Learn about the evolving Ebola epidemic and its various aspects including disease prevention, management and treatment, response to the epidemic, ethical considerations, and the post-Ebola global health landscape.
Nursing Perspectives on Treating Patients with Ebola
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En provenance du cours de Emory University
Ebola Virus Disease: An Evolving Epidemic
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À partir de la leçon
Patient Care of Persons with Ebola Virus Disease
Upon completion of this module, learners will be able to: Identify the clinical features of Ebola Virus Disease (EVD). Discuss risk assessment as it relates to the selection of personal protective equipment (PPE). Explain the differences between donning and doffing. Recognize the lessons learned from providing care to Ebola patients in the United States.
Rencontrer les enseignants
Dabney P. Evans, PhD, MPHAssistant Professor
Hubert Department of Global Health. Rollins School of Public Health. Director, Center for Humanitarian Emergencies.
Carlos del Rio, MDChair
Department of Global Health at the Rollins School of Public Health
Welcome to today's discussion on nursing perspectives on treating patients
with Ebola.
The Serious Communicable Disease Unit at Emory University Hospital consists of
a specially trained team of infectious disease doctors, lab personnel, and
ancillary support staff from departments such as Environmental Services and
Distribution.
And of course part of this team consists of specialty trained nurses and
some are here with me today.
My name is Sonia Bell, I'm the program coordinator for
the serious communicable disease unit at Emory University Hospital and
directly to my left, I'll start with Josia.
>> I'm Josia Mamora, I'm a surgical ICU nurse here at Emory University Hospital.
I used to do ER back in Southern California and
I'm a participant, I'm, I'm a participating member
in the serious communicable diseases unit here with these two other nurses.
>> I'm Bryce Barnes, I'm one of the nurses for
the serious communicable disease unit, I also work on the cardiovascular ICU, and
has been a great pleasure to work with all of these nurses.
>> My name is Sharon Vanairsdale and
I am the clinical nurse specialist in the emergency department in the serious
communicable disease unit.
>> All right, so our first question will be,
why did you want to be part of Team Ebola and why did you volunteer?
Bryce?
>> Thank you, so the reason I wanted to be part of Team Ebola,
after I saw the devastating effects that it had in West Africa and
I saw that it could be coming to the USA.
I saw it as a more global epidemic and I saw that it would be a chance for
me to work with some great health care workers and work in collab,
collaboration with them and for us to work to trying to cure Ebola.
And improving health care as a whole.
>> I absolutely agree.
It was, it seemed like an amazing opportunity and
experience to work on something that we have never worked on before in the country
so when I was asked I accepted.
I don't regret a single moment of it.
>> I was asked as well and
after the big heart to heart talk with my wife over the phone.
We both decided that it was a big, career opportunity, but
not only a career opportunity, but, a lifetime opportunity, to be able to treat,
such a virulent disease, and, you know, in the most controlled setting possible.
>> And our second question that I'd like to ask Sharon is how did you train and
how did everyone train to become a part of Team Ebola.
>> So training was taken very seriously and we had
competencies that we had to demonstrate before we were allowed in the unit.
Our first day of training was about a 10 hour day of very precise methods,
almost drill sergeant-like methods on how we put on and removed our PPE.
We also talked about waste management, what we would do with, with the waste.
How we would keep the area clean, how we would disinfect.
How we would practice the clinical care of our patients.
How we were going to do an EKG, how we were going to use a ventilator.
So we had an initial group that we started with, and
then soon realized that we were going to be getting another patient.
And brought on more team members and went through very similar training.
>> I like the fact that even though we did this large training up front,
we are still doing continuing competencies.
This is not something that we have just learned once.
We are constantly retraining or
retrained to make sure we are at our best performance.
And it's just a safety issue.
That's something that was very important to all of us as a team.
We wanted to make sure that we were able to perform in a precise and safe manner,
so that we could all be safe and
return home to our families and the people that we love and care about.
>> Yeah, training was definitely very tedious, but it needed to be very,
again, like Sharon said, very drill sergeant like.
Not everyone can follow or
be consistent in the process.
And it was very important especially to, not only our safety but
the safety of our family members as we, as we go home from our our patient care.
>> All right and then Josiah, so what was your biggest fear while caring for
a patient with Ebola?
Did you have any?
>> Definitely, I mean the biggest fear of course is to contract the disease itself
and not only that, but bring it home to my family, my wife.
Another big fear was if I didn't do my part in the protocol,
monitoring my partners in the unit, if I allowed them to get sick or
contract a disease, that'd be very heart-breaking.
