The OR in the Midst of an Ebola Outbreak
When Ebola was at its peak in West Africa, epidemiologist Janet Martin, PharmD, was working with the WHO to understand best practices for surgeons and health care workers in those countries to keep them and their surgical teams safe
By Crystal Mackay, MA'05
It’s 2014, the height of the Ebola crisis in West Africa. Across Liberia, Guinea and Sierra Leone, the virus is spreading rapidly, infecting dozens of people each month and killing 40
You are a general surgeon in a hospital in Liberia. A patient has come in doubled-over in pain with symptoms that suggest acute appendicitis. The patient’s fever, headache and bloodshot eyes make you wonder whether Ebola should be part of the differential diagnosis.
The patient denies any known exposure, making the decision difficult: preliminary results from diagnostic testing will take at least a day. As the patient’s condition worsens, you decide to perform emergency surgery.
Stories of health care workers dying from the virus across the country ring in your ears as you search for new latex gloves, try to find an impermeable apron and affix your surgical mask. You know the equipment your hospital supplies is not enough to prevent exposure during surgery if your patient is infected.
Just before you enter the operating room, you reach for your raincoat, hanging still damp on the back of your office door from this morning’s rainstorm, and hope it’s enough to keep you safe.
This was the reality at the height of the Ebola epidemic in West Africa, with surgical teams being exposed and infected while providing care.
As the Co-Directors of the Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI) at Western University, Janet Martin, PharmD, and Dr. Davy Cheng were invited by the World Health Organization (WHO) to lead a group of international experts including surgeons, obstetricians and anesthesiologists from West Africa, to understand the magnitude of risk for surgical teams during Ebola outbreaks.
As a newly designated WHO Collaborating Centre focused on global access to safe surgery, MEDICI was tasked with developing guidelines and best practices to protect the surgical team from infection while providing care for patients.
A super spreader is defined as an event that causes a disproportionate number of people to be infected than the number already carrying the disease.
“We noticed surgeons and surgical team members being infected, and it was occurring at a higher rate than other settings,” said Martin. “In countries where there are only three or four surgeons in the entire country, this was a huge health crisis not just in terms of the virus itself but also in the context of access to safe surgery.”
The team found the ratio of infectivity for surgical team members was several-fold higher than the general population, and more exaggerated where there was limited access to personal protective equipment.
“We were quite surprised that the infection ratio was that much greater. We suspected that patients presenting with Ebola also had symptoms that were presenting like surgical conditions. If the surgical team doesn’t suspect it, they are unlikely to use the extra protective equipment required to prevent exposure to the virus during surgery,” she said. “Our research revealed that surgery and other invasive procedures on infected patients without adequate protection can induce a super-spreader scenario.”
They started to examine specific cases where Ebola might masquerade as a condition requiring surgery and found that patients were sometimes diagnosed with a threatened miscarriage, appendicitis, gastrointestinal bleeding or cerebral hemorrhage.
In countries with limited access to imaging techniques and rapid diagnostic tests, physicians may perform exploratory surgery to determine the source of the symptoms. However, without knowledge of the patient’s infection and time to supply adequate personal protective equipment, the surgical team may be unknowingly exposed.
Together with the WHO and surgical experts from Africa, Martin and Dr. Cheng’s team developed a set of evidence-based recommendations and an algorithm to assess benefits versus risks of different scenarios for surgery in patients with potential or confirmed infection. Most importantly, they recommended that if the team decided to move forward with surgery and the procedure could not wait until infection risk had passed, the team needed to use full personal protective equipment.
“That part became tricky because it’s easy enough for us to say they have to wear all this protective gear, but in a lot of these low- and middle-income countries they don’t even have an adequate supply of latex gloves, never mind a full impermeable body suit and respirators or fitted goggles,” Martin said.
Some surgeons and obstetricians described buying their own face masks and gloves and using whatever clothing they could find to help protect themselves, including their own raincoats. While there hasn’t been the same attention, Ebola has made a resurgence in the Democratic Republic of Congo (DRC) in 2019.
The MEDICI team is now working with the WHO to disseminate the guidelines to all front-line health workers and surgeons. An additional challenge is getting the message across in a way that is sensitive to the cultural, social and political climate in the affected countries.
In the eastern part of DRC, armed groups have killed millions during the past two decades and the region’s residents have endured years of political corruption. Ebola responders are asking for the trust of communities that had never heard of this disease before, and many are cautious and mistrustful of any intervention, particularly from foreigners.
With this in mind, one of the goals is to dispel misconceptions about Ebola to improve the uptake and spread of evidence-based recommendations in culturally-relevant ways.
Somewhere in Rwanda on the border of DRC, a taxi driver has a worn diagram in his front pocket. Scribbled in blue ink on the back of a dinner receipt, it shows how scientists believe the Ebola virus first spread to humans through exposure to fruit bats or infected bushmeat and how it moves from person to person.
Martin gave it to the curious taxi-driver during her last visit hoping it would help inform the public; that maybe he would also tell his colleagues and friends and help dispel the myth that it was a curse from the gods, inevitable and unstoppable. She hoped it might change a mind, or prompt someone to get vaccinated, or to respect the hospital staff’s need for full-body protective gear during invasive procedures.
Martin hopes that maybe, in some small way, that chance encounter and tiny diagram will help to amplify the message.
That it will be enough.
