"Against stupidity, even the gods strive in vain." -- Fredirich Schiller
I’ve been glued to the Ebola news, riding the roller coaster of emotions. While very impressed with CDC’s director, Dr. Tom Frieden’s, initial press conference (10/2/14), I became infuriated at the subsequent statements from Lisa Monaco, Homeland Security Advisor, and the tragicomedy of the Dallas hospital’s farcical response, prompting this post.
Dr. Frieden was calm, reassuring and authoritative in handling this CDC press conference. He conveyed the critical messages well, “Remember, Ebola does not spread from someone who is not infectious. It does not spread from someone who doesn't have fever and other symptoms. It's only someone who is sick with Ebola who can spread the disease.” And he was candid: “It is certainly possible that someone who had contact with this individual, a family member or other individual could develop Ebola in the coming weeks. But there is no doubt in my mind that we will stop it here.” He emphasized basic, proven public health strategies of careful infection control, contact tracing, and isolation.
In contrast, although she acknowledged the possibility of a secondary case, Ms. Monaco appeared less credible as she stated, “I want to emphasize that the United States is prepared to deal with this crisis both at home and in the region. Every Ebola outbreak over the past 40 years has been stopped. We know how to do this and we will do it again.”
While I agree that we have the knowledge, experience, and resources to be able to control Ebola, most of the experts are academicians or practice in relatively well-heeled ivory towers. I have practiced Infectious Diseases and Infection Control for 30+ years, primarily in a number of community hospitals, and offer a different perspective here, based on these experiences.
Administrators vs. Practitioners
Increasingly, decision makers are administrators who are disconnected from the realities of patient care. The latest fad, for example is to design hospitals to look like hotels and be “inviting” to patients, although they are very dysfunctional for delivering patient care, especially problematic in ICUs.
Similarly, when “bioterrorism preparedness” first became the rage, our hospital and health department focused on high tech units and hazmat suits while ignoring basic hygiene. I went ballistic, given that there was no soap nor any paper towels in the public school bathrooms, something the county health commissioner said was “not within their purview.” Gotta have priorities, right?
It is not all that different now. One hospital I am familiar with has Powered Air Purifying respirators (PAPRs), purchased with bioterrorism preparedness grants, but neither stethoscopes nor other dedicated equipment for isolation rooms. So nurses and docs gown up to go in the room of a patient with a “superbug” but take their stethoscopes into the room and then on to other patients, perhaps remembering to wipe it down first.
The problems with controlling Ebola cases in the United States is not that we can’t care for people well, or with good infection control. We absolutely can. But the Dallas case abundantly illustrates some of the problems in caring for anyone with a communicable illness, whether a antibiotic resistant organism (aka “superbug) like carbapenem resistant enterobacter (CRE), measles or Ebola.
First, the Emergency Room failed to take an adequate history, or to relay important information from the triage nurse to the physician—who is ultimately at fault for not having taken his own history, especially when presented with an accented foreign patient and after warnings about Ebola.
The Texas Health Presbyterian Hospital in Dallas next blamed the error on their electronic medical record system (EMR). This is entirely plausible, as the many brands of EMR I am familiar with are seemingly designed to maximize billing and minimize liability, by giving the illusion of comprehensiveness. They are, however, extraordinarily poor for patient care, as they are so cluttered with needless, clinically irrelevant detail. Though not at fault in this case, some Emergency Room EMRs are not readily accessible to the hospital inpatient units or clinics.
Some of us suspect the Dallas patient was not admitted in part because he was uninsured. He was inexplicably and irrationally sent home with antibiotics for a presumed viral infection, even though he should have been considered an obvious risk. Saul Hymes nailed the absurdity of discharging someone with a viral infection on antibiotics with typical ID physician humor: “He asked for ZMapp and they heard Z-pack.”
Another all too common problem in ERs and hospitals now is that temperatures are implausible. Good luck using that as a screening criteria. I learned that from screening patients for clinical trials. Fevers were often an enrollment criteria, and when axillary temps or tympanic thermometers were used, it seemed like many had a temperature of 36 C, or 96.8 F. Temporal artery scans are considered more accurate than tympanic, yet not reliable for febrile patients, but oral temps, now a rarity, were considered the most reliable. Monitors for measuring respiratory rate are also notoriously inaccurate. The accuracy of medical devices should be more of a consideration than just convenience and speed in obtaining such “vital signs.” A final serious problem in ERs is that patients (even those known to be colonized with superbugs) are generally not isolated in Emergency Rooms; ER staff claim they are "too busy.")
