Dallas Ebola (not a Cowboys post)

[southerndoc]

On the plus side, now that he's an inpatient he won't get a Press Ganey survey...

He was discharged on the first visit, so yes, he will get a Press-Ganey survey.

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[Birdstrike]

Will state again: I would 100% not miss this diagnosis.

Honestly, this forum truly amazes and baffles me at times. Do you actually think this?

Do you even have a test you can order to confirm Ebola, before you dispo a patient?

The best you could ever do in the ED is to diagnose "Viral Syndrome, rule out Ebola." There's nothing "100%" about that. In fact, you're more likely to admit 100 of those and at best, have 1 turn out to be Ebola, cripple your hospital by filling all their beds with viral syndromes and lead everyone to think that you think every flu is Ebola. That puts your diagnostic accuracy much closer to 1%, not 100%. More likely it will be closer to 0%, since you still might not ever see Ebola.

Do you think Ebola is new?

Ebola is not new. It's been around for decades. So has Hantavirus. Are you going to be 100% accurate on diagnosing that, too, if you ever see it? That's a disease as bad a Ebola, and actually has occurred hundreds of times in the US, compared to the 1 case of Ebola diagnosed in the US, to date.

What about MERS virus? Do you have a one hundred percent chance of seeing a patient in the ED and putting a diagnosis of "MERS" on their chart before they leave your ED?

Eastern Equine Encephalitis: You got that one too.

Malaria? You're probably 100% on that one, too, because you can focus in like a laser beam by asking about viral symptoms and travel. Yet you "rarely" even ask about travel:

Its a mistake to not ask viral syndrome patients a travel history, but I rarely ask in honestly.

Hmm...

You just rely on your triage nurse to make the diagnosis of this disease with a mortality rate that averages 50%:

But since I'm not the one screening them, I'm assuming they came pre screened.

Hmm..


So, you're 100% accurate in diagnosing Ebola, when you have no diagnostic test, no CT scan, X-ray or ultrasound that will show it, and when the only diagnostic "tests" in your tool bag is to ask two questions about, 1- non-specific viral symptoms and, 2- travel history, neither of which by themselves can make any specific diagnosis whatsoever?

You're 100% accurate, even when a case could present exposed by secondary contact, with no travel history whatsoever and no knowledge he was ever exposed?

When you ask him your screening questions he answers, "No" because he really doesn't think he's sick, doesn't want to get isolated for weeks or create a panic?

Or because he happened to shake the hand of a guy, who shook the hand of a guy who never traveled to Africa in his life, but who used a toilet in an airport somewhere in Europe vomited on by a guy who got sick after getting off a connecting flight from Liberia, and has no clue he was actually exposed to Ebola?

Wow. Truly amazing, in many more ways than one.

 

[MSmentor018]

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

I hear ya, I use the same (and I use epic). it's a mesmerizing maze like a scene out of " the shining". wonder what they have in dallas? reverse lottery, talk about rubbing off a scratch off card and getting 4 middle fingers back at you

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.

i agree the nursing assessments are legal and will save you one day. communication is always the #1 problem between health care providers. it's when they document a ton of stuff and not tell you, that's the problem

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.

great point. there's tons of studies and whole careers based on improving this issue. in a busy ER it's difficult for the triage RN to literally find and tell a doc. usually triage will call the charge RN then from there the information is disseminated. there's no rule of thumb except for judgement. if something is scaring the charge RN, they'll usually find a doc and rightfully so. if a seasoned nurse is worried about something sitting in triage, i need to know. I am still having trouble believing this triage scenario. it's one thing just to write on the chart in triage, "lethargic"and drop the ball but a guy walks in and says "ebola" to the nurse. that gossip will spread faster than which nurse is banging dr X this week.

 

[DocEspana]

Honestly, this forum truly amazes and baffles me at times. Do you actually think this?

Do you even have a test you can order to confirm Ebola, before you dispo a patient?

The best you could ever do in the ED is to diagnose "Viral Syndrome, rule out Ebola." There's nothing "100%" about that. In fact, you're more likely to admit 100 of those and at best, have 1 turn out to be Ebola, cripple your hospital by filling all their beds with viral syndromes and lead everyone to think that you think every flu is Ebola. That puts your diagnostic accuracy much closer to 1%, not 100%. More likely it will be closer to 0%, since you still might not ever see Ebola.

Do you think Ebola is new?

Ebola is not new. It's been around for decades. So has Hantavirus. Are you going to be 100% accurate on diagnosing that, too, if you ever see it? That's a disease as bad a Ebola, and actually has occurred hundreds of times in the US, compared to the 1 case of Ebola diagnosed in the US, to date.

What about MERS virus? Do you have a one hundred percent chance of seeing a patient in the ED and putting a diagnosis of "MERS" on their chart before they leave your ED?

Eastern Equine Encephalitis: You got that one too.

Malaria? You're probably 100% on that one, too, because you can focus in like a laser beam by asking about viral symptoms and travel. Yet you "rarely" even ask about travel:



Hmm...

You just rely on your triage nurse to make the diagnosis of this disease with a mortality rate that averages 50%:



Hmm..


So, you're 100% accurate in diagnosing Ebola, when you have no diagnostic test, no CT scan, X-ray or ultrasound that will show it, and when the only diagnostic "tests" in your tool bag is to ask two questions about, 1- non-specific viral symptoms and, 2- travel history, neither of which by themselves can make any specific diagnosis whatsoever?

You're 100% accurate, even when a case could present exposed by secondary contact, with no travel history whatsoever and no knowledge he was ever exposed?

When you ask him your screening questions he answers, "No" because he really doesn't think he's sick, doesn't want to get isolated for weeks or create a panic?

Or because he happened to shake the hand of a guy, who shook the hand of a guy who never traveled to Africa in his life, but who used a toilet in an airport somewhere in Europe vomited on by a guy who got sick after getting off a connecting flight from Liberia, and has no clue he was actually exposed to Ebola?

Wow. Truly amazing, in many more ways than one.

