Ebola in America

[johndoe44]

Okay, so big questions. Since this is a residency forum I figured we could probably benefit from this discussion. From what I understand Texas Presbyterian in Dallas apparently saw the patient in the emergency room after having symptoms; fever, aches, malaise etc. and they apparently did not get a travel history? Now, I remember my intern year at my hospital we ALWAYS were encouraged to gather information related to travel or recent exposure to any sick contacts.

So, I guess who dropped the ball? Should the US have had a better infrastructure for people entering the united states from these countries?

Should the hospital be at fault for not at least thinking about ebola given the many many CDC warnings. Is there none of the ED physicians, hospitalists, residents etc who could have seen this? I mean, its been all over the news?

Very interesting to see how this will all play out. I think the Governor also just said on CNN that children may have been exposed and they are likely in school. Again, we must realize that Ebola is almost never contagious until person shows signs of the illness; nonetheless, this person was in the community and likely surrounded by several people during a critical 4 day window in which that patient could have been isolated.

What are your thoughts?

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[Evisju7]

The reaction surrounding this is embarrassing.

It is one case as of now. Lets get some perpective on this. People are willing to take away rights to protect themselves from a constructed threat.

 

[AMEHigh]

I don't have time to google, but on another forum there was an article linked saying that the nurse got the travel info, but the nurse didn't tell anyone and obviously the doctor didn't ask the nurse or the patient.

But regardless, no I don't think the hospital is at fault.

 

[rokshana]

I don't have time to google, but on another forum there was an article linked saying that the nurse got the travel info, but the nurse didn't tell anyone and obviously the doctor didn't ask the nurse or the patient.

But regardless, no I don't think the hospital is at fault.

Though I bet some ED doc is losin' his job...

 

[Raryn]

Though I bet some ED doc is losin' his job...

I doubt a doc is losing his job for failing to immediately pick up Ebola. Even with all the news, it isn't exactly high on my differentials for people walking in the door.

It's like I had a MKSAP question on smallpox that I didn't recognize, mostly because I thought there was no frackin way they'd ask me about smallpox.

 

[calvnandhobbs68]

I doubt a doc is losing his job for failing to immediately pick up Ebola. Even with all the news, it isn't exactly high on my differentials for people walking in the door.

It's like I had a MKSAP question on smallpox that I didn't recognize, mostly because I thought there was no frackin way they'd ask me about smallpox.

I doubt he's losing his job but I bet the whole department is getting an "educational" session on recognizing signs and symptoms of Ebola and making sure you get a good travel history. I mean come on...the guy was FROM Liberia and just visiting here. Any super basic social history would have found out that he doesn't live in the US. Sure, it sounds like the nurse got it and didn't communicate it to the physician but at the end of the day the buck stops with doctor. If some guy who lives in an area where an epidemic is happening right now comes into your ED with symptoms consistent with that disease (even if they are very general and vague symptoms), I'd hope Ebola shoots up higher on your differential.

 

[Arcan57]

They won't lose their job but if anyone besides the index patient dies from Ebola, it would be a devastating emotional burden and probably carry at least some legal risk. I'd also like to point out that the amount of screening that is done at triage combined with widespread EMR implementation leads to an environment that is extraordinarily supportive of these types of misses. The scenario may have gone as such:

1) Triage nurse sees patient, free texts chief complaint into EMR - fever, diarrhea.
2) Triage nurse goes through check boxes including TB risk, intimate partner violence screening, fall risk assessment, tobacco use, and recent travel.
3) Pt answers yes on recent travel, nurse clicks appropriate box but doesn't amend HPI to include travel information because that box is on the prior screen.
4) With no formalized hospital policy for isolation for suspected cases, pt is placed into a room to see pt.
5) Doc sees patient in room and diagnoses pt with a viral syndrome (technically correct but unfortunately too non-specific). Doc knows that nurse asks about travel hx as part of triage and figures that information would have made it into the nurse's HPI so doc doesn't explicitly ask about it. Information is actually buried in the triage assessment form on page 2 below an absolutely punishing wall of text that the doctor had tried previously to glean useful information out of and had given up in a learned helplessness response.
6) Pt is discharged to spread a deadly disease.

I'm not saying that's exactly what happened but it's definitely plausible. Like any significant error, there were multiple opportunities to prevent it. There could have been a hospital policy that had recently been in-serviced when Ebola hit the radar again (what happened in our hospital), triage nurse could have placed patient into isolation from triage even in the absence of an official policy, nurse could have directly communicated to doctor the travel history (either by prominently placing it on the CC "Fever from Africa" or verbally to doc). Doctor could have asked about recent travel (coming from another city with an international airport in TX, that's a pretty standard question for anyone with a fever that's not a young child or a NH player).

 

[Evisju7]

My thoughts on who losses their job isn't the doc who sent him home, but the person who released his name.

I'm not too familiar with this, but isn't that a violation of patient confidentiality? Illegal?

 

[Evisju7]

I would be pretty irritated if I was the patient. I wonder how much harassment his family is receiving over this

 

[BlondeDocteur]

I see a couple of scenarios. As arcan noted, the triage nurse got the travel history but her triage note is not a permanent part of the medical record. Given the patient's Liberian nationality he has a very "American-sounding" name (versus something like Mamadou Diallo) so the somewhat-stereotypical-but-useful alarm bells re: travel history were not rung. An adult male with low-grade fevers, body aches and other vague symptoms would not be triaged highly. Seen by mid level and diagnosed with viral syndrome. EP agrees. Throw abx at patient and he's out the door. No diarrhea, no vomiting, and certainly no signs of coagulopathy.

Does that make the provider any less liable for not asking relevant questions, including a basic social history? Of course not. But it's plausible, despite the massive amount of awareness and training we've all gone through re: Ebola in the last 2 months.

