MSmentor018

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you mean don't you always ask your patients "what'd did you do on vacation, drag some ebola riddled bodies around?"

there's a ton of this story that doesn't sound right.....if you just came from a place that had publicized, country wide warnings of ebola and death and you touched one then got sick. wouldn't you tell someone at the hospital besides "Hi I am from out of town" I am sorry the guy got ebola but that's an important tid bit he left out. i am sure either the RN will laugh or go nuts hearing the word ebola

from the link above; Josephus Weeks told NBC News. “So I called them to ask them why is it a patient that might be suspected of this disease was not getting appropriate care.” I am assuming the cousin called CDC or NBC news before the 2nd visit that led to the admission/ebola full court press. otherwise why would he question the appropriate care.

SO did this douche
1. know his cousin was coming from an ebola outbreak?
2. now suspected his cousin might have ebola?
3. didn't bother telling anyone !

hmmmm...I wonder if he bought travel insurance or we eating this bill
what's a face to face CDC consult go for , level 5 with 1000000 hrs critical care time
 

Perrin

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Now if only the ED doc had a medicine intern rotating with him, it would have been picked up on. Also would have picked up on pt's undiagnosed G6PD, carrier status of ACHOO syndrome, and severe internal hemorrhoids.

j/k
 

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Wait, so you guys really don't think this is a miss? I think you would have to be pretty dense to not think of Ebola in a black man with a foreign accent and a fever. That is Ebola until proven otherwise. The first question out of my mouth will be a travel history. Crazy this wasn't thought of by the doctor. Ebola is all over the news and expected to infect over a million people. Expect to see more cases, but they should be pretty easy to spot based on the demographic information alone.
 
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What do you think the odds are that this patient was initially seen in fast track, maybe even by a midlevel provider? Not to bash midlevels but it certainly is possible... It changes the context a bit when this guy a) withholds critical info and b) rolls through fast track with a nice fat viral illness label as his chief complaint from the "helpful" triage nurse. I bet he didn't even stay 90 minutes in the ED.

I'm getting really tired of Sanjay Gupta et al bashing on the EM providers at Presbyterian Dallas. I have worked with these folks, they are a quality bunch and this is even a Community EM training site for UT Southwestern's EM residents. It certainly sucks there was a large communication breakdown, but this is not some podunk ED staffed by some non-BC FP. Still ridiculous to expect everyone to nail the long shot zebra the first time it hits the U.S.
 
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Perrin

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Wait, so you guys really don't think this is a miss? I think you would have to be pretty dense to not think of Ebola in a black man with a foreign accent and a fever. That is Ebola until proven otherwise. The first question out of my mouth will be a travel history. Crazy this wasn't thought of by the doctor. Ebola is all over the news and expected to infect over a million people. Expect to see more cases, but they should be pretty easy to spot based on the demographic information alone.
We don't know what history the ED doc got. Flu like symptoms with travel from Africa... are you going to pull the Ebola trigger with the hospitalists and call the CDC for every patient. Might be easy with the story of, "Was helping care for someone in the hot zone who was vomiting blood," but we don't know what the story was. Perhaps the patient said Liberia and they thought Libia or Lebanon, not everyone is Vasco de Gama.

I think a bigger miss is letting people travel to and from the endemic areas at will.
 

DocEspana

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I think the story is pretty clear. The guy said he came from Ebola Africa and told the nurse. the nurse didn't document the travel history. The doctor saw the guy, didn't see any vital sign changes, and called it a viral syndrome. The nurse needs to be unemployed for not documenting that. the doctor needs to facepalm for not asking about travel history.


Over here in NYC the CDC mandates we screen every single patient for travel in the last 28 days. Carribbean travelers get screening questions for chikungaya and Dengue. Middle eastern travelers get MERS screened. African travelers get a stat rectal temp and a symptom screen.

The CDC doesn't mince words on this. Travel to impacted Africa and fever is isolation and CDC call. Do not pass go. Do not administer $200 worth of Tylenol. Go straight to CDC regardless of any more likely diagnosis.

Its rather cut and dry he dropped the ball since the CDC has made it clear every patient should be screened. Our screens have caught three cases of confirmed chikungaya, one of confirmed dengue, idk if any MERS and four Ebola-rule-outs (obviously no confirmed) just in the ~1 month I was on service this year so far.
 

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We can speculate all we want but the fact of the matter is that we have ZERO knowledge of what actually transpired between "provider" and patient. You could come up with tons of scenarios that could explain the "provider's" (we still don't know if it was a physician or midlevel) decision in either a positive or negative light but it's all conjecture at this point.

Personally, I'm very suspicious of the patient. The NYT reported today that he lied to the airport officials about having any recent contact with any person suspected of having Ebola. I agree with MSmentor on the fact that if you had recently come from ground zero of the epidemic, had carried a woman actively dying of Ebola, and then developed a fever... well, wake up man!!! You don't have to be a genius to put this puzzle together!!! And I really can't imagine that if he had given a forthright history anybody would have discharged him.
 

