Enterovirus D68 (EV-D68)

Enterovirus D68 (EV-D68) is one of more than 100 non-polio enteroviruses. This virus was first identified in California in 1962.

What are the symptoms of EV-D68 infection?

EV-D68 can cause mild to severe respiratory illness.

• Mild symptoms may include fever, runny nose, sneezing, cough, and body and muscle aches.
• Severe symptoms may include wheezing and difficulty breathing. See EV-D68 in the U.S., 2014 for details about infections occurring this year.

Anyone with respiratory illness should contact their doctor if they are having difficulty breathing or if their symptoms are getting worse.

How does the virus spread?

Since EV-D68 causes respiratory illness, the virus can be found in an infected person’s respiratory secretions, such as saliva, nasal mucus, or sputum. EV-D68 likely spreads from person to person when an infected person coughs, sneezes, or touches a surface that is then touched by others.

What time of the year are people most likely to get infected?

In the United States, people are more likely to get infected with enteroviruses in the summer and fall. CDC expects, as with other enteroviruses, that EV-D68 infections will likely begin to decline by late fall.

How common is EV-D68 in the United States?

In general, a mix of enteroviruses circulates every year, and different types of enteroviruses can be common in different years. Small numbers of EV-D68 have been reported regularly to CDC since 1987. However, this year the number of people reported with confirmed EV-D68 infection is much greater than that reported in previous years. See EV-D68 in the U.S., 2014 for details about infections occurring this year.

Who is at risk?

In general, infants, children, and teenagers are most likely to get infected with enteroviruses and become ill. That's because they do not yet have immunity (protection) from previous exposures to these viruses. We believe this is also true for EV-D68. Adults can get infected with enteroviruses, but they are more likely to have no symptoms or mild symptoms.

Children with asthma may have a higher risk for severe respiratory illness caused by EV-D68 infection.

How is it diagnosed?

EV-D68 can only be diagnosed by doing specific lab tests on specimens from a person’s nose and throat.

Many hospitals and some doctor’s offices can test ill patients to see if they have enterovirus infection. However, most cannot do specific testing to determine the type of enterovirus, like EV-D68. CDC and some state health departments can do this sort of testing.

CDC developed, and started using on October 14, a new, faster lab test for detecting EV-D68. Read more about what CDC is doing about EV-D68 in 2014.

CDC recommends that clinicians only consider EV-D68 testing for patients with severe respiratory illness and when the cause is unclear

What are the treatments?

There is no specific treatment for people with respiratory illness caused by EV-D68. Talk to your child’s doctor about the best way to control his or her symptoms.

Some people with severe respiratory illness may need to be hospitalized.

There are no antiviral medications currently available for people who become infected with EV-D68.

How can I protect myself?

You can help prevent yourself from getting and spreading EV-D68 and other respiratory illnesses by following these steps:

• Wash hands often with soap and water for 20 seconds. SeeHandwashing: Clean Hands Save Lives.
• Avoid touching eyes, nose and mouth with unwashed hands.
• Avoid close contact such as kissing, hugging, and sharing cups or eating utensils with people who are sick.
• Cover your coughs and sneezes with a tissue or shirt sleeve, not your hands.
• Clean and disinfect frequently touched surfaces, such as toys and doorknobs, especially if someone is sick.
• Stay home when you are sick.

Also, see an infographic that shows these prevention steps.

There are no vaccines for preventing EV-D68 infections.

What should people with asthma and children suffering from reactive airway disease do?

Children with asthma are at risk for severe symptoms from EV-D68 and other respiratory illnesses. They should follow CDC’s guidance to maintain control of their illness during this time.

CDC recommends:

• Discuss and update your asthma action plan with your primary care provider.
• Take your prescribed asthma medications as directed, especially long term control medication(s).
• Be sure to keep your reliever medication with you.
• Get a flu vaccine when available.
• If you develop new or worsening asthma symptoms, follow the steps of your asthma action plan. If your symptoms do not go away, call your doctor right away.
• Parents should make sure the child’s caregiver and/or teacher is aware of his/her condition, and that they know how to help if the child experiences any symptoms related to asthma.

For additional information, see “What Parents Need to Know about Enterovirus D68” in

• English
• Spanish
• Haitian Creole (translation provided by State of New Jersey Department of Health)

Surviving Sepsis with the Sepsis Protocol

Does Your Hospital Use the The Surviving Sepsis Campaign?