 

[costales]

My thoughts on who losses their job isn't the doc who sent him home, but the person who released his name.

His sister identified him in an interview with AP.

 

[Evisju7]

His sister identified him in an interview with AP.

Oh... solved.
Thanks, I didn't realize that.

 

[foo]

...
5) Doc sees patient in room and diagnoses pt with a viral syndrome (technically correct but unfortunately too non-specific).
...

Doc/hospital/ED was unaware of CDC Ebola guidance that has been recently provided to hospitals?
Doc prescribes an antibiotic?

 

[colbgw02]

Heard on news that local officials are planning on prosecuting the patient for lying on some sort of health questionnaire. Haven't seen that in print yet.

eta: so apparently it's liberia that plans to prosecute the guy, not anyone in texas.

 

[Arcan57]

Doc/hospital/ED was unaware of CDC Ebola guidance that has been recently provided to hospitals?
Doc prescribes an antibiotic?

Didn't know about antibiotic Rx. In terms of unaware, I'm sure if you asked anyone in the hospital about looking for Ebola in patients that were recently in the Big 4, they would have said "of course". Unfortunately, there's a huge gulf between being aware of something and operationalizing that knowledge into something that works well and is relatively error resistant in a chaotic environment.

 

[BlondeDocteur]

They're talking about the WHO screen for the quarantine. (It's actually quite stringent-- I myself was quarantined for SARS in Hong Kong back in 2004. Yanked off a plane by 6 officials and everything). He basically fled Liberia for the US due to fears of Ebola. He had relatives here and had talked about visiting or attempting to immigrate for years, but after the Ebola-related deaths of two people he was in close contact with, he bolted. He obviously didn't disclose that when exiting.

 

[foo]

They're talking about the WHO screen for the quarantine. (It's actually quite stringent-- I myself was quarantined for SARS in Hong Kong back in 2004. Yanked off a plane by 6 officials and everything). He basically fled Liberia for the US due to fears of Ebola. He had relatives here and had talked about visiting or attempting to immigrate for years, but after the Ebola-related deaths of two people he was in close contact with, he bolted. He obviously didn't disclose that when exiting.

There are news reports that the Dallas man helped/accompanied a sick neighbor in Liberia with Ebola symptoms. The neighbor was turned away by four different hospitals because "they had no room" and "there was nothing they could do for her", and the neighbor ended up returning to her home, where she died two hours later. I imagine that he probably suspected that he was exposed to ebola...

When he filled out a form asking if he had been exposed to ebola, he would have considered: If I say "yes", I'll may get ebola, and will probably die at home because I know that the four hospitals I just visited are still full. But I'm feeling OK and I am asymptomatic, and therefore probably not contageous at this time. If I say I have not been exposed, I get to leave Liberia and fly to the US. Best case scenario, I don't have ebola, worst case I'll develop ebola in the next few days, but I will have access to good care in the US and may survive ebola.

What would you do in this situation?

There is a good chance that when he originally went to the Dallas hospital, he was already worried about having ebola. Otherwise why would someone go to the hospital for a low grade fever, headache, and vomiting? The woman that accompanied him TWICE told people in the ED that he had just been to Liberia. I think he would have tried to lead the Doc, nurses, janitors, etc., to the ebola diagnosis; he must have connected the dots by now, even if he had not suspected ebola prior to his flight... Most likely the Dallas hospital SCREWED UP because their patient would have been trying to lead them to the ebola diagnosis! (What would you have been doing in this situation, giving what had happened in Liberia?)

This is why a couple of days later, when he was taken to the hospital by ambulance, his nephew (who is in North Carolina, not in Dallas), CONNECTED THE DOTS, AND CALLED THE 800 NUMBER FOR THE CDC BECAUSE HE THOUGHT THE HOSPITAL WAS NOT TAKING THE SITUATION SERIOUSLY!

I think this is a likely scenario...

 

[colbgw02]

Otherwise why would someone go to the hospital for a low grade fever, headache, and vomiting

Things people ask who have never worked in the ED.

 

[foo]

Things people ask who have never worked in the ED.

Ah, I see, people that work in the ED can become numb with their routine, because its never a zebra case...

That is why people that worked in the Dallas ED never asked a patient with low grade fever, headache, and vomiting why he came to their hospital. I have to believe that the patient would have said: last week I was living in Liberia, and had very close contact with a neighbor that died from ebola. Where I am from its often ebola, ebola, ebola, ebola...

I am sure people that work in the ED in the US have never seen ebola, but I am sure someone from Liberia must know a lot about ebola...

Sometimes someone with a low grade fever, headache, and vomiting is sick, really sick...

 

[colbgw02]

Sometimes someone with a low grade fever, headache, and vomiting is sick, really sick...

Your early comment indicated that people wouldn't present to the ED for garden variety low-grade fever, headache, and vomiting. That's way off. They do, and for much, much less. All the time.

 

[evilbooyaa]

Ah, I see, people that work in the ED can become numb with their routine, because its never a zebra case...

That is why people that worked in the Dallas ED never asked a patient with low grade fever, headache, and vomiting why he came to their hospital. I have to believe that the patient would have said: last week I was living in Liberia, and had very close contact with a neighbor that died from ebola. Where I am from its often ebola, ebola, ebola, ebola...

I am sure people that work in the ED in the US have never seen ebola, but I am sure someone from Liberia must know a lot about ebola...

Sometimes someone with a low grade fever, headache, and vomiting is sick, really sick...

I doubt the patient started his history with "I just flew in from Africa, and I have these symptoms. I had contact with someone with Ebola. Doc, you think I might have Ebola?" and the doc just went "No, lol, you just have a viral GI bug. Here's some Abx so you'll give me good press-ganey scores. Want an Abd. CT for the road? I'll throw it in for free (lol like you're gonna pay for this visit yourself anyways) if you can guarantee me straight 5s."

