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EBOLA: Are We Ready, (Part II)?: Clearly Not

U.S. Healthcare System Crisis Readiness

In my earlier pieces, I speculated on the complexity of a lethal, communicable disease entering a U.S. healthcare system that likes to promote itself as excellent, and so fire-walled against any real danger of Ebola Virus (EV) spreading out into our communities should a case arrive on our shores. However, that excellence is only in comparison to much of the non-developed world medical systems and in reality probably only exists with uniformity in the best urban, academic medical centers. Anyone who has practiced at a subspecialty level on medically critical cases in the broader healthcare system where most of us end up when we’re in need knows that the intellectual and operational processing of a difficult, complex case is often mediocre or unacceptable at many levels – lab, nursing, and, yes, physician expertise and capability. Anyone who has been a patient or had a loved one with a problem outside the norm has seen this. It is a complex question why this is so, given what is charged for the service. But, our payor system obstructs, harasses, and pressures under-utilization of testing (which is sometimes a product of efficiency, but more often the result of shallow thinking, lack of professional focus, intellectual apathy, and/or poor training). Add in dispirited performance from increasingly employed and controlled healthcare workers in a system that rewards “team players”, deliberately undermining individualists and non-conformists, and you get a broken mediocracy, most evident when the stakes are highest. This is the corporatized medicine model (as hospitals unite into “systems” of care). I am tempted to say, “you get what you pay for.” But, you don’t. You pay a lot for uninspired, worrisome performance. Hold onto all this and we’ll come back to it as the context which surrounds the Ebola virus disease (EVD) cases that are now headline news. I want to now fill in that picture.

 

The Emory University Ebola #1 Case Experience

This past week I attended the Infectious Diseases Society of America (IDSA) annual “IDWeek” in Philadelphia, PA. One of the presentations was by Dr. Bruce Ribner, the team leader at Emory University on the first U.S. Ebola virus disease case that our government imprudently brought to our homeland from West Africa. His observations are shocking if you take them as a whole and consider the implications, in contrast to statements U.S. government officials have been floating to the American people on Ebola virus. By the way, virtually everything I recommended in my warning letter regarding Ebola virus disease preparedness to our local hospital system in Houston in August turned out to be so by Emory’s experience with an actual case. Realizing that Emory is the hospital in Atlanta intimately tied to the Centers for Disease Control (CDC), also in Atlanta, and among perhaps 4 U.S. hospitals capable of highest level infectious agent containment, let’s look at their experience with their Ebola virus disease case,

  1. Dr. Ribner stated that in Africa clinical evaluations of patients (meaning by those educationally and intellectually capable to do so for Ebola virus disease) were limited and there was virtually no lab-support (testing). The take home? We have no real idea how bad the Ebola virus outbreak is in scope or rate of growth. We know it is unprecedented. We know it is a tsunami compared to the beach wave prior Ebola virus outbreaks. We know it is continuing to build and will go on for months. Cases will be showing up across the world unless we strictly quarantine those countries.
  2. Clinical Care: The patient required around-the-clock nursing attention at the bedside. There were huge physiological problems with massive bodily fluid losses and shifts between tissue compartments, resulting in rapidly dangerous electrolyte disturbances, heart arrhythmias, and circulatory malfunction. The clinical staff had to be nimble, entirely attentive, and expert to deal with these fast-breaking problems. The Ebola virus caused the circulatory tree to be a hole-ridden, leaky sieve. Without the highest level ICU care, survival would be highly unlikely.
  3. Lab: If just one specimen from an Ebola virus disease case spilled in the lab (not unusual), the entire lab would be closed down for hours until the environment could be certified as clean. What about all the other hospital patients’ labs? They would not be done. Their care would be compromised. The possibility of collateral damage or secondary deaths of other patients was virtually certain.

Furthermore, the Emory team dealt with the real concern that on-site lab technicians, at the premier hospital for communicable disease cases, would refuse to run tests on Ebola virus disease patients (not wanting to handle their specimens).

The team’s answer? They set-up lab testing at the point-of-care (adjoining the patient’s room), away from the hospital lab.  Think about this. One of the hospitals in the country designated for such care and you have support staff refusing to do their jobs on an Ebola virus disease case that requires almost continuous lab samples. Because of this, the team kept lab testing to a minimum, per Dr. Ribner. Did this compromise care? Maybe.

  1. Specimen Handling: Ebola virus is a Category A infectious agent – the highest CDC level precautions in handling and isolation. Category A’s require special packaging and shipping for clinical specimens. Despite such packaging, commercial carriers refused to accept Emory’s Ebola virus disease specimens for shipping.
  2. Regulatory Expertise: The hospital safety officer needed to navigate numerous federal, state, and local regulatory requirements. Expertise was needed to not break laws and to protect public safety. Do you think this would be possible at your local community hospital? Or even at your local academic hospital not accustomed to Category A agents?
  3. Waste Management: CDC guidelines say that sanitary sewers are acceptable for patient waste, but Atlanta’s local water authority disagreed. It did not trust the CDC or Emory U (they’re not alone).

Emory had to disinfect all patient liquid waste with bleach or quaternary detergents for
5 minutes before flushing into the general water waste system.

Furthermore, the hospital waste disposal contractor would only pick up materials certified as EV-free. So, the hospital had to dedicate an autoclave sterilizing unit (and physically move it) to process everything used in the Ebola virus disease case in order for its acceptance as regulated, safe medical waste. By the end of the Ebola virus disease case’s hospital stay the autoclaved and boxed materials “filled several trailers”.