This campaign was created to help healthcare workers implement the recommended guidelines for Severe Sepsis patients in the Emergency Room (ER) and Intensive Care Units (ICU). 

The Surviving Sepsis Campaign kits include posters, pocket guides, bundle cards, lapel pins and a list of resources to aid your implementation efforts using the most recent edition of the international sepsis guidelines.  The Surviving Sepsis Campaign has developed pre-packaged kits to help clinicians within institutions to improve sepsis identification, management and treatment. 

"The Surviving Sepsis Campaign (SSC) partnered with the Institute for Healthcare 

Improvement (IHI) to incorporate its “bundle concept” into the diagnosis and treatment 

of patients with severe sepsis and septic shock. We believe that improvement in 

the delivery of care should be measured one patient at a time through a series of 

incremental steps that will eventually lead to systemic change within institutions and 

larger health care systems. "

Are You A LEADER??

L Learn about sepsis and quality improvement by attending local and national sepsis 

meetings. 

E Establish a baseline in order to convince others that improvement is necessary and 

to make your measurements relevant. 

A Ask for buy-in from institutional leadership and seek initial support from the emergency 

department (ED) and ICU staff and directors, quality improvement personnel, nursing 

staff, and others. 

D Develop an institution-specific protocol comprising all bundle elements. 

E Educate stakeholders in the ED and ICU and floors according to shift schedules. 

R Remediate errors and anticipate obstacles along the way. 

What is the First Step??

"The first step in improving the care of patients with severe sepsis and septic shock is 

making a solid commitment to improving that care. This commitment includes a strong 

and well-worded aim statement that sets an aggressive global aim. It is critical that the 

overall aim has a measurable objective and a specified time frame."

What Can You DO??

1. Time from ED triage to presumptive diagnosis of severe sepsis is less than 2 hours
2. Time from ED triage to all patients’ meeting severe sepsis criteria having a serum lactate is < than 3 hours
3. Time from ED triage to appropriate antibiotics given is less than 1 hour
4. If hypotensive or if lactate > 4.0 mmol, immediate fluid resuscitation is started (at least 30 mL/kg normal saline or lactated ringers solution within 1 hour)
5. If MAP < 65 mmHg and not responsive to adequate (at least 30 mL/kg) fluid resuscitation, vasopressors are started immediately
6. If blood pressure or serum lactate not responsive to fluid, a central venous pressure monitor is instituted within the first 6 hours

What About Bundles?

"​The Surviving Sepsis Campaign Bundles are the core of the sepsis improvement efforts. Using "bundles" simplifies the complex processes of the care of patients with severe sepsis. A bundle is a selected set of elements of care distilled from evidence-based practice guidelines that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone."

Bundle Implementation

Your hospital's sepsis protocol may be customized, however, it must meet the standards created by the bundle. Enhancing reliability of these bundle elements allows teams to focus on aspects of the changes they are implementing to create a reliable system that achieves the goal of 25 percent reduction in mortality due to sepsis called for by the Surviving Sepsis Campaign.

Hear His Story??

To Learn more and get all of the Surviving Sepsis Campaign resources visit their site here.

References

http://www.survivingsepsis.org/Pages/default.aspx

I Got Your Breach!! Where is My EBOLA!!

SO I have been thinking about Nina Pham.  Who is Nina?  Well if you have to ask; then I think you should stop reading and go check your heart and soul.  The Center for Disease Control and Prevention (CDC) has a poster that has been put out that shows you exactly how to put on and take off your Personal Protective Equipment (PPE) in case you have a patient in isolation for whatever reason.

However, I have been studying this poster and thinking about all my years of training; not only in the civilian world; but the military as well.  What is missing from the poster?  Can you guess?

The Poster provided to us by the CDC is shown as follows:  

Well, have you guessed?  What about the healthcare provider cover their hair or head?  What is a patient with the EBOLA virus is having a coughing spell; or having massive diarrhea and you are the one having to help them and care for them?  What if those small particles get on your head and hair?  No, not possible?  Then look at the next part of the CDC poster when you are to remove your PPE.

Look at numbers 2, 3, and 4 in the photo below.  You have already taken off your gloves the way you have been trained; but then you reach up to remove your goggles; then untie or pull off your mask and at anytime in these steps it would be easy for a healthcare provider to brush against the back of their hair.  TRUE, the next step is to wash your hands; however, what if you are hot and sweating and you forget and accidentally rub your face without even blinking and eye.