If you can finish tripping over yourself to try to make this a "defense of doctors" issue maybe you'll catch what I've been saying in every post since I first posted.

1) CDC says every human being who enters the ER should be asked if they traveled to Liberia, Siera Leone, Nigeria or that fourth country that is on the (literally) twenty five maps posted between all the ER entrances and the end of both walk in and EMS triage.

2) this screen is done at triage and the patient cannot be put into a the ER unless they are critical or an answer of "no" can be confirmed. Critical patients are revived and bloods are identified as BIOHAZARD bloods for your lab until they can be asked about travel history or they expire.

3) if they say yes they are asked if their complaint includes fever, body aches, nausea, or cough. Also a temp is taken immediately.

4) a yes in section 3 leads to them immediately going to an isoolation room and a call being placed to the CDC.

5) the CDC then runs the patient for you and takes responsbility for directing the exam to rule Ebola out.

If you can follow five steps above, the only way you're missing Ebola is by your hospital choosing to not follow the criteria, the patient lying about his travel history at triage, or the patient dying during the initial resuscitation. I could be a third year med student and get 100% accuracy for any patient that isn't lying as long as I know how to listen to the CDC on the phone and how to perform the bare basic history and physical the guy on the phone asks for. The physician DOES NOT make any clinical decisions until the CDC has ruled out Ebola for you with this screening method.

As I mentioned. My hospital has had 3 rule out Ebola in the last two months. The hospital closest to us has had at least two that I know of (one of which was the first required to get blood confirmation of no Ebola) and the next closest has had a handful (~5) per a conversation with a resident a few days ago.

The issue here is this Texas hospital chose not to follow the CDC guidelines. the NYSDoH took that choice away from NY hospitals. Don't follow the guideline and this is infinitely more difficult to assess. Follow the guideline and you find out Ebola is like HIV: there is no way you are exposed to Ebola and don't have a damn good idea that you might have been, so it's easy to rule out on history if your asking the right questions; which the CDC asks for you.

 

[Vandalia]

but this is not some podunk ED staffed by some non-BC FP.

Actually a "podunk ED" did pick up on it. Not Ebola, but the first US case of MERS.

http://www.cnn.com/2014/05/02/health/indiana-mers/

The patient was admitted to Community Hospital in Munster, Indiana, on April 28, the same day he visited the emergency department there, the health department said. He has been isolated and is in stable condition.

 

[Druggernaut]

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.

Here's the problem I think people have with what you're saying: You would 100% not miss this diagnosis, but in making that bold claim, you're actually not doing anything to make the diagnosis based on what you're telling us. So you're taking all the credit for a system that's in place where you are, and blaming the physician at a place where this same system is apparently not in place.

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 you're relying on the nurses to ask this. Kind of like the physician in Texas. Someone slipped through the cracks, either because it wasn't documented properly or because he didn't see that it was documented. Sounds exactly like what you're doing, and if your system breaks down, you're going to almost always miss it, just like this guy did.

1) CDC says every human being who enters the ER should be asked if they traveled to Liberia, Siera Leone, Nigeria or that fourth country that is on the (literally) twenty five maps posted between all the ER entrances and the end of both walk in and EMS triage.

2) this screen is done at triage and the patient cannot be put into a the ER unless they are critical or an answer of "no" can be confirmed. Critical patients are revived and bloods are identified as BIOHAZARD bloods for your lab until they can be asked about travel history or they expire.

3) if they say yes they are asked if their complaint includes fever, body aches, nausea, or cough. Also a temp is taken immediately.

4) a yes in section 3 leads to them immediately going to an isoolation room and a call being placed to the CDC.

5) the CDC then runs the patient for you and takes responsbility for directing the exam to rule Ebola out.

If you can follow five steps above, the only way you're missing Ebola is by your hospital choosing to not follow the criteria, the patient lying about his travel history at triage, or the patient dying during the initial resuscitation. I could be a third year med student and get 100% accuracy for any patient that isn't lying as long as I know how to listen to the CDC on the phone and how to perform the bare basic history and physical the guy on the phone asks for. The physician DOES NOT make any clinical decisions until the CDC has ruled out Ebola for you with this screening method.

Again, what's your role in this? Is it "nothing," or "assessing the patient for other medical conditions and trusting other people have done the work to rule out Ebola?" Whichever you prefer. I'd personally opt for the latter, since it seems a little more flattering, but they're essentially the same thing. What if the nurse asks and they admit to travel, but she's on autopilot and hits the box for "no travel" while hammer-clicking through all the other crap the EMR presents her with? Or they just fail to act properly to positives in #2 or #3 and don't place the patient in isolation or call the CDC? How do you stop these errors from others from impacting your perfect record?

I rarely, if ever, ask about travel history in someone with a fever. Hopefully this thread will prompt me to do so from here on out, as I'm in locations where people are unlikely to be travelling internationally as Veers said. I very well may have missed this patient too, and it sounds like you're in the same boat. I'll own that. But you're claiming you would "100% not miss this diagnosis," despite doing nothing to prevent missing it. You don't see the disconnect here?

 

[da8s0859q]

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.

Hi there, other SDNers new to this thread. Missed this post the first time? No worries. I quoted it for you.

Take care of your own, folks.

 

[Birdstrike]

There is no such thing as 100% diagnostic accuracy. It doesn't exist with any person, disease, or test.

 

[DocEspana]

Here's the problem I think people have with what you're saying: You would 100% not miss this diagnosis, but in making that bold claim, you're actually not doing anything to make the diagnosis based on what you're telling us. So you're taking all the credit for a system that's in place where you are, and blaming the physician at a place where this same system is apparently not in place.



So you're relying on the nurses to ask this. Kind of like the physician in Texas. Someone slipped through the cracks, either because it wasn't documented properly or because he didn't see that it was documented. Sounds exactly like what you're doing, and if your system breaks down, you're going to almost always miss it, just like this guy did.



