Ebola Care: Puilling 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.

And The "Official" Numbers Are STILL Bull$#!^

(Guardian UK) - The number of people with Ebola in west Africa has risen above 16,000, with the death toll from the outbreak reaching almost 7,000, the WHO says.
The number of deaths is more than 1,000 higher than the figure issued by the WHO just two days ago, but it is thought to include deaths that have gone unreported in the weeks or months since the outbreak began. Most of the new deaths were recorded in Liberia.
The WHO has warned that its figures could be a significant underestimation of the number of infections and deaths. Data from the outbreak has been patchy and the totals often rise considerably when backlogs of information are cleared. The latest confirmed data shows that almost half those known to have been infected with Ebola have died.

...And most of the other half only just got Ebola in the last three weeks, as always.

What the hell, it's only 1000 dead people (1165, actually) Liberia "forgot to" get around to reporting, which explains why the infections numbers continued to skyrocket while the death rate went backwards at one point recently. So apparently rumors of non-lethal Ebola didn't pan out.
And those are just the ones they actually tested for Ebola at some point before they were buried or set on fire.

Just remember every time you see these reports, that they're tabulated by governments in countries with literacy/numeracy rates of 50% give or take. All WHO does is collect them.
Doubtless witchcraft played some part.

(h/t to commentor geoffb for the direct link)

Why No One Wants To Play With The Ebola Kids

Apparently the Washington Post was able to sneak out an Ebola story when Ebola Czar Klain was busy in the men's room:

(WaPo) - U.S. officials trying to set up a network of hospitals in this country to care for Ebola patients are running into reluctance from facilities worried about steep costs, unwanted attention and the possibility of scaring away other patients.
“They’re saying, ‘Look, we might be willing to do this, but we don’t want to be called an Ebola hospital. We don’t want people to be cancelling appointments left and right,’ ” said Michael Bell, director of laboratory safety at the Centers for Disease Control and Prevention. 

The handful of U.S. hospitals that have treated Ebola patients have discovered that doing so can be costly, requiring around-the-clock care involving scores of nurses and other health workers. That would be a big challenge for many hospitals, where staffing is often stretched thin.
 

TL;DR Highlights:
* No one with any sense wants to play with Ebola

* Remember that when you hear about a hospital that does.

* Since Thomas Duncan's diagnosis, the CDC has barely managed to visit 1 hospital per day to evaluate as potential Ebola treatment destinations. (We won't ask WTF they were doing for the last 40 years since Ebola was discovered.)

* "Airport screening" is touted as having prevented outbreaks so far; in reality, they haven't successfully screened out anyone here, as evidenced by all the US Ebola cases to date.

* THP-Dallas was gutted by the consequences of treating Duncan.

* The cost to each dedicated facility, like Emory and U NE, for treating a single Ebola patient, is between $600K-$900K PER PATIENT.

* TWO MONTHS INTO THIS, most hospitals STILL have no idea how to deal with the basics, like training employees, segregating potentially infected persons, or how to deal with the mountains of medical HAZMAT waste generated by even a single patient.

* At this point, hospitals and private insurers (if there are any) will have to eat the costs of treating an Ebola patient, and any opportunity costs of closing departments or the entire facility. There is ZERO financial incentive to do that, and most hospitals nationwide struggle to break even or stay in-budget year to year - particularly the teaching facilities that the CDC would like to use for this, who tend to serve the poorest strata of patients, on city and county budgets already being raped by the long-term recession and staggering unemployment.

Mali Ebola Free - For The Moment

Nov 29 (Reuters) - Mali has no more confirmed cases of Ebola after the last patient known to be suffering from the virus was cured, President Ibrahim Boubacar Keita said on Saturday.Mali has registered eight cases of Ebola - seven of them confirmed and one probable - after the virus spread from neighbouring Guinea, the World Health Organization (WHO) said this week.
Six of these people infected have died, the WHO said. A further 285 people who came into contact with them are being monitored but have shown no sign of the disease.
"At this moment, there are no cases of infection (in Mali)," Keita told a summit of francophone nations in Senegal.
"The suspected case turned out to be negative and the day before yesterday we had the good news of the first cured case of Ebola so I can now say zero cases in Mali," he said.

...except for those 285 people still under surveillance for the next week or two.

And the next infected carrier from across the border who plops a case there.

Graveyards Filling, Hospital Stays Empty

(UK Telegraph) - The British government’s flagship hospital in Sierra Leone is caring for only eleven Ebola victims, it has emerged.

The Department for International Development has put £230million towards helping Sierra Leone fight Ebola, but only 28 people have been treated in the new facility since it opened several weeks ago.

Another hospital a few miles away is having to turn Ebola victims away from its doors, meaning that they return to their homes and risk further infection in the community.

The British response to the Ebola crisis is facing serious criticism locally for its management, and has been called a “complete mess”, by aid workers in Sierra Leone.

Questions have been raised about DFID's decision to hand the management of the new facility in Kerry Town, near the capital of Freetown, to the charity Save the Children.

Sir Edward Garnier, a Conservative MP, said he was concerned about how few Ebola victims were being seen by the medics at Kerry Town.
"What strikes me is that this is not a good use of public money and it is not achieving its aims," he said. "The Connaught hospital in Freetown is overflowing and turning people away, back into the community, although they are infected with Ebola. This hospital has 92 beds, and they are almost all empty. It seems to be going very slowly."
DFID and Save The Children insisted that the plan had always been to scale up the new facility over time, despite the urgent demands by the World Health Organisation that there was an immediate response to the Ebola crisis.
 The Kerry Town complex includes an 80 bed treatment centre and a 12 bed centre staffed by British Army medics specifically for health care workers and international staff responding to the Ebola crisis. However, dozens of beds are lying empty. 
The construction of the treatment facility was overseen by British Army Royal Engineers.
The site also hosts an Ebola testing laboratory run by British scientists to accurately diagnose patients.
The £230 million Ebola response package from Britain includes funding for supplies such as chlorine and protective clothing, burial teams to increase capacity and work with communities on new burial practices. The roll out of community care centres is also planned.
"Britain is today providing 211 Ebola beds in facilities that the UK has built, expanded or kept open - including 23 beds rolled out so far at Kerry Town - and 232 beds and places in community care centres where Ebola sufferers are going for initial care and diagnosis,” said a DFID spokesman.
"Save The Children, a major global NGO which includes the international health charity Merlin, was available and keen to take on the management of Kerry Town at a time when other NGOs were stretched and unable to do so."
A spokesman for Save The Children said:  In answer to questions about patients, I can confirm that as of this morning, 28 people have been treated for Ebola at the [centre]. This is a cumulative figure of those treated since opening."

I got nothing. There's no attempt to explain this, or make any sense of it, because it's simply insane.
But with 100 cases a day popping up in Sierra Leone, this should keep those burial teams busy well into the new year.