The average person touches his or her face 2000 times a day or more without even recalling that we did it.  Just like driving home in the morning after a long twelve hour shift and cannot even recall what we did or saw because it has become automatic.

Well what does the World Health Organization (WHO) say about EBOLA and how to protect yourself?  Well, they say that a provider should use rubber boots if at all possible; but if not available, then shoe covers.  Did you hear me?  Rubber boots!!  This is what we used in the military during chemical warfare training.   They also go on to say that "If an impermeable  gown is not  available, place waterproof  apron  over gown."  Where is that in the CDC Protocol?

What about the products we use to clean and disinfect.  The "Purple Top Super Sani-Wipes."  How effective are they at killing the EBOLA virus?  Have they been tested on this virus?  Did you know it can live on inanimate objects outside the body for up to seven weeks?  What is the kill time when using these products on this specific virus? Well, there is a lot of information out there to try and protect yourself; the only issue is there are a lot of conflicting protocols and standards and no one seems to be on the same page.  Speaking of page; read page 29 in the CDC's Viral Hemorrhagic Fever Manual and you can see the conflicts I am referring too..

The WHO is much more specific in removing the PPE especially the mask, headgear, 

and face shield.

This is only the tip of the Iceberg as when dealing with such a virulent pathogen; there really should be a designated spot between the clean and dirty side of the decontamination area as well as nurses should be using the buddy system.  Did Nina have a buddy?  What is the patient to nurse ration in Texas? Do they have one?  These are all important questions that should have been raised before Nina stepped into the room.  However, as nurse for over 20 years, I know that if one were to ask such simple questions you may get an answer of; "well if you do not like it, find another job."

Well, I am not advocating for nurses to walk off just yet; remember you took a pledge when you were pinned as a nurse.

"I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care."

Stay Safe and Speak Up!  We are all in this together and we must rely on each other to get the truth out and save our own lives as well as our patients.

Dr. D.

Central Valley Medical would like to introduce "Heather Connor." 

 Heather Connor is originally from The Unites States; however, she has spent the last 11 years in Canada. Two years ago, after a long search that yielded no answers for the cause of her boys mystery symptoms, she gave up her career as a Surgical Device Rep, to focus on getting her kids the care and treatment they needed. Since then, both of her children and husband have been diagnosed with Dystonia, a little known neurological movement disorder that causes painful twisting and contractions of any voluntary muscle in the body. She has found her voice as an advocate for dystonia through her blog "Raising Dystonia".

by Heather Connor October 13, 2014

He was younger than I imagined. Maybe forty...tops. He was tall and attractive with light brown hair and glasses. He was Yale educated with a B.Sc, an M.Sc, a Ph.D and an MD. My research revealed that he is a pioneer in the field of neurogenetics and our  Pediatric Neurologist had told me he is the most brilliant diagnostician he had ever met.  Needless to say, his reputation preceded him.  His list of medical discoveries and publications was shockingly long.  It was the kind of resume I had expected from an older seasoned  physician.  Not from the young, unassuming man standing in front of me.
He entered the room with an entourage that made him seem more like a celebrity than a neurologist.  He quickly introduced himself and the team he brought with him. The doctor then sat down and immediately started asking questions.   He had clearly read the gigantic chart in front in him.  It took up a whole binder and contained the medical transcripts of my boys from their last eight specialists.  He asked mostly new questions, questions not a single doctor or nurse had asked us in four years, which amazed me.  I thought we had been asked everything possible, but apparently there were gaps in the previous assessments. It gave me hope that he could be the one to confirm that their issue was indeed neuromuscular.

After he examined the boys, he listened to us talk for an hour, as we explained the symptoms and events that led us to this appointment. I kept trying to rush. Experience had taught me that specialists were always in a hurry. But it was hard, there was just too much information between both boys and so many tests and different doctors. However,  this appointment was different. In an action so simple yet so powerful, he became the first doctor to never once look at his watch. And I loved him for it.

After we were done, he leaned forward in his chair placing his elbows on his knees.  He looked at me most sincerely and said,  "I'm not sure why anyone ever thought this was neuromuscular, It's not.  I'm sorry. I know you've been given the run around and I can only imagine how frustrating this process has been."  My heart sank.  It was not neuromuscular, and he was going to pass us on the the next specialist just like all the rest.  I could feel the lump forming in the back of my throat and I tried to swallow the urge to cry.  The search for answers was going to continue.  "But," he went on, "for reasons that professionally frustrate me, I can only say that I'm sorry their Dystonia went missed for so long."

