Ebola in America

[mercaptovizadeh]

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.

Which is why in just 2 weeks on an ICU rotation at a "top 10 hospital" I've seen 2 patients go into shock, get thrown on pressors and antibiotics, without anyone but 1 person in the whole team noting that the patients were on prednisone at home that was abruptly stopped and that they needed stress dose steroids. You know why? Because none of the attendings or fellows in the ICU gave a **** about the fact that the patients had psoriasis or RA...

Just saying.

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[SouthernSurgeon]

Which is why in just 2 weeks on an ICU rotation at a "top 10 hospital" I've seen 2 patients go into shock, get thrown on pressors and antibiotics, without anyone but 1 person in the whole team noting that the patients were on prednisone at home that was abruptly stopped and that they needed stress dose steroids. You know why? Because none of the attendings or fellows in the ICU gave a **** about the fact that the patients had psoriasis or RA...

Just saying.

How exactly would a rotation in africa help this?

Sounds like you are really enjoying the arm-chair quarterbacking. I'm glad you're such a better doctor than everyone else.

 

[Over9000]

What separates us from midlevels is our knowledge of the physiologic principles of medicine and our ability to spot the zebras.

Relegating medical training to solely that of tweaking the most common situations is skirting awfully close to the mostly experiential and algorithmic skills of nurses. Not to say that a firm grasp on common things is not important - its expected. But that is but one part of the equation that makes up a whole physician.

 

[mercaptovizadeh]

How exactly would a rotation in africa help this?

Sounds like you are really enjoying the arm-chair quarterbacking. I'm glad you're such a better doctor than everyone else.

Never said it would. I was analogizing. Just as the ICU docs think it is beneath them to spend 5 seconds thinking about a patient's transplant immunosuppression or autoimmune disease, likewise you seem to think it is pointless for American internists/pediatricians/ED docs to know what malaria or miliary TB look like. And I disagree with you.

 

[SouthernSurgeon]

Just as the ICU docs think it is beneath them to spend 5 seconds thinking about a patient's transplant immunosuppression or autoimmune disease, likewise you seem to think it is pointless for American internists/pediatricians/ED docs to know what malaria or miliary TB look like.

Well, the intensivists I know do spend five seconds reviewing the medication list, and are usually pretty systematic about thinking through patients from a systems based perspective, including immunosuppression and endocrine issues in their algorithm. If anything the ones I know are way too quick to pull the trigger on steroids for a potential adrenal insufficiency for any patient not responding to treatment.

I just think you're extrapolating a lot of problems with the system from individual experiences. You also seem very quick to lay blame at everyone else's feet.

 

[mercaptovizadeh]

What separates us from midlevels is our knowledge of the physiologic principles of medicine and our ability to spot the zebras.

Relegating medical training to solely that of tweaking the most common situations is skirting awfully close to the mostly experiential and algorithmic skills of nurses. Not to say that a firm grasp on common things is not important - its expected. But that is but one part of the equation that makes up a whole physician.

I agree 100%.

 

[Law2Doc]

What separates us from midlevels is our knowledge of the physiologic principles of medicine and our ability to spot the zebras.

Relegating medical training to solely that of tweaking the most common situations is skirting awfully close to the mostly experiential and algorithmic skills of nurses. Not to say that a firm grasp on common things is not important - its expected. But that is but one part of the equation that makes up a whole physician.

First, odds are high this guy was handled by nurses and midlevels before he saw a doctor. Second, there's no reason to believe the next zebra to enter this country won't go to an urgent care or minute clinic staffed by midlevels. Third, the symptoms are totally nonspecific and the only thing that might have helped in this case aren't an ability to spot zebras but an ability to get this guy to open up and spill his guts. Nothing about this guy screamed rare disease except his passport. And as mentioned, even in Liberia Ebola would not be at the top of your differential. What might happen as a result of this case is bad medicine. Doctors worrying about rare birds that have no business being on the differential.
Yes it's scary and yes I worry that this will spread to the U.S. And yes, you could always do better in taking a history. No question. But if you focus on what you are most worried about personally rather than what the patients most likely have, you are practicing very bad medicine. Part of the reason midlevels are so comfortable working in this area is precisely because you can provide pretty good medical care following algorithms. Other than this guy being African he fell comfortably on an algorithm.there was nothing an astute doctor would recognize by exam that would put Ebola at the top of the list, unless the patient volunteered his exposure.