DocEspana

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We can speculate all we want but the fact of the matter is that we have ZERO knowledge of what actually transpired between "provider" and patient. You could come up with tons of scenarios that could explain the "provider's" (we still don't know if it was a physician or midlevel) decision in either a positive or negative light but it's all conjecture at this point.

Personally, I'm very suspicious of the patient. The NYT reported today that he lied to the airport officials about having any recent contact with any person suspected of having Ebola. I agree with MSmentor on the fact that if you had recently come from ground zero of the epidemic, had carried a woman actively dying of Ebola, and then developed a fever... well, wake up man!!! You don't have to be a genius to put this puzzle together!!! And I really can't imagine that if he had given a forthright history anybody would have discharged him.
No... we have an incredibly clear time line. The guy showed up in the hospital immediately after exisitng the plane. He said today (aka not then) that he felt bad for lying on his US immigration forms about traveling to an ebola nation. So he went to the ER and was seen initially by a nurse (not RN, not PA) who he told that he had traveled to an ebola country and was feeling aches and pains and mild fever. The nurse didnt document the travel history. The physician saw him and didnt ask about travel history. Travel history was not documented in the physician note. Patient was discharged with a diagnosis of viral syndrome.

this has all been widely reported alreadyyesterday, with comments from the law enforcement backing up much of it today in their public comments about considering charging the patient with purjuring a federal questionairre utilizing the medical records from his first visit to find that he did indeed suspect he was infected from the plane ride in.
 

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It was a big miss, I don't think there is any doubt about it. There were multiple points where someone could have intervened to get this guy into isolation and it didn't happen. Now, you have a potential patient zero with multiple children exposed.

I like the point above about dengue, MERS and malaria... How would someone feel missing those, even though they continue to be rare in the US?

Placing the blame on others is not helpful because at the end of the day it's the MDs responsibility to conduct a proper history and physical. In an infectious presentation should include the question "any recent travel?" It takes two seconds, if you're suspicious then ask more questions.

Triage is just that, triage. Sure the nurse blew it and he or she should face the consequences, but this is not the first or last time that will happen- if it's outside the algorithm then a nurse just isn't going to catch it- that's our responsibility.

They screwed up. Acknowledge, learn and move forward. I guarantee ED staffs around the country are having very serious discussions about this in the last few days and that is a good thing.
 

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No... we have an incredibly clear time line. The guy showed up in the hospital immediately after exisitng the plane. He said today (aka not then) that he felt bad for lying on his US immigration forms about traveling to an ebola nation. So he went to the ER and was seen initially by a nurse (not RN, not PA) who he told that he had traveled to an ebola country and was feeling aches and pains and mild fever. The nurse didnt document the travel history. The physician saw him and didnt ask about travel history. Travel history was not documented in the physician note. Patient was discharged with a diagnosis of viral syndrome.

this has all been widely reported alreadyyesterday, with comments from the law enforcement backing up much of it today in their public comments about considering charging the patient with purjuring a federal questionairre utilizing the medical records from his first visit to find that he did indeed suspect he was infected from the plane ride in.
First off, how do you think you know the full story? I would love to know how you know what was written in the patient's chart, what the patient said, and what else was going on in the ED at the time the patient was seen. And until you know all the details it is irresponsible to pass judgement.

That would be like me saying, "Hmm, here are two posters coming to the ED forums to monday morning quarterback the decisions made in the ED. Talking about Chikungunya and shocked a busy ED doc may have not taken a travel history. I bet they're not nice people." (edited to be less snarky, don't want to anger anyone but do think it is important that people wait to hear the full story and not rush to judgement)

But, that wouldn't be fair, right? Maybe you guys are really nice in real life.
 
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jl lin

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I think the story is pretty clear. The guy said he came from Ebola Africa and told the nurse. the nurse didn't document the travel history. The doctor saw the guy, didn't see any vital sign changes, and called it a viral syndrome. The nurse needs to be unemployed for not documenting that. the doctor needs to facepalm for not asking about travel history.


Over here in NYC the CDC mandates we screen every single patient for travel in the last 28 days. Carribbean travelers get screening questions for chikungaya and Dengue. Middle eastern travelers get MERS screened. African travelers get a stat rectal temp and a symptom screen.

The CDC doesn't mince words on this. Travel to impacted Africa and fever is isolation and CDC call. Do not pass go. Do not administer $200 worth of Tylenol. Go straight to CDC regardless of any more likely diagnosis.

Its rather cut and dry he dropped the ball since the CDC has made it clear every patient should be screened. Our screens have caught three cases of confirmed chikungaya, one of confirmed dengue, idk if any MERS and four Ebola-rule-outs (obviously no confirmed) just in the ~1 month I was on service this year so far.
That's how I heard it on my local news. It was missed at two levels of health care. People get into busy mode and forget the basics. News said he had contact with at least a 100 people. Damn.
 

