Wednesday, April 1, 2015

What Ebola? Where?


As noted yesterday, Ebola is not, in fact, gone from any of the three most heavily impacted countries in West Africa.
In fact, the weekly tallies right now are running at a fairly steady percentage of what they were during the apparent peak weeks last fall.
And without laboring yesterday's point, based purely on admittedly bogus numbers of dubious reliability, for any given point in this outbreak, including now.

In the past, outbreaks have burned out; usually by killing 90% of everyone in some remote village, and then going away because the other 10% survived/were immune.

We don't know how the Index Patient in this outbreak contracted it. Just like we don't know where any other Index Patient in any prior outbreak contracted it.

But this time, it hasn't gone away. Because this time, there's a near limitless pool of new victims, because it isn't confined to some remote little village. It's gotten loose across entire countries, and in the large cities thereof.

And it simply hasn't disappeared in any of them. It waxes and wanes, but it's still infecting people, and still killing them in droves. Despite everything we know (and don't know), and despite everything we've done and not done, it just keeps on keeping on.

It keeps infecting the careless, the stupid, the ignorant, and even those taking special precautions and wearing frickin' hazmat gear.

We did not duck this bullet, it just went over our heads last time.
There is absolutely NO reason to assume this will continue to be the case. In fact, rather the opposite: every day it doesn't spread just makes the day it does more inevitable. Like against terrorists, we have to get lucky every time, this virus just has to get lucky once. The calculus on that argues for preparation for what is clearly inevitable.

So how's that going over here?
No ban on flights here from there.

But why do that? No one has gotten here since they started the screenings.

Yeah. And signs prohibiting it are what keeps elephants out of the trees at the local park.

Which argues for several things:
* the screening measures, shoddy as they are, have been good enough to stop obviously infected people from travelling, in most cases (they wouldn't have stopped Duncan)
* it's harder to spread early on, and thus early infectees who are pre-symptomatic are the only ones who can make it past the screening
* we're dealing with a target population for whom taking an airplane flight is only slightly more likely than flying to space.

Unfortunately, that means that:
* those who do travel will have the means to go anywhere
* they won't raise suspicions until they're far from the minimal screenings that exist
* they'll then become symptomatic amidst their home populations, long after they're not under any sort of organized and mandated surveillance, and thus all reporting is completely on their honor and best behavior.

And as witnessed with Dr. Special Case, Dr. Special News Reporter, and Nurse Mimi Crybabypants, people, even trained medical professionals, are self-serving lying little shits who will endanger the public recklessly and repeatedly, left to their own devices, where Ebola and the horrors of quarantines (which latter have been instituted and accepted by all civilized people since medieval times) are concerned.

And that's just assuming the disease stays in West Africa, behind the current zone of interest.
If it gets out of that zone, like the Germans going around the end of the Maginot Line, there isn't anydamnthing to stop it or even slow it down.

And what about here?
We still have a treatment capacity of 11 beds, nationwide. And several of those are permanently reserved for military research casualties, so it's really only 7-8 beds.
I.e., the same number of Ebola cases in any of the three originally affected African countries by Week Two.

Then, it's back to local hospitals.
Which is to say, the Worst Of All Possible Worlds.

Dallas gave you a glimpse of what to expect.

As I've related, I've been flitting hither and yon locally in my professional capacity.
I'm here to tell you, having now seen multiple local hospitals, it's far worse than I could have imagined.

Most hospitals have no supply of protective gear for even a single outbreak case.
Many have no negative airflow room in which to place the victim(s).
None have more than a very few of them.
All of them require moving an infected patient through the entire ER, from lobby to treatment area, completely exposing not only visitors, but their entire staffs, to potentially infectious material.
None of the ERs I've worked at has any personal protective equipment rapidly available.
None of them has adequate PPE available for more than a few staff members.
None of them has conducted anything but cursory training in dealing with potential infectees; most have conducted none at all, and a few don't even address the possibility of it ever becoming necessary.
None of them has any capability to sort infected people before they enter the hospital, nor do most have any plans to do so.
The ones that do have plans are mainly limited to vague incantations about setting up some ad hoc magical whatsis. None have actual sorting facilities, decontamination abilities, nor have held any training or exercises to practice such implementation.
None of them has any capability to treat so much as one potential case, and still safely stay open to other patients, yet that is precisely what they have done and will continue to do, until it becomes apparent that they've already contaminated their entire staff, the entire ER, and recklessly and deliberately exposed dozens to hundreds of unprotected people to the disease.

Go back and read that last sentence again.

Bear in mind we're talking about busy ERs in a diverse, multi-lingual major metropolitan area, wherein reside approximately 10% of the entire US population, countless international tourist destinations, multiple international airports, three major seaports, and an international border within 1-2 hours' ground travel distance. Not the 2 bed ER in Podunk, Inner Wyoming.

Now let's talk about your ER, especially if you're within a tank of gas of those five major destination airports for flights from West Africa.

Then let's talk about your ER if you don't even have that going for you.

And now I'm not even on the home team in those ERs?
Potential Ebola Case walks in, I'm out. Period. Done. B'bye.

And the difference for me is, at least I'll know something there, because they'll come in with suspicious symptoms.
What are you going to do when someone coughs in the market, or is sitting next to you in the theatre or the bus with a fever? Wait until blood is shooting out of their eyes?

Best wishes with that plan.

I repeat, Dallas was a warning shot.

IIRC, Duncan was sick in hospital for a week or so before he died. I don't know how many nurses cared for him there; at 2/day it could have been as many as 14, plus ancillary staff, or as few as two. And with their inadequate protective measures (the same ones I've seen ready or not at most local hospitals) that means he successfully infected between 14% and 100% of his direct caregivers.

All of whom KNEW he had Ebola before they walked into his room.

His one case closed that entire ER for the duration-plus, and the ICU, and for all intents and purposes, a 400- or 500-something bed major acute hospital became a ghost town overnight. It may yet stave off financial ruin and bankruptcy.

Based on the early reports of the first nurse's lawsuit, I wouldn't hold my breath there, and despite the blow to the community, they probably don't deserve to stay open.

Then there was the disruption and expense to the city and county, from a grand total of three actual cases: Duncan himself, and the two nurses. (And both of them were evac'ed to two of those eleven beds mentioned earlier pretty rapidly.)

So the moral of the story is, the first eight or so people infected here have a shot.
Patient Number Nine and following will stand about the same chance as victims in Africa.
Which is somewhere between a 10 to a 40% chance of survival.
And, evidently from recent news, with a lifetime's major permanent disabilities and sequellae, including lifelong vision deficits up to and including permanent blindness in many cases.

So yeah, Ebola has plateaued at a fraction of its peak, but refuses to burn out.
Which is merely that same exponential growth curve, on "Pause".

And given the current mutually-agreed-upon news blackout, your first clue it's rolling again will be when they announce on the news that someone is at County General, and came in shooting blood out both ends after they collapsed at the mall.

And then it's last September all over again.

Oh, BTW, for reference, at one of those ERs, in one week's time I've taken care of ten patients who came in with such routine symptoms as coughing blood, vomiting blood, and/or bleeding out their back end. We won't even talk about how many had fever, headache, and body or joint aches. So yeah, we'll get right on catching that Ebola patient the first time they come through the ER, because it's so easy to spot.

Just like they did in Dallas.

Sleep tight.