 

[mercaptovizadeh]

Well, the intensivists I know do spend five seconds reviewing the medication list, and are usually pretty systematic about thinking through patients from a systems based perspective, including immunosuppression and endocrine issues in their algorithm. If anything the ones I know are way too quick to pull the trigger on steroids for a potential adrenal insufficiency for any patient not responding to treatment.

I just think you're extrapolating a lot of problems with the system from individual experiences. You also seem very quick to lay blame at everyone else's feet.

OK, maybe I'm judgmental, but I'm just seeing how the specialties I'm dealing with seem to think that knowing some basics "belonging" to other specialties is beneath them, or that it's not even their job as physicians. Like the peds attending ordering an upper GI with small bowel follow through (and radiology angrily saying no, because it will take forever) instead of a nuclear medicine scan in a boy who hasn't passed stool in 7 days and has been vomiting postprandially (no obstruction to be clear). Or, to be hypothetical, having an ID doctor put someone on 2 weeks of gentamicin without doing some audiology studies along the way, rationalizing that it's really ENT's problem.

If I had a perimenopausal friend who was complaining of new onset irregular bleeding, bloating, and indigestion, I would want her internist to check her thyroid, order a transvaginal US, and think about working up an ovarian malignancy. It's not enough to just give her prilosec, a prescription for birth control pills, and send her on her merry way - even though, in 95% of the cases, that would be just fine.

 

[SouthernSurgeon]

And as mentioned, even in Liberia Ebola would not be at the top of your differential.

This is probably the only point where I disagree with you.

Even though it is a zebra. If you are treating a patient and you know that they have a recent travel history to Liberia or another exposed African country, and you don't consider the diagnosis, you have made a major fail. The problem in the TX case is that, for whatever reasons, the physician didn't know the travel history.

Differentials have to balanced between the most common and the most deadly.

 

[Law2Doc]

This is probably the only point where I disagree with you.

Even though it is a zebra. If you are treating a patient and you know that they have a recent travel history to Liberia or another exposed African country, and you don't consider the diagnosis, you have made a major fail. The problem in the TX case is that, for whatever reasons, the physician didn't know the travel history.

Differentials have to balanced between the most common and the most deadly.

You can consider it but it still ought to be low on your differential. In Liberia there have been what, 1000 cases? That's a lot but in a population of well over 4 million that's still going to be way below every flu, aids, meningitis, malaria and TB. The symptoms were totally nonspecific. Wouldn't be a slam dunk even if you were focused on the disease. And then move it to Texas where they've never seen a case but see lots of people with exactly those symptoms every day and it has never been Ebola. I'm not sure there's a great fix but I guaranty we will spend a lot of time and resources more out of fear than actual utility.

 

[SouthernSurgeon]

You can consider it but it still ought to be low on your differential. In Liberia there have been what, 1000 cases? That's a lot but in a population of well over 4 million that's still going to be way below every flu, aids, meningitis, malaria and TB. The symptoms were totally nonspecific. Wouldn't be a slam dunk even if you were focused on the disease. And then move it to Texas where they've never seen a case but see lots of people with exactly those symptoms every day and it has never been Ebola. I'm not sure there's a great fix but I guaranty we will spend a lot of time and resources more out of fear than actual utility.

