On the matter of Duncan’s temperature on his initial ER visit
It was reported by the Dallas hospital that treated Thomas Eric Duncan that his temperature was only 100.1 degrees on his first visit to the ER, and this was part of the reason they didn’t red-flag him at that point. It was also reported that the nurse’s assistant in Spain called medical authorities for the first time at a point when her temperature was in that same range, and they dismissed her. For those reasons it seemed to me that the ebola protocols saying a temperature had to be 101.5 and above were incorrect and should be lowered when a patient had been exposed to the virus (as was the Spanish nurse) or was an arrival from an ebola country (as was Duncan).
I still think so, based on the evidence about the nurse.
But as far as Duncan goes—well, the hospital seems to have misinformed us again, if this report turns out to be correct:
Thomas Eric Duncan’s temperature spiked to 103 degrees during the hours of his initial visit to an emergency room – a fever that was flagged with an exclamation point in the hospital’s record-keeping system, his medical records show.
Despite telling a nurse that he had recently been in Africa and displaying other symptoms that could indicate Ebola, the man who would become the only person to die from the disease in the U.S. underwent a battery of tests and was eventually sent home.
Duncan’s family provided his medical records to The Associated Press – more than 1,400 pages in all. They encompass his time in the ER, his urgent return to the hospital two days later and his steep decline as his organs began to fail.
In a statement issued Friday, Texas Health Presbyterian Hospital said it had made procedural changes and continues to “review and evaluate” the decisions surrounding Duncan’s care.
It goes without saying that, if true, this would constitute a very good argument for negligence on the part of the hospital. Something—many things—seem to have gone extraordinarily wrong here.
No wonder the hospital is reviewing and evaluating.
Josephus Weeks, Duncan’s nephew, said the care his uncle received was “either incompetence or negligence.”
If the report is correct, I don’t see how anyone can argue with Josephus Weeks on that score. This is a much bigger error than any that have been alleged before on the part of the hospital in this case, particularly if the fever was flagged with that exclamation point. And (again with the caveat “if this is correct”), why did Dallas Presbyterian previously tell us Duncan’s temperature on that first visit was 100.1, if it was easily demonstrable that it was untrue? Did they expect to get away with that, or did they not even know how to access their own records?
This is truly awful.
Had not seen that report. There is one question as to this that I have. 103F is considered dangerous in adults, no matter the cause. I doubt that the hospital would release Duncan if that was his temperature when released.
It seems we are missing some of the information, and my guess is that while his temperature might have spiked to 103F at one point it stabilized at much lower temperature at the time of his release.
Regardless, it demonstrate why lack of preparedness and the endless attempts to downplay the virus is dangerous. Hopefully, now people are paying attention and any further accidents can be avoided.
Bori:
I’m not a doctor, but I don’t think if his temp had stabilized later it would have mattered. The 103 temp is used as a diagnostic tool. If he had a 103 temp when he came in, he met the criterion, and more, even it later lowered somewhat.
103 is a serious fever, so I will be interested to hear more about this. However, what do you do for a serious fever? Give Tylenol, basically. Which they did.
It also sounds like they made a serious effort to help him, if they did a CT scan. They didn’t just send him home and hope for the best. They just made a mistake. A very serious one, obviously and I am sure they are doing an internal review, but I for one am not the least bit surprised it was misdiagnosed, particularly if Mr. Duncan told the nurse and not the doctor that he was in Liberia (or possibly just Africa, since that’s what the chart said) and nothing about having been exposed to a woman who died of Ebola. I know Neo thinks he didn’t know or suspect, but there is no way for the doctor to have known either. This is the first instance of the disease statewide ever. I think people do not fully comprehend how much the whole ‘look for horses, not zebras’ thing is embedded in our system. Malaria or the flu or something was much more likely. It was just wrong.
But this:
adding that it was “conspicuous” that all the white Ebola patients in the U.S. survived “and the one black man died.”
So irritating. All the other patients were brought into the hospital under strict precautions with the knowledge from day 1 that they had ebola. This was our first case in the wild, so to speak.
I
If he had a 103 temp when he came in, he met the criterion, and more, even it later lowered somewhat.
Yes, I agree, but the problem is more that they were not looking for Ebola.
I will be very interested to see the final rundown of all that happened, if it ever comes out, but I think this was just a terribly unfortunate case of nobody putting the pieces together until it was too late.
Lea:
Of course they weren’t looking for ebola. But they should have been aware that in a person recently come from Liberia, they should have been considering it.
What else was the Africa/Liberia question there for? It is there to alert them to the need to consider infectious diseases from that part of the world. By the time Duncan got to that ER, ebola in Liberia was not exactly a hidden problem or obscure. It was well known.
From Liberia recently.
Fever of 103.
Dehydration.
“Sharp” headache.
Abdominal pain.
All symptoms of or indicators for ebola. And that’s the way Duncan presented.
IMHO, Duncan absorbs all risk by withholding critical information about his exposure to Ebola. He denied his exposure in order to travel freely. His family denys any knowledge of his exposure up to the time of his hospitalization, and then his relative denies published reports suggested Duncan was aware of his potential contamination with Ebola.
