The stunningly horrible news from this morning: another health care worker at Dallas Presbyterian has contracted Ebola.
Health care workers are at extremely high risk for contracting Ebola as patients produce an enormous amount of infected body fluids. I read one report that says 10 liters of liquid stool a day. And then there’s the vomit. Many need procedures that increase the risk of exposure.
While the CDC has argued that standard infectious precautions are adequate, the images and reports from Africa indicate that a higher level of personnel protection is in play than I’ve ever seen used in North America – full body suits (every inch covered) in addition to spraying down with bleach before degowning.
Reading how the biocontainment units at Emory and Nebraska are designed, from the protection for workers to how they meticulously treat lab specimens and infected wastes, leads me to believe that while any hospital could technically care for an Ebola patient, realistically most cannot right now. Only a few have this specialized set up. The facilities in Emory and Nebraska have been training for years to do this very thing. They are farther ahead on the learning curve. Figuring out how to care for an Ebola patient is best not done real-time in the midst of a viral stigmata.
There are reports from Dallas Presbyterian that the infected index patient wasn’t isolated initially, that infectious waste was piling up, that lab specimens went via the regular pneumatic tube system, and most troubling that the personal protective gear was lacking. Nurses have been quoted, anonymously, saying they were told to use medical tape to protect their necks. If true this is an epic breakdown of unimaginable proportions and makes the start of every zombie apocalyptic novel/movie seem slightly more plausible.
But the most basic facts speak for themselves. The two biocontainment facilities that have cared/are caring for five patients with not one transmission to a health care worker. Dallas Presbyterian has cared for one patient, leaving two infected. So far.
I would argue that the Dallas Presbyterian experience is likely more on par with the vast majority of hospitals around the country. Most hospitals don’t have specific ambulances to transport Ebola patients. They don’t have labs in their isolation unit so specimens never travel to the regular lab. They don’t have the ability to autoclave (sterilize) their waste on site. They have labs three floors down, they send their trash out to be incinerated, and they have myoptic hospital administrators beating their chests in public about how great the care at their facility, yet are loath to open additional rooms or call in more nurses. Think of the overtime!
So how do we prepare and who pays? Some hospitals say that an Ebola patient could lead to bankruptcy. One estimate is than an Ebola patient costs $1000/hour. Hospitals in large urban areas with international airports and a higher immigrant population from endemic areas in West Africa are likely to see more cases (especially if the 10,000 new cases a week in Africa floated by the WHO is in the right ballpark) and will initially bear a greater burden than say a hospital in Hays, Kansas, however, if we don’t figure this out now together then everyone will bear the burden down the road.
So who is going to step up? How can we get people trained and hospitals prepared? How can we prevent Ebola from bankrupting some hospitals? How can we care for patients (there will be more) and not put our health care workers at risk?
I don’t buy the CDC’s chipper “everyone can do it” because we have clear evidence that everyone can’t do it. Not yet.
These are my thoughts:
1) Transfer the two (and more if they appear) health care workers from Dallas to one of the biocontainment facilities. They deserve to be at a center with a proven track record. They can also compare their care there with what they were instructed to do in Dallas. This would not only give then the best chance of survival, but be invaluable in figuring out if anything went wrong in Dallas or if it was just bad luck
2) The Joint Commission (accredits hospitals), the CDC, or some other government body must figure out fast the specific guidelines for Ebola care equipment wise, from isolation rooms to waste disposal. Standard infectious precautions is too wishy-washy. To assume that every hospital can autoclave their waste on site is absurd. Doing what these facilities have done might seem like overkill, but yet they have done it right so far. If only 3 or 4 hospitals can meet these needs now, then so be it. But we have to know who can do it safely.
3) Hospitals that prove they can care for an Ebola patient by showing the facilities and training should get extra money. We need more than 3 or 4 centers. I’d liberate money from pork belly projects and transfer it to the Ebola fund just for starters. Medicare can chip in too, giving less to centers without Ebola care capabilities. But the goal must be for each state to have one capable facility. Smaller less populous states can probably manage with a central facility serving a few states and larger states, like California or Texas, might need two. Hospitals that can do this extra care deserve more funding. They will be, of course, helping everyone.
4) Every single health care worker needs to know how to do the basic triage and isolation for a suspected Ebola case. A travel history (or health care worker in Dallas history) is really all that’s required. If a hospital can’t prove that they have the ability to triage, isolate, and transfer then they shouldn’t be accredited.
5) The CDC or WHO or the Joint Commission in conjuction with people who have successfully cared for Ebola patients needs to design the specific Ebola training for every hospital. It can’t be an e-mail or a one hour lecture, because we get a lot of useless e-mails in hospitals. Apparently in Dallas the nurses were told to call infectious diseases, but it seemed no one really had a clue what to do. As they had never seen a patient with Ebola and had likely been trained via an e-mail they couldn’t be expected to know! There must be drills for the basic care (screening, isolation, testing and transfer) as well as drills for the advanced specific care units. Showing up and participating hands on must be required.
6) Funding for research. This NIH says their ability to find a vaccine or antiviral has been hampered by cuts. Well, there is $300 or million in NIH funding to complementary and alternative care research – personally I’d liberate that from the 2015 budget and transfer it to vaccine research. One of the latest CAAM studies funded by the NIH tells us that multiple 60 minute neck massages can help chronic neck pain, but shorter massages do not. I’m not saying complementary medicine doesn’t deserve funding, after all we have to prove that the therapies work or do not, but stopping Ebola everywhere is more important right now. There won’t be any money to study anything else if this gets out of hand.
7) Add a $2 tax to cigarettes. That money can A) help pay for Ebola care in the Unites States and B) will prevent more people from smoking thus liberating the Medicaid and Medicare dollars that would have gone to care for their smoking related diseases.
If we don’t get it together now there will be a larger problem. I still believe the flu and enterovirus are more of a risk to everyday Americans than Ebola, however, most US hospitals are closer to Dallas Presbyterian than the biocontainment unit at Emory. If we don’t get the hospital and health care system geared up this is going to be a long, expensive haul in so many ways. It is estimated that each Ebola patient infects two others.
I think starting with primary and tertiary care Ebola centers (with everyone needing to be a primary care center or you don’t get to be a hospital) is a good way to start. We can shift money to do it. I used to think we didn’t need an Ebola Czar, but since common sense isn’t prevailing, the CDC keeps wringing their hands about universal precautions, and given this will require multiple organizations at both the Federal and State level someone just needs to step in and say take a deep breath, we have a real plan.
And if it were me, I’d start by sending the two health care workers in Dallas to a hospital with a biocontainment facility, like Emory or Nebraska.
***Update: the 2nd health care worker (HCW) will be transferred to Emory. A team of 2 nurses from Emory are apparently going to do hands on training in Dallas.
Adding more concern, the 2nd HCW from Dallas flew the day before she was admitted and now everyone on
that flight needs to be contact traced. There are rumors she may have had a low grade fever the day she travelled.