Again, what's your role in this? Is it "nothing," or "assessing the patient for other medical conditions and trusting other people have done the work to rule out Ebola?" Whichever you prefer. I'd personally opt for the latter, since it seems a little more flattering, but they're essentially the same thing. What if the nurse asks and they admit to travel, but she's on autopilot and hits the box for "no travel" while hammer-clicking through all the other crap the EMR presents her with? Or they just fail to act properly to positives in #2 or #3 and don't place the patient in isolation or call the CDC? How do you stop these errors from others from impacting your perfect record?

I rarely, if ever, ask about travel history in someone with a fever. Hopefully this thread will prompt me to do so from here on out, as I'm in locations where people are unlikely to be travelling internationally as Veers said. I very well may have missed this patient too, and it sounds like you're in the same boat. I'll own that. But you're claiming you would "100% not miss this diagnosis," despite doing nothing to prevent missing it. You don't see the disconnect here?

Wow. Just wow. I can't even wrap my head around how strong everyone's reflexive defensiveness is that they can't even wrap their head around the idea that saying the nurses and administration screwed up is somehow a crucifixion of the physician.

If an institution chooses to ignore the guidelines set by the CDC, they do so at the peril of something like this occurring. The response to me saying that if the hospital listened to the CDC they would catch everyone because the screening mechanism is insanely sensitive is "well what if a perfect storm of slip ups happened". Then you fire the nurse the next day for screwing up her one job and you go on with business. Screening for Ebola isn't the job of the doctor, though he should probably ask too, per the CDC. Don't be the doctor who is put in the situation of having to screen because your hoosital and nursing staff doesn't think the CDC knows what its doing.

I'd catch 100% because a guy isn't likely to come to a hospital for his Ebola exposure and lie about it, and when every nurse knows this question is asked for an Ebola screen and the screen auto-triggers an action that skips the physician... There is little reason for them not be acutely aware of anyone who says "yes", and for the screen to not be approximating 100% sensitivity in any person who can talk. All before the chart ever reaches my eyes. The fact that there are hospitals not following CDC recommendations on a 2 question screening is baffling. If you want a physician defense argument, make it that the hospitals are needlessly shifting the burden onto doctors when the dictum is that the screen occurs in triage to minimize contagion. There is no cost to it beyond a few gowns and masks used on the very rare false positive screen.

 

[Arcan57]

Actually the cost is pretty substantial. We have one hospital in our whole system that is set up to deal with Ebola, which they created by carving out a chunk of ICU beds that could be used for other purposes. Ambulance transport and decon are also quite expensive. Then there's the issue of patient's with critical disease that isn't Ebola. I don't know if you have cared for one of the + screen patients, but there's about a 6-8 hr period where you can't really exam them. And I'm not sure if you're using "very rare false positive screen" to refer to the total number of febrile visitors from Africa or to refer to very few of those patients not having Ebola. Because as I'm sure you're aware the specificity is poor (most patients meeting case definition will have another virus or malaria) for the screening criteria.

Given the number of patient contacts and the fact that most processes have multiple failure modes, your "perfect storm" of slip-up is actually going to be somewhat common. I understand it's super easy to blame people for protocol violations (the "fire the nurse the next day" approach), but it's actually pretty difficult to operationalize a lot of the CDC/JC/Medicare recommendations. Especially with care focused significantly more on tasks than patients, lack of a proper EMR prompt will almost guarantee the system will fail at some point.

 

[DocEspana]

Actually the cost is pretty substantial. We have one hospital in our whole system that is set up to deal with Ebola, which they created by carving out a chunk of ICU beds that could be used for other purposes. Ambulance transport and decon are also quite expensive. Then there's the issue of patient's with critical disease that isn't Ebola. I don't know if you have cared for one of the + screen patients, but there's about a 6-8 hr period where you can't really exam them. And I'm not sure if you're using "very rare false positive screen" to refer to the total number of febrile visitors from Africa or to refer to very few of those patients not having Ebola. Because as I'm sure you're aware the specificity is poor (most patients meeting case definition will have another virus or malaria) for the screening criteria.

Given the number of patient contacts and the fact that most processes have multiple failure modes, your "perfect storm" of slip-up is actually going to be somewhat common. I understand it's super easy to blame people for protocol violations (the "fire the nurse the next day" approach), but it's actually pretty difficult to operationalize a lot of the CDC/JC/Medicare recommendations. Especially with care focused significantly more on tasks than patients, lack of a proper EMR prompt will almost guarantee the system will fail at some point.

As said before. Yes I have had one of the patients.

And if you had you'd know that when you call the CDC they have you ask a battery of questions, and it basically rules out anyone who wasn't literally carrying a dying person or bathing in their vomit. Turns out Ebola is rather non-contagious. Its a really crappy droplet contagion and only contagious for about 8 days where you'd not mistake it for something benign. Low risk people (has a fever. From Africa. Doesn't think they saw anyone vomiting and hemorrhaging) are treated as normal patients. Medium risk (involved with dicey situations but didn't touch or get vomited on by someone dying) are given a regular droplet isolation and can't be discharged until the CDC runs a blood test that takes 36 hours. High risk requires you to basically be carrying or burning dead bodies or say "I believe someone vomited or bled onto my mucus membranes". These guys go into the real isolation that actually costs money. In America this n=2. It was n=1 in the first 60 days of screening until this guy.

And mind you it's not some EMR prompt. You can't blame EMR for this unless you're that one hospital trying to make believe the problem isn't that they didn't really follow the protocols. This is not something Tue doc needs to find in the EMR. It's the nurses job to pull the metaphoric alarm. The specifics of how is institution specific, but its a "do not pass go, do not collect $200" sort of deal. We've been doing it for two months now. That's about 19,000 patients screened. We have three positive screens. All low risk. the cost has been six blue gowns, six face shields, 12 gloves and 3 patients moved out of our isolation room (probably at zero risk to them) to make room for the positive screen patient. Possibly 45 minutes of long distance phone call time too.

Specificity doesn't matter when you want 100% sensitivity and the screening is incredibly cheap in anyone except for the "holy **** that's a convincing history" people.

 

[Birdstrike]

Because as I'm sure you're aware the specificity is poor (most patients meeting case definition will have another virus or malaria) for the screening criteria.

