Clutching our world views with a death grip

By Mary Odum

As I write, I am sitting in what might be my last airplane seat, stacked cheek to jowl with a couple with a cute but runny-nosed baby. My trip was with girlfriends on a bike tour in California, and I made the most of it, living very much in the moment. As I traveled, I wore my infection control hat, scanning the settings with new eyes for potentially dangerous situations. I was careful in public places such as airports, trolleys, and the BART, washing my hands frequently and keeping them folded in front of me. I was much more aware of impulses to touch my face. I watched a couple in the San Francisco airport who were headed to Nairobi touch their faces, many times, as they waited. Airport bathrooms were mostly hands-free, but the automatic toilets sprayed their contents powerfully in all directions when flushed. There was a new sign in the TSA line warning us to wash our hands because of Middle East Respiratory Syndrome (MERS), but no mention of Ebola (EVD). TSA used gloves to pat me down, but they were not washing their hands after contact with people. Boarding passes, drivers licenses, and credit cards were swiped and exchanged, along with bills and coins. I saw a large homeless population on the waterfront in San Francisco with no access to bathrooms or handwashing, who were using the streets as open latrines. I saw prostitutes. Hotels had carpets and mattresses that would defy cleaning in an outbreak. I saw people hugging, and shaking hands, and doing all kinds of human, caring, or even loving things that would be extinguished in a pandemic.

Today the first nurse within the US healthcare system has acquired EVD. My nursing friends are worried. Are we ready for this? How do we communicate risk, or should we settle for optimistic reassurance that our system can handle this? What are our biggest needs in preparation?

Communicating risk or comforting memes?

There have been probable cases of EVD in eight countries: Sierra Leone, Liberia, Guinea, Senegal, Nigeria, DRC, Spain, and the US. Those keeping track of the epidemic maintain the fiction of less countries and less deaths with scrupulous reporting of grossly inaccurate counts, and by partitioning the outbreak into different categories and phases. Is it time to use the P word and call it a pandemic yet?

How The Economist views the issue
How The Economist cherry-picks the issue of readiness

Most who are communicating the risks of this situation are men, who do not work in situations with isolation gowns or patients. They do not fully understand the issues or risks in the acute care setting. Typically, the spokespeople are understating the risks, in hope of avoiding panic, optimism of the best outcome, or denial. None of us have been in a serious pandemic, since the last global pandemic was almost exactly a century ago. So there are many uncertainties surrounding this epidemic. Should we be optimistic and hope for the best, or imagine the worst and try to prepare?

How healthcare professionals view the issue (via Jesse's Cafe)
A different view of U.S. readiness for pandemic (via Jesse’s Cafe)

The massaged messages from our leaders and the mainstream media (MSM) are slowly changing over the past three weeks, from “It won’t come here” to “It might come here” to “Cases are expected, but don’t panic.” Don’t panic, when we’re under-prepared for a deadly pandemic? Isn’t that what anxiety is for—mobilization away from inertia towards preparation?

quitjobA nurse in Dallas who was caring for the first EVD patient in the US, in “full isolation gear”, has contracted the disease. Frieden’s first comment on the situation was to blame the nurse. “At some point there was a breach in protocol. That breach in protocol resulted in this infection,” Frieden said.  He looked panicky as he announced it, but that is no excuse for blaming the victim. Now you’ve made me mad, Frieden, and it seems that you have made other nurses mad, too. If risk communication by the CDC takes this approach, the nurses are just going to say “I quit” like the nurses in Madrid and West Africa. The optics are poor when a series of wealthy white men unfamiliar with isolation procedures start telling the nurses what to do and where they went wrong. Nurses’ voices have been systematically muzzled over the past two decades with the privatization of healthcare, but this may be where we find our voice.

oopsnurseFirst, the CDC cannot be sure that it was a breach in protocol. This case might have been acquired from fomites. The meme that EVD is only spread thru body fluids is simply inaccurate. Or it could be any number of other gaps in the system.

When there are systemic errors, such as gaps in protection from a deadly virus, you don’t blame the nurse. You fix the system. We know there are big gaps in the system. We cannot fix the problems if we immediately seek to place blame on people and not address the systemic problems.

