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Experiences of CDC and Emory Health Care in Managing Persons Under Investigation for Ebola

This information is for historic and reference purposes only.  Content has not been updated since the last reviewed date at the bottom of this page.

Moderator:Loretta Jackson Brown

Presenters:Timothy Uyeki, MD, MPH, MPP, Michael D. Christian, MD, MSc, Niranjan (Tex) Kissoon, MD, FRCPC, FAAP, MCCM, FACPE, and Lewis Rubinson, MD, PhD, FCCP

Date/Time:March 26, 2015 2:00 pm ET


Welcome and thank you for standing by. At this time all participants are in a listen-only mode. After the presentation there will be a question and answer session. To ask a question at that time you may press Star 1 on your phone and record your name when prompted. This conference is being recorded. If you have any objections please disconnect at this time. I would now like to turn the meeting over to Ms. Loretta Jackson Brown. Go ahead ma’am you may begin.

Loretta Jackson Brown:

Thank you (Sharon). Good afternoon I’m Loretta Jackson-Brown and I’m representing the Clinician Outreach and Communication Activity, COCA with the Division of Strategic National Stockpile at the Centers for Disease Control and Prevention. I’m delighted to welcome you to today’s COCA call, Emergency Preparedness for Clinicians from Guidelines to the Front Line.

Free continuing education is offered for this COCA call. Instructions on how to earn credit will be provided at the end of the call.

CDC our planners, presenters and their spouses partners wish to disclose they have no financial interest or other relationship with the manufacturers of commercial products, suppliers of commercial services or commercial supporters. Planners have reviewed content to ensure there is no bias. This presentation will not include any discussion of the unlabeled use of a product or products under investigational use.

At the end of the presentation you will have the opportunity to ask the presenters questions. On the phone dialing Star 1 will put you in the queue for questions. You may submit question through the Webinar system at any time during the presentation by selecting the Q&A at the top of the webinar screen and typing in your question.

At the conclusion of this session the participant will be able to outline the five main levels of disaster preparedness and response from the American College of Physicians guidelines for care of the critically ill and injured during pandemic and disasters, discussed the importance of pediatric emergency preparedness for both pediatric and non-pediatric providers, identify key lessons learned from the recent Ebola outbreak for improving emergency preparedness in North America and describe ways clinicians and public health practitioners can collaborate to respond to disasters and pandemics.

At this time I would like to introduce Dr. Tim Uyeki, the Clinical Team Lead for Ebola Response at CDC. Dr. Uyeki will provide an overview of today’s call and introduce the presenters for today’s COCA call. Dr. Uyeki.

Dr. Tim Uyeki:

Thanks Loretta. So I wanted to really thank all the participants. And we have three very distinguished speakers today. And to start out with introducing the topic I really want to stress the importance of linking up the public health community with the clinical community and in particular our critical care specialists on the adult intensive care and pediatric intensive care side.

I think there’s clearly a real need for the public health and the clinical community to work closely together in the planning stage as well as the response stage for disasters that might be of natural disasters, hurricanes, tornadoes, fires so forth that might result in mass casualty events in which children and adults might be admitted to not only emergency rooms and wards but especially to intensive care units.

In addition it’s pretty clear that we need to work very closely together to plan for the response for large infectious disease threats both epidemics as well as pandemics. And as an example I think, you know, 12 years ago the emergence of the SARS associated Corona virus and the pandemic that we had certainly during the first six, seven months of 2003. We didn’t have that many cases in the United States but certainly our colleagues to the north of us in Canada had some outbreaks, particularly large outbreak in Toronto. This involved cases that became critically ill and also affected healthcare providers caring for those.

Another recent example where public health and the clinical community need to work very closely together was in 2009 for the emergence of the 2009 H1N1 virus, influenza A virus that caused the global pandemic. The first signal for the severity of that came from the adult intensive care unit in Mexico City and in Winnipeg, Manitoba. We then realized that the severity was not quite as great at the tip of the iceberg. But in particular what was notable about that pandemic was a large proportion of cases occurred in otherwise healthy or previously healthy young adults would not typically be folks that you would see critically ill with influenza complications.

More recently since last year I think everyone is familiar with the Ebola virus outbreak in West Africa. And not only has it been a tragedy in the three most impacted countries of Guinea, Sierra Leone and Liberia but it’s affected neighboring countries. And we’ve had a relatively small number of patients but there have been to date 26 Ebola virus disease patients who’ve been either medically evacuated or imported to Europe and the United States with some secondary cases in healthcare personnel. And in the US to date we’ve had 11 Ebola virus disease patients. Of those, two have died, eight have survived and one is currently critically ill while actually I would severely ill, has improved thankfully.

But what is this really masks is the impact on the health care system and it’s clearly affected all of North America as well as worldwide because of the travel from West Africa and the need to really closely monitor individuals who have had travel history or potential exposure to Ebola virus disease in patients in West Africa and the affected countries. And so we have seen the need for the critical community and the public health community to work very, very closely on following suspected cases of Ebola virus disease many of which have had malaria or other tropical infectious diseases.

But this is really highlighting the need for close collaboration. So with that I would like to welcome our speakers. We have three very distinguished speakers today.

Our first speaker is going to be Dr. Michael Christian. And Michael is currently the Chief Safety Officer at Niagara Health Systems. He’s very active in national leadership in the area of critical care as well as disaster response in Canada but as well as North America. Mike is a very unusual guy in that he is actually both an Infectious Disease Clinician as well as an Adult Critical Care Clinician. And he’s used that expertise in a number of infectious disease emergencies. He’s been very active internationally and nationally. In particular he’s also a member of the executive committee at the America College of Chest Physician’s Critical Care Task Force on Mass Casualty Critical Care. And he’s been involved in many other activities.

Our second speaker is Dr. Tex Kissoon. And Dr. Kissoon is the Past President of the World Federation of Pediatric Critical Care – sorry Pediatric Critical and Intensive Care Society. And he is currently the Vice President of Medical Affairs at the British Columbia Children’s Hospital and a Professor of Pediatrics and Surgery in the Department of Pediatrics at the University of British Columbia in Vancouver. He is very, very well recognized internationally in the area of both pediatric emergency care as well as pediatric intensive care. He’s been extensively published. He has been – he’s worked very widely particularly in developed – in developing countries and middle-income countries. Hey also holds an Endowed Chair in Acute in Critical Care Global Child Health at the University of British Columbia.

