Sunday, November 30, 2014

Ebola Care: Puilling The Plug

From comments on one of yesterday's threads:

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.


  1. It's more likely there are 70,000 dead. Somewhere in that order of magnitude, at least.

    I trust math more than statistics, because statistics is people. People!

    Wherever a career is at risk, wherever there is a lazy schlub, or an idiot, or - apparently it needs to be said - wherever they believe in witchcraft, trust them and their statistics like you would trust a chocolate-smeared four-year-old to tell you what happened to the brownies, because that's the mental and moral level of the Great and Good, the Best and Brightest, and the Big Men.

    Common sense is an uncommon virtue.


    1. Should have been on the earlier post - sorry.


    2. I'm thinking in excess of 70,000 dead, after whole families and entire villiages have disappeared, the wild life has it's way with unburied corpses and the sad lack of accurate counting of corpses picked up and buried there is no way to get accurate numbers.
      Much as the BDA body counts of Vietnam were inflated or deflated by politics and the condition of the dead this is the way it's going in the hot zone.
      Counting heads and hips is the only way to be sure, somewhat degraded bodies and danger from them makes digging around through arms and legs a lethal chore.

  2. For the US to do a study is like doing a study of coin toss results after two coins have been tossed, for Africa it's like studying a bag of coins spilled and deciding.
    When the time comes The great spirit forbids, there will be no inclination or time to do a study merely carrying the dying into a safe room to expire.
    People put off end of life decisions because they don't want to think of it and because they don't trust doctors or family to get too dump me in the grave syndrome.