Two nurses who treated the late Ebola-virus victim
Thomas Eric Duncan have been diagnosed with Ebola virus as well. They
treated him at the Texas Health Presbyterian Center hospital in Dallas, where
he died on October 8 after traveling there from Liberia, where he acquired the
virus. Despite apparently
following the protocols recommended by the U. S. Center for Disease Control
(CDC) for dealing with patients with Ebola, nurses Nina Pham and Amber Joy
Vinson are now being treated for the disease as well. Their chances are grim: the death rate from the virus can be as high as 50%.
Besides all that, one could be
excused from believing that nothing else is going on in the U. S. right now
except the Ebola virus, at least judging from the media coverage in Texas. If there is a futures market in Clorox,
now's your chance.
We are used to thinking of
technology only in terms of hardware, or maybe hardware and software. But engineering designs can center
around people and their behavior too.
The elaborate protocols and procedures that integrated-circuit
manufacturers follow are just as essential to making their chips as the silicon
is. A roomful of advanced medical
equipment is just so much scrap metal without the people and plans and
procedures that can use them effectively.
And just as machines can be well or poorly designed, so can protocols.
Let's look at two protocols. One is posted on the CDC website under
the title "Infection Prevention and Control Recommendations for
Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S.
Hospitals." That's pretty
clear. What do they say about
personal protective equipment for the nurses and other personnel who care for
Ebola patients? It's pretty
simple: a face mask, eye
protection (goggles or a face shield), gloves, and a gown ("fluid
resistant or impermeable"). I
don't know about you, but if I was within a few feet of a potential source of
fluid that had a good chance of giving me a deadly illness, I would want to be
covered by something more substantial than a "fluid-resistant" gown.
Now, let's consider another set
of protocols. In an editorial in
the Oct. 16 Austin American-Statesman,
critical care physician Bryan Fisk recalls the protocol he used when he was in
charge of a Biosafety Level 4 Patient Isolation Suite at Ft. Detrick,
Maryland. This was a military
facility designed to handle patients with diseases as dangerous as Ebola. What kind of personal protective
equipment did they use at this facility?
"[F]ully encapsulated positive-pressure protective suits with a
tethered air supply." In
other words, a diving suit without the water. Not only were they trained to do all sorts of
procedures—intubation, catheterization—while wearing these undoubtedly
cumbersome outfits. Once they left
the isolation unit, they underwent a complete chemical scrubdown while still
wearing the suits, with the aid of other technicians. And as long as they were treating the patient and for the length
of the incubation period afterwards, they were confined to on-site quarters and
not allowed to leave until there was no chance that they had acquired the
virus.
There are reportedly about four
of these types of isolation units in the U. S. Understandably, they are more expensive than the standard
emergency-room or intensive-care isolation units maintained by even the best
public hospitals. But in view of
the fact that the CDC protocols, even if followed, fall far short of what the
U. S. military does when dealing with Ebola-type situations, it's hard to resist
the temptation to repeat an old consulting-engineer saying.
The story goes that one day a
consulting engineer gets a call from a factory manager where things are going
haywire. He flies out to the site,
walks around a half hour or so, and then motions for the manager to come into a
private office with him. He sits
down and says to the manager, "Your system is perfectly designed to give
you the results you're getting."
In other words, you should not expect a badly designed protocol to
deliver good results.
Fortunately, nurse Nina Pham has
been transferred to a National Institutes of Allergy and Infectious Diseases
isolation unit in Bethesda, Maryland.
I was unable to find any information on the protocols for protecting
healthcare workers in that unit, but one hopes that it is better than the CDC's
bare minimum.
The perception of competence can
be as important as actual competence.
Doctors and medical-care workers are some of the most trusted
professionals in society, and when a scary thing like an Ebola case happens,
the presumption is that those in charge will follow the best practices
available to ensure that the disease doesn't spread. With the failure of Texas Health Presbyterian Center to use
adequate protocols, whether due to thinking that the CDC knew what it was
talking about or otherwise, that trust has been severely damaged, and the word
"panic" has started to show up in news items on the virus. Professionals can be excessively reluctant
to second-guess other professionals, but in this case it looks like it would
have been better for someone in authority to order the Texas hospital to send
Duncan to a military or equivalent-quality isolation unit the instant it became
clear he was infected. He might
have died anyway, but we would have avoided any possibility that Ebola carriers
were running around in public and flying in planes, which is the situation we
face now.
Realistically, the risk of
catching Ebola for the average person in the U. S. is virtually no higher than
it was a month ago, which was approximately zero. But already, serious damage has been done to the medical
profession's reputation, and it will be some time before the fears of Ebola
subside. We can get there sooner
if every organization involved with Ebola fully acknowledges the seriousness of
the problem and spends the money and resources necessary to deal with it
safely—or else admits they can't do it and defers to an organization that
can.
Sources: Dr. Bryan Fisk's article "We need to send Ebola patients to
U. S. disease-isolation facilities," appeared in the Oct. 16 edition of
the Austin American-Statesman, p.
A10. The CDC's recommended
protocol for Ebola appears at http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html,
and as of this writing was last updated Oct. 6. The Dallas Morning
News has a helpful timeline on Ebola in the U. S. at http://res.dallasnews.com/interactives/ebola-timeline/.
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