 Emily is the hospital epidemiologist at the University of Chicago as well as the medical director of the infection control program and the antimicrobial stewardship program. She's become a close to a lifer here where she completed her internal medicine residency, her chief residency and her fellowship in infectious disease all at the University of Chicago. Her research focuses on trying to improve and prevent the health care associated infections as well as improve the prescription of antibiotics. She's one of the rising stars here in terms of clinical arena, quality of care and public health and I haven't shared the story with her yet but a couple weeks ago I was talking to the commissioner of public health in the city of Chicago, his name is Bashar Shakir who's an outstanding commissioner. But as you can imagine the Ebola virus has taken a lot of its time over the past half a year or so and the Chicago city has consortium of four of the universities including the University of Chicago but he's specifically singled out Emily as well as Steve Weber who is our chief medical officer as being particularly helpful in these citywide efforts. So Emily is going to speak upon a different title than what's in the brochure is the ethics of Ebola preparation in American hospitals. Anyway so I want to talk today with a little bit of evidence and a little bit of information about some of these prevailing ethics questions related to Ebola that are surrounding all of us that are in the media and all around everything that we're reading about this and if you're a hospital epidemiologist they're sort of the only thing you think about. But the point being there are three big sources here. First we did an ethics, I asked for an ethics consult from the McLean Center back in July about a lot of these questions and that's a big source of the information that we have for how we're doing things at the University of Chicago. Secondly there's an Ebola, the Chicago Ebola resource network that Marshall mentioned has an ethicist from each of the hospitals that are working together. I'm representing us and we are creating consensus guidelines that can be published soon for others to use about some of these thorny issues in infection control ethics. And lastly there's a paper that's going to be submitted I think today where we actually sent out a survey to the all sort of bad metrics aside to US News and World Report top hospitals and top medical schools asking them about their current policy decisions about how to take care of patients with Ebola and you'll see that data here today. This is the first time anybody's seen the data. The last survey came in less than a week ago. So getting started you know the important thing to remember we're going to talk a lot about how we manage Ebola in American hospitals but the real issue of Ebola is happening in Western Africa but we need to begin this discussion by understanding that the way we take care of patients in Western Africa is very different than the way that we take care of patients in Chicago and in every other city in the United States and that's an important informer in the way that we approach some of the ethical issues of caring for Ebola patients here in the United States. But this is the first time that Ebola took root in a incredibly poor war torn urban area and that's what's allowed it to spread so rapidly and spread to other parts of the world. But that's no reason to believe that we're going to have a massive outbreak in the United States so please don't be too afraid. But the bottom line is that preparing to care for patients in the United States is really hard. It means we have to rethink everything about how we do medical care in the United States and there are as I sat down to address these thousands of questions when I was making the slide the font got down to size six and I decided that I would take some off but you can see the point being there are hundreds and hundreds of questions and buried among them are a lot of ethical questions about Ebola and that's why Mark was very gracious and let me not talk about hand hygiene and about Ebola today which is the only thing I've done since mid-July. And I want to address some of these today so let's start with the biggest of these issues and that really is who should care for these Ebola patients when they come to our hospitals and that answer is going to be given in the context of what we're seeing now which is onesies and twosie patients not this massive outbreak of 100 or more patients in any given city at any given time because that's not likely to happen and so I don't think we need to spend too much time worrying about it based on what we have right now. So these are the results of the survey that went out to these hospitals. We had a 76% response rate. We have 27 responses to the survey and you can see here that those that are marked in red are not allowed to care for Ebola patients regardless of volunteer status. Yellow is allowed to care for them if they volunteer and green is you're expected to care for these patients regardless of your volunteer status. And you can see by the caregiver types that most hospitals are not interested in having medical students care for these patients or nursing students. There are a couple that are allowing interns if they volunteer and residents if they volunteer a few that will allow fellows if they volunteer but most hospitals have decided to go with a volunteerism method involving staff nurses and attending physicians and then some other support staff. So is this the right thing to do? Well, there's a lot of talk about duty to care and Ebola and the history of epidemics