Regardless…
Insufficient “Consent” was also a component according to insider details provided at this link:
KeraNews: Friend Speaks Out On Behalf Of Ebola Patient’s Family
Troh did not think Texas Health Presbyterian Hospital should have released Thomas Duncan from the emergency room on Sept. 26.
According to Lloyd, hospital staff told the family that they did not have the consent to treat Duncan for his initial fever.
“The family members were right there — how could you not have consent to treat him?” [Saymendy Lloyd, a friend of Louise] Troh asked.
She also said the staff made the decision to put Duncan on dialysis without the family’s consent, but delayed in giving him the experimental drug Brincidofivir because of lack of consent.
In a statement on Thursday, Texas Health Presbyterian officials said that doctors treated Duncan with Brincidofovir after consulting with experts, as well as the Centers for Disease Control and the Food and Drug Administration
With further implementation of Obama care get ready for ineptitude to rule the day at hospitals nationwide.
Serious medical mistakes are in our future & just like the IRS, Fast & Furious & Benghazi & 9/11 nobody will be held accountable, nobody will lose a job the most likely reprimand will be forced retirement with a fat pension. Stay Healthy people !
wtd:
I’ve already written at great length about the fact that the evidence is that Duncan did not withhold information about his ebola exposure; he was not yet aware of his ebola exposure.
Too long to go into now, but do a search on the blog, or look in recent posts. There’s plenty of info here about it.
But even if you don’t accept that argument, the way Duncan presented (described in my comment above) should have alerted the hospital to the possibility of ebola for him. They had more than enough information.
Aside from the specific issue involving Duncan, can you not imagine a person being exposed to an ebola patient and not knowing it? Answering “no” on a questionnaire when the answer actually should have been “yes”? If that person exhibits a series of symptoms that point to ebola, and had been to a country with an ebola epidemic, do you really think medical people who see that patient have no responsibility to even think of ebola as a possible diagnosis? If so, that’s a very odd idea about the duties of medical people who see patients. Patients do not always give all the correct information, or even have all the correct information. But despite that, if the general picture points to a certain disease, or a strong possibility of that disease, medical people should be considering it. They don’t need pateints to dot every i and cross every t for them before they are willing to consider it.
What else was the Africa/Liberia question there for?
Generic travel history. but you don’t look for the weird stuff first, generally.
Look, I have been following this story for months and probably would have jumped on it, but it is very easy to say this sort of stuff in hindsight. A fever could have been all sorts of things, even coming from Africa, without the crucial information that he was exposed to Ebola. The hospital quite obviously made a mistake. I completely agree. I just see how easily it could happen with a disease that the majority of doctors have quite literally never seen before. If you aren’t spending a lot of your time reading about current events or emerging diseases, you probably weren’t thinking about this one.
As far as assigning all risk to Duncan, in a lawsuit they could easily claim *diminished capacity* people with fevers of 103, are not thinking clearly & can even suffer hallucinations at a temp that high.
Professionals dropped the ball here big time.
Answering “no” on a questionnaire when the answer actually should have been “yes”?
What does that questionaire actually say?
Lea:
There’s a VERY lengthy discussion of the questionnaire in my several comments to “DNW” in this previous thread.
However, it’s the questionnaire he was given in Liberia before flying. I’ve never seen the questionnaire he was given in the hospital (or at least I don’t recall, and don’t have time to look for it now). Don’t know whether it was the same. I think the hospital one focused mostly on travel in Africa, and he answered “yes” that he’d just come from Liberia (or some reports say “Africa”).
I just see how easily it could happen with a disease that the majority of doctors have quite literally never seen before. If you aren’t spending a lot of your time reading about current events or emerging diseases, you probably weren’t thinking about this one.
Except this is a hospital in an area with a Liberian population of about 10,000. I would think they’d have been especially tuned into the possibility of Ebola showing up there.
I can see how starting dialysis may not require additional consent since it is standard therapy and may have been in the original consent as part of admission. Also he may have been able to legally consent at that point. An unapproved drug would require a separate consent. If he was deemed unable to provide it, then a person who had authority would have to sign, not just any family member.
The legal requirements do delay medical treatment.
It is obvious he should have been admitted simply for public safety. It is not known if the outcome for him would have been different.
What would they have done differently if they had suspected Ebola 2 days earlier besides admit him and stay him in fluids? I don’t know the answer. Just asking
But part of me is wondering if the implication here is we can cure it if we just know what they have.
My understanding is it’s incurable and you have a good chance of dying from it; it could be the last 2 people were lucky. The American doctor and nurse had the disease diagnosed and we’re in serious condition a lot longer than Mr Duncan, didn’t get adequate care until they arrived here. Whatever adequate means.
It seems we are all accepting this would have had a different outcome if he was admitted 2 days sooner. In my opinion, from what little I know, that’s not a valid assumption but this line of reasoning is now a foregone conclusion in everyone’s mind. Are we contending this disease is no match for proper hospital care, and if so, isn’t that the same story the CD has being touting as if it’s a proven fact?
Is it not as likely or more likely he would have died anyway? Or is this just a bad flu like it’s now being made to sound by proponents of better hospital care?
