Saturday, October 4, 2014

Do The Math

Exactly as predicted, now that the horse is some distance down the road, the government officials paid to prepare for emergencies, after being caught in their usual pants-around-their-ankles condition, are busily trying to find a lock for the barn door, and assuring all and sundry that "We've got this."

And also as I noted going back weeks and even years, no, they don't.

But still we get the unicorn-farted happygas from the Dutiful Minions:
At the White House Friday, federal officials sought to reassure the public that the nation’s health-care system was well-equipped to treat the virus and stop it from spreading.
“It’s very important to remind the American people that the United States has the most capable infrastructure and the best doctors in the world, bar none,” said Lisa Monaco, assistant to the president for homeland security and counterterrorism. “The United States is prepared to deal with this crisis.”
Okay, yes we do have the best infrastructure and the best doctors in the world, bar none.
But unless we know how high that bar is, that's like saying you have the world's largest unicorn. It sounds like a lot, but it's not as impressive if you find out it'll fit in your shirt pocket, is it?

So let's look at that infrastructure.
There are, in fact, a total of four medical isolation units in the entire United States, as we noted yesterday, that are capable of handling infected Ebola patients near endlessly.
Where are they, and what can they handle?
Emory University's Serious Communicable Disease Unit is in Atlanta, GA. That's where Brantly and Writebol were treated. It has three beds.
St. Patrick Hospital's ICU Isolation Unit is in Missoula MT. It has three beds.
The National Institute of Health's Special Clinical Studies Unit is in Bethesda MD. It has seven beds.
And the biggest, the Nebraska Medical Center's Biocontainment Unit is in Omaha NE. It has ten beds.
 
3+3+7+10=23 beds, coast to coast.

So, for the entire country, all 316,100,000+ of us, we're fully prepared to treat 23 Ebola patients at the same time. (For reference, that's how many Ebola patients Liberia had last April. It hasn't gone well.)

But the 316M-person question is, what happens when we have 24?

More happygas, anyone?
"But any major medical center could really take care of an Ebola patient," said William Schaffner, an expert on infectious diseases at Vanderbilt University's School of Medicine. 
Most ICUs have isolation rooms that are used for patients suspected to have tuberculosis, SARS, Middle East respiratory syndrome or another infectious disease. Schaffner said that not much would be different for an Ebola patient, though more stringent precautions might be taken to ensure that health care workers are following all protocols.

Why yes, gosh darn it, of course they can!
Just look at how well that worked at Texas Health Presbyterian, a top-tier 968-bed acute primary hospital in Dallas, and a regional healthcare keystone in that city.
They misdiagnosed their first patient.
Their computerized EMR doesn't dump the nurse's triage notes onto the doctor's page, so critical screening information was missed.
They exposed their hospital lab to specimens that weren't safe to handle, because they didn't know Thomas Duncan needed a BL4 response and specimen handling.
They exposed doctors, nurses, staff members, patients, and visitors to Ebola unknowningly.
They sent him back into the community to expose family, friends, EMS workers, and random strangers as well.
Which led to inappropriate hazmat cleaning at his home;
the potential exposure of four public schools to the disease, which has necessitated closing them for cleaning while parents keep their children home, some withdrawing them completely;
and on and on, with 18/100/50 (depending on which number is currently operant) people under self-imposed quarantine and monitoring.

And that was a good look at how it's going to go everywhere else, the first time "shit's getting real". It's called the Normalcy Bias. "We've never had an Ebola patient walk in the door, so we never will, and we won't assume otherwise." Because ABCNNBCBS haven't been hawking any news to the contrary for months, right?

There are other problems: as noted yesterday, once you start traipsing highly infectious patients, frequently vomiting and squirting Ebola-laced body fluids everywhere, the hospital is unavailable for any other use.
That's not even news, it's CDC standard policy!

But don't believe me, go to their Ebola Info Sheet:

Questions and Answers  

on Ebola

General

How do I protect myself against Ebola?

* Avoid hospitals where Ebola patients are being treated.
Hey, that's not fair, when we said "If you travel to areas affected by the Ebola outbreak, we didn't mean American areas! Stop quoting us exactly!"

Because things are different here, because Magic Beans, right?
Ebola behaves differently on American soil, in American hospitals, for American patients, than it does in Africa? Really??

