that we just purchased, we were actually using it at the fire academy. We actually had a couple MRSA outbreaks with our probationary firefighter class that we were losing too many firefighters out being sick and it was in the locker room with the bunker gear just through sweat and crawling on their knees that they were getting these bad infections. We had a company come in and we had test strips with different viruses and we had them all tested and it worked extremely well in the probationary school and now were using it for the back of the ambulance. We are thinking of actually expanding the program and fogging the gear. It all depends on square footage and yes there is residence time, dispersal time and aeration time but it does cut down with no rinse required afterwards. It basically dissipates but if you use a bleach solution you are going to want to wash your equipment otherwise it is going to ruin it.

13. Are the dedicated medics exclusive to the fever/travel calls 24/7?

(Captain Paul Miano December 4th, 2014): The units that are on standby are not paramedic units, they are EMT units. The bulk of these calls are sick calls so they don’t require paramedics per say but once the EMTs get there if they feel they do need paramedics they will request those resources. They are dedicated for 16 hours of the day not 24 but it is seven days a week.

14. In Sierra Leone no one travels in the back of the Ambulance plus the crew sits in a sealed cab in the front and the patient sits in the back which is totally sealed from the front so no bodily fluids can infiltrate the front cab.

(Captain Paul Miano December 4th, 2014): What we do is we have two units respond to the call. We have our Haz-Tac unit (let’s call them the dirty unit for now) they’ll always be in the back of the truck and then we have a second unit who is considered the clean unit and that clean unit will drive this ambulance as well as the second ambulance. We only use van type ambulances where there is a walk through. We have a very small 18X18 inch hole that we call it a boot and that’s what connects the front of cab to the back of the cab. In order to get bodily fluids from the back of the ambulance to the front of the cab, it would almost have to be intentional. But just to be sure we sealed up that little hole with some plastic and some chemical tape.

15. Are the Ambulances in the USA and Canada sealed backs and sealed fronts? Blood, vomit, urine, etc. cannot be allowed to enter the front cab so in Sierra Leone they have sealed the front cab from the back.

Edward Bergamini December 4th, 2014): We have to remember too that the Ebola virus is not considered an airborne virus. Also, it depends on what you’re looking for contamination. We do have procedures for gross contamination which would be vomit, obviously the disinfectant procedure you see would not be effective until you clean up the gross contamination. You want something to be sealed but at this point and time it’s not spread like TB. Generally the signs & symptoms are not coughing or sneezing so all of our patients that we’ve transported have been lethargic and feverish.

16. How much of the rear of the Unit is draped with plastic?

(Captain Paul Miano December 4th, 2014): None of it is draped in plastic except for that 18X18 boot that we mentioned. Because again if there is no blood, vomit, urine anything like that we are not worried about our ability to decontaminate it. The Haz-Mat technician unit – I don’t know if there are many people better than them at doing that so we are not worried about that.

17. One question I had was about the ABC Skeleton concept that you have, what does it look like and how was it used?

Dr. Racht (December 18th, 2014): It is a skeletal frame that can be put together very quickly so that you wrap around it. It avoids you having to take the roof of the ambulance to the cabinetry etc. It essentially creates a box. I had the privilege to go inside the Phoenix Air Aircraft with the clipboard guy before the patient was in there. They have picture of the Aircraft on their website. They’ve done a similar thing to a much greater extent. They have metal frames that can create the skeletal frames to wrap in plastic so when they break down the particular isolation, they still have the frame work that can much more rapidly assemble. I think we have some schematics and I’m happy to send those to you on how we assemble them. Essentially if you think of a tent, it’s a square structure.

One of the questions from the State of California that come up is that if a patient is in a very remote area that needs to be transported how do we do that? We’ve had discussions about securing our providers in the back of the ambulance while the ambulance travels 3-4 hours to the designated facility. While they are secured assembling the skeletal frame work and the majority of the plastic wrap so then on arrival they don’t have another 2 hours of transport time.

 

Care and Treatment

1. Do you suspend use of ALS procedures if you find a patient in the pre-hospital environment that positively screens and switch to BLS in order to reduce exposure opportunities?

Dr. Isakov (October 23, 2014): “My evolution on the ALS BLS question has changed… I encourage everyone to consider their duty to treat.” Patients in North America with Ebola have been successfully treated. It is due to much better resources and expertise. One thing learned is that potassium gets dangerously low due to diarrhea, and managing electrolyte levels can help these patients. Grady/Emory has ALS equipment on board.

Chief Rupp (October 16, 2014): Known Ebola patients are a no-code situation for Omaha. The medical direction is currently assessing whether ALS will be used.

2. What if any interventions did the paramedics provide to the patient during transport?

Chief Rupp (October 16, 2014): The only treatment provided was oxygen. The patient did have a saline lock in, under the Tyvek suit.

3. Are there any demographic indicators of success against Ebola?

Dr. Garza (October 9, 2014): The only demographic indicators of success are that countries with better healthcare infrastructure have better survival, however this is difficult to quantify since numbers are sketchy.