Why we’re all the hospital records released?
To set up a lawsuit against the hospital (nurse), ER doc and Epic Software.
But know that this TX. Med mal caps.
And, most important, Ebola is a new and dangerous disease and even if he was admitted when he first presented there is no guaranty of a cure. It is not like US docs have a whole lot of experienced treating Ebola and the sure thing drug are right on the shelp.
Lawsuit lottery!
southpaw,
So far in this outbreak, Ebola has killed 4,033 people out of 8,399 cases over seven months in seven countries. That would be a 50% mortality rate. In other outbreaks, it’s been as high as 90%.
A doctor in Guinea says that good care of Ebola patients improves the odds of survival.
What T.E.D.’s suffering has demonstrated is that America is WIDE OPEN to ebola.
We’re just as vulnerable as any African nation.
Even the insane idea of shunting ebola candidates through regular hospital admissions is still de jure.
ALL of our protocols have to be changed.
EMTs — specialists only — not run of the mill EMTs — have to GO TO THE CANDIDATE.
Candidates must not move to the hospital. It can’t do anything special for them — truly nothing.
While messing around with dialysis is high tech, it doesn’t work. It hasn’t got a hope in Hell of getting the exponential explosion of ebola under control.
Palliative care is all that anyone has on offer. Period.
So the LAST thing anyone should do is to drag candidates through cities and structures.
Ebola does not move so fast that candidates need the speed of lightning as if responding to a heart attack or a vehicle accident.
So, if it takes an extra hour to bring in specialist EMTs with all of their ‘kit’ it won’t affect the outcome.
EMTs responding to ebola candidates need to be specifically trained — and removed from the general pool of EMTs. They also need to have dedicated vehicles and dedicated aides.
No-one with direct medical contact with candidates is to remove their haz-mat gear. They are to be de-tox’d by their aides — in an appropriate manner — right on the spot. (Probably with conventional cleaners — as it appears that ebola can’t tolerate most surfactants/ detergents.)
This process should be under black light/ UV emission.
(Belt AND suspenders)
A secondary crew (LEOs) needs to quarantine candidates — actively. Food and necessities have to be brought to candidates.
All of these elaborate procedures need only last three weeks… or until the CDC comes up with ebola testing that can ‘clear’ a candidate.
Such containment is beyond the budget of any local authority/ citizen/ institution. Congress is going to have to stump up the monies.
All of this travail will only stop when (west) Africa is quarantined. On present trends, we should expect this tragedy to explode across North America.
Soon, there will be absolutely no co-relation with travel to Africa. Ebola will just start popping up out of the blue.
Thanks, Barry Soetoro; special notice for Harris.(CDC)
Africa is STILL doubling away its ebola victims count — which is obviously grossly low. Like Hawaii in the 19th Century, no-one dares venture out to pull honest statistics. Reality would put your hair on fire.
DC is still in official denial… BIG TIME.
Nix Harris ==> Tom Frieden, instead.
(CNSNews.com) – Speaking in a video message to residents of West African countries currently experiencing outbreaks of Ebola, President Barack Obama dispensed advice on how residents can avoid the disease, including:”You cannot get it through casual contact like sitting next to someone on a bus.”
At the same time, the Centers for Disease Control and Prevention (CDC) is advising Americans who travel to the Ebola-stricken nations to “avoid public transportation.”
“First, Ebola is not spread through the air like the flu,” Obama said in the video released by the White House Thursday. “You cannot get it through casual contact like sitting next to someone one a bus. You cannot get it from another person until they start showing symptoms of the disease, like fever.”
Obama also said that “the most common way you can get Ebola is by touching the body fluids of someone who is sick or has died from it, like their sweat, saliva or blood, or through a contaminated item like a needle.”
&&&
Plainly Barry Soetoro has conflated ebola with HIV.
It’s THAT simple.
&&&
Such “advice” is lethal.
Experts are relating that ebola can pass by way of SWEAT or — apparently — heavy breathing.
If a fellow’s temperature is spiking — does he not sweat?
And in Africa, isn’t just about everyone sweating — most of the day?
The only limit to ebola transmission appears to be that it doesn’t travel well outside the body. Once inside, wham!
Travelling from human to human is (by the record) no trouble at all.
Happy talk at this time is the worst possible thing to do.
So, Barry is ALL happy talk.
The key reason Spanish flu went through humanity like wildfire was because the authorities — every combatant nation — refused to pass on their knowledge — even to the medical community.
Lying to the medical community has to be at least as damaging.
Lea gets it.
Neo says: Fever, abd pain, ‘sharp’ headache, dehydration, “All symptoms of or indicators for ebola. And that’s the way Duncan presented.”
Does any one (other than Lea) know what Differential Diagnosis means? If so, start your list, stop when you reach 50, and post it.
All this chatter reminds me of a medical school joke: after the presentation of a very difficult and complex case to a bunch of medical students, interns and residents, each was asked for his/her favored diagnosis. No one made the right diagnosis until the last, a 3rd yr student said “Carcinoma of the tail of the pancreas.” Correct said the Prof, ” That’s a rare cancer. How’d you figure that out?” Easy, said the student; cancer of the head of the pancreas causes jaundice, and of the body, causes pain. She didn’t have either, so it was obvious.