and pandemics suggest that some doctors stay and some doctors run and there is not a consensus about what exactly one person is required to do and what one is not especially as a blanket group of physicians the generic or nurses the generic. The truth is that the duty to care for a patient is not infinite. It does not, we are not required to exchange our life for that of another human being. That's not what it means to be a doctor. But there are also very substantial competing duties that many physicians and nurses have such as caring for their own families such as caring for patients with whom they have an existing relationship not the one that walks in the door with whom they do not have an existing relationship. Nonetheless, that would make us believe that many physicians and nurses have the ability to opt out of caring for these patients but institutions do have an obligation both legal and moral to care for patients that arrive at their doorstep and that has led us to believe that in our consensus at the University of Chicago and as part of the Chicago Ebola Resource Network that there is something to be said for expertise and proximity. In other words, an ophthalmologist who is wandering through the emergency room as a patient comes in does not have the same level of expectation to care for that patient as the attending physician on duty in the emergency room at that time and the attending physician who's been trained to care for a patient with Ebola has a much greater obligation than one who has not and that I think is important to remember as we make decisions about how to take care of these patients especially when we run out of volunteers. That said, volunteerism is clearly the way to go and I say this is largely from an infection control standpoint as I do from an ethical standpoint. When you have volunteers you're able to concentrate your training resources. Physicians who volunteer to take care of Ebola patients at the University of Chicago get eight hours of hands-on training in the suits putting on and taking off the suits and then doing procedures and sort of simulated patient care and they have refresher training every three weeks. That's a lot of time nurses get double that and so that is what we can provide to people to make them safer when they do care for the patients and that's a big reason why volunteerism is catching on so broadly. It's really hard to train thousands of faculty and staff members at that level. That brings us to the question of when we run out of volunteers is it time to start thinking about physicians and training or should we be requiring other people to care for these patients and I think that this is a really serious question to be asking. Training is evaluative in nature and so trainees may be very enthusiastic about caring for these patients but that may be partly because they want to go to valuation for their training program. They also may not really understand a third month intern may not really understand and their inexperience with caring for patients in general may lead them to be at increased risk of contracting infection. So this there's clearly good reasons why we would not want trainees to be involved. That said they are as inexperienced as they are in providing independent practice. They are the most experienced people in our hospitals when it comes to day to day care including things like how to manipulate the medical record and how to get things done where things are and that's really important knowledge when you're trying to care for a patient. So I think that there are some real benefits to including trainees but the CDC does recommend from a very pragmatic infection control standpoint that you should minimize the care providers. That means that we can't be asking all of our trainees and their supervisors to be caring for these patients at the same time. We believe that that means that fellows and senior level trainees in training programs who would be expected to care for these patients as they proceed into their physician their sort of accredited physician roles probably have already bought in and understand the risks of being a critical care physician or an ED doc and they probably are capable of making an informed choice about volunteerism. In other words a competent trainee volunteer may be a better choice than asking unwilling attendings to participate in the care of these patients and that's a very you know iffy ethical question that I some of you will probably disagree with but that comes down to sticking with volunteers allows us to concentrate those training resources whereas if we require one attending physician to do it we have to require them all. Which brings me to the question of now that we have everyone in the room to take care of the patient what are they and what aren't they going to do for that patient. There's been a lot of discussion about this in blogs and newspapers all over the place and I think it's very telling that the graphic you see here basically shows you that academic medical centers in the United States are all over the map on this. You can look that CT scans and MRI scans are things that really honestly can't be provided to these patients without having to disrupt the care of every other patient in the hospital making them very unlikely to be provided. Think about this practically CT scanners are in open areas they're not separately ventilated if you put a potentially Ebola patient in that CT scanner it can't be used by anyone else until you know whether or not the patient has Ebola and it's been cleaned properly which usually involves vaporized to hydrogen peroxide cleaning of the entire area which can