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Yeah. Smallpox, too. I'm sure you all will pick that up the first time that shows up on this continent, again. Easy. Just like measles. See that all the time, too. I'm sure 100% of you wouldn't put "viral exanthem" on that chart, either. Lol

Bird flu. SARS, too. If that rolls into your ED with chief complaint of "cough, achy" you'll narrow it right on down to the specific one in a million viral diagnosis with no lab test. Oh, what about West Nile virus? Lol

Now you're going to admit all flu to ID with "Rule out Ebola" as a diagnosis. You would've picked up ground-zero case "n=1" of a disease that's never been seen in America before....Ya...

Whatevvvvv
 
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e30ftw

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Anyone who is confident they wouldn't have done the exact same thing as the ER doc in the pts first ED visit deserves the repercussions of their hubris.

the poor doc who saw this guy is not "dense" just extremely unlucky.
 

MSmentor018

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the poor doc who saw this guy is not "dense" just extremely unlucky.
it's a matter of time, let's just hope it only happens once in our careers.

didn't this scenario happen in a book or a made for tv movie? a bunch of terrorist gets infected then come over to the US and spread it around
 
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http://news.yahoo.com/ebola-patient-mishap-prompts-cdc-alert-to-hospitals-205334851.html?bcmt=comments-postbox

Let the retro-spectovision begin...the dumb ER doc's should have identified a guy with flu symtpoms and stable VS's as having ebola, even though it has literally never been diagnosed in the US before
In someone who told the staff he traveled from Liberia and had a Liberian accent?

Yes, it should've been considered. The ball was dropped, and despite the objections to criticism by Sanjay Gupta, I feel like this was a big miss.

I always ask a travel history on anyone with viral type symptoms or fever. I've caught more than a handful of cases of malaria who were initially seen in outside ED's (one in my own ED) and who later returned. Nobody asked a travel history on them.

No matter what you say about the person who called the CDC to say things weren't being done appropriately, that person was ultimately right. It's hard to fault someone for being overly worried when they were right.

If people ultimately contract Ebola because the patient was sent home initially, the hospital and the ER physician may be held liable. Can you imagine if the paramedics/firefighters who helped the patient get Ebola?
 
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There's more to the story
http://www.usatoday.com/story/news/nation/2014/10/02/liberia-ebola-patient-thomas-duncan-airport-screening/16591753/

I think the guy had contact with Ebola, had family in US, and decided to high-tail it out of Africa to the US (where everyone who has been treated survived). I bet he thought he would get in trouble if he piped up (or maybe he was hard to understand, I don't know). Was there a "system breakdown"...definitely. He prob. mentioned he was from Africa (a continent bigger than than North America, BTW), but come on, I wouldn't be quick to throw stones for the biggest Zebra ever diagnosed on US soil (literally it has never been diagnosed on US soil).

Anyways, I know have to attend 8 million hours on Ebola preparedness right as winter is coming and flu season has already started. Thank you, terrible US press
 

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First off, how do you think you know the full story? I would love to know how you know what was written in the patient's chart, what the patient said, and what else was going on in the ED at the time the patient was seen. And until you know all the details it is irresponsible to pass judgement.

That would be like me saying, "Hmm, here are two posters coming to the ED forums to monday morning quarterback the decisions made in the ED. Talking about Chikungunya and shocked a busy ED doc may have not taken a travel history. I bet they're not nice people." (edited to be less snarky, don't want to anger anyone but do think it is important that people wait to hear the full story and not rush to judgement)

But, that wouldn't be fair, right? Maybe you guys are really nice in real life.
It's been reported that way and the police gave a press conference and said some of that. They pulled the record already from the first case. I am taking the word of the lawman in this case.
 

DocEspana

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Yeah. Smallpox, too. I'm sure you all will pick that up the first time that shows up on this continent, again. Easy. Just like measles. See that all the time, too. I'm sure 100% of you wouldn't put "viral exanthem" on that chart, either. Lol

Bird flu. SARS, too. If that rolls into your ED with chief complaint of "cough, achy" you'll narrow it right on down to the specific one in a million viral diagnosis with no lab test. Oh, what about West Nile virus? Lol

Now you're going to admit all flu to ID with "Rule out Ebola" as a diagnosis. You would've picked up ground-zero case "n=1" of a disease that's never been seen in America before....Ya...

Whatevvvvv
Anyone who is confident they wouldn't have done the exact same thing as the ER doc in the pts first ED visit deserves the repercussions of their hubris.

the poor doc who saw this guy is not "dense" just extremely unlucky.
100% certainty that this would not be missed by me and that no one should have missed this.

It's the difference between missing the first case of a previously unknown disease and missing the first case of a previously unknown disease that the CDC *mandates* every patient that goes to your ER be given a two question screen for, of which he fully admitted at triage to be positive for both questions. After two yes answers it's not physician gestalt, its automatically call the CDC and they make the call from there.