>> Absolutely agree.
I mean, part of my role as the clinical nurse specialist was to help develop and,
and update our protocols.
And the last thing I wanted to do was to let any of, of the team members down.
So that was, one of my biggest fears was, you know, one of you guys would get sick,
and, and, having to care for you at that point.
>> Yeah, something that, that I've always been told is,
when it comes to fear, we have to have courage.
And courage is just not the absence of fear.
You know we all had our issues,
we all had our concerns about taking care of these patients.
But we found that there was something that we could be greater than,
than ourselves and to work together and
to accomplish this greater goal was something that we were really trying for.
And we put aside our own concerns and our own safety to accomplish something.
And to see our patients to be healed and to improve day by day was just so
rewarding for all of us, and, and, just as a healthcare team,
to see that we were able to accomplish the goals that we set out to do.
>> So our fourth question I will ask Bryce.
The PPE that you guys wear, it's very difficult to communicate to each other and
the patient,
so how were you able to show compassion to your patients while you are in that PPE?
>> I think one of the things as nurses that we really
pride ourselves on is our ability to, to show compassion in all situations.
And this is one of those extreme situations where we were really,
have to go above and beyond what we do as nurses.
And to have that barrier between us and the patient,
we had to be creative I guess, we had to, the way
we did it mostly is through having long talks was what I felt helped out the most.
They were able to share with us some of their stories, their situations,
their concerns, especially when they were serving other people in Africa.
And it gave us a chance to connect with them as health care workers.
So one of the things that we did, we would, we'd bring in puzzles for
them to do.
Or, one nurse even brought in a, a Nerf basketball set.
And we, we would have a little fun.
We'd play some Nerf basketball with 'em.
And, and, just have a good time, you know?
Sometimes we forget how important it is just to have fun with our patients, and,
even though it is such a, you know,
a debilitating disease, we were still able to, to show compassion when we needed to.
>> Yeah, and it's just, you know, being able to share that humanity, you know,
the, these people in West Africa, once they found out they were positive for
Ebola, they were pretty much isolated.
They weren't able to communicate to anyone on a regular basis.
They weren't able to touch anybody on a regular basis, so
one of the advantages with the PPE, despite having the PPE, to be able
to shake someone's hand for the first time in maybe several days or even a month.
It's, it was very profound.
>> Well I think there is compassion for the patient and there is also compassion
for the family, and I think that we gave the patient the ability to
communicate with their family and see their family in person, you know?
They weren't touching their family members and they weren't in the same room as
their family members, but they had the ability to visit.
And I think that, that also, allowed us to,
to be better nurses to allow the family to be there.
So, while in PPE and playing Nerf basketball, who would win?
>> [LAUGH] I think it end up being a draw.
I think I would one, he won one and then we,
I think, we end up calling it a tie on, on our third game.
So, we'll, we'll call it even.
[LAUGH] >> [LAUGH].
All right and so then Josiah,
how did you combat fatigue while caring for patients with Ebola?
>> Well one of the requirements to be able to take care of these patients
especially during our initial training period was to actually have physical.
The physical endurance to be able to take care of these patients.
So most of our group are fair, pretty fairly healthy but
also you would do things in preparation before you'd go in the room and
before you'd put on your PPE such as,
you'd get a bite to eat, to make sure that you use the lavatory.
[LAUGH] To make sure that you, and and make sure you get yourself a drink and
take care of the necessary bodily processes, so
that you can endure through the time required that you are in there.
>> Yeah, something, I work night shift a lot and so
it's a little bit of a different feeling at night time.
So, it's time for the patient to go to sleep, and I'm sitting there in the room.
We can be in there anywhere from four to six hours.
And sometimes you do get a little sleepy.
And something I found that helped to combat that sleepiness was
just get up and clean.
That was our number one thing that we had to do was to clean, and
make sure that the room stayed clean.
So if I ever felt sleepy, felt my head starting to nod.
I would just get up and start cleaning, mopping,
anything like that that would be beneficial to the keeping the room safe.
>> And one thing that we tried to do for the team members to help combat some of
that fatigue was to provide, you know, the water.
Having food available.
The little things just to keep you guys hydrated and, and
healthy while in the unit.
We also had chaplain support there, in case anybody needed to talk.
We also, we utilized the Faculty Staff Assistance Program.
Again, you know, being a PPE can, can make your fatigue worse so
it was really important that we, that we monitored that and
we, we addressed it as soon as we identified anything.
>> And we're pretty as a group, on time about everything about switching out and
relieving each other especially during shift changes we would come
a little early just to make sure that people weren't tired of,
of being in the anteroom and the patient's room and you know needing to get out.