4. In screening for Ebola in the dispatch environment, if the patient has had positive exposure to someone with flu/flu-like symptoms and then deteriorates to cardiac arrest, what is the recommendation for administering CPR in this situation?

Todd (October 30, 2014): I think you are going to say that unless they’ve had contact with people who’ve traveled to the affected countries, you should treat them the same.

Dr. MacDonald (October 30, 2014) replies: you are correct.

5. What is done differently in Sierra Leone to account for their low case fatality rate compared to those of Guinea and Liberia?

Catherine (November 6, 2014): I don’t know, I think it’s god’s grace. I really don’t know why it’s less, there’s no statistics to why it is less, and there is no evidence. I’m not sure.

 6. My question is for Captain Miano, do the members handling these “fever/travel” calls in NYC receive more money for doing so?

(Captain Paul Miano & Edward Bergamini December 4th, 2014): No, they do not.

 

Communication and information

1. How could the flow of information from CDC to you be improved?

Chief Seals (October 9, 2014): There is now a regularly meeting committee to influence how CDC can improve. CDC was slow to ask what the Dallas Fire Department needed for support. Beyond the firs transport, the CDC has not been proactive reaching out to paramedic services, has not recognized that there is a need for emergency medical services beyond that initial transport. Start working with your local public health organizations to have the contact already in place should you need it.

2. For Chief Seals – after Ebola was identified by the media, did you have a rebound increase in call volume?

Chief Rupp (October 16, 2014): Omaha originally planned to have a media blackout about the transfer of Ebola patients, but that was abandoned. Plan for a lot of media is you do have a patient transfer.

Chief Seals (October 9, 2014): It has not created a big upswing.

3. When people call 911 for EBOLA is anyone directing them and their family to get in a car and drive them self to the emergency room rather than responding ambulance to transport them.

Keith Tyler (October 30, 2014): Not that I am aware of in BC.

Bill Duff (October 30, 2014): No

Mike Provencher (October 30, 2014): No

Peter McMurrough (October 30, 2014): No

Chris Thiele (PNRHA) (October 30, 2014): No to driving themselves to ER

Tony Camps (October 30, 2014): No

Rodger Coppa (October 30, 2014): We do not advise them to self-transport. Our thought is if they think they are truly an Ebola patient, we would rather keep track of them rather than allowing them to stop on their way to the hospital, causing more public exposure (and hysteria).

Charlene Vacon (October 30, 2014): We are following usual dispatch practices with regard to advice to 911 callers in QC.

Patricia Frost (October 30, 2014): No

John Lane (October 30, 2014): Absolutely not. In Winnipeg, we have had procedures in place for some time, since the workers returned to Winnipeg from West Africa way back in August. We have been screening calls since October 10th using the IAED card for Emerging Infectious Diseases. Of almost 3700 911 calls, 1165 met screening criteria for EVD questioning. Only 7 had positive screening response (travel or contact history). We send specially trained paramedics and a medical supervisor to the patient. We also have direct contact with our health authority’s Infectious Disease specialists. In 6 of the 7 cases, the supervisor was able to rule out EVD potential with or without consultation with the ID physician. The only case where the paramedics donned full PPE involved a change in the patient’s story mid-transport. This case was also ruled out with ID physician consultation.

4. Does anyone know what other services such as healthlink /nurse advice lines are advocating?

Mike (October 30, 2014): The one that is working up here in the Yukon is a contract based piece so these folks, as I understand, do what is expected of them under the contract, so that they can, as it’s a paid service, they will ask the questions and follow process that the client asks them to do

Conrad Fivaz (October 30, 2014): The nurseline operators would escalate callers with suspected Ebola to the EMS service for transport per their PPE policy rather than have the family taking the patient. Further to the previous answer we have added some surveillance questions to the pre-triage scripts for those clients using nurse triage systems to assist them with identifying patients at risk of having the disease.

5. Is there a phrase and/or “code word” that people are using for dispatch centers to advise responding crews that they may have a suspected infectious patients? In our part of the US people are using all sorts of language being used. It would be helpful if we had standard lingo.

Todd Stout (October 30, 2014): I would agree Brian, but there isn’t anything standard that folks are doing.

Darrel Donatto (October 30, 2014): South Florida is using the term “Med Alert” for infectious disease cases.

John Lane (October 30, 2014): If we do find a case with enduring potential, we have established procedures with our HA to ensure direct admission of that patient to an isolation area. The ED is the last place we would want to have an unprotected potential EVD patient.

Linda Frederiksen (October 30, 2014): We are using “Isolation Alert” and local hospitals are using “Travel Alert”

6. Would be interested in seeing Maryland’s posters for dispatch centres?

(Richard Alcorta, November 20, 2014): They are posted on the MIEMSS website at www.miemss.org under the Infectious Disease tab, scroll down to the bottom and under the 911 Information is where the posters are located.

 

Diagnosis

1. Because the testing to confirm are not available in every geographic area, are there tests that are more widely available to reliably “rule out” Ebola. If a patient does not have abnormal blood counts, chemistry profiles, or liver enzyme abnormalities, can it be safely said that the patient does not have Ebola?