 

[rokshana]

the news reports and the hospital confirms that the patient told them he came from Africa just a few days…a ball was dropped, swiss cheese holes aligned, whatever you want to call it…and you think the hospital isn't gonna find someone to pin this on?

and we have all been in the ED and know that thoroughness isn't exactly high on the priority of many ED docs…if the triage nurse did document it in her notes and the ED doc didn't read it…its gonna crash down on him…is this not unusual? sure…but this time the $*1t will hit the fan...

 

[Law2Doc]

the news reports and the hospital confirms that the patient told them he came from Africa just a few days...

Right, because when someone is from Africa you start by thinking about the zebras. Please. Its the start of flu season. Even most of the people who LIVE in Liberia who come down with viral symptoms and malaise don't have Ebola. It's more common there than here but I'd bet it not even close to one of the top ten ailments people who walk into an ER IN AFRICA have. If that's at the top if your differential, regardless of where the patient is from, you probably shouldn't be working in the ER -- you are jumping to the least probable conclusion. The ERs in this country are full of people with the flu throughout the entire flu season. People regularly come in to the ED with mild symptoms because they aren't plugged in to a PCP, and want someone to tell them to drink fluids and take a Tylenol, or they bought into the pharmacy driven bad medicine that doctors ought to just give a z-pack to anyone with the sniffles. They all will report symptoms identical to this guy. In a big city there will be lots of people from foreign lands and many with foreign names and even some foreign travel history they may or may not be forthcoming about. 99.9999999% will have sone version of the flu or other garden variety flu-like virus. Even the guy you KNOW is from Liberia who presents with flu-like symptoms most likely has the flu. honestly when someone comes to the ED with flu-like symptoms, you'd better be thinking flu, flu, flu and only if those symptoms somehow don't fit, or if the guy starts telling stories about hanging around with ebola stricken family members do you move on to the zebras. So no, I dont think the ball was really dropped at the hospital. it was dropped when a guy who was caring for Ebola patients was allowed to leave his country, board an international flight, perhaps.

Could we revise things to not make the same mistake? Focus more on travel history? Maybe. But remember, most people with flu-like symptoms, even from Africa, will have the flu, and we cant realistically monitor all of them. And a lot of people with flu-like symptoms aren't even going to go to the academic centers, they will go to the NP at Walmart or CVS.

 

[thehundredthone]

Right, because when someone is from Africa you start by thinking about the zebras. Please. Its the start of flu season. Even most of the people who LIVE in Liberia who come down with viral symptoms and malaise don't have Ebola. It's more common there than here but I'd bet it not even close to one of the top ten ailments people who walk into an ER IN AFRICA have. If that's at the top if your differential, regardless of where the patient is from, you probably shouldn't be working in the ER -- you are jumping to the least probable conclusion. The ERs in this country are full of people with the flu throughout the entire flu season. People regularly come in to the ED with mild symptoms because they aren't plugged in to a PCP, and want someone to tell them to drink fluids and take a Tylenol, or they bought into the pharmacy driven bad medicine that doctors ought to just give a z-pack to anyone with the sniffles. They all will report symptoms identical to this guy. In a big city there will be lots of people from foreign lands and many with foreign names and even some foreign travel history they may or may not be forthcoming about. 99.9999999% will have sone version of the flu or other garden variety flu-like virus. Even the guy you KNOW is from Liberia who presents with flu-like symptoms most likely has the flu. honestly when someone comes to the ED with flu-like symptoms, you'd better be thinking flu, flu, flu and only if those symptoms somehow don't fit, or if the guy starts telling stories about hanging around with ebola stricken family members do you move on to the zebras. So no, I dont think the ball was really dropped at the hospital. it was dropped when a guy who was caring for Ebola patients was allowed to leave his country, board an international flight, perhaps.

Could we revise things to not make the same mistake? Focus more on travel history? Maybe. But remember, most people with flu-like symptoms, even from Africa, will have the flu, and we cant realistically monitor all of them. And a lot of people with flu-like symptoms aren't even going to go to the academic centers, they will go to the NP at Walmart or CVS.

B-but... ebola!

 

[SouthernSurgeon]

T

There is a good chance that when he originally went to the Dallas hospital, he was already worried about having ebola. Otherwise why would someone go to the hospital for a low grade fever, headache, and vomiting? The woman that accompanied him TWICE told people in the ED that he had just been to Liberia. I think he would have tried to lead the Doc, nurses, janitors, etc., to the ebola diagnosis; he must have connected the dots by now, even if he had not suspected ebola prior to his flight... Most likely the Dallas hospital SCREWED UP because their patient would have been trying to lead them to the ebola diagnosis! (What would you have been doing in this situation, giving what had happened in Liberia?

This is why a couple of days later, when he was taken to the hospital by ambulance, his nephew (who is in North Carolina, not in Dallas), CONNECTED THE DOTS, AND CALLED THE 800 NUMBER FOR THE CDC BECAUSE HE THOUGHT THE HOSPITAL WAS NOT TAKING THE SITUATION SERIOUSLY!

I think this is a likely scenario...

Bull.

There is very clear evidence that this guy was less than forthcoming, possibly to the point of being criminally negligent.

It seems more like his nephew called to say he might have ebola because neither the patient nor his partner would. There is zero chance this patient was sitting in a hospital bed for days saying - "hey doc, I think this is ebola" over and over.

The hospital no doubt screwed up in this case. Quite badly.

But the patient was, if anything, actively leading people away from the ebola diagnosis out of fear. Not toward it.

