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Yves here. The media, predictably, is missing a significant part of the real story about Ebola worries. On the one hand, the disease is not terribly contagious, yet coverage has been intense to the point of being hysterical about exactly who the Liberian patient in Dallas was in contact with before he died. Similarly, a reporter at CNN was up in arms about the current lack of screening of inbound passengers at international airports.
As Dr. CB pointed out via e-mail:
Was this reporter shocked at the lack of screening for SARS which has airborne transmission during the height of this epidemic? Did we call for flight bans to and from Asia? Why no outrage for the 8 SARS victims in America in 2003? Why didn’t Emory get any press time for treating 2 SARS patients in our isolation unit?
EBola is transmitted the same way as Hepatitis B and HIV. It is much less contagious than SARS. Very hard to pass it on by casual contact. with SARS you just had to sit next to the guy in the airplane. With Ebola, you have to suck face, handle their poop or vomit and blood. I don’t think airline passengers engage in this initmate way on a normal basis……….Ebola is currently following evolutionary microbiology as it goes from 90% to 50% mortality rate and thus is becoming more contagious. Remember, when a parasite kills its host too quickly and efficiently, it is muck less likely to spread around.
Viruses that become less and less deadly become more and contagious as the host is able to walk around and spread the parasite.
Yves here. Ebola has not caused great alarm in the past, precisely because it was such a speedily deadly disease. Thus, as CC stresses, perversely, if it becomes less of a death sentence on an individual level, it becomes a greater public health menace. While Ebola has a 90% mortality rate, the Spanish flu pandemic of 1918-1919, which killed 20 to 40 million people (more than died in the Great War), had a mortality rate of 2.5%.
However, we stressed that concern about Ebola should lead to more serious investigation of whether the US health system is able to handle the outbreak of a pandemic. Epidemiologists maintain that the outbreak of a pandemic is almost inevitable; it’s a matter of when, not if.
An earlier post discussed multiple reasons why our profit-fixaed system looked ill-equipped to respond to the need to respond to a massive outbreak. This post looks into a particular failure, namely, the handling of the first Ebola case in America, and how it exposes additional shortcomings in how hospitals are managed.
By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
As discussion, if not outright panic, about Ebola infections increases in the US, it is still hard to figure out what heath care professionals and the health care system need to do to protect patients and the public in a very changed world.
One pressing question is how to identify people at risk of having the infection so as to best care for them, and to protect the public from further spread of the infection, without swamping the health care system, needlessly reducing civil liberties, or spreading further panic.
To better answer question, better understanding why the first patient who was diagnosed with and then died from Ebola in the US was initially not diagnosed might help. However, at this time, the whole thing seems mysterious. As a column published on October 7, 2014 in the Dallas Observer was entitled,
“Why Don’t We Know Yet Exactly What Happened When Our Ebola Patient Zero Appeared?”
On this blog, InformaticsMD was the first to speculate that problems with the design and implementation of an electronic health record (EHR) might have enabled the discharge of this patient, after he presented to the emergency department with non-specific symptoms soon after returning from Liberia. The next day, an official statement from Texas Health Resources seemed to confirm that a “flaw” in the hospital’s EHR prevented adequate communication of the patient’s travel history between a nurse and a physician. However, one day later, as InformaticsMD discussed here, the hospital reversed itself, releasing another statement that there was no “flaw” in the EHR. That statement, however, did not explain either why the first statement came out, or anything more about the diagnostic failure.
So, as the Dallas Observer column stated,
The question of why Duncan was sent home initially instead of isolated is still the most stubborn mystery in the saga of ‘Ebola Comes to Dallas.’
As columnist Jim Schultze explained, this question has implications for health care professionals and health care organizations who need to figure out how to best deal with the next patient who shows up who might or might not have Ebola.
If Duncan’s dismissal from the emergency room on his first visit was a bungle, then it’s reasonable to assume that everybody knows about the bungle by now and a similar goof is unlikely to happen again at any decent hospital in America. But if the handling of Duncan grew out of something more systemic, especially a business or management style or policy, then it may be less reasonable to assume the next hospital will be immune from the same issue..
In other words,
if the Eric Duncan mistake flowed from something more systemic, then we absolutely need to know what it was and how it happened so that we can look for the same problems everywhere else. If it was a non-medical problem, I can almost guarantee you it will turn out to be an issue not be unique to this hospital.
Mr Schultze is not the only one to point out the critical need to solve this mystery. He quoted
former Boston hospital CEO, Paul Levy, called on Texas Health to open up: ‘A failure by a hospital to be open about what went wrong in a major medical case such as this,” Levy said, “does a major disservice to everyone else in the health care industry.’
Similarly, the editor of FierceEMR wrote,
The Texas Health situation may be setting a dangerous precedent. This is a major world health crisis for which providers worldwide are trying to prepare. If truly the mistake Texas Health made in releasing Duncan was its mistake alone, so be it.
But if there really was a design flaw, then every provider–and every vendor–needs to know about it, evaluate whether it has the same problem, and correct it.
The patients deserve no less.
So far, to date, we have heard nothing more from the managers of Texas Health Presbyterian or its parent non-profit corporation, Texas Health Resources. It appears we need a reincarnation of Sherlock Holmes to solve this one.