Note: not everyone who comes with a fever. Not everyone who comes with travel history. Not everyone who is black. EVERY PATIENT that is traiged is supposed to be asked their travel history until further notice per CDC.

As physicians, ironically, we may be unaware of the mandate. But the administration and the nursing should be insanely aware of it since it falls squarely on their hands to screen at triage.
 

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Wait, so you guys really don't think this is a miss? I think you would have to be pretty dense to not think of Ebola in a black man with a foreign accent and a fever. That is Ebola until proven otherwise. The first question out of my mouth will be a travel history. Crazy this wasn't thought of by the doctor. Ebola is all over the news and expected to infect over a million people. Expect to see more cases, but they should be pretty easy to spot based on the demographic information alone.
In someone who told the staff he traveled from Liberia and had a Liberian accent?

Yes, it should've been considered. The ball was dropped, and despite the objections to criticism by Sanjay Gupta, I feel like this was a big miss.

I always ask a travel history on anyone with viral type symptoms or fever. I've caught more than a handful of cases of malaria who were initially seen in outside ED's (one in my own ED) and who later returned. Nobody asked a travel history on them.
I was thinking this also - I mean, really? I ask everyone about travel history, and I said to staff where I work (because it's 99.8% white in the community - 8 black folks in an area of ~5000), "If a black man with an accent and fever came in here, and THEN said he'd just come from west Africa, the FIRST thing of which I would think would be Ebola, because that is the WORST thing it could be".

Of course, I wasn't there, but, really? And, if the doc wrote for abx, did it look like strep? I don't know. Or, was it just covering his butt for P-G?
 

DocEspana

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To be fair, I could see it being a state-by-state mandate... But all of our paperwork on the amdated screening is on CDC letterhead not NYSDoH. And screening differently in different states makes no sense in this age of airplanes. It's not like they all come in only by boat.
 

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l have no connection to this case, but you all need to stop and take pause. For all you that bash attorneys for our supposed med-mal "crisis," you're full of crap. Physicians are to blame for that crisis, not attorneys. You are. This thread is proof. Physicians are so arrogant and so quick to judge each other without even knowing a damn thing about a situation, we are our own downfall. Without physicians jumping to testify against their own, as so called "expert witnesses" there WOULD BE NO MED MAL CRISIS. Next time you all come on here and cry and whine about some bogus lawsuit you all got named in and how it's sent you into some deep, self-esteem crushing depression, or cry and whine about the medical malpractice crisis, I'm going to pull up this thread and call you out, one by one. It's sickening, actually. So quick to burn your fellow colleagues at the stake without knowing a damn thing about the situation, first hand.

Also, first to cry and whine like babies when some "mean mean attorney" comes to serve you with papers, in a case where a fellow physician sold you out in. All you jumping to criticize, don't come cry and whine to me or anyone else in this forum when you're called "negligent" or "dangerous" or "willful and wanton" for some case in which another self-professed "expert" such as yourselves criticizes you from afar, not having walked a day in your shoes. Some of you aren't even doctors, let alone attendings yet, and already you are drooling to burn your own at the stake, to show how smarter you are than the next. You all have very promising futures as malpractice plaintiff's "expert" witnesses.

Your day too, will come.

"Where men are the most sure and arrogant, they are commonly the most mistaken"-David Hume
 
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Birdstrike

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Dude, take a couple deep breaths and relax. No one is calling for his head or stating hes an incompetent doctor. The doc didn't ask about travel history, there is really no excuse other than he forgot, we don't need to know anything else about the case. He dropped the ball. Presby has stated that they dropped the ball. There is no argument here. If he had just asked a simple question that was taught to everyone in medical school about taking history for a patient with an infectious illness, we wouldn't be hearing about this story. Is he the only one responsible? Of course not, the nurse and patient shoulder much of the responsibility, as well. Yes, his mistake is a mistake almost anyone could make, but it was a mistake, nevertheless.
Pride goeth before the fall, my friend. Pride goeth before the fall.
 
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Dr.McNinja

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I just think it's funny he was sent home with antibiotics.
And the nurse did chart the travel history, but it was in a part of the EHR that the physician either couldn't access at all, or very easily.
 
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I am curious to your guys thoughts on something. I have spoken with quite a few ED docs about this and some agree and some don't. I believe there is a school of thought that the only history taking/documentation ED nurses should be doing is medications/allergies and vitals. That is it. No initial questions about symptoms, PMH, or anything. I guess the thought is the physician is able to get the full history from the patient in the patient's original version. This would cut down on conflicting stories (dyspnea vs no dyspnea, blood emesis vs green emesis, travel to West Africa). One rather annoyed doc said one of the main reasons billing has so many nursing documentation requirements is because the legal lobby, who is so entrenched, LOVES one more view on a case from a busy RN, maybe sometimes misinformed. He may be stretching, but it's not impossible.
 