Somewhere north of 250,000 people a year die in the U.S. because of mistakes made by doctors / hospitals. I had a brain tumor removed, and got the hell out of there 31 hours later. My cancerous right lung was removed, and I got the hell out 4 days later. I was given two years to live. That was ten years ago. I am lucky, surely. But i am also supposed to be getting chest x-rays every six months. I don’t get them at all. Too many x-rays can’t be good for you either. The last place I want to be in, is a hospital.
1400 pages? Incompetence or negligence, or not, their priority is documentation/CYA, not medicine.
Don Carlos:
I am well aware of differential diagnoses. Please read what I’m actually saying—nowhere have I said “they should have immediately known it was ebola!” And certainly not just from the symptoms—they could be symptoms of probably hundreds of diseases.
My point is that with those symptoms, and his declared recent travel history (which was on my list and a very important part of it, but which you left out when you quoted my list), ebola should most definitely have been on the list of possible diagnoses. It should not have failed to enter their minds as a possibility. It appears it never entered their minds, however. Or, if it did, they certainly haven’t explained why they didn’t follow up to see if ebola was the answer.
And of course—always with the caveat of “if this new information about his having had a 103 fever on that first visit is true—why did the official hospital spokespeople keep saying his fever was a much milder 100.1? Was is that he had many different temperature readings on his visit, and they chose to announce the one that made them look the best? Was it because they lied about 100.1? Or was it because they were mistaken and read their notes wrong? I’m actually quite curious about this.
Your patronizing condescension on this is quite unwarranted.
For good or ill, ER nursing is a cookie-cutter, by-the-numbers affair. You take two temperatures while the patient is there, and look for a trend. It’s stupidly simple. This may not have been an avoidable death, but the errors were right there, simple things that were not done. I’d lose my license if I pulled krep like that.
Cornhead:
This issue is not a cure. I think it would be tough to prove that earlier hospitalization/treatment might have helped Duncan himself.
The issue is contagion. If what we know about ebola is true, one thing we do know is that as time goes on, the patient becomes exponentially more contagious. If no one caught it from him, a huge bullet (a cannonball) was dodged, fortunately. But if anyone gets it, the delay in either hospitalizing him or quarantining him could indeed be grounds for a lawsuit, and understandably so.
I’m not at all sure the plaintiffs would win, of course. But I can see how they would have a cause of action that could win.
neo-neocon:
I re-read the story, it does not say that Duncan came in with a 103 fever but that it had spiked during the time he was there.
It seems obvious that he was there for a long time as there were several diagnostic tests that were done on him. I really doubt that the hospital sent him with home still exhibiting a high fever.
I know that he mentioned that he had arrived from Liberia but let’s be honest, we have heard for days that Ebola coming here was unlikely, by the President no less.
There have been other scares from people who have thought that may have had Ebola and you know the difference in them is that they announced that upfront.
Had Duncan said the same thing at the time he went to the hospital it would have been different. Whether he really thought that he was infected or not, I think that he was not forthcoming enough.
The question about if you been out of the country is common enough, but it by itself does not help. The family had better knowledge about what may have been the cause of his illness, yet they are now blaming the hospital.
I think it is too easy to say that hospital made a mistake and the family is now playing the med-mal lottery and using the race card as leverage to boot. I’ll wait until there is more information to make a judgement.
I am not condescending; I am exhibiting my disappointment. In others, who do not know what they do not know, yet pontificate. Like I said, Lea gets it.
You listed his African origin as a symptom, which it is not, so I let it go. Fever can be a symptom, or it can be a sign, medically speaking.
Now, in addition to ebola, what other diagnoses should have entered their minds?
There is no test at that hospital for ebola at night. Nor in any other US hospital. So what are the ER docs to do? They do the best they can. They examine him, get lab work and a belly ct, and people are mad these racists didn’t admit him to isolation because he’s African? Admit him to non-isolation and by the next day you’ve exposed a lot more healthcare workers than those who were exposed to him in ER and Xray. Funny how no one mentions them, Neo.
Boricuafudd:
I don’t know whether you’ve seen the reams of discussion on this blog about whether he or the family knew he’d been exposed to ebola. Suffice to say I am firmly of the opinion that none of them did, so they were not hiding anything.
Many people disagree with me, of course, but I’ve explained my reasons fully and at great length (much too long to go into again here).
The way the report on the 103 fever is worded—“Thomas Eric Duncan’s temperature spiked to 103 degrees during the hours of his initial visit to an emergency room”—makes it very unclear at what point his fever was that high, how long it remained that high, whether it ever came down, and if so whether that was spontaneously or as a result of being given a fever reducer.
That wording appears to be the journalist’s wording, not the wording of the medical report, so it would be clinically rather meaningless if we want to know the details of the course of the fever. All we really can tell from it is that it appears that at some point when he was at the ER for that first visit, his fever was that high. This contradicts earlier reports, which reported it as 100.1.
