While I agree that we have the knowledge, experience, and resources to be able to control Ebola, most of the experts are academicians or practice in relatively well-heeled ivory towers. I have practiced Infectious Diseases and Infection Control for 30+ years, primarily in a number of community hospitals, and offer a different perspective here, based on these experiences.
Administrators vs. Practitioners
Increasingly, decision makers are administrators who are disconnected from the realities of patient care. The latest fad, for example is to design hospitals to look like hotels and be “inviting” to patients, although they are very dysfunctional for delivering patient care, especially problematic in ICUs.
It is not all that different now. One hospital I am familiar with has Powered Air Purifying respirators (PAPRs), purchased with bioterrorism preparedness grants, but neither stethoscopes nor other dedicated equipment for isolation rooms. So nurses and docs gown up to go in the room of a patient with a “superbug” but take their stethoscopes into the room and then on to other patients, perhaps remembering to wipe it down first.
The problems with controlling Ebola cases in the United States is not that we can’t care for people well, or with good infection control. We absolutely can. But the Dallas case abundantly illustrates some of the problems in caring for anyone with a communicable illness, whether a antibiotic resistant organism (aka “superbug) like carbapenem resistant enterobacter (CRE), measles or Ebola.
First, the Emergency Room failed to take an adequate history, or to relay important information from the triage nurse to the physician—who is ultimately at fault for not having taken his own history, especially when presented with an accented foreign patient and after warnings about Ebola.
Some of us suspect the Dallas patient was not admitted in part because he was uninsured. He was inexplicably and irrationally sent home with antibiotics for a presumed viral infection, even though he should have been considered an obvious risk. Saul Hymes nailed the absurdity of discharging someone with a viral infection on antibiotics with typical ID physician humor: “He asked for ZMapp and they heard Z-pack.”
Another all too common problem in ERs and hospitals now is that temperatures are implausible. Good luck using that as a screening criteria. I learned that from screening patients for clinical trials. Fevers were often an enrollment criteria, and when axillary temps or tympanic thermometers were used, it seemed like many had a temperature of 36 C, or 96.8 F. Temporal artery scans are considered more accurate than tympanic, yet not reliable for febrile patients, but oral temps, now a rarity, were considered the most reliable. Monitors for measuring respiratory rate are also notoriously inaccurate. The accuracy of medical devices should be more of a consideration than just convenience and speed in obtaining such “vital signs.” A final serious problem in ERs is that patients (even those known to be colonized with superbugs) are generally not isolated in Emergency Rooms; ER staff claim they are “too busy.”)
Other Infection Control Issues
It’s fine to have policies for isolation and employee health. Administrators love that, and it looks great when JCAHO (Joint Commission on Accreditation) comes around. The problem is that we need training, practice, and the ability to demonstrate our infection control skills. I have made this plea repeatedly for helping to control superbugs, to no avail. I have suggested that each year or two we practice our skills using Glo-Germ, which will readily show if we make an error. Insert isolation garb pic] For example,I suspect that I contaminate something as I try to balance and take off shoe covers. It’s not easy. Unsurprisingly, now US nurses are saying they are unprepared for caring for Ebola patients.
We need a health care system that cares for all, even for those without insurance, without causing them to delay seeking care until they are seriously ill, perhaps infecting others in the process (e.g., tuberculosis, more commonly).