MSmentor018

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I think it's vital that RN's jot down a sentence or two in the CC. I am not saying write the first 5 things patients spew out of their mouth but the true reason why the pt showed up "abd pain, rlq, 3 hrs. fever, nausea/vomiting" something like that. meds/hx, vitals...etc. if you're doing single coverage in an ED that does direct bedding, it really helps to know who to see first. on the other hand my other job does simultaneous MD/RN triage so the RN triage is useless . but it's a double edged sword, lawyers and patients see RN"s as "their advocate, more trusting than doctors and looking out for their best interest". if rn's write too much then you gotta go back and document the conflict.

granted nurses are suppose to use the SOAP(ier) and nursing dx but no one really uses them except the floor on the care plans. I think that's still a requirement? of course the legal higher ups loves nursing documentation, look at your hosp admin. directors, case mgt, JACHO, OSHA, electronic superusers, you'll see a lot of RN titles. nothing gives a lawyer a woody more than seeing a pile of RN notes that contradicts yours
 

jw3600

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I think it's vital that RN's jot down a sentence or two in the CC. I am not saying write the first 5 things patients spew out of their mouth but the true reason why the pt showed up "abd pain, rlq, 3 hrs. fever, nausea/vomiting" something like that. meds/hx, vitals...etc. if you're doing single coverage in an ED that does direct bedding, it really helps to know who to see first. on the other hand my other job does simultaneous MD/RN triage so the RN triage is useless . but it's a double edged sword, lawyers and patients see RN"s as "their advocate, more trusting than doctors and looking out for their best interest". if rn's write too much then you gotta go back and document the conflict.

granted nurses are suppose to use the SOAP(ier) and nursing dx but no one really uses them except the floor on the care plans. I think that's still a requirement? of course the legal higher ups loves nursing documentation, look at your hosp admin. directors, case mgt, JACHO, OSHA, electronic superusers, you'll see a lot of RN titles. nothing gives a lawyer a woody more than seeing a pile of RN notes that contradicts yours
This is what I was getting at. Most RNs I know hate the tedious and often superfluous documentation they have to do. Vitals, meds, allergies. I get that. Their "interpretation" of lung sounds? Who gives a ****? Its not gonna change the docs plan.
 
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MSmentor018

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This is what I was getting at. Most RNs I know hate the tedious and often superfluous documentation they have to do. Vitals, meds, allergies. I get that. Their "interpretation" of lung sounds? Who gives a ****? Its not gonna change the docs plan.
waste of mb on the computer screen
 
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The EHR's are terrible. Right now looking at my CERNER tab, there are 20 tabs on the left. RN assesment has 20 more tabs. No one looks at all those tabs (if you do, you'd be looking for a new job at our place.)

What is the DDx for flu-like illness in an african patient? Viral syndrome, flu, pna, malaria, yellow fever, gastroenteritis, dengue....Tb, HIV...typhoid...hell Ebola has to be down there somewhere next to River sickness in your differential. We didn't have an Ebola policy until yesterday. To piece togehter a story from media reports (many of which are contridictory) is just asinine.

I agree with Birdstrike--you shouldn't throw stones when you work in a glass house. To the person who would have "100% not missed this diagnosis"...guess what, I 100% guarantee you have missed a diagnosis before, and will in the future. You have no idea how busy it was in the ED, maybe the Doc had 12 other patients, a STemi, a code, the waiting room had 20 in it and just got 4 new people when he saw CC of fever in a black guy who had an accent...maybe he didn't have a fever...maybe he doesn't have an accent...maybe he couldn't understand him..maybe (probably) his VS's looked fine. This is a sentinel, Black swan event.

Fortunately, we are all not lucky to have not been so unlucky to have seen the first Ebola patient ever diagnosed in the US. Now we know what not to do and what to ask for, even though it's got to be like a 1:10000000 chance anyone here will diagnose ebola. You cannot say "I would have done this" because everything is obvious in retrospect...so have some sympathy for the ER Doc who won the reverse-lottery from hell and have an ounce of humbleness, lest the ER gods hear you and take their vengence out on your hubris
 
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DocEspana

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The EHR's are terrible. Right now looking at my CERNER tab, there are 20 tabs on the left. RN assesment has 20 more tabs. No one looks at all those tabs (if you do, you'd be looking for a new job at our place.)

What is the DDx for flu-like illness in an african patient? Viral syndrome, flu, pna, malaria, yellow fever, gastroenteritis, dengue....Tb, HIV...typhoid...hell Ebola has to be down there somewhere next to River sickness in your differential. We didn't have an Ebola policy until yesterday. To piece togehter a story from media reports (many of which are contridictory) is just asinine.