Our third speaker is Dr. Lewis Rubinson. And Lewis is currently Associate Professor of Medicine at the University of Maryland School of Medicine. But he directs the Critical Care Resuscitation Unit, the shock trauma unit at the R. Adams Cowley Shock Trauma Center. Lewis is an Adult Intensivist and before coming to the University of Maryland he was the Acting Chief Medical Officer of the National Disaster Medical System in the Office of Emergency Management within the Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services.And Lewis served as Chief Medical Officer for a number of major events particularly Super Storm Sandy, the 2013 Presidential Inauguration and the Democratic and Republican National Conventions. Dr. Rubinson is an internationally recognized leader in mass critical care preparedness. He has published and lectured extensively on this topic. He’s been especially a proponent of establishing systems and responses to ensure clinical education during public health emergencies. He did – Lewis led the largest critical care registry that was established during the 2009 H1N1 influenza pandemic. And he currently is the co-chairperson of the United States Critical Injury and Injury Trialist Group Program in Public Health Preparedness. And he is continuing extensive work. And of note recently Lewis spent a month as the Clinical Lead at the Kenema Government Hospital in Sierra Leone for the World Health Organization working in the Ebola treatment unit seeing many, many Ebola patients there.

With that I want to turn it over to Dr. Mike Christian who’s going to speak an emergency preparedness for clinicians from guidelines to the front line particularly talking about the task force for mass critical care. Mike?

Dr. Michael Christian:

Thanks Tim and it is an honor to be introduced by such a noted a person as yourself as well. So disclosures, I have no financial or off label disclosures. I – my title because I just changed careers, was a Major in the Royal Canadian Air Force but that’s still on this slide. However I’m now with the Reserves but none of my comments are the official position or policy of the Department of National Defense or the NHS Health System.

So first just a thanks for their support in allowing us to do the work that we’ve done with the development of these guidelines. This is the second generation of these guidelines now.

But first and foremost the Chest and the American College of Chest Physicians but also of course CDC with their generous support in grants and funding for this as well as UC Davis and University of California and the Department of Health and Human Services in the US.

So we all know I’m not going to delve into this but disasters occur of multiple different types and scales. And emergencies have surged from minor right through to major all around the world. And this is an issue that we always have to face. Some of the pictures here of course are the Boston bombings, the Japanese tsunami and then also the Rio nightclub fire some – the Brazilian night club fire — some major disasters that we’ve had in the recent past.

The challenge we face though is although these disasters occur all the time high quality evidence unfortunately is lacking. But people still need guidance and we still have to have some approach to respond. So that’s where our guidelines particularly come in.

So I’m really just going to walk through and give a very quick overview of the guidelines. And so mostly I point people in a direction and give a level of awareness what they can find in the guidelines when they go to search for them. To me they are free available free and online at the Chest Web site. So if you go to the guidelines section you can access all of these chapters.

So the basic overview is the introduction and executive summary. And I have to note to my co-authors on this, Asha Devereaux, Jeff Dichter who are not on this call but also Lewis and Tex who are on this call with me today. And this is many years of effort from all of these people plus all of our members of the panel and panels that sat on this to create this well over 100 some odd people in the development of these guidelines. So the big difference with his current guidelines is the methodology from the first guideline.

So the first guidelines were published in 2008 and were really a consensus-based document bringing together the people that we had. But this time we really increased the, raised the bar in terms of the methodology and the rigor that we used.

Initially – I’m sorry we’re on to the methodology slide. Now I forgot that I have to keep on telling you which slide we’re moving too, sorry. The methodology slide, so this is what we did this time is we looked for evidence but unfortunately evidence was not readily available as we would want so we had to stick with the consensus process. But we made it much more rigorous.

So next slide, the task force included 100 participants, just over actually. So we had 14 content experts, 68 panelists and 18 topic editors coming from nine countries around the world a number of continents with a wide variety of specialty disciplines involved in this time everyone from critical care through trauma surgery, pulmonary internal medicine right through to hostile medicine ethics legal, law and public health.

We also tried to strengthen the quality of the document by having a much more diverse number of professions that were represented of course physicians, nurses and respiratory therapists but also pharmacists, public health and administrators among others. We also included a greater variety of representation from the adult and pediatric populations with representation from 15 different professional societies.

And this was – went on at the end of publication or for publication towards extensive literature reviews both internally with in CHEST as well as external peer review. And we relied upon the PICO and Delphi methods in developing our recommendations.

So the list of the reviewers — next slide — is available online but is a broad number of people so again trying to increase the rigor of the documents that we were able to produce in the guidelines.

Next slide, This is just to tell you that this end result of our work were 12 manuscripts with over with 267 suggestions, 177 pages long as I said all of which are freely available online at the CHEST Web site.

The number of associations — next slide — that endorse this are listed here. And again we have a wide variety of the key societies in both critical care as well as trauma and other types of emergency medicine groups that supported these developed and these guidelines and the final guidelines.

Next slide, so the – I’m getting into the chapters now. So the first chapter, first two chapters actually focus on surge principles and they really cover the bases in terms of the structure that needs to be in place. The first one is on surge principles then we dive down more into the actual, the actual depth of surge logistics. But again we talk about how the individual hospital level fits into a whole system of care right up to the national and through to the international and some kind of in some situations.

Next slide, the surge capacity principles delves as well into the issues of how does mass critical care which was the primary focus of the first supplement fit into the whole spectrum of care? So we see here that we talk about surge size from minor through to major and that this correlates with the response capabilities or response frameworks from conventional contingency onto crisis and how, you know, the critically ill in all of these different sizes of surge require different types of strategies to care for them. And that’s on the slide to the right of the – or pics figure to the right of the slide which talks about our addressing it through the staff stuff in space as well as standards of care and strategies for expanding ICU for caring for the critically ill.

The other thing I’ll mention is that the other unique thing about this document is that it’s really care of the critical and injured wherever they are. It’s not just in ICUs. It’s any place in the spectrum where these of health systems in hospital and out of hospital that this document covers.

Next slide, we go on then to talk about surge logistics. And this is really digging down into the staff stuff and space that people require to care for these populations of patients and provide very useful tables and information about with detailed information for the frontline providers in terms of how they need to prepare, how they need to thing about stockpiling what services they need to consider having available.

Next slide, the – we then move on to evacuating ICUs. And this is particularly pertinent after the issues with the hurricane in New York and provide information about types of things around agreements that need to be in place, the role of assimilation planning, requesting assistance, equipment, how to prioritize patients, how to prepare them, how to distribute them as well as information transfer and transport methods and tracking and provide some strategies and guidelines particularly focus on the critically ill patients in terms of how do you frame the decisions about to evacuate and not to evacuate and how to go about doing it when you do make that decision to evacuate.