So, you can either have an Ebola hospital, or a regular one. Personally I work at a hospital with +/- 10 negative airflow rooms, in the entire building. So that's how many Ebola patients we could care for, max. But 6 of those rooms are in the ER. Let me be more specific: 6 of those rooms are in the ER that sees 300-500 patients a day 24/7/365, 110,000+ patients a year, and of whom 99-and-change% of them go home alive. So we can care for them, or we can take in 6 Ebola patients, of whom 0-3 will likely survive. While all those other patients go somewhere else. Or nowhere else. And we can multiply that times every city that gets an Ebola patient, if we try to use existing facilities. Sorry, if my choice is the entire community, or a handful of individuals of whom 50-90% will certainly die anyways, "Best wishes with your Ebola, we have a bus waiting outside to take you to the treatment center in BFE."
Not even close to a tough call. And it's a choice we'll have to start making if ever the patients coming in overtop our ability to deal with them. And if you're in a one-hospital locale, that'll be the choice on Day One. I can't imagine the community that'll rather see everybody with a heart attack(stroke/asthma attack/diabetic emergency/car accident...you get the idea) die, just to save a few of the Ebola patients. Call me when the head of the CDC, or the local hospital CMO talks about that on the news, and they're ready for it.


But certainly, our medical people are up to the task.
"We have been training for this," Ribner said of preparations for the two American Ebola patients. These doctors know how to handle Ebola and will use an abundance of caution when working with an infected person.
Medical workers across the country have also been told to watch out for Ebola symptoms and question patients who have recently traveled to West Africa. They are trained to recognize Ebola cases and can quarantine them early, keeping others from coming into contact with an infected person's bodily fluids while the disease runs its course.
Let's be fair: CNN pulled that quote from Dr. Ribner, of Emory, totally and completely out of context when they tried to make him say all healthcare workers everywhere in the US are prepared, rather than just his team at their special unit. What he said was true; what CNN did, in trying to lie it into a general quote about the entire American healthcare system, is exactly the sort of bullshit editing and outright falsehood we're all up against every time we read a story on something without digging into it like a terrier with a rat. We shouldn't have to, and the press shouldn't lie, but they do, 24/7/365, and on this subject, frequently out of both sides of their mouth at the same time.

Back to the greater question, how are healthcare workers going to do with this, if they're forced to try to cobble a response to it out of facilities not designed for it, with staffs untrained for it, and without adequate equipment? (If any of you are reading this from Liberia or Guinea, stop me if you've heard this one...).

They're going to fall flat on their ass, and it's going to kill people. Duh.
Says who?
They have these protocols and policies in place , but they don’t actually make it down to the level where the nurse is providing that care,” said Deborah Burger, a registered nurse in California and co-president of National Nurses United, the largest nurses union in the country.
She cited a study that the union recently completed of nearly 700 registered nurses around the country, in which the vast majority said their hospital had not communicated any policy with them regarding the potential admission of Ebola patients. To the extent there had been training, the nurses said, it was largely conducted by computer and didn’t offer the chance to pose practical questions about how to provide such care. A third of the respondents said their facility lacked adequate supplies of protective gear.
So somewhere, they have a CYA binder for when the Joint Commission breezes in, to prove they have a policy, which apparently everyone will gather around to read when someone's at the front desk shitting their guts out.
Then they'll travel out to the back parking lot, break into the ISO shipping container where all those expensive supplies are locked up, and based on 15 minutes of mandatory pencil-whipped computer "training" they'll become instant experts equal to the folks at those four dedicated facilities, who drill on the same thing regularly, frequently, and intensely, and actually train other facilities and workers in foreign countries.

Sh'yeah, right. When monkeys fly outta my butt.

There will be a Level 1 Spaz-Ex, followed by a Chinese Fire Drill (my apologies to actual firefighting professionals in Beijing or Shanghai) to get into unfamiliar equipment and render care under conditions they seldom experience every day.


Some among the Grand Order of Internet Assclowns keep trying to portray this exercise as "just following standard precautions, but with a little more stuff".
Let's go to the tape::


“When we started putting them through the PPE (personal protective equipment) exercise, everyone was excited, trying to be first in line to try on the gear,” Hurley said. “But then they’d get it on and start moving around for 30 or 40 minutes and realize – this is kind of tough.”
Ebola clinic staff must wear full-body protective suits including complete face shields. Hurley said the hardest thing for her to get used to was the condensation that would fog over the mask, limiting her vision to the places where sweat had trickled down.
“You can’t touch your face,” Hurley said. “You can’t move your hands above your shoulders. You can’t sit down. And you stay in this for three or four hours at a time. It got to be all about the hydration.”
Hurley said clinicians used a buddy system to check that gear was worn properly, procedures were done carefully and no one was getting too tired to work competently.
“We got really good putting it on and taking it off,” she said of the clothing.

Hurley is the nursing supervisor at the Missoula ICU BL4 Isolation unit. She's got years in the ICU with normal isolation procedure, yet this is clearly not just another day at the office, for her, for the doctors, or anyone else.

