Dallas Ebola (not a Cowboys post)

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jl lin said:
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.
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I agree that most hospitals could do a MUCH better job of exercising infection control precautions. However, it sounds like you're mixing up droplet precautions with contact precautions. They don't have the same indications or requirements, and just throwing everything you have at every patient on isolation will likely lead to precaution fatigue which will lead to protocol violations.

NB: I am not familiar enough with Ebola's transmissibility or the situation as Dallas Presby to speak specifically on that situation - the above statement is in no way meant as a judgement of the nurse in Dallas who contracted Ebola.
 
jl lin said:
I have seen hospitals play Russian Roulette like this. It's ethically, and in my mind at least, legally wrong.
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I don't know enough about the law to speak to its legality, but I agree that hospitals play odds games for profits, made most clear to me by "lean" staffing models. I agree that this is ethically wrong.
 
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"Towards of end of the illness, the virus is trying to live and thrive. It's trying to get out of the person's body. It's producing massive amounts of fluid," he said.
At that point, caregivers need to add more layers of protective gear, such as double gloves and a respirator or a full bodysuit. Those kinds of decisions need to be made by managers who are constantly assessing the risk to healthcare workers, Kaufman said.

That supports my feeling that it's the people caring for end-stage patients that are at the highest risk.
 
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As a little medmal side note, you all know peter Rosen is now an expert witness for plaintiffs attorneys right?
 
Dre8 said:
As a little medmal side note, you all know peter Rosen is now an expert witness for plaintiffs attorneys right?
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It wouldn't surprise me if true. Do you have a link?
 
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jl lin said:
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.
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Best post I've read in regards to Ebola in America thus far. The American PPE system is so flimsy it's a joke. People need to quit talking about protocol breaches because the protocol has failed. As I said in another thread, let's throw the kitchen sink at Ebola in America.
 
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WilcoWorld said:
I agree that most hospitals could do a MUCH better job of exercising infection control precautions. However, it sounds like you're mixing up droplet precautions with contact precautions. They don't have the same indications or requirements, and just throwing everything you have at every patient on isolation will likely lead to precaution fatigue which will lead to protocol violations.

NB: I am not familiar enough with Ebola's transmissibility or the situation as Dallas Presby to speak specifically on that situation - the above statement is in no way meant as a judgement of the nurse in Dallas who contracted Ebola.
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No. That is not at all what I mean. Contact isolation takes on a more involved meaning when you have, say, someone on a ventilator--or someone that in a coagulopathy state. For the kids on vents we did not use in-line suctioning. (Also, in-lines many times have to be bypassed.) At that time cardiac intensive care unit, the protocol was to use the mapleson, and in all but extreme emergencies, use two-person protocol, and suction that way. Plus, in-line suction was not used on babies. Anyway, the point is, when an internal system has to be opened, the whole contact isolation issue is now expanded, b/c there is the potential to get things from within the patient into the nose, eyes, mouth--mucus membranes of the healthcare people. Plus you have the wonderful added benefit of positive pressure ventilation running through the tubing that was attached to the baby. All that is on the inside of the tubing is pushed by positive pressure ventilation out. Now, when a numb nuts person isn't careful and allows the tubing to be turned in your direction--direct face, and you are bagging and suctioning a kid on the verge of coding, I don't know, it's this pretty forceful shower of YUCK that is pushed up into your nose. Quite fun and wonderful. And even if the RRT hadn't been more careful b/c he had to move quickly for some reason and that loaded ventilator tubing was pointed at me in the line of fire, if ID had kept the masks in there instead of demanding that we no longer needed them, b/c it's "merely contact isolation," I would not have been infected. This was ID looking to cut-costs across the board, and limiting the situation to a textbook definition of simple, contact isolation. Um, when people are on artificial ventilation, their care is no longer considered simple for a number of reasons. When someone has taken a hit to the liver and has developed mass coagulopathy or a patient develops DIC--and they are infectious, they are no longer simple, and now we have to go beyond the thinking of simply, skin-based, contact isolation.

With the baby to which I referred this is what should have been applied: Transmission-based Precautions-->Contact + Droplet Precautions should have been but were not implemented by ID--only Contact w/o the consideration of the need to frequently "open systems" on the patient. Droplet would have allowed for the continuation of masks in the isolation room. They were bugged b/c so many masks were being used, and the reason was b/c the kid had to have a ton of suctioning. When he didn't get it, regardless of whatever else we were doing for him, his HR would drop to 30, and yes. The kid had been coded several times.