Sifting a Few Clues
I am not he. But I do believe there are some clues, however, weak, that suggest system flaws. They can be found in an interview of the new Texas Health Resources chief operating officer (COO), Dr Jeffrey Canose, published in Healthcare Informatics a few weeks before Mr Duncan presented first to the Texas Health Presbyterian emergency department.
One of his points was that the hospital system is changing its emphasis from acute care to population health (however that may be defined),
we made the decision to become more of an integrated health system, and started to build the infrastructure for population health
Then,
The biggest challenge is to continue on our journey to increase our capabilities as a fully integrated health system; to develop the competency to be a high-performing system in the realm of population health management; to shift our focus from sick care to actually managing well-being….
Also, he referred to participation in the Pioneer ACO program as
one of our first significant efforts in shifting our focus from being acute-care-centric to being more focused on the full continuum of care
Recall Mr Schulze’s point that the failure to diagnose Mr Duncan could have been due to a business management style or policy. So maybe we have a clue that the hospital’s policy to reduce emphasis on acute care, including the emergency department, might have had to do with problems in the ED leading to a diagnostic misadventure.
In addition, Dr Canose noted,
the electronic health record is a huge enabler to all this; the next challenge will be to enable things further, including through data mining, working with big data, and clinical and operational support
So,
around collaboration at the sharp point of redesigning patient care—… people in IT are mission-critical partners in hearing what kinds of problems we’re trying to solve, and in helping us to figure out how to drive clinical transformation and care design, and how to drive efficiency.
So maybe we have a clue that the management was very heavily intellectually invested in their health care information technology infrastructure, and perhaps thus less willing to think about how health care IT could be the cause, rather than solution of problems, such as diagnostic problems in the ED.
Finally, this may be just a hint, but Dr Canose spoke
We have a clear focus on continuing to elaborate the infrastructure we need in order to do population health management, and we’re continuing to build those capabilities over time, and explore ways we can deploy through our employed physician groups,…
This implies that many physicians who practice at Texas Health Resources hospitals are in fact its employees. We have at times written about the perils being a corporate physician. One is loss of autonomy, as physician employees become beholden to organizational managers. So maybe we have a clue that physicians’ loss of autonomy, perhaps the autonomy to put patients ahead of corporate policies and managerial edicts, such as those deemphasizing emergency care, could have enabled the failure to diagnose the Ebola “patient zero?”
Summary
We wrote earlier that the rise of generic managers as leaders of health care organizations degrade the US’ ability to deal with Ebola. In the mystery of the discharged Ebola patient, we seem to see the sort of managerial obfuscation that seems characteristic of many generic managers. More transparency from the management of Texas Health Resources would surely help the US deal better with the ongoing challenge of Ebola. In the long run, Ebola may teach us a hard lesson about the need to put health care leadership in the hands of people who understand health care, and subscribe to its mission to put patients and the public health first.
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one things for sure…the planets are alined for Obama & his care. healthcare workers are facing risks unlike other flu’s and Leaders won’t be able to hide from this…for long.
electronic systems also rout accountability…and ‘they’ didn’t see this on the horizon?
money before people will bankrupt them one way or another…ebola will just add speed to the equation.
The biggest challenge is to continue on our journey to increase our capabilities as a fully integrated health system; to develop the competency to be a high-performing system in the realm of population health management; to shift our focus from sick care to actually managing well-being…
Translation: Having determined that merely treating people who are actually sick, many of whom won’t seek our services until they’re terminal anyway, is simply not profitable enough, we’ve decided to expand the scope of our “services” to convincing perfectly healthy people that they have something to fear as well, and that if they’ll just pay our exorbitant fees, we’ll allay their fears through our “drugs for life program” and magically make them “healthier.”
A hundred years ago we labeled these bozos snake oil salesmen. Now they’re perfectly respectable corporate capitalist “well-being managers.” Same tried and true con game, better marketing. And I think I can manage my own well-being just fine, thank you very much!
Yeah, the irony is that we do need to shift our resource focus from treating individual sickness to promoting healthy living among the general public.
But putting hospital executives in charge of public health is like putting car executives in charge of rebuilding our passenger rail system.
Sorry, but I doubt very much western medicine as it’s currently conceived is equipped to provide well-being to any meaningful extent whatsoever. The current and ongoing cholesterol scare is a prime case in point. Nearly thirty years on, we’re discovering that not only was the original research done with a preconceived end in mind (selling cholesterol meds to a gullible populace for life) and entirely specious, but that increased consumption of refined sugar (the natural caloric replacement for all that lost fat) was the prime culprit all along and that statins and low-fat diets simply pour fuel on the fire and add extra billable ailments to the mix as an added bonus.
On the other hand, the profits were enormous, so there ya go!
http://www.biblelife.org/cholesterolmyth.pdf
Lenfant made his request at a meeting in May of 1986. In a group generally notable for the calm of its proceedings a
heated debate ensued, and in a rare rebellion the advisory council refused to endorse the director’s proposal. “Physicians
just aren’t convinced (about cholesterol), ” said Eliot Corday, a prominent Los Angeles cardiologist and the council
member who led the dissent. Nonetheless, the heart institute’s machinery cranked relentlessly on. Six months later the
proposal was resubmitted and rejected again, after additional debate. But after another year, at a moment when the
mixture of council members in attendance was slightly different, a scaled-down research program was narrowly approved.