 

[foo]

Right, because when someone is from Africa you start by thinking about the zebras. Please. Its the start of flu season. Even most of the people who LIVE in Liberia who come down with viral symptoms and malaise don't have Ebola. It's more common there than here but I'd bet it not even close to one of the top ten ailments people who walk into an ER IN AFRICA have. If that's at the top if your differential, regardless of where the patient is from, you probably shouldn't be working in the ER -- you are jumping to the least probable conclusion. The ERs in this country are full of people with the flu throughout the entire flu season. People regularly come in to the ED with mild symptoms because they aren't plugged in to a PCP, and want someone to tell them to drink fluids and take a Tylenol, or they bought into the pharmacy driven bad medicine that doctors ought to just give a z-pack to anyone with the sniffles. They all will report symptoms identical to this guy. In a big city there will be lots of people from foreign lands and many with foreign names and even some foreign travel history they may or may not be forthcoming about. 99.9999999% will have sone version of the flu or other garden variety flu-like virus. Even the guy you KNOW is from Liberia who presents with flu-like symptoms most likely has the flu. honestly when someone comes to the ED with flu-like symptoms, you'd better be thinking flu, flu, flu and only if those symptoms somehow don't fit, or if the guy starts telling stories about hanging around with ebola stricken family members do you move on to the zebras. So no, I dont think the ball was really dropped at the hospital. it was dropped when a guy who was caring for Ebola patients was allowed to leave his country, board an international flight, perhaps.

Could we revise things to not make the same mistake? Focus more on travel history? Maybe. But remember, most people with flu-like symptoms, even from Africa, will have the flu, and we cant realistically monitor all of them. And a lot of people with flu-like symptoms aren't even going to go to the academic centers, they will go to the NP at Walmart or CVS.

The patient told an ED nurse he had traveled from Liberia. The woman accompanying the patient twice told someone in the ED about his travel history. Not exploring his history was a screw up. Without the travel and exposure history, flu should be at the top of the list (in Liberia, perhaps malaria might be more of a concern than flu).

Did he lie about his exposure to Ebola in Liberia so he could fly to the US? Sure, probably. But his neighbor was denied care at four hospitals in Liberia, and died. What would you do if you were in his shoes?

Can he get in trouble for that lie? Sure, apparently Liberia wants to prosecute him for lying. I think this is nonsense, prosecution for lying is not much of a deterrent, if one is concerned about a potentially deadly disease. I am not condoning lying, but I do understand human nature.

Did the patient tell the ED doc about his close contact with an ebola victim, and lying to get on a plane? Of course not.
The patient may have been scared of getting in trouble (or getting deported back to Liberia). Sounds like a reasonable concern if one was from Liberia (where four hospitals denied care to his neighbor, or one can be prosecuted for lying about exposure).

The ED nurse communicated the travel history via the EMR system, which the ED doc did not see (nor did he ask the patient about his recent travel history). The patient must have been scared (I would have been), so staff need to talk to him, make him feel at ease, and perhaps he would have divulged his exposure.

His nephew did the right thing by contacting the CDC when he thought the hospital was still not taking things seriously. He is a hero, thank you!

I have a family member working/living in West Africa. We Skype often. We don't talk about the flu season, or the incidence of malaria in West Africa, we do talk about ebola. My family is not in Liberia, where the conversation is probably: ebola, ebola, ebola (not flu, flu, flu).

The ED screwed up.

 

[Arcan57]

The patient told an ED nurse he had traveled from Liberia. The woman accompanying the patient twice told someone in the ED about his travel history. Not exploring his history was a screw up. Without the travel and exposure history, flu should be at the top of the list (in Liberia, perhaps malaria might be more of a concern than flu).

Did he lie about his exposure to Ebola in Liberia so he could fly to the US? Sure, probably. But his neighbor was denied care at four hospitals in Liberia, and died. What would you do if you were in his shoes?

Can he get in trouble for that lie? Sure, apparently Liberia wants to prosecute him for lying. I think this is nonsense, prosecution for lying is not much of a deterrent, if one is concerned about a potentially deadly disease. I am not condoning lying, but I do understand human nature.

Did the patient tell the ED doc about his close contact with an ebola victim, and lying to get on a plane? Of course not.
The patient may have been scared of getting in trouble (or getting deported back to Liberia). Sounds like a reasonable concern if one was from Liberia (where four hospitals denied care to his neighbor, or one can be prosecuted for lying about exposure).

The ED nurse communicated the travel history via the EMR system, which the ED doc did not see (nor did he ask the patient about his recent travel history). The patient must have been scared (I would have been), so staff need to talk to him, make him feel at ease, and perhaps he would have divulged his exposure.

His nephew did the right thing by contacting the CDC when he thought the hospital was still not taking things seriously. He is a hero, thank you!

I have a family member working/living in West Africa. We Skype often. We don't talk about the flu season, or the incidence of malaria in West Africa, we do talk about ebola. My family is not in Liberia, where the conversation is probably: ebola, ebola, ebola (not flu, flu, flu).

The ED screwed up.

Nobody is questioning that the ED should have caught this, but "the ED screwed up" is not a useful statement in terms of preventing it from happening again. I'm also not sure why you're so quick to dismiss the idea of prosecuting someone that lied and exposed dozens of people to a potentially deadly disease for which there is little effective treatment. "He was scared" will be little comfort for the people he may have infected and breaking quarantine is sort of a big deal, the kind of thing for which they used to shoot you or blow your ship up with cannons. Also, as others have pointed out, he didn't tell the doc he was worried about having Ebola. I'm sure on that first visit he probably knew he had Ebola and deliberately hid information in order to get the doc to diagnose something else. Unfortunately, denial is a common human reaction and one we see all the time in the ED on everything from people that had + home pregnancy tests and try and hide that they're pregnant to patients with inflammatory breast CA that come in after their breast has already necrosed and fallen off.

 

[Arcan57]

Ah, I see, people that work in the ED can become numb with their routine, because its never a zebra case...

