Why Ebola patients should be triaged to specialty centers

Transporting these patients to specialty centers is the best way to safely manage this virus, and companies are already able to do this


It seems logical at first glance that any hospital with the ability to safely care for a patient on contact precautions could handle a patient with Ebola. But recent events make it obvious that we may not be as prepared to safely handle a disease like Ebola as once thought.

The failure by Texas Health Presbyterian Hospital to safely care for Thomas Eric Duncan, the first patient to be diagnosed with Ebola in the U.S., is an indication that individual hospital systems have failed to adequately prepare for an event that while foreseeable, is unlikely and thus difficult to budget for. Hospital systems survive based on revenue, and one hospital simply cannot be adequately prepared for every conceivable emergency.

We don't expect responders trained to a basic hazmat-awareness level to operate, much less manage, a hazardous material incident. Why should we expect health care workers to know how to safely operate in these environments with little-to-no real training or experience? In any other context, this would be unacceptable.

That is where triage plans and specialty centers become indispensable.

It's clear that triaging these patients to specialty centers is the best way to safely manage this virus. This is not based on panic or fear, but on the fact that we already have a system in place that provides tiered levels of care for patients.

If your patient has been severely injured, you go to a trauma center. If your patient is having a heart attack, you go to a facility that has 24-hour PCI coverage with surgical backup. If your patient is having a stroke, you airlift her to a 24-hour stroke facility with interventional radiology.

We do all those things for patients experiencing major health events, why not make the same effort for someone with a unique virus? A disease this deadly deserves our respect and a treatment regimen that requires specialty staff and facilities.

It can be done

The good news about transporting patients like this to other facilities is that we already have organizations ready and able to perform at the highest levels.

When the first two American Ebola patients were brought from West Africa to the U.S., I visited Phoenix Air, the company that managed the international leg of the transport.

You may have seen one of their slate grey Gulftstream IIIs on the news. For more than a decade, these seasoned professionals have worked with the Centers for Disease Control, Grady EMS that handled the ground transport of the patients, and Emory University Hospital, one of four hospitals nationally with a highly specialized isolation wing.

Phoenix Air is part of a continuous chain of high-level medical care that begins at the time their providers reach the patient, to the time the patient is well enough to go home. As of October, Phoenix Air providers have transported 13 Ebola patients with no adverse events.

Program Director Vance Ferebee showed me around their facilities, and explained that like Grady EMS, they have been prepared for this kind of event for years.  

A look inside an isolation transport tent

Phoenix Air has a unique onboard isolation tent. The tent's design was a group effort, with overall design by the Department of Defense, frame design by the CDC, and the mounting tray and HEPA filtration system by Phoenix Air's in house engineers.

The whole assembly fits perfectly inside the plane and provides a comfortable and safe capsule around the patient. It includes a patient area and a vestibule airlock area. The whole structure is under negative pressure with multiple layers of HEPA filtration on both the inlet and exhaust.

All monitoring equipment and IV pumps are kept outside the tent with cables and tubing entering through sleeves, which are sealed. This arrangement allows for providers to administer medications and monitor patients without donning protective equipment and entering the capsule unless necessary.

While the latest Ebola patients have garnered much in the way of media attention, Phoenix Air and Grady EMS have been safely caring for and transporting unique patients for years.

Why it's done

According to Ferebee, Phoenix Air was first contacted by the CDC over a decade ago when it was exploring options to care for its employees who may become exposed to novel pathogens while abroad.

"CDC employees wanted to know how they would be cared for if they became exposed to something while working in a cave in the Congo," he said.  

Neither he nor the rest of the team were concerned about their ability to safely care for and transport these patients. In fact, one of the biggest lessons learned was that multiple changes of base layer clothing were necessary for the providers wearing Tyvek suits.

The isolation coveralls are very hot and uncomfortable, especially during long-duration flights, so by the time they entered and exited the tent to provide patient care their clothes were soaked with sweat. Many people were surprised to see Grady EMS personnel in powered air purifying respirators.

What is often misunderstood is that a major reason for this was provider comfort. During the first flights, Phoenix Air medical personnel did not use these devices and had to cope with greater discomfort. 

Ferebee said he and others on their team have had to deal with skepticism regarding the treatment of highly infections patients.

"I've met and talked to people who said 'you can fire me I don't care, I'm not touching that.' We didn't really have a lot of that here.

"Our providers are well-educated and well-cultured. We understand the realities of the risk. These patients are contact precautions."

What EMS can do

Ebola is spread through contact with body fluids. Whether direct or indirect, to become infected one must have contact with body fluids that are heavily contaminated with the virus, then somehow absorb these fluids through the eyes, nose, mouth, or a wound, for instance.

Knowing this, wearing a full-face mask or a hood is often to simply keep one from inadvertently touching his or her own face with contaminated gloves. In our job of preparing and training for the worst, one must always think of the what-if. Ensuring that there are redundancies raises the level of safety for providers.

With the CDC contact precaution recommendations in mind, all EMS providers can safely care for and transport infected Ebola patients with the equipment currently available as part of routine standard care. There would be risk, but carefully done, the risk would be minimized.

As new cases of Ebola emerge, the Phoenix Air team will be ready to provide high-level care for patients with dangerous viruses. In the case of Ebola, we know how it's spread, and how to avoid becoming infected ourselves.

We now simply need to learn to properly manage these patients and minimize the possibility of further exposures. The best way to do this is by triaging patients to facilities with experienced, skilled providers who can safely manage the patient.

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