As in the following:
Isolation precautions
Isolation precautions create barriers between people and germs. These types of precautions help prevent the spread of germs in the hospital.
Anybody who visits a hospital patient who has an isolation sign outside their door should stop at the nurses' station before entering the patient's room. The number of visitors and staff who enter the patient's room may be limited.
Different types of isolation precautions protect against different types of germs.
Standard Precautions
You should follow standard precautions with all patients.
When you are close to, or are handling, blood, bodily fluid, bodily tissues, mucous membranes, or areas of open skin, you must use personal protective equipment (PPE). Depending on the anticipated exposure, types of PPE required include:
  • Gloves
  • Masks and goggles
  • Aprons, gowns, and shoe covers
It is also important to properly clean up afterward.
Transmission-based Precautions
Transmission-based precautions are extra steps to follow for illnesses that are caused by certain germs. Transmission-based precautions are followed in addition to standard precautions. Some infections require more than one type of transmission-based precaution.
Follow transmission-based precautions when an illness is first suspected. Stop taking these precautions only when that illness has been treated or ruled-out and the room has been cleaned.
Patients should stay in their rooms as much as possible while these precautions are in place. They may need to wear masks when they leave their rooms.
Airborne precautions may be needed for germs that are so small they can float in the air and travel long distances.
  • Airborne precautions help keep staff, visitors, and other patients from breathing in these germs and getting sick.
  • Germs that warrant airborne precautions include chickenpox, measles, and tuberculosis (TB) bacteria.
  • Patients who have these germs should be in special rooms where the air is gently sucked out and not allowed to flow into the hallway. This is called a negative pressure room.
  • Anyone who goes into the room should put on a well-fitted respirator mask before they enter.
Contact precautions may be needed for germs that are spread by touching.
  • Contact precautions help keep staff and visitors from spreading the germs after touching a patient or an object the patient has touched.
  • Some of the germs that contact precautions protect from are C. difficile and norovirus. These germs can cause serious infection in the intestines.
  • Anyone entering the room -- who may touch the patient or objects in the room -- should wear a gown and gloves.
Droplet precautions are used to prevent contact with mucus and other secretions from the nose and sinuses, throat, airways, and lungs.
  • When a patient talks, sneezes, or coughs, droplets that contain germs can travel about 3 feet.
  • Illnesses that require droplet precautions include influenza (flu), pertussis (whooping cough), and mumps.
  • Anyone who goes into the room should wear a surgical mask.
References
Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf. Accessed February 20, 2014.
Update Date: 2/3/2014
Updated by: Jatin M. Vyas, MD, PhD, Assistant Professor in Medicine, Harvard Medical School; Assistant in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
 
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Spikebd said:
Best post I've read in regards to Ebola in America thus far. The American PPE system is so flimsy it's a joke. People need to quit talking about protocol breaches because the protocol has failed. As I said in another thread, let's throw the kitchen sink at Ebola in America.
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I'm sorry if I'm wrong in this possible assumption; but is this sarcasm? I mean on one hand I think no, based on some things you have said.

Regardless, we need to learn and now get very serious with this; b/c we are kidding ourselves if we think it can't spin out of control here. People seem to have this magical thinking about America and American medicine. "This could never happen here. " Oh really? Sure about that? The relative ease of transmission, especially as patients with Ebola become increasingly sicker, seems to suggest otherwise.
 
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Dr.McNinja said:
I'll just leave this here.
http://thehealthcareblog.com/blog/2014/10/12/six-sigma-vs-ebola/
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This suggests to me NOT that we don't need Risk Mgt involved or that RCA does not need to be done. It suggests that bureaucratic mechanisms w/ most systems and their RM people are screwing up the process. In other words, what RM does should be objectively evaluated as well. I know one RM person at a recent job, and she is nightmare in that she can't look at the whole picture, and she makes absolute mountains out of molehills. She thinks she knows what she is doing, but she is working with partial perspective, and she often doesn't have the ability to put things together well. She then needs an objective system of evaluation of her thinking and approach to RM. Add to that some strange, teen-like need for her to make a drama out of things in order to show the directors her "added value." It's a farse.