I mean you can argue whether they are right in doing so, but the CDC is clear on this:

"Fever or compatible EVD symptoms in a patient who has travelled to an Ebola affected area in the 21 days before illness onset"

Should result in the following actions:
1. Isolate patient in single room with a private bathroom and with the door to hallway closed
2. Implement standard, contact, and droplet precautions (gown, facemask, eye protection, and gloves)
3. Notify the hospital Infection Control Program and other appropriate staff
4.Evaluate for any risk exposures for EVD
5. IMMEDIATELY report to the health department

So according to the CDC, any ED provider who doesn't adequately respond to the combination of travel history + fever has failed majorly. The problem is that in this case the provider for whatever reason didn't know the travel history.

http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf

 

[Law2Doc]

I mean you can argue whether they are right in doing so, but the CDC is clear on this:

"Fever or compatible EVD symptoms in a patient who has travelled to an Ebola affected area in the 21 days before illness onset"

Should result in the following actions:
1. Isolate patient in single room with a private bathroom and with the door to hallway closed
2. Implement standard, contact, and droplet precautions (gown, facemask, eye protection, and gloves)
3. Notify the hospital Infection Control Program and other appropriate staff
4.Evaluate for any risk exposures for EVD
5. IMMEDIATELY report to the health department

So according to the CDC, any ED provider who doesn't adequately respond to the combination of travel history + fever has failed majorly. The problem is that in this case the provider for whatever reason didn't know the travel history.

http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf

Sure. But they have issued similar warning for countless ailments over the years including west Nile virus, dengue, sars, bird flu, swine flu, the list is endless. They want doctors to be cognizant that some of these rare things can come here too. At the same time they tell the public not to worry. At the end of the day you have to treat the patient for what he most likely has. And run your ER to treat most of your patients ailments well, not the 1 per decade that's a total wtf.

 

[Raryn]

OK, maybe I'm judgmental, but I'm just seeing how the specialties I'm dealing with seem to think that knowing some basics "belonging" to other specialties is beneath them, or that it's not even their job as physicians. Like the peds attending ordering an upper GI with small bowel follow through (and radiology angrily saying no, because it will take forever) instead of a nuclear medicine scan in a boy who hasn't passed stool in 7 days and has been vomiting postprandially (no obstruction to be clear). Or, to be hypothetical, having an ID doctor put someone on 2 weeks of gentamicin without doing some audiology studies along the way, rationalizing that it's really ENT's problem.

If I had a perimenopausal friend who was complaining of new onset irregular bleeding, bloating, and indigestion, I would want her internist to check her thyroid, order a transvaginal US, and think about working up an ovarian malignancy. It's not enough to just give her prilosec, a prescription for birth control pills, and send her on her merry way - even though, in 95% of the cases, that would be just fine.

Your attendings must be different than mine. Our intensivists in particular are basically "supermedicine" and pay attention to all organ systems. Now, do they worry as much about the long-term stuff that isn't relevant to their acute critical illness? Well no. They aren't making the decision on the exact meds to discharge the patient with. But they look at all issues both acute and chronic in their decisionmaking.

Our ID most certainly pays attention to side effects of their meds, and I can't believe there are any ID attendings who don't.

No comment on the peds situation, I have no idea what the appropriate test there is.

 

[SouthernSurgeon]

I just think it's rather complacent to basically shrug at a CDC mandate. Certainly from a med-mal standpoint you open yourself up to a huge liability exposure, but also from a public health/epidemiology standpoint its a bit dismissive. Whether you agree with the CDC's policies is a larger matter for debate.

But if they tell me to report something specific findings to them or my local health department - I'm reporting it if I come across it. Even if in my personal opinion it seems like overkill.

 

[BlondeDocteur]

I think the argument that physicians coming into contact with patients from 'exotic' places rationally ascribe the same differential diagnosis to them as to anyone else is, well, bunk. Totally counter to human psychology. If anything we all have to work on over-suspecting exotic pathologies in exotic patients.

 

[foo]

Sure. But they have issued similar warning for countless ailments over the years including west Nile virus, dengue, sars, bird flu, swine flu, the list is endless. They want doctors to be cognizant that some of these rare things can come here too. At the same time they tell the public not to worry. At the end of the day you have to treat the patient for what he most likely has. And run your ER to treat most of your patients ailments well, not the 1 per decade that's a total wtf.