I froze.  I thought I just heard him say something that resembled a diagnosis, but I was too afraid to be told otherwise to ask.  Instead I sat frozen and stared at him as he explained, "There are many forms of the disorder so more tests must be done.  I wasn't sure what was wrong, so I brought the whole team. I didn't want you to have to make a separate appointment to get your questions answered."  I couldn't believe what I was hearing.  Here, in this room, were the answers we'd been searching for years to get. I was beyond surprised that he was opening the door for more questions and not getting ready to kick us out for taking so long.  I felt immediate relief.  I had something to call what was happening. Dystonia. I also felt validation for all the years I spent feeling like I was crazy.  But mostly, I was confused. How could he diagnose so quickly? It seemed so easy and it left me wondering why it had been so hard for everyone else?   My husband and I said nothing. We were  too overwhelmed.  As we stared at him, the doctor leaned forward and placed his hand on top of mine.  When he spoke it was as though he knew exactly what I needed to hear,  "Ma'am, you are NOT crazy.  You are right. Something is hurting your boys.  It's called Dystonia. I want you to know I am confident that I can help them."

I found myself wrapped around the doctor in a hug entirely too large to be appropriate.  He hugged me back and  comforted me as I cried.   "Thank you!" I said over and over again.  His lack of surprise and perfect response to my flood of emotions told me I was not the first mom to flip out on him after receiving a diagnosis.

After I pulled myself together I couldn't help but ask, "How can you be sure it's Dystonia?" He just smiled, and informed me that it was as clear and classic a presentation as they come. He had no doubts.  All seven members of his team nodded their heads in agreement.  "If it's so classic, how did eight specialists miss it!? How did neurologists miss it!?", I protested, still confused how the answer was seemingly so obvious. He looked at me with compassion on his face and his answer broke my heart, "It's one of those things that professionally saddens me," he explained, "They don't really teach much about Dystonia in medical school.  It's the third most common movement disorder and yet, somehow, even movement disorder specialists sometimes miss it. Your boys went undiagnosed for so long because there is a lack of awareness within the medical community.  I'm sorry."  I nodded to let him know I understood. But I did not. How was it possible all those doctors could not have known!? How could they not be aware of it?! It made me both angry and sad.
After we asked all our questions, he handed me a requisition for DNA tests, prescriptions to help the boy's pain, and the personal contact information for everyone on the team.  As he opened the door to leave, he said to me,  "I really think I can help your boys.  I'm going to use all my resources to make sure I do."  I smiled at him, and with tears rolling down my face, said, "You know you just changed our life, don't you?"  He just nodded and said, "I hope so ma'am. I really hope so."  He closed the door behind him as he went to see his next patient.

With each new interaction with our neurologist he has continued to impress. His reputation for brilliance is well deserved.  But what I was not expecting was his bedside manor.  More than any other specialist he understands the importance of our relationship with him.  He believes that we are a team and he knows that I see day to day what he cannot. When I tell him what is happening, he believes me.  Most importantly, he never forgets that I am a mother. When I email him freaking out late at night because I'm scared that my child is convulsing, he replies right away.  Even if he is not "medically" concerned, he knows that for a mother, waiting till the morning is waiting an eternity. 

 No longer do I wrestle with unending fear and helplessness.  He has changed our lives in more ways than he could know.  We sleep, eat, play, and live better because of one person's compassion and awareness. My boys have never done so well for so long.  Aside from the medicine and information he has given us, it's his ability to diffuse our fears and believe in us as parents that  has made the biggest impact on us.  I feel like he has given me back my power as a mother.  I feel like for the first time, I have support from someone who can actually help. The feeling is amazing.

It is a feeling I wish more families facing our challenges could experience. Tragically, our experience is a microcosm of what the Dystonia community experiences.  But, we are luckier than most. More often than not, patients have to live without ever finding that life altering, compassionate specialist. Dystonia is more common than ALS, Muscular Dystrophy, Parkinson's and Huntington's Disease. Yet the medical community is not familiar with it. There are roughly half a million families in North America fighting the same battle as me.  It saddens me that the system is ill equipped to diagnose and treat them and that they must endlessly struggle with the fear and helplessness that has defined our past four and a half years.