In this situation, however, sound RM should be applied. It would seem to me that the people most qualified to supervise and make appropriate correction is the CDC people. Which is why I stated they needed to have anticipated the potential for risks and complications when they first heard about Mr. Duncan. He really should have been carefully moved to a facility that has the top of the line equipment, practice, and protocol, or they needed to be at that hospital around-the-clock enforcing and closely monitoring if the protocols were being strictly followed--and teaching/reinforcing these things with the staff.

Also, the PPE should have been superior to what was given IMHO. Yes. It's costly. But see. This is why there are non-frivolous lawsuits. The institution is obligated to provide the most appropriate (gap free in this case) PPE for their employees.

I mean really. No one thinks ahead anymore? No one reasons the potential problems when they must accept such a patient? Really? It's time to start teaching students chess. You have to anticipate--not too much--but sensible reasoning for God's sake.

Sigh
 
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jl lin said:
I'm sorry if I'm wrong in this possible assumption; but is this sarcasm? I mean on one hand I think no, based on some things you have said.

Regardless, we need to learn and now get very serious with this; b/c we are kidding ourselves if we think it can't spin out of control here. People seem to have this magical thinking about America and American medicine. "This could never happen here. " Oh really? Sure about that? The relative easy of transmission, especially as patients with Ebola become increasingly sicker, seems to suggest otherwise.
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Sorry I didn't mean for it to be sarcastic, I'm agreeing with you. It's scary that a lot of doctors are playing this down. Us health care workers are on the front lines, especially emergency physicians. So to brush this off as an "African thing because they have worse PPE" is a serious mistake.
 
I'm sorry. It's just that I cannot actually believe the amount of idiotic responses I have gotten from people. This magical thinking, where, especially Gen Y types think it could never happen, and they are so up their own arses, they can't possibly think on global terms. And neither can they anticipate risks. When you reasonably suggest that we think and make corrections, and take this crap seriously, they say you are a scaremonger.

No one is saying the freaking sky is falling. We're saying, we can do better, and indeed at many points thus far have dropped the ball. We need to figure out why the ball has been dropped at so many points, and we need to fix it now--carefully, thoughtfully--anticipate needs here. Gear up for some real accountability.

It never ceases to amaze me how there seems to be some people that want responsibility w/o true accountability. Too many bad examples in leadership have been part of setting the tone for this IMHO. You shouldn't get the responsibility or title w/o the commitment and courage to have full-frontal accountability. I guess I am like the "Judge Judy" of healthcare. IDK.
 
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Somebody also needs to get to work on a vaccine, like yesterday.
 
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Great post @Dr.McNinja

CNN, surprisingly, had a good post on where the CDC went wrong in its guidance. I know this is one of those situations no one, including the CDC, can ever 100% prepare for, but as an Epi student it did surprise me that some of these weren't being done.

Im not a fan of Monday morning quarter backing, but I think this is a good analysis and hopefully people are taking some of this into consideration as the situation develops.

http://www.cnn.com/2014/10/13/health/ebola-cdc/index.html


Standard PPE instead of Tyvek suits. Yes standard PPE should be sufficient if used properly, but it has more components to deal with and is probably harder to safely remove. So let's just get rid of the risk associated with that "if" as soon as they know its Ebola, the CDC should send those suits to be used.

Second, lack of disinfection of the suits on people when they exit before de-gowning. They do that in Africa if they have the supplies, and at the CDC labs, and they did it at Emory if the patient was vomiting, etc.

They also apparently didn't suggest the buddy system as is done in a lot of locations working with Ebola.

Third, the vast majority of hospitals haven't drilled for this much, if at all. But we have 4 really expensive biocontainment facilities where they do drill for this, were they have proper waste removal, and have small labs inside. So let's get our money's worth and put them through the paces. Let them work out the kinks, become the experts, and offer guidance to the rest of us for later use.
 
wholeheartedly said:
Great post @Dr.McNinja

CNN, surprisingly, had a good post on where the CDC went wrong in its guidance. I know this is one of those situations no one, including the CDC, can ever 100% prepare for, but as an Epi student it did surprise me that some of these weren't being done.

