On Monday Nov 17, Dr. Martin Salia died from Ebola at the Nebraska Medical Center in a facility that is well prepared for this disease.

By the time he arrived in the United States, Martin Salia, a surgeon who contracted the deadly Ebola virus in Sierra Leone, had “no kidney function and was unresponsive.” That sent doctors scrambling — ultimately unsuccessfully — to save his life at a Nebraska isolation facility equipped for treating Ebola patients.

This accounting of his treatment appears to be the same as the last day or so of Thomas Eric Duncan’s life in medical care for Ebola a month ago.  In particular, the following description for Mart Salia’s care appears to be same as experienced by Duncan:

Salia was rushed onto emergency kidney dialysis and a ventilator and was given several medications to support his organs.

The difference is the Salia also had transfusions and ZMapp medication that were not available to Duncan.  Given the severe condition he was in when he arrived at Nebraska, it does not appear that these immune-response efforts would have made a difference.   In the remote chance that the organ failures could be reversed, this immediate medication may allow time for the immune system to start killing off the virus.   Alternatively, this choice may been necessary to another malpractice lawsuit similar to what was settled with Duncan’s family due to the lack of these experimental treatments.

When news first came out over the weekend that Dr. Salia was being flown from Sierra Leone to Nebraska in critical condition, I questioned the wisdom of this transport.

Justification for the medical flight may have come from claims of our superior medical practices for curing Ebola.  I very much doubt we have any advantage for treating a viral disease compared to what can be done locally in Sierra Leone.  I heard that we had more comfortable beds, though.   The treatment for Ebola involves bed rest, isolation, intravenous hydration, and administration of medications or transfusions.   All of these are within the capabilities of the local hospitals.

There two areas were our better funded facilities have an advantage.  One is that we are better able to protect the health care providers in special treatment centers such as those at the Nebraska Medical Center.  This does not help the patient at all.   The second is our access to advanced medical equipment for organ failures when Ebola reaches the late stages.   The organs are failing because of high viral loads.   Both Salia and Duncan experienced organ failures and both still died despite appropriate care for organ failures.  However, there are other cases (such as this one) where intensive care can save the patient.  Given the fact that the viral loads are causing the organ failures, these efforts require very lengthy intensive care and still have a high fatality rate.   But, I acknowledge the fact that more advanced hospitals in USA or Europe are better equipped to provide this level of intensive care.

I question the decision for this transport because when this transport began, Dr. Salia was already in critical condition.  The problem I see is that during this period of being in this critical condition he would have to spend at least a day in an airplane that almost certainly offered less optimal medical attention than would be available if he had stayed in Sierra Leone.  That was my uninformed opinion the moment I heard that the airlift was in progress.   This article shows that my opinion was not unusual.

Diagnosed on November 10, Salia was five days into his battle with the disease and “critically ill” when the decision was made to fly him to Nebraska. In the minds of his fellow Sierra Leoneans, it was too late to make that call. “He should not have been flown out of the country,” says Arthur Pratt, a pastor and youth organizer living in Freetown, where Salia worked. “He would have more chances of survival here.”

Although I earlier mentioned our superior and more plentify life-support equipment, much of that equipment is available locally in Sierra Leone.  In particular, they probably had emergency dialysis machines.  It is not obvious to me that the local facilities were inadequate to the task of saving his life.   It is even less that he could have received better care when the long air transport was included in that care.

When I heard he was en-route to Nebraska, I imagined that the flight itself would be detrimental to his care.  This is a disease that progresses rapidly to kill within days and here we are wasting a day or two with the patient in transit between two hospitals on two different continents.   Not only was the viral disease making its deadly progress during that flight with poorer quality care, but the flight itself could encounter severe or prolonged turbulence that would further interrupt care and certainly discomfort the patient or injure the health workers.  Also disrupting his care would be the necessary refueling stops and the transfer to ambulances.

