Andrew McD Johnston

Mystery of the blue pigmentation.

To the Editor: The medical mystery in the April 1 issue1 involved a 79-year-old woman, shown here in Figure 1, who had had discoloration of her face and eyes for several months. Examination reveale...

A Health Care Worker with Ebola Virus Disease and Adverse Prognostic Factors Treated in Sierra Leone.

We describe the management of a Sierra Leonean health care worker with severe Ebola virus disease complicated by diarrhea, significant electrolyte disturbances, and falciparum malaria coinfection. With additional resources and staffing, high quality care can be provided to patients with Ebola infection and adverse prognostic factors in west Africa.

Targeted Electrolyte Replacement in Patients With Ebola Virus Disease

TO THE EDITOR—We would like to highlight the importance of performing tests to facilitate targeted electrolyte replacement in patients with Ebola virus disease (EVD). Patients with EVD often develop gastrointestinal symptoms including abdominal pain, nausea, and anorexia followed by vomiting and profuse diarrhea [1, 2]. The gastrointestinal losses may be significant, leading to profound hypovolemia and electrolyte abnormalities. The mechanism of death remains unknown in many cases, but sudden death has been reported and could be due to electrolyte disturbances [3]. Potassium losses in EVD may be significant, and symptoms of severe hypokalemia include generalized weakness and lassitude, muscle necrosis, impaired respiratory function due to ascending paralysis, and cardiac arrhythmias, some of which have been reported among EVDpositive patients [4–6]. During the initial response to the current outbreak in West Africa, many organizations opened isolation centers aiming to prevent virus transmission and provide symptomatic management of patients [7]. Laboratory or point-of-care electrolyte testing was not always available and many patients did not have electrolytes measured. This was problematic when patients were no longer able to maintain oral hydration and intravenous fluid resuscitation was required [7]. A recent report on the clinical features of EVD-positive patients discussed the limitations of such empiric therapy and emphasized the need for routine blood tests to guide symptomatic treatment [5]. It will be important in future outbreaks for clinicians treating patients empirically to be aware of the quantity of electrolyte replacement required, particularly potassium. The United Kingdom’s Defence Medical Services opened and staffed an Ebola treatment unit in Kerry Town, Sierra Leone, in November 2014. It included both laboratory and bedside point-ofcare testing for blood biochemistry. We reviewed the charts of 36 consecutive patients with confirmed EVD treated there and examined the quantity of potassium replacement given by oral and intravenous routes. Oral potassium supplements were not initially available, so 20 mmol of the intravenous preparation of potassium chloride was mixed with fruit juice to create a well-tolerated oral preparation. Intravenous potassium chloride was delivered as 20–40 mmol/L of sodium chloride, in lactated Ringer’s solution or, if central venous catheter access was available, as 40 mmol potassium chloride in 100 mL sodium chloride solution. Patients were also offered oral rehydration solution. Potassium replacement varied widely among our patients during admission, ranging from 0 to 630 mmol (mean, 193 mmol; standard error of the mean, 30 mmol) (Figure 1). There was no significant association between potassium replacement and mortality, however, the total quantity of potassium given and length of admission strongly correlated (Spearman r = 0.61 [95% confidence interval, .34–.78]; P < .0001). These data support the requirement for rapid deployable point-of-care testing in future outbreaks to identify, monitor, and appropriately treat electrolyte losses,

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

Highlights • EVD is associated with life-threatening electrolyte imbalance and organ dysfunction.• Clinical staging/early warning scores can be useful EVD prognostic indicators.• Enhanced protocolized care is a blueprint for future treatment in low-resource settings.

Evaluation of a disposable sheath bronchoscope system for use in the deployed field hospital

At present, UK field hospitals use standard flexible bronchoscopes which require specialised disinfection services that are not integral to the hospital. This leads to prolonged turnover of used bronchoscopes as they have to be sent away to external facilities, which takes 1–3 days and is dependent on air transport to other facilities. In contingency operations, off site sterilisation facilities may not be available. There is a need for a bronchoscope system which can be rapidly cleaned and reused. We evaluated the Vision Sciences EndoSheath Bronchoscopy system, which uses a disposable outer sheath to remove the need for specialised disinfection. We report our experience of using this system in a deployed field hospital in Afghanistan.

Operation Gritrock: Christmas bulletin from UK army medics in Sierra Leone

Several months into their mission to the Ebola epidemic in Sierra Leone, how are the UK army medics faring? There have been teething problems, admit Lieutenant Colonel Andrew Johnston and colleagues, but the quality of care and levels of motivation are high

Operation Gritrock: first UK army medics fly to Sierra Leone

After comprehensive training, 150 army medics are ready to help fight the Ebola outbreak in Africa. Andy Johnston and Mark Bailey describe the deployment

Sepsis management in the deployed field hospital

Sepsis, a syndrome caused by severe infection, affects a small proportion of military casualties but has a significant effect in increasing morbidity and mortality, including causing some preventable deaths. Casualties with abdominal trauma and those with significant tissue loss appear to be at a greater risk of sepsis. In this article, the diagnosis and management of sepsis in military casualties with reference to the Surviving Sepsis Campaign guidelines are examined. We discuss the management considerations specific to military casualties in the deployed setting and also discuss factors affecting evacuation by the UK Royal Air Force Critical Care Air Support Team.

UK doctors head home from Ebola frontline.

As the Ebola epidemic in west Africa subsides, UK military medics Andrew Johnston and Oliver Bartels reflect on the hardships of working in Sierra Leone at the height of the outbreak and the inequities in treatment between African patients and those from Europe and America

Hyperglycaemic Control in Paediatric Intensive Care

In paediatric intensive care (≤16 years of age), tight glycaemic control is not associated with a mortality benefit. There is a higher risk of significant hypoglycaemia. In cardiac intensive care unit patients, this hypoglycaemia is associated with a significant increase in mortality. Level of evidence: 2B (CEBM).