Ebola guidelines are comprehensive – or are they?

March 18th, 2015

With all the Ebola information dominating the news, particularly healthcare news, you would think every aspect of the virus had been covered. Personal protective equipment? Check. Environmental cleaning? Check. Surgery? Oops.

As guidelines and information started flying across the World Wide Web, surgery was noticeably omitted. No one seemed to be thinking about the fact that some patients with Ebola might also end up needing surgery. It’s happened in West Africa. A 16-year-old was shot during the quarantine in Liberia and then bled to death because no one stepped forward to help, according to two doctors who wrote an opinion piece in the San Jose Mercury-News. His wounds could have healed with surgery, the doctors wrote.

Coming to the rescue in terms of preparing U.S. providers is the American College of Surgeons and the Association of periOperative Registered Nurses. http://www.aornjournal.org The authors of the opinion piece mentioned above adapted CDC recs for the OR environment. (To access “Surgical Protocol for Possible or Confirmed Ebola Cases,” click here.) Sherry M. Wren, MD, is a professor of surgery and director of the Global Surgery at the Center for Global Health and Innovation at Stanford University's School of Medicine. Adam Kushner, MD, MPH, FACS, is a general surgeon and associate at the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, and founder of Surgeons OverSeas. Between the two of them, they have more than 30 combined years working in developing countries.

They reported that, at least in Sierra Leone, providers continue to offer emergency surgery. “We shudder at the personal sacrifice and bravery of these unsung heroes,” they wrote. In these countries, providers often don’t have even the most basic personal protective equipment, such as appropriate eye protection. On top of that issue, patients who have Ebola symptoms must first go to the evaluation and isolation wards, and surgery is delayed. Many die, they wrote. They point to the “overwhelming” moral dilemma: “How does one operate on a patient infected with Ebola, yet at the same time protect the surgical staff?”

The doctors issue a call for more training, protocols, and personal protective equipment. “Just as surgery is a necessary part of a functioning health system, surgery must be part of the discussion during this time of Ebola; otherwise, the death toll will not only include those unfortunate to have died from the virus but also those unlucky to have developed a treatable surgical condition in this time of Ebola,” they wrote.

They compare the surgical Ebola issues with those of AIDS patients in the mid-1980s, when the disease often was fatal. Many surgeons and OR staff members wouldn’t treat the patients out of fear of contracting the disease. Over the years, the stigma against those patients lifted.

The doctors say that after writing the Ebola surgery protocol, it was adopted by 10 African countries. “A whirlwind response to an unanticipated need,” they wrote. Interesting choice of words, considering that’s what type of response is needed from healthcare providers around the world to stop the burgeoning Ebola threat in West Africa. However, with the growing fear and quarantines of U.S. providers returning from treating patients there, that response doesn’t seem highly likely. (For more on the Ebola crisis, see our blog, “CDC addresses Ebola concerns; infected nurse in isolation.” Follow Ebola breaking news on our publisher’s HICprevent blog and on Twitter @HICPrevention. For more information on Ebola and surgery, see the upcoming story in the December issue of Same-Day Surgery.)