Um, please don't second guess the CDC...

Let's look at the West Africa ebola data and future predictions. See:
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6303a1.htm?s_cid=su6303a1_w

The number of ebola cases in West Africa is doubling every 15 - 40 days. There are currently 8000 reported cases. The estimated unreported factor is 2.5x, so actually there are probably 21000 cases. CDC has created a model to predict the future number of cases and by January 20, 2015, the estimated number is 550,000 cases which corrected by 2.5x (unreported cases) predicts 1.4 million cases in West Africa. Worst case there would be 25,847 ebola cases per day by January 20, 2015. (The population of Liberia is around 4 million, and for Sierra Leone is 6 million).

This is why the US government will be deploying 4000 people (soldiers) to West Africa, to try to prevent the worst case scenario from happening, and why deployment needs to happen immediately.

Obviously there are going to be ebola cases outside West Africa, including in the US, and the CDC expects EDs TO NOT SCREW UP SO THAT WE ARE RELATIVELY SAFE IN THE US. EDs HAVE TO CONSIDER HISTORY OF TRAVEL IN WEST AFRICA.

Do you think you know better than CDC?

 

[foo]

The NY Times has an excellent series of articles regarding this topic. In particular, see:
http://www.nytimes.com/interactive/...ction=US Open&region=Article&module=Promotron

 

[Law2Doc]

Um, please don't second guess the CDC...

Let's look at the West Africa ebola data and future predictions. See:
http://www.cdc.gov/mmwr/preview/mmwrhtml/su6303a1.htm?s_cid=su6303a1_w

The number of ebola cases in West Africa is doubling every 15 - 40 days. There are currently 8000 reported cases. The estimated unreported factor is 2.5x, so actually there are probably 21000 cases. CDC has created a model to predict the future number of cases and by January 20, 2015, the estimated number is 550,000 cases which corrected by 2.5x (unreported cases) predicts 1.4 million cases in West Africa. Worst case there would be 25,847 ebola cases per day by January 20, 2015. (The population of Liberia is around 4 million, and for Sierra Leone is 6 million).

This is why the US government will be deploying 4000 people (soldiers) to West Africa, to try to prevent the worst case scenario from happening, and why deployment needs to happen immediately.

Obviously there are going to be ebola cases outside West Africa, including in the US, and the CDC expects EDs TO NOT SCREW UP SO THAT WE ARE RELATIVELY SAFE IN THE US. EDs HAVE TO CONSIDER HISTORY OF TRAVEL IN WEST AFRICA.

Do you think you know better than CDC?

In terms of common sense? Probably we all on this thread do, because I don't serve a frightened public or work for an elected administration. This isn't the medical establishment weighing it, it's a federal agency. I don't pretend to have the answers but I know they don't.

The TSA obviously isn't heeding the CDC when they are letting people fly with passports from these countries, and frankly imho that's the only "fix" that has a shot at working.

 

[rajhanda]

So 24 h ago Texas presbytarian was saying the ED docs couldn't see the nurse's entry bc there was a "flaw" in the system. Now they're saying there was no flaw and the docs did have the info.. Wondering if they got an important phone call from Epic yesterday...

 

[SouthernSurgeon]

So 24 h ago Texas presbytarian was saying the ED docs couldn't see the nurse's entry bc there was a "flaw" in the system. Now they're saying there was no flaw and the docs did have the info.. Wondering if they got an important phone call from Epic yesterday...

I think it's a pedantic quibble over what a "flaw" means. The media picked up on it as if there were some sort of software glitch. Every physician (probably nurse too) knows that what they meant by a "flaw" was that Epic sucks giant balls, and information like this gets buried in an onslaught of notes and alerts.

 

[Law2Doc]

When did we start treating viral conditions with antibiotics? I didn't catch that one in med school...the hospital screwed up just too much!