be days away because there's only one company that does it in the entire country. So you can see that that's just not feasible you wouldn't be able to provide care to any of your other patients. But there are other things like vasopressors massive transfusions dialysis both intermittent or continuous renal replacement therapy intubation and things like that it's surgery and CPR that are a bigger issue and people seem to be all over the map on. So the reality of treatment limitations for Ebola are largely based on fear and you can see a picture here of the suits that we ask our people to wear and the once people have undergone training in these outfits and they feel much more confident providing some of these procedures that we otherwise wouldn't think would be a great idea because they are really impermeable to fluids and if they're trained well on how to get them off correctly and there's adequate staff and support they probably can provide these things very safely with very very little risk. And so PPE training and planning ahead to do things semi-electively as opposed to emergently can really mitigate a lot of the risk and make some of these things make it easier for us to provide a usual standard of care to patients even those with Ebola. The other important thing to think about is that rule out patients are very different from confirmed Ebola patients. Rule out patients in the United States there have been 350 patients at least tested for Ebola. You haven't heard about all of them because only four have tested positive. Two nurses, Mr. Duncan and one physician in New York City. That's it. That means 99% of people who need to be tested for Ebola will be negative and they will have something else wrong with them and that's where we need to think about whether we're trying to protect our staff or whether we're trying to predict outcomes and so clearly staff needs to be protected when they take care of these kinds of patients that are being ruled out but at the same time the outcome may not be as grave as what we expect for any Ebola patient if the patient just has malaria and you can't avoid giving them care in the first two days while you're waiting for testing results. That makes a careful wing of risks and benefits essential and at the University of Chicago we do a lot of training, we teach our, we limit it to doctors and nurses, they do all of the x-rays, they do all the point of care testing, they do all the spill cleanup, they do the intubation, they do the daily cleanup of the, they do the transport of the patient because it's easier for us to train one set of people to do everything than it is to train 50 sets of people to do one thing each. And so I want to point out that this Ebola risk benefit balancing act is complicated. In real life we have the risk to the patient and the potential benefit to the patient and we try and explain everything to the patient and then we have the patient's preference and that's what we go with. When you have Ebola you have this risk to the provider which is a very heavy weight on the side of not doing things, especially if you overestimate it because of fear. And as we saw earlier physician recommendation often trumps and influences what patients want. And so when you have a fearful physician who feels like their own life is at stake in caring for a patient, they're much less likely to recommend things. And that is something that we don't usually take into account in the way that we make decisions in with patients. And it's something that we need to really be very careful that we eliminate that risk as much as possible and we help our physicians and providers to feel as comfortable as possible so that their fear isn't getting as much in the way. It is really, we need to make that as real as possible and not as overbalanced. Which brings me to the question of the unilateral DNR. So this is controversial even in regular patients whether or not we can decide that something is futile. I'm sure we all agree that there are times when it's clearly futile to do a code on someone but there are other times where it's in the middle. And I think it's important to remember that even with Ebola patients there are codes from which these patients could survive very easily. They're very likely to present with electrolyte abnormalities early in the course that may result in an arrhythmia that's actually very savable. They may have a PE as they're recovering from Ebola when they're no longer very infectious. And those are times when we may want to code these patients. So making a blanket statement about all Ebola patients from the moment they come in the door, even if they haven't been diagnosed yet, all the way through to the time we discharge them, doesn't make any more sense for an Ebola patient than it does for any other patient coming into the hospital. But a code in a patient with Ebola would look very, very different from a pragmatic standpoint just like all the care looks really different. It looks very white and full of Tyvek. And it doesn't involve the usual code team. It doesn't involve training every single resident who is leading a code team to be able to provide a code on an Ebola patient. At the University of Chicago, it looks like a constant ongoing risk assessment that includes ethics, includes infectious disease, infection control, the attending physician in the room, their skill level and the patient's current condition, what other conditions the patient may have. And it's two quarantine doc providers, two nurses and one doc. There's always a nurse and a doctor in the room of the patients that we have at the University of Chicago because we need to have