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EBOLA: Are We Ready?

Ebola – Are We Ready?

 

Medical Culture

Having followed this outbreak closely, on August 12, 2014 I wrote a several page letter to leadership of our hospital system in Houston. I suggested that Ebola was not someone else’s problem, far, far away. In a city where the economy is based on companies that transact a great deal of their business through traveling employees, especially to energy resource rich countries, like those in West Africa where Ebola Virus Disease (EVD) currently rages, we are only a plane flight away from the virus showing up at a regular U.S. doctor’s office, hospital Emergency Department, or urgent care center.

My concern was that medical culture is reactive, not proactive. At least that has been my experience as a practicing Infectious Diseases/Internal Medicine specialist over the 40 years of my career. Doctors are highly trained and skilled, but they are slow to take action on new or developing events. Perhaps that is because so often “new research breakthroughs” are disputed and finally discounted within the first few years that they are proclaimed. So, docs tend to hold back in their responses. And, this deliberative inertia plays out in an overall conservatism and complacency in action throughout the U.S. healthcare system. It moves slowly; note the FDA drug approval process.

However, though such a trait may be beneficial in the long run in the evolution of best medical practices, requiring due process and due diligence to achieve acceptance of innovation as evidence-based, it is a clear liability when a destabilizing crisis arrives explosively. The penetration and propagation Ebola Virus Disease over just a few months across a dense and huge population is such a crisis.

Another potentially cataclysmic aspect of this crisis would be its arrival on foreign shores, into fresh populations. Knowing this, I recommended to our hospital system a number of measures to be defined for implementation upon immediate notice, as a proper response to that first patient calling in to say they had been in West Africa within the past 3 weeks and now felt “flu-like” with fever. What should happen? What calls should be made? Where should the patient go and who would meet them upon arrival? How should they be conducted through a virtual isolation/containment operational “corridor” to protect the public and healthcare staff? How should the broader medical and non-medical community be informed and counseled? All of this must be thought out and articulated as a first-response action plan. I suggested that every hospital must be prepared, but I also suggested that every physician and his/her office support staff must be informed on how to recognize a potential incoming Ebola Virus Disease case, and must have a plan of action for triage to a proper containment facility.

 

First Missteps: The First U.S. Case

Now that an Ebola Virus Disease case has arrived in a Dallas, TX hospital, our local hospital system has notified the physicians on staff to be alert. I had forwarded to the hospital system a protocol to be passed on by email to my colleagues for use in office-based practices in order to cordon-off potential Ebola Virus Disease cases upon first notice. As far as I know, that never happened, since, being on the medical staff, I would have received the alert. This is not a criticism, rather an example of my earlier point – that our medical culture is a reactive one. I am sure hospital officials, just like government officials, want to downplay all this until they must deal with inevitable reality. I think the entire Houston physician medical community should have been schooled with an Ebola Virus Disease response primer months ago as it was clear that the epidemic was picking up momentum and sustaining, uncharacteristic of past Ebola virus outbreaks. It would not end anytime soon, and the longer it persisted, the more chance of viral mutation and of international spread. Texas, with its internationally based economy was a natural target for imported Ebola Virus Disease.

Again, by experience, I can tell you my colleagues will think Ebola Virus Disease is not their problem – not if they’re a cardiologist, urologist, general surgeon, pediatrician, or family practice doctor. They will see this as something for those Infectious Diseases (“ID”) guys to be mulling over. It would be natural for me, with daily traffic through my office of travel-related illness, often fever-associated, to have an heightened awareness and appreciation for what is at stake. But, an Ebola Virus Disease case can show up anywhere and at any time, disastrously. To be sure, the Texas Medical Association and U.S. Centers for Disease Control have posted information on the Internet. But, it will be the exception for a doctor to sit down to look over something not in the backyard of their specialty and at play in their daily work. Regardless of this, the profession as a whole has an obligation to be attentive with such an extraordinary public health risk. They are not off the hook because it is not their specialty. It’s everyone’s problem.

There are grave implications for the community and for healthcare professionals of an EV infected traveler walking around among us thinking they are sick from a random infection they do not immediately connect to a trip to Africa several weeks before because of EV’s possible 21-day incubation period.

 

The Broader U.S. Culture and Healthcare System

Some of the problems can be attributed to the medical culture I have described. The other issue at work is that Americans are increasingly ignorant of what goes on in the world, beyond their immediate world. This is especially so in a place so culturally disparate from and figuratively and literally remote the U.S. as is impoverished West Africa. I think we have all seen the embarrassing guesses by U.S. college students on questions of geography, such as locations of countries and names of capitals of countries. Let’s face it, we have a society that is much more informed on who is ahead on “Dancing with the Stars” and where Beyonce’s next stop is than on the threat of a 30-90% fatal virus that has killed more than 3,000 (and counting) in W. Africa in about 10 months (and a 12-16hr plane flight away).