“The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them” (Institute of Medicine, 1999, To Err is Human PDF). Errors happen all the time in complex systems, and blaming the nurse is not the way to fix them. And we need to fix them, now, or else we will have to adopt a community-based caregiving model for this or another pandemic when hospitals become overwhelmed. Hospitals in the US are overly complex, with excessive treatment. Preexisting gaps in the chain of infection for this deadly disease could create avenues for spread if not closed. And we will have to make some ethical decisions about triage and fair care if this pandemic expands further.

Sally Sellers, RN illustrates just one of the systemic problems that needs to be worked through in our system. Our isolation rooms typically have a single anteroom, which may have been adequate for less lethal diseases. But Ebola is different.

“. . . when it comes to an isolation room, whether it has negative pressure or not, there is only one ante room where both the dawning of clean PPE and disrobing of contaminated PPE is performed….where there is a linen cart for dirty PPE, where there is a trash can for contaminated supplies/PPEs. What the heck are the chances that a nurse takes off her PPE correctly inside-out and disposes correctly . . . but the ante room is dirty as it is in contact with infectious material? Awaiting the well trained nurse to touch contaminated surfaces in the ante room . . . awaiting the next healthcare worker who has yet to dawn PPE to touch contaminated surfaces, etc.?” (Sellers, 10/12/14)

scratchfaceIn addition to systemic problems, there is the problem of human complacency, fatigue or lack of training for the degree of caution needed with this virus. As a nursing professor, I taught students how to safely protect themselves in situations where isolation was required. After reading about infection control and practicing isolation techniques in the lab, students would apply what they learned in actual hospital isolation rooms with patients. Invariably, garbed students would attempt to touch their faces within minutes of entering the isolation room, sometimes multiple times after being reminded. I have also seen complacent experienced nurses forget and do the same. I’ve seen huge lapses in isolation room compliance, by visitors who seem to be exempt from isolation rules, ancillary staff, physicians, and housekeepers. Even in a good hospital, there are gaps, poor handwashing compliance (less than 50%, typically), and spread of drug-resistant germs in hospitals through contamination of the setting.

disgustingIntensive care nurses are particularly vulnerable in caring for EVD patients, as we deal in extreme procedures that aerosolize body fluids. One issue here is the recurring ethical question of extreme care of some patients in intensive care, when other patients who lack healthcare do not receive any. It also raises the ethical question of varying levels of protection for caregivers. At this point, most hospitals do not have BLS-4 type hazmat suits, and hospital administrators consider “full Isolation gear” to be paper disposable isolation gowns that are one-size-fits-all, and often too short, leaving much of the body exposed or which tear in use (see header). Masks are either simple surgical masks, or N-95 respirator masks that do not screen out all aerosols, and nurses must wear their own scrubs and shoes home and wash them at home, potentially exposing their families. At the very least, these inadequate costumes need to be upgraded to theater gowns or some other more impervious garb. Another gap is chronically understaffed nursing care, which also creates lapses in infection control, as nurses have to pick which policies and standards are most important. There are both holes and inequities in the healthcare system that add to systemic gaps in infection control. Unfortunately, the gaps are large enough to drive a truck through.

PPE considered essential by MSF leaves no skin showing, in contrast to standard full isolation PPE in use in US hospitals
PPE considered essential by MSF experts leave no skin showing, in contrast to standard “full isolation” PPE in use in US hospitals

Another comforting meme or spin is that EVD may become endemic and become the next AIDS. How did we rush past epidemic to endemic in the minds of journalists, when pandemic is what we are headed for? AIDS is now often considered a chronic illness, and antiretrovirals have been effective at holding off immunodeficiency. In comparison, Hepatitis B is about 20 times more transmissible than AIDS, and Ebola, due to its virulence and multiple modes of transmission, is probably much more transmittable than hepatitis. Yet journalists and spin doctors choose AIDS as a comparison disease. Ebola is much easier to catch than AIDS, as it is transmitted in all body fluids, and the disease causes very messy viral shedding in its victims. Transmissibility is a critical issue that needs more research.

Why did they stop the simulation at 78 days?
The assumption used for Ebola CFR is probably too low. Click on the Washington Post link to see the simulation run.