>> So did you ever find it mentally too fatiguing?
>> For me, no.
I, I, I found the, intimate relationship with the patient, and
with patient's family, actually very.
>> Rewarding? >> Rewarding.
So.
>> And I think, with each other.
I mean, we had daily huddles, daily meetings with our team.
And I think that was a great opportunity for
us to discuss if there was any challenges, and what we were kind of feeling.
Even the debriefing immediately after coming out of the room I
think was important so
that we wouldn't have all that stress and everything weighing on our shoulders.
>> Yeah.
>> Okay, our sixth question I am going to ask Sharon what was the most
memorable moment for you while caring for patients with Ebola.
>> Sure, you know.
But when you hear Ebola, you, you hear about the, the death rates and, and
the care that they receive in, in West Africa.
And I think that was that was a huge fear of ours, that one of our patients would
passed away but I think one of the most memorable experiences for me was when
our first patient was discharged, and we had a small little ceremony for her, and.
It was just very quiet and she snuck out the back door, but that to me was,
was a conclusion that we could care for patients safely.
It was very rewarding, and even the relationship that we still have with,
with her and her family it's just it's, it's been very, very nice.
>> My greatest experience was or my most memorable moment was, when our second
patient, when he got the word that he had been declared Ebola free.
And he was just so ecstatic so happy, and he just wanted to hug people.
He just wanted to hug people.
And it was so nice to, to be able to be there with him and give him that big hug.
Is that human contact, you know sometimes you just want to,
it's just like the greatest, biggest bear hug you have ever given somebody.
It just, it just felt so real, it just felt so necessary at that point and
it was just nice to have that human contact with him again, you know?
Just because I know he had been missing it for so long.
Yeah with patient two as well I think of the moment where
he was able to get out of the special bed the suite,
the Ebola suite and into a regular patient room.
When he first met his wife.
That first kind of.
Contact between two people who have been so intimate, but at a distance.
>> Yeah.
Yeah, I think we all have memorable patient experiences, but
there's also experiences that we shared with the team.
And I think one of the most difficult times for
us was when we received our fourth patient who is.
A nurse, was a nurse in the United States and, contracted Ebola while caring for
her patient in the United States.
And that was very frightening to us and I just remember the team coming together and
we would have daily text messages,
probably about 60 a day, and we were comforting to each other.
And that was very special to me.
Just hearing.
You know, the, the comfort that we keep going, that we stay strong, that we keep
doing what we're doing, and we stay the course, then we'll be all right,
and that, that got me through those first couple of days, and I appreciate that.
That was very, very memorable experience for me.
>> Yeah.
Patient three was very sick, and, and I think what the.
Receive a patient in such a short amount of time, it didn't allow us to,
not that we were physically fatigued, but we didn't have time to, I think.
>> Debrief, yeah.
Right. >> Mentally debrief.
And it was a very hard situation, but again, it,
it goes to show you the quality of team members that we had here prior.
The, the, the quality of team members that we had, that you know we all kind of step,
stepped up to the plate and were there for each other.
>> Yeah, I agree.
>> All right, and our next question, I'm going to go ahead and ask Bryce.
Here, we have over 20 years worth of nursing experience between the three of
you, and I know you guys have seen many challenges, but
how did this particular one stack up against what you've experienced already?
>> I know when we first got the call, we didn't really know what we were to expect.
And so, once we were able to go through the training, and to meet our, our team
members, I think we all grew to better understand and learn to trust one another.
We knew that this was going to be a great challenge that we're,
that we're looking at, and we were able to.
Work as a team and
overcome a challenge that we could have been potentially dangerous for everybody.
But this was probably by far the greatest challenge I have experienced as a nurse.
But it was also an experience where we saw nursing where it was working
as it should have been.
We had open communication amongst each other.
We had open communication with the doctors.
It was exactly how a nursing unit and a health care team should have been around.
>> Yeah I mean I'm used to putting together protocols and
procedures and, and but this took it to the next level.
I mean you had to get it right.
You had to get it right every single time.
'because you certainly didn't want to let your team down.
You didn't want to let your, the staff at the hospital down.
You didn't want to let down the community.
So it was this is definitely.
I have the most writing on this for, for sure.
One of the biggest challenges I've experienced in my career.
>> Yeah, and you know, coming from a previous ER background and
a surgical ICU background I've seen a lot you know, through a patient,
to my own like, kind of patient care experiences, but this was,
was very unique, in that what we did as an institution but also,
what we did as in, in our nursing practice will really reflect
across the board, across the nation as to how, you know, it,
it was our opportunity to make a dream unit and I think we did that.
