Sunday, November 30, 2014

Ebola Care: Pulling the Plug



From comments on one of yesterday's threads:
Question

Has anyone performed a study or reviewed the Ebola cases to determine if heroic measures like dialysis and ventilators are effective in curing people?

If dialysis and ventilators are not effective, wouldn't it be better to let the poor suffering victim die sooner? I do not want my life extended if I am suffering and in pain, if I am likely to die anyway. I would not want someone to catch Ebola, trying to fruitlessly prolong my life. At a certain point, maybe an OD of morphine would be a pleasant release.

Great question.
Short answer: No, no one's done that study.

Bear in mind that prior to last December, when this outbreak began, the total number of Ebola cases worldwide, ever, was something like 2400-ish. Given where they were infected and treated, neither dialysis nor mechanical ventilation was an available treatment option, AFAIK.

The entire US experience to date is limited to the ten or so cases we've seen here, and only two have died despite all efforts, whereas the rest survived with far lesser interventions.

Thus, in that extremely limited dataset, the key seems to be catching the infection early (or not), along with actually giving care .Which, in case it isn't clear, is not what happens at the plastic ETUs in Africa - no IVs, no fluids thereby, no other major treatment. They don't have the supplies, the staff to do it, nor the wish to attempt it on such a large scale, not least of which would include the risk of trying to jab a vein on someone delirious, vomiting, and febrile while the caregiver starting the IV is wearing a hazmat spacesuit. One miss/needlestick, and both patient and caregiver die. Not to mention that their cases typically present far later in the course of infection in the first place, coupled with the lag - up to days - waiting for confirmatory lab work to make the diagnosis. Thus most of their cases are in the too late to save category before they even get them, some of them only diagnosed at all because they totally collapsed on the street before they were brought to hospital in the first place.

Almost all of ours, just the opposite.

So no one here is going to base entire treatment protocols or prognosis off of our entire two applicable cases, especially when we're talking about terminating or limiting response efforts.

That day may come, but only if/when there's a lot more empirical data (God spare us that knowledge!) at which point I suspect the determining factors will be too many cases and not enough hospital space, care staff, medical equipment, or all three.

As long as we're seeing single cases, and there's a chance of saving someone, we're going to try it if we can, absent advanced patient directives.

If we get to the point where we have so many cases as to make a study possible, we'll have much bigger fish to fry. Which, frankly, is good, because the last thing anyone wants to have to do is play God with other people's lives if they don't have to.

The burden on individuals is far too high at that point. It's tough enough unless people come in already dead with CPR in progress. Those of us "in the biz" have all seen 97-year-old grandpa come in with 12 co-morbid conditions including metastatic cancer, in full arrest, and a "full code" either expressly requested, or left by default from lack of prior thought. Even then, we make an effort. (If the family or patient had made sensible decisions beforehand, those patients wouldn't have been dragged to the emergency department in the first place.
PSA: If you or yours are anywhere in life where you ought to think about this, discuss it, and put some advanced directives in place, please, for everyone's sake, do it now, and pass around copies to all next of kin so literally everyone is on the same page regarding how you want things to go when your time comes. 5000 ER and ICU staffs thank you.)

Change that patient to a 40-year-old husband or wife with kids at home, and cutting off efforts will be immensely hard, unless you already have 50 other cases. And even then, you aren't going to be the Morphine OD Fairy dispensing terminal doses. You'll be too busy with the ones you can save, and let Death collect his own. He does just fine wrangling patients without any help from any of us.

So I understand where the question is coming from, but either way, it isn't going to happen like that. And anyone in healthcare who wants things to get there, for this outbreak or any other reason, is a ghoul, IMHO.

Killing people used to be my job. But since leaving the military and getting into health care, the institutional priorities are a bit different, as I'm sure you can understand.

11 comments:

geoffb said...

These are just my thoughts but I'm no expert.

The viral load in the initial infection, exactly where it enters the body, and the general health of the person infected seem to be major factors in how fast the disease progresses.

I agree with this from a piece in the Boston Globe but then again this is the case for all infections.

“At some very basic level, whether you live or die is essentially whether your immune system is able to catch up with the virus and overcome it,” said Dr. Adam C. Levine, who worked in Liberia with the International Medical Corps and is now developing training materials for the organization. “It’s kind of a race between your immune system and the virus.”

Most all of our treatments for Ebola are to help the immune system to overcome the virus. The one exception would be the antibiotics which are administered to fight the septic infections which come from leakage of intestinal bacteria into the body cavities due to the effects of the virus on the cells of the intestinal wall.

The one most extensive study of an Ebola patient that I'm aware of is the one written up in NEJM about a patient, a WHO epidemiologist that contracted Ebola in Sierra Leone and on the tenth day after symptoms first showed was admitted to a level 4 treatment facility in Hamburg Germany. Another patient who was later treated at the Frankfurt Germany facility would seem to have had a similar treatment regimen but did not respond as well and then received a new treatment by a filtration device, used in a dialysis machine, which can extract and immobilize the virus particles from the blood allowing the immune system to recover and get ahead of the virus.