Another comforting meme is that we must keep global air transportation moving so that we can “fight it over there so it doesn’t come here.” We are mobilizing a lukewarm linear response to an exponentially growing pandemic. Branswell’s analogy to burning embers in a fire is an apt one. West Africa is a conflagration, with burning embers scattering everywhere as the fire grows. But it will eventually come here, slowly perhaps, if we do shut down air travel, but inexorably, especially as it reaches other crowded countries that are not isolated, either by geography or by modern travel. If you could halt air travel to slow the transmission of EVD to the US, would you? In descent we will have to slow or stop using air travel—this would be a good trial of what it would be like. Or this is how air travel might go away?

What now?

iwearbodyfluidsSpanish nurses are defecting from the fight in Madrid, citing poor pay and inadequate PPE. I have been there, working in isolation rooms that weren’t set up properly, or with disposable isolation gowns that were too short or gloves that were too thin or too small and tore easily, with a patient load that didn’t allow time for adequate or safe care. If I was close to retirement age and I was a nurse, and my hospital administrator earned 20 times or even 100 times what I earned, and he was telling me that hospitals were prepared, and I knew they weren’t, and I was powerless to change the situation, I would be ready to walk.

need-to-be-autoclavedNurses are on the front line of this disease, unlike hospital administrators or even physicians in most cases. Unless one works in the rare Magnet hospital, where high level, autonomous nursing care is prevalent, and nurses have a voice in managing the system, hospitals these days are run by MBAs in suits, who know more about profitability than healthcare. What would stop me from quitting, and saving my ammo to care for my family, if I knew that a deadly pandemic was coming, and my hospital would not listen? Those journalists who promote headlines blaming the spread of EVD on nurses need to reconsider the slant they are promoting. And the MBAs running hospitals had better give nurses a seat at the table to manage these issues, now, before this pandemic heats up and we go into crisis mode. Focus groups with nurses to tighten up the gaps would be a good place to start.

Healthcare workers and the general public need to be educated. We will need to teach community members how to protect themselves for the long term, and perhaps also how to care for family members safely. We need to teach people about quarantine, why it is important, and how to prepare for the possibility. We need to teach people about the chain of infection and the basics of infection control.

Doctor Schnabel [Dr. Beak], a plague doctor in seventeenth-century Rome
PPE trends over time–Doctor Schnabel [Dr. Beak], a plague doctor in seventeenth-century Rome
There are many research needs. We need much better science on how this disease is transmitted—there is still much we do not know. We need to research the best non-disposable PPE gear, and the best ways to decontaminate. Another need is an optimal formula for oral rehydration therapy (ORT). At Emory, the team found that patients had significant hypocalcemia, hypokalemia, and hyponatremia, requiring specific intravenous fluid replacement dependent on lab values. A low-transformity ORT specific to EVD for home care (with and without sugar) is needed. We need community care kits with bleach, buckets, PPE, and other items for caring for EVD patients in the home. And we need to figure out how much waste incineration is necessary for Ebola patients in both home and hospital settings. The apartment clean-up in Dallas was very dangerous because of inexperienced workers (15 people), and it created 140 drums of waste, and a $100,000 bill. Who will pay that bill, is it sustainable as the plague spreads, and would it just be simpler and safer to burn houses down if thorough decontamination is really necessary? We also need self-organizing networking capabilities where people can report exposure, contacts, home care needs, and deaths on a community organization basis.

The biggest question, however, is whether we should quarantine by limiting air travel? This is a deadly but slow disease, slower than the flu, because it is not airborne and the incubation is longer–unless you throw in global travel. Arguing not to close borders assumes we can stop this—in my opinion, we are already past that. Shutting down commercial flights to slow things down is the first step. But it would have to be shut down entirely, or else the impact would just be to slow the spread. On the bright side, many of the adaptations that we will have to make in this epidemic, such as less travel, more relocalization, and less global trade are things that we need to do anyway in descent–here is our impetus.

Hope for the best but imagine the worst

Americans are hoping for the best, but it is important to be prepared for the worst. Sandman and Lanard suggest that “telling the truth about the situation, admitting what we don’t know, acknowledging problems, asking more of people and speculating on what-ifs and worst-case scenarios” help us to improve the system.

Models suggest that there may be 1.4 million cases by January. What happens after January? What would happen if half of our society died of Ebola? It gives a whole new meaning to the idea of being left behind. Would our karma here in the U.S. consist of trying to keep the electricity and economy limping along in a society with not enough people, to run too many white elephants, such as shuttered nuclear power plants with over-stacked spent fuel pools?


The  Ebola series is linked here, also in the pull-down Topics list at upper left.