Dr. Garza (October 9, 2014): No. The clinical definition for Ebola is a PCR assay specifically designed to amplify and identify the virus’ genetic material. The lab kits may become more available, but this lab test is necessary.

2. How long did the confirmation of Ebola in the patient take, and how was it communicated to you and the other public safety partners?

Chief Seals (October 9, 2014): The call occurred on Sunday the 28th. Sept 30th, the hospital called to say Ebola virus disease was possible. It was confirmed in the media on Tuesday evening.

3. Mike; With regards to your progression discussion from flu like symptoms, general malaise to the vomiting and diarrhea piece, does this have a time period generally or is it patient specific that you go from flu like symptoms then to the vomiting diarrhea stage?

Dr. MacDonald (October 30, 2014): The typical time course in the average healthy person is the flu like symptoms / cold are typically from onset for 1-2-3 days and at some point, 3-4 days in the patient start develop the GI related illness and symptoms and that can progress for a few more days. It’s usually 7-8 days in that the patient truly experiences the significant symptoms the hemorrhagic rash, the bleeding and the profound hypovolemic stage if they’ve gotten to that. It’s not usually until a week in that you clearly identify clinically that this is something really really different from flu or a common cold.

4. The CDC just came out and made a comment that while Ebola is not really airborne, that droplets can travel through the air. Can you explain the distinction between why they say it’s not airborne but droplets can travel and what we need to know about that in EMS.

Dr. MacDonald (October 30, 2014): I think your concern came out of something I saw yesterday or earlier today as well. There is a question that was posed and I’m not sure where it originated. Is there a potential that the virus can be on respiratory secretions, somebody then cough or produces and then are spit out or cough out and then travel a short distance from where the patient cough or sneezed or what not. There is a theoretical risk that it could be possible, in other words you’ve got bloody sputum or you’ve got a high viral load or a high concentration of it in you respiratory secretions and those secretions then get cough out and are not on your person and may rest on a surface. There is no clear science of proof that it does exist, it is theoretical. Given the number of outbreaks that have taken place, given the number of patients that have been affected by this virus, one would think that if it was to be spread by the droplet or airborne route, we would of identified it up to now and the speed with which the outbreak is taking place would be different if it was spread by that route. Because obviously something that is droplet spread or even worst, airborne spread tend to disseminate quite quickly in close confinement and in areas where the is high population and person density. So while possible or theoretical, there is no practical proof that it has been the case. As of a couple hours ago the CDC was pretty silent on that other that stating previously it is not droplet spread. I think it is safe to say that the best science tells us right now it is not.

5. Dr. MacDonald is saying flu like symptoms, but flu while creating, malaise, etc. is upper respiratory, runny nose, congestion, etc are we not sending a mixed message when we continue to say flu like symptoms? I am concerned we will end up with patients saying they have Ebola symptoms when in fact they have the flu or a cold.

Dr. MacDonald (October 30, 2014): Dr. MacDonald; I echo the concern that the person asking the question has in terms of mixing the two. If we look at the initial symptomology, there are some similarities to it. The public may not be able to distinguish those similarities and when we are actually taking those 911 calls, the call taker, the EMD might not be able to distinguish them either. That’s why from a risk management perspective, having our crews being aware that there is a risk when they make patient contact. But I think if we look at relative likely hood within the next month we’re going to have community infections related to influenza and influenza like viruses. They are going to be spreading, they’re spread is typically predictable and the numbers a typically predictable. So on a strictly risk perspective or likely hood perspective, if we are getting that call that the patient is not an at risk patient by virtue of travel or contact, the likely hood they have Ebola is negligible or nil. That’s all about asking the right questions. Whether is the EMD or the dispatcher call taking center or the paramedic physically on scene. If they haven’t been to an at risk country and they have not had at risk contact with somebody who has been or is symptomatic with Ebola, the likely hood they have Ebola is incredibly small if not nil.

6. Do we know how long the virus can live on a surface outside of a host? I.e. How long after transporting an EVD positive patient would hard surfaces in the back of a vehicle be a threat to those required to clean the vehicle?

Dr. MacDonald (October 30, 2014): I don’t know the answer to how specific as to 12 hours, 24 hours. I do know the virus is relatively fragile and easily disrupted or destroyed by routine cleaning agents like hydrogen peroxide and basic bleach. It’s not a hearty virus that lives on the surface for days but again I couldn’t tell you 12 hours, 24 hours because I don’t know the answer to that specific number.

Dr. Charlene (October 30. 2014): The latest information was the research is not clear, however the latest information is that if it’s in a wet environment so if it’s in dried blood it will be 4 to 6 hours and if it stays in a wet environment the virus could live longer, up to 24 hours.

7. Have there been any EMS scene responses that resulted in the transports for Ebola patients that are actively producing large volumes of fluids?

Todd Stout (October 30, 2014): To my knowledge, the only unscheduled EMS transport in the United States or Canada was Thomas Duncan in Dallas and according to Chief Seals in the very first webinar, he was not producing any bodily fluids. If you weren’t on that first call one of the interesting thing was as the crew walked up to the house, the family actually came out and told them that they were going to want to put more stuff on to protect themselves. So they went back to the unit and put on PPE. But there were no bodily fluids, apparently not even much sweat although we were told that his house was very full of sweat.