Here are the ebola criteria and the wording about fever is “fever of greater than 101.5 F.” Not that the fever has to stay at that level and never be lower; just that it needs to be at that level at some point. You will note that his symptoms met the criteria for being isolated and reported.
Those guidelines I just linked to were revised on Oct 1. Duncan had come to the ER some time between September 24-26 (various reports state different dates), so it was before that. But this CDC website has the same criteria, and posted in early September before Duncan got sick. He met the criteria to make him a PUI [emphasis mine]:
Don Carlos:
Actually, I didn’t say travel from Liberia was a symptom. I said the list was a list of things that were “all symptoms of or indicators for ebola.” I don’t think of “indicator” as a medical term, and it’s certainly not the same as “symptom.” Of course I’m aware that travel from Liberia is not a symptom!
My point is that you were writing as though I didn’t know what a differential diagnosis is, implying that I thought that the list of symptoms you quoted me as listing should have been enough to have them diagnose ebola. That, of course, is not what I wrote, and you left out the all-important indicator (factor? what word would you prefer?) of Liberia travel.
Not that any of them ought to have told them “ebola, he has ebola!” However, it should have led them to suspect it and treat him as a possible case, where the ebola diagnosis needed to at least be eliminated in some way. It appears they never even considered it as part of the differential diagnosis, and they should have.
You don’t think you’re being condescending? You have sounded quite condescending, in many threads on this topic, for several days. You would not really be the best judge of whether you sound condescending or not.
By the way, Here are the CDC ebola criteria that were in place in early September, before Duncan got sick. As best I can tell, it appears he met the criteria to make him a PUI [emphasis mine]:
neo-con:
I am not disputing your points, just sowing doubt on some of them. Yes, I have read why you believe that Duncan did not know he was infected, but he should have suspected.
A bad analogy, but I think it fits. If I am ask where I am from and I say, Egypt. Chances are you are thinking that I am Muslim.
When both the lady Duncan was transporting and her brother died in short order and there is an epidemic ravaging your country, my first guess is that when I get sick that I would think that was the reason.
Now, I do understand that we are humans as such we fail, and often delude ourselves about things. Duncan probably is in that category, he deluded himself that he got out before the epidemic could get to him.
As to the hospitals, I can’t seem to fit right now, but for what its worth, the fever has to be constant. The direction as I recall it was that the temperature was taken every 30 minutes to make a determination.
When you are sick spikes in temperature are not unusual, as your body tries to fight whatever is causing your illness.
This is why I am waiting for the reports to made available or more information. One thing I know, that if Duncan had said I think I have Ebola he would have been treated differently. He obviously did not think he had it, but we expect the hospital to do so, especially after the effort to downplay the virus?
Neo-
I figured you would trot out your use of “indicator.” And you did.
OK, with the benefit of hindsight, what should the docs in the ER have done with Duncan? After the CT scan, I expect it was after midnight. So they cannot rule out Ebola? There has never been a case in the USA, they can’t test for it, and Frieden and Fauci and the White House are all telling all Americans all not to worry, the chances are extremely low. They cannot rule out typhoid. They cannot really rule anything IN. What in practical reality would you have them do?
It is well and good to criticize, but what should the ER docs have done?
Citizenfour Official Trailer 1 (2014) – Edward Snowden Documentary HD
http://commoncts.blogspot.com/2014/10/citizenfour-official-trailer-1-2014.html
Seems to me the most important thing for the hospital to have picked up on was that Duncan had just come from Liberia. It’s not clear whether his medical record indicates he told the ER staff that he was from Africa in general, or from Liberia in particular. In any case, since there are 10,000 Liberians living in the greater Dallas area, the hospital should have been very cautious and assumed that he was from Liberia, which they had to have known was one of the three hot spots for Ebola. If they didn’t know that, they hadn’t paid any attention to earlier CDC alerts about Ebola.
The Liberia red flag — added to the symptoms he was showing — should have been enough to admit him to the hospital and to put him in isolation.
Also, although Obama may have said Ebola would never come to the U.S., back in August the head of the CDC had said it was inevitable that Ebola would spread to here.
Boricuafudd:
The pregnant woman who died was the first person in the neighborhood to get ebola. Her family (and the staff at a clinic) thought she had malaria—or, alternatively, a complication of late pregnancy. She had not been exposed to ebola, as far as they knew (in fact, no one to this day really knows how she got it).
But more importantly, your timeline is off about the timing of her brother’s illness and death. By the time the brother (and others who had helped her) became ill, Duncan was already ill with his own symptoms, in far-off Dallas. There is no reason to suppose he got the news instantaneously, or even that he was in any contact with them at all (they were not relatives of his, nor were they even alleged to have been close friends).
Hindsight is 20/20. He did not have the benefit of that. He did not have access to that information.
See this and this. And for the correct timeline, see this.
Even if the medicos weren’t looking for Ebola, they should have thought about dengue fever, or hanta virus, both hemorrhagic viruses, that have similar symptoms and exist in Texas.
Ann says Duncan’s Africa and symptoms “should have been enough to admit him to the hospital and to put him in isolation.”