Other Infection Control Issues
It’s fine to have policies for isolation and employee health. Administrators love that, and it looks great when JCAHO (Joint Commission on Accreditation) comes around. The problem is that we need training, practice, and the ability to demonstrate our infection control skills. I have made this plea repeatedly for helping to control superbugs, to no avail. I have suggested that each year or two we practice our skills using Glo-Germ, which will readily show if we make an error. For example, I suspect that I contaminate something as I try to balance and take off shoe covers. It’s not easy. Unsurprisingly, now US nurses are saying they are unprepared for caring for Ebola patients.
In previous epidemics, especially during the SARS outbreak in 2003, removing personal protective equipment (PPE) was the most dangerous and health care workers (HCW) reported insufficient training. As Mdecins Sans Frontires (MSF, or Doctors Without Borders) has demonstrated, HCW can be much safer by having a second HCW guide them through the removal process.
We don’t need high tech to control Ebola. This has been demonstrated repeatedly. In the 1995 Kikwit oubreak, we learned that transmission was not airborne and that the epidemic could be controlled with very basic personal protective equipment. PAPRs and HazMat suits may, in fact, be more of a risk, given they complicate care. This WHO manual from 1995 is a great visual explainer on protecting yourself from hemorrhagic fevers when you have limited resources.
Clearly, we need basic education and a buddy system like this, not just for physicians and nurses, but for EMTs, housekeeping, radiology techs, etc.—everyone who might come in contact with infectious patients or their secretions. We only need see the photos of the janitor with his hazmat sleeves rolled up, or workers spray washing the sidewalk outside the apartment* to be reminded how easy it is to succumb to routine.
First, the global community failed to respond to Ebola in West Africa, allowing it to spiral out of control, in part because funding for the World Health Organization (WHO) has been slashed. Mdecins Sans Frontires has shown the most leadership, effectiveness, and humanity. Now we have our first case in the US, causing panic.
We don’t need posturing from politicians from the 2016 GOP presidential hopefuls and conspiracy theorists. Texas Gov. Rick Perry, the most restrained, had “noted that noted that his is one of just 13 states in the United States to have completed U.S. Centers for Disease Control training in Ebola diagnosis, laboratory verification and containment.” Perry also blithely said, “rest assured that our system is working as it should,” he said. “There are few places in the world better-equipped to meet the challenge this patient poses. The public should have every confidence.” It soon became all too apparent that this was not true. We learned, for example, that the hospital did not send the patient’s blood for testing in a timely manner. Then there was no one to transport infectious waste, so it was more than a week after he became ill before the cleanup began. During that time, the patient’s contacts were quarantined, with no thought to providing them food nor to protecting them from the soiled linens still in the apartment. As David Dobbs concluded in his scathing post, “So the richest country on earth has no team to contain the first appearance of one of the most deadly viruses we’ve ever known.”
We need an infrastructure that considers all the players who need to work together. We need to be proactive, as New York has been, with using “fake” patients to test hospital readiness and practice drills to identify lapses in procedures.
We need a health care system that cares for all, even for those without insurance, without causing them to delay seeking care until they are seriously ill, perhaps infecting others in the process (e.g., tuberculosis, more commonly).
And we need to take the politics out of funding for public health and research. We need to approve a strong Surgeon General like Dr. Vivek Murthy, and not have appointments like his be derailed by the NRA and their politicians. NIH's budget was reduced by $446 million from 2010 to 2014, and subjected to inappropriate politically motivated interference in its decision making. The CDC’s discretionary funding was cut by $585 million during this same period. Shockingly, annual funding for the CDC’s public health preparedness and response efforts were $1 billion lower for 2013 fiscal year than for 2002. These funding decreases have resulted in more than 45,700 job losses at state and local health departments since 2008. Again, it is not just the Ebola that is a looming threat. We need to worry about vaccine-preventable but neglected infections like influenza, measles, and whooping cough; the serious emerging viral infections in the US like Enterovirus-D68, chikungunya and dengue, as well as overseas MERS and bird flus, and natural disasters.
At this rate, what is happening in Dallas is going to be about as effective as the shameful response to Hurricane Katrina was.
*Note: I have been unable to reach WFAA regarding details of this photo--re timing, whether it was even secretions from the Dallas index patient, etc. This is only implied by their photo and story.
Atul Gawande - The Ebola Epidemic Is Stoppable
David Dobbs - Our Ebola response shows our true colors. Ain’t pretty.
Eli Perencevich - Ebola and WHO budget cuts
Laurie Garrett - Obamacare may hold the key to saving the U.S. from Ebola
epigram via Garcia
CDC funding graph: CDC
"Molecules to Medicine" banner Michele Banks