That is why people that worked in the Dallas ED never asked a patient with low grade fever, headache, and vomiting why he came to their hospital. I have to believe that the patient would have said: last week I was living in Liberia, and had very close contact with a neighbor that died from ebola. Where I am from its often ebola, ebola, ebola, ebola...

I am sure people that work in the ED in the US have never seen ebola, but I am sure someone from Liberia must know a lot about ebola...

Sometimes someone with a low grade fever, headache, and vomiting is sick, really sick...

I had forgotten about this post when I made the above reply to your other post, but the mixture of condescension and misinformation in this post merits comment. As other posters noted, non-specific findings are an incredibly common reason for coming to an American ED and in the vast majority of cases the patient has little to no actual concern for a life-threatening illness. I can understand if you are used to an African system where the barrier to seeking medical care in a hospital is extraordinarily high, but in America EDs are the most convenient method of obtaining care for acute problems. In the ED we hunt for the very sick amongst the worried well, and in the absence of a travel history (which should have been obtained by the MD) there is no way to make the diagnosis of Ebola. For many deadly infectious diseases, the window between diagnosable and treatable can be quite small (think meningococcemia) and it's simply not possible to pre-emptively treat everyone that presents with non-specific symptoms for all of these diseases. The cornerstone of management for these patients is good instructions regarding conditions for which to return to the ED. The only thing that separates Ebola from this group is the relatively high transmissibility and the inability to provide post-exposure prophylaxis.

 

[SouthernSurgeon]

I had forgotten about this post when I made the above reply to your other post, but the mixture of condescension and misinformation in this post merits comment. As other posters noted, non-specific findings are an incredibly common reason for coming to an American ED and in the vast majority of cases the patient has little to no actual concern for a life-threatening illness. I can understand if you are used to an African system where the barrier to seeking medical care in a hospital is extraordinarily high, but in America EDs are the most convenient method of obtaining care for acute problems. In the ED we hunt for the very sick amongst the worried well, and in the absence of a travel history (which should have been obtained by the MD) there is no way to make the diagnosis of Ebola. For many deadly infectious diseases, the window between diagnosable and treatable can be quite small (think meningococcemia) and it's simply not possible to pre-emptively treat everyone that presents with non-specific symptoms for all of these diseases. The cornerstone of management for these patients is good instructions regarding conditions for which to return to the ED. The only thing that separates Ebola from this group is the relatively high transmissibility and the inability to provide post-exposure prophylaxis.

Also on the "travel history" question - we have no idea how the information was presented/elicited from the patient. The context matters.

If a patient comes in and says "I just got here from Liberia and now I have abdominal pain and a fever" - that's one thing.

If a patient is less than forthcoming and says "my stomach hurts, I feel sick" and then ten minutes later while filling out a routine form that they fill out for every patient, the nurse asks "any recent travel?" and the patient responds "Liberia" - it is easier to see that the dots might not get connected.

 

[costales]

Duncan's sister, Mai Wureh, said he notified health-care workers that he was visiting from Liberia when they asked for his Social Security number and he told them he didn't have one.
http://www.usatoday.com/story/news/nation/2014/10/01/texas-ebola-patient/16525649/

 

[Arcan57]

Duncan's sister, Mai Wureh, said he notified health-care workers that he was visiting from Liberia when they asked for his Social Security number and he told them he didn't have one.
http://www.usatoday.com/story/news/nation/2014/10/01/texas-ebola-patient/16525649/

Let me translate that for you:
The business office registered the patient and in the area where insurance information goes it was left blank (ie self-pay).

The business office is deliberately separate from the health care team due to concerns over even the possible appearance of violating EMTALA. Usually they have no clinic information on the patient other than the chief complaint (likely put as abdominal pain) and that the doctor felt there was at least a possible emergency medical condition (ie not a screen-out). I'd be more surprised if that information had gotten kicked back to the care team than that it wasn't.

 

[Spikebd]

I think the bigger issue is the botched clean up of that apartment. I saw a photo of CDC employees entering the guys Ebola infested apartment without any sort of PPE on, which is shocking. I saw another photo of two dudes who looked like apartment maintenance pressure washing the vomit outside of his apartment complex, I hope and assume they thoroughly disinfected it before that took place. The photo could be bunk but if it's true it shows you how incompetent these guys running the clean up are.

 

[costales]

This pic?

https://twitter.com/wfaachannel8/status/517739906211528704
WFAA-TV Dallas/Fort Worth. ABC affiliate. Official station Twitter account.
HD Chopper 8 caught crews cleaning the sidewalk outside the Ivy Apartments where the #Ebola patient stayed.

 

[Spikebd]

This pic?

https://twitter.com/wfaachannel8/status/517739906211528704
WFAA-TV Dallas/Fort Worth. ABC affiliate. Official station Twitter account.
HD Chopper 8 caught crews cleaning the sidewalk outside the Ivy Apartments where the #Ebola patient stayed.

Yea, haha. If that's actually his vomit that's a really bad way to clean it. Wow. I don't know how people can feel so confident American healthcare is so exceptional at preventing an infectious outbreak after this cleanup job. It's not that unfathomable that this thing spreads in the U.S.

 

[rokshana]

Right, because when someone is from Africa you start by thinking about the zebras. Please. Its the start of flu season. Even most of the people who LIVE in Liberia who come down with viral symptoms and malaise don't have Ebola. It's more common there than here but I'd bet it not even close to one of the top ten ailments people who walk into an ER IN AFRICA have. If that's at the top if your differential, regardless of where the patient is from, you probably shouldn't be working in the ER -- you are jumping to the least probable conclusion. The ERs in this country are full of people with the flu throughout the entire flu season. People regularly come in to the ED with mild symptoms because they aren't plugged in to a PCP, and want someone to tell them to drink fluids and take a Tylenol, or they bought into the pharmacy driven bad medicine that doctors ought to just give a z-pack to anyone with the sniffles. They all will report symptoms identical to this guy. In a big city there will be lots of people from foreign lands and many with foreign names and even some foreign travel history they may or may not be forthcoming about. 99.9999999% will have sone version of the flu or other garden variety flu-like virus. Even the guy you KNOW is from Liberia who presents with flu-like symptoms most likely has the flu. honestly when someone comes to the ED with flu-like symptoms, you'd better be thinking flu, flu, flu and only if those symptoms somehow don't fit, or if the guy starts telling stories about hanging around with ebola stricken family members do you move on to the zebras. So no, I dont think the ball was really dropped at the hospital. it was dropped when a guy who was caring for Ebola patients was allowed to leave his country, board an international flight, perhaps.

