Looking forward – April 2017

David B. Hoyt

David B. Hoyt, MD, FACS

As I was drafting this column, news of the death of Salome Karwah, a Liberian nurse who was a 2014 Time Person of the Year, was topping the headlines. Ms. Karwah lost her parents to Ebola, survived the disease herself, and went on to provide care to many patients who had fallen victim to the West African epidemic. Ms. Karwah reportedly died as a result of complications from childbirth, and the lingering suspicions of some Liberians toward Ebola survivors reportedly were partly to blame. What happened to this heroic health care professional in February 2017 is the most recent example of the lasting effects of this epidemic.

At the height of the outbreak, which was first recognized in March 2014, and in response to growing reports that health care professionals were becoming ill and dying from the disease, two Fellows of the American College of Surgeons (ACS)—Sherry M. Wren, MD, FACS, FCS(ECSA), and Adam L. Kushner, MD, MPH, FACS—sought to turn the situation around and avert tragedies like this one. Their story and the recollections of other health care professionals who were on the front lines during the Ebola crisis are told in a new book, Operation Ebola: Surgical Care during the West African Outbreak.

Responding to a crisis

Operation EbolaA major side effect of the Ebola epidemic was that it reduced access to already limited surgical and medical services. As Ebola spread from Guinea to Liberia and Sierra Leone in 2014, health care facilities in the region closed, and some physicians, concerned for their safety and the well-being of their families, left or stopped operating. A number of those who stayed contracted the disease and died. As a result, many patients with ordinarily treatable conditions went without proper care.

Health care workers who did remain often insisted that all patients be tested for Ebola, regardless of whether they were showing symptoms. Waiting for the results of these tests created unnecessary delays in the delivery of surgical services, which inevitably led to the loss of more lives.

All of these problems were aggravated by the lack of material and financial resources in the affected countries. The White House and U.S. Department of State tried to intervene by establishing international priorities, including containing the outbreak through isolation of patients, mitigating economic instability by working with the International Monetary Fund, and coordinating efforts with other nations and nongovernmental organizations.

An International Command Center was established in Monrovia, Liberia. In the U.S., the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services, and the Department of Defense sought to address epidemiology, infection and disease control, emergency medical services and hospital readiness, and treatment guidelines for personal protection.

Guidelines for protective surgical attire

Around this same time, Drs. Wren and Kushner began taking action. Their work centered largely on collaborating with health care professionals in West Africa to create guidelines for personal protective equipment (PPE) for health care workers.

Typical African operating room (OR) attire is cotton scrubs covered with a plastic butcher’s apron to prevent blood from soaking through to the chest and abdomen. Topping this gear is a cotton gown that blood can easily penetrate. Recognizing the insufficient protection this attire provided and the impact it was having on the delivery of surgical care in the affected countries, Dr. Wren, a past-member of the ACS Board of Governors Executive Committee, and Dr. Kushner, founder and director of Surgeons OverSeas, searched the medical literature as well as the World Health Organization (WHO) and the CDC websites for PPE guidelines.

After scores of e-mail exchanges with colleagues at their U.S. institutions—the Center for Global Health and Innovation, Stanford University, CA, and the department of international health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, respectively—Dr. Wren and Dr. Kushner eventually learned that the Association for the Advancement of Medical Instrumentation had gown and drape standards for virus and blood imperviousness. Using these documents, guidelines on OR instruments and sharps management, and protocols for operating on patients with known blood-borne diseases, Drs. Wren and Kushner drafted recommendations and sent them to the ACS leadership for review and dissemination.

The guidelines, posted on the ACS website, contain recommendations on patient selection, PPE, conduct of a surgical procedure, the OR checklist, and specimen handling. These standards were readily and enthusiastically adopted by the College of Surgeons of East, Central, and South Africa—a 12-country consortium.

Timeless lessons learned

On January 14, 2016, the World Health Organization declared the end of the West African Ebola outbreak. In all, the virus caused more than 11,300 deaths, including the deaths of more than 500 health care professionals. The nearly two-year plague taught us all some valuable lessons about how to handle the next epidemic—lessons that are both universal and timeless.

The fact of the matter is that humankind has witnessed countless contagions throughout history, and undoubtedly will experience more in the future. Although the protocol that the ACS issued with the leadership of Dr. Wren and Dr. Kushner was created specifically in response to the Ebola epidemic in West Africa, it can be applied to protect surgical team members the next time a virus ravages a region of the world.

We also learned a good bit about working with nongovernment agencies such as Surgeons OverSeas and Partners in Health to ensure that adequate financial, material, and human resources are available. The College is committed to working with these and other organizations through Operation Giving Back to stimulate international outreach to help nations facing health care crises.

Finally, the contributing authors to Operation Ebola teach us much about courage and the true meaning of humanitarianism. These exemplars of professionalism put themselves at great personal risk to provide care to patients in need. They inspire us to recommit to giving back to our fellow man and to averting the tragic deaths that Ms. Karwah and so many other West African patients and providers experienced.

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