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Case Report: Pregnancy Could Mask Symptoms of Ebola

Posted on Mon, Jun 22, 2015
 Case Report: Pregnancy Could Mask Symptoms of Ebola

Suppressed immune response might delay symptoms, experts say 

THURSDAY, June 18, 2015 (HealthDay News) -- The unique immunologic status of pregnant women might alter the disease presentation and progression of Ebola virus disease (EVD), according to a letter published in the June 18 issue of the New England Journal of Medicine.

A new case report describes a 31-year-old woman in late pregnancy who went to a hospital in Liberia complaining of mild lower abdominal pain, possibly pregnancy-related. Routine Ebola testing revealed she was infected with the virus, though she had no obvious symptoms, such as body pain, vomiting and diarrhea, or bleeding. After three days, however, EVD symptoms emerged. The patient and her unborn child died several days later.

The researchers suspect the woman's reduced immune response due to the pregnancy could have allowed the virus to remain in her body undetected for some time.

"This case highlights the challenges that clinicians may face in assessing pregnant women for possible infections, including EVD, and the potential risk for health care staff," Emma Akerlund, M.D., of Doctors Without Borders, and colleagues write in the letter. It's possible that she could have infected others before her symptoms appeared, the researchers said. But experts said the implications really aren't clear.

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With a Little Help from My Friends: How EmCare and Its Sister Companies Tackled Ebola

Posted on Thu, Dec 11, 2014
With a Little Help from My Friends: How EmCare and Its Sister Companies Tackled Ebola


Three months ago, Ebola was another exotic disease in some far away land. Then on Sept. 30, the Centers for Disease Control and Prevention (CDC) announced that the first Ebola patient had been identified in the United States. That distant shore became our front door.

Watching the news, you would have thought Ebola was about to run rampant through the streets of every city, county and state. The challenge for public health officials became two-fold: get ready to deal with the possibility of Ebola and calm public fears.

Envision Healthcare’s clinical leadership team understood those challenges and began to address concerns unique to each company. EmCare has two sister companies under the Envision Healthcare parent: Evolution Health, a physician-led company specializing in the management of complex patients in the home and alternate settings; and AMR, the country’s largest emergency medical services provider.

As the nation’s largest physician services company, EmCare was in the spotlight. Dighton Packard, M.D., Envision Healthcare’s Chief Medical Officer, communicated regularly with clinicians as well as partner hospitals and developed web-based informational resources.

“The key to stopping this disease is to quickly identify and isolate potential carriers,” said Dr. Packard.

“Our goal was to provide the latest CDC recommendations as well as helpful clinical resources that addressed concerns unique to our various practice environments.”

Al Sacchetti, M.D., a Medical Director for EmCare, created instructional videos for EmCare clinicians. The videos were sent to EmCare-managed locations across the country.

“The highest probability is that an Ebola patient who enters the U.S. will find his way to an emergency department,” said Dr. Sacchetti. “As a leader in the field of emergency medicine, EmCare is making sure all our affiliated clinicians have the best tools to deal with the situation. We want them to be able to recognize Ebola patients, and respond appropriately and quickly.”

RELATED: Managing Ebola, Enterovirus and Other Infectious Diseases

The videos Dr. Sacchetti created focus on the correct ways to don and doff personal protection equipment (PPE). They were quickly reshot several times as the CDC changed its recommendations.

“Things change,” said Dr. Sacchetti. “When we made the first videos, we had the associates putting on goggles. A few days later, the CDC recommended against goggles because people kept adjusting them and touching their faces. Now we have hoods.”

EmCare also developed a special website for updates, educational resources and messages from Dr. Packard. The site, is still active and will be updated as needed.

Not too long before the first patient was identified in Dallas, AMR had worked with the CDC to transport a known Ebola patient. The transport wasn’t publicized, but AMR leaders realized there was a very good chance more Ebola transports were imminent.

They were right.

“From the very beginning, our primary consideration was the health and safety of our caregivers, our patients and the communities we serve,” said Ed Racht, M.D., AMR’s Chief Medical Officer. “Ebola is a concern for emergency medical services (EMS) because the out-of-hospital setting is unpredictable and identifying potential cases is challenging.”

Dr. Racht’s clinical team began by developing EMS Ebola screening criteria. The document was sent to every operation and the 44 AMR communications centers that answer 911 calls and dispatch ambulances. It was also added to MEDS, AMR’s electronic patient care record, and within six weeks more than 117,000 AMR patients had been screened for Ebola. Eighty-six met the criteria to be considered a potential Ebola patient and were transported accordingly.

AMR also launched an Ebola resource website at that has generated more than 63,000 hits and become a valuable resource for hospitals, fire departments and other EMS providers around the country.

RELATED: Nina Pham, Amber Vinson and other ‘Ebola Fighters’ named Time’s Person of the Year

AMR’s clinical team then worked with the logistics and supply departments to identify and order upgraded personal protective equipment for paramedics and EMTs.

“We looked at the CDC recommendations and felt we needed equipment that in some instances exceeded those standards,” said Ron Thackery, AMR’s Senior Vice President of Professional Services. “The CDC was focused on managing hospitalized Ebola patients. We knew transporting patients would be more challenging, so we developed guidelines that took every possible scenario into consideration.”
The team also set up a hotline at Evolution Health’s Williams Medical Command Center in Dallas (MCC) where nurse practitioners and members of the AMR medical leadership team provided clinical and operational support. Most of the questions regarded the transport of suspected Ebola patients. That changed when the CDC requested AMR’s assistance in transporting two known Ebola patients.

On Oct. 15 and 16, AMR’s preparations were put to the test when Ebola-stricken nurses Nina Pham and Amber Vinson were transported from Texas Health Presbyterian Hospital to Dallas Love Field Airport.

