Our team assessed there was a probability that a US city caught by surprise with Ebola runs a higher risk of a preventable outbreak. And unnecessary socio-economic disruption, as evidenced by already observable market shifts in the transportation sector.
- Human error has occurred.
- There was a failure in communication not only between the nurse and staff in the ED regarding the travel history of the Liberian traveler, but an apparent failure in the midlevel / physician who saw the patient to cross-check the travel history. Failure, in general, to check a travel history in an already-busy emergency department is a common problem.
- Media coverage has focused on the emergency transport team being isolated as well as the dozen or so other contacts of the Liberian, including 5 children. Pediatric infections (and especially fatalities) would represent a major nidus of social anxiety for Dallas above and beyond baseline social concern for the adult cases. But one aspect of coverage has been missed- the reported fact that the Liberian has had routine bloodwork done. This raises serious questions regarding infection control issues for that hospital's clinical laboratory. Compromise of that laboratory's capacity to process specimens may compromise their ability to efficiently process patients in a high throughput setting. Universal Precautions, by themselves, are a major inhibitor to the spread of Ebola. But to backtrack and examine not only the human contacts, but also potential contamination of the involved clinical equipment used in the care of the patient (with a special eye on the laboratory) can be a major challenge.
- While CDC's Director has eloquently expressed confidence in his agency's ability to respond to Ebola inside the US, and we share his optimism- but only from the viewpoint of public health's performance. From the viewpoint of medical performance, we are far less confident. And we note that public health often "lives apart" from daily clinical medicine, often failing to fully appreciate the challenges faced on a daily basis. We note the following:
- We are observing added stress being placed on an already-severely stressed medical infrastructure. The context of massive changes in the healthcare environment have contributed to provider fatigue, stress, and lack of bandwidth to deal with anything except for what is standing right before them. Warnings about an exotic disease a hemisphere away are difficult to keep front and center- particularly when the warnings are confused with a sense of "crying wolf" provided with seemingly every other public health crisis that preceded it.
- We are entering influenza season, where A/H3N2 may dominate the season. The implication is added stress on the ED/ICU grid. And, increased opportunity for more human error to creep in as the Ebola disaster continues to escalate in West Africa.
- And lastly, there appears to be a lack of understanding of the clinical signs of Ebola infection. CNN quoted a hospital official with the following: "At that time, the patient presented with low-grade fever and abdominal pain. His condition did not warrant admission. He also was not exhibiting symptoms specific to Ebola." If this quote is accurate, this indicates a fundamental lack of understanding. One of the most common diagnoses confused with true Ebola infection is gastrointestinal infection such as typhoid. This was precisely what happened during the compromise at the Samaritan's Purse facility in Liberia- a staff member presented to work complaining that he believed he had typhoid. They missed this valuable clue, which ultimately resulted in Dr. Brantley's exposure and collapse of the clinic's operational status.
We have asked all practicing physicians in America to watch the story unfold in Dallas very carefully. It is important that we all ask ourselves uncomfortable questions. Questions like, "Are we REALLY prepared to screen a suspect Ebola patient?" "Are we REALLY paying attention?" "Do we REALLY understand the FACTS about Ebola?"
Our team is the primary source of medical intelligence to 1/3 of American physicians through a partnership with Sermo. We have conducted 3 identical polls at various points in the Ebola disaster thread over the last several weeks, asking "Is your local hospital prepared to manage a suspect Ebola case?" All three polls gave remarkably similar answers: 90% of our physicians do not believe we are truly prepared.
This is a telling and disturbing finding, and we would do well to heed the warning indicators.