Could we revise things to not make the same mistake? Focus more on travel history? Maybe. But remember, most people with flu-like symptoms, even from Africa, will have the flu, and we cant realistically monitor all of them. And a lot of people with flu-like symptoms aren't even going to go to the academic centers, they will go to the NP at Walmart or CVS.

maybe he has Ebola on the brain, but even Dr. Fauci has said that the ball was dropped by the hospital…

http://wtkr.com/2014/10/03/dc-hospital-admits-patient-with-possible-ebola-symptoms/

“A travel history was taken, but it wasn’t communicated to the people who were making the decision. … It was a mistake. They dropped the ball,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

 

[Law2Doc]

The patient told an ED nurse he had traveled from Liberia. The woman accompanying the patient twice told someone in the ED about his travel history. Not exploring his history was a screw up. Without the travel and exposure history, flu should be at the top of the list (in Liberia, perhaps malaria might be more of a concern than flu).

Did he lie about his exposure to Ebola in Liberia so he could fly to the US? Sure, probably. But his neighbor was denied care at four hospitals in Liberia, and died. What would you do if you were in his shoes?

Can he get in trouble for that lie? Sure, apparently Liberia wants to prosecute him for lying. I think this is nonsense, prosecution for lying is not much of a deterrent, if one is concerned about a potentially deadly disease. I am not condoning lying, but I do understand human nature.

Did the patient tell the ED doc about his close contact with an ebola victim, and lying to get on a plane? Of course not.
The patient may have been scared of getting in trouble (or getting deported back to Liberia). Sounds like a reasonable concern if one was from Liberia (where four hospitals denied care to his neighbor, or one can be prosecuted for lying about exposure).

The ED nurse communicated the travel history via the EMR system, which the ED doc did not see (nor did he ask the patient about his recent travel history). The patient must have been scared (I would have been), so staff need to talk to him, make him feel at ease, and perhaps he would have divulged his exposure.

His nephew did the right thing by contacting the CDC when he thought the hospital was still not taking things seriously. He is a hero, thank you!

I have a family member working/living in West Africa. We Skype often. We don't talk about the flu season, or the incidence of malaria in West Africa, we do talk about ebola. My family is not in Liberia, where the conversation is probably: ebola, ebola, ebola (not flu, flu, flu).

The ED screwed up.

Um no. Even if they knew he was from Liberia, the first three most likely diagnoses for flu-like symptoms are still not Ebola. Ebola is a headline because it's devastating and scary but even in Liberia it's not close to the most common ailment people are coming into their EDs with. Should you investigate more if a guy is from Liberia? Sure, but again, it sounds like this guy wasn't forthcoming and withheld the fact that he was with relatives with Ebola. Im not sure the typical ED anywhere would ever come to the conclusion of Ebola without history far in excess of that this guy was selling. Also plenty of us have dealt with patients who are hypochondriacs -- guys who have the sniffles and worry that they have smallpox or the plague. so a guy in Texas hinting that he's worried about Ebola pretty reasonably might get shrugged off unless his story is pretty forthcoming and compelling. And we have patients in our EDs who say what they think they need to say to get the meds they want. True for morphine, true for antibiotics. So even hard to get excited about anyone who comes into the ED with mild symptoms. This is a tough case because there's alway more you could ask/do but not clear it would actually make a difference and im not at all certain putting a zebra higher on your differential because you are scared of it is good medical practice.

 

[Law2Doc]

maybe he has Ebola on the brain, but even Dr. Fauci has said that the ball was dropped by the hospital…

http://wtkr.com/2014/10/03/dc-hospital-admits-patient-with-possible-ebola-symptoms/

“A travel history was taken, but it wasn’t communicated to the people who were making the decision. … It was a mistake. They dropped the ball,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

What's he supposed to say, after the fact? We did nothing wrong but lots of people got exposed, BFD"? It's lose lose, so he chose to take the position that retains faith in the healthcare process -- that the ED is able to parse out the flu from ebola, which I think all if us know is questionable without the patient spilling their guts.

 

[foo]

What's he supposed to say, after the fact? We did nothing wrong but lots of people got exposed, BFD"? It's lose lose, so he chose to take the position that retains faith in the healthcare process -- that the ED is able to parse out the flu from ebola, which I think all if us know is questionable without the patient spilling their guts.

THE ED SCREWED UP!!!

Patient shows up with low grade fever, headache, vomiting and the ED suspects viral infection...

There is no excuse for the ED not getting or ignoring the RECENT TRAVEL HISTORY IN WEST AFRICA (Liberia is in West Africa - this is for the geographically challenged). ;-) ;-)

The ED can also determine how recent the travel was. For example, has the patient been in the US longer than 21 days?

When the patient was RECENTLY IN WEST AFRICA, ask if the patient exposed to anyone with similar symptoms.

There is an RT-PCR blood test for Ebola (for a symptomatic patient)! If the hospital can't do the test, send the blood to a lab in the CDC Lab Test Network.

At least do this to protect the people working in the ED, so that they stay healthy and don't spread Ebola. ;-) ;-) ;-)

 

[Law2Doc]

THE ED SCREWED UP!!!