Next slide, so we then move on to triage and resource allocation. So and again how do you decide when you do get the point after you’ve expanded your resources to the maximum capacity how do you make decisions about prioritizing where those resources that you’re going to have and trying to do the most for the most to have the most number of people live at the end of the day. And this chapter provides a discussion around both the system and process that needs to be in place as well as delving into some of the actual decisions that need to be made.

Next slide, we have a chapter on special populations of critically ill and injured recognizing that there are certain groups that are particularly vulnerable particularly those that are on dependent for life support on a regular basis and how to prepare for them to hopefully mitigate the need for them entering the healthcare system during a disaster but also how to manage some of the special considerations if they do and what plans and preparations need to be in place.

Next slide, we then move onto sort of the 100,000 foot level of system planning and coordination and communication and talk about of all these different piece of the puzzle need to be put together. And we look at things like the government structures and how they interface with the hospitals and lower level structures communication networks and flows and what needs to be in place and then how to manage surgery resources at the highest level and coordinate the whole system.

Next slide, we also include a section on business and continuity of operations particularly for hospitals and healthcare systems to understand their vulnerabilities in supply chains there we see even on a day to day basis now with sometimes manufactured drug shortages. But particularly during disasters when we have limited suppliers of critical items, health information technology and how much we depend on that now and the continuity after disasters as well as preparedness of planning for this information systems during disasters.

Next slide, and moving towards the end of the chapter as we start to discuss engagement education and the need for this to be part of medical school and other health professional curriculums but also how to disseminate this, how to engage the providers on the front lines so that they’re prepared to deliver this because these guidelines are fantastic to have. But unless they’re actually people are aware of them and they’re disseminated they’ll have minimal impact.

Next slide. We have a chapter on legal preparedness that discusses the need for mass critical care plans, issues around evacuation resource allocation and triage, multijurisdictional plans and how to legally prepare the system to respond in a disaster that involves large numbers of critically ill or injured patients.

Next slide, we have a chapter that delves into the ethical considerations laying the framework for upon which decisions around triage and resource allocation are made. Duties to patients’ families, patients and their families, responsibilities to providers, duty to care, et cetera, and also conduct of research and the role of responding to international disasters on the part of various groups and organizations.

And then finally the last two chapters address care of the critically ill and injured in resource poor settings outside of the typically developed world and offer a number of strategies which has been very pertinent to what we’ve seen with the Ebola outbreak.

I’ll hand this off now to my colleague Tex Kissoon to speak more about the pediatric focus within disaster preparedness but also within the guidelines. Tex.

Dr. Niranjan (Tex) Kissoon:

Thanks very much Mike. May I have the next slide?

Loretta Jackson Brown:

Your slide is up sir. Please move forward.

Dr. Niranjan (Tex) Kissoon:

Okay great. I also have no financial conflicts and no off label products.

Basically with pediatric preparedness we have been woefully deficient in pediatric preparedness in very many areas. And what I’d like to discuss today is the value of preparing is a threat to real in pediatrics is it worth there? But I think most of us on the call would agree it is. And some of the challenges as it relates to children and then talk about some of the preparedness guidelines that was really initially fueled by the supplement that was sponsored by the CDC that was in pediatric critical care medicine, some of the IUM guidelines and then the – our ACCP guidelines that Mike spoke about.

Now disasters are not rare. In fact there are usually about 40 or 50 a year. And many of these we do not hear about it. And furthermore no part of the country is immune to these disasters so I would say that yes the preparation is worth it. More so in children what we have is that there are few pediatric hospitals. In fact when you look at let’s say Washington State there’ll be one pediatric hospital in many places.

There are a small number of pediatric beds or a small number of specialty centers that can take care of children. So when we think in terms of a large number of children let’s say about 300 to 500 critical ill injured children from any major disaster we are looking at really mobilizing a tremendous amount of resources.

And if we are not prepared this can lead to a major issue and (unintelligible) the children. Because when we look at the United States very few emergency departments, in fact you see here only 6% have all the supplies. And many emergency departments are woefully undersupplied for the critical equipment and skills we need.

Furthermore pediatric skills deteriorate very rapidly. And in many cases until recently disaster preparedness have really under looked the needs of children. Also when we look at the study looking at the EMS systems in the United States many, in fact only 30% had a pediatric specific plan. There were very few, less than 20% with pediatric beds in triage system and in many cases only about ten or 12 cases can a pediatrician being involved in local planning.

So the fact is with these sort of numbers one can understand what is happened then. In fact looking at the response to Ebola in West Africa many of the same issues have arisen.

So the issue that Tim presented earlier on this is not a thing of the past. You can see many patients require critical care respiratory support, et cetera. We think that we need to prepare because this may happen again.

So what are the challenges with children? Well under normal circumstances we know that survival for children is better when high risk complex conditions are treated in pediatric hospitals, both the ICU data NIC data and trauma data have shown this.

On the other hand we know that children are also very vulnerable for a variety of reasons from the point of view of biological, physiological reasons, smaller airway size, dehydration, immunological compromise, et cetera. They tend to have psychological problems, behavioral problems which family centered care has to be introduced very early on to mitigate some of it.

And also the fact is that in many cases the deficiencies of many of the things that children need because whereas the adult is mostly one-size-fits-all in children the equipment, the staffing needs, the system that has to be created for children are also very unique. So we have also had in the past as Mike did mention SARS epidemic we had very sort of mixed messages when it came to SARS.

As you can see on the one hand children are markedly well protected. On the other hand you can see where the child is not protected and the adults are. And this sort of schizophrenic approach has posed a problem for us.

So to summarize so far we know emergency department and emergency medical services while they are unable to meet everyday challenges there is no doubt they will be unprepared for disaster. We know that most of the pediatric hospitals – most children are seen in pediatric – non-pediatric hospitals, for instance general emergency department.

And we know that in many instances included as I said the Washington State and New York State, et cetera, and even in Canada is the same issue there are very few pediatric beds and very few vacant for disaster surgeons. The pediatric beds are clustered also in a minority of hospitals which poses a difficult situation.

Moreover clinical – the critical care beds are also clustered in those specialty hospitals. And if these specialty hospitals are nonfunctional for whatever reasons it stands to reason that hospitals with – adult hospitals or mixed hospitals will have to take care of these patients.

So while regionalization works on everyday circumstances the fact is in a major disasters or pandemics the normal and regionalization of high risk complex conditions and pediatric hospital will not or may not work.

So to prepare for that there are other challenges too with children. The fact is that many of the systems do not have good tracking mechanism to track critical care needs and resources in real-time. Real-time analysis of clinical syndromes, age specific differences, and risk factors for children and complications we need to be able to track these in real-time because many of what we had seen including Ebola now each one and one when it was then SARS we we’re seeing it for the first time and real-time analysis is going to help.

