Tuesday, October 28, 2014

Kids, Don't Try This At Home!

{h/t to Doc Grouch for the source material for this one.}

NEJM has just published a clinical case study of the course of treatment provided to a man sent to Germany with fulminant Ebola virus infection.

1) It's exhaustive, and fascinating.
2) If you're any medical clinician interested, or likely to see/treat Ebola in any context, go there now and read it.
3) If you're non-medical but a quick study, it's still worthwhile.
4) If you're not either, it will be worse than trying to follow Chinese opera.

I have gotten, and still see on the Internet (I see those links to my site, and I visit them from time to time, so I see you people out there!) folks who still cling to the doomed fantasy that they're going to stock up on supplies, and care for family/friends/fellow tribesmen, out of love, humanity, or simply pigheaded ignorance of the futility of the gesture. Allow me to lovingly smash that foolish dumbshittery to bitsy pieces with my 18# surgical steel sledgehammer of reality, just one more time. Remember, I yell because I care.

So with apologies to any clinicians who will quibble or object to the following summation, in hopes of making this clear to people, I present another foray into explaining in laymen's terms that even someone perplexed by the plotlines of Dumb And Dumber and Dude, Where's My Car? will be able to grasp. What follows is entirely my summary. If you want the actual case, RTWT from NEJM. (And thank them for posting it all where anyone can get it. This is what the Internet should be for, not just pR0n and kitten videos.)

The patient was a 36 y.o. male epidemiologist who became infected in Sierra Leone, probably by a colleague with whom he shared an office and bathroom. Said colleague contracted Ebola and died.
Patient was treated for malaria at first, by quickly became symptomatic of and tested positive for Ebola. On Day Ten after initial symptoms, he was transferred to Germany for intensive treatment.
Day 1: malaise, headache, bodyaches
Day 2: Fever of 101.2 F
Day 6: Positive Ebola blood test
Day 7: abdominal pain, nausea, vomiting, diarrhea
Day 8: Beginning of IV fluids and single-dose antibiotics
Day 10: Transfer to German hospital ICU isolation ward in Hamburg
Blood tests: suggestive of massive dehydration, lab values totally fucked up (that's a clinical term)
Ultrasound of inferior vena cava (the route blood from the body takes to get back to the heart) showed that it was flat. In other words, circulation was upgefuchten (German clinical term).
Patient shitting out more than 2 gallons of diarrhea per day for 3 days straight, and digestive tract blocked. Given 10 liters of IV fluid/daily, plus potassium supplements
Ebola blood concentration begins to decrease
Day 11: feeding tube placed
Day 13: vomiting stopped; Fever and general secondary infection noted, more antibiotics started
Day 15: central venous line placed; diarrhea decreased to less than 1 quart/day
Day 17: Ebola absent from blood concentration
Day 18: altered mental status and respiratory failure; placed on external ventilation
Day 20-25: hallucinations and delirium
Day 26: respiratory and mental recovery
Day 30: Ebola no longer detected in urine
Day 40: Ebola no longer detectable in sweat
Day 60: Patient discharged to return home to Senegal.

Truly, read the whole thing. This guy nearly died at least twice and perhaps three times; once when the Ebola nearly killed him, and again when the complications of Ebola caused bacteria from his digestive tract to leak out of it and into his body, causing a massive infection, and finally when the monstrous amount of fluid to stave off the Ebola, plus aspiration of blood caused lung and breathing problems, almost drowning him in his own fluids, and caused his brain to swell to the point of impinging on normal respiratory function.

By any standard, that medical team are rock stars.