Patient shows up with low grade fever, headache, vomiting and the ED suspects viral infection...

There is no excuse for the ED not getting or ignoring the RECENT TRAVEL HISTORY IN WEST AFRICA (Liberia is in West Africa - this is for the geographically challenged). ;-) ;-)

The ED can also determine how recent the travel was. For example, has the patient been in the US longer than 21 days?

When the patient was RECENTLY IN WEST AFRICA, ask if the patient exposed to anyone with similar symptoms.

There is an RT-PCR blood test for Ebola (for a symptomatic patient)! If the hospital can't do the test, send the blood to a lab in the CDC Lab Test Network.

At least do this to protect the people working in the ED, so that they stay healthy and don't spread Ebola. ;-) ;-) ;-)

Um no. A guy shows up at the ED with flu- like symptoms during flu season in Texas, and the ED treats him like everyone else in the ED that day with the same symptoms. There has never been a case of Ebola in Texas before this point. Texas is a state where a healthy percent of the people have a history of foreign travel -- lots of people walk to Texas from one, so that question doesn't necessarilly ring as many bells.

The fact that the guy came from Liberia would be useful to pursue, especially when Monday morning quarterbacking, but even in Liberia most of the people with flulike symptoms won't have anything worse than the flu. Saying west-Africa equals Ebola is exactly what you should be learning not to do in med school. TB, AIDS, syphillis, malaria, filaria etc, are all much more likely if you are going down the zebra path. If you are in Texas and you put Ebola on your differential it had better be dead last -- there had never been a case in TX before, hopefully won't be more, and the symptoms aren't very specific. Yes it would be nice to run a pcr on everyone in the ED who gives a certain travel history, but there is ample evidence this guy sat on the key information of exposure in this story. He's the one who put people at risk here.

 

[SouthernSurgeon]

Um no. A guy shows up at the ED with flu- like symptoms during flu season in Texas, and the ED treats him like everyone else in the ED that day with the same symptoms. There has never been a case of Ebola in Texas before this point. Texas is a state where a healthy percent of the people have a history of foreign travel -- lots of people walk to Texas from one, so that question doesn't necessarilly ring as many bells.

The fact that the guy came from Liberia would be useful to pursue, especially when Monday morning quarterbacking, but even in Liberia most of the people with flulike symptoms won't have anything worse than the flu. Saying west-Africa equals Ebola is exactly what you should be learning not to do in med school. TB, AIDS, syphillis, malaria, filaria etc, are all much more likely if you are going down the zebra path. If you are in Texas and you put Ebola on your differential it had better be dead last -- there had never been a case in TX before, hopefully won't be more, and the symptoms aren't very specific. Yes it would be nice to run a pcr on everyone in the ED who gives a certain travel history, but there is ample evidence this guy sat on the key information of exposure in this story. He's the one who put people at risk here.

I think the truth is somewhere in the middle.

Ideally the system should have diagnosed the guy the first time around.

Despite its rarity, the CDC and hospital systems have been pushing for awareness of Ebola risk factors (Atul Gawande even made another fancy checklist, lol), because I think most reasonable people knew something like this was going to happen eventually.

Clearly after this case and the huge negative publicity, hospitals are going to be running a LOT of negative screens for ebola. No one wants to be the next hospital to miss a case. Our hospital sent out an email blast with a formal ebola protocol for outpatient, ED, and inpatient settings.

But there are a number of issues that prevented timely diagnosis in this case that are much harder to fault the ED for

The biggest is, as you said, this patient sat on the key information and was clearly less than forthcoming.

The next biggest are all the issues regarding ED care and triage you've mentioned. "abdominal pain" is probably one of the top 3 chief complaints in the ED, and as you said most of those patients are fundamentally well and just have a viral gastroenteritis

The third is the communication disconnect between hospitals' billing offices, nurses, and MDs. And the utterly useless nature of EMR "flags". The media keeps describing this as a "glitch" in the EMR. It's not a glitch in that nothing was technically wrong with the EMR - i.e. not a software bug or crash. It's just the crappy nature of the EMR in general.

Anyways. TL;DR - hospital definitely made mistakes, but had a number of issues conspiring against it that are very easy to understand to anyone who has spent time in the ED.

 

[Law2Doc]

I think the truth is somewhere in the middle.

Ideally the system should have diagnosed the guy the first time around.

Despite its rarity, the CDC and hospital systems have been pushing for awareness of Ebola risk factors (Atul Gawande even made another fancy checklist, lol), because I think most reasonable people knew something like this was going to happen eventually.

Clearly after this case and the huge negative publicity, hospitals are going to be running a LOT of negative screens for ebola. No one wants to be the next hospital to miss a case. Our hospital sent out an email blast with a formal ebola protocol for outpatient, ED, and inpatient settings.

But there are a number of issues that prevented timely diagnosis in this case that are much harder to fault the ED for

The biggest is, as you said, this patient sat on the key information and was clearly less than forthcoming.

The next biggest are all the issues regarding ED care and triage you've mentioned. "abdominal pain" is probably one of the top 3 chief complaints in the ED, and as you said most of those patients are fundamentally well and just have a viral gastroenteritis

The third is the communication disconnect between hospitals' billing offices, nurses, and MDs. And the utterly useless nature of EMR "flags". The media keeps describing this as a "glitch" in the EMR. It's not a glitch in that nothing was technically wrong with the EMR - i.e. not a software bug or crash. It's just the crappy nature of the EMR in general.

Anyways. TL;DR - hospital definitely made mistakes, but had a number of issues conspiring against it that are very easy to understand to anyone who has spent time in the ED.