8. Can people that have been successfully treated for Ebola contract it again if they are re-exposed?

Catherine (November 6, 2014): Well we know of cases (unable to understand) that have been treated and have survived Ebola. But I cannot say they will not contract it again because Ebola is viral disease and it’s not well studied. I will not say that I cannot be contracted again because we don’t know if it has mutated (unable to understand) I don’t know.

9. Statement

Peter (November 6, 2014): “If you are male recovering from Ebola, your semen can continue to be contagious for up to three months if you have unprotected sex during that time. It’s like giving them a death sentence.”

 

Hospitals

1. Have regional receiving hospitals changed their receiving procedures?

Chief Seals (October 9, 2014): The hospitals are changing their practices and many now have Ebola screening procedures in place.

2. Are you concerned about the hospitals not communicating that a patient is, in fact, EVD positive?

Chief Rupp (October 16, 2014): The county health department has jurisdiction over these cases. HIPAA does not affect the ability of providers to get information about a positive Ebola virus confirmation.

 

Personal protective equipment

1. How does your EMS staff feel about the difference in the level of PPE between 911 crews and inter-facility or special operations crews? How is that issue perceived by the public?

Mr. Jamison (October 23, 2014): We use Priority Dispatch in the 911 program, so that patients will be flagged. For flagged patients, a warning is sent to the responding unit. The 911 medic protocol includes the medics wearing contact isolation PPE for interviewing the patient or relatives.

2. What is the cost of the PPE? Are you disposing of all equipment after each transport (including PAPR)?

Coming soon!

3. Do they have specific equipment lists and links to maybe You Tube videos showing how they do their training or draping?

Dr. Isakov (October 23, 2014): What is most important is not the particular product but that it works for what it is needed to do. We are not endorsing any particular product. You need to look for the utility. EMory and Grady do not yet have YouTube videos but we do want to produce them.

Dr. Lowe (October 16, 2014): Donning and doffing lists specific to first responders can be viewed at http://app1.unmc.edu/nursing/heroes.

4. Strong contrast to the Dallas story re: PPE – what caused you to use the level of PPE you chose? How does that square with CDC recommendations?

Mr. Miles (October 23, 2014): In the south, it is very hot. You get very sweaty. No matter how disciplined and trained you are, the instinct is to wipe the sweat out of your eyes. D

r. Isakov (October 23, 2014): Grady EMS chose PAPR, Tyvek and the level of PPE that we did because we did not know fully what the patients’ conditions would be after a 14 hour flight to Atlanta. Grady and Emory needed to be prepared if the patients were vomiting and had diarrhea. The PAPR also precludes having to change PPE for an aerosolizing procedure.

After practicing with the PPE for a decade, we saw that medics sweat and want to wipe the sweat. The goggles fog up no matter what you do or slide down your knows. It is much more comfortable to wear the hooded PAPR and, because wiping sweat away is absolutely unacceptable, this increases safety. The blowing from the PAPR also provides some cooling and prevents the fogging of the eyewear. he PPE Grady chose is operationally more appropriate. It was not strictly necessary given the infection control guidelines.

Chief Rupp (October 16, 2014): The CDC did not really have guidelines in place for EMS. They had guidelines for healthcare workers but not specific to the EMS context. Omaha has been practicing this type of transport for many years. We did not want any exposed skin, which was one reason why we do the taping. A biocontainment expert helps with donning and doffing.

Omaha uses the three glove method. The third pair is the patient care glove. If it is soiled, it can be removed and new gloves put on. The booties are pulled up and taped.

Dr. Lowe (October 16, 2014): Omaha uses donning and doffing partners for PPE. Checklists are used to avoid contamination. Omaha generated 6 containers of Category A waste which was transported to the autoclave to create Category B waste.

5. Is the use of PAPR purely above and beyond? CDC is still suggesting use of N95 masks. Are those sufficient?

Dr. Isakov (October 23, 2014): The special team dedicated to transport of confirmed Ebola patients uses hooded PAPR, Tyvek suits, and head-to-toe skin covering. CDC guidelines to date have been for in-hospital setting. The illness goes through a spectrum that begins with fever and progresses to vomiting and other bodily fluid emissions and an altered state where the patient may not be able to follow commands so well. The CDC guidelines address this later state where the patient is very ill. Not every patient requires this level of PPE.

Chief Rupp (October 16, 2014): The PAPR is not necessary; it was used for the comfort of the medics. With the first patient, Omaha used the mask and goggles but after a time it was not comfortable. The goggles were fogging up. With suspected patients, Omaha may hold off on decontamination until patients are confirmed to have EVD. The Biocontainment Unit can get test results for EVD within four hours.

Dr. Lowe (October 16, 2014): For suspected patients, Omaha limits the number of care providers that interact with a suspected patient. PPE includes Tyvek suits, N95 masks and goggles. For the first EVD positive patient, that level of PPE was sufficient; however, it was not comfortable. The use of the PAPR is for patients that meet the case definition or known patients, and was implemented to keep the paramedics comfortable and better able to work. Medics may be standing by waiting for the patients to come off the plane for some time, and Omaha wants them ready, with PPE donned, while waiting. The PAPR makes this wait much more comfortable.

