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Why Dallas needs to be a wake-up call about Ebola

Director of the Centers for Disease Control and Prevention Tom Frieden
Director of the Centers for Disease Control and Prevention Tom Frieden
Alex Wong/Getty Images

When the first Ebola patient diagnosed in the US arrived at a Dallas hospital, Texas Health commissioner David Lakey exuded a cool confidence about the situation. "This is not West Africa," he said at a press conference. Texas Presbyterian could deal with the case because, as Lakey put it, "This is a very sophisticated city, a very sophisticated hospital."

Since then, we have learned that Texas Presbyterian was not nearly sophisticated enough. Its botched handling should be a warning: American hospitals are not ready to safely care for Ebola patients. 

Texas Presbyterian may be "considered the
Neiman Marcus of hospitals" but it miserably failed the Ebola test. And what's disturbing is that it seems other hospitals are missing the lesson from Dallas.

The Dallas wake-up call

Day after day, new details emerge about the fumbling of "patient zero" Thomas Duncan's case. First, there was the failure to diagnose the Liberian national on his initial hospital visit, which not only delayed his care and may have increased his risk of death, but also sent him back to the community and to his family's small apartment while he was infectious.

Then, there was the news that those caring for Duncan for several days before he was diagnosed — including two Texas nurses who now have Ebola — didn't wear full protective gear and had their skin exposed to his contagious bodily fluids. Yes, we didn't know Duncan had Ebola at the time. But this was also a patient who just arrived from the Ebola hot zone with a fever, projectile vomiting, and diarrhea, a patient who became so overwhelmed by the virus, he died days later, on October 8.

We learned on Wednesday that one of the nurses took a Cleveland-Dallas flight, which had been approved by the CDC, while she was running a low-grade fever the day before she was diagnosed.

Yesterday, at a Congressional hearing about Ebola, we also learned that staff at the hospital got no in-person training in how to care for Ebola patients. This, despite the international attention on Dallas and the months of warnings from public-health officials that hospitals in the US need to be ready to handle Ebola patients.

Briana Aguirre, the first Texas nurse to speak publicly, echoed that lack of preparedness. On the Today Show, she said the nurses at her hospital never talked about Ebola before Duncan arrived, and only received an optional seminar about the disease. What's worse, her neck was exposed while she was caring for an Ebola patient, the infected nurse Nina Pham. "On the second week of an Ebola crisis at my hospital the only gear they're offering us at that time... is gear that is allowing our necks to be uncovered." She voiced her concerns to hospital officials and the CDC and they fell on deaf ears. 

When asked whether she'd go to Texas Presbyterian for treatment of Ebola, she said, "Knowing what I know, I would try anything and everything to refuse to go there to be treated."

Nurses say US hospitals have no Ebola protocol in place

The National Nurses United, America's largest nurses' union, recently surveyed more than 700 of its members from across the US. They found that the overwhelming majority of nurses in this sample reported that they are ill-equipped for Ebola.

Like the nurses in Dallas, they have not received hands-on training in how to don and doff protective gear and deal with an Ebola patient, should one turn up. Eighty percent of their hospitals don't have Ebola protocols in place, and a third of respondents said they don't have the CDC-recommended supplies (eye goggles, fluid-resistant gowns) necessary to treat an Ebola patient safely.

Nurses are concerned because they are the ones who work on the front line of health care, giving patients fluids, mopping up their vomit, changing their sweat-drenched bedsheets. They're also the ones who will be dealing hands-on with potential Ebola patients, said Deborah Burger, a nurse in Santa Rosa, California and president of the association.

At Burger's clinic, medical staff were only pointed to videos and guidelines from the CDC, relying on workers to teach themselves how to handle an incurable virus. But, as Vox's Sarah Kliff showed, these guidelines involve dozens of complicated steps that aren't exactly easy to follow. And experts say Ebola preparation requires rehearsal and interactive training.

Another nurse, Diane McClure, told Vox that the botched handling of a suspected Ebola patient at her hospital (Kaiser Permanente South Sacramento) in mid-August still hasn't resulted in any hands-on training. "We were not prepared," McClure said, "and we still are not prepared."

"When you look at what happened in Dallas," Burger said, "it wasn't because of the nurses' breach in protocol. It was because the employer at that hospital who said they were ready for a potential Ebola patient did not have the proper equipment available for the nurses or the protocols in place."

While health officials are still investigating exactly how the Dallas nurses got sick, it's clear more could have been done to protect them. Their infections were avoidable, and future infections of health workers will be inexcusable.

The CDC urges health workers to "think Ebola"

We can say "hindsight is 20/20" and that Texas Presbyterian is the test case. We can view the mistakes in Dallas as a learning experience at a hospital with no prior Ebola experience — albeit one that might have cost several lives.

But we need to make sure that the Dallas lesson is learned by clinics and hospitals across the US. Now.

In its guidance to hospitals, the CDC recommends, among other things, isolating suspected Ebola patients, and making sure health workers have access to impermeable gowns, face masks, neck hoods, shoe and leg coverings, and eye goggles.

The agency can't enforce these guidelines, so it's up to hospitals to get in shape for a potential case. And, as American tropical medicine expert Mark Kortepeter wrote in the Annals of Internal Medicine, doing so won't be easy. To get a sense of what Ebola preparedness means, check out his detailed list:

"Every piece of the care continuum must be well-choreographed with significant attention to detail. At a minimum, preparations must be made for patient entry and movement pathways, optimal patient location and access control, safe donning and doffing of personal protective equipment (PPE), handling and testing of laboratory specimens, disposal of significant volumes of waste, safe and unexpected cleanup of spills and bodily waste, and minimizing use of sharps. Donning and doffing of PPE need to be regimented and monitored, with plans in place for peer policing. Lapses inevitably occur in infection control routines in conventional medical settings, but once a patient enters the facility, there is no margin for error. Significant risk for infection control errors occurs especially during doffing of potentially contaminated PPE."

At the Ebola Congressional hearing, CDC director Tom Frieden put it more simply. He said health professionals need to "think Ebola" from here on out. Take a travel history, he urged, and "any time a patient is suspected, isolate them."

Dallas didn't do that. But again, Dallas was the first. When more Ebola patients unexpectedly turn up here, hospitals need to be ready — not only to care for their patients but also to protect their staff.

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