Given the number of patient contacts and the fact that most processes have multiple failure modes, your "perfect storm" of slip-up is actually going to be somewhat common.

I agree. Just like there is no test, imaging study, prediction rule or diagnostician that is 100% sensitive, neither is any "triage screening algorithm" that is 100% sensitive, CDC generated or not. So to criticize a specific doctor about such a thing in public without knowing specific details first hand, is naive at best, foolish and arrogant worst, and just shows a complete misunderstanding of the entire concept of testing and diagnosis, and how such processes always have inherent imperfections at every step along the way, including those within each and every one of us.

 

[deleted109597]

1) CDC says every human being who enters the ER should be asked if they traveled to Liberia, Siera Leone, Nigeria or that fourth country that is on the (literally) twenty five maps posted between all the ER entrances and the end of both walk in and EMS triage.

I have not seen a single one of these signs (still) in the multiple EDs I work at in Texas. Are you talking about this thing? http://i.dailymail.co.uk/i/pix/2014/08/08/1407497116091_wps_1_US_Centers_for_Disease_Co.jpg

The issue here is this Texas hospital chose not to follow the CDC guidelines. the NYSDoH took that choice away from NY hospitals. Don't follow the guideline and this is infinitely more difficult to assess. Follow the guideline and you find out Ebola is like HIV: there is no way you are exposed to Ebola and don't have a damn good idea that you might have been, so it's easy to rule out on history if your asking the right questions; which the CDC asks for you.

I've looked up and down the CDC website and still have no idea what you're talking about.

 

[DocEspana]

I have not seen a single one of these signs (still) in the multiple EDs I work at in Texas. Are you talking about this thing? http://i.dailymail.co.uk/i/pix/2014/08/08/1407497116091_wps_1_US_Centers_for_Disease_Co.jpg

I've looked up and down the CDC website and still have no idea what you're talking about.

Nope it's a decision nonogram. We have two nearly identical ones, one with the CDC logo and one with the NYSDoH logo on it.

 

[Arcan57]

Nope it's a decision nonogram. We have two nearly identical ones, one with the CDC logo and one with the NYSDoH logo on it.

Just was looking at the latest CDC interim guidelines and unless they lied about his temp to the press, the patient would not have met criteria for being Person Under Investigation (PUI) on his initial eval. So swing and a miss on your 100% sensitive idea.

 

[DocEspana]

Just was looking at the latest CDC interim guidelines and unless they lied about his temp to the press, the patient would not have met criteria for being Person Under Investigation (PUI) on his initial eval. So swing and a miss on your 100% sensitive idea.

It also asks about cough chills and subjective fevers. I'd Imagine he'd hit on one of those.

For the sake of ending this, I'm out of this thread. Feel free to Monday morning QB this, as I already have. You guys are definitely with merit, but the blind devotion to no fault is a bit scary to me.

 

[Arcan57]

It also occurs to me that you have a very different experience with these patients being from a place that has a substantial public health infrastructure. I have no idea what public health looks like in Dallas but if it's anything like Houston or the other major Southern cities I've worked, it's not exactly like the cavalry is coming. My patient took roughly 6 hours to wind through the "Ebola risk stratification" process with the eventual person pulling the trigger on lifting isolation being a private ID doc at one of our other system hospitals. If you're experience is significantly different, I'd enjoy hearing how things could be streamlined.

 

[wholeheartedly]

So, just out of curiosity, what preparations do your institutions have in place and for how long have they had them?

I think the places I'm affiliated with have had protocols in place for a couple of months and have been doing simulations to test out the protocols.

 

[diphenyl]

Should move all the quarentined to the Cowboys stadium. Nobody caches anything there

 

[Birdstrike]

What this underscores, is how truly unique and difficult Emergency Medicine really is, in that anything can walk in the door, at any time, anywhere and the expectation is that there will 100% perfection in diagnosis, care, and outcome. Despite the fact that malpractice is supposed to be defined as meeting the "standard of care" of what a "reasonable physician" would dictate, the expectation is really closer that of "100% right, 100% of the time." If a bad outcome occurs then it is automatically concluded, 1-Somebody must have screwed up, and 2-They need to pay for it. A bad outcome is assumed to have been always preventable and therefore, somebody must be to blame for not having done their job. Then those accused must work backwards, to prove it wasn't their fault. It's classic,

Guilty Until You Prove Yourself Innocent

The first case of a disease previously never seen in your country could walk in any day, and 100% accuracy is assumed, despite no one ever having seen a case of it, and not even having a test to diagnose it. A famous person could be traveling through town, drop dead in your ED and all off a sudden, everything you did is wrong and you're an incompetent hack, with your name splashed across international blogs and TV screens. A person can walk out of your ED and drop dead 3 days later, from something that has nothing to do with why they were there to see you, and it's assumed it's your fault.

Most other professions and even other many other physician specialties, don't have to be exposed to the combination of that level of retrospective scrutiny, expectation of perfection, combined with a potential disease or injury spectrum that has more in common with Russian Roulette than any sort of controlled set of circumstances that could be prepared for, to the level of 100% accuracy. These factors should always be considered before jumping to conclusions and reflexively criticizing emergency personnel, doctors, nurses, PAs and medics included.

 

[strongboy2005]

Well, that guy from Dallas died from his ebola today.

 

[Arcan57]

And a nurse's aid in Spain was diagnosed, likely from having the glove hit her face when she was removing it. I'm just praying that the Dallas patient didn't infect anyone here.

 

[MSmentor018]

And a nurse's aid in Spain was diagnosed, likely from having the glove hit her face when she was removing it. I'm just praying that the Dallas patient didn't infect anyone here.

the Spanish govt killed her dog too, apparently they can carry it?

Well, that guy from Dallas died from his ebola today.

and now it only gets worse. what's next?
http://abcnews.go.com/Health/family...died-upset-unfair-treatment/story?id=26050956

 

[EMIM2011]

Lawsuit time!