Moreover when it comes to children there’s a dearth of clinical trials and medications. The fact is research across the board from both pediatric and adults are woefully deficient and must be turned on with preapproved protocols because we will not be able to address those in real-time when a disaster occurs. So the so talent is very important. I think we will all agree with that.

So what I’m going to say in the next few slides is based on this pediatric critical care medicine supplement that I mentioned previously some crisis standard of care from the IOM [Institutes of Medicine] and also what – the supplement that Mike had spoken about. So in children there are several suggestions that came out of this. And I will give you the suggestions very briefly.

So the – one of the first suggestions when we talk to increase capacity in children is that regional planning should include the expectation that all hospitals can provide initial stabilization for children and regional expertise for children should be included in all planning. In fact we also suggest that the access to regional expertise for care of patients requires specialty critical care including just-in-time response because with children as I said the referral pattern may change.

We also suggest that we have a regional stockpile of equipment, supplies and pharmaceuticals for children because these are unique. And we – when we say regional stockpiles we should not forget infant formula and diapers, et cetera.

We also should look for expert consultation in pediatrics. And every effort should be made to ensure that expertise is available at least by minimum by remote consultation. And hence we need to use technology as a multiplier in this case. For instance telemedicine may be able to work and other sort of electronic platforms. Boeing evacuation of children also provide unique challenges. So the transport system for children, for technology dependent children has to be organized a priority. For instance incubators for young children in neonatal ICU we need to designate hospitals that will accept these patients. We need to have certainly warmers that – and also specially adapted ventilators, for instance the gas flexible neonatal ventilators, et cetera, that can be used for children. So evacuation for children will pose a unique challenge.

Now some of these suggestions on triage refer to both pediatric and adults in the sense that what we said that in – when we have special populations and now children and others considered a special population. They may be unique but they are not a special population because they are distributed from their entire society. But for trauma, burns and four children and for the critically ill if we have triage officers who do this on a daily basis this would really facilitate triage more quickly.

And we also suggest that we have these tertiary care triage protocols for use during a disaster such that we can make a rational decision based on inclusion and exclusion criteria that will develop a priority. We also suggest that patients who have a low probability of survival and where significant benefit is unlikely be excluded from ICUs and we have some suggestions for those that are spelled out in the document.

I did mention as I said special populations. Now children are not a special population. But special population refers to those populations that present unique challenges who are chronically ill and technology dependent. For example those who are on chronic dialysis and those who are ventilator dependent at home. So these are the special populations that we need to prepare for because admitting them to an acute institution may overwhelm our resources.

So what we suggested is that for these specific populations the healthcare correlation and regional health authorities should have the ability to track these populations. They should designate specialist resources for these that may be outside the hospital or with partner hospitals that will not be taking critically ill patients and there again leverage other things like telemedicine capability and utilize resources such that we can use the technology as a false multiplier to keep these patients out of the acute care hospitals.

This really summarizes much of what I’ve said before it’s to really coordinate at a system level we need to have pediatrics involved very early on. We need to designate the pediatric surge personnel and where kids will be going. We need to identify the transport. We need to identify key supplies and medications. And we need to have educational resources such that just in time sort of education is there but also a priority to provide links such as those who would be taking care of children welfare. In addition in the adult hospitals we think that we should identify those who have experience with children and who are willing to care for these children.

And with this I’ll turn it over to Lewis.

Dr. Lewis Rubinson:


Loretta Jackson Brown

Go ahead Dr. Rubinson.

Dr. Lewis Rubinson:

So my first slide will be my title slide and then moving on to disclaimers and disclosures.

The most relevant disclosure that I have is that I was a consultant for the WHO during the fall of 2014. And this talk is in fact does not represent any form of WHO guidance or policies. And the analysis and opinions are only my own. In addition I’ve put in a number of disclaimers and disclosures related to both grant and contract work I’ve done as well as being on scientific advisory boards for disaster related events. I’m not going to speak to any off label use of any products during this discussion.

Next slide, so Ebola virus disease as with many serious transmissible illnesses predictably causes severe organ dysfunction. So in planning and also during the response it was clear that the critical care entities would likely play a role. This – the next following slides are going to talk not as much about the guidelines which Mike and Tex are really heroically summarized but in fact we’ll talk more about how are we doing to date? When we tried to apply some of the principles to the guidelines what did we get right and what are still some opportunities for improvement?

So again in thinking about next slide which is organ dysfunction and death it’s clear that Ebola through its pathways to leading to death causes organ dysfunction. And when you look at to the right of this slide severe academia as well as renal dysfunction as well as whether or not the AST correlates with Rhabdo or within fact liver dysfunction is difficult to tell because these studies were done with point of care testing where we’re not able to get creatinine kinase done at point of care testing.

But it looks like clearly renal dysfunction, hematologic dysfunction and severe metabolic academia are part of the syndrome of severe sepsis or septic shock associated with Ebola virus disease. And therefore if these patients were treated in an environment where critical care was expected that there needs to be some planning to be able to provide organ support.

Next slide, so EBD and critical illness. The overall impact and expectation of what role the ICUs in resource rich environments would play for Ebola was unclear. It was expected that there wouldn’t be large numbers of cases tracking back to Europe, South America or the US. And in fact that has been the case. It’s been less than 30 overall. And then trying to figure out how many folks would actually have organ dysfunction, who would be in resource rich environments is also difficult to predict given that the description of organ dysfunction is quite sketchy at best still in West Africa. In addition we don’t know if there’s any way to forestall critical illness by earlier treatments whether it’s with disease specific therapies or with just general supportive care.

The common consensus among providers who’ve been out in West Africa have also practiced in resource rich environments is there probably is a way to reduce the amount of critical illness with supportive care. But again the likelihood that we can make it zero is very unlikely.

Therefore definitive treatment sites in the US, Europe, et cetera, really should expect that they’re going to have to be able to provide critical care support for people that are either coming back as part of a repatriation from known illness or if there actually unknown imported cases that show up at Western hospitals. The flipside is it’s not business as usual. So given the issues around transmissibility, critical care has been proposed to need to be modified.

If it’s just business as usual the communication that needs to happen between public health and critical care probably is less important unless surge is very high. But when you’re actually changing the provision of care there needs to be people who are experts in a variety of different elements to really speak at what’s the best way to protect healthcare staff but also to give the best possible care to the patients.

Next slide which is called Emergency Mass Critical Care, these principles of using expert opinion of a diverse background of people to try to weigh-in on how do we modify critical care whether again it’s to modify critical care to surge or modify critical care to protect healthcare workers the consensus statements that initially started in 2004 were redone again in 2007 and now most recently published in Chest which Mike went over shows us that there’s a way to actually deliver this guidance.