Im not a fan of Monday morning quarter backing, but I think this is a good analysis and hopefully people are taking some of this into consideration as the situation develops.

http://www.cnn.com/2014/10/13/health/ebola-cdc/index.html


Standard PPE instead of Tyvek suits. Yes standard PPE should be sufficient if used properly, but it has more components to deal with and is probably harder to safely remove. So let's just get rid of the risk associated with that "if" as soon as they know its Ebola, the CDC should send those suits to be used.

Second, lack of disinfection of the suits on people when they exit before de-gowning. They do that in Africa if they have the supplies, and at the CDC labs, and they did it at Emory if the patient was vomiting, etc.

They also apparently didn't suggest the buddy system as is done in a lot of locations working with Ebola.

Third, the vast majority of hospitals haven't drilled for this much, if at all. But we have 4 really expensive biocontainment facilities where they do drill for this, were they have proper waste removal, and have small labs inside. So let's get our money's worth and put them through the paces. Let them work out the kinks, become the experts, and offer guidance to the rest of us for later use.
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Thanks WH for posting the link. I agree with what's in the article.
1. I disagree with you re: the PPE, specifically B/C education and supervision is part and parcel with the necessity of using the better suits. *** The suits should be impervious and without spotty coverage--seamless and uninterrupted.
***Both careful donning and removal must be given with training, practice, and supervision. This means that CDC supervisors cannot just pop in and out. They must participate in the co-practice of care, and they must continue to do so with supervisor and best practices in training, until the appropriate number of folks meets their standards, with 0--that's zero error after a set number of times.
(It also means that they should probably limit the time the clinical spends with these patients--meaning--is it better to do 8, 10, or 12 hours at a time? Oh. That means more staff. You bet it does. So what? Better to be fresh than to be tired and make a mistake that could kill you. I don't know what the answer is to the number of hours. But I bet the CDC people have a better idea from previous experiences and so forth.) *** If that's can't be done right/well, for whatever reason, listen, have the CDC specialized centers, where people are routinely experienced in the use of these suits and other vitally important procedures, take these patients. Carefully transport or have special transport from the centers transfer the patient/s to these places.

2. I also agree with this. Was this being done in Dallas? I think probably no.

3. The buddy system? Drilling? Yes, and yes. It must be part of the training and education, which should be overseen by the CDC--or transfer to a specialized CDC center. The rest of what you said, ITA.

Thanks again WH.
 
Birdstrike said:
"This summer, the CDC produced a PowerPoint detailing how to put on and take off Personal Protective Equipment, or PPE. It has 49 slides."

http://www.vox.com/2014/10/13/6968775/ebola-nurse-united-states-texas-directions-protocol-breach
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Here's a more concise explanation of PPE application and removal (aka donning and doffing). There's no CME, but I decided to brush up on it anyway.

Note that the way you take it off matters as much as the way you put it on, perhaps more.
 
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jl lin said:
That's nice. Sorry. *shrug* That's not good enough. Being drilled and tested is a lot different than watching a PPT, don't you think?
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I just thought it was an interesting article.
 
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Birdstrike said:
I just thought it was an interesting article.
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I am not saying it isn't. But I guess I am saying that if the implication was "Here's the PPT. Watch it, and you're good." Well, I would have to strongly disagree.

Oh well. It's too late for a glass of Merlot. :)
 
wholeheartedly said:
you aren't really disagreeing with my thoughts on PPE. I just didn't go into as much detail.
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LOL :)

I am fired up though WH. Can you tell? Seriously. I hope this nurse fairs well. And every time I see a picture of Mr. Duncan, it makes me sad. I mean there are pictures of him reading his cell phone, looking all fine, and he's days a way from death. IDK. Major suckage.
 
you bring up great points in the posts. even with proper standard PPE use, she got infected somehow which the CDC states ain't easy. did duncan hug her and touch broken skin on your ear? bits of particle blood flew around her head into her nostril when she ungowned? in the end when you turn into a can of tomato soup is the viral count so high all it takes is a dried micron of blood on the bed rail to blow up under your faceshield? or is it as simple as she wiped her eyes with a bloody glove?

the PPT was a major buzzkill, even the merlot couldn't keep up

I hope she pulls through and thank god they're not going to execute her little dog.
although I like the nurses lobbying. once CDC blamed her this morning, they came out strong by lunch (with the hint of disability and inadequate training lawsuit) and viola....CDC backpedaling faster than MJ doing the moonwalk
 
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southerndoc said:
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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I'm just happy knowing that you would never have missed it. Makes me feel good.
 