6. What type of PPE is being used now (in Dallas, October 9, 2014)?

Chief Seals (October 9, 2014): Dallas Fire Department is adding the full face shield and leg covers. The department is evaluating the quality of the gowns that paramedics have but they do have full length gowns. PAPRs will be requested for the field supervisor vehicles. Dallas Fire Department is looking at the full body Tyvek, probably for supervisors on calls with a lot of bodily fluids. Due to cost, these items will be limited to supervisors.

7. What type of PPE did the Dallas paramedics use (in responding to the call from the index patient)?

Chief Seals (October 9, 2014): There were no bodily fluids involved at all. The paramedics used gloves, their uniform, and a facemask. The paramedics did start an IV and did glucometry. CDC put the medics in the low-risk category.

8. What did the crew members (in Dallas) do with their uniforms after the call?

Chief Seals (October 9, 2014): “Washed them in a washing machine.” That was all that was required. CDC guidelines are clear that warm water and soap will kill the Ebola virus.

9. We saw Frisco use Level C hazmat gear (October 8, 2014). Is that out of the “fear” and media hype you spoke of or is it because that is all they have now?

Chief Seals (October 9, 2014): It seems like the way the patient presented, and out of an abundance of caution, they decided to do full hazmat and PAPR. It is not in alignment with CDC or WHO guidelines. Dallas is trying to spread the lessons that we are learning here.

10. Is this more than contact, droplet standard precaution? Is being in the residence an issue?

Chief Seals (October 9, 2014): “I have talked to epidemiologists way more in the last 8 or 9 days than I ever thought I would ever have a possible need to.” Epidemiologists assured Dallas that going into the apartment, even though the patient had been there for 5 or 6 days, even though he had vomited in that apartment, was not a high risk.

11. Tell us about the PPE donning and doffing.

Peter (November 6, 2014): I went to the (unable to understand) hospital which is the main isolation hospital, to go into the isolation unit with a guy called Will, in England he is quite famous because he actually is a nurse who contracted Ebola, went back to England, was treated in isolation and recovered and has come back to Sierra Leone to carry on with his work. So he went through the whole of the PPE equipment with me.

Todd, one of the most important things here is yes there is a strict procedure for putting the PPE on, which obviously we want to follow strict procedure to make sure we put it on correctly but the most important part of the PPE is actually disrobing. When you’re in the suits in the isolations center, the temperature in the suit can rise above 40 degrees in 5 minutes, you dehydrate massively and the shield fogs up so you can’t see through the shield as it’s steamed up. You get up to 40 degrees, you get incredibly hot, very dehydrated and if you are working a night hour shift, the nurses go in for periods of time of about 40 minutes to an hour, then they come out for 40 minutes to an hour and then they go back in for 40 minutes to an hour and they keep doing it in rotation and drink absolute gallons when they come out. They must rehydrate. The issue is Todd, when they come out and are disrobing out their PPE, that the biggest risk of actually getting contaminated because you have to follow the strict procedures.

Now what they’ve gone and done in the decontamination room is they’ve put great big pictures of every single step to make sure you follow the pictures. If it’s written or typed and you can’t see it because you mask is fogged up, you can’t read the next instructions. If you have a big color picture, you’re more likely to be able to see what it is you are supposed to do next. They equally have a buddy that watches them to make sure that they do it correctly, they also have a full length mirror in the decontamination room so if there is no body available when they are decontaminating, they are doing it in front of a mirror so they actually see where the zip is to pull it down and they can see how to get their mask off without touching their skin.

The biggest risk is that you have the contaminant, the virus on your gloves and then as your taking off your robe, your one piece suit, that you touch your chin when you got to unzip the actual suit so you’ve now got the virus on your chin so obviously that’s bad news. Or you’ve touched the side of your head, just to the side of where your eyes are, where the elastic strap of the face shield is. So those are the two points of contact; the bit next to your eyes, when you take the face shield off and your chin when you try to unzip it by missing the zip and touching the skin. The full length mirror is vital. Equally you need a clock with the second hand so when you wash your hands; you wash your hands for a minute. If you sing happy birthday, the whole rendition to yourself, four times if there is no clock – it takes a minute. People might think you’re mad signing happy birthday but it will buy you that minute so you can make sure you’ve decontaminated your hands thoroughly.

Follow up question – Do they double glove?

Peter (November 6, 2014): Yes they double glove. The first gloves are normal gloves that you would wear – normal latex gloves and the second gloves, I call them the marigold gloves – they are the big long gloves that almost come up to your elbows. Bigger thicker gloves, they are the over gloves so they are the ones that are washed for a minute – the big gloves. As soon as you take them off, you then wash the gloves underneath for 30 seconds. Obviously there is a very strict procedure on how you do it.

12. A few commonly asked questions – When the crews were finished doffing, what do you have them do with their uniforms? Secondarily, do they go straight back to work doing other things? What happens next?