Not how it works. We don’t arrest people for felonies and incarercate them without serious evidence of crimes and arrest warrants signed by judges. It also takes more than suspicion in hospitals: People have civil rights and must give informed consent.there must be evidence of the adnitting diagnosis An isolation room is pretty much a cell. A patient can sign out against medical advice at any time, for any reason,
He had no findings justifying isolation on his first visit. The appropriate things were done and he went home.
Neo:
Thanks, I had forgotten that Davey Boy died later but my points still stands. Duncan was in a better position than anyone at the hospital to suspect he might have been infected, while he did not deny he was from Liberia if he had added a little emphasis to that it might have changed things. I leave you with a quote from an editorial from the Liberian newspaper:
“The third lesson we can learn from our brother Eric is honesty. We are compelled to be honest with ourselves and all others around us. We must realize that it is highly dangerous to engage in what Winston Churchill called “terminological inexactitude,” which means a lie or untruth. See how far Duncan’s lie led him–all the way across the Atlantic and into contact with airline passengers and crew, as well as his fiancé and all the others in the home and neighborhood in Dallas, Texas. It is only by the grace of God that so far, no one has been found to have been infected by him. Let us pray it remains that way. The fact is that if we are not honest with ourselves we could infect others, as we saw in the case of Miss Liberia in Caldwell, where she and several others in the household died.”
http://www.liberianobserver.com/editorials/what-can-we-learn-eric-duncan
Don Carlos:
If you want to see an example of your condescension, you just gave one: your use of the phrase “trot out,” as in “I figured you would trot out your use of “indicator.” And you did.”
So, first you imply that I know nothing about the concept of differential diagnoses and how they might be made, and you list the symptoms I listed but leave out the all-important indicator (recent travel to Liberia) that I also had listed with them, and which was the clue that would have tipped off the staff at Dallas Presbyterian to at least start thinking about ebola as a possible diagnosis. In that way you made it seem as though I was thinking simplistically enough to think that the other symptoms (without that Liberia clue) would point strongly to ebola, when I had said nothing of the sort. By leaving out the Liberia part, you made it seem as though I had written something more ignorant than I had actually written.
Then, when I defend myself by pointing out what I had actually said, you condescendingly say you knew I’d “trot out” that phrase—the phrase that defended me. And then, you went on to something else.
If you already knew I’d “trot” that out, then what made you “trot out” your accusation about the lack of differential diagnoses knowledge in the first place?
But to answer your second question (which I believe I’ve answered before on other threads)—basically my answer would be to follow the CDC recommendations.
Here they are. Once the person falls on the left side of the page (which is where, if you look at it, Duncan’s symptoms and travel history placed him), this is what a hospital should do:
I assume the Dallas hospital has protocols for isolation, etc.. While it is true that they might not have been adequate for dealing with ebola (and I’m not sure they are even adequate today, in that hospital or most hospitals), the staff had already been exposed to Duncan and his illness under far more dangerous conditions (sans protection). People care (at least, I do) about the staff, but they were already at risk, and sending the patient home exposed many many other people to risk.
If they could not have done that for some reason, or decided not to do it, at the very least they should have called the public health authorities (the CDC, for example, has various 24-hour hotlines) and reported the situation as a potential ebola case and asked their advice. In the meantime, before release, tell him to stay home away from the public till he feels better, to take his temp every couple of hours, to report back to them if the temp goes up and/or if he gets any of the following symptoms (vomiting, etc., higher temp, bleeding).
I have been released from ERs, or taken people to ERs who have been released, with instructions and sheets like that for much lesser things: “call us immediately if any of the following happen.”
Now, I assume that the Dallas ER gave him some sort of instructions on release, standard ones. I don’t know what they were. But they should have included instructions that were specific to watching for signs of ebola. They should have suspected ebola and at least entertained it as a possibility, and taken some minimal precautions to monitor him (or have him self-monitor) in that way, if they couldn’t manage the stronger action in that CDC list.
I almost forgot, one last thing. Duncan lived in the same house as Ms. Williams who infected him. He did not leave until four days after her death. It would be hard for me to
Sorry, finishing up. It would be hard to believe that during those 4 days his other room mates the owners did not broach the subject of her death to Ebola.
Boricuafudd:
Where did you get the idea it was the same house? Marthalene Williams father was his landlord, and they lived in the neighborhood, but not described as the same house:
And here it says the Williams family were Duncan’s “landlords and neighbors.”
Plus, let me repeat: neither the Williams’ nor anyone in the neighborhood knew she’d died of ebola until long after Duncan was already in Dallas, and after he had started to take ill, and others in the neighborhood had become ill and died. He and they knew, of course, that she had died a few days before he left for the US, but they thought it was from malaria or complications of pregnancy (and a clinic had told them the night she died that she had malaria).
Neo:
Will look for the source, but from what I read the rooms was next to the main house where the landowners lived on their land. A very common practice around the World for added income.
Regardless, don’t you think that Duncan knowing he is leaving for the US and not returning for several years, that he would not inquire about the landowners daughter that he help take to the hospital before he left?