Unfortunately though most of these efforts typically happen in peacetime and there hasn’t been a mirrored response effort that allows us as we get to know more about an outbreak to be able to really give guidance in near real-time to clinicians to be able to understand what are the things they should change. Because again we do not need to teach critical care providers how to provide critical care. What we really need to do is to inform them how to change what they normally would do to either be safe or to be able to treat larger numbers of patients.

So next slide, this is the one entitled Rubinsons’s Principles. So unfortunately what mostly happened during the current outbreak is a number of people such as myself had to really make up principles. And they weren’t really consensus principles. They weren’t broad-based principles. They were principles made up by a variety of people with a variety of different backgrounds. I think most of them are defensible. But I think our opportunity for improvement was we probably could have got more guidance from more input from a wider range of people to be able to guide out a way potentially provide care in Ebola treatment units — this slide’s specifically for US hospitals — but in any resource rich environment.

Next slide, this one’s entitled The Devil’s in the Details. So when we are in the midst of a response or still planning clearly there sometimes will be untoward or unintended consequences. Even though there are well- meaning guidance sometimes guidance will in fact when it gets pushed down to the end-user clinician may in fact create new problems that weren’t seen. It may have been able to be identified earlier had an acute care specialist been more in the conversation.

The first one I draw to attention is next slide, general isolation strategies. Clearly with the concern for both the perception of how Ebola is transmitted in addition to how Ebola likely is to be transmitted patients when they were brought into modern facilities were not expected to be able to travel through the Hospital and probably would not get access to most of the technological diagnostic equipment that’s used for modern day both acute- care and critical care management.

Because of that — next slide — there were potential possible adverse consequences. As Dr. Uyeki already told us there’s only been 11 patients in the US that have Ebola. And in fact we have 5700 plus hospitals probably about 3700 with ICUs. And there were a fair number of persons under investigation screened in a variety of these hospitals. So the first box which is the green box suggests that what do we do if we’re immediately isolating someone with a travel history if they have signs and symptoms of time sensitive critical illness such as something that could be suggestive of a CVA?

Next box within that slide, so should those patients immediately be isolated or should they go to a CAT scanner and be evaluated to see if they have evidence of a stroke and if they don’t to be considered depending on their NIH stroke scale and their consultation with a stroke expert of whether or not they should rapidly be administered intravenous TPA.

Next sentence down, in addition the patient in fact especially with new data that’s now available — and this has been a process that we’ve used in our institution for quite some time before even the most recent studies – should the patient go to the neuroangio suite even though they may have a travel history suggestive of Ebola? But what if the more likely thing is they don’t have Ebola and now they don’t in fact get the ability to have a thrombectomy or ambulectomy?

Next box which is the blue box, how do you decide what’s best for the patient? How is staff safety actually factored in which usually is not a major part of our decision-making in modern healthcare facilities? And how to do this in such a fast way that allows for the time sensitive window not to be lost and who’s responsibility is it?

Next slide, so where I work we had started to work on building a rapid Ebola virus disease assessment team given our concern for potential untoward consequences of isolating someone so early who had a low likelihood of having Ebola but was going to be mandated that they’re isolated when in fact they would miss a time sensitive window for critical illness.

I think most of us have been able to dodge this bullet. But again it comes down to best intentions of local public health agencies, state public health agencies, federal agencies as well as professional societies and bedside clinicians to really probably have a more active discussion on how do we ensure that we minimize harm to people during our response? Even if we have our best intentions in mind we really need to be thoughtful about what the guidance actually leads us to do.

Next slide which is the potential for transmissibility as Ebola dramatically reduces surge. So while there is general consensus on the most likely ways that Ebola is transmitted I think there’s still not 100% consensus on whether or not fomite transmission is possible and whether not airborne transmission may be possible in certain scenarios. Given that uncertainty the best we can do — next slide — is to go back and look at data. And unfortunately when you look at previous event much of the data was quite limited. Now fortunately there was some decent epidemiologic data to help generate expectations of how Ebola might be transmitted.

Next slide, but even when you look at things such as sweat in the 2007 study which I showed before there was only one evaluation of one sample for sweat that was negative for PCR and negative for culture. And then there was sweat that was positive for PCR in Germany. This potentially creates confusion. And while clearly this is part of a burgeoning effort to be able to learn about transmission the uncertainty can have profound impact on the delivery of care in institutions.

So next slide which is the uncertainty impacts of capacity and capability, when we talk about overall surge in the US for most disasters we talk on the order of being able to increase even critical care capability, you know, sometimes 100% up to 200% depending on timeliness of the event. For, you know, anecdotally in talking to a number of people that had institutional Ebola treatment units most of us felt like we could do one or two patients. So you can imagine the dramatic reduction in surge that is there when you have a disease that is perceived to have a high transmissibility with low therapeutic options. And that will dramatically impact the posture you have to be able to take care of any patients.

Next slide, so when we look to a modern organ support I still think especially in the critical care community there continues to be a need for better discussion on as we change the way we therapeutically interact with patients and we do more to their airways and we do more physiologically to the patient, the traditional categories of infection control may or may not still be relevant. And we need to be able to make sure that we can ensure our staff that the best possible safety means are being used and that there’s ongoing learning so that we don’t just guess at how it’s being transmitted but in fact that we learn over a period of time.

I think Mike O’Connor, and I believe a group in Europe did the same did a tremendous service by even through single patient on renal replacement therapy being able to look at the effluent of continuous renal replacement therapy in one patient. And demonstrating that you cannot in fact find virus in the effluent was very, very useful. And I think those are the kind of things that we need to have collaboration between diagnostics experts, public health experts and clinicians to be able to more readily understand our technology in the midst of an outbreak.

So finishing up resource intensiveness to prepare and respond for EVD requires regional collaboration. The strength in the US is we have 5700 hospitals. Our struggle in the US is we have 5700 plus hospitals. It’s very hard with that multiplier to be able to maintain a state of readiness across all of those hospitals. And even in every day care there are different roles and responsibilities of different institutions. The struggle with our privately run healthcare system though is who coordinates that especially during a response? And especially when there’s certain economic and business decisions that may bode poorly for an institution that’s standing up.

I think the ASPR HPP program through their recent granting effort to be able to provide resources to facilities that did step up as Ebola treatment units as well as looking now at ten regional referral centers is in the excellent step forward at being able to see one that we should not be redoing this for every disease and two that we can’t expect every hospital to have this same level of readiness.

And the last topic I’m just going to reach on is something that also came out of our guidelines and continues to be an ongoing struggle during outbreaks which is how do we learn and especially how do we learn in the timeliness of a response?