I agree with Birdstrike--you shouldn't throw stones when you work in a glass house. To the person who would have "100% not missed this diagnosis"...guess what, I 100% guarantee you have missed a diagnosis before, and will in the future. You have no idea how busy it was in the ED, maybe the Doc had 12 other patients, a STemi, a code, the waiting room had 20 in it and just got 4 new people when he saw CC of fever in a black guy who had an accent...maybe he didn't have a fever...maybe he doesn't have an accent...maybe he couldn't understand him..maybe (probably) his VS's looked fine. This is a sentinel, Black swan event.

Fortunately, we are all not lucky to have not been so unlucky to have seen the first Ebola patient ever diagnosed in the US. Now we know what not to do and what to ask for, even though it's got to be like a 1:10000000 chance anyone here will diagnose ebola. You cannot say "I would have done this" because everything is obvious in retrospect...so have some sympathy for the ER Doc who won the reverse-lottery from hell and have an ounce of humbleness, lest the ER gods hear you and take their vengence out on your hubris
Will state again: I would 100% not miss this diagnosis. It's not because I'm some master practitioner. Its because the CDC mandates every human being who comes into the ER stable is asked IN TRIAGE if they have been to Africa in the last 28 days, and then to get a temperature if they say yes. This isn't falling in your shoulders, it's the administration and nursing because that's where the screen is protocalled (and in many states mandated) to occur.

The CDC doesn't have enforceability. I just looked into this today. The NYSDoH is the enforcement agency in our hospitals ER and have been enforcing this screen be done on 100% of patients that are not critical. We've been doing this for 45 days now. The CDC protocols came out about 50 days ago. I seriously doubt a single hospital administrator in the US is unaware of the CDC protocol. The question is: does your administration and your state DoH care enough to have been enforcing this.
 

TooMuchResearch

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I am curious to your guys thoughts on something. I have spoken with quite a few ED docs about this and some agree and some don't. I believe there is a school of thought that the only history taking/documentation ED nurses should be doing is medications/allergies and vitals. That is it. No initial questions about symptoms, PMH, or anything. I guess the thought is the physician is able to get the full history from the patient in the patient's original version. This would cut down on conflicting stories (dyspnea vs no dyspnea, blood emesis vs green emesis, travel to West Africa). One rather annoyed doc said one of the main reasons billing has so many nursing documentation requirements is because the legal lobby, who is so entrenched, LOVES one more view on a case from a busy RN, maybe sometimes misinformed. He may be stretching, but it's not impossible.
I don't like it when the patient's history is a misleading textbook description of disease after the RN asks a lot of leading questions.

I also don't like it when the history taken down by the nurse looks like the patient has life threatening pathology when a thorough history reveals non of the charted red flags are possessed by the patient.

And don't get me started on floor/unit nursing notes peppered with "MD paged. No response."
 

Apollyon

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Will state again: I would 100% not miss this diagnosis. It's not because I'm some master practitioner. Its because the CDC mandates every human being who comes into the ER stable is asked IN TRIAGE if they have been to Africa in the last 28 days, and then to get a temperature if they say yes. This isn't falling in your shoulders, it's the administration and nursing because that's where the screen is protocalled (and in many states mandated) to occur.

The CDC doesn't have enforceability. I just looked into this today. The NYSDoH is the enforcement agency in our hospitals ER and have been enforcing this screen be done on 100% of patients that are not critical. We've been doing this for 45 days now. The CDC protocols came out about 50 days ago. I seriously doubt a single hospital administrator in the US is unaware of the CDC protocol. The question is: does your administration and your state DoH care enough to have been enforcing this.
I'm looking at the CDC criteria right now, and it says "2. Travel to West Africa (Guinea, Liberia, Nigeria, Senegal, Sierra Leone or other countries where EVD transmission has been reported by WHO) within 21 days (3 weeks) of symptom onset." Just saying, not 28 days.

(Or "28 Days Later"!)
 

DocEspana

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Wrote after a night shift. I provably got my number wrong. Thus why I said I can forgive any practitioner who doesn't ask. Its a mistake to not ask viral syndrome patients a travel history, but I rarely ask in honestly. But since I'm not the one screening them, I'm assuming they came pre screened. So I clearly messed up the screen criteria by a week.

I may be a bit strong on the opinion because I had one of my instutions three Ebola rule out cases. So I got the full dose of the protocol (which is a lot of phone calls and blood send outs) already. Ithe criteria itself infected my brain worse than the virus infects your vascular supply.
 

southerndoc

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I am curious to your guys thoughts on something. I have spoken with quite a few ED docs about this and some agree and some don't. I believe there is a school of thought that the only history taking/documentation ED nurses should be doing is medications/allergies and vitals. That is it. No initial questions about symptoms, PMH, or anything. I guess the thought is the physician is able to get the full history from the patient in the patient's original version. This would cut down on conflicting stories (dyspnea vs no dyspnea, blood emesis vs green emesis, travel to West Africa). One rather annoyed doc said one of the main reasons billing has so many nursing documentation requirements is because the legal lobby, who is so entrenched, LOVES one more view on a case from a busy RN, maybe sometimes misinformed. He may be stretching, but it's not impossible.
How many ER docs screen patients for domestic violence, suicidality, etc.? There are so many requirements that nurses shouldn't just ask about PMH/allergies.