Dr. Racht (December 18th 2014): We use the same crew for both of the patient movements. They were a volunteer crew and we had a lot of discussion. We were fortunate that a crew volunteered – if they didn’t, what on earth would we do? Because we had an obligation to move them so, fortunately they had volunteered. Day 1 they wore their uniform with a T-shirt underneath the Tyvek. Day 2 they wore their own comfortable clothes just from a heat standpoint. The clothes and the uniform from day 1 was actually taken back to our facility and were appropriately decontaminated and I believe they were disposed of. They did not go back home with the providers. We monitor our providers; we actually did it with an iPad based telemedicine monitor so they took their temperature every day for 21 days. They had the ability to do consultation with the four of us, 2 Doctors and 2 nurses. When the 21 days was over, they were released back. The initial move was we would pull them out of direct patient care and today we would put them back into direct patient care. Once appropriately decontaminated they should be able to go back into service. What we did underestimate was at about day 16 or 17 we should of spent more time talking to them about what they’ve done or if they had questions like how are you feeling? There is all the National news with Ebola and how horrible it is. We didn’t do as good of a job as we should of right after the call like do you have questions or concerns. Really essentially a debriefing. When debriefing/defusing the event we now have that as part of our process to spend a lot more time with them and their off going shift.

 

Health and safety

1. How were paramedics decontaminated?

Chief Rupp (October 16, 2014): The paramedic treating the patient accompanied the patient to the room in the treating facility, and then the paramedic followed decon procedures as per the biocontainment unit. His clothes were set out for him so that at the end of his shower he could get into them. He wore scrubs under his PPE.

2. Has any sort of mental health counseling or something similar been made available to the medics, as well as other personnel?

Chief Seals (October 9, 2014): That was closely evaluated. The chief drove two of the medics home himself and kept close contact with all three of them. Dallas Fire Department has followed their CISM protocols. The medics assured their supervisors that they were fine. The chaplain checked in with them, and there will be a follow up after the monitoring period is complete.

3. Were the medics placed under “quarantine” for the 21 days?

Dr. Isakov (October 23, 2014): Remember that with Ebola there is no contagion until the patient is showing signs and symptoms. So a paramedic that has treated a patient, and then is monitored, does not pose a risk if he or she is not sick. Do not give in to anxiety and fear, but use an informed approach. Show leadership on this issue.

Chief Seals (October 9, 2014): The paramedics were brought into the hospital to have baseline health information. They are being monitored by the CDC and by Dallas Fire for 21 days. There was a lot of confusion in the first four or five days. The paramedics were first asked to self-confine to their homes. That changed and the paramedics have been able to move freely. Dallas Fire is now exploring whether the paramedics can come back to work in a non-patient care role, which the CDC supports.

4. What type of support has been offered to paramedics and their families during quarantine?

Chief Seals (October 9, 2014): A text group was set up by the medical director and the chief to check in with the medics twice a day. The CDC checks in face to face for a once daily temperature check.

5. Are the paramedics being paid for the 21-day monitoring period?

Chief Seals (October 9, 2014): Yes.

6. How are you monitoring your paramedics? Did they return to duty immediately?

Chief Rupp (October 16, 2014): Paramedics are self-monitoring, taking their own temperature and reporting in twice a day. The paramedics continued to work during the 21 day monitoring period.

7. Draping seems to be an important component of the transport of EVD patients. How is Grady EMS ensuring the safety of staff in the back of a draped truck – floor, handholds, seatbelts etc.?

Coming soon!

 

Triage and risk stratification (protocols)

1. Would like to hear from Clawson regarding protocol 36.

Dr. Clawson (October 16, 2014): The CBRN committee has been working on it.

2. How many First Watch or ProQA will this be sent to and when? Trying to get a sense of how many CAD’s will be starting to use this.

Dr. Clawson (October 16, 2014): Go to http://www.emergencydispatch.org to find links to information, updated manual cards, and where to get protocol updates for ProQA. The tool is a PDF that can be viewed along with your CAD or ProQA. The card is available in many languages.

3. Did your agency (Dallas) have dispatching protocols to identify Ebola patients at the time of them coming in contact with the index patient?

Chief Seals (October 9, 2014): At the time of the Index patient’s call, we had no call centre protocol. One of the questions we have added is, “Are you currently being monitored by the health department for Ebola?” The CDC has plans in place for what should be done if one of the 48 people being monitored does call in and they need transport. These people are all throughout the state. Regional providers with training and equipment will respond.

4. Has there been direction from the county or state EMS agency for all providers to change protocol, not just their dept. doing it independently?

Chief Seals (October 9, 2014): Texas is organized by delegated medical acts, so the agency medical directors set the protocols.

5. Are you saying that our dispatchers are to use this tool anytime they receive a call with flu like symptoms or are they only to use the tool during outbreaks?

Dr. Clawson (October 16, 2014): We leave it to the medical directors in each place, but EMDs should consider using the tool now on cards 1, 26, 18. Later, when the outbreak is more diffuse, it may be used on card 21 – non-traumatic hemorrhage. The Emerging Infectious Disease Surveillance (EIDS) Tool was edited with the CBRN committee for the Ebola outbreak. The tool was originally developed for SRI/MERS. Check the IAED website for regular updates. Local policy will help to dictate local updates to the tool. During MERS for example, Toronto was affected before other areas and therefore had to use different parts of the tool before those other areas.