What are we talking about?
A freaking hazmat suit. If you're a long-time medical or EMS professional, you may know the arcana of the difference between this:


this:


 

and this:

 

For most people, especially if you see people walking towards you on the street, or in a hospital, it's of no practical matter or difference.

The bottom line is, none of those three are everyday wear in most US hospitals, anywhere, anytime. And the number of US healthcare workers who are experienced in working in them regularly is probably smaller than your high school graduating class, unless you were homeschooled.

Feel free to explore what getting ready to work involves. Compared to most hospitals currently, where starting your shift normally means only showing up and clocking in.

So, does your hospital currently have people ready to see patients who are suited up like this 24/7 right now?
I ask because there are currently over 100 instances, so far, of patients walking in the door to be evaluated as potential Ebola victims. And because the CDC sent out an Ebola Preparedness Checklist to every hospital in the country three weeks ago, well before Tom Duncan was even infected in Liberia.
It includes:

PREPARE TO RESPOND C IP NS
Review, implement, and frequently exercise the following
elements with first-contact personnel, clinical providers,
and ancillary staff:
Appropriate infectious disease procedures and

protocols, including PPE donning/removal,
Appropriate triage techniques and additional EVD

screening questions,


So since they know to do this, why haven't they done so?
Because when someone walks up to the first stop at the ER check-in desk, coughing blood and puking their guts out, it's too late at that point to begin the 20-minute suiting up process.
Do they have their tents set up outside to segregate possible Ebola victims from everyone else, and from each other, so the real ones don't infect the ones who are negative?
If they don't, now that it's here, and now that multiple potential cases are showing up, why don't they?

And if they aren't set up to screen such patients, segregate those patients for everyone's safety, and have appropriately prepared and equipped staff members to see, transport, and treat them, how in flaming F**k can anyone say "We can handle this."

We aren't ready for anything.

STILL.

46 comments:

Brian said...

What a fantastic blog and excellent piece of writing. I am signing up, right here, right now. I laughed my ass off all the way through this because I know it's true. As a former advanced EMT working out of a hospital...I know exactly how fucking prepared we are. Nurses at the nurses station scrolling FB.

I even love your subtitle. Thank you for this.

Mr. Frankenstein Government by way of the Feral Irishman.

Brian said...

Oh yea and I forgot to mention after reading your right margin... I am a retired cop. I am going to link you at my site.

Aesop said...

Thanks, and enjoy.

Personally, I'll be happier when I don't feel like I'm doing play-by-play on the sunset of humanity.

gamegetter II said...

Well said.
I agree we are in no way prepared for a large scale ebola outbreak,and most ER's in most hospitals really have no clue what to do.
Me sister is an RN who works for Cleveland Clinic-supposedly one of the best hospitals in the U.S.
They have not even mentioned ebola to the nursing staff.

Anonymous said...

I used to be a HVAC mechanic for a 360 bed hospital. We had 12 negative air rooms. My job was to check the air flow monthly, unless the room was in use. Then a preadmitance check and one every 24 hours to insure air was exhausted.

Protocols would break down with possible TB patients. Gowns not worn, unprotected family allowed in room. One room's fan was noisy and nurses would ask an engineer to turn it off.

We had some monstrosity called an "isolation flange." It was supposed to allow a normal patient wing to be converted to negative air. Didn't work, would stay up.

Hospitals will rapidly collapse if the patient count exceeds 20-30.

Ex-Dissident said...

Great post. I have been making the same points at my hospital for several days, and while the docs are in agreement, very little is being done. Yesterday I went to work praying that the gastroenteritis patient admitted overnight got better and could be sent home. I don't know what I would do if the symptoms persisted. One other point that should be made is how much do you trust others at work? I could sort of laugh at the shoddy workup in the past and being able to fix things and set everything straight in the morning. Now it's not only my life that these colleagues put at risk but also the lives of everyone close to me.

Robohobo said...

The local Insane Clown Posse here in Dallas, to include Clay Jenkins have left the pooch walking bowlegged in the worst way.

I am not confident this will turn out well.

Anonymous said...

As an airline pilot at a major airline here in the US, I can only say that our industry is no more prepared than hospitals. The CDC states that Airlines have been training personnel, nothing could be further from the truth. All they give is a paragraph or two of guidance in a link somewhere on the company website. One Captain asked his flight attendants on 4 different flights if they had received any training. None had received any. Meanwhile we have possible ebola passengers almost every day. The entire thing almost is starting to feel like willful disregard on the part of the Obama Admin and the Executive Branch. It is like they want Ebola to get here. Common sense says shut down air travel for anyone from Western Africa. I think it is almost too late to stop this from becoming a worldwide pandemic, and meanwhile we have political correctness limiting efforts to defeat the most hideous virus of all time.

