What is the Psychiatrist’s Role in the Ebola Outbreak?

The latest Psychiatric News issue carried a story about the mental health needs of West African patients, families and health care workers stricken by the Ebola crisis.

Coupled with what I learned at a recent informational forum I attended at our hospital this week about our strategic plan for responding to patients suffering from Ebolavirus infection led to reflection about how we’re going to provide psychiatric care for Americans trying to cope with the effects of the epidemic in the U.S.

The University of Iowa Hospitals and Clinics has been planning for Ebola since August this year through the efforts of our Bioemergency Response Team (BERT). Our plan is similar in most respects to the Centers for Disease Control and Prevention (CDC) guidelines:

There are only 4 biocontainment hospitals in the country and other hospitals around the country are being identified that could be regional centers which could care for Ebola patients. In our state, The University of Iowa Hospitals and Clinics would be the logical choice.

A recent CNN story has the major points right. We’ll be extra cautious about the temperature check, setting the threshold a little lower to be on the safe side. Other important information at the forum included are in the shortened version of the talk using WordPress Presentation Shortcode below.

As always with this presentation shortcode, you have to use the arrow keys to navigate each and every line on the slides. If you want to see the slideshow in full screen, click the 4 arrrow icon in the lower right hand corner. Hit ESC to exit full screen.

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Obviously there was a great deal more information given at the presentation, not all of which was necessarily pertinent for this focused post. It is beyond doubt that it’s critically important to maximize safety for the patient and health care staff. This means only intensivists will be entering and leaving the patient’s room. Psychiatrists are consultants and therefore I will not be allowed to do that. I’m used to donning and doffing a gown, gloves, and a mask in order to interview patients with other kinds of contact precautions. I always feel like this makes it challenging to develop rapport and connect with the patient.

And I always wonder whether, conversely, the patient finds it difficult to connect with me. However, we will be able to communicate through a thick glass door and “iPAD technology.”

The forum presenters identified anxiety and other forms of psychological distress that patients will likely suffer. They mentioned psychiatric nurses but not psychiatrists. It was not clear to me whether psychiatric nurses would be allowed in the room but I doubt it.

They will have plenty of benzodiazepines available. I winced slightly at that as you can well imagine, not because I’m critical of the approach but because there are so few choices.

I can’t touch patients in this scenario because it’s just too risky. And then there’s the risk for the most frequent syndrome I encounter in the intensive care unit–delirium, which unfortunately can be caused by benzodiazepines.

A colleague who also attended the forum asked an important question about what would be done about Code Greens, which are emergency events involving violent patients in which a whole crowd of health care professionals including psychiatric consultants like me, rush to the location in the hospital where quick help is needed to manage potentially violent patients with nonviolent measures although there is a lot of hands on activity. Often the patient is delirious, hallucinating, delusional, agitated and terrified and must be restrained in order to protect himself and others. Patients afflicted with Ebolavirus have numerous medical complications which typically cause delirium.

I still can’t remember the answer to my colleague’s question. I keep thinking it was something along the lines of “We hope those don’t happen.”

I hope not either.

I did a quick search of the internet looking for what psychiatric care is typically provided for patients with Ebolavirus infection. I didn’t find much, but ironically discovered the news item about a psychiatric hospital in New Jersey where it’s being proposed some patients with Ebolavirus infection be quarantined.

And then there’s the challenge of caring for the carers. Because only the ICU doctors will be providing direct care for the patients and there’s not many of them, fatigue can and probably will be an important issue to be aware of. Providing support during the long hours that the intensivists will be putting in will be vital.

There will be no way to express the gratitude I’ll have to them for risking their lives and sacrificing so much in terms of time away from their families.

And I’m not using the subjunctive mood here with respect to grammar because I think Ebola is probably going to happen to Iowans or to someone passing through Iowa. I hope it doesn’t but it’s happening elsewhere in the U.S. and while I doubt that there will be a widespread epidemic like the one in West Africa, I suspect we will have our share of sorrow.

So what is the psychiatrist’s role in the Ebola outbreak? I keep thinking of the popular TV show M.A.S.H., and the role of Sydney Freedman, the psychiatrist, played by Allan Arbus who, incidentally, died only last year. Sydney took care of shell-shocked soldiers in the Korean War and empathy was his sidearm. I never saw him give anyone a benzodiazepine. We can think of the Ebola outbreak as a sort of war. It feels like it was thrust on us arbitrarily. It makes no sense, killing indiscriminately. Doctors who fight the war on Ebola have to witness tragedy every day. Patients and families suffer in silence, isolated and afraid.