6. Is there an option to choose which determinants to mandate the screening to be completed? Not forcing the dispatcher to complete opens up opportunity for variability in screening or missed calls.

Dr. Clawson (October 16, 2014): Local policy dictates when to use the tool. It does not auto launch at this point since some systems think that would be overdoing it. Using the tool as much as possible early on will help with surveillance to see if there are any trends or patterns emerging.

A PDF of the call taking tool is available to everyone, including those who are not using ProQA.

Version 13 of Paramount ProQA has the Emerging Infectious Disease Surveillance Tool built in.

Todd Stout (October 9, 2014):

Check for travel.
ePCR: monitor temperature, chief complaint, free text, impression fields.
ProQA and Paramount have updated questions specific to Ebola.
CAD-based fields to monitor include chief complaint.

7. Do NY Medical Protocols allow treatment (IV & AGMP etc.) versus withholding treatment during transport?

(Captain Paul Miano December 4th, 2014): We do not withhold treatment. We’re medical professionals and that what we’re here for. We’ve had extensive discussions with our Medical Directors about this and we’re advised to go ahead. Now my Haz-tac paramedics they are trained actually in these suits, we put them in the back of an ambulance and we drive them around our training facility. If you’ve seen any movies regarding how New York people drive, that’s pretty much the way we drive the ambulance around while they’re in the back of the truck and we ask them to start IV’s, inter-tracheal intubation, CPR, we do all of this and we feel comfortable treating in the back of the ambulance while we’re moving, regardless of what the patient is suspected of having.

8. Is it possible to receive copies of these procedures/policies FDNY uses to direct your response?

(Captain Paul Miano & Edward Bergamini December 4th, 2014): If your agency contacted our agency maybe we would be able to do that. It would have to be vetted through our higher authorities.
to see the Donning/Doffing procedure utilized by FDNY for potential Ebola response please visit; http://www.nyc.gov/html/fdny/html/events/2014/112514a.shtml

 

Training

1. What training was provided to your 911 and inter-facility or special operations teams?

Chief Seals (October 9, 2014): After the transport, Dallas brought the supervisors in first to give them information. This was done to combat fear and the lack of adequate information.

Dr. Isakov (October 23, 2014): Emory identified a knowledge gap around serious pathogens like Ebola among EMS special teams. Our training for the Grady EMS Biosafety transport team has included education on serious pathogens. This has focused on the nature of these diseases, routes of transmission, infection control, prophylaxis and immunization when it exists, post-exposure prophylaxis and methods of treatment. This education helps special teams care providers understand what they are dealing with. It eliminates misconceptions and contributes a needed comfort level for these paramedic care providers.

The training of our special teams includes competency based training on proper donning and doffing of PPE. Routinely EMS providers do not apply PPE meticulously. In the case of serious pathogens this cannot be tolerated. The preparation of the ambulances is also covered in training.

2. When you rolled this out, did you have any challenges getting people to go through it? Did you offer statewide web-based training or did every agency do their own training?

(Richard Alcorta, November 20, 2014): First off we are very blessed from an EMS perspective, from a public safety perspective we all are using the same tool. Each of the counties decided to do it on their own but that’s also in collaboration with our state wide numbers board. They are the entity that oversees all of our 911 centers. Both for education, it’s where they get their funding from. When you can attach funding or the string of funding, you tend to get compliance.

Number two, when we put this out as this is what the CDC expects, this is what our department of health and mental hygiene, our secretary of health is saying we will do and then MIEMSS having the authority to move in to and give guidance to each one of our 911 centers, we are able to do that. Clearly there has been pushback, particularly from our large volume centers. One of our counties, Montgomery county sees about 150,000 911 calls per year. With that understanding, by adding a few seconds 10, 15, 20 seconds to ask a series of questions is a significant challenge. The reality is, is they have gone ahead and implemented these strategies realizing the need and the fact that they are a high risk area with NIH sitting in their backyard. They have gone ahead and adopted it.

The second aspect is that the state of Maryland also has a single EMS protocol which is established by the EMS board under my hospices, not the board mind you, the protocol under my hospices as the lead state EMS Medical Director. We are able to establish standards of care and through our weekly conference calls with the highest EMS officials, their Medical Directors, the Medical Directors of 911 centers, we’ve been able to get this message across and communicate it effectively. The training has been the responsibility of the services. That’s where the posters come in. We are trying to facilitate, make it easier for them realizing this is not an automated tool yet. It’s still an operator interpretation and activation process.

3. How are your regular EMTs reacting to the level of PPE and level of training they have received? Do they want or need more training, ongoing practice?

(Captain Paul Miano December 4th, 2014): They are Haz-Tac trained EMTs so they are trained already to operate in this level of PPE. I have 15 paramedics Haz-Tac units and 11 EMT Haz-Tac units. Everybody wants more training and more practice but they are well versed in operating in these suits.