 

DISCUSSION

The Unexpected and Our Medical System

So, a highest-level U.S. expert hospital with all academic staff virtually joined at the shoulder to our federal center for infectious diseases capabilities had these problems. Do you recall Thomas Frieden, MD, head of CDC and Anthony Fauci, MD, National Institutes of Health (NIH) Chief, assuring us that we have Ebola virus disease covered in the U.S.? Do you think so when you hear of the operational breakdowns at the starship hospital? Support services were running for the hills. How would that translate in the type hospitals accessible to most of our citizens?

Well, we have a healthcare worker Ebola virus disease case who “violated” isolation protocol… they think. But, do they know? No one has said what that break was. Otherwise, is it still possible, as I have discussed before, that the Ebola virus is more easily transmissible than they have been letting on? Of course, these government- paid officials are still digging in on their premises. However, Dr. Ribner even detailed how crude is the information on the African outbreak – all we know is that at least 4,000 have died (possibly many more), and counting.

And at this IDSA meeting a CDC epidemiologist even admitted that the premise that Ebola virus is only transmissible after the patient develops symptoms is based on “observational” epidemiological data. In other words, experience in prior epidemics shows that people who get Ebola virus disease had been around symptomatic (sick) Ebola virus disease people. And people who were in contact Ebola virus disease patients only prior to onset of illness did not tend to become ill. But, it is not a solid, scientifically proven fact that Ebola virus disease cases might not be shedding virus hours or a few days before they have symptoms. Remember, we are talking about a fact-basis for these Ebola virus disease premises developed in Third World countries with only relatively limited, short outbreaks before. Yet, the “21-day incubation period” and “no-risk prior to illness onset” are being proclaimed bedrock fact as though from biblical tracts.

 

Ebola And The New U.S. Healthcare System

Now that we have our own, homegrown Ebola virus disease case contracted here, the reassurances about our healthcare system’s tacit superiority are a bit hollow. I think this will only get worse. Go back to my opening paragraphs about the actual day-to-day performance of the healthcare system at the community level and you know we will have more such cases, and the breakdowns and accidents are inevitable. When I penned my letter to our Houston-based hospital system leadership in August, 2014 warning then of all that has since happened and the need for a tight operational plan, the leadership had not even thought about all this. Ebola virus disease was somewhere across the globe and irrelevant. I do credit them with taking action immediately. But, do you think this is so in most communities?

 

ObamaCare and Ebola

Think about all the problems at Emory, and then multiply them exponentially when you realize that hospitals are more focused on their business model than anything else. You can see it in everything they do. If Medicare told them to paint themselves red and to blow out all the windows, they would do it. That’s why they’ve all gone over to electronic health records (EHRs), one of the problems (aside from mindless nursing and poor physician performance) that sent the first Dallas Ebola virus disease case back to his apartment complex where he could expose many people, including the ambulance crew and other professionals. EHRs have been required by payors so they can tabulate data and control the profession. They are an immature technology tool, not ready for prime-time. They have fragmented communications between doctors and nurses and have created a cumbersome, error-prone interface with the hospital support services (lab, pharmacy, etc.). Yet, hospital physician staff and nurses are mandated to use the EHR by the hospital, no matter the time-waste, interface generated mistakes, and adverse work cultural changes imposed by machines that distance physicians and nurses from the bedside. Been to a hospital lately? See how many of the nurses are staring at video screens instead of answering patient calls or talking with them or their families. I don’t want this to sound like a rant (probably failed already), but when you try to understand the missteps in that first Dallas Ebola virus disease case, you can see what changes in healthcare culture imposed by the Affordable Care Act as well as by the corporate-federal medical complex have brought about.

You can appreciate the tenuousness of the local healthcare system in dealing with life-critical problems like Ebola virus disease that require oversight by proactive (not reactive) medical experts and individualists who are not controlled by corporate bosses, other employers, and payors who have steadily eroded the medical profession and are increasingly controlling it. The public interest needs financially and professionally autonomous physicians – unencumbered by ties to the hospital business, payors, or other third parties whose interests often are truly at odds with those of patients and the profession. You must conclude we are headed for trouble, with all due respect to Drs’ Fauci and Frieden.

 

Inescapable Conclusions

With the comments about Emory’s experience, could a local hospital handle three Ebola virus disease cases? Two? One? What ambulance crew would want to go there with someone evolving a stroke or heart attack? What patient there would want their blood drawn knowing the technician may have been near an Ebola virus patient? Who would want elective surgery there? Once there is a reasonable doubt that risk of acquiring a lethal pathogen cannot be assured, the entire care model breaks down and the hospital is a modern leper colony. And yet, hospitals are a vital community institution whose accessibility to handle your acute medical problem is a personal and public interest necessity.

When you take all this in you must conclude that countries with endemic Ebola virus activity must be completely quarantined until this outbreak is over. Not controlled.

By the way, to end with irony, apparently the healthcare workers in some of the West African Ebola virus countries are demanding “risk” pay, or they may walk. These are countries with terrible economies on their best days, abject poverty, social disorder, and healthcare systems that are pathetic. Who do you think they are looking to for bonus pay for their own, homegrown epidemic? I think we all know that answer. Be clear. They are not satisfied with just help. They want a personal bonus to take care of their own, while we send our own in harm’s way to help them. The world has gone insane.

Everything written in these articles are my personal opinions based on available information, training, and experience.

 

Edward R. Rensimer, MD

Director, International Medicine Center