If any medical personnel here can provide some meaningful guidance for us to use on airlines please provide it. I am thinking we all need to be carrying at least liquid barrier goggles, and at least p95 level respiratory protection with us when we fly. I would appreciate any thoughts. Thanks.

Aesop said...

@Anonymous CATP
I am one of those medical professionals.

There's nothing you could carry onboard that would help that's less than the full Ebola ensemble.
For the entire flight crew.
And you'd have to be wearing it full-time, every day.

Less than that is just asking for problems. For those not in direct contact (say, on the flight deck) I'd go with N100 masks, not N95, and only wear them if someone is symptomatic (fever/headache/muscle pain/nausea/vomiting).
Cabin crew and nearby passengers would be hosed. You're going to have your hands full keeping them from opening the cabin door and chucking someone out from altitude if anyone ever collapses in-flight.

If either that scenario, or crew wearing Ebola suits inflight doesn't empty out the seats on your airline, (let alone the cockpits) nothing will.

The answer on this is simple. Mercy flights into the affected countries, no commercial passenger flights out whatsoever.

Anyone transferring to another airline at a third-party destination who is coming from the three affected countries goes into 21-day isolation quarantine (at their own expense) before being granted permission to enter the US.

Problem solved.

OTOH, doing it the way we are, the next Duncan could become symptomatic after boarding, spread the disease to seatmates, flightcrew, and into the seats/restrooms, and until they sought treatment in a few more days, no one would know, and any infectees would also go on to infect second- and third-tier contacts.

Short of transporting everyone inside a sealed bubble like how they transported Brantly and Writebol back with known EVD, there's no other way to continue flights there that isn't asking for further transmission and outbreak. It's just one big game of Russian Roulette.

And as the death toll climbs in W. Africa, more people will get more desperate, and there'll be more Duncans, and more Ebola outbreaks.

And that's without even getting into intentional ones.
Somebody willing to strap dynamite to his chest and pull the pin wouldn't take much any convincing to work in a charity ward unprotected for 2-4 days, get flown out asymptomatic someplace like Paris, London, D.C., NYC, etc., wait to pop a fever, and then go to town, literally, someplace else, infecting infidels for Allah.

Contact tracing depends on the innate honesty of those questioned.
It becomes meaningless if somebody is resolved to minimize and lie about their history and contacts. And if I've figured that much out, so has Al Qaeda et al.

Ex-Dissident said...

To airline pilot. I too am a medical professional who is reading this blog. Specifically I am medical doctor with 15 years of work experience and I never felt this uncomfortable about my work before. If you think the n95 respirator and gloves will stop you from getting this bug, consider that numerous doctors and nurses wearing much more protection became ill nevertheless and died. The only sensible thing to do is not carry people who are potential Ebola carriers. We are going to need leaders on the ground who take matters into their own hands and declare this policy despite the administration's assurances that all is well. The administrators and governing bodies have failed us countless times, they don't know what they are doing, and they are putting your and your family in harm's way. I also understand how difficult it is to take such a step yourself and risk being unemployed afterwards. I am facing the same challenge. Later today, I plan to meet with other doctors at my hospital and work on making a joint statement. There is strength in numbers and if a significant number of pilots stand together against this insanity, a more sane policy will emerge and perhaps we will stop this outbreak. The rest of the flight crew are going to be with you. You might be separated from that sick passenger and you can bring your own drinks, meals, and use a handheld urinal to avoid opening the cockpit door, but the stewardess has to touch his napkins and cannot avoid coming in contact with his invisible secretions. Also with you, will be the vast majority of the flying public. They don't wish to share the isle with a sick person from West Africa.

The way Ebola epidemics have always burned themselves out in the past is through difficulty of movement the afflicted populations faced. You might see a group in a remote village that was devastated by the outbreak but travel by foot is slow and they would die before spreading it to other groups. This time, major city centers are affected and the numbers will continue to climb. Add air travel and the disease has gone worldwide. We have to slow down its movement.

Anonymous said...

very well stated..and as someone who worked on a designated iD floor during the swine flu scare...we had to share N95's with each other..wearing in thepatients room and then hanging it on the doorknob for the next person, because that Hospital and most of the others didnt have enough equipment...crazy....so we all got seasonal flu from one worker who came in sick and spread it to all of us via the sputum covered mask we are guessing...aids virus stays alive in body fluids for a while...what makes anyone think this bug is not still alive in body fluids outside fo the body for a time...where's the freaking testing on that....

we need to prepare at home....Hospitals will never be able to prepare entirely for pandemic...its too big....

and in hospitals and other healthcare facilities today..it will always be the employees fault when it does spread as the systems are all perfect :)

we cant even hold facilities accountable legally because they all use "care plans" as weapons to cover themselves against lawsuit...