Quite frankly, I've had quite a few saves from nurses and I don't discredit them. I would never have a "who gives a crap" philosophy about lung sounds coming from them. They spend way more time with the patient than I do, so I find the information they provide invaluable.
 

jl lin

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Although I feel that this could probably blow up on me, I will say that professional RNs are educated and required by their nurse practice act and SOP to obtain admission assessments and histories. The RN, if she/he is one, is responsible to not only take such relevant information down and be aware of the implications of it, he or she is also required to report these findings directly, by face or by phone, with a physician supervising the medical care of the patient and to in fact indicate that she has done so. He/she would be required, by professional practice, to communicate the potential concern to the nursing supervisor as well. Communication is vital in healthcare. We all know this. Also, if one doesn't document something, by law, it wasn't considered done. Knowing, however, that communication is vital for safe practice, he/she must follow-up on the given information in a timely manner and document that carefully as well. You'd think to at least cover her/his own butt, he/she would have included the date, time, and fact that she made the covering physician aware, what the doc's orders were and the effects of the interventions, if there were any ordered. You keep it simple, but it still has to be documented.

Everyone needs to function to the level of their SOP, always keeping best practices in mind. Supposedly the nurse was given this relevant information from the patient. If the nurse documented this fine, but the nurse is responsible to go beyond that. None of us practices in a vacuum. Part of his/her plan of action, interventions, and evaluation of those depends on her/him communicating such relevant and information to the physician in charge. It is b/c he or she can and should be held to maintaining the SOP by law under his/her licensure that he or she should then also document responses of the communicated information and medical plan from the physician.

It's a team mission caring for sick people and helping to maintain or optimize wellness for people. It's not about who is the ultimate boss. I can dig and do respect the physician in charge, and I have no problems communicating with her or him. I also have no problems documenting, b/c it's absolutely essential. It's about working together for the sake of the patients and others. At the very least, the nurse had an ethical, public-health responsibility to report this and document adequately. Personally, if I were the nurse manager and/or director over this nurse, he/she would be pulled in for administrative action. The nurse fell short of not only good sense, but what the law considers as her responsibility under her/his license. I'd be surprised if the nurse doesn't get some kind of disciplinary action if it proves true that she didn't report the information to the physician, document that information, and follow-up appropriately with it.

As for the physician, I'm not one yet; therefore, I will just report what the news shared, and that I personally feel that if people are educated to take relevant histories--and in light of the abundant news, they would pay special attention and ask relevant questions--following CDC guidelines. I wasn't there and I don't know what was going on with the physician. But I do think that the nurse had an obligation to report this information to the physician, if indeed he or she did not. If so, why the nurse didn't report and follow-up is beyond me. It's not like this Ebola business hasn't been media-blasted everywhere. But yea. Unless one was there or has all the pertinent information, it's unfair to state absolute judgments. In practice, we get stressed or become too comfortable. This scare should get people's attention though and make them think twice.

I also agree that this patient probably knew when he left Liberia that he was putting others at risk, but he probably was scared and wanted to hightail it out of there to the US ASAP. I mean, who wouldn't want to go where they would get the best care and the best treatments for survival? I think that is why he communicated this to the ED nurse after omitting that information before leaving Africa--that is, if all the information given proves true. He probably didn't expect the nurse or anyone else to drop the ball.
 
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grotto

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From NYT:

DALLAS — Health officials’ handling of the first Ebola patient diagnosed in the United States continued to raise questions Friday, after the hospital that is treating the patient and that mistakenly sent him home when he first came to its emergency room acknowledged that both the nurses and the doctors in that initial visit had access to the fact that he had arrived from Liberia.

For reasons that remain unclear, nurses and doctors failed to act on that information, and released the patient under the erroneous belief that he had a low-grade fever from a viral infection, allowing him to put others at risk of contracting Ebola. Those exposed included several schoolchildren, and the exposure has the potential to spread a disease in Dallas that has already killed more than 3,000 people in Africa.

On Thursday, the hospital, Texas Health Presbyterian Hospital in Dallas, released a statement essentially blaming a flaw in its electronic health records system for its decision to send the patient — Thomas E. Duncan, a Liberian national visiting his girlfriend and relatives in the United States — home the first time he visited its emergency room, Sept. 25. It said there were separate “workflows” for doctors and nurses in the records so the doctors did not receive the information that he had come from Africa.

But on Friday evening, the hospital effectively retracted that portion of its statement, saying that “there was no flaw” in its electronic health records system. The hospital said “the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow.”
 

jl lin

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From NYT:

DALLAS — Health officials’ handling of the first Ebola patient diagnosed in the United States continued to raise questions Friday, after the hospital that is treating the patient and that mistakenly sent him home when he first came to its emergency room acknowledged that both the nurses and the doctors in that initial visit had access to the fact that he had arrived from Liberia.