Its an expected "screw up". In the ED they err on the side of overprescribing..

 

[BlondeDocteur]

L2D I'm surprised you have a low opinion of the CDC and its expertise. These aren't petty career bureaucrats; they're phenomenally-qualified professionals who are the world's elite experts on topics such as these (the pathology and epidemiology of emerging infections, special pathogens, etc). Before USAMRIID fell apart they might have given them a run for their money, but now they're the lone superpower. They don't fear-monger and I can't ever remember reading any of their communiques that I disagreed with even remotely.

For those of you unfamiliar with the countries in question, a devastating outbreak of a highly lethal infectious disease couldn't have happened in a worse set of countries. There's a reason Senegal and Nigeria rapidly stamped out their infections while Sierra Leone, Liberia and Guinea have not. Sierra Leone had probably the most brutal scorched-earth series of civil wars imaginable over the last 20 years; Liberia might come in second in that regard, and Guinea was ruled by a dictator for decades. There is zero infrastructure, no hospitals, no trained health professionals, nothing. You've all probably been reading accounts of how, in Liberia in particular, patients are actually lining up at the treatment centers and being turned away due to a lack of space. (And treatment means, for the most part, laying on a concrete floor in a pool of your own excrement, being periodically sprayed with chlorine, until you die, alone and untended). There's literally nowhere for them to go and no one to take care of them. This includes the woman who infected our Dallas patient.

 

[Mass Effect]

I think it's a pedantic quibble over what a "flaw" means. The media picked up on it as if there were some sort of software glitch. Every physician (probably nurse too) knows that what they meant by a "flaw" was that Epic sucks giant balls, and information like this gets buried in an onslaught of notes and alerts.

Not to derail the thread, but of the EMRs I've used during med school, away rotations, and now in intern year, Epic is actually one of the best I've seen. I don't know what this "flaw" was, but I don't put it past a hospital PR team to spin an oversight by an overworked doctor who simply didn't look.

 

[SouthernSurgeon]

Not to derail the thread, but of the EMRs I've used during med school, away rotations, and now in intern year, Epic is actually one of the best I've seen. I don't know what this "flaw" was, but I don't put it past a hospital PR team to spin an oversight by an overworked doctor who simply didn't look.

this is purely speculative, but I'm assuming that the "flaw" is just that flags/alerts get routinely overlooked by providers.

My n is small, but Epic is the worst of the 5 EMRs I've used, including CPRS at the VA.

 

[Mass Effect]

Here's an article that details the hospital's statements. Sounds very much like spin to me. I'm glad they had to retract it.

http://www.bloomberg.com/news/2014-...-gap-allowed-ebola-man-to-leave-hospital.html

 

[mercaptovizadeh]

Completely disagreeing with L2D, as usual. Amazing that he now thinks the CDC is scaremongering....

 

[link2swim06]

When did we start treating viral conditions with antibiotics? I didn't catch that one in med school...the hospital screwed up just too much!

You missed the class on 'customer service' and 'press ganey score.' When people come to the ER "for antibiotics" and the doc tells them it is viral and they don't need antibiotics you know what happens? They fill out that they got bad service and the doctor gets money docked off his/her paycheck.

Or they waste 20 minutes arguing with the patient and then a patient in the waiting room with something really wrong gets fed up by the wait and goes home and dies.

 

[rokshana]

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.

however…its not flu season yet.

 

[rokshana]

You can consider it but it still ought to be low on your differential. In Liberia there have been what, 1000 cases? That's a lot but in a population of well over 4 million that's still going to be way below every flu, aids, meningitis, malaria and TB. The symptoms were totally nonspecific. Wouldn't be a slam dunk even if you were focused on the disease. And then move it to Texas where they've never seen a case but see lots of people with exactly those symptoms every day and it has never been Ebola. I'm not sure there's a great fix but I guaranty we will spend a lot of time and resources more out of fear than actual utility.

actually to date, 3834 cases in Liberia alone, with 2069 deaths…with a total of 7074 cases and 3431 deaths…i would image in Liberia, Ebola IS higher on the differential than the flu.