Another aspect not immediately apparent to the general observer of all this is the diminished frontline expertise of our healthcare system. The medical insurance system, Medicare, and the Affordable Care Act (ObamaCare), as well as the American hospital system (combined I have termed this the “federal-corporate medical complex” elsewhere) have increasingly relaxed who is qualified to practice medicine and how patients are seen by changes in the payment for such services. More and more patients complain to me about expensive hospital Emergency Department visits where they never saw a doctor. The hospitals make more money “per unit work” and the insurers pay less per unit as it is now commonplace to have a single ER physician overseeing several “surrogates” – nurse practitioners or physician assistants. Of course, no one speaks up or risk the backlash of the hospital or ER staff leading to decreased referral business. But, routinely, as one might expect, these surrogates who are trained to practice at the most basic “cookbook” level misdiagnose or mistreat patients with unorthodox presentations or uncommon diseases. They can only “think” through a limited number of scenarios they have seen before and learned to react to by “rote”. They do not have the depth or breadth of a medical mind cultivated through years of the most grueling course complexity and load imaginable (med school) and thousands of hours and cases and dozens of years of experience. Yet, it is un-PC to even mention the dangerous disgrace that has been wrought by the payors and hospitals on the public and the medical profession (and I do use this restrictively meaning physicians). These “would-be “doctors’ professional societies reach more and more to claim traditional physician turf. The public is ok with it for their sprained ankles, bronchitis, and bladder infections. It would seem cheaper (not really). But, when something is complex, out of the ordinary, or uncommon, then the case comes to appropriate expertise, often with compounded problems and complexity that could have been avoided. What’s this got to do with the Ebola Virus Disease discussion? The Dallas case presented to the ER with fever and nausea. Nothing unusual about that. So, the triage nurse saw the patient and the patient was discharged from the ER. He did see an actual physician. But, the nurse never told the physician that the patient had offered that he had recently been in Liberia (and apparently physically handled an Ebola victim who soon after died).  That doesn’t explain why the physician didn’t ask about recent travel. It tells you the level of medicine being practiced in a hospital ER – focus is on the mundane cook-book stuff. It tells how fractured communications have become with this “team” and surrogate care model.

Next, the hospital’s chief medical officer was on TV nervously saying that critical information was never passed on to the rest of “the healthcare team”. Remember, as doctors are increasingly forced out of private practice by the payors and the hospitals who compete with them for healthcare dollars, they move into employment…. by hospitals! So, the physicians explaining the facts for the hospital are on their payroll. They will circle the wagons and defend the hospital business and “care” model. Wow! Oh, “the team” is part of the PC new healthcare paradigm where physician autonomy and authority (but not ultimate responsibility) is diluted across all the other as-valuable team members… “it takes a village.” We must bring those rich, arrogant doctors down and make them understand they are not special – surrogates with a fraction of the education and a scintilla of the difficulty of the training (or they would have gone to med school!) are capable of substituting in an emergency department. Think of it. Emergency Department! Medically urgent, unstable cases handled by substitutes – play doctors. With the presiding physician maybe looking over some of the paperwork and giving the surrogate the benefit of the doubt on their eyes, ears, minds without ever seeing the patient. Time is money and a cadre of surrogates at 1/3 the cost seeing 5 times as many patients for only one supervising physician’s salary and benefits – great math if you’re a hospital administrator. Even if a physician actually saw this case, the ER model currently working in most large urban hospitals is a potential comedy of errors waiting to be a tragedy.

So, a guy shows up from Liberia where a deadly disease rages. But, to catch on to the significance of that you need to be watching medical bulletins, alerts and/or literature. You must be interested in high-level, complex, uncommon medical issues – not just in how to suture a deep flesh wound, treat an ordinary bladder infection, or evaluate a routine flu case. And because we’ve gone to the surrogate oversight model, the physician is somewhat disengaged on many cases and all “the providers” (hate that payor term, designed to obscure who is a doctor and who is not) are required to access information on a patient from the mandated hospital-based computer system (EHR, or electronic health record – another idea of payors and hospitals for their business models) or to enter it there. All the medical staff are staring more at computer screens than actually discussing the issues of a case or seeing the patients, so we have many ways to foul-up patient encounters by fragmented service and miscommunication. Apparently, the ER physician on this case never saw the intake nurse’s notes recording what the patient offered up – that he had recently been in Liberia. How could he? It resided in the nurses part of the EHR, not easily in front of the busy ER doc. The physician termed him a viral illness and supposedly gave an antibiotic prescription (which makes no sense, since antibiotics don’t work on viruses… one more embarrassment). So, the patient is discharged, to show up two days later with advanced Ebola Virus Disease and who knows how many unsuspecting citizens exposed to a 60% mortality virus (so far, this epidemic) – 6 out of 10 chances you die. And staff in the ER were exposed. And the hospital lab. And who knows what other hospital staff and patients in the waiting room? How about exposure of the general public away from the hospital? Yes, this all happens when you have non-experts handle atypical, critical work that requires expertise.