There are key questions — next slide — where failure is just not an option. We need to know those answers.

And we continue to struggle with getting those answers because there is not really a form to be able to come up with what those key prioritized questions are then to make sure that their resourced properly to be able to answer them. So the question of whether Ebola is transmitted by respiratory droplets is one. Clearly again there’s a number of folks who look at the West Africa data who say absolutely not. And I would agree from that data.

The thing is we do not know in modern healthcare environments when we use such things as high flow oxygen through nasal cannula, how does that change things especially when we can keep people alive more in the US than we can West Africa and they in fact may shed from their respiratory tract? It may happen, it may not happen but clearly that’s a question that needs to be answered because we saw respiratory failure in Europe and the US but not in West Africa. And then how do we make sure that people are safe taking care of them?

Issues on diagnostics needed to be answered. And then even some of the most basic things of what is a regimen for supportive care that we think actually works despite over 20,000 patients? We really have just scratched the surface and we truly don’t understand what kind of critical care should we be providing to these patients.

Next slide our strengths are we have really in the past ten to 20 years made the science, especially translational science excellent. Early in response the epidemiology of the outbreak is really continues to strengthen as IT support continues to be able to increase and data sharing increases. But on the opportunity level I think we still tend to be missing patient level physiologic data. And unfortunately almost everyone who would be collecting that is part of the response rather than being able to use a small subset of folks to ensure that we actually look at what we’re doing, ensure that it’s making a difference because there are a number of things that are well- intentioned which in fact may be hurting patients. We just do not know.

In addition it takes us a very long time to be able to pull the trigger on disease specific therapeutic trials. And the supportive care strategies and effectiveness continues to be unanswered questions which really should be the low hanging fruit.

And last slide I just want to bring up why this is so important. A number of folks outside of the critical care community think you can at least get safety data from being able to evaluate therapeutics. Given baseline organ dysfunction in these patients it’s nearly impossible to get safety data any better than you can get efficacy data. It might be a little easier but it’s clearly not something that you can do in an un-standardized way. Therefore we need to continue to have develop an infrastructure to be able to organize to learn rapidly to make sure our therapeutics are working. One example that FDA and BARDA has funded which I’m a PI on and think is a really great idea by HHS to continue to build that in support is using critical care research networks to be able to develop an infrastructure to just turn the lights on for these events so that we are able to better understand therapeutics when an event actually happens. We learned from 2009 H1N1 as well as SARS that if you didn’t have the infrastructure in place before hand it’s nearly impossible to get it going in the midst of the outbreak.

Last slide, thank you very much for your time. I’ll send it back to you Tim.

Dr. Tim Uyeki:

Yes thanks very much.

Loretta Jackson Brown:

I’m going to go ahead and just remind everyone that you can find additional information at emergency.cdc.govcoca. We also have a link under call materials to the article in Chest that the presenters have referred to. We will now open up the lines for the question and answer session.


Thank you. If you would like to ask a question please press Star 1 and record your name when prompted. That is Star 1 if you’re on the phones and you would like to ask a question. Please record your name when prompted. One moment while we wait for the first question.

Dr. Tim Uyeki:

Well, while we wait for the first question this is Tim Uyeki from CDC, I just wanted to thank our three speakers for highlighting many of the issues and the challenges as well including both for adults and children.

Also in addition to the Chest supplement as Dr. Kissoon mentioned the supplement in pediatric critical care medicine specifically focusing on the pediatric needs. Operator are there any questions?


I’m showing no questions at this time.

Loretta Jackson Brown:

And we do have one discussion point. And this is to Dr. Kissoon. What would be your suggestion to ensure children issues are adequately addressed in disaster planning?

Dr. Niranjan (Tex) Kissoon:

Yes that’s a very good question. I think that one of the things that we need to do I feel and based on what Lewis is already saying the number of hospitals private versus public, et cetera, this is not going to happen on its own or going to happen with just with goodwill. I think that there has to be some responsibility or some mandate from the government to say that this needs to happen.

For instance I think that what needs to happen is that there needs to be the mandate and resources such that adult hospitals will need to identify groups of individuals who may be able to take care of children who may have had past experience or sort of the willingness to do that. They also need to identify areas in the hospital where children can be housed. They need to identify just in time learning protocols, et cetera, that they’ll be using. And they also need to identify the resources that they’re going to have from other children have done, et cetera, and how many, ah, children they may be able to house.

But this is not going to happen just willingly because as we said that these episodes are unpredictable. We cannot predict when they’re going to happen. There need to be resources in place. And in times like this where we need to stockpile equipment, et cetera, and put resources into it I think that we need some federal mandate for it.

Loretta Jackson Brown:

Thank you. We’re going to go back to the operator on the phone. Any questions from the phone?


I am showing no questions at this time.

Dr. Tim Uyeki:

This is Tim Uyeki. I think since Dr. Rubinson brought up some of the issues about the need for rapid data collection and analysis and feedback I – I’ll ask Dr. Rubinson a question.

So you mentioned some of the recently funded projects. Do you have any thoughts about some other things that you would like to see move forward in order to facilitate clinical data collection and rapid analysis and basically to inform clinical management not just in the US but globally particularly when you mentioned the Ebola virus out – disease outbreak in West Africa, the collection of clinical data in West Africa and those challenges and sharing with the international community?

Dr. Lewis Rubinson:

Thanks Tim. Obviously that’s a complex question. But just getting at a few of the maybe easiest parts of that question, so I think the first thing is to look at the model of what we do well. And I would argue although I’m not in this community that the vaccine community is a very well-run community at being able to get a vaccine together and to organize a network and to have sufficient resource to rapidly learn during an event.

But what I think we need to do is to learn from that and develop parity for the acute management of people to be able to do the same. I think again preventive strategies and vaccine strategies are essential. And I’m not arguing to take resource away from them but instead to look at their successes.

And I think the struggle is typically we consider a clinical care that if you just put some good clinicians in front of them they’ll just figure out what to do. And unfortunately for many of us who are ICU clinical investigators we know that our best of intentions and even some good physiologic basis sometimes steers us a very wrong way. So we need very early on to understand the things, especially the things that would be different from what we do every day. And I think mostly that requires some international body to convene. Like you say, we need harmonization across the world.

In addition it requires a deploy ability almost like we’re still struggling to even get clinicians for an outbreak response such as Ebola. But we probably should have deployed a protected group of clinical investigators early on at the same time to be able to ensure we were learning. Because a year later we were in the same situation as we were when we started.