Birdstrike said:
It wouldn't surprise me if true. Do you have a link?
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I used to work with some aaem higher ups, and I asked them if this was THE Peter Rosen. They confirmed it.

http://www.epmonthly.com/features/c...-slippery-slope-for-dubious-expert-testimony/

The patient’s parents filed a medical malpractice lawsuit against the treating emergency physician and the emergency physician’s group. The trial court dismissed the case for failing to meet the “gross negligence” standard of proof. An appellate court then affirmed the trial court’s decision. The Georgia Supreme Court reviewed the case, including testimony from plaintiff experts Drs. Peter Rosen and Dr. Steven Gabaeff. According to the court opinions, Drs. Rosen and Gabaeff testified that the EKG showed “Q3T3” abnormalities and the chest x-ray demonstrated cardiomegaly – which were allegedly both suggestive of a pulmonary embolism. Dr. Rosen’s opinion was based on his experience diagnosing “hundreds if not thousands” of pulmonary emboli in his career. Rosen and Gabaeff opined that the patient’s symptoms “presented a classic case of pulmonary embolism” and that the diagnostic measures that the emergency physician took in response to those symptoms “did nothing to prove or disprove the presence” of a pulmonary embolism. While the treating physician believed that relief of pain from a pulmonary embolism would not occur with administration of Toradol, the experts called that reasoning “ridiculous.” Both experts stated that the standard of care required the treating physician to obtain a CT scan in order to rule out a pulmonary embolism in the patient, and that failure to do so was “grossly improper, egregious, and contrary to well-known and fundamental medical principles.” Given these expert opinions and other testimony in the case, the Georgia Supreme Court held that the treating physician’s treatment may have been grossly negligent and that a jury would have to decide the issue.


http://www.aaem.org/publications/co...elax-volunteers-medical-malpractice-liability

I found this funny, as Walker just dodged the question (he's not the guy I worked with, though)
 
Dre8 said:
I used to work with some aaem higher ups, and I asked them if this was THE Peter Rosen. They confirmed it.

http://www.epmonthly.com/features/c...-slippery-slope-for-dubious-expert-testimony/

The patient’s parents filed a medical malpractice lawsuit against the treating emergency physician and the emergency physician’s group. The trial court dismissed the case for failing to meet the “gross negligence” standard of proof. An appellate court then affirmed the trial court’s decision. The Georgia Supreme Court reviewed the case, including testimony from plaintiff experts Drs. Peter Rosen and Dr. Steven Gabaeff. According to the court opinions, Drs. Rosen and Gabaeff testified that the EKG showed “Q3T3” abnormalities and the chest x-ray demonstrated cardiomegaly – which were allegedly both suggestive of a pulmonary embolism. Dr. Rosen’s opinion was based on his experience diagnosing “hundreds if not thousands” of pulmonary emboli in his career. Rosen and Gabaeff opined that the patient’s symptoms “presented a classic case of pulmonary embolism” and that the diagnostic measures that the emergency physician took in response to those symptoms “did nothing to prove or disprove the presence” of a pulmonary embolism. While the treating physician believed that relief of pain from a pulmonary embolism would not occur with administration of Toradol, the experts called that reasoning “ridiculous.” Both experts stated that the standard of care required the treating physician to obtain a CT scan in order to rule out a pulmonary embolism in the patient, and that failure to do so was “grossly improper, egregious, and contrary to well-known and fundamental medical principles.” Given these expert opinions and other testimony in the case, the Georgia Supreme Court held that the treating physician’s treatment may have been grossly negligent and that a jury would have to decide the issue.


http://www.aaem.org/publications/co...elax-volunteers-medical-malpractice-liability

I found this funny, as Walker just dodged the question (he's not the guy I worked with, though)
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We had a thread on this months ago, when William Sullivan wrote his article. I thought you were referring to something having to do with this Ebola situation, and lawsuits that might come out of it.

http://forums.studentdoctor.net/threads/what-do-you-think-of-this-expert-testimony.1059639/
 
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I'm going to be really blunt: everything regarding the government's management of this disease thus far has been political and driven by two things:

1. Try and minimize public concern
2. Don't institute a travel ban that would stigmatize African countries.

The first rational step in controlling the spread of a disease is to stop importing new cases.
 