I don't totally disagree with you but it's also very dangerous if we start assuming everyone with eg flulike symptoms or abdominal pain, etc in the ED might have Ebola, everyone with an abnormal CXR has SARS, etc. The EDs can only afford to stay open if they rapidly get those without real illness out ther doors fast. You don't want to be in a situation where you feel you need to hold nonforthcoming patients while you run gels. You can't treat every nonspecific set of symptoms like a plague just to be right 0.001% of the time. You are better off running gels at the airport on anyone coming to the US with a west African passport than try to deal with it at the various community hospital EDs or worse at Walmart. If this case tells us anything, it's that the EDs across the country will spend a lot of time and money on a very rare illness, likely at the expense of dealing with the more common.

 

[SouthernSurgeon]

If this case tells us anything, it's that the EDs across the country will spend a lot of time and money on a very rare illness, likely at the expense of dealing with the more common.

Unfortunately, that's pretty good description of ED care as a whole...

 

[mercaptovizadeh]

What it tells us is that doctors are taking ****ty histories, and/or that our PMH/SH/FMH/ROS templates don't interrogate enough. Anyone with flu like symptoms who just came back from Liberia should have set off alarm bells not just for Ebola but also malaria, dengue, and the other viral hemorrhagic fevers.

It also makes me think that internists, pediatricians, and perhaps ED docs would do well to have a required 1 month rotation during residency in Subsaharan Africa or Amazonia just so they get a taste for that "other side" of medicine that everyone in the US forgets about - worms, parasites, protozoa, arboviruses, leprosy, etc.

 

[SouthernSurgeon]

It also makes me think that internists, pediatricians, and perhaps ED docs would do well to have a required 1 month rotation during residency in Subsaharan Africa or Amazonia just so they get a taste for that "other side" of medicine that everyone in the US forgets about - worms, parasites, protozoa, arboviruses, leprosy, etc.

I think this is sort of what L2D is saying though (I don't want to put words in his mouth, but it's what I've taken away from his posts)...it would be a ridiculous waste of resources to require our trainees to spend a month of their lives learning about diseases they might encounter once in a career.

 

[mercaptovizadeh]

I think this is sort of what L2D is saying though (I don't want to put words in his mouth, but it's what I've taken away from his posts)...it would be a ridiculous waste of resources to require our trainees to spend a month of their lives learning about diseases they might encounter once in a career.

It's not a waste of resources, you'd pay them the same salary and a bit extra to cover the month (living expenses being much less, travel covering the bulk), and there'd be the opportunity cost of 1 less elective month. It would make internists and pediatricians think in a broader way than the cookie-cutter BS way many of them think these days on the more complex patients: test, test, test and test some more and consult everyone. I see patients being plied with haldol who get thrown on antibiotics the minute they spike a fever without anybody even thinking of NMS or malignant catatonia, despite their muscular rigidity. I've seen neurologists push antiepileptics on children with no comprehension of what an adverse drug reaction is when it hits them in the face. And back in medical school there was an Indian patient who came in with distal polyneuropathy who got diagnosed by the astute Chinese-immigrant neurologist with leprosy. Most American pediatricians have NO idea what measles or rubella look like. Experience matters.

 

[Law2Doc]

I think this is sort of what L2D is saying though (I don't want to put words in his mouth, but it's what I've taken away from his posts)...it would be a ridiculous waste of resources to require our trainees to spend a month of their lives learning about diseases they might encounter once in a career.

Precisely. You'd do a lot more good in the ED spending that month making yourself even better at the things you see every day than you might knowing a bit more about a zebra that in Texas you hopefully will never see again. What we don't want to do is get reactionary and start treating bogeymen. There's a good reason very smart people have for generations taught the "when you hear hoof beats think horses, not zebras" metaphor. It's just good medical practice to rank your differential based on likelihood.

 

[SouthernSurgeon]

It's not a waste of resources, you'd pay them the same salary and a bit extra to cover the month (living expenses being much less, travel covering the bulk), and there'd be the opportunity cost of 1 less elective month. It would make internists and pediatricians think in a broader way than the cookie-cutter BS way many of them think these days on the more complex patients: test, test, test and test some more and consult everyone. I see patients being plied with haldol who get thrown on antibiotics the minute they spike a fever without anybody even thinking of NMS or malignant catatonia, despite their muscular rigidity. I've seen neurologists push antiepileptics on children with no comprehension of what an adverse drug reaction is when it hits them in the face. And back in medical school there was an Indian patient who came in with distal polyneuropathy who got diagnosed by the astute Chinese-immigrant neurologist with leprosy. Most American pediatricians have NO idea what measles or rubella look like. Experience matters.

I think, first off, it's ridiculously naive to think that a month elective in a 3rd world environment would have a profound impact on the way physicians practice medicine.

I think, second off, that yes the opportunity cost of a month that could be spent doing something more broadly applicable would be a significant waste of resources. You only get so much time to train as it is.

I think, third off, that there are definitely bad doctors out there. I don't think that thinking "outside the box" or looking more for zebras will fix their individual problems.

 

[mercaptovizadeh]

Precisely. You'd do a lot more good in the ED spending that month making yourself even better at the things you see every day than you might knowing a bit more about a zebra that in Texas you hopefully will never see again. What we don't want to do is get reactionary and start treating bogeymen. There's a good reason very smart people have for generations taught the "when you hear hoof beats think horses, not zebras" metaphor. It's just good medical practice to rank your differential based on likelihood.

Nobody said it wasn't good practice ranking differentials based on likelihood. It's even better practice to take a consistent travel and sick contacts history on people with symptoms of infection lest you facilitate the exposure of people to a deadly virus through negligence.

 

[Arcan57]

Unfortunately, that's pretty good description of ED care as a whole...

And how would you structure the ED workup?

 

[SouthernSurgeon]

And how would you structure the ED workup?

I don't mean to say I would do anything differently. It's just that the ED is under tremendous external pressure to practice defensive medicine. I'm thinking of the case of the "missed" diagnosis of viral myocarditis that just got a ridiculous malpractice award.