One reason for the initially low public profile of the National Cholesterol Education Program is that its primary goal was to
influence the physician community. Starting in late 1987 every practicing doctor was sent a report summarizing the
institute’s “consensus” conclusions on cholesterol. A much more elaborate information kit on treatment went to 200,000 of
the nation’s physicians, including cardiologists, doctors in primary care, general practitioners, internists, and
family-practice physicians. The heart institute’s eager partners in promoting cholesterol consciousness are the drug
companies, which are understandably excited that the government is creating their largest new market in decades.
Most drugs face the inherent limitation that they soon solve the medical need that led someone to take them, and are no
longer necessary. Drugs that are needed indefinitely-such as tranquilizers and medications for hypertension and
angina-are the biggest money-makers. Thus the medical journals were soon packed with advertisements for
cholesterol-lowering drugs, and salesmen were knocking on the doors of physicians’ offices from coast to coast. And what
could be more effective in beating down physicians’ sales resistance and skepticism than the explicit endorsement of
government experts?
I lowered my cholesterol by cutting carbs and sugar and enjoying such yummy snacks as a piece of fried bacon spread with brie and topped with sliced strawberry. Lost weight too. Alas, I couldn’t stick strictly to the diet as I do love a bit of potato with my protein.
I’m eating nearly 2 dozen eggs per week now with lots of real butter, real cheese, and real meat (mostly low fat Turkey, but not strictly) on Ezekial sprouted bread. Dropped all the incessant LSD cardio, which never seemed to do me any good anyway, in favor of a heavy dumbell high intensity weight regime with intense fitness bike cardio “rest” intervals. Spend less time exercising now and although my weight has returned to its naturally “high” equilibrium, I’m packing muscle I never imagined I had and feeling better than ever before. All in my mid 50s. Carbs per se aren’t the problem, although potato and other similar cooked root vegetables are admittedly not the best choice. Sodas, beer(!), and alcohol in general are sure fire diet/liver killers for most people, as well as all the usual refined white flour culprits and sugary snacks in all their forms. And the best part is that once you get off the sugar habit you begin to lose your taste for it altogether. Nothing a little low carb Greek Yogurt and Stevia can’t handle in a jiffy!
I’m very much on the fence about how much of a danger Ebola might be in the USA. My only (thankfully only one so far) experience recently with an ER is that it was sheer utter chaos, pandemonium & bedlam. Most incoming patients were kept waiting for hours on end in the waiting room & many didn’t even have a chair to sit on, even those bleeding profusely (and not even offered some kind of dressings to staunch the blood flow) or clearly in extreme pain or vomiting (on the floor), etc.
It was eye-opening, and this was at what is considered one of the “better” hospitals. My mother in law was pre-admitted by her Dr, which led to her being placed on a gurney in a sort of semi-private area (she is 93), but we had to wait six hours for her to get treatment. SIX.
It’s hellacious. If you need any kind of care, do your utmost to go to your Dr or an Urgent Care (which aren’t fabulous but seem much better than ER).
I don’t see how ERs can cope if there is some kind of spread of Ebola, even given that it’s alleged to be not that contagious. Having witnessed first hand people bleeding profusely and vomiting on the floor and chairs around them does make me feel confident about Ebola not spreading. ERs are going to have to come up with better Triage arrangements than what I’ve witnessed so far, or we’re screwed.
“Health care” by spreadsheet. Not a good idea.
I’ve seen HMOs say they will pay for Emergency Room care out of state, but not doctors visits etc. If one has a better insurance plan like a PPO it will pay for doctors visits and pretty much any medical care you need out of state, but HMOs often only pay for Emergency Rooms. I wonder where Urgent Care fits in that, whether it is covered or not. If not it’s DRIVING people to the emergency room. I mean the reality is people will leave the state for vacations, for special occasions or the holidays to visit family etc..
I don’t see how ERs can cope if there is some kind of spread of Ebola, even given that it’s alleged to be not that contagious. Having witnessed first hand people bleeding profusely and vomiting on the floor and chairs around them does make me feel confident about Ebola not spreading. ERs are going to have to come up with better Triage arrangements than what I’ve witnessed so far, or we’re screwed.
Especially when something like this goes down (from Richard Preston’s The Hot Zone, quite a sobering read):
Monet maintains silence, waiting to receive attention. Suddenly he goes into the last phase – the human virus bomb explodes. Military biohazard specialists have a way of describing this occurrence. They say the victim has “crashed and bled out.” Or more politely, they say he has “gone down.”
He becomes dizzy and utterly weak, and his spine goes limp and nerveless and he loses all sense of balance. The room is turning around and around. He is going into shock. He leans over, head on his knees, and brings up an incredible quantity of blood from his stomach and spills it on the floor with a grasping groan. He loses consciousness and pitches forward onto the floor. The only sound is a choking in his throat as he continues to vomit blood and black matter while unconscious. Then comes a sound like a bedsheet being torn in half, which is the sound of his bowels opening and venting blood from his anus. The blood is mixed with intestinal lining. He has sloughed off his gut. The linings of his intestines have come off and are being expelled along with huge amounts of blood. Monet has crashed and is bleeding out.