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Old_Mil said:
I'm going to be really blunt: everything regarding the government's management of this disease thus far has been political and driven by two things:

1. Try and minimize public concern
2. Don't institute a travel ban that would stigmatize African countries.

The first rational step in controlling the spread of a disease is to stop importing new cases.
Click to expand...
Since when has the government placed the idea of closing borders to stop diseased or unvaccinated people from coming into this country unfettered, above political correctness and voter demographics?

After all, isn't an inalienable right of all human beings outside of this country to come in unquestioned, as they wish?
 
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Old_Mil said:
I'm going to be really blunt: everything regarding the government's management of this disease thus far has been political and driven by two things:

1. Try and minimize public concern
2. Don't institute a travel ban that would stigmatize African countries.

The first rational step in controlling the spread of a disease is to stop importing new cases.
Click to expand...

I agree it's crazy. We've decided that as a society we would rather have a potential pandemic disease ravage half our population, than do the politically incorrect, but correct steps to contain this.

As far as air travel goes, there are no direct flights from the disease-stricken countries to the U.S., which is good. I think that we should refuse entry to any non-U.S. citizen who has traveled from those countries within the last 21 days. U.S. citizens will be quarantined for 21 days at their own expense.

It would be difficult for someone to circumvent the system, as most travel visas, and entries/exits from countries are tracked electronically now.
 
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we will stop ebola in its tracks... every hospital is capable... see training materials at cdc.gov... the nurses breached protocol.. its very hard to catch the virus... its ok to sit next to mr duncan for hours in the er ... don't have neck protection? use medical tape!!!

Now cdc says "hey don't look at us. We're not a regulatory agency..
The state health department is responsible! !!!!"

Freiden is a hack and should resign... he is a coach without a game plan... all hat and no cattle as they say in tx
 
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As an emergency physician in Dallas, it has become apparent to me that this is not going to be a two-or-three type case event. I wasn't super concerned before, but I think this is highly likely to be a significant outbreak.
 
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Also, who's idea was this that any hospital can take care of ebola? Doesn't the CDC know that most hospitals take care of bull**** chest pain and confused old ladies with a creatinine of 2 all day? These cases need to be handled in designated centers with the appropriate equipment and training. Or else it gets transmitted to the healthcare workers.
 
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goodoldalky said:
Also, who's idea was this that any hospital can take care of ebola? Doesn't the CDC know that most hospitals take care of bull**** chest pain and confused old ladies with a creatinine of 2 all day? These cases need to be handled in designated centers with the appropriate equipment and training. Or else it gets transmitted to the healthcare workers.
Click to expand...
This is the key issue here in stopping an outbreak (and @Arcan57 made the same comment earlier). There are 4 specific locations (Emory, UNMC, NIH and some place in MT) with bio-containment units. Confirmed cases in the US need to be wrapped in plastic and shipped to one of these places as soon as the diagnosis is made. At the very least, they need to not be kept in whatever community hospital they wander into (or work in). I mean, when US healthcare workers have been infected in Africa, it's not like they're being sent to the hospital nearest their home for treatment, they're going to UNMC and Emory. Why should any other case in the US be different?
 
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rajhanda said:
we will stop ebola in its tracks... every hospital is capable... see training materials at cdc.gov... the nurses breached protocol.. its very hard to catch the virus... its ok to sit next to mr duncan for hours in the er ... don't have neck protection? use medical tape!!!

Now cdc says "hey don't look at us. We're not a regulatory agency..
The state health department is responsible! !!!!"

Freiden is a hack and should resign... he is a coach without a game plan... all hat and no cattle as they say in tx
Click to expand...


I'm sorry. I am betting the boat that this man is being told to say the utter BS he is saying. It's PURE POLITCAL SPIN. Some people actually think many folks cannot see it for what it is, but THEY CAN.

Meanwhile UN and WHO are cool that this is here in the US. "Hey, now the USA's attention is peaking. Great job." But the WHO refused CDC help for a while, and physicians had to go and plead to get them to listen.
This is such total BS.
 
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I think a travel ban would have stopped this all from happening. We should have shut our borders the second this all started!