that back up there. It takes 15 minutes to get into the suit and a nurse outside who's half dressed and ready to go, which means we can do a code with three providers. And that means we need to be able to do as many things ahead of time as we can. So all of our Ebola patients will get central lines early on. This allows us to be able to take that off the task list of a code or an emergent situation. It also means we don't have to stick the patient with a needle every time we draw blood, thus reducing the risk to the providers. So there are a lot of things that can be done to mitigate the risks of these code situations. And those are things that we all have in my opinion and in our opinion, both the Chicago Ebola Resource Network and the University of Chicago, it's our obligation to mitigate the risks to the providers to as much of an extent as possible in order to be able to provide patients with the standard of care. Which brings me to the recent ACOG practice advisory. That's the American Congress of Obstetrics and Gynecology. And it will sound like I'm picking on them because I am. They have written, it may be prudent to avoid the usual obstetric interventions such as fetal monitoring, cesarean delivery, induction, or surgical repair of lacerations in this select group of extremely ill women. They go on to qualify this saying that people who've recovered from Ebola or who are in the very earliest stages of Ebola may benefit from some of these treatments and you might want to change, you may want to do them. However, they go on to say for people who are being ruled out for Ebola. In other words, the woman who comes in for all women with EVD, there will be a window in which EVD is suspected but has not been confirmed with laboratory testing. These women should be treated in a similar fashion to that described above, recognizing that a portion may prove negative. That portion is 99%. And 99% of women who have traveled to Western Africa will come back without Ebola. And if they happen to be pregnant, they deserve to not be put into a room without a monitor and without a physician and they deserve to have some level of treatment as safe as we can provide it to everyone. Yes, the outcomes are very poor in Africa for both moms and fetus, but that's not the same as the United States. We have no experience with this here and we have no idea whether or not we can survive, whether what mothers or babies can survive this. We also know that cesarean delivery in the throes of DIC is contraindicated and dangerous for mom and probably not a good idea, but there are a lot of stages of Ebola that are not disseminated intravascular coagulation. And so even vaginal delivery is messy and fluid producing, putting providers at higher risk. Some of the obstetricians I've spoken with don't even want to participate in vaginal deliveries until I remind them that these patients routinely make 15 liters of stool a day. And so we're not talking about something that's significantly different from the other care of any Ebola patient. But it remains very unclear what to do about rule out patients. There are probably some circumstances in which it is not a good idea to do a cesarean section in a rule out patient because it could be dangerous for everyone. It's certainly not a good idea to take them to your positive pressure operating suite in the labor and delivery area where you're now contaminating all of the other areas where everyone else can now can't get a C-section. So at the University of Chicago we have a very complex plan and this is the same plan that most of the other hospitals in the Chicago Ebola Resource Network are going with, which is to do active ongoing assessment with fetal and maternal monitoring. The argument that you don't do fetal monitoring because you're not gonna do a C-section is a bad one. Fetal monitoring can lead to other interventions like fluids and positioning which can improve the outcome for mother and baby. And so should be included, they are standard of care, they are non-invasive, the belts, you know? These need to be included in the care of patients with Ebola and I would strongly discourage anyone going home and advising their own hospitals from following the ACOG guidelines or the ACOG practice advisory in sort of word for word. But we do avoid but don't prohibit surgical management. The other problem with the ACOG recommendations is that it suggests to hospitals that they don't need to be prepared to perform C-section on a patient that may have Ebola. There may be a very low risk patient for whom it would be appropriate to perform a C-section because the risk to the mom is very low, the potential benefit to both is very high, but where the providers still need to take all of the precautions that they would otherwise take for an Ebola patient. And if you haven't prepared your staff to do that, you won't be able to do it. And so I think it's very important that we be prepared to provide care, but we make every effort not to do any additional care, probably a little bit more like we should be practicing medicine all the time. But you know, ethicists are available so are, oh now I have the red light, darn it. Ethicists, all of these hospitals have ethicists, all of these hospitals have infectious disease specialists and all of this can be done more nuanced way than making blanket recommendations. So I just wanted to thank our ethics team, the CERN ethics team which is made up of Cathy Neely from Northwestern, Clayton Thompson from Rush, Kelly Mickelson and Joel Frater from Lurie and the University of Chicago Ebola incident command team and the co-authors from the paper that has not yet