Crozet Annals of Medicine: The Real Killers

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By Dr. Robert C. Reiser

“Hey, Dr. Reiser, are you prepared to take care of an Ebola patient?” the ER charge nurse asked me recently.

Uh oh.

I scanned the computer tracking board in the ER, looking at the complaints of the patients waiting to be seen.

  • Back pain- denies travelling outside of country or exposure to person from or who has traveled outside of US who has been ill.
  • Leg pain- denies travelling outside of country or exposure to person from or who has traveled outside of US who has been ill.
  • Penile discharge- denies travelling outside of country or exposure to person from or who has traveled outside of US who has been ill.

Hmmm. We seem to have added a few questions to the usual triage complaint since Ebola has come to the U.S.

That’s good. But I did not see anyone listed who appeared to be at any risk of Ebola.

“Well, Dr. Reiser, do you feel prepared to take care of an Ebola patient?”

A small group of nurses had subtly gathered within earshot to hear my answer. Since Thomas Eric Duncan fell ill in Texas from Ebola, nurses have taken the brunt of the blame for allowing Ebola to gain a foothold in the U.S. First it was alleged that although a nurse had taken Duncan’s travel history from Africa, she had not alerted the doctors caring for him on his first ER visit when he was mistakenly sent home. This was simply not true. The doctor caring for Mr. Duncan had the information recorded in the electronic medical record, but he did not read it.

Next, when nurse Nina Pham came down with Ebola, the head of the Centers for Disease Control, Dr. Thomas Frieden, asserted that she had made an error in adhering to the hospital protocol for caring for Ebola patients. In fact, the issue was the hospital protocol, which was inadequate, constantly changing and not well-drilled. Dr. Frieden later apologized after hearing from many nurses nationwide, including this remarkable statement put out by the nurses at the Texas hospital where Thomas Duncan had died: “In the end, the nurses strongly feel unsupported, unprepared, lied to, and deserted to handle the situation on their own.”

And yet when nurse Amber Vinson took to a plane, Dr. Frieden was quick to put his foot in his mouth again, saying, “She was in a group of individuals known to have exposure to Ebola. She should not have traveled on a commercial airline.” Later that same day it was revealed that the CDC had cleared her to fly when she called in to report a low-grade fever.

In contrast, Kent Brantly, the doctor who had contracted Ebola caring for patients in Africa, was widely hailed as a hero.

So I had the background to hazard an answer. Nurses nationwide were mad as hell.

“Well, Christine, I have not received any training, if that is what you are asking.”

I could see the nurses’ satisfaction with my answer, sharing and confirming their feelings of being unprepared. I probably should have stopped there.

“But I do know that as a doctor, if something goes wrong, I should blame the nurses.”

The hot, incredulous looks I got lasted only a moment before everyone dissolved into laughter. Crisis averted. I had not wanted to leave the discussion on the previous negative note.

Since then, U.Va. hospital has offered training in the current CDC protocols for caring for a potential Ebola patient. Time will tell how it is going to go. The training includes instruction in donning and doffing head-to-toe personal protective equipment (PPE). The PPE donning and doffing is always watched by a second clinician who is vigilant for any breaks in the barrier protection protocol—any body areas not covered or contaminated with body fluids.

As I write this I am actually on a double self-monitoring regimen myself. In the past two weeks I have been exposed to a patient with active pulmonary tuberculosis and a patient with potential MERS, the Middle Eastern Respiratory Syndrome, which carries a mortality rate of 30 percent.

Tuberculosis is an old acquaintance for me, having been treated successfully for TB in the distant past and exposed multiple times since then. Familiarity breeds equanimity I suppose. But to put TB in perspective with Ebola, worldwide 9 million people will get TB this year and 1.5 million will die. So far 5,000 people have died of Ebola. Where is the outrage, the fear about TB?

MERS is a flu-like illness with cough, fever and severe respiratory distress, first identified in Saudi Arabia in 2012. In the two years since then, seven hundred cases have been diagnosed, almost all of them in and around the Arabian peninsula, and almost all of them with some direct connection to Saudi Arabia. There have only been two cases in the US, both of them in health care workers returning from patient care duties in Saudi Arabia. They both did fine.

MERS is caused by a newly discovered virus in the coronavirus family. Like Ebola, it is a zoonosis, a disease that jumps from animals to humans. Like Ebola, the animal vector is likely bats, specifically Egyptian tomb bats. Can you think of anything spookier than an Egyptian tomb bat? From there, human-to-human spread is possible, like Ebola.

We were notified by a local primary care doctor that our patient was inbound with a fever and shortness of breath after a flight home from the Mideast. We consulted our hospital epidemiologist and huddled with staff to put together a plan. Despite the unfamiliarity of the disease and the rather fearsome mortality, there was no hesitation on the part of the staff to step up and care for the patient.

As we were gowning up, I noticed how careful and meticulous each team member was being in the application of their personal protective equipment. It was clear the Ebola training was carrying over to current clinical practice.

As we donned our PPE, a small knot of ER staff gathered around us. As befits a senior clinician I rather casually donned my gown and mask. After all, I was an old hand at this. Unlike most of our staff, I had not yet had my PPE training.

A tech stepped up to me and solemnly handed me eye protection and motioned for me to put it on. That was new. I felt someone tugging at my neckline from behind, snugging up and straightening out my gown on my shoulders. It was a clerk from registration. A nurse checked my waist tie and redid it to her satisfaction. I felt like a toddler being dressed up to go out and play in the snow. Once fully gowned, we inspected each other for any lapses in barrier protection. Good to go. We had each other’s back.

I realized then that we all were prepared to take care of an Ebola patient, the way the ER is always prepared. We are a family, we watch each other’s backs, and we turn toward disease, not away. And we all get our flu shots.

Flu will kill far more Americans this winter than Ebola. Get your flu shots!

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