Many people who have succumbed to Ebola have contracted the disease from handling and disposal of the corpses of loved ones. There is much information out there of how to avoid catching Ebola, setting up a sick room etc, but there is little mention of disposal of infected corpses.
In a national crisis expert teams will be dispatched to collect corpses, but if they are overwhelmed the corpse needs to be dealt with before more infection occurs. In a really extreme situation help may not be forthcoming, and that’s what this article is about.
Some may find the following upsetting and rather dispassionate, and for that I’m sorry, but this article isn’t about feelings and grieving, it’s about staying alive.
Okay, so, a loved one has died of Ebola and you are left with a highly infective corpse. What do you do? Well, first you need to understand what often happens at the time of a ‘normal’ death, and what always happens at the time of an Ebola death.
Once death occurs degradation starts almost immediately and for bodies not taken away and dealt with by undertakers, morticians and coroners visible signs of decay can start in as little as 15 minutes after death if the conditions are warm and humid.
At the point of death the body starts to cool, within four hours the body will be at or close to the temperature of its surroundings. During this time the skin will have paled visibly and will be waxy looking. Postural lividity caused by blood pooling and coagulating in the lowest part of the body will have occurred so, someone lying face down will be discoloured, looking a purple/dark blue colour on the front of their body.
The muscles that control the bowel and the bladder will have lost their tonicity, they will be relaxed and moving the body will cause both to evacuate. Rigor Mortis, which literally translates as ‘stiffness in death’ will be complete at around the 12 hour point after death. The only way to change the position of the body once it has set in is to ‘crack’ the rigor, literally snapping the muscles to alter the position. Rigor will wear off over the next 18-24 hours but by then, if left the internal organs of the body have started to decay. Gases build up in the gut and intestines and are not passed out of the body as they were in life and this gives the corpse a swollen and bloated appearance.
These gases cause the putrification of the internal organs, turning them first to jelly and then to liquid which will escape from the body via the orifices. This foul smelling liquid will exit via the bowels, bladder, mouth,ears, nose and even the eyes.
With a death from Ebola this liquidation of the internal organs has already happened and there WILL be considerable expulsion of these liquids from the body. ALL of those fluids are full of Ebola virus and are highly infective.
If you are nursing someone with Ebola it is a sensible precaution to consider the possibility of their death and limit the exposure of the rest of the family to the disease. A thick plastic sheet or mattress cover should be on the bed, under the sheets of anyone suffering from a contagious disease and this is even more important with Ebola. The reason for this is two-fold.
- To protect the bed from infection
- To have a large sheet of plastic in situ already to aid with wrapping the corpse after death
On top of this plastic put a thin sheet, and then another layer of plastic such as a decorators sheet and then make up the bed as you normally would.
As I explained above there will be a good deal of infectious bodily fluids expelled at the point of, or just after death. Leave them where they are, make no attempt to clean the deceased.
Protective gear, which you should have been wearing to nurse the patient anyway should be reinforced. Put on another pair of gloves, then another coverall, and then a third pair of gloves over the cuffs of the coverall. This is important because it effectively gives you multi layer protection from secretions. Put on overshoes to protect your feet. Rubber boots are better but the coverall needs to go on after the boots to prevent anything getting inside them.
Okay, moving on:
- Carefully un-tuck the bedding to the level of the uppermost plastic sheet. Bring it across the deceased, do not tuck it under them as the risk of a breech in your clothing is too great.
- Do not stretch over them, move to the other side of the bed and throw the bedding from that side across, then return to the other side of the bed and pull it down snug. using duct tape fix in place as best you can.
- Take a strong garbage bag and gather it up as you would when putting on a pair of long socks. Slip it over the feet of the deceased and slide it up the corpse, unfurling as you do so.
- Take a second bag and repeat working from the head down.
- Duct tape the bags together on the top of the body, do not force you hands and arms underneath.
- Un-tuck the lower plastic sheet and wrap from the sides first. tape in place.
- Repeat the garbage bag procedure but this time when they are securely taped roll the deceased to one side TOWARDS YOU and tape where you can see at the back. Move to the other side of the bed, roll the deceased TOWARDS YOU and apply more tape. The reason for doing this is to prevent the deceased falling off the bed which could displace the wrappings and contaminate both you and the room.
- Roll up a light coloured sheet leaving about two feet unrolled and lay it along the length of the deceased. The unrolled portion should hang over the side of the bed. Move to the other side of the bed and roll the deceased towards you. Tuck the rolled portion of the sheet under the corpse and gently lay the deceased back down.
- Go to the other side of the bed, where the sheet is hanging over the edge of the bed and roll the deceased towards you. You will see the rolled sheet in the centre of the bed. Push it away from you, it will unroll over to the other edge of the bed. Lay the deceased back down.
- You now have a wrapped body lying on a white sheet. Pull the sheet down over the head and tape in place. Repeat with the foot end and then the sides, securing each portion of the sheet in place before moving on. The light coloured sheet will show you if there is any seepage, a final warning light for want of a better term.
