http://www.nytimes.com/2015/01/02/health/ebola-doctors-are-divided-on-iv-therapy-in-africa.html 2015-01-02 04:18:20 Ebola Doctors Are Divided on IV Therapy in Africa Doctors seeking to stem the Ebola epidemic disagree on whether most patients in West Africa should, or can, be given intravenous hydration, a standard therapy in developed countries. === Medical experts seeking to stem the The debate comes at a crucial time in the outbreak. New infections are flattening out in most places, better-equipped field hospitals are opening, and more trained professionals are arriving, opening up the possibility of saving many lives in Africa, rather than a few patients flown to intensive care units thousands of miles away. The Every hospital there should have “early, liberal use of intravenous fluid and electrolyte replacement,” said Dr. Robert A. Fowler, a Canadian critical care specialist who leads a W.H.O. Ebola team. Anything less, he said, is “not medically justified and will result in continued high case-fatality rates.” Experts who favor aggressive rehydration point to several hospitals that claim unusually low death rates as evidence that it is effective. Skeptics say other factors may be at work. Even two of the most admired medical charities have squared off over the issue. Partners in Health, which has worked in Haiti and Rwanda but is just beginning to treat Ebola patients in West Africa, supports the aggressive treatment. Its officials say the more measured approach taken by “M.S.F. is not doing enough,” said Dr. Paul Farmer, one of the founders of Partners in Health, using the French initials for Doctors Without Borders, whose staff members have worked on the front lines of Ebola outbreaks for years. “What if the fatality rate isn’t the virulence of disease but the mediocrity of the medical delivery?” Doctors Without Borders representatives strongly disagreed, saying that Dr. Farmer’s assumptions about Ebola were incorrect, that intensive rehydration would probably not save as many patients as he believes, and that the W.H.O.’s position has not been proved. The group’s overwhelmed doctors do what they can, officials said, but it is hard to insert needles while wearing three pairs of gloves and foggy goggles. IVs must be monitored, drawing virus-laden blood for tests is dangerous, and patients yank needles out — sometimes in Ebola patients lose up to five quarts of fluid a day through Rehydrating patients and replacing those elements “is the antidote to the idea that everybody’s going to die,” Dr. Farmer said. Every Ebola hospital, he argued, should have a team that specializes in inserting IVs — or, better yet, peripherally inserted central catheters, or PICC lines. These are thin plastic tubes, inserted in the arm or chest and threaded through a vein, that can be left in place for days and the needle discarded. Along with doctors at the London School of Hygiene and Tropical Medicine, who published However, not all doctors know how to use PICC lines or bone needles, or how to inject fluids into empty abdominal spaces, another technique endorsed in the Lancet article. (The article was accompanied by Doctors Without Borders normally puts IV lines in as many Ebola patients as it can manage, said Dr. Armand Sprecher, an Ebola expert with the organization. That practice was temporarily stopped in September, when the disease was spreading so fast that doctors had only one minute per patient during the one hour they could work in their sweltering protective suits. The fatality rate across the group’s six Ebola treatment centers in West Africa was about 60 percent then, and is now 40 to 50 percent, Dr. Sprecher said. He disputed Dr. Farmer’s contention that rehydration could bring it down to 10 percent. “It would probably push it down some, but I’d be surprised if it were dramatic,” Dr. Sprecher said. Dr. Farmer cited the treatment given at a unit in Hastings, Sierra Leone, as an example of the kind of care he endorses. In a Dec. 24 Each of the 581 patients the center has treated immediately received IV fluids with electrolytes, they wrote. Even without lab tests, each patient also received an “That’s effective case management,” Dr. Farmer said. “We’re cheering them on.” The fatality rate at the unit Partners in Health runs in Port Loko, Sierra Leone, is 35 to 40 percent, its director, Dr. Corrado Cancedda, estimated. Up to 80 percent of patients there receive IV rehydration, Dr. Cancedda said, and some have had bone needles inserted; no PICC lines have been used. Battery-powered electrolyte monitoring machines are being introduced. Dr. Sprecher said death rates at Doctors Without Borders’ six hospitals in the region varied, with the lowest being 36 percent in Bo, Sierra Leone. But he could not explain why. Some of the hospitals see more young adults, who tend to survive. At rural centers, the sickest patients die on the way there. Rehydration was only one lifesaving factor for the handful of patients transported to American or European hospitals, Dr. Sprecher argued, because all of them also received intensive nursing, and some received He was reluctant to have his doctors seen using bone-needle guns on patients. “Not long ago, we were being accused of stealing organs,” he said. “You have to be sure people understand what the heck you’re doing.” Dr. Sprecher also disputed Dr. Farmer’s comparison of Ebola to “In cholera, you can get fatalities down from 50 percent to 1 percent,” he said. “We’ve been putting people on IVs for Ebola for 14 years. If just tanking them up worked, we’d be doing it.” Lab testing is a crucial issue. For example, while low potassium can kill, so can overdoses. Potassium is used in executions by lethal injection. West Africa has at least eight laboratories run by various American, Canadian and European government agencies, Dr. Sprecher said. Until recently, they tested only for Ebola and diseases that mimic it, like Now, he said, about half can test for electrolytes. Because heat and humidity knock out the machines that analyze blood chemistry, labs must be air-conditioned, said Dr. Thomas R. Frieden, director of the Sometimes, conservative guesswork is called for, Dr. Frieden said. His father, a physician, gave potassium to patients who needed IV rehydration long before such tests were routine. The best-equipped treatment center in West Africa is the 25-bed United States Public Health Service hospital in Monrovia, Liberia, which is reserved for doctors, nurses, burial teams and others fighting the epidemic. It is fully air-conditioned and has 32 medical personnel, who wear high-tech protective gear that sucks in fresh air. Its on-site lab tests blood for electrolytes and proteins. The pharmacy has drugs to raise Since it opened in November, it has had 14 Ebola patients. Seven recovered, five died, one was transferred and one is in treatment, a spokeswoman said. (Ten other people who were admitted did not have Ebola.) That is a 42 percent fatality rate, though based on a small sample, for the 12 patients whose fates are clear. Other units tread a middle ground, relying on what measures they have at hand. The fatality rate at the International Medical Corps hospital in Bong County, Liberia, is about 55 percent, said Dr. Pranav Shetty, the agency’s international emergency health coordinator. All patients who need IV lines get them, Dr. Shetty said. But when there are too few nurses around, usually at night, the IVs are unhooked, so patients may get only one quart of fluids a day. And only patients still urinating, indicating that their kidneys are working, receive electrolytes. Spending money on air-conditioning “doesn’t even cross our minds,” Dr. Shetty said, because other needs are more urgent. When IV lines are impractical, the W.H.O. urges doctors to make patients drink six quarts of rehydration solution a day. Nigeria’s Still, even oral rehydration is hard, doctors say. Patients need anti-nausea drugs and must be pressured to drink. The solution tastes better when refrigerated. But, like air-conditioning, that requires electricity.