The other patients in the waiting room stand up and move away from the man on the floor, calling for a doctor. Pools of blood spread out around him, enlarging rapidly. Having destroyed its host, the hot agent is now coming out of every orifice and is trying to find a new host.
But of course, hospitals should not be in the business of acute care. We have other facilities for acute care don’t we? Why do I continue to be amazed at the monetization and corporatization of every facet of life?
I think the long term plan is for acute care to be merged with mortuary services, thereby creating another insurance racket, err… market. ‘Healthcare’ will thus be reserved for the wealthy and the healthy (catchy slogan there!), the presumption being that if you’re not wealthy you have no right to expect to be healthy as well.
I would say far too much over analysis.
First how many people (until maybe the last couple of weeks know where Liberia is or what is going on in W. Africa. Especially if you are a working nurse, maybe raising a family and maybe being a single parent. I jokingly say, he walked in and said he was from Liberia and she thought that was in Kansas.
Second he is in the emergency room probably stuffed to the hilt with illegal aliens all waiting to see a doctor for free. This is a process of take their temperature, talk to the patient for a few minutes (who knows he might be hard to understand), give them a few antibiotics and out the door. That takes care of 99.9% of the patients who walk in the door looking for free care. It is not like he went in and saw his doctor that he has been seeing for years (now this is an issue which might be destroyed by the new socialized health care plans).
I should note that a few weeks ago in Oklahoma I was talking to my sister who works in one of the top EN&T clinics in the state and I asked her what procedures do they have in place to spot a potential Ebola patient. She had no idea what I was talking about. Now she does work in accounting so not on the front lines, but she has worked in hospitals for 40 plus years and has a good idea of what is going on. I would say they had no procedures in place.
A doctor is not going to see you that day. You need to book well ahead. Urgent care will see you that day (and last I’ve seen they’ll take CASH, ok not for the very poor who won’t have the cash, but if one is merely without insurance … as I have been when unemployed at times it’s a relief to hand over a few 20s and be seen for your immediate pain, granted if you needed surgery or something say hello to bankruptcy) and it’s generally preferable to the emergency room.
It is clear an independent IG report is needed so we can see what really happened. I don’t buy the hospital’s responses.
Private health insurers often refuse to pay emergency room providers for treatment of medical conditions that are not deemed to be sufficiently dire as to be considered an emergency. Presenting with flu symptoms does not as a rule constitute a billable emergency and as such only a non-emergency primary care provider would be paid by an insurer.
With flu season fast approaching, this should get interesting. I’m guessing our gleaming, “best in the world”, certainly most expensive, high tech health care system with its byzantine payment schemes and unconscionable exclusions will be found wanting and in need of some adjustments.
I’m guessing our gleaming, “best in the world”, certainly most expensive, high tech health care system with its byzantine payment schemes and unconscionable exclusions will be found wanting and in need of some adjustments.
Relax. We’re just awaiting accurate price discovery for pandemic/Ebola remediation/prevention, then all will be right with the world again.
This guy had no health insurance. The hospital is getting stuck with a half million dollar bill unless the govt reimburses them for some reason. He is from Liberia. No health plan in Liberia and he certainly did not have health coverage in the US.
Maybe a deadly pandemic is the only route to quality universal healthcare in this country. OTOH, if the ’08 crash is any indication…..
I’d say, more likely a deadly pandemic might be the perfect excuse for the powers that be, assuming they were able to insulate themselves from it of course, to finish the job. But either way, I just don’t see universal “healthcare” ever having a chance, even within the limited scope of western medicine. Western medicine is really good at diagnosing and treating grossly manifest physical disease and trauma, but quite a bit less so at anything less than that. I think that aligns perfectly with our national defense posture, which seeks to identify hostile external threats, and then bomb (read: drug, treat, or cut out) them into submission. The western mindset is one of the hostile, external “other” as a threat, never for an instant pausing to reflect on the possibility that the true enemy might just lie within itself, personally and culturally, in the form of our own cherished preconditioned notions and paradigms.
No, the hospital is BILLING a half-million dollars in hope some government agency will pick it up by sponsoring a special bill in Congress.
In Canada the patient would have been treated. Period. Many Americans have been treated while vacationing there and have been shocked by the level of care provided. We in the USA are just so retarded we are truly in jeopardy “when the (untrained) troops come home” from police duty in Africa.
That is where I believe the problem lies; he didn’t have insurance. Once stabilized they can release him. They were following procedure for uninsured patients. And like one of the doctors opined; it is a national problem. If he had insurance they would have found a hundred tests they could have used to diagnose him and then the patient would have been worth something to the hospital. In his state and no insurance they could count on one thing; it was going to cost them plenty. So they dumped the patient and all is well with the hospital’s bottom line. This time it backfired in a big way but every hospital in the country likely has the a similar policy. No insurance, stabilize and send the patient on his/her merry way.
It isn’t just that he didn’t have insurance, he went to the wrong hospital. Counties in Texas have a public hospital funded by property taxes. In Dallas County, the hospital is Parkland; in Tarrant County (the City of Fort Worth), the hospital is John Peter Smith. The public hospitals treat anyone who shows up, regardless of insurance status or ability to pay. That’s where poor, uninsured sick people are supposed to go and they’re supposed to know it.