The things most needed from the technology standpoint, to me, would be an effective and inexpensive vaccine and a test that is accurate early on, easy to do, and gives results quickly. Sooner treatment is cheaper and more effective than later but can only be done if the disease is diagnosed early. Later requires more extensive, and expensive, treatments, though they can be very effective even then though expensive in money, equipment, and number of trained people per patient.

Tucanae Services said...

Care to comment on this -- http://www.washingtonpost.com/national/health-science/us-hospitals-wary-of-caring-for-ebola-patients-because-of-cost-and-stigma/2014/11/28/928aa2bc-71cc-11e4-893f-86bd390a3340_story.html

I am just surprised that it is not their insurance companies preventing this.

gamegetter II said...

It seems that in order for treatment in W. Africa to be effective,those infected would need to seek care sooner,and those providing the care need much,much better facilities in which to provide that care.
The U.S. patients all had aggressive IV fluids,and either experimental drugs or blood from an ebola survivor to help them beat the virus.

From what I can see,the only way those who get infected in W. Africa have a chance is if better facilities are built,and they can get IV fluids,blood from Ebola survivors,and maybe the experimental drugs.
otherwise,they will contiue to die at the same rate-or worse.

Anonymous said...

Since you're answering a question - How 'bout another?

I have been curious about something. Let's say you contract Ebola, get all the way into the latter stages - lots of bleeding, etc - but receive heroic treatment and recover. What kind of long term issues are you dealing with? I'm picturing extensive organ damage and such.

geoffb said...

That indeed would be good to know. The most that seems to be said is like this: "The patient ultimately recovered, with all laboratory values, including liver-enzyme levels, within the normal range, and he was able to return to his family in Senegal without assistance."

Aesop said...

@Tucanae

I covered that entire article yesterday:
http://raconteurreport.blogspot.com/2014/11/why-no-one-wants-to-play-with-ebola-kids.html

So far, there have been too few cases for this to be an issue.
(Not to mention Duncan was uninsured, and his care tab got picked up by the citizens of TX, whether they wanted to pay or not.)

But in a bigger outbreak, insurance companies will probably try to pull something. The question is whether they can elect not to cover Ebola.

IANAL, but it would be tough to pencil it out.

What they'll likely do instead is cap the care, and when you hit your limit, your card is maxxed out, and you're done. At that point hospitals will probably eat the cost, and take what they get, just like in every other case, and pass the costs on to everyone. That's how you get a bill for an $80 Tylenol.

They already do this on the front end by making the patient liable for the first 10/15/20%.
But when you're sick with a life-threatening disease, you aren't going to care about the bill you might owe if you survive.

Aesop said...

@Anon 2:34

Your body recovers.
Bear in mind that you recycle yourself every month, internally.
The machine rebuilds itself, and if lab values are normal, function is restored.

I don't think there have been enough long-term survivors to follow for 10/20/30 years down the road.

Again, this is a <40 y.o. disease, most of the infectees of which live on a continent where the median life expectancy is in the mid-50s.

So it's yet another gaping hole in the universe of things regarding Ebola about which medical science doesn't know a helluva lot.

Ex-Dissident said...

Aesop, you gave a well thought out answer in your post and essentially I agree with almost all of your talking points, but I am going to disagree with your answer. The question was whether dialysis and ventilation make much of a difference in the outcome for someone infected with Ebola. My answer is simple - yes. If you need dialysis and intubation and you don't receive such support, you die. If you live, it is only because you have received such care while your body took the extra time to fight off the infection with Ebola. This is what occurred in the case of the patient treated in Germany, who eventually was able to leave the hospital.

The other part of the question that inspired your post is something everyone must decide individually - Should I go through all this, if I don't stand much of a chance? This is where I am in complete agreement with your post, in that we don't have the studies to say how much more likely is someone to survive if they are that far gone and receive such advanced life support measures. Obviously in some it has made the difference, and how long a shot it is no one knows. However, everyone has a different answer for what sort of odds they are willing to gamble with.

Finally like you said in your post, if we ever get to the point of having enough people infected to perform such a study, we will be in a different and far worse situation. By then, that choice may no longer be up to the sick individual. At that point, the country will need to decide whether we abandon everyone else in the hospital and care for those infected with Ebola, or whether we don't spend the money we don't have on providing these patients with advanced life support.

Aesop said...

Actually, I didn't address whether or not intubation or dialysis per se are effective and therefore rational care, because of the utter dearth of examples either way making any conclusion unsupportable.

That being the case, I'd err on the patient's side in every case.

Were I either the patient or the caregiver, and providing either or both was both an available option, and medically indicated, I'd do it, and/or want them done for me.

As clinicians, we know that the only time the ethical rules change is when we're confronted by vastly more patients than we can deal with, like the first paramedic on scene at a train or airplane crash.

Stopping to "do everything" with the first critical patient we find may result in them dying anyway, but tying ourselves up in futile care may cost 20 other salvageable people their lives too.

No one wants to be that guy in that situation (I sure don't), so until the water gets up to our necks, there shouldn't be any reason to jump to that protocol early.

Ex-Dissident said...

Then, I am in complete agreement with you.

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