(Said no reasonable person ever)
 
Ha. Travel ban for west africa, waiting period for visas? That would be soooo totally racially motivated

Here's the official biocontainment bedcount for the u.s
10 - neb. but director said can't handle > 2
3 - emory
3 - mont.
3 - nih
 
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gutonc said:
There are 4 specific locations (Emory, UNMC, NIH and some place in MT) with bio-containment units. Confirmed cases in the US need to be wrapped in plastic and shipped to one of these places as soon as the diagnosis is made. At the very least, they need to not be kept in whatever community hospital they wander into (or work in). I mean, when US healthcare workers have been infected in Africa, it's not like they're being sent to the hospital nearest their home for treatment, they're going to UNMC and Emory. Why should any other case in the US be different?
Click to expand...

I agree. Most hospitals rapidly transport out trauma patient's to a trauma center despite oftentimes having the physical plant and staff to manage those patient's adequately (and I'm an advocate of that). I assume Texas Presbyterian has a similar ICU to every other community or academic ICU I've been in, and I have yet to see an ICU have the facilities that would enable a physician or a nurse to properly decontaminate upon exiting the patient's room. Normally, there is another patient's room 10 feet away, a workstation 7 feet away, and no shower or wash basin for dirty feet within 100 feet.

If the infection rate of healthcare workers in the US remains remotely close to what we are seeing in Dallas then I think we are going to have a major issue of finding staff to work with these patients if the outbreak spreads.
 
I won't treat Ebola patients. I agree that with proper precautions the rate of transmission is low, but I can't think of any other disease that we treat routinely that is communicable and has a >50% mortality rate.

I will simply leave any area that has an Ebola outbreak. If it becomes widespread throughout the country, then I will not practice medicine at all.
 
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Transferring every Ebola patient to Emory and 2 or 3 other hospitals will only work to the extent that's there's so few cases that all from a country of 300 million people can be handled by a handful of hospitals. Once, and if, the cases are into the hundreds or thousand, "Transfer all Ebola to one of 4 hospitals" as a strategy collapses like a house of cards. Also, transferring to Emory or wherever else, does nothing about possible transmission that can occur at the diagnosing hospital prior to transfer before and while the patient is being diagnosed, which is how it appears cases #2 and #3 occurred. So every hospital needs to be "next level" or their just going to create more cases before getting patients out, and the cycle will repeat.

One thing I know for sure, is that there is no shortage of people who though they were ready for Ebola, but turned out to be 100% wrong and now have egg on their faces. Unfortunately, we've seen that's there's a huge learning curve with this, and more people are likely to get sick in the process. This is a big enough national health and security issue, that the people at the top such as Obama and his CDC, need to be accountable.

Call it what it is,

"EBOLAGATE"
 
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Birdstrike said:
Transferring every Ebola patient to Emory and 2 or 3 other hospitals will only work to the extent that's there's so few cases that all from a country of 300 million people can be handled by a handful of hospitals. Once, and if, the cases are into the hundreds or thousand, "Transfer all Ebola to one of 4 hospitals" as a strategy collapses like a house of cards. Also, transferring to Emory or wherever else, does nothing about possible transmission that can occur at the diagnosing hospital prior to transfer before and while the patient is being diagnosed, which is how it appears cases #2 and #3 occurred. So every hospital needs to be "next level" or their just going to create more cases before getting patients out, and the cycle will repeat.

One thing I know for sure, is that there is no shortage of people who though they were ready for Ebola, but turned out to be 100% wrong and now have egg on their faces. Unfortunately, we've seen that's there's a huge learning curve with this, and more people are likely to get sick in the process. This is a big enough national health and security issue, that the people at the top such as Obama and his CDC, need to be accountable.

Call it what it is,

"EBOLAGATE"
Click to expand...
Birdstrike said:
Transferring every Ebola patient to Emory and 2 or 3 other hospitals will only work to the extent that's there's so few cases that all from a country of 300 million people can be handled by a handful of hospitals. Once, and if, the cases are into the hundreds or thousand, "Transfer all Ebola to one of 4 hospitals" as a strategy collapses like a house of cards. Also, transferring to Emory or wherever else, does nothing about possible transmission that can occur at the diagnosing hospital prior to transfer before and while the patient is being diagnosed, which is how it appears cases #2 and #3 occurred. So every hospital needs to be "next level" or their just going to create more cases before getting patients out, and the cycle will repeat.

