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infectious diseases

Stopping Ebola in the U.S. starts with transferring the two patients from Dallas to Emory

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.

Discussion

22 thoughts on “Stopping Ebola in the U.S. starts with transferring the two patients from Dallas to Emory

  1. Jen – you just make sense. That’s why we have areas of specialization, as well as hospitals that are really excellent at what they do. If it were me, I’d want to be at Emory – as you said, they’ve already demonstrated that they can do it right.

    Posted by Melissa Barthold | October 15, 2014, 9:48 am
  2. I agree with everything save the cigarette tax. Why make only cigarette smokers pay the costs? Add a lesser tax to every can of soda or candy bar. I don’t know about everywhere else, but here in Washington State; smoking has dropped drastically — cigs already top $7 per pack.

    Posted by syrbal-labrys | October 15, 2014, 9:56 am
    • I’m for adding more taxes to soda, alcohol etc. whatever costs Medicaid/Medicare more money!

      Posted by Dr. Jen Gunter | October 15, 2014, 10:00 am
      • I never agree to these type of “sin taxes” being connected to a single cause, no matter how worthy it might be (and this one is much more than worthy). Dr. Gunter, your argument for the cigarette tax in your original post points out exactly why I oppose it. You state one of the goals of this tax “will prevent more people from smoking…” While that would be a good thing beyond your stated reason of saving Medicare and Medicaid dollars, what would become of the funds needed for the Ebola research when the cigarette tax revenues drop because more people have stopped smoking? Those funds would need to come from another source.

        I get the idea – and this is not my reaction just to your suggestion but anytime I hear this type of idea – tax this item to fund this project and let’s hope less people use the item. If one goal is met, the other one won’t be.

        Posted by Lance | October 15, 2014, 11:42 am
      • Lance, if Medicare/Medicaid stops having to shell out as much money for smoking-related issues, then whatever is saved can go to fund Ebola. So Ebola research either gets the cigarette tax or the savings from not having to treat smoking-related illnesses. I certainly don’t know the math on that, but considering how much it cost to go to the ER for something minor (which would be extra taxes on 500 packs of cigs), I’d bet that more money is saved if smokers quit smoking since you’re looking at ongoing medical expenses.

        Posted by Anxious Mom | October 15, 2014, 4:36 pm
  3. These are all good ideas and I agree, we need to move the 2, now 3 patients to containment centers. One small mistake and another person becomes ill.

    Posted by bethhavey | October 15, 2014, 10:02 am
  4. If each Ebola patient infects two others then I would suspect they could be infectious before symptoms appear. Doesn’t look good.
    Leslie

    Posted by swo8 | October 15, 2014, 10:27 am
  5. We have known for a long time that this was coming but NO ONE is or was prepared. Being in Dallas right now, I cannot tell you how angry I am about the flippant CDC director’s response and the lack of training cross the board. We have been told to just use surgical gowns, masks, gloves, and face shields if we have someone show up at a clinic. This is shameful and embarrassing. All I can do is shout a loud “AMEN!” for your post above.

    Posted by Victo Dolore | October 15, 2014, 10:57 am
  6. One other thought – we just celbrated Coumbus Day in the US and some are opposed to celebrating it because with the influx of Eurpoean immigrants to the continent, this lead to Native Americans being infected with diseases they did not know how to treat. Are we seeing a repeat of this over 500 years later?

    Posted by Lance | October 15, 2014, 11:44 am
  7. I agree with your recommendations for this. As a retired ER/ICU nurse who has worked at many hospitals in the Dallas area I can tell you that it is highly unlikely that any hospital is prepared to provide intensive care to an Ebola patient. None of the hospitals have the proper PPE to protect their staff.

    If the letter that the Nurses Union read from the Presby nurses is true I am not surprised. I can totally see administrators putting pressure on staff nurses. I worked as a nursing supervisor at a hospital in Dallas in the late 1980’s and was required to call the administrator on call (not a nurse) before I made any staffing decisions for upcoming shifts. The bottom line is the most important thing for these administrators and I am sure that the PPE that these hospitals have would never fly at a facility that had a biocontainment unit.

    That being said, there was no way that these staff members that provided care for Mr. Duncan should not have been monitored by CDC. That nurse from today should never have been traveling out of the Dallas area.

    Posted by rekster | October 15, 2014, 11:48 am
  8. This morning’s headline, “Latest Ebola patient exposed 132”. Really, we need containment centers! In addition, military personnel are being sent to Ebola areas, where will infected military go?

    Posted by Suzanne Fouche | October 15, 2014, 12:25 pm
  9. Super informative and clear. Thank you for posting.

    Posted by Jan Wilberg | October 15, 2014, 12:31 pm
  10. Precisely, Jen! How could staff decontaminate in the basic 3 X 5 anterooms outside the isolation rooms most hospitals have? Here we have a decontamination shower in the ER area, but that’s it.