Anonymous said...

Bubba says
Oh wow now I'm really scared!
Great info & comments
Forward this to everyone I know
Thanks!

Always On Watch said...

Excellent information! Thank you for all these details.

So, now what?

Anonymous said...

Aesop,

Couple of questions...

Can EVD live in water? For example, a tank or reservoir, downstream of the treatment plant?

I've seen info online that it is killed during our normal sewage treatment, but didn't those guys powerwashing just put it into the storm drains? How long can it survive out of the host? The only study I can find suggests it's not too hardy on surfaces, but no info on say warm water...

Finally, do you know of any specific guidance for the 'superior' care being provided here? I only find CDC guidance that says support with fluids, and control secondary infections. What I'm looking for is something much more detailed. Like "Give anti-diarrhea meds, IV fluids at such and such rate, and some dose of a particular anti-biotic as a prophylactic"-- for example. How else can anyone plan or assess someone's readiness if we don't know how much fluid, etc to stock??

Are analgesics indicated? Anti-inflammatory? which ones are beneficial?

Someone must be setting care guidelines if CDC says hospitals are 'ready."

Thanks for your voice in the wilderness, and I fully support your desire to stay home. We'll need trained staff if we get through to the other side of this...

nick

CATP said...

ok, thanks guys for your comments. I agree that a full hazmat suit would be the solution for us in we are in close proximity to an ebola stricken passenger, but wouldn't goggles and some sort of adequate mask function well if you are not nearby? Say 10 feet or more from such a person?

For pilots we are mostly in the cockpit, and our air supply does not mix much with the air passengers are breathing. This is to allow for quick removal of smoke and fumes from the cockpit in a fire. Also, all air in the plane generally moves aft towards the outflow valves and is exhausted outboard. New air is constantly being brought into the cabin throughout the aircraft also. So, as a rule, the air up front in the plane is cleaner than the air in back. There is however some air that is recirculated to all parts of the plane, so being in the front is not a guarantee of clean air.

I completely agree about limiting air service to endemic areas to only mercy related flights and shutting down travel for all folks from those areas. Many pilots feel the same way as I. I have contacted my elected representatives to express my opinion, but so far all I get our platitudes about they are monitoring the situation.

I personally think it is too late, but we have to try to stop this thing from worsening. I think it is going to take personal action by flight crews to get this point made in public. Of course anyone who does so will be branded as politically insensitive somehow in the media I am sure.

How about sanitizing our aircraft after an Ebola passenger vomits on the plane? What will be needed to make it safe again for new passengers? I think that all cloth interiors will be impossible to sanitize adequately, not too mention seat belts, etc. Any thoughts?

It seems to me it is going to take first responders and transportation personnel working together to actually get a grasp on this epidemic. We are the front lines.

Aesop said...

@CATP,

With Ebola, distance is life.
Direct contact, even as little as shaking hands, can spread the disease.
Unless you're within splash range of vomit, diarrhea, or coughing bloody sputum, you probably don't need anything at all.

Now the caveat:
Go back and read my last few post re: Ebola, and note that until 9/19, the key phrase (since removed) from the CDC info page included the important phrase "we really don't know how Ebola is spread".
And we still don't, because until June, we'd only had a few thousand Ebola patients total since 1976, and most of them died rather rapidly, and far from any serious medical research.

That science hasn't changed, but admitting that what we knew was limited undermined the ongoing efforts to lie to people, I mean, um... massage the truth, so they took it down.

For the full answer on what to do next:
http://raconteurreport.blogspot.com/2014/10/epidemic-management-101-how-it-works.html

@nick
Medical management of Ebola is evolving. Most of what we know isn't even written down yet, because most of the patients ever seen are the ones happening right now.
If you're thinking/wondering about how to prepare to care for folks amidst this here if it becomes like Liberia etc., the short answer is, "Don't."

The success rate in Liberia is running at 10-29%. The infection of healthcare workers who are caring for victims was 10% of the casualty figures, before the infected population skyrocketed.

The strategy to "manage" Ebola if it comes to your state/county/town, is to keep yourself indoors, away from the disease, be able to stay there as long as necessary, with stored water and food, until it's safe to come out. That could be weeks to months.
In short, manage Ebola by not catching it to begin with. Otherwise, under the rosiest scenario, half the people who do will die. Worst case, 90%.
Imagine those numbers for your county, town, or family, and tell me why you'd want to play the game at all if you could avoid it.

CATP said...

Aesop,

Have you seen the studies where monkeys got ebol from pigs while in separate cages? Everything I am reading makes me think that at least at short range ebola is transmissible by aerosols. So, if someone who is infected sneezes or vomits or coughs near you, you could be infected. As you said, no one knows for sure how this is transmitted yet, otherwise there would not be so many infected health personnel.