Boricuafudd:
Inquire WHAT about her? He already almost certainly knew she had died; the whole neighborhood knew it. They all thought they knew that she’d died of malaria or pregnancy complications. They didn’t learn until long after Duncan had gone to Dallas that she had actually died of ebola (when the others who’d been around her had become ill), and by that time he was ill, too,in Dallas.
So why would he have anything to ask them about her disease before he left Liberia? He didn’t know what he didn’t know.
Neo;
I see from your tone that this is irritating you so I will drop it. I will say this for the last time, whether he knew or not it not the question. The question should be that based on the circumstances at the time in his country, something that they have been reading and hearing about for weeks, what the symptoms were, what to look out for, how to handle sick people, etc. it is reasonable to expect Duncan to not suspect that Ms. Williams could have been infected with Ebola?
However unreasonable the circumstances of her contracting the virus, in view of the what was going on, he should have at least been suspecting that this was a possibility.
Boricuafudd Says:
October 11th, 2014 at 1:25 am
The whole problem with the “he should’ve known” angle is that mortality is so high in Liberia — all the time.
In particular, you can just about take it to the bank that the Williams family was ALWAYS approaching her illness as being malaria — which is endemic to the area.
BTW, at seven-months into her pregnancy, it was odd that she was much outside of the house. IIRC, it’s rather taboo for gals in their third trimester to ‘mingle.’
My conjecture is that she received a visitor who just HAD to put hands on her swelling belly. Such a touch is, apparently, lethal — when the visitor has even asymptomatic ebola.
Now that’s frightening!
Ymar doesn’t know what he does not know.
…
BTW, Ymar, scientists in aggregate understand a tremendous amount about the human body. It is regrettable that Ymar has put on his nihilist, know-nothing hat. He is simply unable to comprehend Occam’s micro-lecture.
Occam is blessedly 100% right-again, as always-and always lucid, which I am not.-DC
Scientists in aggregate, is it. By that, DC means doctors, referring to the previous.
Not the first, won’t be the last of the Doctor Classes thinking they know something we don’t.
http://ymarsakar.wordpress.com/2014/10/03/hfcs-sugar-diabetics-and-human-microbiome/
Meanwhile the amount of ignorance in their so called professional circle is not just stunning, but gravitationally crushing at this point.
They know less about the human body than they think, which is truly an insult to their profession or perhaps it is a religion now.
Should we now think instead that doctors don’t know what they don’t know, or do we need to wait for some other Super Duper health dip and dieting formulation from the Masters?
I was out of town working for a week, as usual. My very young daughter (at the time) was having congestion and other problems as i went out of town. My wife promised to take her to the doctor. Chest cold is what I heard on the phone that night. When I got home 4 days later, she was worse. Both her eyes were black. She was weak, lethargic. I went ballistic and took her to another children’s doctor group. She had double pneumonia. They aren’t perfect, and they aren’t all knowing. Until recently, why would any hospital, any doctor think Ebola! in this country?
I am not sure what this blogger’s agenda is. I never read this site anyway but this caught my eye. Duncan assisted, had close contact with an extremely ill person in Liberia. He knew that Ebola was rampant in Liberia so for the blogger to claim he didn’t know of his exposure, is absurd.
However the bigger picture is this – this blogger is a neocon. Neocons are known to engage in pointless activities to “help” other people. The Iraq war is a good example of such activities. Not only did the war not help anyone, it made the condition much worse for that country and the USA. And on top of all that it cost trillions of dollars and thousands of lives. The blogger endorsement of Duncan because he tried to help in Liberia is analogous to this bigger picture. He “helped” so therefore we are supposed to help and sacrifice the public safety of American citizens for some nebulous feel good concept.
Ok, I’ll jump into the fray. Has anyone considered cultural differences?
I used to work for a nonprofit international development agency and I have been in West Africa (Togo, Burkina Faso and Mali).
First, this blogger community tends to keep up with what is happening in the US and the world. But, there are many in the US who are not tuned into national and world events. How can we make the assumption that people in West Africa are news savvy? From what I’ve seen in the news, the governments are having a hard time with the distribution of the basic public health information relating to Ebola.
In this country, when was information sent to state health agencies and the health care community on specifics of how to handle Ebola? It seems that the CDC and other government agencies were sending out messages that it couldn’t happen in the US. Even Emory Hospital seemed to have had issues with proper waste disposal. And they knew that they were going to have a patient transported to their facility.
Back to the patient and the hospital, English is the primary language in Liberia but there are many ethnic groups there so I will assume that there are secondary languages spoken. So, did he understand the nurses and doctors at the hospital and did they understand him?
Another cultural issue – was the nurse female and was he hesitant about disclosing information to her? Did he repeat information to the doctor about where he came from, how he felt and other things? Was he assertive in his medical treatment? When I took my mom to see doctors, there were things she didn’t tell them and was angry when I brought them up. But, it impacted her medical care.
In 1994, when I came back from that African trip, I went to the ER covered in red spots. First thing I mentioned was international travel, the medicines I had taken, illnesses during the time out of country as well as the fact that I took antibiotics while on the long trip back since everyone around me was feeling bad and my stomach started feeling queasy. They put me in isolation and called the infectious disease doctors. It turned out to be an allergic reaction to the antibiotics. But, I think that my active participation in my health care impacted what the ER staff did.