It sounds like the role of the psychiatrist will be difficult to define and empathy will have to be filtered through a thick glass door and “iPAD technology.” I hope there’ll still be room for a sense of humor, and maybe the awareness of all the little wounds that can erode us as well as the tragedies.

Hawkeye: Here we are in the middle of all this shooting, and I get laid up because of something that happened to me when I was seven.
Maj. Sydney Freedman: Oh sure, it’s the little battlefields, a pond, the bedrooms, the school yard, that leave the biggest scars.

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Comments

  1. This is a link to the WHO – the link on the right is a PDF of a pamphlet with basic principles. Our stuff contained more information on the statistics of how many people develop PTSD and what typical emotional and psychological responses are:

    http://www.who.int/mediacentre/news/releases/2011/humanitarian_relief_20110819/en/

    Some versions also have information of how to deal with anger and rage as a response but we did not.

    In our training sessions we also studied a lot of material from DEEP including links from this page but their entire web site and the materials we got from their lectures were very useful:

    http://www.deep.med.miami.edu/x415.xml

    In the end I was fairly pessimistic. It seemed like very little could be done to decrease the death rate and available resources would be quickly overwhelmed. I don’t know how long psychological first aid would help in a scenario like that unless there was a countermeasure like a vaccine that could be rapidly dispersed at the same time. I read Barry’s book The Great Influenza about the 1918 Influenza epidemic and I hope what is documented in that book never happens again. Here is one example:

    “In Cape Town, South Africa, Charles Lewis boarded a streetcar for a three-mile trip home when the conductor collapsed dead. In the next three miles six people aboard the streetcar died including the driver….” p. 242

    People dying in public and dying rapidly were not exceptions.

    Barry’s book also references a paper by Karl Menninger that was reprinted in the Am J Psychiatry in 1994 on the “almost unequalled neurotoxicity of influenza” where he noted that there was acute post influenza schizophrenia. The course was that 2/3 of the patients recovered after 5 years. I was also fortunate to obtain a copy of Constantin von Economo’s Encephalitis Lethargica from the same period. The combined information suggests to me that there may be a larger demand for psychiatrists to do other things if a similar virus starts to spread. When I first started out in medical school I remember caring for a significant number of survivors of von Economo’s with persistent movement and psychiatric disorders.

    When I think about what is happening with Ebola right now, my usual thought is that I am thankful it is not one of these mutated flu viruses and that it is not airborne.

    Liked by 1 person

    • Many thanks, George. There are some Dos and Don’ts that I think are helpful in one of the pdfs on psychological first aid, http://www.deep.med.miami.edu/media/P1stAidWellinDisUSUHS.pdf

      I had not heard of the Center for Disaster and Extreme Event Preparedness (DEEP Center). There’s a wealth of information there. The American Psychological Association Task Force Fact Sheet on foster resilience in adults, http://www.deep.med.miami.edu/media/FostResilRspTerAdltsAPA.pdf lists several individual characteristics of resilient people including a sense of coherence and hardiness, which are important for both patients and health care professionals, including our ICU docs specifically in the event our hospital admits a patient infected with Ebola.

      It reminded me of my Mindfulness-Based Stress Reduction (MBSR) course I took this summer and which I’m still practicing. It turns out that these resilience characteristics could be developed and enhanced by learning how to practice mindfulness meditation. Jon Kabat-Zinn discusses this in Section II The Paradigm: A New Way Thinking About Health and Illness: Chapter 15 Mind and Body: Evidence That Beliefs, Attitudes, Thoughts, and Emotions Can Harm or Heal in his book Full Catastrophe Living.

      Liked by 1 person

  2. Jim,

    I was part of the surge suppression and psychological first aid initiative for Avian Influenza.

    The theory is that when people start dying there will be a mass move on hospitals and ERs. We had specific interventions to prevent mass movement to the ERs by people who were not ill. In the case of the anthrax panic in DC they had over 10,000 people in the ER early on.

    I taught a course in psychological first aid and we certified people who were ready to do it. But luckily – no bird flu.

    The saving grace of this virus is that it it not airborne.

    Liked by 1 person

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