Local media were reporting yesterday (picked up by the NYT today) that Mr. Duncan was much sicker than the hospital originally reported. Medical records released by the man’s family show that he had a fever of 103 and was suffering severe abdominal pain (8 on a scale of 10). http://www.nytimes.com/2014/10/11/us/thomas-duncan-had-a-fever-of-103-er-records-show.html?_r=0
This is in conflict with the report made by the hospital a week ago, and still not revised, that his temperature when he first went to the emergency room was 100.1, a convenient 0.4 degrees below the 100.5 that is supposed to be a symptom of Ebola. http://www.dallasnews.com/ebola/headlines/20141003-hospital-cites-flaw-in-use-of-electronic-records.ece
He should never have been sent home but was, I suspect, because he didn’t have insurance. The hospital isn’t going to release details about the decision they made to discharge him because they’re most definitely facing a lawsuit. Not that medical malpractice in Texas pays much, or even enough to make it worth a lawyer’s time, but maybe a bright attorney can get around that. Wrongful death, maybe?
“That’s where poor people are supposed to go and they’re supposed to know it.” Really? Even if they are too new to Texas or too culturally and socially isolated to have been told about it or even heard it at all? If they are “supposed to know it”, then some Texan in authority had better make sure that “someone is supposed to tell all of them all about it, and make sure they all get it”.
I think I need to simplify this for everyone. No need to over analyze the first case at this point.
1) If we soon get to the point where we do have contagion in this country, or Europe, or Asia, then nurses and/or doctors will no longer be able to diagnose a patient’s illness by checking his/her recent travel itinerary.
2) For the first two days or so, the symptoms are described as “flu-like”. During this time it apparently shuts down your immune system and then goes about dissolving your cardio-vascular system.
We may want to consider how we handle a few million people during garden variety flu season. Is it flu or Ebola??? Both??? Two days of contagion time while we are checking the millions of snifflers and sneezers.
Not that Ebola could be contagious, or anything. No problem in Africa, it seems. If all our doctors and nurses die off, then we’ll know for sure.
You’re not so crazy. The points you raise are important.
It may be reasonable to assume that since our heath care system hasn’t really, really dealt with an easily-transmitted and deadly disease within the experience of doctors currently practicing medicine, and that the institutions we would rely on to identify, treat, and contain a disease like Ebola are unprepared from top down and from the ground up.
So much is unknown about this disease that we can’t take anyone’s word at face value. For instance, the assertion that it is spread like Hepatitis is just that–an unscientific assertion. Past outbreaks resembled transmission like that, but this one is different. It may well be that primary transmission is still through contact with body fluids, but that the virus is active longer in those fluids, or that it can be aerosolized. There is a lot of withering derision at the idea that the virus may be transmitted in an aerosolized form, but no empirical data to refute it, or support it for that matter. We need data, we need science, not assertions based on previous experiences.
We would be well advised to view this as a human health issue, not a poor immigrant black person issue. While the disease may have originated in Africa, and its initial victims may be African, its predation is by no means limited to our fellow human beings who happen to live there. Admissions questions for travel to Africa may be relevant, for now. If America’s patient zero infected someone who never went to Africa and was unaware of their exposure to him, what difference will it make when the newly-infected person presenting with early onset Ebola like symptoms answers “no” to the question: Have you traveled to Africa lately or been exposed to someone with Ebola? In many ways, the knee-jerk reaction to pooh-pooh right wing racist hysteria about Ebola, merely for its racism and because its proponents are wrong 98 percent of the time, is as unproductive and unhelpful as the right wingers for seizing on it as yet another way to politicize the phenomenon and castigate their perceived racial political enemies. Human pathogens don’t care what color you are. Hospital administrators and the CDC have their heads up their asses and must must must get prepared.
Finally, treating health care as a commodity to be consumed by those who can afford it, rather than as a potential prophylactic against a potential pandemic, will inevitably lead to a reckoning to the Prince Prosperos and their courtiers, a la Edgar Allen Poe’s “The Masque of the Red Death.”
And another thing: We don’t even know which antiseptics work best for decontamination. Bleach? An iodide solution? How can we not know this yet?
I have to wonder if Americans’ general ignorance about the world – stemming from our miserable education culture – contributed to this specific oversight.
Imagine a guy just in from Liberia who, feeling unwell, walks into an admissions ward staffed by average products of the anti-intellectual American education system.
“I’m from Liberia, and I have a fever,” he says.
“Liberia . . . that’s in Indiana, right?” asks the clerk, completely missing the potential implications of a sick man reporting he just arrived from ground zero of the Ebola outbreak.
If they learned about Liberia a decade ago in school, even if they could find it on a map and tell you the entire history of the country, it’s economy, it’s culture, like a walking Encyplopedia, what good would it all do if they aren’t following the news?
What the post doesn’t address is why Texas Health Resources wants to shift from acute care to “population health management.” (Very Orwellian – I hope it’s nothing like wildlife population management, i.e. culling the herd.) It’s nice to think their primary objective is patient (customer?) well-being but I’d bet all the money I don’t have it’s about money. Acute care only pays after treatment and then only if the insurer or patient can pay up. It sounds to me like PHM is trying to mimic the GMO model: get a regular monthly income stream regardless of services provided, which of course inevitably leads to a focus on serving the healthy and telling the poor to sod off.