>> So then with the new things that you learned and
experienced, what were you able to take back to your home units?
>> I think the greatest thing that we learned was accountability.
We were accountable to ourselves.
We were accountable for each other.
If we were mess, if we messed up somehow,
it was up to us to fix that problem or we always had a spotter there with us.
We also had a second nurse.
If they saw something that was wrong it was their responsibility to make sure
that everybody was safe.
So we were always accountable to ourselves and to one another.
And that's something that I have taken back to my home unit.
I feel like we're starting to incorporate that more.
>> And the ability to communicate with each other.
And, just like you're saying the whole, the hold, other staff members accountable.
>> Mm-hm.
>> And especially, and, and you know it's, it's staff members ranging from
your docs to the nurses to the ancillary staff I it's,
it's a team effort again you know that's something that we've,
I think we've all carried to our own units to where we can provide those tools to,
or at least, you know, provide the reasoning and to be able to,
you know, to communicate to our units that we need this communication.
We need to be able to kind of work together not just as a nursing team or
a physician team, but as a health care team.
>> And I think we all think about infection prevention much differently now.
We all wash out hands a lot more than we did before.
We all put on and take off our gloves much differently, at least I do,
than I have in the past.
>> All right and so Sharon,
I would like to know, everyone came from all these different units,
from different ICUs, from different hospitals within the Emory system.
So how did it work when they all came together from these different backgrounds
to create such a successful team?
>> Well, I think the first thing you have to do is develop trust amongst each other.
And, and we did that through our training.
So we all went through training together.
And we developed some family rules.
We called ourselves a family, we're not just a team, we are a family.
These are my brothers and, and we created family rules that we would use to
communicate and, and rules that we would use to care for our patients.
Our first family rule was to ensure that we're following all standard
operating procedures, so that we did the same thing every single time.
Second family rule was to hold each other accountable, and
ensure our teammates follow all of the standard operating procedures.
You know, our third family rules was to go ahead and report any incidences.
It wasn't, you know, to get somebody in trouble, or, it was really so
that we could learn and, and grow.
It was really important that we had the opportunity to take what we are doing and
get better with it.
Our fourth family rule was to report any symptom that math, that matched
the pathogen, so if we developed any of the same symptoms of, of Ebola that we
would have to report that and, and make sure that we're monitoring that and,
of course, our last family rule was to report any new medical conditions and
I think that developed, that set the foundation for
how we built our team and the trust amongst our team.
>> This is something that we, that we reviewed every single day
during our huddles and I think it helped to build a sense of unity amongst the team
because we knew what was expected of us every single shift.
And everybody was expected to do the same thing every time.
And so
it was nice to have that, that family of rules that we could always rely on.
And we knew that they would be there to protect us and keep us safe.
>> Yeah, and again, you know we hold each other accountable.
I mean we spent 12 hour, you know, 12 hours out of the day with each other.
And we've seen each other in various forms of undress, and
I think the closeness just in the patient
care unit itself endears you to each other.
Especially with the type of work that we were doing, to where it was very serious.
If, you know, if we were ever to, if we ever failed to adhere to the rules,
how the disease can kind of break out of the unit.
>> All right.
So our nurses work 12 hour shifts.
There were three of them.
They all worked 7 to 7.
And a lot of people want to know how did the typical day go?
When did you arrive, when did you switch shifts?
How did the day look?
>> So it does take a long time to don and doff so be there around, you know,
at the latest, 6:45, just to make sure that the night shift crew knows that we
are there and ready to be able to relieve them by seven, so,
you know, everyone leaves on time.
But the donning process itself takes especially in the beginning,
takes about 15 minutes just because you want to be sure that everything is
taped up and covered and you've put on everything in the right order.
We have all of our protocols kind of lam,
on laminated paper that's taped up to the walls.
And the doffing calls as well.
And, you know, we wanted to be there as support just to be sure, you know,
if there's any last minute medications or any types supplies that they needed at,
at the end of the night shift you know,
I wish we were there to be able to get it for them.
>> And that effort had to be very coordinated,
because there's only one bathroom to change in.
We weren't just changing out in the open, I mean,
you had to, somebody had to go in and change and then come out and don,
and somebody else had to go in and change and then come out and don, and
in the meantime somebody was doffing and, and getting ready to go into the,
the locker room to take a shower so it was a very well coordinated,
very planned a methodical way of, of doing it every single time.
>> Mm. >> Yeah.