And in fact, I’m not sure that many people had those resources just been used for clinical care like they were I’m not sure that many more people got better care rather than having a small cadre of researchers out there at the same time being able to provide information. Clearly we need to make sure that it’s not just research for the sake of research but, it’s actually learning and learning to be able to improve care in West Africa at the same time so people who are being enrolled in clinical science actually have the potential to benefit or their community does.

But I think we need to rethink about how we send so called the clinical troops in. And there does need to be a group that really their main issue is about developing proper data collection, being able to analyze quickly and then most importantly being able to report back to the front line users so it makes a difference to the people who care the most. And that’s the communities that are impacted.

Dr. Niranjan (Tex) Kissoon:

Thanks Lewis. This is Tex. And two comments based on what you’re saying. I agree with you fully. But one of the pleas that I would make is that when we start looking at collective relevant data that would make a difference I think we should make every effort to include children. And as we know in many cases protocols a design or data collection is undertaken and children are not included.

The second point is I think that as you know well – we – as you’re rightly concerned we’re in the midst of the Ebola crisis and we’re dealing with that. But, as I said before, this another thing of the past. We will have recurrent things. And one of the issues and that we need to stress also is the strengthening of the public health systems and making the systems more robust in the regions such that they can deal with it.

Because obviously when we hear the lack of infrastructure, the lack of health care workers and the lots of fees in the healthcare system and other patients we have not stressed many more patients are dying from malaria and other forms of infection and sepsis. In fact about from what I understood about 20% increase in deaths from malaria, et cetera, that has not been highlighted.

So unless we have a robust healthcare system that can take care of those sort of situations we will have much untoward effect on other disease and loss of fees in healthcare system.

Dr. Lewis Rubinson:

Yes Tex I agree wholeheartedly with both of your points. I think every component of the response is crucial. And the public health infrastructure foundation is essential to be able to build your response. And absolutely right not only kids across the ages but especially with Ebola pregnant woman and other groups that we really needed to better understand quickly to see if treatments needed to be any different for them. Great points.

Loretta Jackson Brown:

Should we go to the phone? Operator do we have a question?


We do have a question. Our first question comes from Dr. (Nathan Berger). Go ahead sir, your line is open.

Dr. (Nathan Berger):

Good afternoon gentlemen. This is Dr. (Nathan Berger). I’m in Emergency Medicine attending in Louisville, Kentucky, wanted to go over some thoughts that we had in our community and see if you maybe could help us out if it’s a good idea or not.

Basically we’re really lucky in the Louisville southern Indiana area in that we meet regularly, all the hospital systems, all the heads of the emergency departments, all the ministers get together monthly or every two months and actually break bread with each other which is rare in other communities. And, you know, day to day we basically our hospitals on diversion including the children’s hospital.

And what we came up with and based upon what happened in Texas Presbyterian Hospital is that their census with, you know, the Ebola patient they got went from the high 90s down to, you know, the 5% so and low percentage. So besides, you know, the economic and business loss what’s going to happen to your hospital and taken down, take it out? So what are your thoughts on – we came up with – we identified a vacant building that we converted into a hospital medical type building near the local airport and staffing that by all the community hospitals just to keep the patients out of your hospital.

Because if not you’re going to take, you know, a couple people like well, just send them to our trauma center but it would take the whole hospital down. So basically, you know, working together and finding a building and keep them out of the hospital, your thoughts on that?

Dr. Tim Uyeki:

Dr. Rubinson do you want to address that?

Dr. Lewis Rubinson:

Yes, I was hoping you were going to pick Mike. Sure Tim I’ll start and Mike, feel free to chime in afterward. I could argue both sides of this. The – using a facility that would not be impact your everyday functioning of course is a very appealing thing. The downsides is processes of delivery of care as you know being an emergency department clinician it takes many iterations of chaos in an emergency department to fine-tune your processes.

When you put something in a whole new facility you generally have an enormous learning curve to try and figure out how to provide care again from what are the process is for ordering medicines, et cetera, et cetera. For having a single patient it probably could be done. And so, I’m not arguing to guess what you did. It’s just you had to be very cautious about delivering care in that situation.

I think a number of facilities have looked to use a part of their facility that doesn’t have ongoing patient care functions in order to isolate the delivery of care for Ebola from their every day care. But there is the potential obviously of either public perception or problems with functionality especially if there’s secondary transmission. Dallas is the only place where that happened with the other group places that actually had separate entities. They were able to provide the care. So I’m kind of talking out of both sides of my mouth but really give you more of what are the thoughts of which – how to think about each one. Because I see both being useful and both being potentially harmful. It really just comes down to as a community what works best for your community.

Mike, do you have anything else to add?

Dr. Tim Uyeki:

Unfortunately Lewis, Mike had to leave the Webinar and had other responsibilities. I think Mike are you still on? Yes, I think he signed off.

Loretta Jackson Brown:


Dr. Tim Uyeki:

So let me just see if Dr. Kissoon wanted to make any comments from the pediatric angle. Yes.

Dr. Niranjan (Tex) Kissoon:

Yes, no. I agree with everything Lewis is saying. But my question would be in this endeavor was children considered and what about regionalization for children in your area? You mentioned your children’s hospital. Do you have more than one children’s hospital or did you go about looking at other options for children’s also in this facility?

Dr. Lewis Rubinson:

We do have just one which is the Kosar Hospital. We have – they’ve got some satellite. You know, the next one would be the University of Kentucky. But that was also put into the system.

We were just trying to come out – come up with struggling with, you know, the day to day, you know, issues in the hospitals and then have this is -you, you know, and having one or two patients could take your hospital down. It’s just, you know, working together as a community to find a separate, you know, area to at least, you know, triage them with that with not impacting hospital.

But yes we have one major children’s hospital which is usually, you know, very busy on diversion. So we’d have to think about going to an hour and a half away to Lexington.

Dr. Niranjan (Tex) Kissoon:

Yes. So your situation is no different from any of us when it comes to children — same struggles.

Dr. Tim Uyeki:

Yes.So it seems like…

Loretta Jackson Brown:

Doctors we have a question from the Webinar.

Dr. Tim Uyeki:

Sorry, go ahead.

Loretta Jackson Brown:

…from the Webinar, and the participant wants to know what gaps have you all identified in the US EMS system?

Dr. Tim Uyeki:

Dr. Rubinson do you want to try to address that gaps in the US EMS system?

Dr. Lewis Rubinson:

Yes. I mean I haven’t seen any formal data. And I have some interface with both inter-facility transport as well as emergency medical and services. But I’m far from someone who does that for a living anymore. So I’m cautious to get too much of an answer. But clearly I think for the persons under investigation that we had the changing guidance and the issues of what level of PPE, what provision of care should you deliver, how should you interface with your healthcare facility, how do you doth your PPE? How do you get your ambulance back into service?