I vote systemic.
Exactly. Emergency rooms are a money pit, so this organization is trying to make moves to reduce their exposure to the loss-leading treatment of the underinsured, and the indigent. Logical from a corporate-bottom-line perspective, but from a standpoint of a societal interest this is abominable.
But then again, maybe not. Mortality rates go up, Ezekiel Emmanuel should be happy because it bends the curve to conform to his desired shape. You’ve heard of the desirability of OPM – Other People’s Money – being available to avoid personal monetary risk; for him it’s OPM – Other People’s Mortality – to avoid personal exposure to death. Rock on, NeoLiberals. Are you your brother’s keeper? Well, fuck no.
As a physician, I have seen first-hand over the last decade that corporatized medicine focuses on bogus MBA concepts like economy of scale and streamlined resources to respond to CMS corporatized directives to become more ‘efficient.’
None of this has anything to do with the care of the patient. There is no doubt that electronic health records are not designed for ease of care from the physician perspective. They are designed for ease of audit under the false assumptions that using the same diagnosis code should mean using the same treatment with the same outcome. The ER doctor has no control over budget, but has little directive from the hospital other than to make the billings income sufficient to balance the budget costs. When a pandemic hits, ER doctors will continue to turn people away until their bosses give them permission to change the pattern, which will only happen when the government promises to treat it like a FEMA emergency. No hospital administrator wants to be blamed for a ‘cost center’ to merely provide adequate care.
Unfortunately, even in New Zealand where medical care is completely covered and doctors are relatively trusted to care for the patients, there is pressure from administrators to reduce costs. We want to be healed but traditional market forces would render a more third-world system than any of us are willing to accept. There is a reason hospitals used to be run by charities and modern medicine doesn’t seem to get any more affordable over time.
If only we could label viruses, bacteria and cancer cells ‘terrorists’….
Oh, goodie!
We can solve the virus problem the same way we solved the freedom-fighter problem.
The EMR is a red herring. The shift to full continuum care is nonsense. They just blew it. As soon as he told the intake person he had been in Liberia, he had a fever and thought he might have Ebola, the intake nurse should have been running around like Robbie the Robot. They should not have been wiling to go back into that room without adequate protection. They should have wanted the room decontaminated before working in it again. This is a competence issue, not a process issue.
Steve
Agree. Looking at the changes in overall hospital management style or “mission” misses the point. It is a question of competence, of people on the ER front line (who are often overloaded with work) being briefed clearly on what is critical.
Mistakes happens in all large organizations. If it is a screw up on a spread sheet, someone points it out at a meeting and it gets corrected.Consequences here of screw up are regrettably more serious.
I’m with Steve on this. They hospital just blew it by not paying attention to an international (because it had moved over the borders of several countries by then) disease and were presented with a patient from that area. I don’t think it’s any more sinister than that – they were caught totally off guard, just like all the major institutions that are SUPPOSED to deal with things like this – the WHO, the UN, CDC, etc. (I read that the head of the CDC went to Africa in August – MONTHS after I heard reporters on Democracy Now decrying the inadequate response – and only after that trip did he go to the President and ask for the resources we’re deploying now.)
Not that I don’t think our fragmented, totally decentralized, profit driven health care “system” WON’T create a pandemic with their fragmentation, crapified management, and profit driven motives, but I just don’t think that’s the case in this instance.
With that said, I maintain to all my coworkers and family that I am 100% way more afraid of Ebola than any sword-wielding maniac from either the Middle East or anywhere else. Evolution is for real, and viral diseases mutate very, very quickly.
Yves:
By law and maybe I am wrong on this premise; Texas has no obligation to treat an uninsured person beyond stabilization. Furthermore, this becomes even more serious as nonprofit hospitals will not be reimbursed for caring for the uninsured by the Feds.. Florida stands to lose $22 billion over the next decade in funding also. I would think Texas might have treated this as more of a flu bug or Strep infection rather than invest more time and money in investigation.
“Lying liars and incompetent fools are putting us all at risk” alert:
Dallas Hospital Alters Account, Raising Questions on Ebola Case
If the staff were as ‘competent’ as the average American at geography, they probably thought Liberia was a Canadian province, or “that peninsula with Spain on it.”
That admission still trips the BS-o-meter, because if they thought he had an unspecified viral infection, why did they send him home with an Rx for antibiotics, which are useless against viruses? (Perhaps they model their response on a typical House episode: Bombard patient with expensive drugs and hope resulting side effects reveal true causal agent before they kill the patient. Somehow in House bankrupting the patient is never invoked as an intermediate potential outcome.)
But OTOH why would we expect any glimmer of competence on the part of the hospital staff? After all, this is a place where key public officials tell obvious and dangerous whoppers of lies on a routine basis:
Right … because asymptomatic = uninfected. “All I know about epidemiology I learned in Sunday school.”
And at the federal level officials are peddling soothing PR balm about “containment” and “the system is sound” which sound eerily like those in the year leading up to the global financial crisis. And illogic abounds, e.g. here with respect to proposals for a travel ban from the Hot Zone countries:
Right, because such a ban wouldn’t have kept folks like the guy who came back infected from coming back … oh wait, it would have, wouldn’t it? Re. “prevent medical workers and other assistance from reaching Africa” – the proposed travel restrictions are on flights *from* the hot zone, not *to* it.