1) The study was co-authored by 12 board-certified critical care specialist MDs, all of whom were directly involved in treating this one patient.
2) The patient was in the ICU, certainly what we call a 1:1, and probably more like a 4:1, i.e. at least one, and probably four nurses (two for care, and two to make sure the first two were sterile and safe) for his course of care, for at least 26-30 days of his care, if not the entire time.
3) 10 liters of saline/day times 10-18 days: $5/bag, 180 bags minimum=$900, and it's all Rx.
(BTW, there's been a national IV Saline shortage for months, to the point that hospitals are having trouble getting enough, just FYI)
4) New IV tubing every 3 days, probably two sets, $3@, figure another $100, all Rx.
5) The associated supplies to start the IV, another $300
6) rare and exotic antibiotics, including the big guns for the drug-resistant infection he developed from what leaked out of his guts and into his body because of the Ebola
Probably $5-10K worth, if you could get them
7) the full-body positive pressure hazmat suits and HEPA powered respirators that prevented one single reverse infection during the patient's treatment - $2K@
8) the x-ray, ultrasound, and CT scanners, roughly $1M worth, and all the techs to run them
9) the 24 hour lab, equipment, and specific tests to detect his various infections and run his blood tests
10) the sterile BL4 facility to house and care for the patient.

If you have a spare $10M to build that, and another $3+M/yr payroll to keep 15 doctors, including a pharmacist, radiologist, and pathologist, plus 24 ICU nurses to cover those shifts 24/7/365, and keep them all standing by for your family/friend/whatever, and all the ancillary staff as well, ROWYBS.

Of course, for a lot less, you could have bought and fully stocked one of those old missile silos or obsolete commo bunkers, and skipped the problem entirely, being instead watching your collection of every DVD movie known to man, playing ping pong, and eating steak and lobster off the BBQ 7 days a week for the next ten years, right now.

But if you have that kind of money, you could open a for-profit hospital now, and fund  making movies, and be raking in money hand over fist 24/7/forever, in which case you're likely too busy to read this blog.

You're sure as hell not going to pull it off clipping coupons and holding down any middle class job (or twenty) anywhere in North America.

And as for "But I've GOT to try!" let me help you with that:
"But I've GOT to DIE!" There, fixed if for ya.
And you're going to not only get sick, but give it to your whole family and anyone else nearby. Do them and yourself a favor: kill yourself now, and save Ebola the trouble.
Or at least, stop thinking there's anything you can do that isn't going to be throwing gasoline on the fire.

There's one correct answer where Ebola and similar pathogens are concerned:
Don't Catch Them.
Don't Let Those You Care About Catch Them.

*(And nota bene that Our Victim in this was infected by a trained ace medical colleague, who worked - until he collapsed - while infected until a mere four days before he died of Ebola, certainly coming to work with a raging Ebola virus infection for days beforehand, and spreading it to this poor guy and an unknown number of other medical colleagues.
That is why smart medical people will GTFO when Case One comes to their hospital, in most cases, and nearly everywhere. This is not something anyone without massive clinical support and brilliant co-workers and supervisors should ever play with.
Do you work in health care? If so, how bright are your colleagues and management?)


  1. Reposted from below;

    Per FNC; http://www.foxnews.com/politics/2014/10/28/lawmaker-claims-plans-may-be-in-pipeline-to-bring-non-citizens-to-us-for-ebola/

    "Lawmaker claims plans may be in pipeline to bring non-citizens to US for Ebola treatment"

    I am at a loss as to what possible reason there could be for doing this. We cannot stop this disease by transporting individuals from Africa to here. At best we would be able to treat some limited number of people, greatly increasing the risk to ourselves. This would also further incentivize those people in impacted countries who are able to get here on their own seeking treatment.

    Obviously I would like to see as many people as possible get treatment, but protection and security of our people has to take priority for us! This makes no sense whatsoever!

    One has to assume that the only possible motive for this decision is that bringing this disease to our shores is in reality the end goal.

    Which is beyond troubling. Indeed I cannot imagine the depths of the evil and irresponsibility required to plot such a course of action. But what other conclusion can possibly be drawn?

    And big government is firmly in control of this bus, and hitting the gas to go deeper and deeper. We are in deep doo doo.

  2. The list of what kills grows, Stupidity, incompetence, unprofessional behavior and over confidence.
    Ebola, hell it's just the trigger.

  3. So how the hell do we have a shortage of sterile salt water in this country? I can't imagine it's that hard to make, so my only other conclusion is that some government policy has restricted the supply. Am I right?

  4. Not really.
    There are two primary manufacturers.
    One had production issues, and the other had manufacturing contamination issues, and the last flu season drove demand through the roof.

    Nobody else makes it, because there's basically no profit.

    Perfect storm.