The arrival of the Ebola virus in the U.S. last year caught at least one medical facility off guard and has prompted officials to rethink response protocols when it comes to the highly fatal, infectious disease. While some of the media coverage has sensationalized the risk of a widespread outbreak in America, providers, including radiology departments, still need to be on high alert in case they encounter a patient with this disease.
Easing the fears of those hoping to learn how to contain Ebola, a number of leaders have emerged to help guide those in the radiology community on best practices. Among them are David A. Bluemke, MD, PhD, of Johns Hopkins Hospital in Baltimore and the National Institutes of Health (NIH) Clinical Center in Bethesda, Md., and Carolyn C. Meltzer, MD, professor and chair of radiology at Emory School of Medicine in Atlanta.
Emory University and the NIH Clinical Center represent two of the four biocontainment sites for Ebola patients in the U.S.—the others being St. Patrick Hospital in Missoula, Mont., and Nebraska Medical Center in Omaha—and Bluemke and Meltzer are sharing the experiences of their institutions in both the radiology literature and at professional conferences.
Speaking at the recent annual meeting of the Radiological Society of North America (RSNA), Meltzer urged calm and reasonable preparation to counteract the confusion and concern in the general public. She noted that valet attendants at Emory briefly donned facemasks, which is not the most welcoming sight for a patient who might already be nervous about the news of Ebola’s debut in the U.S. Vendors also expressed reservations about servicing equipment at sites where the disease is treated.
“Clear and frequent communication with the healthcare staff is essential during this time of heightened public concern and understandable caution,” Meltzer said.
Last October, many expressed outrage that Thomas Eric Duncan, the first Ebola patient to die in the U.S., was not treated more carefully after returning to Texas from a trip to West Africa. Meltzer explained that nurses were aware of Duncan’s recent travels, but this information was not communicated to physicians, which calls for an examination of workflow and EMR communication processes.
Bluemke, who spoke with Meltzer at RSNA and also co-authored with her a list of recommendations for handling Ebola cases that was published in Radiology, said it’s important for radiology staff to understand Ebola symptoms because a patient may make first contact with a provider through an outpatient imaging exam. There are two key questions: Has the patient recently traveled to an affected country or has the patient made contact with a known Ebola patient?
If the answer to either question is yes, it’s time to raise some red flags.
The Role of Radiology
Bluemke and Meltzer noted that the role of medical imaging in Ebola is mainly supportive. Chest x-rays can help exclude pneumonia and other diagnoses and imaging can assess complications of the disease. A major component of treatment is fluid replacement and ultrasound helps place central venous catheters. Bluemke noted that testing is currently being done with MRI and CT in infected rhesus monkeys to see if either of those modalities can play an increased role.
As far as protocols, Bluemke and Meltzer said the best way to protect medical staff and still provide the highest level of patient care is to perform all imaging examinations in an isolation unit. The exact details of the standard operating procedures will vary by institution based on facility layout and equipment available.
Bluemke and Meltzer described two current strategies used for radiography in the case of infectious diseases. In one, the exam takes place inside the “hot” room with the patients. Radiology technologists stay in the “warm” room (anteroom) and provide instructions on equipment use to medical staff inside the hot room with the patient. Only nurses handle the detector.
Extensive prep before the procedure is required to keep staff from having to repeatedly enter and exit the anteroom. Detectors should be double-bagged in plastic in a “cold” room away from the patient. After the procedure, the contaminated outer bag should be removed by a nurse in the anteroom. Isopropyl alcohol can be used to decontaminate cassettes.
In the case of more complicated equipment or extenuating circumstances, the radiology technician enters the hot room to perform the exam. No matter what, however, every effort should be made to avoid transporting the patient out of the hot room.
CT and MR equipment are not designed for imaging patients with infectious diseases, and Meltzer described a mock scanning session in which an isolation pod used to transport patients to a CT scanner was torn away by the moving parts of the machine. Not a scenario that should play out with an actual patient.
Patient rooms and ultrasound equipment can be sterilized with vaporized hydrogen peroxide, though its effect on larger equipment like CTs is unknown.
Healing patients, protecting staff
Another speaker at the hot topic RSNA session was Bruce Ribner, MD, MPH, medical director of Emory University Hospital’s Serious Communicable Disease Unit. Ribner garnered national headlines as one of the faces of healthcare in the new U.S. fight against Ebola, and offered some stern warnings for those who attended his lecture.
“There’s nothing more dispiriting to staff than to have one of your healthcare workers acquire infection while caring for a patient with Ebola virus disease,” he said, stressing the need to extensive caution among staff.
Ribner described the conditions in West Africa as the worst Ebola outbreak in history, and one that will not go away anytime soon. While the threat of a massive outbreak in the U.S. is not large, the smattering of domestic cases means providers here must prepare. And that goes for everybody—a single Ebola patient requires the attention of nearly every department.
The good news? While Ebola is a scary disease, the mortality rate for cases treated in resource-rich areas is much lower than those treated in West Africa. With this home field advantage, aggressive supportive care and communication, patients in the U.S. have as good of a chance as ever to overcome Ebola. HI