(I understand there is an “how would medical staff be able to return after a tour of duty?” angle to it, but I have no problem with special exemptions for flights organized by governments and aid agencies for such purposes – folks on those flights would be subject to a period of mandatory supervised quarantine on return, and would have departed with full knowledge of this requirement. It’s the unsupervised commercial travel that be suspended.)
Does the incompetence, lies and snafu-riddled response in Dallas strike anyone as “seamless”? Does the fallout from this single (so far) patient there strike anyone as “scalable to epidemic levels”?
While I agree with Dr. Poses about the obvious dangers of Medicine as Das Korporation, this Ebola case also has much more prosaic roots: You don’t readily diagnose what is uncommon without a very high index of suspicion.
http://www.medrants.com/archives/7892
BTW, the article I linked to above is from last weekend … I considered posting/commenting at the time I first saw it, decided to wait a few days to follow developments. Note we already have one flip-flop on the part of our dear federal officials: the very next day after the above piece appeared they announced that they would be stepping up the screening of passengers arriving from West Africa. So, were they lying before about that being ineffective? (My suspicion is that in fact they know it’s likely to be ineffective, but it provides political cover on the “being seen to be doing something” front, which they hope will dampen calls for a travel ban, which appears to be the nightmare scenario for them, for whatever reason – fear of panicking the herd, perhaps, or maybe something to do with “bidnis as usual is the #1 imperative”?)
Also note that there are widely divergent views about the effectiveness of a travel ban among public health experts. My own view is echoed by this fellow:
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Now to a Reuters link from today:
Fears grow in United States over Ebola’s spread outside West Africa
“Soothing balm of BS” quote des Tages:
And what ‘facts’ might those be, Ms. Burwell? The fact that the current outbreak indicates an ease of transmissibility far greater than that previously advertised by ‘the experts’, perhaps via microscopic fluid droplets like those mass-released in a simple sneeze? The fact that the mortality rate is still shockingly high?
Now, as to the comparison with SARS, which I agree is useful, though perhaps not in the way the author of the above NC guest article hopes, a few points:
o The 2003 SARS outbreak was pretty scary at the time, though less so than the 2014 Ebola outbreak. But perhaps there are rational bases for the differences, perhaps because the ‘unenlightened rubes’ (my wording, not hers) HHS Secretary Burwell seems to be invoking in fact *are* apprehending enough of the relevant facts to realize just how dangerous this could become, and the responses to the patients who carried the disease to Spain and Texas strike them as hopelessly, dangerously incompetent.
o The 2003 SARS outbreak featured a similar total-number-infected as the Ebola outbreak, but the Ebola outbreak shows no signs of slowing down.
o The 2003 SARS outbreak had a mortality rate of less than 10%. (Overall; it varied widely from region to region). the Ebola outbreak is around 50%.
Lastly, to the points made by “Dr. CB”:
“To and from Asia” is a whole other order of magnitude than W Africa in terms of number of people affected. By the time the Chinese health authorities fessed up about the severity of the outbreak the disease had spread far and wide in E Asia. Why no outrage for the SARS victims in the US? (Note that cites 27 such, not 8.) Perhaps because none of them died? Perhaps because there was greater trust in our authorities back then, in the halcyon days before the global financial meltdown and the realization of the emergence of a full-blown law-flouting post-9/11 national security state which invariably puts the interests of its corporate paymasters and military ahead of its ordinary citizenry?
And most importantly: Public Health officials like Dr. Poses (the author of the aove piece) appear to be sure that the fizzling-out of the 2003 SARS outbreak was due to skill, not luck. My question: given that it is possible that this is in fact wrong and that humanity dodged the proverbial global-pandemic bullet then, how much should we be willing to risk on the bet that we were indeed more skillful tha lucky? A million lives? 10 million? A billion?
As a healthcare worker I’m very familiar with the EHR and I can’t help but think this was a key part of the problem. So much patient information is taken to meet the “meaningful use” requirements, that it is entirely possible to miss the important details. At every visit, vitals are entered, medications and allergies are reviewed, smoking status is noted and cessation counseling may be discussed, body mass index (BMI) is taken and weight reduction counseling may be discussed, family medical history is reviewed and social history ( alcohol and drug use, sexual partners and activity) may be reviewed. It is a data miners dream. Hospitals with high compliance rates of entering in meaningful use information get paid a bonus. As a result, compliance with meaningful use is monitored by the hospital and discussed with doctors if they fall below a certain level. I’ve had a meaningful use re-education session, myself.
In all the data collection, it is easy to see how the important detail of a recent trip to Liberia might get overlooked. The EHR has some benefits but also can be a huge barrier to doing the job of actually caring for sick people. The profit motive problem with meaningful use compliance risks a repeat of the Dallas Ebola anywhere and should be discussed as more details (hopefully) emerge.
One can contract HIV from kissing?
The article did not say kissing, it said “suck face,” which in my understanding of the lexicon is extended French kissing, and thus means you’ve exchanged bodily fluids.