The lengthy transport of such a seriously ill patient could to be a form of malpractice in itself.   The airplane flight suspended the opportunity to cure him for a day or two for a disease that kills within a couple days.  I am not a medical professional, but this seems incompetent.  From the Daily Beast article,

Walking around Freetown as he speaks to me on the phone, the typically upbeat Pratt sounds frustrated. Sierra Leoneans are sad about the loss—but angry, too. “People are not happy about it. Flying him out of Freetown, it wasn’t right,” he says. Pratt says the discontent centers on the portrayal of his country as completely incapable of caring for even a single Ebola patient—something he contests to be true.

From what I’ve read elsewhere, the medical facilities in the cities in Western Africa may be strained by the case load but they may still be capable of providing quality medical care.  In particular, they are very familiar with treating Ebola.   Perhaps a case can be made that the center in Nebraska is better equipped than the center in Freetown, but I’m not sure that can make up for the degrading conditions endured during the inferior treatment he received while in flight.

I suspect the decision to send Dr Salia to Nebraska is mostly informed by our prejudices of a failed medical system in West Africa.  We may also have been motivated by our charitable intentions of sharing our medical facilities for the fight against Ebola.   I doubt that there was much medical justification for this decision.

For the remainder of this post, I want to relate this latest Ebola case to some of my earlier posts on Ebola.

Mysterious method of contracting the disease

This is another example of an Ebola patient contracting the disease without a clear path for infection.  As noted in the Washington Post article, it is not clear how Dr Salia contracted the disease.   I have heard that although he was in an area where Ebola was present, he was trained as a surgeon and may have been there for some administrative role that did not bring him in direct contact with patients.   I don’t have a reference for what he was doing there, but a surgeon is typically not needed to treat Ebola, a viral disease.   Even if he had direct contact with patients, he was well-trained and he understood how to protect himself.   On the other hand, I have heard that sometimes the local conditions in hospitals are not ideal for protection so it is possible that he may have been exposed through lack of proper protection due to circumstances outside of his control.   I think that if that happened during his practice of medicine, this would have been recognized as risky and a likely explanation for the infection.   Because, the article says it is not clear, I assume there is no record of an obvious risky exposure.  If there were record of any risky situation, it would have been identified as a likely cause.

Continuing treatment after organs begin to fail

This is another example of a patient suffering through late-stage Ebola when organs start to fail.   When Ebola reaches this stage, the fatality rate increases dramatically so that any treatment may simply draw out an agonizing death.  As I mentioned in my post about the lessons learned from the Duncan case, we should consider whether this extra effort is merited.  Given that there is no reliable treatment for this stage, I wonder whether it would be better to assume an automatic approval of allowing a natural death instead of taking extraordinary procedures to try to save the life.   Historically, there have been several cases of treatment of late stage Ebola succeeding and the survivor being grateful for the effort.   However, even in those cases the current available treatment requires large teams over a long period of time.   We can only do this kind of treatment for a couple people at time time, worldwide.

We learned in the Duncan case that the risk of infecting caregivers increases dramatically during the late stage of the disease.   The treatment facilities in Nebraska are superior than the facility in Texas, and I don’t expect that there will be any healthcare providers getting the disease as a result of transporting and caring for Dr Salia.   Because the risk increases dramatically in its later stages, Ebola treatment has to be in an advanced facility like the one in Nebraska in order to protect the healthcare workers.

So far, our country has had to deal with only a couple cases of Ebola and only one severe case at a time.  The government assures us that an outbreak within our borders will be very unlikely.  With this assurance, the ethical choice is to invest in full efforts to save a life.   Despite this assurance, we should be thinking of policies for how to respond if we did have a larger outbreak of dozens (or more) severe cases at a time.  The above policy for allowing natural death when organs begin to fail may be justified in order to conserve resources for treating cases with earlier stages of the diseases.  It may even make sense to permit euthanasia to end life when fatality becomes more likely such as what Duncan and Salia experienced in their final day or two of life.   The fatality rate and infectious risk of late stage Ebola presents a special case that may merit euthanasia because in addition to providing a merciful earlier death (although eliminating the remote possibility of recovery), the earlier death will end the production of the virus in the body.

