How to assess an Ebola patient with only your senses
You will not find an EKG monitor, pulse oximeter or even a blood pressure cuff; medical providers work with nothing more than their hands, eyes and ears
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 — Have you noticed who the “rock stars” of medicine are in your ambulance company? It is always the person who can rapidly assess a patient and create a management plan, and that person always seems to know the right thing to do before the monitor is connected to the patient.
Frequently it is an older paramedic who was not trained to rely on pulse oximetry or other electronic monitoring devices. Modern medicine has created a dependence upon equipment for assessment of the patient and the practical “hands on” assessment skills have gradually decreased over the years.
Few assessment tools
There are few assessment tools available or accessible in the Ebola Treatment Unit (ETU). The caregiver must be completely enveloped in personal protective equipment (PPE). As such, the ears are not accessible and a stethoscope is useless. Furthermore, every piece of equipment stays in the ETU until the ETU is closed and destroyed. As you can imagine, you will not find an EKG monitor, ultrasound machine, pulse oximeters, or other equipment in the ETU. Even a blood pressure cuff is rare.
Caregivers look, listen and feel
Resources are scarce. In the ETU we have are eyes, ears and hands, but even those are covered so deeply in plastic that any assessment is difficult. While it is challenging, a patient assessment is required and it is possible to provide a quality assessment and care under these difficult solutions.
My career has taken me from remote locations where resources are scarce, to battlefields in the Middle East where lighting a scene was a deadly risk, to helicopters and airplanes where noise hampers patient assessment. I have learned how to use my hands, ears, eyes to keep the patient alive. I was surprised to find these same skills were exactly what I needed in an ETU.
Assess the ABCs
Assessment of the ABCs is easy to achieve without any assessment tools. If the patient is breathing, their airway is open. The respiratory status of the patient is also easy to evaluate without any equipment. Look at the patient and notice the rate and quality of the respirations? Fast or slow breathing? Full or shallow breaths? Near death, the Ebola patient may have Kusmall respirations. If the skin is pink, he is oxygenating well; if it is blue, he is not. Do we really need a quantifying number?
Patients with Ebola also frequently have additional medical problems that may complicate management. You can assess for pulmonary dysfunction without any tools by simply placing your hand centered on the chest. Close your eyes and feel the breathing. Up and down motion is good. In a dark environment, this is how you can determine the rate. Can you feel the patient using all his muscles to breathe? If so, he has labored breathing. Let your fingers rest in the intercostal spaces of the rib. Can you feel intercostal retractions with inspiration? If so, the patient is wheezing. Feel the air go in and out of the lungs. Can you feel gurgling? If so, there may be pulmonary edema. While mild bronchospasm and mild pulmonary edema are not going to be noticed in this environment, certainly, a life threatening condition can be evaluated and treated based upon these findings.
When considering circulation, we do not measure blood pressure in an ETU. With Ebola, dehydration, hypovolemia and shock are the big killers, so evaluating circulatory status is critical. While at the bedside, I check the carotid and radial pulses. Absent radial with positive carotid suggests hypotension.
The same is true for a cap refill that is greater than two seconds. We check for “tenting” of the skin. Tenting suggests dehydration. Tenting and absent radial pulse suggest hypotension from dehydration, while good skin turgor with hypotension suggests hypotension from shock.
Combine skin assessment with the pulse check. Some patient care areas have clocks, many do not. The patient's pulse is either fast, slow, or regular. To manage hypovolemic shock in this environment I provide IV fluids boluses and, if needed, hang a dopamine drip titrated to obtaining a radial pulse.
Rapid, low-tech assessment
We can assess a person’s level of consciousness and relate it to oxygenation, cardiac function, and blood sugar level. Urine output tells us that Ebola has not yet caused end organ failure (a critical finding if we are going to give potassium for hypokalemia secondary to vomiting and diarrhea). Furthermore, based upon the color of the urine, we can determine the extent of dehydration caused by the vomiting and diarrhea. Dark urine is serious dehydration, while light urine suggests lack of dehydration. Touching the head will give us an idea about fever, but in the ETU, most areas have thermometers available. All of this patient assessment is done in the same amount of time it takes to inflate and deflate a blood pressure cuff.
Learning the Ebola care
The ETU is as hostile an environment as any I have previously encountered. I have just arrived here and I am still learning. The wearing of PPE in the West African heat and without air conditioning reduces the time a medical provider has to assess and care for the patient. The scarce resources and limited time are the factors that require quality medical providers to work with nothing more than their hands, eyes and ears. This is the world of Ebola medical care.
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 firstname.lastname@example.org.