It is my hope that one day families with Dystonia do not have to constantly explain to doctors, nurses and first responders about the cramping and twisted posturing that is Dystonia. And it my prayer, that they will understand Dystonia well enough to have compassion for a disorder that is simultaneously so silent and debilitating. I can only dream that there will be more people with Dystonia hearing, "I know what's wrong," and forever have both their lives and families transformed.

So to you Dr. D, thank you for caring about Dystonia! Please know that you are changing the lives of patients that are desperate for answers to questions that so many of your peers are unfortunately unable to answer. My kids will probably never understand just how much you have done for them, but I will never forget.  Thank you for your patience, kindness and for not treating me like a crazy mom.  But more than anything, thank you for giving my boys back their childhood.  It's the most beautiful gift anyone has ever given them, and I will remain forever in your debt.
 

Ebola Epidemic! Are You Ready?

EBOLA

The Ebola virus has been around for quite some time and in fact first appeared in 1976 in the Democratic Republic of Congo.¹

However, with the invention of social media our population has 24 hour news coverage and this news can be brought to us immediately from around the world. We have recently seen an uptick in the discussion of the Ebola Virus due to the recent outbreak in Western Africa.

“The U.S. Centers for Disease Control and Prevention said that from 550,000 people to as many as 1.4 million people when under reporting of cases is taken into account could be infected by mid-January in Liberia and Sierra Leone, in a worst-case scenario generated by a computer modeling tool the agency constructed. Around 21,000 cases would occur by Sept. 30.”²

So with this information at your fingertips; are you ready for the increase in Ebola cases here in the U.S.? Is your hospital and medical staff ready to treat these types of patients? “The current outbreak in West Africa, which first started in March 2014, is the largest and most complex Ebola outbreak since the Ebola virus was first discovered in 1976.”¹ This recent outbreak has developed more cases and deaths than all other previous outbreaks combined and it is only a matter of time before we have a worldwide epidemic on our hands. If the healthcare professionals and hospital administrators are not ready for this outbreak to hit our shores it could mean a catastrophic event like we have never seen; nor lived through before.

How is Ebola Transmitted? 

Ebola spreads through human-to-human transmission via direct contact such as through broken skin or mucous membranes, or through the blood, body secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids. Healthcare workers have frequently been infected while treating patients with suspected or confirmed Ebola Virus. This has occurred through close contact with patients when infection control precautions are not strictly practiced.

Would Your Recognize Ebola?

The incubation period, or the time interval from which a healthcare professional or patient has come into contact with the infectious disease and the onset of symptoms is 2 to 21 days.1 Healthcare workers and patients are not truly infectious until they develop symptoms. The first symptoms are the sudden onset of fever, fatigue, muscle pain, headache and sore throat. These are also classic signs of the influenza virus thus causing medical professionals to assume the flu and delaying the appropriate treatment. Then these initial symptoms are followed by vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and in some cases, both internal and external bleeding (e.g. oozing from the gums, blood in the stools).³ How are these patients going to get fluid replacement and hydration if they are severely dehydrated? How can we monitor their fluid status, and draw blood as safe as possible? What if there was a device invented that could be placed through a peripheral IV and left in place even after the patient went home? ⁶ Well, it is here; just keep reading.

How Do We Treat Ebola? 

No specific vaccine or medicine (e.g., antiviral drug) has been proven to be effective against Ebola. Symptoms of Ebola are treated as they appear. The following basic interventions, when used early, can significantly improve the chances of survival:

• Providing intravenous fluids (IV)and balancing electrolytes
• Maintaining oxygen status and blood pressure
• Treating other infections if they occur

 However, a recent medication known as ZMapp was given as an experimental treatment to the first U.S. patients with a positive effect. Recovery from Ebola depends on the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. If this virus is such a highly contagious virus and very few healthcare workers have any knowledge on how to treat it or protect themselves from it; how can they effectively treat the patient? The patients will become severely dehydrated and most likely suffer from severe sepsis and thus will be needed to be treated following the Severe Sepsis Protocol as well as be monitored for fluid status. How can this be done if the patient will need to be housed in a Bio-level 4 containment facility? Do most hospitals have this level of protection? Well, according to the Government Accountability Office (GAO) there are only 15 BSL-4 facilities were identified in the U.S. in 2007, including nine at federal labs.<sup>5

Stay Tuned for more coming..................</sup>