Yeah, welcome to your new (and getting worse by the day) healthcare system voted on by the American public in the last election. Ebola Virus Disease is only one of many future iterations of the coming narrative of mindless incompetency, feckless performance, and embarrassing unprofessionalism, as well as operational breakdowns which we will all experience as victims. This is the face of depersonalized medicine (ultimately socialized medicine) confronted with serious, high-risk medical illness rather than “wellness”. It fails. Keep these ideas close as you listen to the weak-kneed explanations of the failures and results of the Dallas Ebola Virus Disease. This story is far from over. We’ll see more of this around the country.

 

The Fall-Out

Beyond the pathetic “first-response” model of surrogates who are trained to handle minor, noncomplex problems, consider that most hospitals do not have a clearly defined, scientifically sound operational scheme to identify an Ebola Virus Disease case at-a-distance and then to contain it. They have neither the vision nor the expertise to appreciate the problem of an Ebola Virus Disease case walking through the door, nor the downstream effects on the psyche of staff, patients, and community. A hospital with Ebola Virus Disease cases will likely go into lockdown or at least be shunned by ambulances and the public (a virtual “leper colony”). Who will want to go there when ill, knowing they must count on U.S.  healthcare workers who are unfamiliar with the criticality of fastidious, highest level containment procedures for a likely fatal viral infection? Will a careless hospital worker bring their Ebola Virus contaminated skin into your room as they arrive to draw blood or change a wound dressing? This is what will go through patients’ and their families’ minds. What if there are a number of cases in the community shuttering several hospitals? How will that affect bed availability (and ICU rooms) for other critically ill patients? The collateral damage of Ebola Virus Disease will be non-Ebola Virus Disease patients dying from more usual acute medical problems (strokes, heart attacks, sepsis) because of delayed access to care from blacklisted hospitals.

There are limitations on trained medical staff, equipment, and supplies which have never been tested, in modern times, by a natural public health phenomenon of this type. It would not take a massive outbreak to quickly cause a chain reaction of resource implementation. No one is implying that we are not better prepared to contain an outbreak so that it never reaches the level occurring in West Africa. But, that epidemic has demolished the social, economic, and medical systems of those countries. Short of that, a significant number of Ebola Virus Disease cases would severely stress our medical capabilities, and the adverse community reaction would be overwhelming on every level. We just don’t believe large-scale threats to our secure and privileged lives are part of the American experience ,“911” not withstanding. That was an anomaly. We think (or like to think) we are prepared. I doubt it, even with a modest multi-case outbreak. The CDC says otherwise. I would hope they’re right, but would prepare and watch for the worst.

Now the news media is working the Dallas story, and that will die off quickly in a few days when the news cycle focuses on the next hot story. Based on experience, I would not bet that most physicians will take personal action to configure a plan for them and their staff. Most hospital administrations may possibly discuss the issue in a meeting or two, but they will not see it as their problem, until it shows up at their front door. Too late! Then it will be “crisis management” and “information control”.

 

What About Ebola Virus Mutation?

This complacency will likely result in true public health emergencies as cases do finally land on our soil and as some of us are exposed to the virus. I do believe that we are far better prepared at the federal level (CDC) to understand what needs to be done on first notice of a case. But, by the time CDC is brought in, likely the horse will be out of the barn, at least for a number of unfortunate, exposed U.S. citizens. Hopefully (I hate to say this), the officials reaffirming that Ebola Virus does not spread casually (airborne) are right…. hopefully. Nevertheless, when asked if he could assure the American public that the current EV has not and will not develop the ability to be more easily transmitted, Anthony Fauci, MD, National Institutes of Health Chief (government employee), stated he was not at liberty to comment on that. Reassured?

I am still concerned that Ebola Virus could mutate (if it has not already) to a more transmissible form. Though the CDC maintains Ebola Virus only spreads through body-fluid contact, it did issue a warning (late August) to commercial airlines crews to put a respiratory face mask on any individual traveling from W. Africa who became ill en route. That instruction allowed for the worst (if not proven or yet observed) possibility. With such an ominous disease agent, why wouldn’t you caution about the worst, while still asserting what had been proven? It certainly makes you wonder about censoring information, which has been the case in prior public health crises (see my “Ebola Overview” elsewhere). It also compels the question on why, given the unique nature of the current Ebola Virus Disease disaster, which has been officially deemed an international emergency by the World Health Organization, any country would rationally bring an Ebola Virus Disease infected individual within its borders? Can we be so confident in our knowledge of the biological nature of the current Ebola virus (which has mutated numerous time during this 11-month outbreak) as to bring it to our homeland? As the outbreak broadens and intensifies, some of these incongruities of perception and reality and action/inaction may magnify the jeopardy and may amplify the collateral damage.