>> [COUGH] Something else that they also did to bookend our,
our shifts was we we would check our temperatures and
also report any signs and symptoms that we might have.
And that was just a early system that we set up, just in
case there was any kind of issues, like if we were to have been exposed potentially.
So we were able to check within a 12 hour period if we had potentially had any type
of exposure or anything.
We would look for our temperatures,
I mean any symptoms that we might have had through the shift.
>> And we did utilize a schedule,
we again, everything had to be very planned and organized.
Especially when we had two patients, because when we were talking about two
patients, we are talking about twice as many staff you've got all the family and
so you had to organize it and, and
really put it on paper to say what was happening when, you know?
When did lab need to be there, so that we could go ahead and, and, and
run those specimens?
And when did we need to actually get those specimens?
And who was going to get those specimens?
So it was very, very organized.
And, and, it really, it, it took the entire team to make sure it all happened.
>> I think something else was important.
It's a very necessary process.
But you had to plan for
your shift, because you're going to be in there from four to six hours.
And you have to go in there prepared meaning that you needed to eat,
drink, you needed to go to the bathroom before you go into the room,
because once you're in that room you cannot come out.
It is a long process for you to don and doff your, your gear, and so it would just
take away from that time with the patient that, that they would probably need.
So we, as healthcare workers, just had to be very prepared for
any situation that might occur in the room.
>> Mm-hm.
>> Yeah, and you have to streamline the process quite a bit.
I know in the beginning.
We had probably twice the amount of staff that we actually needed, but
as soon as, you know, we learned more, again, with the family rules and,
the daily huddles, we were able to kind of bounce off ideas among all staff members
at all levels of the health care team, and kind of streamline the process.
And I think our protocols have been very successful.
>> One thing that we would usually end our shift with
was collecting all the trash and waste.
And that was a large, large portion of our, of our time spent in the room.
These patients, we ended up having a lot of stool and other waste with them.
And so we have a protocol set up, and
that will usually take anywhere from one to two hours to accomplish it properly.
And so, we would definitely have to plan for that, as well.
Just because it is such a large portion of our shift.
>> Yeah, and on an hourly basis as well.
Other than doing patient care, most of what we did was clean.
>> Mm.
>> We clean the anteroom, we clean the patient's room.
We cleaned our showers, we cleaned the patients' showers.
It was a lot of cleaning.
>> Yeah, we had a motto.
You have time to lean, you have time to clean.
>> Yes. >> And they did a lot of cleaning.
>> Did a lot of cleaning.
And that, you know, and again, the amount that we clean and the vigorousness of,
in which we cleaned, I think [LAUGH] endeared us to each other,
especially because we were always working.
And if I saw my partners in the anteroom working,
I expect myself to be working as well.
>> Yeah.
>> The last patient with Ebola was discharged in October, and
with no active patients in the unit currently,
what is the serious communicable disease unit team up to now?
>> We've been quite busy.
We've been doing a lot of training and sharing best practices.
So we not only have been doing system wide training throughout Emory, but we've also
been cooperating with the Centers for Disease Control and Nebraska since they
also have a biocontainment unit, and we've been putting on training for
other designated treatment centers that would be caring for patients with Ebola.
And we've really been incorporating our team members in that training not only,
again, at that national level, but at our system level.
And we have monthly training sessions where they will come and they will go
ahead and teach those PPE principles and the donning and doffing procedures.
>> Yeah. Although we are back working on our home
units now we are still very involved in the SCDU unit we,
like Sharon said, we are helping out with trainings.
So it's a good chance for us to maintain our competencies, we're constantly
practicing what we have been preaching to one another.
So it's, it's nice to be able to meet other healthcare teams from around
the country and work on best practices, see what, see what we do well versus what,
what they do well.
And really, working together to, to create the the best possible product for
for treating Ebola.
>> Also we're using this time to train new partners in,
for the team, our new recruits, per se.
And we're using that time to just kind of not only refine our, our protocols, but
also, like they mentioned, we were learning best practices from other
places like Nebraska and other international places and
to see what PPE they have and to see if we can improve anything.
Because, you know, we, we don't necessarily claim that we have the best
procedures, we just know that it, it worked for us.
But it doesn't necessarily mean that we can't improve on it.
So it's an ever ongoing kind of process.
And again, it comes back down to our openness as a unit and
as a healthcare system to kind of learn and continue to do what's best and
what's best for our patients.
>> Absolutely.
>> Well, thank you so much for sharing all of your experiences.
I know that I have greatly enjoyed my time working with you and the rest of our team,
and I hope that you also enjoyed your time with us today.
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