One thing I know for sure, is that there is no shortage of people who though they were ready for Ebola, but turned out to be 100% wrong and now have egg on their faces. Unfortunately, we've seen that's there's a huge learning curve with this, and more people are likely to get sick in the process. This is a big enough national health and security issue, that the people at the top such as Obama and his CDC, need to be accountable.

Call it what it is,

"EBOLAGATE"
Click to expand...

All true. At this point, most of us can only hope and pray that it remains limited.

I love how everyone came down on the second nurse, when she contacted the CDC and they told her that 99.5F was beneath the threshold, so she could go ahead and get on the plane. If she was not coughing, vomiting, oozing, or spewing anything, those people on the plane are probably fine. But KNOWING that she was in very close contact with Mr. Duncan and his secretions, with substandard PPE, and then the nurse having a low grade fever, the CDC's advice was idiotic.
Seriously, what is up with the CDC?
 
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jl lin said:
All true. At this point, most of us can only hope and pray that it remains limited.

I love how everyone came down on the second nurse, when she contacted the CDC and they told her that 99.5F was beneath the threshold, so she could go ahead and get on the plane. If she was not coughing, vomiting, oozing, or spewing anything, those people on the plane are probably fine. But KNOWING that she was in very close contact with Mr. Duncan and his secretions, with substandard PPE, and then the nurse having a low grade fever, the CDC's advice was idiotic.
Seriously, what is up with the CDC?
Click to expand...
it was probably some flow chart dial-a-nurse hotline kinda thing
 
MSmentor018 said:
it was probably some flow chart dial-a-nurse hotline kinda thing
Click to expand...


Well, whoever it was, it was someone from the CDC. If a nurse or doctor, really? I mean I have worked with some not so swift people, but come on. If the nurse gave them her specific details, what kind of thinking process went on there? Plus, what the hell was she thinking? I am not trying to knock her--I am totally concerned and feel for her. Maybe she was in denial. Maybe she was worried and wanted to see her mother. Maybe she thought that if she gets sick, she might never see her again. Whatever. She should have thought it through; but denial is the mechanism by which people avoid thinking things through. So, understanding how people are with the potential or the reality of having a deadly illness, the healthcare person on the other end of the line at CDC needed to tell her "No." I don't understand why the CDC was not in closer contact with these people.

Meanwhile Dr. Freiden reportedly stated, in reference to when he was in the full, CDC HAZMAT suit while visiting a clinic in Liberia, that he was wearing that particular suit b/c it is the protocol in the particular WA clinic. Yet he stated the other day that he would feel comfortable going into the room of a patient with Ebola in Dallas with the piece-meat set-up--with exposed areas of skin, etc. What the???? Guess there are some that don't have a problem with this either.

Notice how, today, in Washington, all the docs stood/sat together re: the issue of suspending flights from the hot zones today. I am all for unity, but not when it's idiotic and purely political.

This could blow up in many people's faces; b/c Americans will be so concerned that this virus has been allowed to get a foothold here in the US, that's what they will focus on--not the need to help get things under control over there.
Even when thinking globally, charity begins at home.

And I don't know why people don't read about the ignorance that has allowed Ebola to spread. You have plenty of bush people out there that have no trust for those medical people that are there to help. That's why a group of 8 people, with somewhere between 3 to 5 physicians in the group were killed by backward tribal-like people over there. They dumped their bodies in a sewer afterwards.

This is not something that anyone will get under control easily or immediately; b/c there are numbers of people over there that resist help, and many of them still gut and eat the bushmeat that is thought to be a source for Ebola. Heck, it can be hard to nearly impossible to get health compliance here is America. Stepping outside of America will generally be tougher.

People should read Faadiman (1998): The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures
Regardless of what you think of it, you can't help but feel for those doctors and nurses--how frustrated they became.

You see, when it comes to health issues in other cultures, it's tough to try and push progress. It takes time. The level of resistance can be incredible.

This is so complicated on many levels. Trying to force Americans into the "solution" over there is going to blow up. Wrong approach.

Do the hot zones need a lot more help? Definitely!!! How to get more help? This ain't it. Regardless, it's going to take some time.

And if you want the help from those in this nation, you have to show that you're on the ball here in a nation with better infrastructure.
 
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