 

[JMC2010]

I work in a community hospital in North Carolina. One of our docs is pretty anxious about our preparedness, which is fair since our mothership recently sent us a plastic bin with a piece of paper taped to the top that says "Ebola response kit" and contains a plastic gown, a facemask, and a pair of booties in it...yikes.

It sounds like some of you folks are working in MUCH better prepared places, probably because you have major international airports nearby.

Given that the above discussion may have devolved a bit...It would be helpful for me and I suspect others to hear some of the basic plans you have in place as I've been debating what to do if a potential Ebola patient lands in my ED. The questions below are very basic but alarmingly our ED group has not been given clear instructions on different conceivable scenarios.

1. If screening is successful and a nurse picks up on a potential Ebola patient in a triage room: what then? Do they stay in the triage room for hours until appropriate authorities are contacted? Get moved back to isolated area in ED?

2. Let's say they are in the ED somehow: do they get 1:1 coverage by a physician and a nurse? I would assume so. Do you then call in extra physician back-up to keep the dept running? I find it a bit alarming that the Spanish nurse contracted Ebola. This was an advanced hospital with serious protective gear and she got it because 'maybe' her gown touched her face? Doesn't sound so difficult to contract to me.

3. How do the other patients in the ED respond to docs and nurses being spotted in 'space suits' if that's what is used? How do you prevent panic?

4. What if your Ebola patient comes via EMS and is promptly isolated...and his family shows up in the WR 10 minutes later touching counters/chairs, etc: what then? Quarantine them and check temps and hope no fevers?

While the possibility of Ebola coming to my ED is low I worry about how quickly things could go wrong.

 

[Arcan57]

1. Our policy is they get immediately placed in a negative pressure room in the ED and CDC is contacted. They are placed on droplet, airborne, and contact precautions.

2. They don't get 1:1 coverage and in fact they tend to need very little care beyond the initial blood draw +/- fluids.

3. We don't use spacesuits.

4. They definitely need to be screened, would be difficult to make a case for quarantine. Unless they all traveled at the same time, if a patient does come in symptomatic then it's likely going to be several days to a couple of weeks before their contacts would become symptomatic and thus infectious.

One of the things to realize is that the initial ED contact is going to be mostly with patients that are mildly symptomatic. The people that have made the news for becoming infected typically had close, extended contact with end-stage victims who are secreting far more in the way of bodily fluids than in the early stages of infection.

 

[Birdstrike]

This is an interesting read. Though not scientific, I think they're right, in that their featured quote explains, 1-Why this disease has spread so rapidly in mainly 3rd world countries, and 2-Why we have a much greater chance of containing it, if the right steps are taken.

"Nurses, some not wearing gloves and others in street clothes, clustered by the door as pools of the patients’ bodily fluids spread to the threshold."

http://www.businessinsider.com/one-...lains-why-ebola-has-spread-so-quickly-2014-10

Health providers don't have the resources or training to use universal precautions, and they're so overwhelmed at this point, they can't even respond, decontaminate or dispose of bodies, to the extent that corpses are laying in wait, with their infectious bodily secretions and fluids pooling in their homes and places of death. A large amount of the problem is simply economic, in that they don't have the money to adequately quarantine, decontaminate or buy protective equipment for all those needed. They also don't have doctors with 100% diagnostic accuracy, like our very own DocEspana.

 

[Apollyon]

They also don't have doctors with 100% diagnostic accuracy, like our very own DocEspana.

C'mon, man...that wasn't necessary. I mean, I think the guy likes to hear himself talk, and perceives himself to be a polymath scholar, but just let it go.

 

[Birdstrike]

C'mon, man...that wasn't necessary. I mean, I think the guy likes to hear himself talk, and perceives himself to be a polymath scholar, but just let it go.

You may be right. But personally, I thought it was a little bit "unnecessary" to publicly criticize a fellow physician, who certainly cannot publicly defend him-/herself due to HIPAA and medical-legal reasons, in a case where the person criticizing had no first hand knowledge, but used the unfair advantage of retroscopic vision, on the grounds that he has 100% diagnostic accuracy in relation to a disease he's seen zero cases of. I want better than that for myself, for you, and for him, too.

But, you're probably right, in that it's likely time, and certainly more dignified, to let it go.

 

[sum dude]

I work in a community hospital in North Carolina. One of our docs is pretty anxious about our preparedness, which is fair since our mothership recently sent us a plastic bin with a piece of paper taped to the top that says "Ebola response kit" and contains a plastic gown, a facemask, and a pair of booties in it...yikes.

It sounds like some of you folks are working in MUCH better prepared places, probably because you have major international airports nearby.

Given that the above discussion may have devolved a bit...It would be helpful for me and I suspect others to hear some of the basic plans you have in place as I've been debating what to do if a potential Ebola patient lands in my ED. The questions below are very basic but alarmingly our ED group has not been given clear instructions on different conceivable scenarios.

1. If screening is successful and a nurse picks up on a potential Ebola patient in a triage room: what then? Do they stay in the triage room for hours until appropriate authorities are contacted? Get moved back to isolated area in ED?

2. Let's say they are in the ED somehow: do they get 1:1 coverage by a physician and a nurse? I would assume so. Do you then call in extra physician back-up to keep the dept running? I find it a bit alarming that the Spanish nurse contracted Ebola. This was an advanced hospital with serious protective gear and she got it because 'maybe' her gown touched her face? Doesn't sound so difficult to contract to me.

3. How do the other patients in the ED respond to docs and nurses being spotted in 'space suits' if that's what is used? How do you prevent panic?

4. What if your Ebola patient comes via EMS and is promptly isolated...and his family shows up in the WR 10 minutes later touching counters/chairs, etc: what then? Quarantine them and check temps and hope no fevers?

While the possibility of Ebola coming to my ED is low I worry about how quickly things could go wrong.

Isolating a positive screen is easy: right this way sir (or maam)--don't touch anything, here catch this mask and put it on, do not leave this room, here's a bedside commode and tv remote...and lock door from behind. Then Call CDC, HD and make it someone else's problem.

