Friday, August 8, 2014

Pandemic: How It Works At The Pointy End

First, read this forum post.

This guy nails it, because he knows what he's talking about.

Let me break it down for you.
I've been a nurse for nearly 20 years. Twelve of them at two of the busiest ERs in the country, one of them the busiest ER on the planet.

A healthy chunk of my time at both facilities was primary triage, which is bar none the hardest job in the ER, and the one they assign to the nurses in each ER with the best grasp on emergency nursing.

My job, frequently for weeks on end, including especially during some epic flu epidemic seasons, was to sort people into degree of urgency, do a basic history, screening, and evaluation of presentation, and then get the sickest people in to be seen first, while continuously keeping up with the flow of inbound patients, room availability, incoming ambulance critical cases, admissions, discharges, etc. In a large department, that involved having 100+ people waiting to be seen, 50+ rooms occupied, and keeping workloads appropriate between 6 doctors, a resident, a medical student, four physician assistants and twenty nurses.

On crappy flu season nights, we saw well over 500 patients in one 24 hr. period, and our 24/7/365 average is well north of 300 a day, any and every day.

That and a buck gets me coffee at Denny's. So what?

Let's put ONE patient with latent Ebola into that mix, and look at a worst case.

Patient Zero hits the door, sees the nurse just inside at the front door, there to eyeball everybody, and speedball the critical ones coming in with SOB (shortness of breath, not bastardlyness) or acute Chest Pain, after the patient pulls up in his vehicle, which he's coughed and sneezed in and all over, which is then parked by valets. The valet is infected. Then he grabs the set of keys of a family discharged and heading home, touching their keys, steering wheel, shift, parking break, seat belts, etc. So now that driver is going to get infected.

The valet now goes back, after rubbing his eye, nose, or mouth, and handles a phone, pens, clipboard, and key locker. Now the other 2-5 valets are going to get infected. And all the patients leaving whose cars they park or retrieve. And their families. And the valets' families. If not tonight, then tomorrow or the next day.

Meanwhile, the patient, presenting with sore throat, cough, fever, maybe vomiting and/or diarrhea, clearly non-critical compared to having a heart attack, stroke, or asthma attack, sits down in the waiting area and fills out their short form info sheet: chief complaint, name, personal info. Then brings the clipboard and pen back so the nurse and financial clerk can input them into the computer database, so that their prior records can be matched up, and to put them on the master patient tracker so that the charge nurse, triage nurse, and all the treating physicians can see what's waiting on deck.

The pen and clipboard are now contaminated, along with possibly the nearby patients and visitors, the chairs, maybe the drinking fountain, and perhaps the restroom doorknobs and faucets. Perhaps they go to the cafeteria while they're waiting, or one of the other newly contaminated people does. They grab a few forks from the cutlery bucket, the doorknobs, the food freezer handles. etc., which the entire hospital uses the next day.

Other than an "eyeball survey", they haven't even been seen yet, and they've already killed 200 people, in about a month from now. Including the outside nurse, who took the pen and clipboard from them. And her family. And her spouse's and children's friends. And all the other kids at their school, and in their neighborhood. And their parents. And their parents' friends and co-workers. And their kids. And the other kids and teachers and other staff at their schools. And their parents, and their parents co-workers. And on and on.

In a month or two, just one Patient Zero has wiped out a county of several million people.
And everyone they shake hands with, cough or sneeze on, or whose door handles and shopping carts they handle, everybody on every bus, airplane, or train they ride in, etc.
And just for fun, there are four major destination theme parks nearby, one of them known as the happiest place on earth, which is currently seeing 20,000 visitors a day, from all fifty states and 100+ countries, this week alone. We regularly treat their employees and guests, who then return to work there.

Note please that Patient Zero hasn't even been triaged yet, let alone put into a room to see a doctor. And Ebola is "droplet precautions", i.e. the virus is transmitted by body fluids, including cough and sneeze droplets, which fly through the air and land on clothing, surfaces, etc., as well as secretions like tears and snot, not to mention linger on the hands when someone is less than surgically sterile after washing up from a bout of vomiting or diarrhea.

Thing is, at this point, no one knows the patient has Ebola.

Test for it?
No problem. Takes 2-3 days, after sending the sample to CDC in Atlanta.
Take precautions just in case? Sure.

The best-equipped ER I've been in had a total of four negative airflow rooms, where the air is sucked inside under negative pressure to keep snot drops and such from migrating out, and the air is exchanged through HEPA filters multiple times per hour to filter out contaminants, for things like patients with known or suspected TB, etc.
All the other rooms share airflow with the normal circulation system, which is all of the ER, the co-located X-ray department, the financial services office, the observation unit next door, and the main waiting area.
And each time on that shift that someone goes in, they have to don a new set of gloves, put on a new disposable gown, and Ebola requires fully enclosed goggles and a head-covering hood which we don't even carry or stock. So that's a full box of gloves and gowns per patient, per shift, even if no one goes in more than once an hour on a twelve hour shift. That would be a shipping pallet of such disposables per day, for a hospital that doesn't go through that stuff at the rate of a pallet a week. So in hours we'll be out of all the supplies we'd need to adequately and safely care for even one or two such patients if we only suspect Ebola, and take appropriate precautions.