With enough info the exact trail of events regarding patient zero will be figured out. But in the end human beings screw things up, always.
There will be more screwed up Ebola admissions and treatments. More people will die. It’s just in the nature of things.
That’s why you want layers and layers of watchers, tests etc. to hope that somewhere along the line Ebola patients will be identified.
Software is regularly tested, tested, and tested again, but as soon as it goes out in the field serious bugs are found.
Mike Wallins–You don’t know what you are talking about and your straw man analysis about a host of things in two small paragraphs is exactly what one does not regularly encounter at this blog. So unless you want to more than scratch the surface about our hostess and what she thinks and believes, please move on. There are myriad forums that function as you do and you can have them.
At some point in time, the travel issue will not be important.
Are there enough public health workers who can be involved in the contact tracking?
Will those people who are part of that list follow directions, take their temps and stay isolated?
Per news reports, the woman who was connected to “patient zero” wanted to leave the apartment to shop and the sheriff who was in the apartment was not part of the contact tracking.
At some point in time, there will be an Ebola patient who was not in West Africa and was not knowingly in contact with someone who traveled.
What’s going to happen when the flu season arrives and people start worrying about fevers? Are the hospitals going to treat every fever as an Ebola event?
Healthcare and public health costs are going to increase. BTW, I am defining public health costs = costs associated with identifying and tracking contacts, dealing with transportation of patients and cleanup of infection sites. These costs will be greater than the costs of direct patient care.
Imagine you are Duncan and you fear you may have ebola and may spread it to your family and loved ones so you want to go to the hospital and isolate yourself. you go to the hospital and they tell you don’t have it. You return to the apartment and, relieved that you do not have it, interact with your family and loved ones, including school aged children. Your family and loved ones go out into the community because you checked with the hospital and they confirmed that you did not have ebola so you know it is safe to do so. Your children go to school and interact with other children because it is safe to do so, you know it is safe because the doctor told you so.
From the very start, political pressure from the Obama administration, and its incompetent appointees–Obama, for instance, recently broadcasting a supposedly authoritative and reassuring message to West Africans that “Ebola is very hard to contract,” telling them that “they’ll never catch Ebola by sitting next to someone on a bus,” while, at the same time, the CDC was warning U.S. visitors to the area to “avoid public transportation”–screwed up their response to this whole incident.
Compounding the problem and making things far worse is when race hustlers like Jesse Jackson inject themselves into this situation, and stir up and chum the waters for their own benefit–and it looks like maybe the family of patient zero have caught on, and are now talking about how “race and prejudice” reduced his level of care, and are thinking of suing.
Such intensifiers will make it almost impossible to conduct a fair and dispassionate inquiry into what actually happened, given all the additional pressure that Jackson and his ilk have added to this event. And this additional pressure will inevitably tend to skew the results of any investigation more than they would otherwise have been, given things like the hospital’s normal CYA to avoid lawsuits.
As with many other events that have taken place during the Obama administration, once politics and/or race get into the mix, we’ll probably never know the truth of what really happened.
br549:
You write, “Until recently, why would any hospital, any doctor think Ebola! in this country?”
I can help you out with that one:
(1) there had been CDC guidelines sent out about ebola prior to the time Duncan came to the hospital
(2) the ebola epidemic in West Africa (especially Sierra Leone and Liberia) was ENORMOUS news, including the fact (and controversy over that fact) that American health care workers with ebola had been sent back to the US and survived
(3) he had symptoms of ebola
(4) most importantly, the question about recent travel (which he was asked and answered correctly) is a standard one to screen for the possibility of infectious diseases from other countries and continents, not just ebola. They absolutely should have red-flagged him for something, and something possibly quite contagious (including perhaps other hemorrhagic diseases), on the basis of that and his symptoms alone.
Did Duncan bear no responsibility for bringing his contagious disease to another continent, exposing millions of people? Seriously?
You’re expecting every person in every hospital to know everything? Seriously?
The perp is always the victim, huh?
geran:
You obviously have not read most of what I’ve written on the subject, or if you have you haven’t understood it, nor do you realize that defending perps is not what I ordinarily do.
Logic and facts are on my side here, and they are what interest me.
Sunday AM. Second TX patient with Ebola.
CNN crew violating quarantine. They should be arrested and made an example.
The medical establishment is indoctrinated thoroughly with “If you hear hoofbeats, think ‘horses,’ not ‘zebras.'” Except sometimes, it is zebras!
I have a feeling that “flu” is “horses,” while “Ebola,” even if someone recently flew in from West Africa, is “zebras.”
Sorry Neo, but this post is what I’m commenting on, not some other post you wrote, or think you wrote. I’m commenting on THIS post where you blame the hospital for the spread of a contagious disease.
Logic and facts are on MY side here.
geran:
I’m not going to write a book for you in a post, just to prove something on which I’ve already written many thousands of words that are available on the blog.
Do your own homework.
But I’ll give you a hint on the homework assignment: do a search for “Duncan,” and “ebola” on the blog. Make sure you read all the posts, and don’t forget to read all of the comments from me in the comments threads, too.