The problem is what do you do with a positive screen who is unstable (even though much more likely they have sepsis or malaria or another issue causing them to be ill rather than actual ebola)? Do nurses go in and put in lines, fluids, etc? Do you put in central lines? Foleys? Intubate? Lactates every hour (J/k)? Or do you lock them in a room, throw them a couple 2L's of gatorade, box of sudafed, some zofran and tell them to drink real fast while calling in reinforcements?

 

[kat82]

The more I think about this case the more I can see how any one of us could have made the mistake that doctor #1 made. Its hard to remember, but before the Thomas Eric Duncan case, we were much less obsessed with Ebola and I guarantee it was not nearly as much on everyones radar as it is now. I didn't get any real memo from my administration on Ebola screening until after this case came to light. Before this case, were you really taking a travel history on every single febrile patient? I am sure you missed a few, and chances are those patients hadn't traveled. I know it was on the triage nurses check list which is great (and unfortunately was not communicated to the doc and also missed on his/her history). Perhaps if you worked in Iowa where your patient population was 99.9% white, a Liberian man with an accent may have triggered something in you. But perhaps the Texas Health Presbyterian sees a very large Liberian population, so when "a Liberian man walks into your ED" it may not set off all sorts of red flags and alerts in your brain. It was still a miss- but I can see any one of us missing it too.
This poor doctor could have been any one of us and I feel really sorry for him/her every time I hear Sanjay Gupta talk about this "major blunder" by the ER doctor. UGH

Also, I can't handle all of this nonsense with Jesse Jackson, and the family claiming that the patient got subpar care because he was black. "Why did all of the white people live and the black man died" Ugh its disgusting. What doctor would ever give someone subpar care based on their race? not even the worst doctor would do that. Not to mention- this hospital is already suffering a PR disaster due to the miss on the ER's part- seeing as they're in the spotlight I would think they did everything in this power to help this man survive.

 

[MSmentor018]

Also, I can't handle all of this nonsense with Jesse Jackson, and the family claiming that the patient got subpar care because he was black. "Why did all of the white people live and the black man died" Ugh its disgusting. What doctor would ever give someone subpar care based on their race? not even the worst doctor would do that. Not to mention- this hospital is already suffering a PR disaster due to the miss on the ER's part- seeing as they're in the spotlight I would think they did everything in this power to help this man survive.

once i saw him on the news, that's exactly the problem that I'd knew would surface. let's face it, jesse wasn't there b/c ebola hit the states. he's there cause there's a pot to stir. dallas pres has been under so much pressure I am sure they bent over backwards for the patient and family. yes it's unfortunate the guy died but he did contract an extremely deadly virus that we have no cure for. granted he did want any desperate human would do by lying and hopping over here to get 1st class care but exceptional care doesn't mean a cure.

The problem is what do you do with a positive screen who is unstable (even though much more likely they have sepsis or malaria or another issue causing them to be ill rather than actual ebola)?

I've been wondering the same. I saw the ideal "drill" on abc showing ems gowning/masking the suspected ebola pt, transferring the pt outside in the ems bay, then nurses already gowned with the stretcher entering through the decon room and placed in an isolation room. sounds great, the pt is pre wrapped like a burrito before entering the building. chance of spreading anything is pretty much down to 0. what about the guy that walks into triage, coughing, vomiting, spitting up blood....etc. won't the triage room and RN be contaminated?

 

[JMC2010]

I walked into my shift after posting yesterday and we now have an Ebola guidebook answering a lot of my questions...better late than never.

 

[wholeheartedly]

I'm not intimately involved in our overall protocol, given my role in the diagnostic lab side of things, but here's the gist of what I've gathered from hearing bits and pieces here and there at various mgmt meetings.

1. Travel history is taken on everyone coming in regardless of symptoms
2. Positive travel history with pos Ebola symptoms gets you isolated and infection control is called (they coordinate notification of state health dept and cdc)
3. Isolation room has security guard posted who refuses access to anyone not in appropriate PPE and folks not authorized. Log sheet tracking entry/exit.
4. Lab /imaging/ etc orders are done on paper forms and not through the EMR because
5. There are specially trained personnel to carry out those orders, bypassing the EMR prevents just anyone from showing up to collect labs. Specimens are NOT supposed to come to my lab (however I did insist my team comes up for a game plan for it and how to decontaminate the analyzers, etc) when someone slips up
6. Specimen sent to CDC for confirmation.

No clue after that

 

[rajhanda]

Lawsuit time!

Every tv expert is saying they'll have a hard time finding a lawyer in TX.. or a sympathetic judge or jury. maybe the hospital will settle to avoid further harassment by Jesse Jackson

 

[WilcoWorld]

Every tv expert is saying they'll have a hard time finding a lawyer in TX.. or a sympathetic judge or jury. maybe the hospital will settle to avoid further harassment by Jesse Jackson

Who will have a hard time, the plaintiff?

 

[Vandalia]

The Associated Press was given access to his medical records: This is the most accurate information on the ED aspect we have:

Duncan had come to the same emergency room complaining of a headache and abdominal pain. His temperature spiked to 103 at one point, and on a scale of one to 10, he rated his pain as an eight.

Doctors ran CT scans of his head and abdomen and did extensive blood tests before deciding it must be sinusitis. They sent him home with a course of antibiotics and told him to follow up with a doctor the next day.

A nurse's note said Duncan told her he recently had arrived from Africa. Somehow, that information did not make it to the attending physician.

Now, Duncan was back, only this time his symptoms included vomiting and diarrhea. His temperature was 103.1 degrees.

This time, the nurse's notes made it clear that Duncan had "just moved here from Liberia." This time, the doctor got the message.

"I followed strict CDC protocol," wrote Dr. Otto Javier Marquez-Kerguelen, referring to the U.S. Centers for Disease Control and Prevention guidelines for treating potentially infectious patients. Wearing a mask, gloves and full gown, Marquez-Kerguelen began his examination and took a history.

http://bigstory.ap.org/article/c9de...-enterprise-records-chronicle-duncans-decline

The interesting thing is that immediate access to advance testing might have worked to his disadvantage. Without the "clearance" given by the CT, and presumably some of the lab testing, 103 temp with abdominal pain might have been admitted. It almost certainly would have been 30 years ago, but that was of course a far different era for many reasons. That is the other paradoxical aspect of this case: if he HAD been admitted to a standard hospitalist service, there almost certainly would have been an extensive outbreak.