CATP

Tarry Tillie said...

I am supposed to get a second knee replacement but I am too afraid to schedule it. I keep thinking of all kinds of "Suppose..." and "Hypothetically speaking.." to take the risk. I am able to get around pretty well now with only a very slight limp. I will live with that until we have the all clear sign--not from bureaucratic medical personnel but from several blogs such as this one.

Anonymous said...

"Imagine those numbers for ... family"

That's why I'm asking. If it breaks out, and there is no real treatment, there is no reason to take a member of my household somewhere else to die thru lack of care. And I'm not willing to push my child "out the airlock." Given our shared accommodations, by the time one of us shows symptoms, there is a pretty high likelihood we all have it. (Unless we see otherwise in Dallas, but now that the family is isolated, will we be getting accurate and timely status updates?)

So, anti-diarrhea meds, pedialyte, fever reducers, pain killers, and anti-biotics for secondary infection prevention. In the absence of info to the contrary I'll start there. It would be nice to know if any of that helped at all. I can't be the first one willing to try. It would be nice to know if some secondaries are more likely than others. SOME people are living thru this, at least for a while. I'm going to try like hell to be one of them if worst comes to worst.

I am prepared to isolate my family for a period of time to try to avoid contact. I'll be working on lengthening that time while the clock ticks.


As an aside, I'm not seeing ANY coverage of a European response or plan. Surely they must be talking about it. They have much closer ties to the affected regions.

Further aside, not much discussion about where aid will come from if the USA is stricken. WE come to others aid, we haven't needed much, and we aren't likely to get much from the rest of the world.

thanks again for the posts,

nick

Aesop said...

Ebola lives in bodily fluids.
That includes bloody sputum and saliva.
The range of both when coughed/sneezed can be measured in yards.

Somebody in a closed-door cockpit would be at minimal risk.
Anyone working in the passenger cabin would be in a death zone.
Nota bene, spending time exposed to a contagious Ebola patient without protective gear for an unspecified period of time is itself, considered close contact sufficient to transmit the disease even without direct contact, per CDC guidelines.
"being within approximately 3 feet (1 meter) of an EVD patient or within the patient’s room or care area for a prolonged period of time "
(They say "prolonged period", but don't specify if that's 20 minutes or 10 hours or whatever).
Thus in effect, someone with EVD is a disease hand grenade, and anyone close enough, long enough, is going to catch shrapnel.

If it ever mutates to becoming fully airborne in the sense that TB bacteria is, it will kill millions to billions essentially unhindered.

Tionico said...

I'm no medical professional, but I'm well aware that present protocols are a clown show. To prevent disease spreading, STOP THE MOVEMENT of vectors. Merchant vessels of old were required to go into quarantine upon arrival in a foreign port, and remain isolated for set periods of time. I've read how typhoid was spread throughout the Northwest native populations, and also how it was stopped (in the rare instances it was). And our "protectors" in government refuse to end commecial flights from affected areas, and impose quarantines? Insane.

Your "best case scenaria" detailed in hospitals shows some hope of effectiveness in such settings. But yuo never addressed what WILL happen when symptomatic individuals begin showing up at community health and urgent care centres. There will be no stopping it at that point, if indded we are not already past the point of no return.

The kinyun is rattling his gums prattling on about how "we've got this"... no, clown, your (in)action proves you/we do NOT. Will it take pilots and flight crews refusing to take flights to/from affected areas to preempt your failures? Our Resident is on a whinge because his "appointment" for replacement surgeon general is being rejected (due to his rabid anti-gun stance and attendant plans to use his new position to further restrict them). He seems to have nothing to say regarding handling of this REAL crisis. One can only guess (most likely accurately) that he's as clueless in real world medical issues like "how to stop ebola".

Anonymous said...

Army of the 12 monkeys

Anonymous said...

Yikes, and I was having such a good day, even for a Monday. I think I hate you. thanks

Anonymous said...

The incentives for the infected to procure Western medical care and perhaps increase their odds of survival by 30-50% is a problem. As the infections spread to countries like Haiti, Mexico, India, and every other country unprepared to isolate and treat patients, there will be individual proactive efforts to move sick patients towards the best care available. All of this advertising of Ebola survivors walking from the hospitals with big smiles on their faces may be counterproductive. The Western nations could become magnets for Ebola patients with transmission happening all along their travel routes. If my child contracted Ebola in Africa and I had family in suburban Atlanta, I'd be looking for a ticket on Pan(demic) American Airlines without a doubt.