been published, but you all have seen now. And our volunteer providers because they're doing a great thing for all of us and they're allowing many of us to not have to go and take care of these patients. So I'm really impressed by them and appreciative to them. And my infection control team that works really hard to make sure the University of Chicago is ready to take care of these patients safely. And I'll leave you with this lovely thought. You like that? I think we should put that up in the clinics although I haven't gotten approval to do so yet. Are there any questions? Hi, I'm Michelle Harrington of the University of Chicago. I was, that was a fascinating and very informative presentation and I just wonder from an epidemiological perspective about the duties of care providers, both professionals and perhaps lay persons. Have you all thought about survivors of Ebola who are presumably... Yeah, survivors of Ebola are great candidates to take care of these patients. Unfortunately, most of them are, it takes a really long time to fully recover from Ebola and this is moving pretty rapidly. And I don't think the good news is that people that medicine's on frontier and Samaritan's Purse do a good enough job taking care of their providers that we don't have very many survivors to create a usable workforce. But yeah, I agree, they'd be great. Hi, Dr. Landon. I had more opportunity to talk with physicians in New York, primarily emergency department physicians. And one of the things that emerged from the panel that I was on was that they were going to have teams. Teams that would come in at the time than anyone suspected of Ebola was going to be admitted. And I apologize, as much as I was down at UIC this week, I did not look at the Chicago Medical Preparedness to see if there is a line that says that you bring a team in because they have done enough rehearsals, tabletop exercises that they can deploy this readily. That's, so comment on that. So each hosp... The four Ebola resource hospitals in Chicago, Luri, Northwestern, they're not quite ready to take patients yet, but Rush and University of Chicago have teams that get called in and they take over the care of the patient. Our frontline providers do have to provide what I like to refer to as bridge care for the first hour or so until those volunteer providers can arrive at the bedside and take over the care of the patient. And then CDC has a go team for every area of the country. They will send a team within 24 hours if you have a patient. We've taken care of a rule out patient here at the University of Chicago and it went very smoothly considering all of the difficulties involved in doing this. And then given that there's only 55,000 supposedly in our area that could likely be from West Africa, one of the questions emerged, I trained at Cook County and it was a Cook County physician who said, it's the distinction between the workup and the rule out and then the protections that come on the floor where the gaps are. And so what specifically, other than the preparedness you've talked about, I see that. But in terms of a non-complicated pregnant woman who you disagree with the ACOG as much as I do, could there be the possibility she would be delivered in an intensive care setting? For example, similar to a malaria patient. Yeah, so we have a quarantine unit that we stand up within three hours of having a patient that's walled off from the rest of the hospital, all in ICU beds, the patients would be delivered there. But if they, and rule out patients go there too, because rule out patients require all the same protections from an infection control standpoint of a patient with full balonibola. You just don't know and so you must take those precautions. And we're prepared to deliver a patient in labor and delivery if they need to deliver in the first three hours before they can move up to the quarantine area. Marshall, I just wanna thank Lainey Ross because I read your blog along with Joel Freider. Yeah, it's great blog. Before I was on that plane and I just can't thank you enough because it gave really good insight and thank you again, Dr. Landon, thank you. Thank you. So we'll get to a last very short Oh, Shola. Before Emily short insert before our lunch. I'll make it very brief. Great presentation, Emily. You know, there are about 18 countries in West Africa. And I think we start, when we start stigmatizing everybody coming from West Africa, we make things uncomfortable for people that travel and not in any Ebola related country. As part of a network, can you try to influence how we characterize where Ebola is so that we can be a little more country specific because they're just a handful of countries where there is Ebola. And when people come from there and you put them through all this ridicule. Yeah. It's not what we should be doing. As Jay Leno pointed out many times on The Tonight Show, Americans geography is awful. And that just goes to show. I mean, I get calls to triage patients all the time that are from Ghana, which isn't even in Western Africa. And it's horrendous. And so I can keep showing maps all I'd like and encourage us to, yeah, we definitely, no one needs to be stigmatized. No one needs to be, it's not their fault, regardless of where they come from, but patients coming from places like Nigeria where Shola's compadres did an outstanding job eliminating Ebola from the entire country are safe. And they're perfectly, there's no reason to believe that there's any risk for those kinds of patients. It's a great point. Thank you. So thanks, Emily. And maybe one more hand for our standing panel with Stacey Grange and Anouk. Thank you very much.