The body is now ready to be moved. At least two people should do this to avoid damaging the protective wrapping. Where possible Ebola patients should be nursed on the ground floor of a home to facilitate easier body removal should the need arise.
Ebola victims may be buried, but burials should be in an isolated area where there is no possibility of any run off caused by rain or flooding damaging the wrapping of the body and the remains ending up in water courses. Graves should be very deep to discourage animal disturbance of the remains which could result in the spread of the disease.
Unless you are in a rural location cremation may be the best option. It’s unlikely that a body will fully cremate outside of a crematorium so everything possible should be done to ensure complete disposal.
In order to cremate a body you need high heat and good airflow for a considerable amount of time. To achieve this there will ideally be some kind of platform for the bodies to rest on with the fire built underneath this, and then combustible material placed on and around the bodies. If a reusable platform can be built all the better. Piles of bricks or rubble crisscrossed with metal posts or beams, or a metal bed frame would be one way of saving precious fuel, a pyre for multiple bodies is going to take a great deal of it. Regardless of how you construct your pyre the bodies need to be well off the ground or they will not combust effectively, there has to be good airflow all around to get anywhere near complete combustion.
Open cremation is still practiced in many cultures. It is far less labour intensive and has the advantage that germs and disease are destroyed, but as people across the world who have used fire to destroy evidence of crimes have found, bodies do not burn that well. You may need to add an accelerant at certain points during the cremation to make sure that nothing survives the fire.
A Dakota fire pit, is much more labour intensive that an open cremation but uses far less fuel and due to its construction burns much hotter than an open pyre.
Obviously ignore the sizes on the diagram above, that’s just included to show you a cross-section through the pit.
The pit should be at least a foot bigger than the body all around and there should be four air vents around it, one each side, one at the head end and one at the foot. Non-combustible materials should be placed at the bottom of the pit and the fire built on top of this, and the body placed on top of the combustible material used to make the fire.
Whichever method you use stand down wind. The smell of burning flesh is not pleasant and there can be particulate matter in the air that is harmful. Bodies that are cremated move and contract, giving them what pathologists call ‘the pugilistic pose’ the legs bend at the knees and the arms come up, fists clenches as if taking up a boxing stance. This is normal, but is often accompanied by popping sounds as the muscles contract in the heat. Depending on the amount of gases built up in the bodies there is a risk that some may explode, the same with skulls that are exposed to extreme heat.
Typical pugilistic pose and incomplete cremation of a corpse
Your protective gear should remain in place at this point, until you are certain that the fire is burning well and that you will no longer have to touch the body or its wrappings, or until the body is buried and the soil replaced.
At this point you should wash your gloved hands in a bucket of strong bleach water. Remove the gloves and drop them into an open garbage bag. Then:
- Before removing the second pair of gloves wash your hands in the bleached water, unzip the coverall sand step out of it, drop it in the bag with the first pair of gloves. Remove the overshoes and dispose of them if you are wearing them.
- Wash your hands in the bleach water and remove the second pair of gloves. They go into the bag.
- You should now be wearing a mask with a visor, glasses or safety goggles and one pair of gloves, and if you opted for them, rubber boots.
- If the facemask is tied at the back get someone to cut the tie and remove the mask from your face in one fluid movement. Hold each side and pull it away from you, drop it in the bag. Safety goggles and/or glasses can be dropped into the bucket of bleached water.
- Still wearing your last pair of gloves remove your shoes, one at a time and slip on clean ones.Put the shes in the garbage. If you are wearing rubber boots leave them on for a few more minutes.
- Wash your gloved hands in the bleached water. Remove the gloves and put into the bag.
- If you are wearing rubber boots getting them off without contaminating yourself can be tricky. One foot at a time stand in the bucket or bowl of bleach. Each foot should be in there for a few minutes. As you remove your foot from the bleach put it directly into a rolled down trash bag. Repeat with the other foot.
- Final bit of disrobing now. Leaving the trash bag in situ pull off one boot and put you foot directly into a clean shoe. Repeat with the other foot.
- The boots should be left in the bags until you can stand them in something and using a strong bleach solution saturate them inside and out before leaving them to dry naturally. Many hospitals have rubber boots that are brightly coloured to mark them as those to be used specifically for infected cases…I have a bright purple pair tucked away at home so I know at a glance which boots are which.
- As soon as possible you should shower, not bathe, take care not to swallow any of the water that rolls down off your hair and keep you eyes closed until you have rinsed the shampoo off.
If Ebola does make it out of Africa all precautions need to be taken to prevent it’s spread. Having said that there will be deaths, we all know this. Hopefully the authorities will not be overwhelmed but if they are the steps outlined above will massively reduce your chances of contracting the disease from handling a dead body.
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Contributed by Lizzie Bennett of Underground Medic.
Lizzie Bennett retired from her job as a senior operating department practitioner in the UK earlier this year. Her field was trauma and accident and emergency and she has served on major catastrophe teams around the UK. Lizzie publishes Underground Medic on the topic of preparedness.