Sneezing, cough, fever, vomiting, and diarrhea is the nightly symptom set of 1/3 of all ER patients every night, forever. {As noted in a prior post, by the time they start vomiting and crapping blood and their internal organs, and bleeding from the eyeballs, the freeways to Anywhere But Here will be bumper-to-bumper outbound, and there won't be anyone triaging or treating them, least of all yours truly.}

And being non-critical on arrival, if it's a busy day or night (most people come at night, because stupid, and because why miss work when it costs you money, when you can come by after 6PM when most of the hospital is closed and your private doctor is home or asleep, right?) they'll wait up to an hour to be initially triaged, and on horrible nights during flu season, four or six hours to be seen. During which time, they're coughing, sneezing, and perhaps vomiting - with splashback - out in the main ER waiting area, with not just up to 100 patients, but their families, including any number of unrestrained and unsupervised children from ages 2-17, who typically run around like wild baboons on crack.

So after infecting everyone nearby, they get put into a room, see a doctor, infect their treating nurse, the tech who takes their vital signs, perhaps the housekeeping staff who comes in after a vomit or diarrhea episode that misses the target, their doctor(s) - one may leave at the end of their shift, and hand the patient off to a second doctor, the x-ray techs who take a chest x-ray, the relief nurse who comes in during the primary nurse's break period, the financial person who does their in-room interview after the doctor sees them, and then anyone else whom those staff members see, touch, care for, etc., and their families and random contacts as well. (Try to recall that 300-500 patients a day thing, when you realize that the medical staff - doctors, nurses, techs, etc. will be back the next night, and the next, only now even more infectious as the Ebola they unknowingly contracted multiplies in their systems too, until they're finally sick enough to call off.) And if somehow they're miraculously admitted for what is generally a non-fatal set of symptoms, multiply this by all the staff and visitors on an upstairs ward, which equals more disease spread, faster.

So let's say that patient came in to Somewhere Unlucky ER last Friday, August 1st. By the end of the month, everyone in the hospital is infected or dead. In six weeks, the county is all sick or dead. At seven weeks, the entire state is. In eight to twelve weeks, the country and the world. 

Halloween isn't going to have nearly the same meaning when 60-90% of everyone's dead, will it?

And that's with first-world health care, at generally excellent facilities, because there's no effing way to put everyone there in a spacesuit 24/7/forever, and put all incoming patients into a bubble and a HEPA-filtered mask and gown for everything until Hell freezes over.

And that's what's one unlucky patient away from us all, with nothing more stringent than airlines asking people where they've been, and occasionally checking the sick-looking ones for a fever. Only British Air and Emirates have fully suspended flight service to the affected countries. (Which means if the disease skips to other non-quarantined countries, it won't work even for them.)

Bear in mind that both of the American victims brought to Emory in Atlanta walked into the hospital under their own power days after being confirmed as infected. And try to recall that people desperate to flee for their lives might actually -gasp!- lie on an airline screening form.

Sleep tight, cupcakes.


Anonymous said...

We have now had the "unlucky" in Dallas. If MSM is to be believed, there was only one additional casualty, a nurse who cared for Zero, allegedly in full protective gear. If they are lying we shall soon know better.

If this virus was as contagious as you claim, there are a few African countries that would now be depopulated.

What I find especially interesting is that in Africa, the number of casualties among caregivers seems to be higher for fully protected medical workers than for unprotected family members. I wonder why?

Aesop said...

Hindsight being 20/20, Dallas Presbyterian achieved a perfect 2 R-naught, successfully infecting two ICU nurses, despite their half-assed (and CDC-approved) "precautions, which are dreadfully short of what MSF/Doctors Without Borders has established empirically - in the hot zones - as the right way to do this. The spread stopped because they
a) transferred the two nurses to CDC BL-IV hospital beds, of which the entire US has 8 available to the general populace,
b) got no more new Ebola patients
c) shut down their ICU and ER because their staff all threatened to walk out permanently if they didn't.
d) turned a 600-bed hospital into a ghost town overnight, because their own doctors and patients weren't as dumbass stupid as the CDC and their own hospital administration.

The virus is not this contagious in Africa because lacking the money, patients there don't go to hospitals until they're nearly dead, and sometimes not even then. A notable number just die at home, or wandered out into the jungle to die.
The ones who collapsed in town were taken, not to regular hospitals, where they'd create that exact course of epidemic I outlined, but rather to purpose-built Ebola clinics, where they were strictly quarantined from first contact field pick-up in a way that would be draconian if practiced hereabouts.

The "fully protected" medical workers are, nota bene, contracting the Ebola when they leave the hot zone wards, and see un-quarantined sick patients (fever, vomiting, diarrhea) while they themselves are unprotected by the MSF Ebola-protocol PPE, in the normal clinical areas of the same hospitals, and get infected exactly as I described in this essay.

Almost like I knew what I was talking about, huh?