Anonymous said...

http://www.newyorker.com/news/daily-comment

Atul Gawande is a very good writer and physician/surgeon. His stories of people living with and caring for Ebola patients without getting sick themselves are important for understanding the danger and how to deal with it.

A few days ago I read an article by the MD who was first cured here in the US. He said all the medical people felt themselves safe in hazmat suits, that they all caught Ebola in the ER clinics where they first see a patient, can't be sure who has Ebola. They all do both because they can't spend long in the hazmat suits, see the clinic as the dangerous place.

So you don't need the highest level of isolation until it really goes airborne, which doesn't seem to be a problem yet.

Anonymous said...

I also work in a hospital- RRT. Could not agree more. No one that I know of is the least bit prepared. Infection control as a general principle is already a joke. If hospitals were on top of ID, then where are all these MRSA and C Diff infections coming from?

We had a couple of emails go around a few weeks ago- forwards from the CDC about ebola. But like someone else said, we often run short even of regular masks. I doubt I could get an N95 or 100 mask for love or money at work if I were to go in there today looking for one.

Christine said...

The CDC and the government are in "don't panic the masses mode". What they don't seem to comprehend is most of us out here have the internet. Most people out here are not fooled by the lies. I listen to them and only believe a quarter of what they say. And that has to be the common sense information. They are lying to us and they know it. Time could get really interesting here in the US in the near future. More cases will cause at least some of the sheep people here to wake up.

Christine said...

Here is a petition to sign in an attempt to stop passenger flights from W. Africa. It may or may not work, but at least it is an attempt. It definitely won't work if people don't sign it.
https://petitions.whitehouse.gov/petition/have-faa-ban-all-incoming-and-outgoing-flights-ebola-stricken-countries-until-ebola-outbreak/FFJHH9yX

Anonymous said...

23 total, eh? And Duncan has already infected possibly that many by himself - who if infected will have to be flown all over the country for treatment. Which risks a multi-location outbreak, starting with the treatment experts. What's not to love about this deal?

And the 24th Duncan recipient? Hell, that one stays in Texas to infect everybody in town because there's no room for him. Well, maybe we should just put these folks in tents along the border, eh?, and let them infect all the drug smugglers. There could be a sliver lining in this storm cloud after all.

Aesop said...

Who will then spread it among the 20M illegals here now, any number of legal residents, and 80M residents of Mexico?

Because what we need is a large minimally-educated, non-Emglish speaking population living in crowded conditions with poor/no healthcare, to become the next batch of handy Ebola disease carriers, at (among other places) potentially every food vendor from Texas to Minnesota?

Are you out of your mind??

Anonymous said...

Some limited success has been reported by treating Ebola patients with the older AIDS anti-virals, specifically Lamivudine.

This drug is readily available and relatively cheap.

Success in this context means a mortality rate of 15% instead of 70%.

The sample population was rather small (about 20 people in Liberia) and could be a statistical fluke or merely wishful thinking.

If anything is found that works, you can be sure that it will not be through randomized, double-blind clinical studies approved by the FDA.

Robin Datta said...

Raconteur:

Really appreciate your shovelling aside the mountain of male bovine faeces to expose the reality to the light.
- a retired ED doc.

Aesop said...

YW, Robin.
Thanks for the link on NBL!

Aesop said...

@Anonymous 6:59

Yeah, I saw the CNN report from the Liberian doc several days ago.

A 10-day course for a notional 20,000 patients would run $1M, call it $2M for clinical field studies.

The .gov pisses that away in 5 minutes, and the (expired) patent holder GlaxoSmithKline made $11B in profits last year, so in exchange for the US and UK extending patent protection for this new use, they should be asked to supply it absolutely gratis to W. Africa, starting five minutes ago.

It's already tested and proven to be safe for human use, and if it works, even only partially, it could kick this outbreak right on its ass overnight. Worst case, they write the $2M off on their taxes as a research dead end. Win-win for everyone, and a potential anti-Ebola drug in hours, not years.
And the Liberian doc and the CEO of GSK get Nobel Prizes for Medicine and/or Peace.

Robin Datta said...

The AirForce has pressurised suits for aviators above 40,000 feet. Those should work to keep eBola out. But those suits are perhaps not suitable for long-haul flights: the aviator can't eat or drink, and has to relieve oneself in the suit.

And then again, chopping off 40% or so of the "entitled" folks (Social Security, Medicare, Welfare, etc.) will be immensely helpful to Uncle Sam. So the elites and oligarchs may actually welcome eBola!

Anonymous said...

As a recently retired nurse, I will agree that everything you've said is true, if not worse. I worked ER and isolation. I volunteered for the bio response team at our hospital after 9/11. Ebola has the potential to burn through America and make Africa look like a wet match. When the average person comes to the hospital for a broken nail or constipation, and can travel 500 miles at the drop of a hat, there will be no containing it. And people assume that doctors and nurses will stay and die for ebola patients. Some will. Lots will quit on the spot.