Limited options after death

In this latest case, I notice that the body was quickly cremated.  Making efforts to save the life until the last possible moment leaves the body so concentrated with the virus, we eliminate all funerary options except cremation, and we require the cremation to occur quickly.   One of the things that I find concerning is that death by late-stage Ebola also prevents the opportunity to do an autopsy.  Autopsies of Ebola victims may provide more information about how the disease attacks the body’s organs and possibly some cascading consequences.   This information may help us identify better treatments.   Safe autopsies are not practical because the body remains too infectious.   An earlier death may reduce the risk and thus permit some additional level of forensic analysis.

Treatment in place instead of transport to hospitals

The main motivation for this post was the extraordinary transportation of the severely ill patient in order to access a supposedly superior treatment center for this disease.   In an earlier post, I described that we should start to think of two categories of health care.   The approach for treating infectious diseases can be very different from non-infectious diseases and conditions.   However, our current approach is to send both categories to hospitals.

The health care for infectious diseases (especially viral diseases) involves relatively simple medical technologies of isolation, bed, hydration, and some medications.   This level of care can be provided locally without any need for transport.  With suitable protective material, this care can occur at home without needing to transport to a hospital at all.

Infectious diseases can progress to begin to cause organ failure and such situations need hospitalization.   However, when a disease like Ebola has high fatality and infectious rates when it reaches this stage of organ failure, bringing the patient to a hospital risks infecting the healthcare workers and other patients.   An ethical case may be made to allow the natural death with prompt burial or cremation rather than to bring the infection risk into a hospital.   The current policy is to treat in hospital and not stop trying to save the patient until the very end.   I think it is worthwhile to at least have a debate about whether this really extraordinary effort is appropriate.

I noted that Dr. Salia was a trained surgeon.  I assume there are many surgical services he could have been providing to the local hospital.   However, Ebola treatment typically doesn’t involve treatment by surgery.   As mentioned, I have no information about how he contracted the disease.   But it seems likely that his role was limited to treatment of non-Ebola conditions.  If so, he may have contracted the disease because of the coincidence of there being Ebola patients in the same building.  If this is what happened, it illustrates the collateral risk of attempting to treat Ebola (or other infectious diseases) in a hospital that also provides treatments for other conditions.   This risks of bringing infectious disease patients into hospitals may be unacceptably high.

Obligation to participate in healthcare

I am bothered by the loss of free will that occurs when we come down with some illness.  When we become ill, we will very likely seek out care for the hope of getting cured.   However, once we enter the healthcare system we seem to lose any rights to get out of it.  In the case of Dr. Salia, his illness was in a very late stage when someone decided to transport him to Nebraska Medical Center.   The description from the news reports indicates that no one is sure why this transport was considered or who approved it.   There is a chance (and I think a likely chance) that Dr. Salia would have preferred to remain in Africa instead of enduring the reduced care environment during the day or two of transport between hospital beds.  Instead, it seems other authorities had made this decision on his behalf.

I did read reports that the family requested the transport and offered to pay the expenses.   I doubt that this was his personal request, but maybe it was.   I suspect the transport was arranged or encouraged in part for the opportunity to treat an advanced Ebola case in the US hospital setting.   Our recent successes gives us confidence in the experimental medication and the observed curative power of transfusions from a cured patient.   I suspect the medical science invited this case for an opportunity to prove they had a curative solution.   Certainly, he received these treatments promptly when he arrived.

This appears to be another example of what I discussed in an earlier post about the obligation to participate in healthcare for the sake of gaining better knowledge about treating a disease.    In that post, I considered the options of declining further treatment or even choosing medically-approved suicide.   Dr. Salia’s case presents another option of whether he had a say in terms of staying in Africa to continue to fight the disease locally.   I suspect the goal of bringing him to a US hospital overruled his personal wishes or even his own professional opinion.   We needed this opportunity to apply our latest discoveries to save his life.   He may have died in either case, but as I quoted earlier, there is an opinion that he might have survived if he were not transported to USA.   I worry that we may have compromised his chances of survival for the learning opportunity to treat him with the latest techniques available in the USA.