Ebola: A medic’s challenge of communicating in the hot zone

Humidity and decontamination needs make documentation a low priority in Liberia, but without it few treatment lessons will be learned


Editor's Note: RN and paramedic Rene Steinhauer is working as the chief nurse in an Ebola treatment in Liberia. He is sharing dispatches with EMS1 readers and asking for your ideas and support. The views expressed are his own.

By Rene Steinhauer RN, EMT-P

LIBERIA, West Africa — Every aspect of this outbreak continues to challenge even the most seasoned disaster manager and medical professional. The challenge to work with such a deadly virus in the most extreme environment has resulted in less than adequate medical care, heat injuries to those working in an Ebola Treatment Unit (ETU) and it has even resulted in the death of healthcare workers. It seems as if even the most basic tasks are difficult to complete.

Accurate documentation of patient care

Paramedic Rene Steinhauer is working as the chief nurse in an Ebola treatment in Liberia.
Paramedic Rene Steinhauer is working as the chief nurse in an Ebola treatment in Liberia. (Image Rene Steinhauer)

One such example is the challenge of accurately documenting patient care activities in the ETU. Every time a medicine is given, every time oral or IV fluids are administered, every time the patient urinates or has diarrhea, the amount needs to be measured and documented. Dehydration is the underlying cause of organ failure and death for a patient with Ebola.

ETU is a hot zone

Any equipment that enters the ETU – the hot zone – stays in the ETU. Nothing comes out unless it is being burned or soaked in bleach. This includes paperwork since it cannot be removed. Furthermore, it is impossible to write on a document without it getting soaked in sweat and bleach.

Oppressive heat and humidity

The personal protective equipment (PPE) combined with the heat and humidity inside the ETU make the working conditions so hot that it is unsafe to stay in the PPE for longer than two hours. Many healthcare providers can only last an hour before they risk suffering a heat injury.

The amount of perspiration is so heavy it runs out of the suits. A nurse may be responsible for scores of patients and he or she has only minutes to complete the medical care, document findings, wash between patients, and continue to the next patient. As such, documentation has been low on the priority of those working in the ETU. When faced with the choice to save lives or write about saving lives, we always choose to save lives.

Documentation helps save lives

But documentation is also about saving lives. In the United States the patient care report is often more about the medical/legal concerns than it is about communicating to the other nurses and doctors. In Liberia, so little is known about the disease and the best way to manage the disease, that without extensive documentation regarding how the patient was managed and the outcome of the patient, few lessons will be learned.

If we can find a way to document easily in this environment, then perhaps we can save more lives now and in the future. Data can be collected, evaluated, and the best practices can be shared. But at this time, minimal data is being obtained and nurses continue to be challenged with how to document and collect data.

Some of the ways documentation is being collected:

1. Yelling information from the hot zone to the cold zone

Nurses in the hot zone may write some information on a paper and hope the ink does not run when wet from their perspiration. Then the nurse walks out of the tent to a fence that separates the hot and cold zones by six feet or more. There, while still wearing a mask, the nurse yells the information to someone on the other side of the fence. Despite screaming sensitive personal details in the presence of everyone around, it is not easy to understand someone who is screaming in PPE.

2. Writing on white boards

Some ETUs have white boards and they write information on them in the ETU. While information can be passed on between shifts, there is no way to save the data. Some healthcare providers place a white board in view of the cold zone so details can be seen and copied by others.

3. Filming treatment with a GoPro camera

Some journalists have been able to film and photograph documents in the ETU using a GoPro camera. This is one of very few exceptions that are allowed at the ETU. Afterwards the camera is soaked in bleach for 30 minutes before being returned to the journalist.

4. Waterproof paper and waterproof ink

There is a man at the International Medical Corps in Liberia who is working on a plan to use waterproof ink and paper. The paper would be soaked in bleach for 30 minutes then removed from the ETU. It has not been successful yet, but they are working on it.

5. Digital camera with wireless technology

This idea to photograph care and documentation has some promise. Of course the camera must be able to withstand the bleach and moisture.

6. Computer tablets

One idea that was recently brought up was the use of military grade computer tablets with a stylus for imputing data that would be sent wirelessly out of the ETU. For this to work, a program would need to be developed to capture data, document nursing activities and even note what doctors orders need to be completed. The odds of creating a hardware and software system like this before the outbreak is resolved are low.

Share your documentation ideas

Documentation is just one of many challenges we face every day in the ETU. My nephew, Westley, has made a suggestion similar to the first idea of using someone to take notes. I challenged his grade school class to come up with other suggestions and send them to me. I also challenge each of you to think about methods to help us collect data.

We need a low tech method to get info from the hot zone to the cold zone. How quickly could we implement it? Is it personnel intensive or easily accomplished? Every resource here is scarce and valuable. Think outside the box and share your ideas. You can be part of this Ebola Army; think of yourself like “Q” in the James Bond movies and find me a solution to this problem. Email me your ideas at rene@renesteinhauer.com or share them in the comments.

About the author:

Rene Steinhauer RN, EMT-P is the chief nurse of an Ebola treatment unit in Liberia. He is the author of Saving Jimani; Life and Death in the Haiti Earthquake. Available now in print and kindle versions from Amazon.com. You can contact Steinhauer with ideas and support by email at rene@renesteinhauer.com.

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