Anonymous said...

And please don't forget that the police issued a warrant of arrest under mental health for the homeless man that was exposed to the Ebola patient. When the homeless man had no idea what was going on......can anyone say abuse of power???

Aesop said...

Actually, he was by all accounts a legitimate mental health case, even more so because on the loose he was quite literally a danger to himself and others.

The problem comes in that it's pretty tough to do isolation quarantine concurrently with psych holds.

The concept of a roomful of people trying to maintain contact precautions while trying to restrain him if he flips out is the point at which a taser becomes a medical device.

Percy said...

Just found you, Aesop. Wonderful blog, this one, and grand trip down Ebola Lane. I will return often.

Surely most people with brains already know all this and knew it would be the case if the disease ever got here. What remains unknowable is how many people here and in Europe it will kill before it burns itself out or does whatever it does so it is no longer killing people we notice.

Your math on what makes sense using hospital isolation rooms is unanswerable. But we won't control their use that way -- not soon anyway. Not until they are full of ebola patients. Surely hospital managers and medical staff are already having very bad dreams about this.

What number of cases, do you think, Will that be enough to put our society and values on tilt? And then what? Not a pretty picture.

Aesop said...

One case crushed Dallas' ability to cope.
To date, I'm still waiting for news of anything they did right the first time.

Ten such patients would utterly crush medical services in that city.

One hundred, and it would be no different there than in Monrovia, Liberia, in a matter of days.

Not least of which because I don't expect the staff anywhere to continue to work at Ebola General Hospital. They'll simply stay home, and that will be that.

Anonymous said...

Thank you for this blog! I have been telling anyone that will listen (pretty much nobody) that what we are being told by the CDC is downright unconscionable. I live in Dallas, and have been watching local and internet coverage of the breakdown in care/isolation for the ebola patient, subsequent handling of his family, apartment, the sidewalk outside his apartment - all with my jaw on the floor. I saw the apartment's maintenance man power washing the ebola laden vomit wearing nothing but a t-shirt, jeans and sneakers. I saw the mist from said power washing swirl around him as well as an Indian woman standing roughly 10 ft away from him, and about 2 feet away from the runoff in nothing but her street clothing and sandals.

I watched as the local crazy judge man walked into the ebola hot zone apartment with two assistants in nothing but street clothing to speak with the now quarantined family of the ebola patient. Two days later I saw the same local crazy judge man transport said family to a different locale in his own car. Four days after that I watched a hazmat team decontaminating his vehicle.

I've also worked in hospitals as a mental health clinician. EDs, ICUs, step-down units, med-surg floors. I often had patients with MRSA that required a psych eval. Most times I didn't realize that the patient even had MRSA unless I happened by chance to see a gown cart parked outside the patient's room, and gowned-up on my own. None of the clinical staff felt it necessary to relay that info to me. As a side note, I once remember speaking to a psychiatrist that followed-up on one of my patients, and when I mentioned to her the patient had MRSA, she said "Great. I didn't gown-up. If I catch MRSA on my butt it's because I sat on the chair next to the patient's bed while I spoke to him." Yep, that's hospital communication for you.

Given what I've experienced working in medical environments, the audacious and somewhat hostile attitudes that are rife in such places, as well as watching step by step the complete and total failure of the CDC and local gov't to handle a single ebola patient, I am just shaking my head wondering how long before I turn on the news and hear that we have 100 patients with ebola here in Dallas.

Like a lot of people have previously said, it may be too late to contain ebola in the US. Given our government's abject refusal to limit air travel to necessary medical personnel, and ideally a 21 day mandatory isolation period before those people return to the US, I just don't see a lot of hope of containing it to a single patient.

The only beacon of light I see are blogss like this one where at least everyone isn't in a constant state of denial, gazing admiringly at the emperor's new clothes…

Aesop said...

@Anonymous 12:34
Pull up a chair and sit for a spell, my friend.

mcridge said...

Good article, lots of excellent points. As an industrial hygienist from industry, I know how the suit-up, work, clean-p scenario goes, even with well trained, experienced personnel.

One question: I believe that all specimens should be handled in level 4 labs with level 4 procedures. How many hospitals, even those with isolation rooms are equipped and trained in their labs?

Robin Datta said...

EBola from a somewhat wider and longer-term perspective:


Ebola and the Five Stages of Collapse

pb2014 said...

Why dont pilots and flight attendants go on strike not to fly there? It is their lives also...

Robin Datta said...

When they start keeping patients outside those twenty-three beds, the emmeffs are endangering hospital staffs.