Obviously that took some time for a variety of different organizations and agencies to really get that to the point where they probably felt functional and operational. And my guess is there’s probably still some organizations that are still struggling with the variety of the issues of the potential to transport especially an unidentified patient, you know, someone who they haven’t even identified for a travel history yet and how to ensure in the midst of providing emerging medical services then you can identify that early and also so a safety stop.

And my guess is that’s probably still an ongoing struggle for some jurisdictions. But I hesitate to speak any more on that on it because again I haven’t seen any formal valuations.

Loretta Jackson Brown:

And this is Loretta with COCA. I will add that we actually had [webinar] an EMS and Ebola field experience with transporting patients on December 15. In that transcript the recorded Webinar are on our COCA Web page. So I would ask participates they also consider reviewing the content share during that presentation.

I think operator we have time for one more question.


Okay, our next question comes from (Paula Whiteman). Go ahead ma’am your line is open.

(Paula Whiteman): Hello? This is (Paula Whiteman).

Dr. Tim Uyeki:

Go ahead please. Yes?

(Paula Whiteman):

I’m an emergency physician with subspecialty training in pediatric emergency medicine in Los Angeles County and currently the President of the American Academy of Pediatrics California Chapter 2.

I was listening intently to your call. And in Los Angeles County we are undergoing a pediatric surge project where under the guidance of Dr. (Millicent Wilson) from the EMS agency to potentially double the number of beds in Los Angeles County in a disaster situation where NICUs can take younger kids, expand up. And hospitals that don’t normally care of kids might take kids 8 and over or putting older teenagers or older kids on adult floors and perhaps in some areas have to rely on adult doctor, internal medicine doctors who take care adolescents like 13, 14 and 15.

What are your suggestions in terms of the medical legal implications of an internist who won’t see a 13-year-old because their medical mal-practice won’t go below age 18 or 16 in a disaster situation where they’re the only provider available?

Dr. Tim Uyeki:

Thanks for that question. I think I’ll ask Dr….


(Paula Whiteman):

Would Good Samaritan Laws extend to them?

Dr. Tim Uyeki: I’m sorry, what was the last part of that?

(Paula Whiteman):

And with good Samaritan Laws extend to them?

Dr. Niranjan (Tex) Kissoon:

Yes, no, that’s a very good question. And this is one of the issues as I mentioned early on that there has to be some sort of mandate from the government that this should occur. When we put together the document that we mentioned we struggled mightily with the issue of the legal issues because there are ethical and legal issues that we have to grapple with. And much of the legal issues sort of center around the issue of extended protection to individuals who in the best interest of patients took care of them under difference to consensus. And we came to the conclusion that this while there are different jurisdiction that has progressed in different ways it is not a universal sort of thing. So that’s one thing that we really grapple with right now.

And then the ethical issue is to provide care under the consensus as you mentioned, the good Samaritan sort of thing. I think that for the most part we came to the conclusion that at least at the present – my present understanding is you’re really are appealing to someone as sort of better judgment of whether to take care these patients. And if someone chooses not to I suspect they can be assigned in other areas that can help in a mass casualty or disaster.

But I think that coming on to what can be do is a really a mandate from the institution saying that this is what we will do. Because I think you’re going about it the right way. You have to double the bed – at least double the bed capacity. And I know how very difficult it is in children. We did the same thing in Canada also. And I know my colleagues in New York stated the very same thing that you do you put protocols in place and say that okay, the neo-natal ICUs will take care of all the children may be less than a year, et cetera. The other ICUs will take care of teenagers older children and the disaster if it becomes more intense then we will slide down the age.

We were lucky in working with our other colleagues together. And I think that their pressure may – will give you other series – a group of other colleagues in the institution that are willing to work with you to put protocols in place, put just in time education in place and have all these transports facilities et cetera a priority.

I think that that may be in the peer pressure. We as clinicians as you know are very competitive then to peer pressure. That may be the tipping point to that at may occur. I don’t have any bright answer to that.

Dr. Tim Uyeki:

Let me just ask Dr. Rubinson if he wanted to comment from the adult intensivist view?

Dr. Lewis Rubinson:

Yes, I mean, I can only speak for myself and for the working groups I’ve been on but my general perception is most of us are absolutely wanting and willing to help. We look to our pediatric colleagues to give us guidance. But I think for most of us if it’s, you know, roughly 12 years and up and they do not have for instance a congenital physiologic repair that requires me to actually had to figure out how to even diagram it those are people I probably should not be taking care of.

So I think we can – we’d be willing to do what the pediatric intensivists think we can do. And I think on the most part most folks would be willing to do so against what – unless they’re – they have chronic conditions many, you know, normal-sized 12, 13-year-olds up do not require additional equipment nor a lot of additional changes in what we do every day. There’s some minor ones but not huge ones.

So I think we’d be willing to participate. It’s when we’re really operating so far out of our territory that we don’t even know where to start, that we don’t even know what the normal vital signs are. That’s probably where it gets more difficult. Tex would you agree?

Dr. Niranjan (Tex) Kissoon:

Yes, no I fully agree. And I think one other alternative that we suggested in a document is that maybe from the children’s hospital we can send some team members across the adult institution to work with them so if you have a resource, let’s say a pediatric intensivist or pediatrician working with a alongside you to give them – to fill in the areas that you are uncomfortable with I think that would make a good team especially when we say that we have so many children’s hospitals are so limited. And if they cannot function then you will have healthcare teams that may logically be sent to adult institution to help with their children there. So that is another way of looking at it also.

Dr. Tim Uyeki:

Great. Thanks very much. I hope that helped addressed the question. And I think we’re run out of time. So I wanted to especially thank Dr. Mike Christian, Dr. Lewis Rubinson and Dr. Tex Kissoon for their presentations and especially to Dr. Kissoon and Dr. Rubinson for answering questions after their presentations. And with that Loretta I’ll turn it back to you to close the call.

Loretta Jackson Brown:

Thank you Dr. Uyeki. We invite you to continue to communicate to our presenters after the Webinar. If you have additional questions for today’s presenters please email us at . Put March 25 COCA call in the subject line of your email and we will ensure that your question is forwarded to the presenter for a response.

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Join COCA on Tuesday March 31 at 2:00 PM Eastern Time for a COCA call, experiences of CDC and Emory Health Care and managing persons under investigation for Ebola. During this COCA call participations will learn about components of domestic surveillance that rapidly identify and monitor travelers, assess symptoms and isolate patients, persons under investigation for Ebola in the US so they receive appropriate medical care. Visit the COCA Web page for more information at emergency.cdc.govcoca.

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