Are Our Hospitals Prepared for Ebola?

Of the first four Ebola victims treated on American soil, one has died and three others have recovered. That would be considered an excellent survival rate in the African countries which are at the heart of the outbreak where treatment facilities are far more primitive.   However there were differences in circumstances and  care of those four patients which require serious consideration.

The first survivors were Dr. Kent Brantly and Nancy Writebol, a healthcare worker and missionary respectively, who were diagnosed with the virus in Africa and were then transported to the US for treatment. Both were treated at Emory University Hospital in Atlanta which has a sophisticated isolation unit and much experience in treating dangerous infectious diseases. The circumstances were similar for Dr. Rick Sacra. He too was diagnosed in Africa and transported to the US. He was treated and ultimately released from the Nebraska Medical Center, another hospital well equipped to treat the virus.

As you are probably already aware, the situation of the fourth Ebola patient was quite different. Thomas Duncan, a native of Liberia, was not symptomatic (and therefore not contagious) until several days after he entered the country. When he sought treatment at Texas Health Presbyterian Hospital in Dallas his Ebola symptoms were misdiagnosed and he was sent home  even though he made it clear that he had traveled from Liberia where an Ebola epidemic is raging. He was correctly diagnosed and admitted to the same hospital two days later. He died eight days eight days after his admission on October 8th.

So in summary, what were the major differences between the Ebola victims who survived and the one who died:

  • The three patients that survived were diagnosed in Africa and transported to hospitals in the US well known for their ability to treat dangerous infectious disease. Thomas Duncan was came down with symptoms in the US and went to a hospital close to where he happened to living at the time.
  • Both Emory University Hospital and Nebraska Medical Center were informed and prepared for the arrival of their Ebola patients. Duncan turned up on Texas Health Presbyterian Hospital’s door steps and they originally botched his diagnoses.
  • The three patients that survived were all US citizens engaged in humanitarian work and fighting Ebola in Africa when they contracted the disease. Thomas Duncan was a Liberian who happened to travel to the US after contracting the disease, but before he became sick and he may have lied about his association with Ebola victims.
  • Two of the patients who survived received blood transfusions from Ebola survivors early in their treatment. (Blood from Ebola survivors have antibodies which are thought to help patients combat the disease.) Duncan did not, but neither did Nancy Writebol. Their blood types were not compatible with the blood of survivors.
  • All three of the patients who survived were given experimental Ebola drugs early in their treatment. Duncan was given the same experimental drug as Sacra, but six days after he was diagnosed. He died two days later. There may have been a good reason for this, but none has been provided.

As expected, questions have arisen as to why Thomas Duncan died while the other three survived. His family seems to think that he received substandard care because he was a foreigner, and perhaps because he was black and/or because he lacked insurance. I think this is very improbable. Perhaps it was because he was initially improperly diagnosed and treatment did not begin for two days while he continued to be an infectious danger to others. Or perhaps it was because the other three patients received experimental drugs early in their treatment and he was not given one of these drugs until well into his illness. Or perhaps it had nothing to do with any of the above and Duncan simply didn’t possess the physical strength and immune system to fight off the virus despite getting excellent care. On initial evaluation I suppose any of the above or some combination could have been the reason(s) why Duncan did not survive.

However, a tragic event announced today may provide additional clarity – a nurse who cared for Thomas Duncan at Texas Health Presbyterian Hospital in Dallas has now also been diagnosed with Ebola. Dr. Tom Frieden, head of the CDC, was quoted as saying that there was evidently a breach of safety protocols at the Dallas hospital and all of the health care workers who treated Duncan may have been exposed.

Any failure by medial workers treating Ebola patients to observe very strict protocols can put them risk. Infections of health care workers have occurred multiple times in the primitive conditions they face in Africa, but to have it happen here in a modern, well equipped hospital in the US is deeply troubling. Along with other failures associated with Mr. Duncan’s care, I believe that this latest development points to the fact that Texas Health Presbyterian was ill prepared to receive and safely care for an Ebola patient. And if that hospital was ill prepared, what does that say about so many other hospitals across the United States.

On its website Texas Health Presbyterian Hospital in Dallas advertises itself as “an 898-bed acute-care hospital treating some of the most complicated cases in North Texas.” A major hospital in one of America’s largest cities, Presbyterian has an excellent reputation. US News and World Report ranked it among the best in the nation in seven of eleven specialties. (Treatment of infectious deceases was not one of the specialties ranked by the magazine). If that hospital can’t properly deal with a man with Ebola symptoms who turns up in their emergency room, I have serious concerns about the capabilities of most of the hospitals across the country, especially those in smaller cities and those which are less well equipped. Think of the hospitals in your area – do you think they would do a better job than Texas Health Presbyterian?

Hopefully the huge amount of the publicity given to Thomas Duncan’s case will serve as lessons learned and hospitals everywhere are reviewing and updating their procedures, and training and drilling their staffs so they can be prepared. This is an absolute necessity for hospitals in large cities which are likely be prime destinations for travelers from Ebola hot spots. However, hospitals in other cities and small towns are not immune. Given that the Ebola incubation period can be as long as twenty one days, an infected patient could turn up just about anywhere in the country.

However, identifying Ebola patients and isolating those with whom they have been in close contact is only the first prerequisite. The Dallas situation has clearly illustrated that even many of the best hospitals in the country may be incapable of effectively and safely treating Ebola victims. It is my opinion that for the well being of the patients and safety of those providing them primary care, it is important that Ebola patients be transported immediately to those hospitals like Emory and Nebraska Medical Center which have the care givers, facilities, and experience to deal with dangerous infectious diseases. In these facilities we can build up experience and improve competence in dealing with the disease while providing maximum safety for the caregivers and the general public.

While I truly don’t believe Ebola will become an epidemic in this country, influenza will always take a far greater number of lives every year, we are almost certain to have additional people who will come down with Ebola after entering this country from abroad. Others may also contract the disease from these victims before they are isolated. Since the disease is exceedingly deadly, the lives of more than a few people are at stake. Our hospitals have to be ready.

Cajun   10/12/14

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