    Posted by Beth | October 15, 2014, 2:06 pm
  11. I was wondering about average community hospitals handling cases. Healthcare seems to run on everyone checking the boxes that their job requires and for people to be more productive than an eight hour day will allow. Ebola does not fit the system. A system that requires everyone to take annual classes on how to handle oxygen containers but trains for Ebola by email and a phone number?

    Posted by Katie | October 15, 2014, 5:33 pm
  12. Anxious Mom: Your logic makes to much sense for our system of taxation. The money saved in Medicare and Medicaid disbursements are out back in the state or federal treasury. Good luck convincing the politicians to put that into Ebola research. And that goes equally for both political parties.

    Posted by Lance | October 15, 2014, 5:41 pm
  13. Given the information we’ve heard from the nurses in Dallas, I’d be willing to bet that the failure that got them sick was in proper removal of PPE. It sounds like few if any of them had intensive training or practice in this, and it’s a lot harder to do right than people might imagine.

    I’ve worked in labs with infectious agents much less dangerous than ebola, but because I was an undergraduate at the time and our lab was certified to work with more infectious agents, I was trained to work as if the agent was BSL3 [biosafety level 3 — ebola is level 4] (If you want to get technical, I was trained to work under BSL2+ conditions, which is mostly BSL3 level procedures but in a BSL2 facility, and with slightly intense PPE). It took several weeks of training before I was allowed to work with live virus, and I can’t tell you how many mistakes I made in that time, usually while cleaning up and removing protective gear. Everything must be done in the proper order and bleached/treated with alcohol [depending on the lab and the agent in question] at specific points in the process. And I was in a quiet, calm lab environment working with chemicals and cell culture flasks, not working on a critically ill patient, with all the additional stresses and unexpected events that entails! Not to mention, treating an ebola patient involves LITERS of infectious fluid, where as I was working with MICROLITERS.

    Now, the level of precaution we take in lab environments is usually higher than is required or even practical in healthcare environments. The circumstances are somewhat different–we’re lab workers often dealing with very concentrated samples of dangerous agents, while healthcare workers are dealing with much more dilute samples, generally, but in much larger quantities. But the care required to remove contaminated PPE without risking infection is the same in both instances.

    It was drilled into my head as an infectious-agent researcher that all the protective equipment in the world wouldn’t protect me if I was using it improperly, and that that proper use required lots of practice followed by constant vigilance… and/or my boss standing over my shoulder, narrating every step and ready to stop me if I made one wrong move. Even if these nurses were amazing at their jobs and had some great in-the-moment training, it doesn’t sound like they had the benefit of practice or of the watchful eyes of an experienced person to protect them.

    I think you are right that we should be allowing hospitals where they have extremely well-trained-in-infection-containment staff handle ebola cases to the extent that that is possible. But to protect the frontline workers at ordinary hospitals, there should probably be both drilling in these procedures AND the requirement of some kind of buddy system to compensate for the lack of every day practice/long term experience.

    Posted by keelyellenmarie | October 16, 2014, 5:06 pm
    • Thanks for your detailed and on point comment!

      Posted by Dr. Jen Gunter | October 16, 2014, 5:49 pm
    • I slightly disagree with the precautions in lab environments being higher than in a clinical environment, simply because in theory infectious materials are carefully handled in small amounts. Meaning if you need your PPE equipment to keep you from getting sick and dying, you’re incredibly sloppy*. In the case of Ebola, your PPE equipment is the only thing standing between you and death. You have to assume that it’s contaminated after working with a patient. It boggles my mind that anyone would think they could take the PPE suit off without decontaminating with bleach it first.

      * Noting that people being incredibly sloppy with infectious agents was recently in the news.

      Posted by Gibbon1 | October 16, 2014, 11:27 pm
      • My apologies, my comment was imprecise. You are right that a healthcare environment is much more dangerous than a lab environment, and therefore the PPE requirements should be greater. What I was attempting to convey in terms of the precautions being greater in labs wasn’t so much about the type of PPE but the procedures on the whole–in a lab you work in a hood, do everything in an incredibly controlled way, etc. And if we don’t know how dangerous a pathogen is, we tend to default to fairly high level precautions. Generally speaking, you can’t do that in a healthcare environment–we don’t put people in a sterile bubble when they come in with an unknown infection, and you can’t take half an hour to meticulously set up for every procedure [some, yes, but there are emergencies].

        But that’s generally, of course. You are right that once we KNOW we are dealing with ebola, the precautions taken should be every bit as intense, if not more intense, than in a lab environment.

        And yea, I’m in total agreement that they should be basically bathing in bleach before they take of their PPE. ALL OF THE BLEACH.

        Posted by keelyellenmarie | October 17, 2014, 10:56 am

Trackbacks/Pingbacks

  1. Pingback: Hubris Or Stupidity? | herlander-walking - October 15, 2014

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