4. Is there a resource for agencies to get “Trained Observer” training?

Dr. Racht (December 18th, 2014): There are. Essentially they are donning and doffing. We found that video training for that is much better than a list. I think we posted the CDC version of that video on our website- that’s what we’ve used. It’s very effective because you literally watch the event occur. I’m happy to look for that if it’s not there. We’ve found that it’s been the most valuable. Just a side note, we initially thought we train a whole boat load of folks to be trained observers. Given the frequency of this occurring, we actually had the discussion of shouldn’t everybody in EMS have trained observer awareness but the actual trained observer technicians would be folks that have much more in depth knowledge and would constantly be refreshed. I’ll tell you now. I think hospitals are huge resources for that. They are training their staff intensively. I’m happy to forward that if you can’t get it from the website.

 

 

Situation in Sierra Leone

1. Are the stories correct about the dramatic increase in the number of cases in Sierra Leone?

Catherine (November 6, 2014): Yes. There is an increase in the number of cases in Sierra Leone right now because sometimes the patients/ suspected cases that are left in the community are too high. Sometimes, on a very bad day, we leave about 58 cases in the community and everyone case you have, there is 10 people that can be infected from that one person. So we have about 580, if you try to project the figures is what I’m saying. So if you leave (unable to understand) in the community, if you have a projected figure, it would be about 580 cases that you expect to happen in the coming weeks or month. So the problem with increased infection is because of the cases being left in the community that infect other people and those people also infect others. The isolation centers we have, about 7 right now and we have a massive load in the west end area, that capacity is so small it cannot get enough people going into the isolation centers because there is no space. So you end up leaving them in the community where they infect more people, so you have an increase of infections and there is only one treatment center right now in Sierra Leone the other one is just coming online and it has not started taking patients yet. The treatment center is so full, you cannot get people from the isolation center into the treatment center, therefore you cannot get people out of the community into isolation.

Follow up question – So Peter/Catherine it sounds like the issue there is an issue of capacity – there is not enough beds to take care of all of the cases of Ebola. In turn it that leaves them out in the community to pass that infection on to other people in the community, is that correct?

Catherine (November 6, 2014): Yes definitely that is it.

Follow up question – Now Sierra Leone, I believe was a former French colony if I remember my history correctly. Are you getting any support from European Government?

Catherine (November 6, 2014): We were colonized by the British. We are getting support from Brittan – some of the soldiers form Brittan are here helping out.

Follow up question – Are those medical workers?

Catherine (November 6, 2014); Some of them are medical workers but most of them are logistics.

2. Have any of the ambulance crews tested positive? Are they regularly monitored?

Catherine (November 6, 2014): We have lost two drivers and a nurse because they tested positive and they died. Presently, Pete was generous enough to get us thermometers – infrared thermometers which would check the temperatures of the drivers and nurses everyday they turn in for work so we know their temperature.

3. Although the EMS attendants are pictured in street clothes, what personal protective equipment do they use when responding to an Ebola call?

Catherine (November 6, 2014): Yes definitely. They have scrubs like those you would wear in surgery. For example if you are performing a surgery you have scrubs and then they have a face mask and the face shield. They have gloves, they have the coveralls. They are Pyrex coverall suits, they have boots like (unable to understand) boots that they wear and aprons. So we have about 7 items, there is a picture that Pete will send to you to see what they wear.

4. What is the call volume the service is experiencing? Is it all Ebola related calls or mixture? Would anyone call 1-1-7?

Catherine (November 6, 2014): Just Ebola calls. The calls come in from one number; 1-1-7. Which goes to a communication switchboard they take the call and can have more than 100 calls a day and then that call is passed on to the district surveillance officers who go to the site where the call was made and see if the person who made the call meets the case definition of Ebola and they report back to us and we take it from there.

Follow up question – How many district officers do you have?

Catherine (November 6, 2014): We have a lot of them. There is probably more than 30-40.

5. Where or how would someone contact if interested in coming to help?

Todd (November 6, 2014): For the UK: UK-med or kings college hospital in London. We will reach out to US and Canada and post the information on www.paramedicchiefs.ca/eid
**note: This information will more than likely come later as we are trying to contact folks in Sierra Leone and in the United Kingdom

6. If someone would like to help the ambulance service members (uniforms, etc) what would be the best way to do so? Is your ambulance service in need of any supplies?

Peter (November 6, 2014): The entire country is in need of supplies. The difficulties they are having right now is there is very few airports here, the ships are not coming in as they used to. There is sort of a national shortage. You name it, they are short of it from body bags to PPE suits. I can’t answer the specifics of what their stock holdings are and how many days they’ve got left of each particular item. I know gloves, if you think of all the PPE kit items there would be gloves, aprons, the suits, face shields. If you name it, we need it in a bucket load.

**Note – Pending confirmation from Catherine…
(Supplied by Peter Simpson) The address the PPE supplies need to go to is:
Catherine Jackson-Cole
Ambulance Coordinator, Ebola Command& Control Centre – The British Council
20 AJ Monoh Street
Tower Hill
Freetown
Sierra Leone

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