For reasons that remain unclear, nurses and doctors failed to act on that information, and released the patient under the erroneous belief that he had a low-grade fever from a viral infection, allowing him to put others at risk of contracting Ebola. Those exposed included several schoolchildren, and the exposure has the potential to spread a disease in Dallas that has already killed more than 3,000 people in Africa.

On Thursday, the hospital, Texas Health Presbyterian Hospital in Dallas, released a statement essentially blaming a flaw in its electronic health records system for its decision to send the patient — Thomas E. Duncan, a Liberian national visiting his girlfriend and relatives in the United States — home the first time he visited its emergency room, Sept. 25. It said there were separate “workflows” for doctors and nurses in the records so the doctors did not receive the information that he had come from Africa.

But on Friday evening, the hospital effectively retracted that portion of its statement, saying that “there was no flaw” in its electronic health records system. The hospital said “the patient’s travel history was documented and available to the full care team in the electronic health record (E.H.R.), including within the physician’s workflow.”

Beyond all of that, hell, don't doctors and nurses actually talk to each other anymore? This is one of those kind of things where the nurses and doctors need to have "hand and mouth disease"--typing in the information or writing it by hand AND opening their mouths to communicate. Does this ED not work with open communication between nurses and doctors? I am perplexed.
 

GeneralVeers

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I don't ask about travel in patients (unless I am worried about PE). The fact is that Americans, especially those in the middle of the country travel internationally very infrequently. We're simply not worried about tropical obscure diseases. I can completely see how these Dallas providers missed it.
 

GeneralVeers

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He first visited the hospital’s emergency room on Sept. 25 with a temperature of 100.1 degrees, abdominal pain, a headache and trouble urinating, according to a statement released by the hospital late Thursday.
http://www.star-telegram.com/2014/10/04/6174449/dallas-ebola-patient-now-in-critical.html#storylink=cpy

So not even a fever...
Right which would prompt a UA, CBC, BMP, and possiblly CT. All of which would be normal in the face of Ebola. This could be 10 patients on any shift I work that get sent home.
 
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d2305

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Duncan failed to mention he was dragging an Ebola infected woman to several Liberian ERs prior to hopping on a plane to Belgium. I think that would have helped in getting the ED attention.
 
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ihearttriangles

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l have no connection to this case, but you all need to stop and take pause. For all you that bash attorneys for our supposed med-mal "crisis," you're full of crap. Physicians are to blame for that crisis, not attorneys. You are. This thread is proof. Physicians are so arrogant and so quick to judge each other without even knowing a damn thing about a situation, we are our own downfall. Without physicians jumping to testify against their own, as so called "expert witnesses" there WOULD BE NO MED MAL CRISIS. Next time you all come on here and cry and whine about some bogus lawsuit you all got named in and how it's sent you into some deep, self-esteem crushing depression, or cry and whine about the medical malpractice crisis, I'm going to pull up this thread and call you out, one by one. It's sickening, actually. So quick to burn your fellow colleagues at the stake without knowing a damn thing about the situation, first hand.

Also, first to cry and whine like babies when some "mean mean attorney" comes to serve you with papers, in a case where a fellow physician sold you out in. All you jumping to criticize, don't come cry and whine to me or anyone else in this forum when you're called "negligent" or "dangerous" or "willful and wanton" for some case in which another self-professed "expert" such as yourselves criticizes you from afar, not having walked a day in your shoes. Some of you aren't even doctors, let alone attendings yet, and already you are drooling to burn your own at the stake, to show how smarter you are than the next. You all have very promising futures as malpractice plaintiff's "expert" witnesses.

Your day too, will come.

"Where men are the most sure and arrogant, they are commonly the most mistaken"-David Hume
Couldn't agree more with this post! Where's the solidarity people? Before med school I spent a good amount of time in the presence of cops and firefighters. You know what they do really, really well? They watch out for each other. They get each others backs. They work in very dangerous environments and over time have learned that united they stand and divided they fall. If a news story breaks that reports some purported wrong doing by a cop, and it's not some egregious crime against humanity, every cop I know will automatically defend the accused cop. What happens if you hit a cop? Five of his cop buddies take you out back and beat the crap out of you.

Physicians are the complete opposite of this. Constant in-fighting seems built into the House. ED doc missed the zebra, ortho can't manage HTN, blah blah blah. So much bickering. And think about what happens if you punch a physician? Do his buddies take you out back and kick your butt? Nope. Absolutely nothing happens. Not saying we should start beating up anyone who punches a doc but we do need to learn to stick together. We need to change our culture such that we are all watching out for each other. If we actually fought like a team maybe WE, not the lawyers and politicians, could shape our health care system the way it should be shaped.