 

What Should We Do?

A deadly virus, unfamiliar to our medical culture, with a long incubation period (from acquisition), and a dumbed-down medical care system staffed with non-physician substitutes or physicians who are working in a disjointed, obligate work process which fragments and compartmentalizes (electronic health record in computers) labs and other patient information between all levels of care providers in the assembly line – is it too much to call this a perfect storm?

What should we do to minimize Ebola Virus Disease risk to the U.S.?

  1. No immigration or travelers from the affected countries to the U.S. (or anyone from anywhere who has been in close contact with anyone in those countries in the prior 3 weeks)
  2. No importation of any Ebola Virus Disease patients
  3. Anyone who arrives in U.S. in violation of #1 must be evaluated by an Infectious Diseases specialist, including blood tests, immediately, at day 7, day 14, and day 21 post-arrival
    • Such individuals to be quarantined x21 days
    • Mandatory immediate education on Ebola Virus Disease first-response procedures of all hospital emergency department and urgent care center staff (certification required to continue practice in those areas)
    • Hotline to CDC and local health departments for whistle-blowing reports by the general public on individuals who fall under #3 and who are suspected of not having had medical evaluation

These may seem fairly extreme measures, but if this virus has or will become more easily transmissible we will see more and more cases outside of West Africa, and secondary cases soon after in the new locations. No matter what people want to hear and hope is true, with such a deadly virus, what is to be lost in assuming the worst until we have lock-solid information on why the African outbreak is so different from prior ones and until we have conclusive information on the nature of the current virus version? That should be the operative position until the current epidemic is clearly turning the corner with the rate of new cases declining. Remember, it appears that the Ebola Virus Disease man in Dallas may have lied on the medical section of his immigration forms he filled out to return to the U.S. Liberia may prosecute him if he survives. The point? You cannot trust people to tell the truth when they may be quarantined (tying up their lives), feel stigmatized, feel their lives are at risk, or just want such medical information private. They will also do anything they must to get to the U.S. if they are or may become ill. Anyone would do this. People have repeatedly lied to me about sexual behavior, alcohol/drug use, and other sensitive aspects of their medical histories. Would you bet your or your loved one’s life on someone exposed to Ebola virus telling the truth? That’s what we do when we give “honor-system” questionnaires to those seeking to cross our borders. It is medically insane, but politically correct. We don’t want to offend people or restrict their “rights” unduly. Well, with rights come responsibilities. And, the Dallas Ebola virus disease man, if he lied, was criminally irresponsible.

Be clear. I am not into panic. I am no chicken-little running to and fro. Life is full of risks as soon as you go vertical. I do not dread Ebola Virus Disease, yet. I am an observer and collector of information, so I can decide (without being told) what to think and how to respond. As I saw this outbreak continue and accelerate, I spelled out a protocol to protect me, my staff, and my patients (and the broader medical community) from inadvertent Ebola Virus Disease exposure. I learned this in the 1980’s. My private practice career started 6 months before the first AIDS cases showed up in San Francisco and New York City. For awhile, we didn’t know what caused it. There was no known “HIV”, yet. As a few years passed, the developing literature and clinical experience with such patients, refracted through my training in science and biology, allowed me to speculate on causes for various HIV-associated problems and to treat them. It allowed me, through knowledge and hypothetical biological musing, to interact safely and comfortably with HIV patients, and to extend their lives and to mitigate their suffering through speculative clinical practices. It was all I and they had. There was no clear standard of care for treating the yet unknown, but we worked through it with the best results in a terrible situation. A number of times colleagues refused to consult on these cases for me, fearful of the risk to themselves. But, I learned that FDR’s aphorism, “we have nothing to fear but fear itself” is bedrock in such circumstances. Ignorance is the foundation of fear. Knowledge is the antidote. It opens the possibility of a solution. At least that’s how we optimists think – the ability to make the best possible outcome of any situation. I feel this way about Ebola Virus Disease. Panic and fear are not options. In fact, I am more worried about official misinformation (keeping me ignorant and unable to act judiciously) than about Ebola virus. This is not the message of a panic-monger. Panic is a sign of weakness and the province of victims. And, with problems as serious as this Ebola virus outbreak, there is no room for infirmity. My message is, get informed and constantly re-test that information for validity.

We are not ready.

 

Edward R. Rensimer, MD

Director, International Medicine Center