 

[rokshana]

this is purely speculative, but I'm assuming that the "flaw" is just that flags/alerts get routinely overlooked by providers.

My n is small, but Epic is the worst of the 5 EMRs I've used, including CPRS at the VA.

i agree that CPRS is one of the better EMRs, but trust me there are EMRs *cough * Allscripts *cough* that are waaay worse than EPIC…actually kinda like it.

 

[Law2Doc]

actually to date, 3834 cases in Liberia alone, with 2069 deaths…with a total of 7074 cases and 3431 deaths…i would image in Liberia, Ebola IS higher on the differential than the flu.

The CDC figures for Liberia as of September are much lower than yours -- I think your totals are probably for a couple of the west African countries combined. Anyway the various influenza strains affect millions worldwide each year with another big chunk of the population infected but relatively asymptomatic, so that, along with the "common cold", this is always going to be the most likely diagnosis for flu-like symptoms no matter where on the planet you are. Ebola is certainly something you'd be foolish not to worry about more in West Africa than Texas, but in neither place is that the most likely ailment with these nonspecific symptoms. and that's kind of the problem here -- by the time this illness declares itself for what it really is, it too late.

Which means you are totally dependent on the patients being forthcoming. This guy KNEW he had been in contact with Ebola patients -- and yet that was not the first thing out of his mouth when the triage nurse or doctor asked him "what brings you here". He was criminally deceptive. It's very hard to ever help a patient with nonpecific symptoms who hides things from you. So maybe the answer is simply we dont let people with West African passports come to the US for a while, until they get this under control. Because counting on US ED docs and worse Walmart NPs to draw out histories from uncooperative patients is unrealistic and unworkable. Everyone is going to say yes the ED could have done better in taking a history or that the EMR demographics and billing info wasn't shared or perused (because frankly in 99.9999999% of cases in Texas it isn't relevant to the ED doc) or that there should have been a knee jerk reaction when hearing the word Liberia. But again, someone presenting with flu-like symptoms during flu-season isn't exactly something that should be setting off alarms. You can always do a little better but with a Non-forthcoming patient your history will always be lacking, and that's not something you can fix systemically. I think a lot of us are worried about a deadly disease we can't cure getting a foothold in the US, but I think revising the approach in EDs to put more effort into ferreting out very rare things most or maybe none of their patients will have simply isn't a great use of resources. The CDC issues warnings annually. Ebola, bird flu, swine flu, sars, west Nile. There's always something new to be on the lookout for. And it's never something that should be at the top of your differential. Its not really good medicine to worry that every patient with relatively benign symptoms carries a deadly plague. Because most won't, even if they are from Liberia.

 

[Law2Doc]

...

How are you going to explain yourself in court if the patient develops an adverse reaction to a drug they didn't even need? You are the doctor, you make the call. You don't get bullied into prescribing meds you don't have to prescribe. There's always a better way to handle such patients. Take a trip around the world(I suggest Germany) and see how they handle such patients.

I agree with you about overprescribing antibiotics being problematic but the reality is that given the vague symptoms people tend to have, ER doctors often err on the side of caution, more afraid to be sued sending a patient away empty handed than the risk of side effects, want the patient to leave felling their problem was addressed rather than come back later, and it's pretty hard to second guess what someone else observed on exam so their decisions are tough to contest. I agree that in other countries they do a better job of limiting antibiotics, but they are fighting a losing battle when we are breeding super bugs that know no borders.

 

[rokshana]

The CDC figures for Liberia as of September are much lower than yours -- I think your totals are probably for a couple of the west African countries combined. Anyway the various influenza strains affect millions worldwide each year with another big chunk of the population infected but relatively asymptomatic, so that, along with the "common cold", this is always going to be the most likely diagnosis for flu-like symptoms no matter where on the planet you are. Ebola is certainly something you'd be foolish not to worry about more in West Africa than Texas, but in neither place is that the most likely ailment with these nonspecific symptoms. and that's kind of the problem here -- by the time this illness declares itself for what it really is, it too late.