If you have an open sore in your mouth and French kiss, the answer is yes, although I believe the density of HIV in saliva is way way lower than in semen, so the odds of transmission of HIV that way are likely super super low but not impossible. May be higher for hepatitis. I know someone who is convinced he got Hep C from using the razor at a trick’s apartment, since he never did injections or got a tattoo (something like 20% of the Hep C cases in Oz are due to tattoos).. For HIV, the odds of infection are vastly higher if you are, to use the term of art, the sperm recipient. Even so, the risk on any one exposure is low, but people have gotten HIV from a single sexual encounter.
In my book, French kissing is kissing…!
Thanks for your reply; more or less what I thought, except for the transmission by saliva. Likelihood of transmission would also depend on the viral load of the infected participant, no doubt.
The comparison of Ebola with HIV and Hep C is misleading as sexual transmission is so preponderant in the latter two cases. Ebola patients when symptomatic are unlikely to be in the mood for, or objects of, romance, which is why caregivers, not spouses per se, are so often the next round of victims due to coming into contact with bodily fluids. And no, HIV is not transmitted by saliva, period.
Saliva often contains trace amounts of blood, from open sores, AND FROM FLOSSING, VIGOROUS BRUSHING, etc.
Perhaps saliva does not transmit HIV. Traces of blood in saliva certainly do.
Corporations don’t die, but make the decisions for those that do. Governments control the alienable rights to corporations. Corporatism saves corporations first, people are required to have extract the necessary funds to save the corporate financial health. The universal desire of human’s freedom from bankruptcy by environmental happenstance trumps public health. This drama is thus a required experience that shows every ability to enact secondary agendas of pubic control rather than disabling the prime unmover.
Doesn’t seem mysterious to me.
IMO Thomas Duncan got caught up in bread and butter disparity, the like of which is an every day occurrence in health care. The Texas gov. rejected ACA Medicaid expansion and so roughly a quarter to one-third of poor Texans still have no health insurance, disproportionately so Hispanics and Blacks. The hospital staff sent Thomas Duncan home because it was improbable he had Ebola and he didn’t have insurance. They rationalized they were doing him a favor, protecting him from a whopping hospital bill he couldn’t afford. They were also doing themselves a favor. Funds to hospitals for disproportionate care of persons without insurance/cash are beginning to dry up and in essence the hospital played the probabilities to save themselves the cost of more aggressive treatment.
I doubt the EHR ever had anything to do with it really.
In hospitals in states that rejected ACA, there’s a real funding headache. They’re not getting Medicaid dollars for treating the poor and on top of that they’re losing disproportionate payments they used to get when they did treat someone without insurance. This high profile case epitomizes the plight of so many poor people in states that rejected ACA medicaid expansion. And also the hospitals caught in this pinch. Many are paying the price. Thomas Duncan just happens to be a high profile case that’s attracting attention.
I would guess that’s part of it. The EHR screw-up (probably happened) is the proxy for the underlying political economy screw-up (lack of universal care).
So it would indeed be ironic if the outcome would be to double down on EHR funding (which is horrible to begin with, because all the taxonomies are about billing, and not about care (the proxy for that being doctors staring at the small screens of EHR devices instead of, ya know, examining patients).
LAS -A physician can only conclude that it is unprobable that Mr. Duncan had Ebola if his recent trip to Liberia fell off the radar – if you think the attending knew this patient’s insurance status but not his pertinent medical history, how can you say that the ERH didn’t have anything to do with it? Both bits of info are found in the EHR – if the attending knew one and not the other – we have an even bigger problem.
Also, I suspect you are wrong about disproportionate share payment concerns. Dallas has a county hospital that sees the vast majority of uninsured. Presby doesn’t handle a disproportionate share of poor patients in Dallas, Parkland does.
Shilling for Medicaid expansion and getting to the root cause of why an Ebola patient was not admitted should not be conflated.
Here is another potential failure mode. Hospital labs won’t perform tests on specimens from suspected Ebola patients? Weak links every where.
Many local hospitals are telling the state Health Department their in-house clinical laboratories do not want to perform some routine blood tests on patients identified as possible Ebola cases.
Hospital leaders say they’re looking for ways to ease lab workers’ worries while ensuring potential Ebola patients get needed care and blood analysis. Health authorities, however, worry the labs could be a weak link in the public health chain and may compromise timely care for patients.
New Minnesota Ebola fear: Labs may balk at testing blood
Add your own extensions with contracted labwork, outsourced labs, profiteering and Galtian excellence.
One of my hero’s In life often used the expression “do not ascribe to malice what could be equally ascribed to incompetence.”
I was quarantined briefly at a Boston research hospital a decade ago for suspicion of SARs for having a UTI fever and having recently been in Asia. Everyone wore the hazmat masks in my room as they laughingly stated that policy required a set of steps be taken when it was obvious I did not have SARS.
3 years ago an ER doctor at the Children’s hospital in Seattle released my 7 year old daughter from the hospital despite her having been referred to the hospital for a ruptured appendix, which required immediate emergency surgery (she was sent back to the ER immediately by our pediatrician). My daughter does not like to show pain or weakness, which is a required symptom according to hospital policy in order to have a simple ultrasound. We had the insurance to pay for the ultrasound, but hospital policy was concerned that overuse of ultrasounds would create false negatives. It turned out that underuse of ultrasound in fact produced a very big false negative.
High liability businesses are glued to reactive policy, which yields sub optimal outcomes. This has nothing to do with corporatism of hospitals or insurance.