 

[southerndoc]

Who will have a hard time, the plaintiff?

Yes, Texas passed significant tort reform several years ago that discourages a lot of lawyers from taking on lawsuits.

 

[rajhanda]

Mr. Duncan infected a nurse. The question is how many more??

 

[deuist]

Mr. Duncan infected a nurse. The question is how many more??

I wonder if Jesse Jackson is going to speak out about that.

 

[rajhanda]

Jesse just got a nice assist from Tom Frieden who said on national TV that the hospital must have breached protocol

 

[Arcan57]

F@$@. "The protocol works but even a single lapse can result in infection. " - from CNN article. I would suggest that it doesn't work since we've had two first world infections among healthcare workers. But so easy to blame protocol violations rather than admit it can't be followed or it's not as effective as it should be.

 

[jl lin]

In Reply to :"5) the CDC then runs the patient for you and takes responsbility for directing the exam to rule Ebola out. - See more at: http://forums.studentdoctor.net/thr...boys-post.1101660/page-2#sthash.sbi6G9yC.dpuf"


I am not at all sure that CDC did this, at least not in the way that they were supposed to, with constant, direct supervision in person, and not remotely.

I am not at all sure that they gave the healthcare providers the same equipment that the CDC would use when dealing with the virus.

Now the nurse caring for the US-index patient, Mr. Duncan, has tested positive.

We're supposed to feel better b/c she has tested with a low viral load--so they say. We don't have the whole picture with this infectious and potentially evolving virus yet.

No one is saying panic; but we should be VERY concerned, and we should be very dissatisfied with how this virus and the patient involved here were dealt with. Yes, the man lied at the airport. Wrong. But perhaps he thought his best chance for survival was in the US. Doesn't make it right, but it's human nature to do this.

The triage RN, and who knows how many others, dropped the ball here, and so far, at least IMHO, it seems that the hospital and CDC may have dropped the ball as well.

Cost containment and lack of direct CDC supervision may have been a factor in the nurse contracting the virus. I'm guessing that it probably was. If I am truly wrong, I apologize in advance. But these kinds of things should be questioned and questioned often. People don't like being questioned, but there are times when it must be done, regardless of whether or not someone likes it.

No one is OUT to crucify anyone. Serious mistakes must be questioned, so that there is learning and proper and thorough intervention.

You know how many people it takes to make an epidemic/pandemic? One.
The sooner we learn and get on board with following the strictest protocols, the better. We are supposed to have the best medicine and healthcare, pretty much, in the world--which is probably one of the reasons why Duncan lied.

People should be not panicked but intensely concerned. And the CDC and leadership have to have their feet put to the fire as well.

 

[jl lin]

F@$@. "The protocol works but even a single lapse can result in infection. " - from CNN article. I would suggest that it doesn't work since we've had two first world infections among healthcare workers. But so easy to blame protocol violations rather than admit it can't be followed or it's not as effective as it should be.

Like I said. I am not at all sure that pure-form CDC policies and directives were followed---neither that the best PPE (What CDC uses for Ebola) were used there.

There were also reports of gloves and other contaminates that were discarded in non-BIOHAZARDOUS trash containers. Dear God, if this is true, really, God help everyone around that Dallas hospital.

This is the time to be absolutely picayune--severely anal-retentive, overly fastidious--and any other synonyms to these words. CDC should have had people there is DIRECT supervision. Gee, they are there now. Thanks.

 

[Arcan57]

** Disclaimer - I have no idea what Presbyterian's capabilities usually are **

I did rotations at Emory Hospital and the CDC is within easy walking distance of the hospital. It has extremely robust capabilities, shares some of it's faculty with the CDC, and if I get Ebola I'd want to be cared for there. I also feel comfortable saying that the chance that a community hospital in Dallas has the capability to be as fastidious and the experience to execute these protocols as well as Emory is minimal. Essentially every hospital I've worked at post residency has been in a constant state of crisis with the idea of surge capacity being something that is addressed in disaster planning by magically creating staffing and resources out of thin air. If a holiday weekend can cause you to lose a third of your nursing staff to call-outs, one wonders what an Ebola patient in the ICU did to staffing. Also, it's probably worth noting that while we have definitions for differing types of isolation, in practice significantly more attention is paid towards keeping the patient from being infected by us then vice-versa. In general we rely on the fact that most significant diseases in our country are only poorly transmissible (blood born pathogens primarily), cause only mild symptoms in immunocompetent caregivers, or have effective post-exposure prophylaxis/treatment. Prior to this outbreak, I couldn't find the PPE required for contact precautions at our hospital affiliated FSED. In my opinion, in the absence of an overwhelming epidemic, a policy that keeps Ebola + patients at non-tertiary care hospitals without direct and ongoing contact with the CDC is dangerous. Ground or fixed wing transport to designated centers should be the standard of care.

 

[Birdstrike]

The bottom line is this:

No one was ready for Ebola to come to this country. No one is ever ready for "the first" of anything. But the first has passed, and you sure as a hell better be getting ready. Are you ready for Ebola? Is your hospital? Your inpatient wards? Your EMTs? Your sanitation disposal staff?

Criticism? Sure, there's going to plenty to go around. There always is unhelpful criticism from the plethora of Monday morning all-star quarterbacks. As professionals, let's try to make ours constructive, based on valid first hand knowledge, and based on more than a perception of our own supposed-infallibility.

Are you ready to have your face, name, title and location plastered across Fox News, CNN, Google and other news outlets worldwide by the Monday morning QBs, when a non-verbal, coding, patient comes in, that turns out later to have Ebola, that you never knew had Ebola? Are you ready for reporters to be calling your house asking for interviews?

How are you going to make the diagnosis, if the patient doesn't walk in and give you the diagnosis? Will you have followed CDC protocol in every viral, or possible viral illness, now that travel to Africa is not necessary to contract this disease, and that any virus could potentially be early Ebola?