Which means you are totally dependent on the patients being forthcoming. This guy KNEW he had been in contact with Ebola patients -- and yet that was not the first thing out of his mouth when the triage nurse or doctor asked him "what brings you here". He was criminally deceptive. It's very hard to ever help a patient with nonpecific symptoms who hides things from you. So maybe the answer is simply we dont let people with West African passports come to the US for a while, until they get this under control. Because counting on US ED docs and worse Walmart NPs to draw out histories from uncooperative patients is unrealistic and unworkable. Everyone is going to say yes the ED could have done better in taking a history or that the EMR demographics and billing info wasn't shared or perused (because frankly in 99.9999999% of cases in Texas it isn't relevant to the ED doc) or that there should have been a knee jerk reaction when hearing the word Liberia. But again, someone presenting with flu-like symptoms during flu-season isn't exactly something that should be setting off alarms. You can always do a little better but with a Non-forthcoming patient your history will always be lacking, and that's not something you can fix systemically. I think a lot of us are worried about a deadly disease we can't cure getting a foothold in the US, but I think revising the approach in EDs to put more effort into ferreting out very rare things most or maybe none of their patients will have simply isn't a great use of resources. The CDC issues warnings annually. Ebola, bird flu, swine flu, sars, west Nile. There's always something new to be on the lookout for. And it's never something that should be at the top of your differential. Its not really good medicine to worry that every patient with relatively benign symptoms carries a deadly plague. Because most won't, even if they are from Liberia.

funny…since i got it FROM the CDC's website…your source may be a bit outdated…it is a rapidly evolving issue.

http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/index.html

 

[rokshana]

I agree with you about overprescribing antibiotics being problematic but the reality is that given the vague symptoms people tend to have, ER doctors often err on the side of caution, more afraid to be sued sending a patient away empty handed than the risk of side effects, want the patient to leave felling their problem was addressed rather than come back later, and it's pretty hard to second guess what someone else observed on exam so their decisions are tough to contest. I agree that in other countries they do a better job of limiting antibiotics, but they are fighting a losing battle when we are breeding super bugs that know no borders.

i think you give ED docs a little more credit that they deserve at times…sure there are many that are good…but my experience has been that in general they are looking to process as many patients in and out and getting them out of the ED as fast as possible…i'v heard attendings boast about how they are handling 12, 15, 20 pts at a time….or that in the last 6 hours they have "seen" 40 pts…or "i don't care where they go, just that they get out of my ED"…

and sorry if you write in your note, mostly likely viral…haven't done anything that resembles an infectious w/u and the give an antibiotic for a viral problem? well then the NP an the Walmart is probably better than you...

 

[Law2Doc]

...well then the NP an the Walmart is probably better than you...

except that the NP at Walmart is seeing 1 patient at a time and works for an employer that makes $ every time the NP writes a script (the ultimate conflict of interest) so the ED doctor would have to be pretty bad to make the NP better. The incentives are different -- the ED doc wants relatively healthy patients to go home while the NP has an incentive to move product. Both may overuse antibiotics so you kind of pick your poison -- but at least the person without a Financial incentive is free to draw lines someplace.

 

[rokshana]

except that the NP at Walmart is seeing 1 patient at a time and works for an employer that makes $ every time the NP writes a script (the ultimate conflict of interest) so the ED doctor would have to be pretty bad to make the NP better. The incentives are different -- the ED doc wants relatively healthy patients to go home while the NP has an incentive to move product. Both may overuse antibiotics so you kind of pick your poison -- but at least the person without a Financial incentive is free to draw lines someplace.

and the ED doc is being pushed by his bosses to see more and more patients or he loses his job…no difference…