Both transports were broadcast live nationally.

“From wrapping the interior of the ambulance to donning and doffing the PPE, the entire process worked just as we had planned,” said Dr. Racht. “I couldn’t have been prouder of the crew members who participated in these transports. It was a shining moment for the entire organization.”

Starting the next day, the MCC provided monitoring services for the AMR paramedics who were in the ambulances that transported the nurses.

“This is another example of how we came together as an organization to support each other,” said Dr. Racht.

The emphasis on Ebola has slowed for now, but its effect on the healthcare system and emergency medical services has been profound.

“Our experience with Ebola has shown that we must remain vigilant and always prepared for new and evolving infectious diseases,” said Dr. Racht. “The new role for EMS moving forward will be to identify, respond and contain new outbreaks as they occur.”

While the role of emergency medical services may have changed, emergency medicine was once again front and center at this critical time.

“Emergency physicians have been, and will continue to be, on the front lines of America’s healthcare system,” said Dr. Packard. “Whether it’s Ebola, H1N1 or any other infectious disease, we will continue to keep our communities safe.”


Ebola Workshop Scheduled for Nov. 3 in Washington, D.C.

Posted on Sun, Oct 26, 2014
Ebola Workshop Scheduled for Nov. 3 in Washington, D.C.

Experts and policymakers will discuss the public health response to Ebola virus disease in the U.S.

THURSDAY, Oct. 16, 2014 (HealthDay News) -- At the request of the U.S. Department of Health and Human Services, the Institute of Medicine and the National Research Council will host a workshop to discuss research needed to prepare for handling the occurrence of Ebola virus disease in the United States, according to a press release from the National Academies.

Health care experts and policymakers will convene at a one-day workshop, to be held on Nov. 3, 2014, at the National Academy of Sciences building in Washington, D.C., to discuss basic science research and public health concerns regarding the response to Ebola. Advance registration is required to attend in person; plenary sessions and discussions will be available via live video webcast.

The researchers will discuss various topics on Ebola, including routes of viral transmission; persistence of the virus on surface areas and transfer of the virus; methods for viral inactivation and disinfection; and protective strategies for at-risk responders, providers, and the general public, including the use of personal protective equipment. Experts and policymakers will identify key areas of biomedical and public health research that should be conducted to protect the public and prevent the spread of Ebola.

"Our goal for this workshop is to provide a forum for key experts and decision makers to discuss what research is needed and can be performed now to assist the public health response to the occurrence of Ebola in the United States," Victor J. Dzau, M.D., the president of the Institute of Medicine, said in a statement.

More Information


In Case You Missed It: Week of Oct. 24, 2014

Posted on Fri, Oct 24, 2014
In Case You Missed It: Week of Oct. 24, 2014

“In Case You Missed It” is a weekly roundup of popular healthcare headlines.

Ebola: A New Way to Learn What's Going On, from Experts, Journalists and Locals. “It all depends on what we do in the next few weeks,” said infectious disease expert Chikwe Ihekweazu, speaking on Ebola at TEDGlobal" ... continue reading this article at

[PODCAST] Commonly Missed Uncommon Orthopedic Injuries. We rarely discuss medico-legal issues on EM Cases because it misguides us a bit from good patient centered care – which is what emergency medicine is really all about... Listen at>>

[from ACP Hospitalist] Population health: what might it look like? There are 2 patients on the hospitalist service in this fine critical access hospital... Continue reading at

[Innovation] This Man’s Simple System Could Transform American Medicine. Katherine Carpenter couldn’t sleep. For more than a week she’d been coughing herself awake every night and then hacking until she retched. Finally, she decided to see a doctor. Continue reading at

[Mobile Health] Why we need to move up the value pyramid for health tech. Samsung, Withings, Fitbit, Garmin, and Jawbone are just some of the 75 most prominent companies entering the mobile health market... continue to

Visit us at these upcoming events!

10/27: ACEP 2014 Booth 1611 

10/28: Residents-Only Happy Hour at #ACEP14

11/6: EmCare's Inaugural Cook County Crash Course (C4)

11/11: Proven Strategies to Advance your Emergency Department: 2-day Studer Group event featuring Dr. Kirk Jensen


Documentation Tip: Ebola

Posted on Tue, Oct 21, 2014
Documentation Tip: Ebola

By Dr. Timothy Brundage

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

Documentation Tip: Ebola

With the rising concern regarding Ebola Virus Disease (EVD) and its spread to the United States, this tip of the week is unfortunately hitting too close to home.

Did you know:
In ICD-9, Ebola first codes to “Fever”, then “Hemorrhagic”, then “Ebola”, for ICD-9 code O65.8. In the coming ICD-10 this will then be A98.4.
Symptoms may appear anywhere from 2-21 days after exposure, averaging 8-10 days. Ebola is transmitted through direct contact with bodily fluids. Individuals are not contagious with Ebola until he/she has symptoms of the disease.

Important Screening Questions for ALL patients:
1) Have you traveled to Guinea, Sierra Leone, Liberia, Democratic Republic of the Congo, and Lagos, Nigeria in the past 30 days?
2) Do you have ANY of the following symptoms: fever (subjective or  101.5), muscle pain, severe headache, abdominal pain, diarrhea, vomiting, unexplained bleeding or bruising?
3) Have you been in contact with a known Ebola patient in the past 21 days?

If NO to question #1 or #3 there is a low probability of EVD and the patient should be evaluated as they normally would.

If YES to any of the above questions, isolate the patient in a private room with single bathroom and implement standard, contact and droplet precautions. Immediately notify your hospital infection control personnel and local County Health Department. The key is early detection and containment of the virus.



Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine. Be sure to visit and

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