That's inevitable, that patients will come in with this disease, not knowing they have it, not knowing they were exposed, and not having or admitting to any travel to endemic regions.

What about when our country itself is a "source country," ie, when we have enough Ebola cases that whether you've been in Liberia is irrelevant, because they've been HERE, where we also have Ebola now?

How are you going to protect yourself? Is wearing isolation gear enough? What about your stretchers, the ambulances, your helicopters? What do you do with them once you put a patient in one after you slapped a "rule out Ebola" on their chart?

Can the chopper still fly, doc? Can the ambulance still run, doc?

And to all you hot-shots, that think you've got you 100% no-miss rate dialed in for Ebola and all other hemorrhagic and tropical fevers: In your zeal to diagnose every "rule out Ebola" will you end up with an ED that the CDC will have to be shut down to go through a process of decontamination until the send out confirmatory labs can be run, because you slapped "rule out Ebola" on "the flu"?

http://online.wsj.com/articles/clinic-near-boston-quarantined-1413148616

What do you do when you rerun out of roomto isolate people because in your efforts to catch every rule out Ebola, you end up isolating countless people, that end up having non-specific viruses? What about tracking down their contacts? What about their pets, their contacts pet? What about when the CDC is overwhelmed by everyone calling them to come rule out Ebola, there's a prohibitive delay, a la hurricane Katrina response, and you must figure it out on your own, to the perfection demanded by the Monday-morning quarterbacks, whose hindsight is always omniscient?

You think you are ready, but are you? The nurse in Texas thought he/she was ready, and per news reports, wore protective gear.

Was the protocol broken?

Or is the protocol ineffective even when followed?

Just some nuggets to ponder...

What say you, to my game of Twenty Questions?


It's here.

 

[TheTao]

"What doctor would ever give someone subpar care based on their race? not even the worst doctor would do that."

A racist one, and it's been around this country for about 400 years or so.

 

[TheTao]

"You think you are ready, but are you? The nurse in Texas thought he/she was ready, and per news reports, wore protective gear."

Or was their some defect in the "protective" equipment?

Signed, a former NIAID scientist

 

[MSmentor018]

How are you going to protect yourself? Is wearing isolation gear enough? What about your stretchers, the ambulances, your helicopters? What do you do with them once you put a patient in one after you slapped a "rule out Ebola" on their chart?

Can the chopper still fly, doc? Can the ambulance still run, doc?



You think you are ready, but are you? The nurse in Texas thought he/she was ready, and per news reports, wore protective gear.

Was the protocol broken?

Or is the protocol ineffective even when followed?

It's here.

that's the questions I've got. something about these "protocols" isn't adding up
also how long do we ask the questions? until a new deadlier disease shows up or will it be imprinted on the triage sheets right next to "do you feel safe at home?"
it's a brave new (and expensive) world
http://www.cnn.com/2014/10/12/health/ebola/index.html?hpt=hp_t1
http://www.cnn.com/2014/10/12/health/ebola/index.html?hpt=hp_t1
"At some point, there was a breach in protocol, and that breach in protocol resulted in this infection," he said at a news conference Sunday. "The (Ebola treatment) protocols work. ... But we know that even a single lapse or breach can result in infection."

but most importantly "Ebola is actually difficult to catch."

guess not

 

[jl lin]

I'm willing to bet everything I own that those people in Dallas Presby were given crappy flimsy plastic shields, crappy masks, crappy gloves and gowns--and NOT the suits the CDC would use when working with Ebola or caring for a pt with Ebola.

In my probably idiotic opinion, that is, to you, I suppose, I think, in general, hospitals in the US can be vary careless and only do the bare minimum when it comes to infection control. I have worked in a ton of hospitals, and many of them "top of the line" medical centers. I have seen where ID decided to cut back on masks for kids on ventilators with contact isolation. I had a kid that was becoming hypoxic and bradying down. The RT and I were in there when I said "Let's suction him." I took the Mapleson and started to bag and then suction the child. ID decided contact isolation didn't require masks, so they stopped storing them in there. I guess inside the eyes, nose, and mouth don't count as mucus membrane areas. Anyway, this kid had known resistant bacteria in his mucus and trach. RT took the tubing off and turned it toward me too quickly for me to do a thing as I was bagging and preparing to suction him. We were in a hurry, and remember, ID and Cost Containment people decided to stop stocking masks in this isolation room. Guess who got hit with the junk from the kid's ventilator tubing b/c the RT wasn't paying attention? Me. It's surprising to me that the RRT didn't think what pointing a ventilator tubing from a sick child attached to a positive pressure ventilator could do to another person. It still blows my mind, and it was more than a few years ago now. I was sick as a dog for months and on multiple antibiotics, and my nurse manager and the institution could have cared less that I became infected there b/c of utter stupidity.

I will repeat myself, and it has NOTHING to do with playing MMQB. The right CDC staff should have been there and stayed there as soon as Duncan was tested positive--setting up protocols, instructing, and supervising, AND the people involved in Duncan's direct care should have had the same quality suits CDC would wear, period.

I have seen hospitals play Russian Roulette like this. It's ethically, and in my mind at least, legally wrong.

Again. How many people does it take to start an epidemic leading to a pandemic? ONLY ONE. It's not worth playing with this deadly infectious virus. There is NO excuse for this. It's time to get serious. Meanwhile, besides this nurse, there are about 50 + people that were involved in this person's care. It would not be improbable for more to test positive. And then there must be the consideration of all the people those people were in contact with. It's insane to get all hot and bothered over blame.

We should have and now need to seriously do better. If you know to do better and can do better, you must be held to accountability for not doing better. How much worse, then, is it if from this point on, if our CDC and health system and national leadership (which includes "We the people" and speaking out) don't get on the stick ASAP--I mean, like yesterday. No more excuses. No more idiotic worrying about blame. Let's get this crap under control now. Let's get the best PPE in and the best protocols and supervision and f/u in place NOW! That's all anyone with any sense cares about. Everything else is BS.