Operating on fear: Performing surgery in a time of Ebola

Security forces shot 16-year-old Shacki Kamara in the legs as he protested against a quarantine the government of Liberia had imposed on his neighborhood, the poor and densely populated slum of West Point.

At Monrovia’s JFK Hospital, the emergency room was short-staffed because two doctors had died of Ebola. The second stop for Kamara was Redemption Hospital, where life drained away as he lost blood and bodily fluids.   

"There is no reason he should have died, those were survivable gun shot wounds," said Sherry Wren, chief of surgery at the Palo Alto VA Hospital and a professor of surgery at Stanford University, after seeing pictures of his injuries which were circulated widely online.

Kamara was an “untold” victim of an invisible crisis wrecking West Africa, dying not from Ebola but from the lack of medical resources and medical staff fears of contracting the disease, which is transmitted through bodily fluids.

To help West Africa cope with the growing number of deaths like Kamara’s, Wren co-authored draft guidelines for the surgical treatment of suspected or confirmed Ebola patients needing emergency care. This week, the American College of Surgeons and the Association for Academic Surgery were among the medical groups endorsing the protocol Wren developed with Adam Kushner, a teacher at the John Hopkins Bloomberg School of Public Health who founded Surgeons OverSeas, an organization that assists physicians in developing countries.

Their initiative, inspired in part by Wren's training during the AIDS crises in the 1980s, aims to expand the Centers of Disease Control and Prevention’s (CDC) official guidelines on Ebola for health care workers including an explanation on how medical personnel can stay safe while operating on patients who might have Ebola.

The CDC has been leading U.S. efforts to alleviate the crisis and is a leading source on infectious diseases for many practitioners in the developing world.

CDC Director Dr. Thomas Frieden likened the outbreak to the initial stages of the HIV epidemic, when fear of infection kept some people from even shaking hands with a person with a cough who they thought might be gay.

“In the 30 years I’ve been working in public health, the only thing like this has been AIDS,” he said at a World Bank summit on Thursday.

Wren said the hesitance to perform surgery on patients with Ebola made her think “of the early days of HIV.”

Nearly 4,000 people in West Africa have so far died from Ebola, the vast majority of those deaths have been in Guinea, Liberia and Sierra Leone. The CDC estimated last month that between 550,000 and 1.4 million people might be infected in the region by January.

And then there are the unknown deaths, like Kamara’s, the ones related to the virus that go "untold" as a consequence of the lack of knowledge, personnel and equipment in countries hit hardest by the virus, Wren said.

The chief of surgery at the Connaught Hospital in Freetown, Sierra Leone, Thaim Kamara, gave another example of an Ebola victim whose death could have been prevented.

Kamara said a physician refused to anesthetize a patient, because he had a history of vomiting and fever. Instead of performing the emergency procedure, the physician sent the patient to an isolation unit and held him there until Ebola test results clarified his status, he told Al Jazeera.

“This may take days to happen,” Kamara said. “That is the problem we face now. If a patient has any of the symptoms regarded as part of the case definition for Ebola, he or she may be sent to the isolation unit and kept there until the result of their tests comes back.”

"Our country needs help to combat Ebola for the obvious havoc it is wreaking on the people as well as the damage it is causing on surgical practice," Kamara said. "This is not obvious to policymakers and is causing unnecessary and preventable deaths."

Wren hopes the new guideline will serve as a starting point to help health care providers in Ebola-stricken countries perform operations more safely, as well as serve as an advocacy tool to prepare others to stock up on the appropriate protection materials — including double gloves, leg coverings with a full plastic film coating, full face shields, masks, surgical gowns made of a hi-tech fabric, hoods and goggles — to stave off virus infection. The draft protocol specifies instructions on how to handle needles and sharp surgical tools, as well as what to do when skin is exposed to blood of the patient during the procedure.

"This guideline matters because it allows surgeons now to prepare,” Wren said. “[And] it helps advocate for making sure that people in Africa have access to the appropriate PPE [personal protective equipment] that they should have."

But as Kushner said, "Aside from just the technical aspects there are many emotional and ethical issues. If such gear is not available, is it even appropriate to operate on these patients?"

Now, in Sierra Leone, the equipment specified in the guidelines is not available. “We use normal fabric gowns, goggles, face masks, caps plastic aprons and rubber boots to protect ourselves when we are operating on any patient,” Kamara said.

And next to equipment, the region’s desperately needs more health care providers.

Encouraging physicians and other medical personnel hesitant to travel to the region to help bridge the shortage of medical field personnel was aim Wren and Kutscher had while drafting the guidelines.

“Fear drives a lot of people, and I think we need to work on understanding how people get this disease,” Wren said.

Jim Brown, program director at Mbingo General Hospital in Cameroon, said that a fear of Ebola was likely keeping away foreign staff from taking up positions in the hospital. “Several visitors who were scheduled to come have canceled or rescheduled,” he wrote in an email forwarded to Al Jazeera. “As of today, there have been no confirmed cases in Cameroon, but we know that could change.”

The Ebola epidemic has disproportionately affected medical professionals. To date, nearly 350 field workers have been infected and more than 180 have died, according to the WHO, citing a lack of knowledge and preparedness as leading factors of the high death toll. 

Wren said the high volume of emails she received upon disseminating the protocol for feedback to colleagues in the U.S. and countries in Africa highlighted the lack of knowledge that has impaired the efficacy of the international response to the outbreak.

Pankaj Jani, head of the College of Surgeons in East, Southern and Central Africa (OSECA), which endorsed the proposed guidelines, said the rules would be lifesaving in his region "in view of the severity and threat of spread of the disease."

With Reuters