

New Texas nurse with Ebola had fever on airliner - anigbrowl
http://www.reuters.com/article/2014/10/15/us-health-ebola-usa-idUSKCN0I40UE20141015

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hga
This is just dandy. We believe the risk of transmission in such a circumstance
are low, but that low risk is counterbalanced by awful consequences if that
belief is wrong or there's bad luck.

Note also that it appears to have been determined that Texas Health
Presbyterian Hospital is not going to become the " _Dallas Ebola Magnet
Hospital of Excellence_ ", she's being sent to Emory, which has 3 of the 23
hospital beds in the country that are truly equipped and prepared for Ebola.

ADDED: more joy, although one should be very careful about early reports of
data that's in this case 2nd or worst hand:

 _However, Dr. Margo Erme from the Summit County Public Health said in an
Akron press conference later in the afternoon that they’re not sure about the
timeline. “We have gotten conflicting dates too, so we are actually looking at
getting the manifest from the airline to actually confirm that because we have
actually heard both.” She said her department is in the process of
interviewing family members in Tallmadge, where they believe Vinson spent
time. According to Erme, Vinson was “quite ill” when she went to the hospital
and may be having trouble remembering details about her movements before she
began to exhibit symptoms._

From [http://pjmedia.com/tatler/2014/10/15/conflicting-
timelines-a...](http://pjmedia.com/tatler/2014/10/15/conflicting-timelines-
and-details-for-new-ebola-case/)

Unfortunately believable given the reported fever, although what "quite sick"
really means is extremely vague.

~~~
anigbrowl
While not very impressed with the administration/CDC's leadership in response
to this crisis (insofar as public oommunication could be a lot better), I'm
downright astonished at how badly THPH has dropped the ball, and how often.

Sending an Ebola-infected patient home, lying about why they did so (blaming a
glitch in their IT system before coming clean), allegedly issuing staff with
paper gowns, and having _76_ different people treating their 'patient
zero'...it's just one bad decision after another - some of which seem to be
local to the hospital, some which are culturally ingrained in the medical
profession (eg patients being treated by large numbers of medical staff seems
to be the norm in the US).

For a variety of reasons the Obama administration has zero political capital
to make any significant changes in the healthcare landscape in its remaining
2.25 years, but I hope that one or more serious contenders for the presidency
in 2016 makes reform of the US medical industry central to their political
agenda.

The market model for health care simply _does not work_ because participants
in a healthcare market are not voluntary actors (with a free choice of when to
enter/exit the market), there is massive information asymmetry between actors
which makes rating providers virtually impossible, and because there are
noneconomic feedback mechanisms - eg irrational actors who choose not to get
vaccinated can end up as epidemic vectors and completely upend the
supply/demand equations for everyone else.

~~~
hga
I think this is more a case of the normal ways things are run practically
everywhere, not all that many steps from total disaster. If I remember
correctly, you've been around for a while; compare your experiences in
organizations of smallish absolute size like a hospital such as this one. It's
big as they go, 900 beds, but as an organization not large, let alone giant.

And they've got a zillion priorities, with Ebola being rather low, prior to
the nation's first Ebola tourist showing up. After all, we were assured the
probability of this was "extremely low".

Hmmm, I guess I should follow the links, especially with the revised report on
Duncan's highest temperature during his first visit, but someone was saying
the CDC's guidelines as of then would not say "EBOLA!" From what I've heard he
presented with symptoms consistent with a lot of things (fever and pain are
not in the least rare!), and they certainly went to a lot of effort trying to
diagnose what was wrong.

For the 2nd visit, I wouldn't expect any other random hospital to be better.
Even the special 4 have not yet, to my knowledge, set up a triage station
before the ER with a suited up attendant. Which is what's really required :-(.

As for your prescriptions, while it's easy to say this outfit isn't as good as
Mayo's, or probably many university hospitals, you give no evidence, nor do I
know of any, that it's possible to achieve a universally, qualitatively better
result across the nation. I've been noting WRT to the now two infected nurses
that we're _at this point in time_ at best only quantitatively better that
West Africa, and I'm not sure about that, we'll find out with more cases
outside of the special 4 hospitals when they get known Ebola cases.

Your dislike of "the market model" does not mean there is a better one, and we
know of _many_ that are worse (e.g. I can't remember the last time a patient
died because the staff failed to feed them, although searching for that it
hopeless since it's the standard way to euthanize patients).

As far a political capital, we're now in a Nixon in China state for the
foreseeable future. Only a "hawkish" Republican (e.g. not Rommnycare Romney,
or McCain) could do this. And do we wonder how the other side of the aisle
will respond???

~~~
anigbrowl
As I recall when Duncan first went o the hospital he said he had recently come
from West Africa (or maybe Liberia in particular) but may have dishonestly
denied having had contact with others who had Ebola. You're right that a fever
on its own doesn't suggest Ebola, but that plus travel should have aroused
someone's curiosity leading to further testing or at least observation.

Obviously, you could get a lot of false positives using a standard like that.
But with a disease that has a longish incubation period and a 70% mortality
rate, I'm OK with that. I'm no epidemiologist or even an amateur scholar of
them; I just learned about it the same way as most other people, reading news
on the internet, watching news documentaries on PBS, visiting CDC.gov. I feel
I have the public health awareness of a normal middle-class adult taxpayer, ie
nothing special other than a good level of general education and an interest
in current events.

Basically I'm saying that I would have expected senior administrators and
clinical staff at a large hospital to have significantly better awareness of
this issue than I would, because it;s their job.

~~~
hga
I guess what I'm getting at is that, especially at this stage of the game, I
expect errors like this. Doctors and nurses _are_ going to make mistakes, no
matter what sort of organization they're in, humans and their ailments are
_complicated_. That's why malpractice is almost always a civil, not criminal
matter. The problem here is that with Ebola, the consequences of making what
would often be a minor and correctable mistake are uniquely grave.

For that matter, an early Ebola diagnosis currently hinges on the patient's
self-reported travel and Ebola exposure history. These screening criteria will
_completely_ miss 2nd stage (? what's the term for this) infections when the
patient doesn't know he had been exposed to someone who'd been to West Africa,
or some place else it will hit in due course. Until the patient gets much
worse and a lot more infective, with the same grave consequences. If we get
enough primary Ebola infections in the US this appears to be certain to
happen.

When was the last time our medical system had to deal with something like
this? Pre-antibiotic, I would think. Nothing comes to mind, only partial
analogues.

I've got a pretty good layman's background in medicine from nurses and doctors
close to me when I was growing up, and serious study of biology and chemistry,
plus paying above average attention to the big events like this. I.e. I can
read the Merck Manual and other secondary and primary sources etc. without
frequent recourse to a medical dictionary. I think we have reasons to be
worried, as outlined in my postings and the obvious extrapolations.

